Every finding on record at Crowne Health Care of Springhill

Based on resident record review, interviews, review of a facility policy titled AGAINST MEDICAL ADVICE (AMA), and review of a facility policy titled Notification of Change of Condition of a Resident the facility failed to ensure the Physician was notified when Resident Identifier (RI) #1 left the facility AMA. This had the potential to affect RI #1, one of three sampled residents. Findings include: A review of a facility policy titled AGAINST MEDICAL ADVICE with a last review date of 10/2022, revealed: . POLICY: AGAINST MEDICAL ADVICE (AMA) . C: Sign Out AMA PURPOSE: To provide consistent guidelines for staff to follow under applicable circumstances . PROCEDURES: . 2- Notify the physician and follow any instructions/orders given. A review of a facility policy titled Notification of Change of Condition of a Resident, with a revised date of 09/2011 revealed: . Purpose: To ensure resident's rights and continuity of care by identifying and reporting a Significant Change in Physical, Mental and Psychosocial well being. Procedure: Notify the Physician of status change. RI #1 was admitted to the facility on [DATE] with a diagnosis of Aftercare Following Joint Replacement Surgery and Right Artificial Knee. RI #1's Departmental Notes documented the following: . 11/25/2022 12:40 PM . Nursing Note . admitted to room . and . Patient left AMA @ 2200 hours (at 10:00 PM) . Patient transported from facility via wheelchair by personal vehicle. An interview was conducted via phone on 07/06/2023 at 12:06 PM with Employee Identifier (EI) #3, Registered Nurse. EI #3 was the nurse for RI #1 on 11/25/2022 at 10:00 PM. EI #3 was asked about RI #1 leaving AMA. EI #3 said, a family member came to the facility and was going to take RI #1 home. EI #3 said, she called the Director of Nursing (DON) to let her know. On 07/06/2023 at 4:28 PM a follow up interview was conducted with EI #3, and she was asked who she should have notified about RI #1 leaving AMA, and she answered, the Medical Director. EI #3 was asked what the facility policy was for notification. EI #3 said, when there was a change in status of any kind, they were to notify the Doctor. EI #3 was asked what the concern was of not notifying the Doctor when there was a change. EI #3 said, so the doctor could give further orders. An interview was conducted on 07/06/2023 at 5:01 PM with EI #2, the Director of Nursing. EI #2 was asked who should the nurse notify if a resident leaves AMA. EI #2 said, the Physician. EI #2 was asked what the concern was of not notifying the Physician of a resident leaving AMA. EI #2 said the doctor needed to be notified in case further orders needed to be given. An interview was conducted via phone on 07/06/2023 at 5:47 PM with EI #1, the Medical Director. EI #1 was asked when he was notified of RI #1 leaving AMA. EI #1 said, he was not notified. EI #1 was asked when he should have been notified of RI #1 leaving AMA. EI #1 said, when the resident left. EI #1 was asked why he should have been notified of RI #1 leaving AMA. EI #1 said, they might could have done something.

Based on record reviews, interviews, a review of the facility's investigation and a review of the facility's policy titled, ABUSE POLICY, the facility failed to ensure a staff member did not post on social media a picture of Resident Identifier (RI) #1 on 02/24/2021. This affected RI #1, one of three sampled residents for abuse. Findings include: The facility's policy titled, ABUSE POLICY dated 11/2016, documented, IT IS THE POLICY OF CROWNE HEALTH CARE OF SPRINGHILL TO ENSURE THAT EACH RESIDENT IS FREE FROM VERBAL, SEXUAL, PHYSICAL AND MENTAL ABUSE, MISAPPROPRIATION OF RESIDENT PROPERTY AND EXPLOITATION. Employees Acknowledgement and Acceptance of Resident Abuse Policy .Definitions .Mental Abuse -- . Mental abuse also includes using social media to post photographs or information about a resident that is demeaning or humiliating to a resident. An acknowledgement dated 02/03/2021 and signed by Employee Identifier (EI) #2 documented he/she read and understood the Abuse Policy. On 02/25/2021, the facility's Administrator reported to the State Agency an incident of mental abuse. According to the report, EI #1, a Certified Nursing Assistant (CNA), reported on 02/25/2021 at 04:15 PM that EI #2, a CNA, posted a picture of one of the residents sleeping the night before with a caption that read, What ever type medicine they got him on I want it the hospital high is best high in world. A written statement by EI #1 (CNA) dated 03/02/2021, included in the facility's investigation, documented, [EI #2] is one of my facebook friends also was employee at my previous job [at another facility]. On February 25, 2021 I happen log into my facebook page. [EI #2] story popped up I clicked on story viewing a picture [he/she] took of one of our residents at [name of facility]. I than reported it my Nursing Supervisor [EI #4] who reported the situation to the Abuse Coordinator, [EI #3], Administrator. A written statement by EI #3 (Administrator) dated 02/25/2021, included in the facility's investigation, documented, This writer was informed at approximately 4:15pm on 2/25/21 by (EI #4), RN (Registered Nurse) Supervisor and (EI #1), C.N.A. that (EI #2), C.N.A. had posted a picture of one of our residents, (RI #1) to her Facebook stories. I reviewed the picture which had the following typed over (his/her) picture 'What ever type medicine they got (him/her) on I want it (insert 2 curious face emoji's) the hospital high is the best high in world (insert 7 laughing face emoji's).' This picture was in the middle of several pictures rotating through her stories on a page under the name of (different name than EI #2). We found out (same last name) is a family name to her. (EI#2)'s picture was the very next picture after our resident's picture. It showed it was posted 23 hours prior to our viewing so that would have been approximately 3:00 p.m. on 2/24/21. (EI #2), C.N.A. worked on 2/24/21 2:00 p.m. to 7:00 p.m. She denied posting any picture of our resident even after I told her I could see her picture right after the resident's picture. She was asked to remove this picture immediately and she was also informed she was being placed on administrative leave pending the investigation. Her Facebook profile is private so we could only see this through (EI #1)'s Facebook page since they were friends. However, after this writer confronted (EI #2), she blocked (EI #1) from her page. Our Staff Development found a mutual friend to check her page again and the picture appeared to have been removed at that time. The facility's letter to the State Agency Complaint Unit dated 03/03/2021, documented, . We have completed the investigation of mental abuse on (RI #1) by the suspected offender (EI #2), CNA on Wednesday, February 24, 2021 at approximately 3:00pm. In conclusion, the allegation is substantiated. (EI #2), CNA has been terminated for violation of our Abuse and Social Media Policy. RI #1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #1's Admission Assessment Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 01/12/2021, listed the resident's Brief Interview for Mental Status (BIMS) as 10. A telephone interview on 06/15/2021 at 04:28 PM, EI #5, Licensed Practical Nurse (LPN), reported EI #1, CNA, showed her the post on EI #1's cellphone. The post was not public but EI #1 could see it because she was a friend to EI #2 on Facebook. EI #5 stated she saw RI #1's face with closed eyes and the resident appeared out of it or sick. EI #5 saw the resident lying in bed wearing a hospital gown. EI #5 stated there were words that said something like give me what [he/she] had. EI #5 reported she provided training to EI #2 that included not taking pictures of residents. EI #5 stated EI #2 understood the policy and signed the acknowledgement. EI #5 stated she thought the post was demeaning because the resident was shown in a hospital gown, very sick and not in the resident's best state. EI #5 stated posting a picture of a resident on a social media site was degrading to the resident. An interview on 06/15/2021 at 05:59 PM, EI #4, RN Supervisor/Nurse Manager, reported he saw a post of RI #1 lying in bed. There was some writing, but he could not quote it. EI #4 reported taking a picture of a resident and posting it on social media was abuse through the use of photographs, video and social media. EI #4 reported the post was demeaning. EI #4 reported if RI #1 knew about the post, the resident would not like it. An interview on 06/15/2021 at 06:29 PM, EI #3, Administrator and Abuse Coordinator, reported the post shown to her was not on EI #2's main page but was under Stories, which rotate and are only available 24 hours. EI #3 stated the post showed RI #1's headshot while the resident resting. EI #3 stated the picture was not demeaning but the caption about EI #2 wishing she had some of the resident's medicine was concerning. EI #3 reported RI #1 had no negative outcomes from the incident. EI #3 reported the allegation was substantiated because policy stated she needed to consider if it was demeaning to a reasonable person. EI #3 determined a reasonable person would consider the words over the picture demeaning. EI #3 reported EI #2 was asked to take down the post. EI #2 was placed on administrative leave and was terminated. EI #3 reported EI #2's personnel file was reviewed and verified they did not miss anything, including training. EI #3 reported staff were re-trained on abuse/social media policy. A telephone interview on 06/16/2021 at 10:33 AM, RI #1's family member reported RI #1 would have thought a picture posted of him/her on social media demeaning as RI #1 was particular with the way he/she looked and would want to look at his/her best. The family member stated RI #1 would not like a picture of him/her in the facility posted on social media. ****************************** Once the facility became aware that EI #2, a Certified Nursing Assistant, posted a picture of RI #1 to a social media site, the facility implemented the following corrective actions: · EI #2 was placed on administrative leave. EI #2 last worked in the facility on 02/23/2021. EI #2's employment with the facility was terminated on 03/02/2021. · EI #3 asked EI #2 to take the post down. EI #3 verified the post was down and reported the inappropriate post through Facebook. · EI #3 reviewed EI #2's personnel file to make sure the employee had been trained properly. · From 02/25/2021 to 03/04/2021, the facility conducted staff in-services regarding Abuse Policy which included the use of photographs and social media. ******************************* After review of the facility's investigation file, in-service/education records and staff interviews, the facility implemented corrective actions from 02/25/2021 to 03/04/2021. This deficiency was cited as past non-compliance as a result of the facility's investigation and corrective actions of complaint/report number AL 302.

Based on observation, interview, review of a facility policy titled, Waste Disposal and review of the, (YEAR) Food Code , the facility failed to maintain the areas surrounding the dumpster in a condition free of debris to prevent insect and rodent attraction. This deficient practice had the potential to affect all 18 residents residing in the facility. Findings Include: A review of an undated facility policy titled, Waste Disposal, documented: POLICY: To provide a safe sanitary environment . PR[NAME]EDURE: .8. Garbage dumpster's are to be leak proof, cleaned around . at all times . The (YEAR) Food Code by the United States Public Health Service (USPHS) and the Food and Drug Administration (FDA) included the following: . 5-501.15 Outside Receptacles . (B). Receptacles and waste handing units for REFUSE .shall be installed so that accumulation of debris and insect and rodent attraction and harborage are minimized and effective cleaning is facilitated around and .under the unit . On 11/ 06/18 at 3:52 p.m., the surveyor observed the dumpster area with EI (Employee Identifier) #1, Dietary Manager. The surveyor observed debris around the dumpster to include wrappers, plastic clear cups, clear top lids and medication cups on the ground around the dumpster. EI #1 was asked to describe what was on the ground around the dumpster. EI #1 said, Wrappers, clear cups, lids, other paper and trash. EI #1 was asked if debris should be on the ground around the dumpster area. EI #1 said, No it should not be there. EI #1 was asked who was responsible for ensuring the dumpster area was free of debris. EI #1 said, It ultimately falls on me. EI #1 was asked what was the potential harm with debris on the ground around the dumpster area. EI #1 said, It could cause rodents.

Based on interviews, review of Resident Identifier (RI) #1's medical record, the facility's Advance Directive Guidelines, FUNDAMENTALS OF NURSING NINTH EDITION, the Prehospital Care Report Summary, the (local hospital) Clinical Documentation Report, and a complaint received by the Alabama State Survey Agency, the facility failed to honor the wishes of RI #1, a resident with an Advanced Directive and a DNR (Do Not Resuscitate) Code Status. Code status describes what type of intervention a health care facility will conduct should a resident stop breathing and/or their heart stops beating. DNR means when a resident stops breathing and/or their heart stops beating, staff are not to initiate emergency medical services, Cardiopulmonary Resuscitation (CPR), in an attempt to revive the resident. During the 10:00 p.m. to 6:00 a.m. shift on [DATE], while being assisted to the bathroom, RI #1 became unresponsive with no pulse or respiration. The facility staff activated the emergency response system, then initiated CPR on RI #1, in an attempt to revive the resident. According the facility staff that was on duty, they were not aware of RI #1's code status until after CPR had been initiated. RI #1 was intubated, a procedure done where a flexible plastic tube is placed into the trachea (windpipe) to maintain an open airway or to serve as a way through which to administer certain drugs, and transferred to a local hospital with a chief complaint of [MEDICAL CONDITION]. RI #1's daughter/responsible party notified the local hospital's staff that RI #1 was a DNR. After speaking with RI #1's son, the family withdrew care. RI #1 was extubated and subsequently went into [MEDICAL CONDITION] and expired at 5:11 a.m. on [DATE]. This deficient practice placed RI #1, one of five residents reviewed for Residents Rights in immediate jeopardy, as the failure of the facility staff to honor a resident's wishes is likely to cause serious injury, harm and/or death. On [DATE] at 4:50 p.m., Employee Identifier (EI) #1, the facility's Administrator and EI #2, the Director of Nursing (DON), were notified of the findings of immediate jeopardy in the area of Resident Rights, F 578. Findings include: On [DATE], the Alabama State Survey Agency received a complaint which alleged, the facility violated RI #1's Advance Directive when they performed CPR on the resident on [DATE]. The facility's policy titled Advance Directive Guidelines with an effective date of (MONTH) 2010, documented: . GUIDELINE . 2. The Advance Directive of the resident or Healthcare decisions made for the resident made in accordance with Alabama Law shall be followed by the Facility . Chapter 23 titled Legal Implications in Nursing Practice page 305 of FUNDAMENTALS OF NURSING NINTH EDITION with a copyright date of (YEAR), documented . Advance Directives include living wills, health care proxies, and durable powers of attorney for health care. They are based on values of informed consent, patient autonomy over end-of-life decisions, truth telling, and control over the dying process . Living wills represent written documents that direct treatment in accordance with a patient's wishes in the event of a terminal illness or condition. With this document a patient is able to declare which medical procedures he or she wants or does not want . Health care providers perform CPR when needed unless there is a DNR order in the patient's chart . RI #1 was readmitted to the facility on [DATE], with an admit [DIAGNOSES REDACTED]. RI #1 had a medical history to include: Cardiac Arrhythmia, Rheumatic Mitral Valve Disease, Hypertensive [MEDICAL CONDITIONS] Fibrillation and Hypertension. RI #1's FACE SHEET listed the resident's code status as DNR. RI #1's physician's orders [REDACTED]. RI #1's PHYSICIAN CERTIFICATION Of Terminal Illness/Condition signed [DATE] by RI #1's Attending Physician and another physician documented: . Terminal: An illness or injury: a) for which death is imminent and there is no reasonable prospect of cure or recovery or b) causing a condition that is hopeless unless artificially supported through the use of a life sustaining treatment . RI #1's Terminal Illness and/or Condition was listed as Chronic systolic (congestive) heart failure. RI #1's S[NAME]IAL SERVICE PROGRESS NOTES dated [DATE], documented: . (RI #1's) family provided the facility Durable Power of Attorney and Advance Directive. A DNR Code Status and POA (Power of Attorney) is on the chart . RI #1's ADVANCE DIRECTIVE FOR HEALTH CARE (Living Will and Health Care Proxy) signed by the resident on [DATE], documented: This form may be used in the State of Alabama to make your wishes known about what medical treatment or other care you would or would not want if you become too sick to speak for yourself . Section 1. Living Will. I, (RI #1), being of sound mind and at least [AGE] years old, would like to make the following wishes known. I direct that my family, my doctors and health care workers, and all others follow the directions I am writing down . IF I BECOME TERMINALLY ILL OR INJURED: Terminally ill or injured is when my doctor and another doctor decide that I have a condition that cannot be cured and that I will likely die in the near future from this condition. Life sustaining treatment - Life sustaining treatment includes drugs, machines, or medical procedures that would keep me alive but would not cure me . The form indicated RI #1 did not want to have life sustaining treatment if he/she was terminally ill or injured. On [DATE] at 1:00 p.m., a telephone interview was conducted with EI #4, a Licensed Practical Nurse (LPN) who worked during the 10:00 p.m. to 6:00 a.m. shift the night RI #1 coded. EI #4 said there were three staff members working that night. EI #4 said EI #5, the Registered Nurse (RN) was assigned to care for RI #1; however, the RN (EI #5) was in another resident's room with EI #3, a Certified Nursing Assistant (CNA). According to EI #4, RI #1 pressed the call light for assistance to the bathroom. EI #4 responded and assisted the resident. As RI #1 approached the bathroom door, the resident began to collapse to the floor. EI #4 yelled for help as she attempted to lay RI #1 down to the floor. EI #4 said when EI #5 entered the room, she placed cold water on RI #1's face and ordered EI #4 to go and get RI #1's chart and call 911. EI #4 said she went to the nurses' station to get the chart and on her way back down to RI #1's room, she looked in the chart and saw where RI #1 was a DNR. EI #4 said when she got back to RI #1's room, she observed EI #3, the CNA and EI #5, the RN performing CPR. When asked if RI #1's wishes were honored when CPR was initiated, EI #4 said no. On [DATE] at 6:14 p.m., a telephone interview was conducted with EI #3, a CNA. EI #3 said she did remember RI #1 coding on [DATE]. EI #3 said herself and the RN (EI #5) were in the room across from RI #1's room taking care of another resident. EI #3 said the LPN (EI #4) answered RI #1's call light. EI #3 said she heard someone call for help and when she entered RI #1's room, RI #1 was on the floor. EI #3 said they attempted to get RI #1 to the bed but the resident was too heavy so RI #1 was stretched out on the floor. EI #3 said she asked the question was RI #1 a DNR and no one knew. EI #3 said when EI #5, the RN, got to the room she got down on the floor and started to check RI #1's blood pressure. EI #3 said by this time RI #1 was not responsive. EI #3 said EI #4 went to call 911 and she (EI #3) started chest compressions. According to EI #3, when EI #4, the LPN returned to the room, she (EI #3) left so that she could let the paramedics in. EI #3 said when the paramedics arrived, she went to the nurses' station to copy paperwork the paramedics would need. It was at this time, EI #3 stated she looked in RI #1's medical record at the Medication Administration Record (MAR) and saw that RI #1 was a DNR. EI #3 said she went back to RI #1's room and told EI #4 (LPN) and EI #5 (RN) that RI #1 was a DNR. On [DATE] at 4:23 p.m., a telephone interview was conducted with EI #5, the RN. When asked what happened during the 10 p.m. to 6 a.m. shift on [DATE] with RI #1, EI #5 said herself and EI #3 (CNA) was in the room across the hall from RI #1's room helping another resident. According to EI #5, the LPN (EI #4) answered RI #1's call light. RI #1 wanted to go to the bathroom. EI #5 said EI #4 yelled out for help and when she and EI #3 went to RI #1's room, the resident was on the floor. EI #5 said RI #1 was going in and out of consciousness. When RI #1 became unresponsive, an attempt was made to put RI #1 in the bed but RI #1 was too heavy. EI #5 said she tried to get vital signs, RI #1 did not have any, so CPR was started. When asked who started chest compression, EI #5 said she thought she did. EI #5 explained that she was trying to revive RI #1. RI #1's Departmental Notes written by EI #5, the RN, dated [DATE] 2:15 a.m., documented . resident requeste (requested) assistance to the bathroom with walker. resident was partially into the bathroom with staff member when (he/she) became weak and unable to stand. resident lowered to the floor and became unresponsive. 02 sat (saturation)=75% on 02, pulse =140. unable to obtain bp (blood pressure) at this time. began CPR and called 911 for emergency responders. resident transferred per ambulance to (local hospital). residents daughter notified. In a telephone interview on [DATE] at 9:36 a.m., RI #'1 daughter/responsible party was asked when the resident was made DNR status. She replied, the resident had [MEDICAL CONDITION] and had been DNR since 2012. When asked when the facility was made aware of RI #1's DNR status, RI #1's daughter/responsible party explained the resident once resided at the facility in (MONTH) (YEAR) for 40 days and the facility was made aware. Then when RI #1 was readmitted (MONTH) (YEAR), RI #1's daughter/responsible made the facility aware again. When asked if RI #1 had an Advance Directive, RI #1's daughter/responsible party replied Yes . My brother came and presented the copy of the Advance Directive . She didn't want CPR. RI #1's daughter/responsible party acknowledged the facility staff performed CPR on RI #1 on [DATE]. When asked what the facility's rationale for performing CPR was, RI #1's daughter/responsible party stated When the nurse (EI #5) called me she said (RI #1) had collapsed. They had performed CPR and was sending (RI #1) to the hospital. I asked her (EI #5) why and she said she did not know (RI #1) had a DNR order. RI #1's daughter/responsible party was asked, what procedure the facility had in place to ensure staff knew a resident's code status. According to RI #1's daughter/responsible party, the Social Worker informed her brother that a blue dot was placed on the resident's door nameplate. When asked if she observed a blue dot on the resident's door nameplate, RI #1's daughter/responsible party replied, she saw the blue dot when she visited the resident on [DATE]. When asked if she saw RI #1 at the hospital on [DATE], RI #1's daughter/responsible party said I did see (RI #1) and (RI #1) was intubated. (RI #1) just wanted to die. (RI #1) had told us that. (RI #1) wasn't really conscious. They had restrained (RI #1's) hands to keep (RI #1) from pulling out the tube. I called my brother and told him what had happened. He came to the hospital and we asked them to remove the tube and they did and (RI #1) died . (RI #1) wasn't conscious. RI #1's daughter/responsible party stated there was just a disregard for the DNR order. The Prehospital Care Report Summary for the (name) Fire-Rescue Department indicated on [DATE] at 2:39 a.m., they received an emergency call for . DISPATCHED TO [MEDICAL CONDITION]. ARRIVED TO FIND A (RI #1) LAYING ON THE FLOOR NOT ALERT WITH CPR BEING PERFORMED BY NURSING HOME STAFF. CC (chief complaint) IS [MEDICAL CONDITION] . THE PT (patient) PRESENTS NOT ALERT WITH A PATENT AIRWAY AND NO BREATHING. THE PT HAS NO PULSE. INITIATED CPR . INTUBATED THE PT . PT STATUS REMAINS UNCHANGED PRIOR TO ARRIVAL AT THE ED (emergency department). RESUSCITATIVE EFFORTS CONTINUED BY ED STAFF . The (local hospital) Clinical Documentation Report for RI #1 with an admitted [DATE], documented . Chief Complaint: [MEDICAL CONDITION]. EMS (emergency medical service) provides history. This (age of RI #1) (Male/Female) patient presents with [MEDICAL CONDITION] occurring many minutes ago . Initial therapy was provided by nursing staff. CPR was initiated . PHYSICAL EXAM: . GENERAL: frail elderly (male/female) undergoing CPR . ENT (ears, nose, throat): ET (endotracheal tube) tube in place. CARDIAC: Pulseless . RESP (respiration): bilateral breath sounds with bagging . NEURO: unresponsive . Resuscitation Note: CPR was performed whenever appropriate during resuscitation efforts . Patient was ultimately resuscitated with a perfusing rhythm . Time 04:50 (4:50 a.m.) . Patients daughter reports that (RI #1) is a DNR and the papers were finalized yesterday and on display at nursing home. She wishes to speak with her brother before withdrawing care. Time 05:21 (5:21 a.m.) . Family wished to withdraw care. (RI #1) was extubated and subsequently went into [MEDICAL CONDITION]. Time of death 0511 (5:11 a.m.) . In an interview on [DATE] at 11:30 a.m., EI #2, the Director of Nursing (DON) was asked when he became aware that CPR had been initiated on RI #1, a resident with DNR status. EI #2 explained that EI #6, the 2:00 p.m. to 10:00 p.m. RN Supervisor, had notified him on [DATE]. According to EI #2, EI #6 had come back to the facility to pick up something she had left. When EI #6 observed what was going on, she notified the nursing staff that RI #1 had DNR status. When asked when RI #1's medical record was updated to reflect the resident's DNR status, EI #2 stated he updated it on [DATE]. EI #2 explained that after the physician's orders [REDACTED].#1's room door; he placed a blue dot on the outside of the RI #1's medical record; the resident's face sheet was updated; the Social Worker was notified to update the care plan; and the facility staff were informed. EI #2 acknowledged that he failed to include the change in RI #1's code status on the facility's 24-hour report. When asked if staff that entered RI #1's room would have saw the blue dot on the door's nameplate, EI #2 said yes. When asked if the above mentioned procedure was in place when the staff initiated CPR on RI #1, EI #2 replied yes. EI #2 explained those procedures had been in place at least since 2009. EI #2 stated that after he completed the investigation, he determined the staff that worked on [DATE] did not reference RI #1's MAR, door label or medical record before CPR was initiated on RI #1. When asked what had been put in place to ensure an incident such as this did not recur, EI #2 explained the actions he took that began on [DATE]. When asked why he waited so long to put measures in place to prevent recurrence, EI #2 stated The more I thought about the situation, the more it kept pressing on my mind. I said I needed to put something in place so it would not happen to another resident. In a telephone interview on [DATE] at 12:47 p.m., EI #6, the 2:00 p.m. to 10 p.m. RN Supervisor acknowledged that she returned back to the facility on [DATE] and observed EMS personnel performing CPR on RI #1. According to EI #6, EI #5, the RN assigned to care for RI #1, asked her if RI #1 was a DNR. EI #6 replied, yes. When asked what procedures the facility had in place to ensure staff could identify a resident's DNR status, EI #6 said there was the DNR order on the chart, a blue dot on the resident's medical record, a blue dot outside the resident's room and a blue dot on the MAR. The surveyor asked EI #6 if these things were in place before CPR was performed on RI #1. EI #6 said she knew there was an order on RI #1's medical record and she recalled EI #2, the DON, saying that RI #1 was a DNR. The surveyor asked EI #6, with RI #1 being a DNR, was the resident's wishes honored when CPR was performed. EI #6 replied, no. During a telephone interview on [DATE] at 6:14 p.m., EI #3, a CNA was asked how she knew a resident was a DNR. EI #3 replied, a blue dot was placed on the resident's name tag on the door; a blue dot was on the resident's chart (medical record); and a blue dot was placed on the resident's MAR. During a telephone interview on [DATE] at 1:00 p.m., EI #4, the LPN was asked if she observed a blue dot on the nameplate on RI #1's door. EI #4 said she did, but that was after they had started CPR and the paramedics were there. EI #4 was asked, what procedures the facility had in place to ensure staff was aware when a resident was a DNR. EI #4 said there was a blue dot on the resident's MAR and a blue dot on the outside of the resident's door. When asked if she looked at any of those places before CPR was started, EI #4 said no. EI #4 said CPR had already begun when she got back down to RI #1's room. When asked how long the facility had the blue dot procedure, signifying a resident who had DNR wishes, in place at the facility, EI #4 said it had been in place for as long as she could remember. EI #4 stated she had been an employee of the facility for [AGE] years. During a telephone interview on [DATE] at 4:23 p.m., EI #5, the RN was asked when she realized RI #1 was a DNR. EI #5 said she was not sure. EI #5 was asked if after the incident, she checked the nameplate on the outside of RI #1's room to see if there was a blue dot. EI #5 said she did. When asked was there a blue dot on the name plate, EI #5 said yes. EI #5 said the blue dot meant the person was a DNR. EI #5 said she realized there was a blue dot on the door when it was all over. EI #5 said when the paramedics arrived and the staff got out of their way and went on the outside of the room that is when she realized there was a blue dot on RI #1's nameplate. When asked what procedures the facility had in place to ensure staff could identify a resident's code status, EI #5 said there was a blue dot on the resident's door nameplate; on the MAR; on the outside of the resident's chart; and the code status was on the resident's face sheet. EI #5 acknowledged these things were in place before CPR was initiated on RI #1. EI #5 acknowledged that EI #6, the 2:00 p.m. to 10:00 p.m. RN Supervisor, who returned to the facility informed her that RI #1's DNR order had been written on [DATE]. When asked if she saw the DNR order in RI #1's medical record, EI #5 said she did after the fact. EI #5 stated the last time she had worked with RI #1, the resident was a Full Code that is why she started CPR. ************************* On [DATE], the facility submitted the following plan of correction to the State Surveyor: Date: [DATE] Problem Statement: (RI #1) was admitted to the facility on [DATE] as a Full Code. When the family met with the admission coordinator on admission, the sponsor said the resident was a DNR. The sponsor brought in an advanced directive to the facility and the applicable paperwork from the MD (Medical Doctor) and order for DNR was obtained on [DATE]. The order was transcribed and a blue dot with DNR handwritten on it was placed on the MAR and blue dot placed on the name label on the resident's door to notify staff that the resident was a DNR. DNR was entered into AHT (American Health Tech) in the Advance Directive section and an updated facesheet printed for the chart. On ,[DATE] at 2:15am, (RI #1) was being assisted to the bathroom and became unresponsive. Staff did not reference the MARs or door label and CPR was initiated by staff and 911 was activated. (RI #1) was transported to the hospital when emergency personnel arrived and CPR continued. How the corrective action will be accomplished for those residents found to have been affected (indirectly or directly) by the deficient practice. (RI #1) was transferred to the hospital with emergency personnel in attendance on [DATE] and did not return to the facility. The RN, LPN and CNA staff on duty on [DATE] ,[DATE] shift were educated on [DATE] on the DNR policy and orders to include the blue dot system used by the facility to alert staff a resident is a DNR. QA committee met on [DATE] discussing the above problem statement. System problem identified was staff failed to implement code status per MD order, careplan and policy. How facility will identify other residents having the potential to be affected by the same deficient practice. All Licensed nurses and CNA staff will be educated beginning on [DATE] to continue until all nursing staff are trained, on Emergency Response procedures the DNR policy and orders, to include the blue dot system used by the facility to alert staff a resident is a DNR. On [DATE] a 100% audit was initiated by the DON/Designee to determine code status and observe the blue dot system on Mars, Door label and chart label. All charts reviewed were in compliance. No corrections needed. What measure will be put into place or systemic changes made to ensure deficient practice will not recur. When a DNR order is received by a licensed nurse, the licensed nurse is to contact the Social Services designees immediately in order for the designee to obtain the needed paperwork and to place it on the medical record. If after hours, a communication is to be completed by the licensed nurse and turned into the Social Services Department. In addition, the nurse should document the 24-hour report. Once the paperwork is on the chart to follow the order, it is Social Services responsibility to contact the staff member responsible for entering Resident Information in the facility, so the DNR/No Code status can be entered properly into that resident's Resident Information/Clinical tab. When this information is entered, a new face sheet is to be printed and placed on the chart. Entering this information into Resident Information in AHT software also allows the DNR/No Code status to print at the bottom of the physician order [REDACTED]. In the interim of the information getting into the AHT system and the updated facesheet being printed and next months applicable administration records, the licensed nurse transcribing the order is responsible to handwrite the current advanced directive status on the facesheet in the medical record and write DNR on a blue dot and place the dot on all the applicable administration records for the resident and a blue dot on the resident's name plate on the resident's door and a blue dot on the resident name plate on the chart to notify facility staff of the advanced directive. The Social Services designee will be responsible to update the resident's plan of care accordingly. Staff are to reference the bottom of the face sheet, orders or applicable administration records to determine if a resident has a DNR status. If a resident is found unresponsive, licensed nursing staff are to determine code status by referencing the medical record for that resident and looking at the bottom of the face sheet, orders or current applicable administration records in order to know if the resident is a full code or no code status. If the face sheet says DNR, then the resident is a no code and should not be resuscitated. It is the responsibility of a staff member certified in CPR to determine code status of a resident by the above means before determining to proceed or not to proceed with initiating CPR. Once CPR is initiated, it is to continue until the MD is contacted for pronouncement of death or Emergency Medical Service assistance arrives and takes over. All newly hired nursing staff will receive education during orientation and annually on Emergency Response procedures to include the blue dot system used by the facility to alert staff a resident is a DNR. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur, i.e., what program will be put into place to monitor the continued effectiveness of the systemic changes. The DON/designee will monitor by interviewing 3 nursing staff members on each shift weekly x 4 then monthly x 3 to determine if the staff are aware of the facility procedure/system used to alert staff a resident is a DNR and emergency response procedures. This will be documented on a monitoring tool and placed with this place (plan) of correction. Any concerns found will be followed with further education and/or discipline as needed. Monitoring to begin by [DATE]. ************************* After review of the facility's plan of correction, investigation file, in-service/education records, Quality Assurance plan, and staff interviews, the facility implemented corrective actions from [DATE] to [DATE], thus immediate jeopardy past non-compliance was cited. The facility has 17 licensed nursing staff and they all received education by [DATE]. The facility has 12 CNAs and they all received education by [DATE]. On [DATE], the facility began to monitor the actions of the licensed staff. When interviewed the licensed staff were able to respond to the different ways a resident could be identified as a DNR. On [DATE], a resident (RI #2) with a DNR code status expired in the facility. From record review, no CPR was initiated. Also, the resident's face sheet reflected the resident's DNR status; there was a blue dot observed on the resident's door label; a blue dot on the outside of the resident's chart; and a blue dot on the resident's MAR. This deficiency was cited as a result of complaint/report number AL 592.

Based on interviews, review of Resident Identifier (RI) #1's medical record, the facility's Care Planning Policy and Procedure, the Prehospital Care Report Summary and the (local hospital's) Clinical Documentation Report, the facility failed to ensure staff implemented RI #1's plans of care related to the resident's DNR (Do Not Resuscitate) code status when the resident became unresponsive without a pulse or respiration on [DATE]. During the 10:00 p.m. to 6:00 a.m. shift on [DATE], while being assisted to the bathroom, RI #1 became unresponsive with no pulse or respiration. The facility staff activated the emergency response system, then initiated Cardio [MEDICAL CONDITION] Resuscitation (CPR) on RI #1, in an attempt to revive the resident. According the facility staff that was on duty, they were not aware of RI #1's code status until after CPR had been initiated. RI #1 was intubated, a procedure done where a flexible plastic tube is placed into the trachea (windpipe) to maintain an open airway or to serve as a way through which to administer certain drugs, and transferred to a local hospital with a chief complaint of [MEDICAL CONDITION]. RI #1's daughter/responsible party notified the local hospital's staff that RI #1 was a DNR. After speaking with RI #1's son, the family withdrew care. RI #1 was extubated and subsequently went into [MEDICAL CONDITION] and expired at 5:11 a.m. on [DATE]. This deficient practice placed RI #1, one of five residents sampled residents whose care plans were reviewed in immediate jeopardy, as the failure of the facility staff to implement a resident's written plan of care is likely to cause serious injury, harm and/or death. On [DATE] at 4:50 p.m., Employee Identifier (EI) #1, the facility's Administrator, and EI #2, Director of Nursing (DON), were notified of the findings of immediate jeopardy in the area of Comprehensive Resident Centered Care Plans, F 659. Findings include: The facility's policy titled Care Planning Policy and Procedure with a revised date of (MONTH) 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 readmitted to the facility on [DATE], with an admit [DIAGNOSES REDACTED]. RI #1 had a medical history to include: Cardiac Arrhythmia, Rheumatic Mitral Valve Disease, Hypertensive [MEDICAL CONDITIONS] Fibrillation and Hypertension. RI #1's care plan titled I have an advanced directive, living will, healthcare proxy, durable power of attorney for healthcare that defines my advance planning and choices re: my care with a problem onset date of [DATE], had a goal of The facility will be aware of and honor my written advanced plan for my healthcare . RI #1's care plan titled I have a valid DNR order with a problem onset date of [DATE], had a goal of The facility will be aware of and honor my DNR . RI #1's Departmental Notes written by EI #5, a Registered Nurse (RN), dated [DATE] 2:15 a.m., documented . resident requeste (requested) assistance to the bathroom with walker. resident was partially into the bathroom with staff member when (he/she) became weak and unable to stand. resident lowered to the floor and became unresponsive. 02 sat (saturation)=75% on 02, pulse =140. unable to obtain bp (blood pressure) at this time. began CPR and called 911 for emergency responders. resident transferred per ambulance to (local hospital). residents daughter notified. In an interview on [DATE] at 3:36 p.m., EI #8, the Licensed Social Worker was asked was there an Advance Directive in RI #1's medical record. EI #8 said there was. When asked if RI #1 was care planned for the Advance Directive and DNR status, EI #8 replied yes. When asked was RI #1's care plan followed when CPR was performed on [DATE], EI #8 said, No. On [DATE] at 6:14 p.m., a telephone interview with EI #3, a Certified Nursing Assistant (CNA) was conducted. EI #3 said she did remember RI #1 coding on [DATE]. EI #3 said she and the RN (EI #5) were in the room across from RI #1's room taking care of another resident. EI #3 said the Licensed Practical Nurse (LPN), EI #4, answered RI #1's call light. EI #3 said she heard someone call for help and when she entered RI #1's room, RI #1 was on the floor. EI #3 said she asked the question was RI #1 a DNR and no one knew. EI #3 said when EI #5, the RN, got to the room she got down on the floor and started to check RI #1's blood pressure. EI #3 said by this time RI #1 was not responsive. EI #3 said EI #4 went to call 911 and she (EI #3) started chest compressions. On [DATE] at 1:00 p.m., a telephone interview was conducted with EI #4, the LPN who worked during the 10:00 p.m. to 6:00 a.m. shift the night RI #1 coded. EI #4 said there were three staff members working that night. According to EI #4, RI #1 pressed the call light for assistance to the bathroom. EI #4 responded and assisted the resident. As RI #1 approached the bathroom door, the resident began to collapse to the floor. EI #4 yelled for help as she attempted to lay RI #1 down to the floor. EI #4 said when EI #5 entered the room, she placed cold water on RI #1's face and ordered EI #4 to go and get RI #1's chart and call 911. EI #4 said she went to the nurses' station to get the chart and on her way back down to RI #1's room, she looked in the chart and saw where RI #1 was a DNR. EI #4 said when she got back to RI #1's room, she observed EI #3, the CNA and EI #5, the RN performing CPR. When asked if RI #1's was the resident's care plan followed when CPR was initiated, EI #4 replied, not if she had a DNR care plan. On [DATE] at 4:23 p.m., a telephone interview with EI #5, the RN, was conducted. When asked what happened during the 10:00 p.m. to 6:00 a.m. shift on [DATE] with RI #1, EI #5 said she and EI #3 (CNA) was in the room across the hall from RI #1's room helping another resident. According to EI #5, the LPN (EI #4) answered RI #1's call light. RI #1 wanted to go to the bathroom. EI #5 said EI #4 yelled out for help and when she and EI #3 went to RI #1's room, the resident was on the floor. EI #5 said RI #1 was going in and out of consciousness. When RI #1 became unresponsive, an attempt was made to put RI #1 in the bed but RI #1 was too heavy. EI #5 said she tried to get vital signs, RI #1 did not have any, so CPR was started. When asked who started chest compression, EI #5 said she thought she did. EI #5 explained that she was trying to revive RI #1. When asked if RI #1 had a DNR care plan, EI #5 said she was not sure. The surveyor asked EI #5, if RI #1 had a DNR care plan and CPR was performed, was RI #1's care plan followed. EI #5 said she guessed not. In an interview on [DATE] at 11:30 a.m., EI #2, the DON acknowledged that he became aware that CPR had been initiated on RI #1, a resident with DNR status on [DATE]. When asked when RI #1's medical record was updated to reflect the resident's DNR status, EI #2 stated he updated it on [DATE]. EI #2 explained that after the physician's orders [REDACTED].#1's room door; he placed a blue dot on the outside of the RI #1's medical record; the resident's face sheet was updated; the Social Worker was notified to update the care plan; and the facility staff were informed. When asked if RI #1 had a DNR care plan, EI #2 said yes. EI #2 was asked, when CPR was performed on RI #1, was the plan of care followed. EI #2 replied, It was not. The Prehospital Care Report Summary for the (name) Fire-Rescue Department indicated on [DATE] at 2:39 a.m., they received an emergency call for . DISPATCHED TO [MEDICAL CONDITION]. ARRIVED TO FIND A (RI #1) LAYING ON THE FLOOR NOT ALERT WITH CPR BEING PERFORMED BY NURSING HOME STAFF. CC (chief complaint) IS [MEDICAL CONDITION] . THE PT (patient) PRESENTS NOT ALERT WITH A PATENT AIRWAY AND NO BREATHING. THE PT HAS NO PULSE. INITIATED CPR . INTUBATED THE PT . PT STATUS REMAINS UNCHANGED PRIOR TO ARRIVAL AT THE ED (emergency department). RESUSCITATIVE EFFORTS CONTINUED BY ED STAFF . The (local hospital) Clinical Documentation Report for RI #1 with an admitted [DATE], documented . Chief Complaint: [MEDICAL CONDITION]. EMS (emergency medical service) provides history. This (age of RI #1) (Male/Female) patient presents with [MEDICAL CONDITION] occurring many minutes ago . Initial therapy was provided by nursing staff. CPR was initiated . PHYSICAL EXAM: . GENERAL: frail elderly (male/female) undergoing CPR . ENT (ears, nose, throat): ET (endotracheal tube) tube in place. CARDIAC: Pulseless . RESP (respiration): bilateral breath sounds with bagging . NEURO: unresponsive . Resuscitation Note: CPR was performed whenever appropriate during resuscitation efforts . Patient was ultimately resuscitated with a perfusing rhythm . Time 04:50 (4:50 a.m.) . Patients daughter reports that (RI #1) is a DNR and the papers were finalized yesterday and on display at nursing home. She wishes to speak with her brother before withdrawing care. Time 05:21 (5:21 a.m.) . Family wished to withdraw care. (RI #1) was extubated and subsequently went into [MEDICAL CONDITION]. Time of death 0511 (5:11 a.m.) . ************************* On [DATE], the facility submitted the following plan of correction to the State Surveyor: On [DATE], the Quality Assurance committee met and discussed the failure of staff to implement the code status per medical doctor order, care plan and policy. On [DATE], RI #1's care plans were reviewed. RI #1 had a I have an advance directive living will healthcare proxy, durable power of attorney for healthcare that defines my advance planning and choices re: my care and a I have a valid DNR order care plan. On [DATE], all residents in the facility who had a DNR code status care plan were reviewed. All residents who had a code status of DNR had care plans to verify the DNR order. On [DATE], a 100% audit of all residents in the facility was initiated by the Director of Nursing/Designee to determine if the care plans were reflective of the resident's code status. All care plans reviewed were noted to have the preferred code status of the resident. Beginning [DATE] until [DATE], all licensed nurses and Certified Nursing Assistants were educated on the facility's Emergency Response procedures, the DNR policy to include the blue dot system used by the facility to alert staff a resident is a DNR. ************************* After review of the facility's plan of correction, investigation file, in-service/education records, Quality Assurance plan, and staff interviews, the facility implemented corrective actions from [DATE] to [DATE], thus immediate jeopardy past non-compliance was cited. The facility has 17 licensed nursing staff and they all received education by [DATE]. The facility has 12 CNAs and they all received education by [DATE]. On [DATE], a resident (RI #2) with a DNR code status expired in the facility. From record review and interview, non-compliance related to the implementation of the resident's care plan was not found. This deficiency was cited as a result of complaint/report number AL 592.

Based on observations, an interview, a review of a facility document titled, Mighty Shakes, and a review of policy and procedures titled, Mighty Shake Policy and Procedure and Use of Leftovers, the facility failed to ensure: 1. two mighty shakes were not observed in the walk-in cooler without a thaw date or a use by date and 2. a baking sheet with twenty-five raw strips of bacon were not observed in the walk-in cooler with a use by date of 10/15/2017 on the initial tour of the kitchen on 10/17/2017. This was observed on one of three survey days and had the potential to affect all fifteen residents receiving meals from the kitchen. Findings Include: 1. A review of a document titled Mighty Shakes, revealed: Mighty Shakes, . Special Notes No preparation necessary. Just simply thaw and serve. Has a refrigerated shelf life of 14 days (unopened) . A review of a policy titled, MIGHTY SHAKE POLICY AND PR(NAME)EDURE, dated 12/04/2012, revealed: MIGHTY SHAKES are to be dated when removed from the freezer and placed in the cooler. This date becomes the THAW DATE, which will be identified by a colored sticker (other than white). date with a thaw date and the expiration date which is 14 days from the thaw date. An observation was made on 10/17/2017 at 3:56 p.m. on the initial tour of the kitchen. Upon entering the walk-in cooler, there was a serving tray with eight thawed mighty shakes. Two of the eight mighty shakes had no thaw date or use by date on them. 2. A review of a policy titled, Use of Leftovers, revealed: Policy: Excessive leftovers should be avoided. Leftovers will be properly handled and used or discarded as appropriate. Procedure: . 2. Leftovers will be covered, labeled, and dated; then stored . 5. Any food that is leftover will be handled . and may be used as follows : . Use leftovers within 3 days or discard . An observation was made on 10/17/2017 at 3:56 p.m. on the initial tour of the kitchen. While in the walk-in cooler, a baking sheet was observed on a stackable food cart. The surveyor observed 25 raw strips of bacon on the baking sheet. The cover over the bacon was dated with a use by date of 10/15/2017. On 10/19/2017 at 2:50 p.m., an interview was conducted with EI (Employee Identifier) #1, the Dietary Manager. EI #1 was asked what the facility policy and procedure was regarding dating Mighty Shakes when thawed. EI #1 replied they were good for two weeks from the thaw date. EI #1 said they were thawed by running cool water over them until thawed, then a thaw date and a used by date were to be written on them and they were to be placed in the cooler. EI #1 was asked what was found in the walk-in cooler on 10/17/2017. EI #1 replied two undated Mighty Shakes. EI #1 was asked what else was found in the walk-in cooler. EI #1 replied raw bacon dated for the 15th, the discard date. EI #1 was asked what the potential concern was for the above two items identified in the walk-in cooler. EI #1 replied it could make the population sick, the residents or the staff.

Based on record reviews and interviews, the facility failed to ensure staff notified the sponsor of RI (Resident Identifier) #1 when changes occurred with the resident. This affected RI #1, one of four sampled residents. Findings include: A review of a facility document titled, Notification of Change of Condition of a Resident, with a revision date of 9/2011, revealed, Purpose: To ensure resident's rights and continuity of care by identifying and reporting a Significant Change in Physical, Mental and or Psychosocial well being. Procedure: Notify the Physician of status change. Notify the resident's legal representative or an interested family member of status change and new orders, if applicable. Document the notification in the medical record. A review of the medical record revealed RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's Admission MDS (Minimum Data Set), with an assessment date of 12/14/15, revealed RI #1 scored 10 out a possible 15 indicating RI #1 was moderately impaired of cognitive skills for daily decision making skills. The assessment indicated RI #1 required extensive assistance of 2 or more staff for transfer and was non-ambulatory. The resident was assessed as requiring extensive assistance with ADLs (Activities of Daily Living) with limited range of motion on one lower extremity. A review of a facility's document titled, Resident Incident Report, dated and timed 12/11/15 at 11:00 AM, revealed RI #1 was involved in an incident. . OT (Occupational Therapist) pushing resident to therapy in wheelchair toward therapy gym, resident feet fell off leg rest. no injuries at this time Immediate Actions Taken: resident was assessed in therapy, no bruising noted at this time, resident c/o (complained/of pain, therapy allowed resident to rest, (resident) then stated okay. Physician notified: (Name of Physician) Date/Time Contact Initiated 12/11/15 03:00 PM . Family notified: (Name of Sponsor) Date/Time Contact Initiated 12/11/15 (no of contact time was indicated) . A review of the medical record for RI #1 revealed no documentation of notification of the sponsor. A review of the Nurses notes for RI #1 revealed, Departmental Notes . (RI #1's name) . Pain . Pain Intervention Notes: C/O pain to knee, medicated as ordered. MD (Medical Doctor) rounds this AM, advised. MD advised pt (patient) of obtaining X-ray of RLE (Right Lower Extremity), pt stated to MD that (RI #1) does not want another X-Ray. N/O (New Order) noted for [MEDICATION NAME] QD (every day) and ES (extra strength) Tylenol PRN (as needed) PT advised, . A review of the medical record for RI #1 revealed no documentation of notification of the sponsor. An interview was conducted with EI (Employee Identifier) #1, an LPN (Licensed Practical Nurse), on 2/11/16 at 12:07 PM. EI #1 was asked where was the notification of the sponsor noted regarding the wheelchair incident with RI #1. She answered, I don't see any. EI #1 was asked who she notified on 12/15/15 when the resident refused an X-ray and new medications were initiated. She responded, Don't think I called the daughter at that time, just the patient was aware. EI #1 was asked if the sponsor should have been notified and she answered, Yes. EI #1 was asked what was the facility's policy regarding notification. She answered, We are supposed to notify the sponsor or next of kin regarding any medication changes or changes in the resident. EI #1 was asked what was the facility's policy regarding documentation. She answered, You're supposed to document the date, time, who you notified, what you notified them of and their response. An interview was conducted with EI #2, an LPN, on 2/11/16 at 2:47 PM. EI #2 was asked where was the notification of the sponsor noted regarding the wheelchair incident with RI #1 on 12/11/15. She answered, I don't see any. EI #2 was asked what she should do if she noted changes in a resident. She answered, Call the Doctor and notify the family. EI #2 was asked what was the facility's policy regarding notification. She answered, Our policy if something happens, notify Doctor immediately, far as the family, we should let them know any changes as soon as possible. EI #2 was asked if RI #1 had any changes in condition while under her care. She answered, Yes. EI #2 was asked who she notified. She answered, Gave X-ray results, but no changes. An interview was conducted with EI #3, an RN (Registered Nurse), on 2/11/16 at 3:23 PM. EI #3 was asked what was her response when RI #1 had an incident with wheelchair on 12/11/15. She answered, I don't recall. She was asked if she had documented. She answered, No, I don't have anything charted. EI #3 was asked if she was RI #1's nurse on 12/11/15. She answered, Yes. EI #3 was asked who she notified. She answered, I wasn't even aware that had happened to her. EI #3 was asked who was responsible of notifying the sponsor of the wheelchair incident on 12/11/15. She answered, It would have been the nurse that was taking care of her if I had known. EI #3 was asked what was the facility's policy regarding notification. She answered, When an incident or changes in condition happen, you notify the Doctor and sponsor. EI #3 was asked what was the facility's policy regarding documentation. She answered, Document what happened, what you did and the people you notified. An interview was conducted with EI #4, the DON (Director of Nursing), on 2/11/16 at 5:10 PM. EI #4 was asked if he was involved in the care of any incidents regarding RI #1. He answered, Yes, I did the incident report. EI #4 was asked who was notified and when. He answered, (Name of Doctor) of the incident and the sponsor of the results of the X-rays. EI #4 was asked what was the facility's policy regarding notification. He answered, We are to notify the Doctor and the sponsor of any incident or changes in condition. EI #4 was asked what was the policy regarding documentation. EI #4 stated, When there is a change in condition or incident, we are to document it at that time. EI #4 was asked if the family was notified RI #1 refused an X-ray and new medications were started. He answered, I don't recall. I don't see where it was documented. He was asked should it have been and answered, Yes.

Based on observations, record review, and interviews, the facility failed to ensure: 1) Pots and pans were not stacked on top of each other prior to completely drying. 2) Ice cream was not found in a chest-freezer in a non-solid state. 3) A dietary cook did not return to the tray line and serve food without removing gloves and washing her hands and re-gloving, after going to the refrigerator to obtain food items. This had the potential to effect 17 of 17 residents served meals from the kitchen. Findings Include: 1) A review of the United States Food and Drug Administration (FDA) guidelines revealed, FDA Food Code 2013: Chapter 4 ., page 149, 4-903.11 Equipment, Utensils . (A) Except as specified in Paragraph D of this section, clean EQUIPMENT and UTENSILS, . shall be stored: . (B) Clean EQUIPMENT and UTENSILS shall be stored as specified under paragraph (A) of this section and shall be stored: (1) in a self draining position that allows air drying; and . On 10/21/2015 an observation was made at 3:10 PM. Metal cooking pans were observed on a metal rack stacked on top of each other. There were a total of ten pans stacked on top of each other and six of them had moisture between the pans. This was observed on one of three survey days. An interview was conducted on 10/22/2015 at 2:12 PM with EI #5, the Dietary Supervisor. EI #5 was asked how should pots and pans be dried. EI #5 replied air dried separately. EI #5 was asked if it was acceptable to have wet pans stacked on top of each other with wet moisture in between them. EI #5 replied not at all. EI #5 was asked what was the potential harm of stacking wet pans on top of each other. EI #5 replied the moisture makes them dirty. An interview was conducted with EI #4, a Dietary Cook, on 10/22/2015 at 2:41 PM. EI #4 was asked how should pots and pans be dried. EI #4 replied air dried. EI #4 was asked if it was acceptable to have wet pans stacked on top of each other with wet moisture in between them. EI # 4 replied no. EI #4 was asked what was the potential harm of stacking wet pans on top of each other. EI #4 replied it could set up bacteria in the pans. An interview was conducted with EI #6, the Dietary Manager, on 10/22/2015 at 3:04 PM. EI #6 was asked how should pots and pans be dried. EI #6 replied air dried . EI #6 was asked if it was acceptable to have wet pans stacked on top of each other with wet moisture in between them. EI #6 replied no. EI #6 was asked what the potential harm was when stacking wet pans on top of each other. EI #6 replied there is a potential for bacterial growth. 2) A review of the United States Food and Drug Administration (FDA) guidelines revealed, FDA Food Code 2013: Chapter 3 . page 88, 3-501.11, Frozen Food. Stored frozen FOODS shall be maintained frozen. A review of a facility document, titled, FACILITY UNIT REFRIGERATION EQUIPMENT, with an Originated date: 10/08, Policy # SI.44. POLICY: The facility ensures the quality and safety of refrigerated foods . PROCEDURE: 1) The temperature of the unit is set to keep the internal temperature of the food to: a) Refrigerator - 41 degrees F (Fahrenheit) or below b) Freezer-completely frozen . An observation was made on 10/20/2015 at 9:14 AM, during the initial tour of the kitchen. The ice cream in a chest-type freezer unit was soft to squeeze and the side could be punctured with a moderate amount of pressure with the surveyor's thumb. An additional observation was made on 10/21/2015 at 3:10 PM of the ice cream in a chest-type freezer unit. The ice cream was soft to squeeze. An interview was conducted on 10/22/2015 at 2:12 PM with EI #5, the Dietary Supervisor. EI #5 was asked how should ice cream be maintained when served to a resident. EI #5 replied anything below zero degrees and frozen. EI #5 was asked what should be done with ice cream that was not frozen solid. EI #5 replied discard it. EI #5 was asked what the harm could be to the resident if ice cream was not maintained frozen. EI #5 replied the ice cream could make the resident sick and could cause diarrhea. An interview was conducted on 10/22/2015 at 2:41 PM with EI #4, a Dietary Cook. EI #4 was asked how should ice cream be maintained when served to a resident. EI #4 replied keep it in the freezer and keep it in a solid, frozen state. EI #4 was asked what should be done with ice cream that was not frozen solid. EI #4 replied discard it. EI #4 was asked what the harm could be to the resident if the ice cream was not maintained frozen. EI #4 replied some residents can choke, it may not be the texture they are not suppose to have. It could also develop bacteria if left in a non-frozen state. An interview was conducted on 10/22/2015 at 3:04 PM with EI #6, the Dietary Manager. EI #6 was asked how does ice cream have to be maintained to serve to a resident. EI #6 replied, Maintained in a frozen environment zero degrees to a minus five degrees. It needs to be maintained in it's form. EI #6 was asked to explain what the form should be for ice cream. EI #6 replied, Cold, soft to solid. 3) A review of the United States Food and Drug Administration (FDA) guidelines revealed, FDA Food Code 2013: Chapter 2, page 47-48, 2-301.14, When to Wash. FOOD EMPLOYEES shall clean their hands . immediately before engaging FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS . and . (I) After engaging in other activities that contaminate the hands. An observation was made on 10/20/2015 at 4:42 PM, of the plating of the supper meal. EI #4, the Dietary Cook, was observed leaving the tray line while serving the supper meal. EI #4 was observed going to the walk-in refrigerator then, with her gloved hand, opened the refrigerator and obtained a ham sandwich and a container of yogurt. EI #4 was observed returning to the tray line with the food obtained from the refrigerator and placed it on the serving shelf to be prepared for a resident. EI #4 was then observed returning to plating food on the tray line. EI #4 was not observed removing her gloves and washing her hands prior to returning to the tray line. An interview was conducted with EI #4, a Dietary Cook, on 10/22/2015 at 2:41 PM. EI #4 was asked when should hands be washed. EI #4 replied every time entering the kitchen, when touching trash cans, contact with anything after gloves are removed, going in and out of storage areas, and refrigerator. EI #4 was asked why does the kitchen staff have to wash their hands so often. EI #4 replied to keep themselves sanitized, prevent cross contamination, and to destroy germs. EI #4 was asked when serving food from the tray line and a staff member had to leave the tray line, can the staff member return to the tray line and start serving on the tray line. EI #4 replied no, they have to change their gloves and they should wash their hands. An interview was conducted on 10/22/2015 at 3:04 PM, with EI #6, the Dietary Manager. EI #6 was asked when kitchen staff should wash their hands. EI #6 replied every time they enter the kitchen, if gloves were changed, if a task was changed. EI #6 was asked why does the kitchen staff have to wash their hands so often. EI #6 replied hand washing was the number one way of infection control. EI #6 was asked if a staff member serving food from the tray line, left the tray line to perform another task, should the staff member return to the tray line and start serving food again. EI #6 replied no. EI #6 was asked what the potential harm was for returning to serving food after going to perform another task. EI #6 replied there could be contamination.

The facility failed to ensure a Physician's medication order was administered correctly to a resident on 10/20/2015 at 4:30 PM. This affected RI (Resident Identifier) #6, one of eight residents observed for medication administration. Findings Include: A review of a facility document titled, 2.3: PRESCRIBER MEDICATION ORDERS, dated 01/2002, revealed, Policy Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe. Verbal orders are received only by licensed nurses or pharmacists or otherwise authorized personnel and confirmed in writing by the prescriber within the state required time limits. Medication orders from the physician assistants, nurse practitioners, clinical nurse specialists and pharmacists are accepted if they comply with the requirements listed below, are in accordance with the state law, and comply with the applicable formularies or prescribing protocols that have been provided to the facility by the responsible physician. A review of the medical record revealed RI #6 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The review of RI #6's Admission MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 9/29/2015, revealed RI #6 had a BIMS (Brief Interview for Mental Status) score of eight out of a possible fifteen. This indicated RI #6 was moderately impaired for daily decision making skills. A review of RI #6's Admission Physicians's Orders dated 10/19/2015 at 3:00 PM, revealed, .19. Carvedilol 6.25 mg (Milligram) P.O. (By mouth) QD (Daily). A review of a facility document titled, PRN (As needed) ADMINISTRATION RECORD, dated 10/2015, revealed, . Carvedilol 6.25 mg p.o. BID (twice daily) at 9 AM and 5 PM 10-19-15. The spaces for nurses to initial to indicate the medication had been given were filled in for the 9:00 AM dose on 10/20/2015, 10/21/2015, and 10/22/2015. The spaces for nurses to initial when the medication was given were initialed for the 5:00 PM dose on 10/19/2015,10/20/2015, and 10/21/2015. On 10/20/2015 at 4:30 PM, an observation was made of medication pass for RI #6. EI (Employee Identifier) #7, an LPN (Licensed Practical Nurse), prepared the medications at the medication cart. The medications prepared were [MEDICATION NAME] 2.5 mg (Milligrams), Carvedilol 6.25 mg and Potassium Chloride 10 mEq (Milliequivalents). RI #6 took the three medications with nectar thick water. When EI #7 returned to the medication cart, she initialed by each medication, in the appropriate space, to indicate the medication had been taken by the resident. On 10/21/2015 at 6:01 PM, EI #7 was interviewed. EI #7 was asked if she had given RI #6 the 5:00 PM dose of Carvedilol 6.25 mg PO on 10/21/2015. EI #7 said yes, that it was documented on the MAR (Medication Administration Record) as given. An interview was conducted on 10/22/2015 at 2:42 PM with EI #1, an LPN. EI #1 was asked to look at the medication order and the MAR for RI #6. EI #1 was asked if there was an issue with the order and if so, what was the issue. EI #1 stated the order and the MAR did not match. The order said every day and the MAR said twice daily. EI #1 was asked what would be the potential negative outcome for the resident of administering a medication from the MAR that did not match the Physician order. EI #1 said it may cause potential harm to the resident. The resident would be getting too much or not enough of the medication. An interview was conducted on 10/22/2015 at 3:16 PM with EI #3, the DON (Director of Nursing). EI #3 was asked to look at the medication order and the MAR for RI #6. EI #3 was asked if there was an issue with the order and if so, what was the issue. EI #3 stated it was twice a day on the MAR and once a day on the Physician order. EI #3 was asked what could be the potential negative outcome for the resident of administering a medication from the MAR that did not match the Physician order. EI #3 said it was according to what the drug was, then EI #3 stated, We should follow policy.

The facility failed to ensure the grease trap did not have a large accumulation of dark brown/black crusted substance covering the entire top grid. This was observed on one of three survey days. Findings include: A review of the United States Food and Drug Administration (FDA) guidelines revealed, FDA Food Code 2013: Chapter 5, page 524, 5-402.12 Grease Trap. Failure to locate a grease trap so that it can be properly maintained and cleaned could result in the harborage of vermin and/or the failure of the sewage system. An observation was made 10/21/2015 at 3:10 PM of the grease trap outside by the dumpster. The top of the grease trap was lifted up and the top grid of the grease trap was completely covered with a large amount of dark brow/black crusted substance. An interview was conducted with EI #5, the Dietary Supervisor, on 10/22/2015 at 2:12 PM. EI #5 was asked who was responsible for the outside grease trap. EI #5 replied MAWSS (Mobile Area Water and Sewer System) was responsible, no one in the kitchen. EI #5 was asked what how should the grease trap appear. EI #5 replied clean with no type of debris on top of it. EI #5 was asked if it was acceptable to have a thick dark brown/black crusty substance covering the top grid. EI #5 replied no.

Based on interviews and record reviews, the facility failed to ensure: 1) Medication orders were completed to include the route of two medications. This affected RI (Resident Identifier) #'s 1 and 7, two of eight sampled residents. 2) Medication orders were transcribed to the MAR (Medication Administration Record) as written by the physician. This affected RI # 7, one of eight sampled residents. Findings Include: 1) A review of a facility document titled, WRITING, TRANSCRIBING, & KEYING PHYSICIAN ORDERS, with a revision date of March 2015, revealed: PURPOSE: To provide a protocol for writing physician orders [REDACTED]. To assure the preservation, integrity and continuity of the medical record as a legal document. POLICY: . 3-All physician orders, recaps/renewals are to be noted by a licensed nurse by writing noted, dating and signing the order with name and title. The nurse retains responsibility for accurate transcription of all physician orders. 10-Content of physician orders [REDACTED]. For some meds . 15-Checking of orders for integrity, accuracy, and continuity will consist of: 1-comparing prior orders to current orders, 2-current orders to current MAR's (all types), 3-current MAR's (all types) to prior MAR's (all types), 4-cross reference for additions/deletions 5-signed off by nurse, after checking, as verification of accuracy. A review of the medical record for RI #1 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the admission assessment on 10/12/2015 revealed RI #1 was alert, without behaviors and no confusion. RI #1 required extensive assistance of one person with all ADLs (Activities of Daily Living). It was documented RI #1 was incontinent of bowel and bladder. A review of the medical record for RI #1 revealed a document titled, physician's orders [REDACTED]. May Give Xarelto 10 mg (Milligrams) @ (at) 5:00 PM. No route of administration was included in this physician's orders [REDACTED].>RI #1's medical record physician's orders [REDACTED]. According to facility policy this indicated the orders were checked for correctness. A review of the medical record indicated RI #7 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The review of an Admission MDS (Minimum Data Set), with an Assessment Reference Date (ARD) of 10/12/2015, revealed RI #7 had a BIMS (Brief Interview for Mental Status) score of 12 out of a possible 15. This indicated RI #7 was moderately impaired with daily decision making skills. A review of the medical record for RI #7 revealed a facility document titled, physician's orders [REDACTED]. decrease [MEDICATION NAME] to 20 units @ hs (Hour of Sleep) . There was no route of administration ordered for this medication. Documentation revealed this order was checked for correctness on 10/12/2015 during the facility's required 24 hour chart check. On 10/22/2015 at 12:00 PM, an interview was conducted with EI (Employee Identifier) #2, an LPN (Licensed Practical Nurse). EI #2 was asked what should an MD's (Medical Doctor) order indicate regarding medications. EI #2 stated the name of the medication, right patient, route, dosage, frequency, and the diagnosis. EI #2 was asked if it was acceptable to administer medications without all of these components included in the order. EI #2 stated she would not think so. EI #2 was asked why it was not acceptable without all of these components. EI #2 stated they needed to make sure these things are present to prevent harm to the patient. EI #2 was asked what the potential negative outcome or harm was for not having a complete medication order. EI #2 stated death or drug reaction. EI #2 reviewed orders of several residents. EI #2 stated the orders were missing the amount of pills to give and the route should read 10 mg (milligrams), one pill, po (by mouth) at 5 PM. EI #2 was asked what was the facility's policy related to medication administration, what had to be present. EI #2 stated to make sure the order was right, the medication was right, the dosage and frequency was right, and it was the right patient. EI #2 was asked what she would do if any of these items were missing. EI #2 stated the corrective action would be to notify the M.D. and notify the supervisor. EI #2 also stated she would get a correction order before giving the medication. EI #2 was then asked to review the [MEDICATION NAME] order for RI #7. EI #2 stated the [MEDICATION NAME] order dated 10/12 had no route on the order. On 10/22/2015 at 2:44 PM, an interview was conducted with EI #1, an LPN. EI #1 was asked what should an MD order indicate regarding medication. EI #1 stated the date, time, the name of the medication, the dosage, route, how often the medication was to be given, and sometimes included education as to why the resident was on the medication. EI #1 was asked if it was acceptable to administer medications without all of these components. EI #1 stated it was not acceptable. EI #1 was asked why it was not acceptable to administer medications without these components. EI #1 stated if they did not have all of the components, they would not know what they were giving the patient. EI #1 also stated if there was one component missing then it would not be a complete order. EI #1 was asked what the potential negative outcome or harm would be for not having a complete M.D. order. EI #1 stated this could cause harm to the resident. EI #1 was asked what was the facility's policy related to medication administration, what had to be present. EI #1 stated the date, time, name of the medication, the dosage, how often the medication was to be given, and education regarding the medication. EI #1 was asked to review RI #1's medication information. EI #1 was questioned regarding the Xarelto ordered for RI #1. EI #1 stated the route was missing from the order. EI #1 was then asked to review the medication information for RI #7. EI #1 stated the route for the [MEDICATION NAME] order was missing. On 10/22/2015 at 3:03 PM, an interview was conducted with EI #3, the DON (Director of Nursing). EI #3 was asked what should an MD order indicate regarding medications. EI #3 stated the right medication, dosage, time, route, and the patient's name. EI #3 was asked if it was acceptable to administer medications without all of these components. EI #3 stated they should not, because they did not have those components in the order. EI #3 was asked to review the medication order for RI #7 for [MEDICATION NAME]. EI #3 stated there was no route listed. EI #3 was asked to review the order for RI #1 for Xarelto. EI #3 stated there was no route listed for the order. EI #3 was asked what was the facility's policy related to medication administration. EI #3 stated the right patient, medication, dosage, and route, these components must be present. 2) A review of a facility document titled, Medication Policies Prescriber Medication Orders, dated 01/12, revealed, . PRESCRIBER MEDICATION ORDERS Policy Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe. Verbal orders are received only by licensed nurses or pharmacists or otherwise authorized personnel and confirmed in writing by the prescriber within state required time limits. Medication orders from physician assistants, nurse practitioners, clinical nurse specialists and pharmacists are accepted if they comply with the requirements listed below, are in accordance with state law, and comply with applicable formularies or prescribing protocols that have been provided to the facility by the responsible physician. 3. Transcription of a physician's orders [REDACTED].\licensed personnel and verified by a licensed nurse. This order is recorded on the physician's orders [REDACTED]. A review of the medical record revealed RI #6 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The review of an Admission MDS, with an ARD of 9/29/2015, revealed RI #6 had a BIMS score of eight out of a possible 15. This indicated RI #6 was moderately impaired for daily decision making skills. A review of the medical record for RI #6 revealed a document titled, ADMISSION physician's orders [REDACTED]. . Carvedilol 6.25 mg P.O. (By mouth) QD (Everyday) (HTN) (Hypertension) . A review of RI #6's MAR (PRN (As Needed) Medication Administration) document revealed: Carvedilol 6.25 mg P.O. BID (Twice per day) @ 9 AM & (and) 5 PM, with a date of 10/19/2015. A further review of the MAR indicated [REDACTED]. On 10/22/2015 at 12:00 PM, an interview was conducted with EI #2, an LPN. EI #2 was asked to review medication information for RI #6. EI #2 was asked how Carvedilol had been given. EI #2 stated the medication had been given BID (twice a day.) EI #2 was asked what the potential harm was for the resident. EI #2 stated it was a heart medication, had to check pulse and blood pressure, and it had to be given with food. EI #2 was asked what was the facility's policy regarding transcription of medication orders. EI #2 stated the Admitting Nurse wrote the orders. EI #2 was asked if the facility had a policy regarding verification and checking M.D. orders daily. EI #2 stated it was done every day.

Based on observations, record reviews, and interviews, the facility failed to ensure the privacy of RI (Resident Identifier) #7 by leaving a Medication Administration Record (MAR) open and unattended on top of the medication cart during a medication pass. This affected one of seventeen residents. Findings include: A review of a facility document titled, Resident Handbook November 2013, revealed, . Medical Records. Information contained in your medical records is confidential and will not be disclosed to unauthorized persons without your written consent or the written consent of your Responsible Party, or attorney in fact, except as required or permitted by law or as set forth below. A review of the medical record indicated RI #7 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An observation was made on 10/21/2015 at 10:15 AM. EI (Employee Identifier) #2, an LPN (Licensed Practical Nurse), was observed in the hallway during medication pass. EI #2 was holding a medication cup in her hand, standing in front of the medication cart outside of RI #7's room. EI #2 left the medication cart and walked into RI #7's room, closing the door behind her. The MAR was left open and unattended on top of the medication cart while EI #2 was in RI #7's room. On 10/22/2015 at 12:00 PM, an interview was conducted with EI #2. EI #2 was asked if she administered medications to the residents. EI #2 stated she did. EI #2 was asked what the residents rights were. She stated privacy, dignity, not to be abused, etc.(et-cetera). EI #2 was asked how resident's privacy rights were possibly violated. EI #2 stated discussing name and [DIAGNOSES REDACTED]. EI #2 was asked why this was a violation of residents privacy. EI #2 stated because of the right to have residents information maintained privately and all of that information was in the MAR. EI #2 was asked what the potential negative outcome could be of this happening to a resident. EI #2 stated people can use the information for monetary gain/steal from the resident. EI #2 was asked if leaving a MAR unattended and open to a resident was an acceptable practice and EI #2 replied that it was not. EI #2 was asked if she had left the MAR open on the medication cart on 10/21/2015, unattended, while giving RI #7's medications. EI #2 said yes. On 10/22/2015 at 3:22 PM, an interview was conducted with EI #3, the DON, (Director of Nursing.) EI #3 was asked if he administered medications to the residents. EI #3 stated he did. EI #3 was asked what the residents rights were. EI #3 stated the right to refuse, right to see their MAR and the right to privacy. EI #3 was asked if leaving the MAR open and unattended, displaying a residents name, room number and medication list was a violation of the residents right. EI #3 answered yes. EI #3 was asked why. EI #3 stated because it was a privacy issue. EI #3 was asked what the potential negative outcome could be of this happening to a resident. EI #3 stated personal information could get into the hands of the wrong person. EI #3 was asked what was the facility's policy regarding protection of patient health information and privacy. EI #3 stated the privacy of each resident should be respected. EI #3 was asked if leaving a MAR unattended and open to a resident was an acceptable practice and EI #3 replied no.

Based on observation, interviews, and document reviews, the facility failed to ensure a resident was administered nectar thickened liquids as ordered, instead of honey thickened liquids. This was observed during the medication pass observation on 1 of 3 survey days, and had the potential to affect RI (Resident Identifier) #6, one of eight residents observed for medication administration. Findings include: A review of the 7th Edition of POTTER- PERRY Fundamentals of Nursing, revealed, "... physician's orders [REDACTED]. unless they believe the orders are in error or are harmful to clients. ..." A review of the medical record revealed RI #6 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the medical report for RI #6 entitled, "Fiberoptic Endoscopic Evaluation of Swallowing (FEES)," and dated, 10/17/2014 revealed, "Direct Pharyngeal Phase Assessment ... no aspiration with regular consistency foods or nectar consistency liquids was noted. CLINICAL IMPLICATIONS ...Regular consistency foods with nectar consistency liquids ..." A review of the physician's orders [REDACTED]. On 11/12/14 at 3:40 PM, a medication administration observation for RI #6 was performed by EI #2. EI (Employee Identifier) #2 gave honey thickened water to RI #6, instead of nectar thickened liquids. An interview was conducted with EI #2, a Licensed Practical Nurse, on 11/13/14 at 4:20 PM. EI #2 was asked what the difference was between honey thickened and nectar thickened liquids. EI #2 stated, "The honey is thicker and the nectar is in between. The honey is thicker." EI #2 was asked what potential harm could occur to a resident if honey thickened liquids were given, instead of nectar thickened liquids. EI #2 stated, "If they failed the FEES and the order said nectar and I give them honey ... I'm not following the doctors orders." EI #2 was asked if honey thickened liquids should have been given to RI #6, instead of nectar thickened liquids. EI #2 stated, "No." An interview was conducted with EI #3, the Registered Dietician, on 11/14/14, at 10:10 AM. EI #3 was asked if honey thickened liquids was the same as nectar thickened liquids. EI #3 stated, "No." EI #3 was asked what the difference was. EI #3 stated, "Honey is thicker than nectar. ... You can't give the honey consistency for nectar consistency." An interview was conducted with EI #1, the Speech Language Pathologist Endoscopist, on 11/14/14 at 1:20 PM. EI #1 was asked if honey thickened liquids was the same as nectar thickened liquids. EI #1 stated, "No." EI #1 was asked what the difference was. EI #1 stated, "There is different consistencies and honey is thicker than nectar." EI #1 was asked what potential harm could occur to a resident if honey thickened liquids were given, instead of nectar thickened liquids. EI #1 stated, "If we haven't tested it on a swallow test, then I'm not sure how a resident would swallow it." EI #1 was asked why was honey thickened liquids given to RI #6, instead of nectar thickened liquids. EI #1 stated, "I didn't realize it. I recommended (RI #6) to have nectar thickened liquids." EI #1 was asked why was the resident receiving nectar consistent liquids. EI #1 stated, "We completed a swallow test, and (RI #6) was having trouble swallowing. I tried different kinds of thin liquids and (RI #6) still aspirated." EI #1 was asked what did the doctor recommend. EI #1 stated, "He agreed with what we recommended." EI #1 was asked if it was appropriate to give honey thickened liquids, when nectar thickened liquids was ordered. EI #1 stated, "If it says nectar thickened liquids, they should follow the orders." EI #1 was asked what could be the potential affect on the resident, when an incorrect consistency was given. EI #1 stated, "(RI #6) could aspirate."

Based on observations, interviews, and document reviews, the facility failed to ensure: 1) Two licensed nurses did not re-cap needles after removing injectable medications from vials. This was observed during medication pass observations on 2 of 3 survey days, and had the potential to affect RI (Resident Identifier) #7 and RI #8, two of eight residents observed for medication administration. 2) A licensed nurse cleaned a vial of an injectable medication prior to inserting a needle into the vial's rubber [MEDICATION NAME] to retrieve the medicine. This was observed during medication pass observation on 1 of 3 survey days, and had the potential to affect RI #8, one of eight residents observed for medication administration. 3) Ice coolers containing thickened liquids were not observed stored on the floors in residents' rooms. This was observed on 2 of 3 survey days, and had the potential to affect RI #'s 1 and 8, two of ten sampled residents. Findings include: 1) A review of Potter/Perry 7th Edition, Fundamentals of Nursing, revealed, "... PREPARING INJECTIONS ... (11) Cover needle with its safety sheath or scoop needle to recap. ... RATIONALE ... Prevents contamination of needle..." A review of the facility's policy dated 01/12, and entitled, "... Policy 7.14 Medication Administration Procedures Intramuscular Medications," revealed, "... Policy Intramuscular medications are administered in a safe and accurate manner. ... Procedures ... 4. Prepare medications as follows: ... G. Cover needle via protective sleeve to ensure safety. ..." A review of the medical records indicated RI #7 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of a physician's orders [REDACTED]. During a medication administration pass observation on 11/12/2014 at 3:47 PM, EI (Employee Identifier) #4, a Registered Nurse, was observed. EI #4 removed the desired insulin amount for RI #7, and re-capped the insulin needle while holding the cap and syringe. On 11/14/2014 at 10:20 AM, an interview was conducted with EI #6, the Infection Control Nurse. EI #6 was asked if it was appropriate to re-cap an insulin needle while holding the cap and syringe. EI #6 stated, "Yes, if it's when you're first drawing up, and not in the patient's room. I'd say yes, it is appropriate."EI #6 was asked if it was appropriate to re-cap a needle while holding the cap and needle. EI #6 responded, "Yes. Any injectable you are drawing up, it is appropriate to re-cap the needle." EI #6 was asked what the potential harm was of re-capping needles. EI #6 replied, "Potential harm is you could stick yourself with the needle." On 11/14/2014 at 12:55 PM, an interview was conducted with EI #5, a Licensed Practical Nurse. EI #5 was asked if it was appropriate to re-cap an insulin needle while holding the cap and syringe. EI #5 stated, "No. Because of safety, and to avoid sticking yourself and contaminating." EI #5 was asked if it was appropriate to re-cap syringes, while holding the cap and syringe, and she replied, "No. Because of contamination and sticks." On 11/14/2014 at 2:07 PM, an interview was conducted with EI #4, a Registered Nurse. EI #4 was asked if it was appropriate to re-cap insulin needles while holding the cap and syringe. EI #4 stated, "No. After you scoop the cap, then it is ok to close the cap. Once the needle is safely covered, then you can secure it." EI #4 was asked what the potential harm was of re-capping needles. EI #4 stated, "Main concern is you're worried about accidental sticks. Exposure to a pathogen." 2) A review of Potter/Perry 7th Edition, Fundamentals of Nursing, revealed, "... Vial containing a solution (1) Remove cap covering top of unused vial to expose sterile rubber seal, keeping rubber seal sterile. ... Firmly and briskly wipe surface of rubber seal with alcohol swab, and allow it to dry. RATIONALE ... Not all manufacturers guarantee that caps of unused vials are sterile. Therefore swab seals with alcohol before preparing medication. ..." A review of the facility's policy dated 01/12, and entitled, "... Policy 7.14 Medication Administration Procedures Intramuscular Medications," revealed, "... Policy Intramuscular medications are administered in a safe and accurate manner. ... Procedures ... 4. Prepare medications as follows: ... D. Swab rubber cap with alcohol. ..." A review of the medical records indicated RI #8 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of the November 2014 Physician order [REDACTED]. During a medication administration pass observation on 11/13/2014 at 8:27 AM, EI #5, a Licensed Practical Nurse, was observed to administer medications to RI #8. EI #5 removed the cap, inserted air, and removed the medication from the B-12 vial. EI #5 did not clean the rubber [MEDICATION NAME] of the vial with alcohol, prior to inserting the needle. EI #5 then re-capped the needle while holding the needle and syringe. During the interview with EI #6, the Infection Control Nurse, on 11/14/2014 at 10:20 AM, EI #6 was asked if it was appropriate to wipe the top of a vial of an injectable medication with alcohol, prior to inserting a needle. EI #6 stated, "Yes." EI #6 was asked why. EI #6 stated, "It cleans it just in case germs are there. Clean with an alcohol swab as an extra preventive measure from germs." On 11/14/2014 at 12:55 PM, an interview was conducted with EI #5, a Licensed Practical Nurse. EI #5 was asked if it was appropriate to wipe the top of a vial of an injectable medication with alcohol, prior to inserting a needle. EI #5 stated, "Yes, if it's (a) multi dose (vial). If it's a single dose (vial), the policy says you should, but I didn't. ..." 3) A review of the medical records indicated RI #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the November 2014 Physician order [REDACTED]. During a tour of the facility on 11/12/2014 at 10:05 AM, an ice cooler was observed on the floor in RI #8's room, under the over-bed table. The cooler contained thickened liquids. During the medication pass observation for RI #8 on 11/13/2014 at 8:27 AM, an ice cooler containing thickened liquids was observed in the room, on the floor, under the over-bed table. EI #5, a Licensed Practical Nurse, removed a container of thickened liquids from the cooler and gave it to RI #8, along with the oral medications. A review of the medical records revealed RI #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the November 2014 Physician order [REDACTED]. On 11/12/2014, at 10:25 AM, an observation was made of RI #1's ice chest which contained the resident's liquids, sitting on the floor. On 11/13/2014, at 11:42 AM, an observation was made again of RI #1's ice chest which contained the resident's liquids, sitting on the floor. An interview was conducted with EI #6, the Infection Control Nurse, on 11/14/2014 at 10:20 AM. EI #6 was asked what the facility's policy was on storage of thickened liquids in resident's rooms. EI #6 stated, "We don't have a policy. We use coolers so that thickened liquids would be cool and at bedside." EI #6 was asked where thickened liquids should be kept. EI #6 stated, "... Off the floor, on a table or stand, near the patient." EI #6 was asked if it was appropriate to store ice coolers which contained thickened liquids on the floor. EI #6 stated, "No. Nothing's supposed to be on the floor." EI #6 was asked why. EI #6 stated, "Because of infection control purposes. We've always been taught nothing should be on the floor. They should be on a table or stand." During an interview with EI #5, a Licensed Practical Nurse, on 11/14/2014 at 12:55 PM, EI #5 was asked if it was appropriate to store ice coolers which contained thickened liquids on the floor. EI #5 replied, "No. It's not appropriate. ..." EI #5 was asked why not and she responded, "Contamination ... nothing is supposed to be on floors." On 11/13/2014 at 4:20 PM, an interview was conducted with EI #2, a Licensed Practical Nurse. EI #2 was asked where the resident's cooler should be stored in their room. EI #2 stated, "Well, that's a good question, because lately they have been stored on the floor and they shouldn't be. Usually when we see it on the floor, we pick it up and wipe it with a sanitizer, empty it and clean it." EI #2 was asked if the resident's cooler should be stored on the floor and why. EI #2 stated, "No, that is unsanitary to have it on the floor." EI #2 was asked what the potential harm was to residents, if coolers containing liquids were stored on the floor. EI #2 stated, "They can be contaminated."

Based on observations, interviews and document review, the facility failed to ensure that a dietary staff member did not wash her hands, then touch a towel dispenser and trash can lid with her clean right hand, then proceeded to donn gloves and work the tray line. Findings include: A review of the United States Food and Drug Administration (FDA) guidelines "FDA Food Code 2013:" revealed, "Chapter 2 - Management and Personnel ... 2-302.12 Cleaning procedure ... (C) To avoid re-contaminating their hands ... FOOD EMPLOYEES may use disposable paper towels or similar clean barriers when touching surfaces ... 2-301.14 When to Wash ... FOOD EMPLOYEES shall clean their hands ... immediately before engaging in FOOD preparation ... (E) After handling soiled EQUIPMENT or UTENSILS: ... (H) Before donning gloves to initiate a task that involves working with FOOD ... (I) After engaging in other activities that contaminate the hands." During an observation in the kitchen on 01/14/2014 at 10:53 AM, EI (Employee Identifier) #5, a Dietary Staff member, was observed to wash her hands, dispense paper towels with her clean right hand, and dry her hands. EI #5 then lifted the lid of a large trash receptacle with her right hand to throw away the paper towel. EI #5 then proceeded to donn gloves and work the tray line. On 01/16/2014 at 10:15 AM, an interview was conducted with the EI #4, the Registered Dietician. EI #4 was asked if a dietary staff member should dispense paper towels and lift the lid of a trash can with her washed hand, then donn gloves and work the tray line and why. EI #4 stated, "No, she touched unclean items her hand became contaminated." EI #4 was asked what was the potential negative outcome if staff failed to perform proper hand-washing. EI #4 stated, "Contamination." On 01/16/2014 at 10:55 AM, an interview was conducted with the EI #3, the Dietary Manager. EI #3 was asked if a dietary staff member should dispense paper towels and lift the lid of a trash can with a washed hand, then donn gloves and work the tray line and why. EI #3 stated, "No, because it could cause food borne illness, it is contamination." EI #3 was asked what was the potential negative outcome if staff failed to perform proper hand-washing. EI #3 stated, "Food borne illness."

Based on observations, interviews and review of documents, the facility failed to ensure: 1) 19 opened items in the walk-in cooler and freezer had a use-by date or date opened, present on the containers to indicate a day or date by which they should be consumed or discarded. 2) Raw chicken was not stored over cooked, partially covered ham. 3) A dietary staff member was not wearing hoop earrings uncovered, while working the tray line. Findings include: 1) A review of the United States Food and Drug Administration (FDA) guidelines revealed, "FDA Food Code 2013: Chapter 3 - Food ... 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. ... (B) ... refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened ... to indicate the date or day by which the FOOD shall be consumed on the PREMISIES, sold, or discarded .... " During the kitchen tour on 01/14/2014 at 7:53 AM, the following items were found in the cooler to be open, with no label or markings of dates: Black-eyed Peas, cooked Ham, Bacon, 2 containers of Pimento Cheese, Cottage Cheese, Honey Mustard, Mayonnaise, Sweet Relish, Sauerkraut, Sausage Patties, a box with 3 quart containers of Liquid Eggs, a large bag with a head of lettuce, Apple Juice, Prune Juice, and Green Onions. Also noted in the cooler was a plastic container with prunes that was labeled, "Prunes" dated "12/7 8:00 AM", and a bag of Celery Sticks with the manufacturer's label, "Best by 12/26/13". In the freezer there was a "Sock-It-To-Me" cake that had been partially consumed. There was no label indicating the date it was opened, or to be consumed by. During the kitchen tour on 01/15/2014 at 7:55 AM, a box of Pork Steak Fritters were observed opened and partially used, in the freezer. This box had no label or markings of dates. In the cooler, there was a partially used gallon of milk that had no label indicating the date it was opened. 2) A review of "Policy & Procedure Manual 3-18 (copyright) Becky Dorner & Associates, Inc. Food Storage ... 14. Refrigerated Food Storage: ... e. Cooked foods must be stored above raw foods to prevent contamination. Raw animal foods will be separated from each other and stored on lower shelves (below cooked foods or raw fruits and vegetables) and in drip proof containers." During a kitchen tour on 01/14/2014 at 7:55 AM, 3 large pans of raw chicken (covered in foil and labeled "Chicken") were found on a rolling cart inside the cooler. Beneath the pans of chicken on the bottom of the cart was a cooked ham that was loosely covered with plastic wrap. 3) A review of the "FDA Food Code 2013: Chapter 2 - Management and Personnel", revealed "... Jewelry 2-303.11 Prohibition Except for a plain ring such as a wedding band, while preparing FOOD, ... " During a kitchen tour on 01/14/2014 at 11:13 AM, EI (Employee Identifier) #6, Dietary Staff, was observed wearing hoop earrings that were uncovered while working the tray line. During a kitchen tour on 01/15/2014 at 8:18 AM, EI #6 was again observed wearing hoop earrings that were uncovered, while working the tray line. On 01/16/2014 at 10:15 AM, an interview was conducted with EI #4, the Registered Dietician. EI #4 was asked what was the policy on labeling and storing of opened food items. EI #4 responded, "Date it is to be used by, 48 hours, not sure." EI #4 was asked if cooked foods should be stored under raw chicken and why. EI #4 stated, "No, bacteria could drip to the cooked food and could be served and not properly reheated to kill bacteria." EI #4 was asked what was the potential negative outcome when food items were not labeled properly. EI #4 stated, "Illness, somebody could get sick, if not labeled you don't know how old it is." EI #4 was asked what was the potential negative outcome when items such as raw chicken were stored above cooked food. EI #4 stated, "Contamination, food borne illness." On 01/16/2014 at 10:55 AM, an interview was conducted with EI #3, the Dietary Manager. EI #3 was asked what was the policy on labeling and storing opened food items. EI #3 responded, "Label date put in the freezer and cooler, and 3 days after that, it should be discarded (in cooler). List that 3 day-date, item name, time, AM or PM." EI #3 was asked if cooked foods should be stored under raw chicken. EI #3 stated, "No." EI #3 was asked what was the potential negative outcome when food items were not labeled and stored properly. EI #3 stated, "Food borne illness." EI #3 was asked what was the potential negative outcome when items such as raw chicken were stored above cooked food. EI #3 stated, "Food borne illness."

Based on observations, interviews and record reviews, the facility failed to ensure that a licensed nurse did not wipe from back to front while providing incontinence care prior to wound care for RI (Resident Identifier) #4, 1 of 3 residents observed for incontinence care. Findings include: A review of the facility's policy titled, "Incontinent Care and Catheter Care Using Disposable Wipes OBJECTIVE: To cleanse the perineum, ... 4. Female - clean entire perineal area (outer and inner labia) with disposable wipe, moving from front to back, ...". A review of RI #4's medical records revealed that RI #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Nursing Admission assessment dated [DATE], indicated that RI #4 was alert, lethargic, and unable to understand. This assessment also indicated RI #4 was incontinent and required assistance with bathing, dressing and toileting. On 01/15/2014 at 10:40 AM, EI (Employee Identifier) #1, an L.P.N.(Licensed Practical Nurse) was observed to perform incontinence care for RI #4, prior to wound care. During the care, using disposable wipes, EI #1 was observed to wipe the right buttock of RI #4 from back to front, then the left buttock, from back to front, then between the buttocks, again from back to front. A very small amount of tan stool was removed at that time. On 01/16/2014 at 11:55 AM, an interview was conducted with EI #1. EI #1 was asked what was the procedure for perineum care. EI #1 stated, "Clean from distal, proximal then medial." EI #1 was asked what the potential negative outcome was if incontinence care was not performed correctly. EI #1 stated, "Potential for infection. Cross-contamination." EI #1was asked what the potential negative outcome was if there was stool present on a resident, and they were wiped from back to front. EI #1 stated, "Potential for infection. Cross-contamination." EI #1 was asked if she recalled wiping RI #4 from back to front during wound and incontinence care. EI #1 stated,"Yes, I sure did. I guess you made me nervous." On 01/16/2014 at 12:10 PM, an interview was conducted with EI #2, the Infection Control Nurse. EI #2 was asked how often employees were inserviced on incontinence care. EI #2 stated inservices were done yearly, and if there was an increased problem with infection control, then more often. She further stated that all new hires were inserviced as part of their training. EI #2 was asked what potential harm could occur if incontinence care was not performed correctly. EI #2 stated, "UTI (urinary tract infection), basically, if it's not done correctly." EI #2 was asked if stool was present and a resident was wiped from back to front, what could happen. EI #2 stated, "UTI, vaginal infection or E-Coli (Escherichia coli) infection, which could lead [MEDICAL CONDITION]."

Based on observations, interviews, and record review, the facility failed to ensure two Dietary staff member's hair was completely covered with a hairnet in the food prep and tray line area. This was observed on two of two days of the survey. This had the potential to affect 20 residents, who reside in the facility and receive a meal from the kitchen. Findings include: On 1/24/12 at 7:52 AM, during the initial tour of the kitchen, EI (Employee Identifier) #1 (Cook) was observed with hair not completely covered in the front with the hairnet. On 1/24/12 at 8:40 AM, surveyor returned to the dietary department to meet with EI #3 (Dietary Manager), and EI #1 was observed with hair not covered completely in the front with the hairnet. Also, EI #2 (Dietary Aide) was observed in the dietary department with hair not covered completely with the hairnet in the front at the forehead or in the back at the neck. On 1/24/12 at 11:02 AM, during tray line observation, EI #1, who was plating the food, was observed with hair not covered completely in the front with the hairnet. Also EI #2, who was covering the plates of food and placing the plates on the trays, was observed with hair not covered completely with the hairnet in the front at the forehead or in the back at the neck. On 1/25/12 at 8:06 AM, EI #2 was observed in the kitchen with hair not covered completely with the hairnet in the front at the forehead or in the back at the neck. On 1/25/12 at 8:27 AM, an interview was conducted with EI #2. EI #2 was asked what was the facility's Policy & Procedure for the dress code in the kitchen. EI #2 stated that the Policy & Procedure was to cover your head, wear aprons and gloves when preparing food, no long fingernails or polish, and no jewelry with the exception of a wedding band. EI #2 also stated that the staff was to wear a hairnet or a cap with no hair hanging from underneath the hairnet or the cap. EI #2 was then asked if all of the hair was to be covered and she stated, "Yes ma'am." EI #2 was asked if all of her hair was covered on 1/24/12 during the lunch tray line observation or was her hair completely covered at the time of the interview. EI #2 stated that at lunch yesterday, a small piece of hair may have been out. EI #2 stated that at the time of the interview she had put her cap on fast and did not realize her hair was out. EI #2 was asked what was the potential negative outcome if all of the hair was not covered. EI #2 stated that the hair could get in the food and this would be bad for the residents. On 1/25/12 at 8:40 AM, an interview was conducted with EI #3. EI #3 was asked what was the facility's Policy & Procedure regarding the dress code in the kitchen. EI #3 stated that uniforms were worn, wedding band, no dangling earrings, hair to be covered, cleanliness, and aprons and gloves were to be worn and changed as needed. EI #3 also stated if the staff leave the department and return they should wash their hands. EI #3 was asked if the staff's hair was to be completely covered and she stated that it was. EI #3 was asked what was the purpose of covering the hair and she stated that it was to keep the hair from getting into the food. EI #3 was asked if during the tray line observation on 1/24/12 was EI #1 and EI #2's hair completely covered with the hairnets. EI #3 stated "I honestly don't recall." EI #3 was asked what was the potential negative outcome for residents if the staff's hair was not covered completely during food prep and service. EI #3 stated that the hair could get into the food and make the residents not want to eat the food. On 1/25/12 at 9:07 AM, an interview was conducted with EI #4 (Registered Dietician). EI #4 was asked what the facility's Policy & Procedure was regarding the dress code in the kitchen. EI #4 stated that the staff were to wear clean uniforms, no hoop earrings or dangling jewelry, no nail polish, and hair was to be covered. EI #4 was asked if the staff member's hair was to be covered completely and she stated "Yes ma'am." EI #4 was asked what was the potential negative outcome for residents if the staff member's hair was not covered completely. EI #4 stated that hair could fall into the food which was not very sanitary and this could be upsetting to residents. EI #4 also stated that hair could fall in beverages or on to the plates. EI #4 was asked who was responsible for ensuring that staff's hair was covered completely in the kitchen. EI #4 stated that EI #3 was responsible. A review of the facility's Policy & Procedure titled "ATTIRE & CLEANLINESS OF FOOD SERVICE STAFF POLICY & PROCEDURE" with "ADPH (Alabama Department of Public Health) Ref. Code (01/21/2005) Reviewed: (2007) (2008) (2009)," revealed "POLICY: To ensure that all staff involved with food services (storage, preparation, handling and serving) wear appropriate attire and promote cleanliness in the food service and dining area. PROCEDURE: ... 2. Kitchen personnel shall wear hair restraints, for example, hair nets, headbands, caps, or other adequate means to prevent contamination of food from hair ..."