Every finding on record at Diversicare of Big Springs

Based on observations, interviews, a facility policy, Resident's Rights and Quality of Life, and a review of the Maintenance Supervisor's POSITION DESCRIPTION, the facility failed to ensure air conditioner vents were not found with an accumulation of dust-like debris, food particles and other foreign objects. This affected Area Locators (AL) #'s 1-8, eight of twelve rooms of observed. Findings include: A review of a facility policy titled, Resident's Rights and Quality of Life dated May 1, 2012, revealed: . POLICY STATEMENT It is the policy . that all residents have the right to a dignified existence, . A resident has the right: . To receive service in a facility environment that is safe, clean, and comfortable . A review of the Maintenance Supervisor's POSITION DESCRIPTION dated 02/01/2023, revealed: POSITION TITLE: Maintenance Supervisor . REPORTS TO: Administrator . KEY RESPONSIBILITIES . Administrative Functions Supervise, repair, plan, organize, and conduct the day-to-day activities of the physical plant and operations department. On 05/08/2023 at 5:54 PM, an observation was made of (AL) #8's air conditioner filter. There were pieces of debris observed on the air conditioner vent. On 05/10/2023 at 7:55 AM, the pieces of debris remained on AL #8's air conditioner vent. On 05/10/2023 at 8:00 AM, the surveyor observed pieces of debris on AL #7's air conditioner vent. An observation was made on 05/1020/23 at 10:32 AM of Area Locator (AL) #3 with an air conditioner filter and outer vents with a heavy accumulation of gray/black/beige/white pieces of debris from one side of the vent to the other. An observation was made on 05/11/2023 at 8:58 AM of AL #5 with an accumulation of a dark substance on the air conditioner vents. On 05/11/2023 at 9:41 AM an observation tour was conducted with Employee Identifier (EI) #3, the Maintenance Supervisor. He was asked to observe the following Area Locations and describe what he saw. AL #3: he described what he saw as the vent and behind it needed to be cleaned because of crumbs behind the vent and dark dust build-up on the vents. AL #5: he described what he saw as dirty buildup on the vents. AL #4: he described what he saw as dark buildup on the vents. AL #7: he described what he saw as food crumbs and paper behind the vents. AL #8: he described what he saw as behind the vents on top was a heavy accumulation of what appeared to be food crumbs and the front vents had a heavy accumulation of dust-like substance. AL #1: he described what he saw as pieces of paper and 2 end-caps for tube feeding line. AL #2: he described what he saw as food crumbs, paper and dust from one side to the other. AL #6: he described what he saw as food crumbs, paper and dust from one side to the other. On 05/11/2023 at 10:08 AM an interview was conducted with EI #3, the Maintenance Supervisor. EI #3 was asked what the concern of dirt/dust-like debris and foreign objects being behind and on the vents that air flows past to enter resident rooms was. He answered it should not be in the air that residents breathe. EI #3 was asked what was the policy of a clean, comfortable and homelike environment. He answered that was how it was supposed to be kept up for residents. EI #3 was asked how would he describe what he saw in the air conditioner vents related to being clean, comfortable and homelike. He answered it was not clean. EI #3 was asked whose responsibility was it to ensure the air conditioners are kept free from a heavy build-up. He answered the maintenance department. EI #3 was asked why was that not done. He answered he did not have any help and he had to take care of the higher priority concerns first. On 05/11/2023 at 11:13 AM an interview was conducted with EI #1, the Administrator. EI #1 was asked what the concern of air conditioners with a build-up of dust-like debris, food particles and foreign objects behind the vents where air flows over them was. She answered for the cleanliness and breathing clean air. EI #1 was asked whose responsibility was it to keep these air conditioners free of a build-up of dust-like debris, food particles and foreign objects. She answered the Maintenance Supervisor. EI #1 was asked why were 8 air conditioner units in the rooms of sampled residents found with a build-up of dust-like debris, food particles and foreign objects. She answered it was an oversight. EI #1 was asked what was the facility's policy regarding the resident's environment. She answered to provide a clean, safe, comfortable and homelike environment. The deficiency was cited as a result of the investigation of complaint/report #AL00042602.

Based on interviews and record review, the facility failed to ensure Resident Identifier (RI) #10, a resident dependent on staff for bathing, was provided a shower as scheduled. This deficient practice affected RI #10; one of nine residents sampled for Activity of Daily Living (ADL) care. Findings include: RI #10 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include Parkinson's Disease and Generalized Muscle Weakness. RI #10's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 02/09/2023, coded RI #10 as being totally dependent on staff for bathing. A review of the shower schedule for the unit RI #10 resides on revealed RI #10 was scheduled a shower on the 2 PM - 10 PM shift on Tuesdays, Thursdays, and Saturdays. A review of RI #10's Task: ADL - Bathing sheet revealed on Tuesday, 05/09/2023, RI #10 was provided a Partial Bath. On 05/10/2023 at 5:04 PM, RI #10 informed the surveyor he/she had not received a shower on yesterday evening (05/09/2023). On 05/11/2023 at 12:20 PM, the surveyor conducted an interview with Employee Identifier (EI) #7, the Certified Nursing Assistant (CNA) assigned to care for RI #10 on 05/09/2023 on the 2 PM - 10 PM shift. When asked when the residents showers were provided, EI #7 said there was a schedule the CNA's used. When looking at the shower assignment sheet, EI #7 said RI #10 was scheduled a shower on 05/09/2023 on the 2 PM - 10 PM shift. EI #7 said he did not offer to shower EI #10 on his shift because EI #10 refused a shower that morning. The surveyor asked EI #7; if RI #10 was scheduled a shower on the 2 PM - 10 PM shift, should RI #10 have been provided a shower at that time. EI #7 said yes. On 05/11/2023 at 1:57 PM, the surveyor conducted an interview with EI #2, the Director of Nursing (DON). EI #2 said residents should be provided showers on their shower days and when they request one. The surveyor asked EI #2 why it would be important to provide a resident a shower on their shower day or when they request one, EI #2 said because it was the resident's right to have a shower and it would be a part of their ADL care. The deficiency was cited as a result of the investigation of complaint/report #AL00043277.

Based on observation, interviews and record review, the facility failed to honor Resident Identifier (RI) #10's food preference of no noodles when RI #10 was served spaghetti and meat sauce on 05/09/2023. This deficient practice affected RI #10; one of one resident sampled for food preferences. Finding include: RI #10 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include Parkinson's Disease and Generalized Muscle Weakness. A review of a Customer Concern/Grievance Communication Form for RI #10, dated 02/09/2023, documented the following: . Actions to resolve: . no seafood, no spicy food, no pasta, no peas no rice . Date received: 2-14-23 . On 05/09/2023 at 12:21 PM, the surveyor observed a plate of spaghetti and meat sauce, with a roll on it in RI #10's room. RI #10 stated he/she could not eat the spaghetti or foods that were spicy. On 05/11/2023 at 12:02 PM, the surveyor conducted an interview with Employee Identifier (EI) #8, the Dietary Manager. The surveyor asked EI #8, looking at RI #10's Customer Concern Form dated 02/09/2023, what date was the action resolved for RI #10's dislikes of no seafood, no spicy food, no pasta, no peas an no rice. EI #8 stated on 04/14/2023. When asked were RI #10's preferences honored if he/she made the facility aware he/she did not like noodles and received spaghetti, EI #8 said no. EI #8 said spaghetti was a noodle. On 05/11/2023 at 1:57 PM, the surveyor conducted an interview with EI #2, the Director of Nursing (DON). When asked if a resident requested to be served no noodles should they receive spaghetti, EI #2 said no. EI #2 said if served spaghetti, the resident's preferences were not being honored. EI #2 said it would be important to honor a resident's preference of food because it was the resident's right to get the food they prefer.

Based on interviews, record review, a review of the, Grievance Log and a facility policy titled, Customer Concern (Grievance) Policy, the facility failed to ensure the grievance process was followed when RI (Resident Identifier) #149's sponsor filed a grievance on 07/30/21. This deficient practice affected RI #149 one of three residents whose grievances were reviewed. Findings include: On 11/03/21, the State Agency received a complaint which alleged RI #149's missing clothes would be replacement and mailed to the complainant, however, the complainant had not received them. A review of a facility policy titled, Customer Concern (Grievance ) Policy, with an effective date of July 2018 revealed: .PURPOSE Support each customer's (patient's/resident's) right to voice concerns (grievances) and to ensure after receiving a concern, the center actively seeks a resolution and keeps the customer appropriately apprised of its progress toward resolution. PROCESS: . It is best practice for the Administrator to follow up with the customer after a period of time to ensure the customer remains satisfied with the concern resolution. A review of the Customer Concern/Grievance Communication Form document: . Dated 07/30/21 . RI #149's sponsor stated RI #149 was missing some black jogging pants .Was concern resolved, SS (Social Service) purchased black jogging pants to replace lost pants with company funds . There was no documented that the Administrator followed up with RI#149's sponsor. RI #149 was admitted to the facility on [DATE] and was discharged on [DATE]. On 01/26/22 at 10:51 AM, an interview was conducted per phone with RI #149's sponsor. She stated RI #149 was missing two pair of jogging pants and this concern was reported to EI (Employee Identifier) # 4, Former Administrator. RI #149's sponsor stated she talked with EI #4 about her concern twice. EI #4 told her the facility had replaced the clothes and would mail them to her, but she never received the clothes. On 01/26/22 at 5:15 PM, an interview was conducted with EI #3, Social Services Director. EI #3 was asked, if RI #149's sponsor voiced any concerns to her about his/her missing clothes. EI #3 said, yes. EI #3 was asked what was missing. EI #3 said two pair of jogging pants. EI #3 was asked did the facility replace the jogging pants. EI #3 said, yes, she went to Walmart to purchase the jogging pants. EI #3 was asked did she send the jogging pants to RI #149's sponsor. EI # 3 said, she was instructed to give them to EI #4. EI #3 was asked, if EI #4 sent the jogging pants to the sponsor. EI #3 said, she did not know, EI #4 told her he was going to take care of it and notify the family. On 01/27/22 at 3:23 PM, an interview was conducted with EI #1, Director of Nursing. EI #1 was asked was a grievance filed about RI #149's clothes missing. EI #1 said, yes on July 30, 2021. EI #1 was asked was the grievance resolved. EI #1 stated, it appeared to have been resolved because there were receipts for the jogging pants. EI #1 was asked if the clothes were given to the family. EI #1 said he did not know. EI #1 was asked, if he knew if RI #4 mailed the clothes to the family. EI #1 said, he did not know. EI #1 was asked, if he did a customer contact or followed up to see if the family received the clothes and was satisfied. EI #1 said, no he did not. On 01/27/22 at 6:14 PM, an interview was conducted with EI #4. EI #4 was asked did he mail RI #149's jogging pants to the sponsor. EI #4 said, yes, he did. EI #4 was asked, if he mailed the clothes return receipt. EI #4 said no, he mailed it regular mail. EI #4 was asked if he followed up with the sponsor to see if she received the clothes in the mail. EI #4 said, no he did not call the sponsor.

Based on observations, interviews and record review, the facility failed to ensure Resident Identifier (RI) #45's 02 (Oxygen) tubing/humidifier water bottle was dated and labeled; and the resident's nebulizer mask was stored in a covering on three of three days of survey. These deficient practices affected RI #'s 45 one of four residents sampled for oxygen therapy. Findings include: (1) RI #45 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #45's January 2022 Order Summary Report (Physician Orders) revealed RI #45 had physicians orders to apply oxygen at 3 liters via (by way) nasal cannula as needed for SOB (shortness of Breath), and [MEDICATION(S)] Nebulization Solution 1 vial via nebulizer three times a day. On 01/25/2022 at 5:35 PM, the surveyor observed RI #45's 02 infusing by way of a nasal cannula/concentrator. RI #45's 02 tubing was not dated/labeled, and RI #45's nebulizer face mask was observed lying on top of the dresser drawer, not in covering On 01/26/2022 at 11:31 AM, the surveyor observed RI #45's 02 tubing remained undated/labeled, and the nebulizer face mask remained uncovered on top of the dresser drawer. On 01/27/2022 at 9:38 AM, RI #45's face mask was observed on the floor, not in a covering, and RI #45's 02 tubing remained undated/labeled. On 01/27/2022 at 10:46 AM, the surveyor conducted an interview with the LPN (Licensed Practical Nurse) assigned to care for RI #45 on the 6 AM - 2 PM shift on 01/27/2022. The surveyor asked EI #2 how often should the oxygen tubing and humidified water bottles be changed. EI #2 said weekly. When asked by the surveyor where would there be evidence that the tubing had been changed, EI #2 said usually the humidifier water bottle would be dated. The surveyor asked EI #2 why would it be important to date the humidifier water bottle and 02 tubing. EI #2 said so the nurses would know when they needed to be changed again, and they would not set up and get mold and infection in the water. When asked how should RI #45's nebulizer mask be stored, EI #2 said in a bag. The surveyor asked EI #2 what was the rationale for storing the nebulizer mask in a bag, EI #2 said for infection control and keeping dust and stuff off of the nebulizer mask. On 01/27/22 at 10:55 AM, the surveyor accompanied EI #2 to RI #45's room. The surveyor asked EI #2 was RI #45's 02 tubing and humidifier water bottle dated. EI #2 said no. EI #2 acknowledged RI #45's nebulizer mask was on the floor, and not in a covering, at this time. On 01/27/2022 at 4:54 PM, the surveyor conducted an interview with EI #1, the Director of Nursing/Infection Preventionist. The surveyor asked EI #1 how often should the residents 02 tubing and water humidifier bottles be changed. EI #1 said typically every seven days. When asked where there would be evidence that this had been done, EI #1 said primarily the 02 tubing and humidifier bottle would be labeled and dated. EI #1 said the rationale behind labeling and dating 02 tubing would be to let the nurse know the time it was to be changed again. The surveyor asked EI #1 what could there be a potential concern for when the 02 tubing was not changed in a timely manner. EI #1 said it increases the risk of infection. When the surveyor asked EI #1 where should the nebulizer mask be stored when not in use, EI #1 said normally in a bag at the bedside. The surveyor asked EI #1 what was there a potential for when not stored this way. EI #1 said infection.

Based on interviews and facility documents titled Team Member In-Service Record the facility failed to include DementiaTraining in the required 12 hour annual training for CNAs (Certified Nursing Assistants), Employee Identifiers' (EI) EI #1 and EI #2. This deficient practice affected 2 of 9 CNA's whose training records were reviewed for Dementia Training. Findings Include: Review of EI #1 and EI #2 Team Member In-Service Record revealed the CNAs had not received Dementia Training as required to be included in their annual training for the year 2020. EI #1 was hired 01/04/2018. EI #2 was hired 01/07/2020. On 03/26/21 at 10:40 AM, an interview was conducted with EI #9, Director of Clinical Operations. EI #9 was asked what Dementia Training have EI #1 and EI #2 received. EI #9 said they had not received any. EI #9 was asked why was there no CEU (Continue Education Units) training for EI #1and EI #2. EI #9 said because their corporate office called back and stated that the 2020 training had dropped off for 2020 and they did not complete the program. EI #9 was asked who was responsible for making sure CNAs had their training in Dementia. EI #9 said the Director of Clinical Education. EI #9 was asked why was it important for CNAs to have training in Dementia. EI #9 said because they have a large population of Dementia in their stations and it helped them to take care of the residents appropriately. EI #9 was asked when should CNAs have 12 hours of training in Dementia. EI #9 said every year. EI #9 was asked did she look for training for Dementia for EI #1 and EI #2. EI # 9 said yes she did. EI #9 was asked what she found for Dementia Training for EI #1 and EI #2. EI #9 said she found a lack of training for Dementia for EI #1 and EI #2. On 03/26/21 at 11:00 AM, an interview was conducted with EI #10, DNS (Director of Nursing Services). EI #10 was asked, what Dementia Training had EI #1 and EI #2 received. EI #10 said when he reviewed the sheet, he did not find any. EI #10 was asked, why was it important that CNAs to receive training in Dementia. EI #10 said so they could properly provide care for Dementia patient and so they would have updated information. EI #10 was asked who was responsible for making sure CNAs have their training for Dementia. EI #10 said his understanding was the Clinical Educator. On 03/26/21 at 12:01 PM, an interview was conducted with EI #1. EI #1 was asked when did she receive Dementia training for 2020. EI #1 said she did not remember. EI #1 was asked who was responsible for making sure she had training in Dementia. EI #1 said the Director of Education. EI #1 was asked what was the importance of receiving Dementia training yearly. EI #1 said so they could see if they have the education to take care of a Dementia patient. On 3/26/21 at 1:49 PM, a telephone interview was conducted with EI #2. EI #2 was asked when did she receive her Dementia training. EI #2 said she did not because the web site was giving them trouble when she was suppose to have done it. EI #2 said everyone was trying to get their training done, this was when the web site was down. EI #2 was asked who was responsible for making sure she received Dementia training. EI #2 said the RN (Registered Nurse) on the unit, the Education person and they did not have one, she left. EI #2 was asked when was the CEU for Dementia due. EI #2 said in January.

Based on interview and record review, the facility failed to provide a summary of Resident Identifier (RI) #1's Baseline Care Plans to RI #1 or RI #1's representative within 48 hours of RI #1 being admitted to the facility on [DATE] and readmitted to the facility on [DATE]. This deficient practice affected RI #1, one of three sampled residents. Findings include: RI #1 was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. RI #1's admission Baseline Care Plan, dated 10/20/2019, was reviewed, and the section indicating whether a summary of the baseline care plan had been provided to RI #1 or RI #1's representative was not checked. RI #1's readmission Baseline Care Plan, dated 11/25/19,was also reviewed and the section indicating whether a summary of the care plan had been provided to RI #1 or RI #1's representative was not checked. On 7/29/2020 at 9:40 a.m., the surveyor conducted a telephone interview with RI #1's representative. RI #1's representative said within the first 48 hours of RI #1 being admitted to the facility no one discussed with her, or anyone in the family, the type care RI #1 would be receiving while in the facility, nor were they given a copy of the care plans. On 7/28/2020 at 1:26 p.m., the surveyor conducted an interview with Employee Identifier (EI) #1, the Social Worker (SW). After looking at RI #1's electronic records, EI #1 said Baseline Care Plans were completed for RI #1 when he/she was admitted to the facility on [DATE], and readmitted on [DATE]. When asked if the Baseline Care Plans were shared with or provided to RI #1's representative, EI #1 said there was nothing on RI #1's 10/20/2019 or 11/25/2019 Baseline Care Plans indicating they were. This deficiency was cited as a result of the investigation of complaint/report number AL 191.

Based on observations, interviews, and the Food and Drug Administration (FDA) (YEAR) Food Code, the facility failed to ensure: 1. the three-compartment sink and the food preparation sink drain pipes did not extend into the floor drains to create potential for backflow; 2. condensation from an air conditioning ventilation duct did not drip onto the surface of a food assembly area and onto individually wrapped ready-to-eat food; and 3. milk in the milk cooler was not expired. This had the potential to affect 108 residents receiving meals from the kitchen, 108 of 112 residents. Findings Include: 1. A review of the FDA (YEAR) Food Code revealed: . ,[DATE].11 Backflow Prevention. (A) . a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. An observation made on [DATE] at 4:19 PM, revealed the food preparation sink's drain pipe descending into the floor drain. The pipe descended below the floor grade. An observation on [DATE] at 9:13 AM, was made of the three-compartment sink. The drain pipe from the three-compartment sink extended into the floor drain beneath the 3-compartment sink. On [DATE] at 9:15 AM, Employee Identifier (EI) #3, the Maintenance Assistant, measured the drain pipe from the three-compartment sink to determine the length of the pipe descending below the top of the floor drain. The drain pipe was found to be ,[DATE] inch down into the floor drain. At that time EI #3 was asked what would happen if the floor drain backed up from the sewer. EI #3 replied the waste-water could back up into the drain pipe and then backflow into the three-compartment sink. EI #3 was asked if there was an air gap between the three-compartment sink's drain pipe and the floor drain to prevent backflow. EI #3 replied, No. An interview was conducted on [DATE] at 3:31 PM, with EI #1, the Dietary Manager. EI #1 was asked where was the lack of an air gap observed. EI #1 replied the three-compartment sink and the food preparation sink drain pipes did not have air gap. EI #1 was asked when she first became aware of this and EI #1 replied she became aware on Monday, (MONTH) 15, 2019 for the food preparation sink and Tuesday, (MONTH) 16, 2019 for the three-compartment sink. When asked why was it important for food preparation and ware washing sinks to have air gap, EI #1 replied the air gap was important to prevent possible backflow from the sewer. Upon being asked who was responsible for ensuring food preparation and ware washing sinks were protected from potential backflow, EI #1 replied, Maintenance and myself. EI #1 was asked what was the potential concern for residents if the three-compartment or food preparation sink did not have the appropriate air gap to prevent sewage back-flow into the three-compartment sink or the food preparation sink. EI #1 replied the concern was contamination of food items or dishware if it were to backflow. 2. A review of the FDA (YEAR) Food Code revealed: . ,[DATE].11 Ventilation(NAME)Systems, Drip Prevention. Exhaust ventilation hood systems in FOOD preparation . areas including components such as hoods, fans, guards, and ducting shall be designed to prevent . condensation from draining or dripping onto FOOD, EQUIPMENT, UTENSILS, LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES. An observation was made on [DATE] at 9:22 AM, of water dripping from an air conditioning ventilation duct box above the food tray line assembly area. The water dripped on top of the resident's food tray assembly table. An observation on [DATE] at 11:16 AM revealed puddles of water and splattered water on the resident's food tray assembly table from water dripping from the air conditioning ventilation duct box. Observed beneath the area where the water was dripping were individual bowls of mandarin orange sections covered with plastic wrap. An observation on [DATE] at 8:20 AM, revealed water dripping from the air conditioning ventilation duct box onto a plastic meal tray containing ready-to-eat covered bowls of dry cereal. An observation on [DATE] at 10:38 AM, revealed water dripping from the air conditioning ventilation duct box onto the plastic wrap of ready-to-eat food, which was labeled as angel food cake with fruit. An interview was conducted on [DATE] at 3:31 PM, with EI #1, the Dietary Manager. EI #1 was asked when she was first aware of water dripping from the air conditioning ventilation duct box onto the resident tray assembly table. EI #1 replied the drip was identified on Tuesday, (MONTH) 9, 2019, and a work order was placed by EI #2, the Registered Dietitian to Maintenance. EI #1 was asked what was the concern or potential harm for residents with water dripping from an air conditioning ventilation duct onto surfaces in the kitchen. EI #1 replied if the water were to make direct contact with food, then it could be contamination. EI #1 was asked when should water from the ceiling or air conditioning ventilation duct box drip onto any surface in the kitchen. EI #1 replied, Never. 3. A review of the FDA (YEAR) Food Code revealed: . ,[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (B) . READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PR[NAME]ESSING PLANT shall be clearly marked . to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded . ,[DATE].18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in ¶ ,[DATE].17(A) or (B) shall be discarded if it: . (2) Is in a container or PACKAGE that does not bear a date or day . ,[DATE].11 Segregation and Location. Products that are . spoiled . shall be segregated and held in designated areas that are separated from FOOD . An observation on [DATE] at 4:00 PM, was made of the milk cooler. The milk cooler contents included the following: - two individual cartons of whole milk with no labeled expiration date, - twenty-one individual cartons of fat free milk were labeled with a sell by date of [DATE], and - one individual carton of 2% milk was labeled with a sell by date of [DATE]. - In addition, the walk-in cooler contained four individual cartons of fat free milk with a sell by date of [DATE]. An interview was conducted on [DATE] at 3:31 PM, with EI #1, the Dietary Manager. When asked what was the potential harm to residents when milk was kept up to six days beyond the sell by date, EI #1 said residents could receive expired milk.

Based on record review, interview, and review of the document titled, Resident Assessment Instrument User's Manual Version 3.0,the facility failed to ensure a timely Minimal Data Set (MDS) quarterly assessment was completed for Resident Identifier (RI) #2. This affected one of twenty-four sampled residents. Findings Include: A review of a document titled, Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.16 , with a revised date of (MONTH) (YEAR), page 2-17, revealed: RAI OBRA (Omnibus Budget Reconciliation Act)-required Assessment Summary .Quarterly (Non-comprehensive) . Assessment Reference Date (ARD) .No later than .ARD of Previous OBRA assessment of any type + 92 calendar days .Regulatory Requirement .(every 3 months) . RI #2 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 7/18/19 at 11:13 AM a review of RI #2's MDS revealed no MDS assessments were completed since the 3/07/2019 Significant Change in Status MDS. On 7/18/19 at 11:43 AM an interview was conducted with Employee Identifier (EI) #9, MDS Coordinator, Registered Nurse. EI #9 was asked what was the date on the most recent completed MDS for EI #2. EI #9 replied the Assessment Reference Date (ARD) date was 3/7/2019. EI #9 was asked when should the next quarterly MDS assessment have been dated as complete. EI #9 replied, the next quarterly should have had an ARD date 92 days after the previous ARD date of 3/7/2019, which would put the date 6/9/2019. EI #9 was asked did the facility assure RI #2 was assessed using the standardized Quarterly Review assessment tool no less than once every 3 months between comprehensive assessments. EI #9 replied, No. EI #9 was asked was RI #2's quarterly MDS assessment late. EI #9 replied, Yes. EI #9 was asked what was the concern with the resident's MDS assessments not being completed timely. EI #9 replied the concern was that the facility was unable to properly assess the resident's needs. EI #9 was asked what was the facility's policy regarding timely MDS assessments. EI #9 replied the facility followed the RAI manual.

Based on observation, interview and record review, the facility failed to ensure that Oxygen cannula tubing was provided with a date when changed out by nursing. This affected Resident Identifier (RI) #6, one of two residents who were observed with utilizing oxygen therapy. Findings include: RI #6 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A review of RI #6's physician's orders [REDACTED]. On 07/17/19 at 03:38 PM, an observation was made of RI #6's oxygen in use per nasal cannula with oxygen concentrator. The oxygen concentrator machine was set on 3 liters per nasal cannula. The water bottle was dated 7/15/19, however, the nasal cannula tubing was not dated. On 07/18/19 at 09:33 AM, a second observation was made of the oxygen in use by nasal cannula with oxygen concentrator. The oxygen concentrator machine was set on 3 liters per nasal cannula. The water bottle was dated 7/15/19, however, the nasal cannula tubing was not dated. The Surveyor interviewed Employee Identifier (EI) #6 Registered Nurse/Unit Manager, on 07/18/19 at 09:42 AM. EI #6 was asked, when was the nasal cannula tubing changed. EI# replied, they change them weekly. EI# 6 was asked, who was responsible for changing the nasal cannula tubing. EI# replied, the nurses or her. EI #6 was asked, where was the change of nasal cannula tubing documented. EI#6 replied, they date and initial it on the bag and the oxygen bottle, also the nasal cannula tubing should be dated. EI #6 was asked, what was the potential harm when the dates are not written on the nasal cannula tubing. EI #6 replied, they could be out of date and used too long past when it should be changed, which could cause them to be nasty and residents get a respiratory infection. On 07/18/19 at 03:56 PM, the Surveyor interviewed EI #12, Assistant Director Of Nursing. EI #12 was asked, what was the facility's policy regarding the changing of oxygen tubing, specifically nasal cannula's. EI #12 replied, they change them weekly and as needed. EI #12 was asked, who was responsible for changing the nasal cannula's. EI #12 replied, the nurse. EI #12 was asked, what nurse. EI #12 replied, the medication nurse on the specific unit. EI #12 was asked, who was responsible for writing the date on the nasal cannula tubing. EI #12 replied, the nurse. EI #12 was asked, should the nasal cannula tubing have a date written on it when it was changed. EI #12 replied, yes. EI #12 was asked, how did the staff ensure the nasal cannula tubing was changed weekly. EI #12 replied, they would look at the date written on the nasal cannula tubing. EI #12 was asked, if there were no date on the nasal cannula tubing how can the change be verified. EI #12 replied, if it was not documented it was not done. EI #12 was asked, what would be the concern be if the nasal cannula tubing was not dated. EI #12 replied, staff would not know when it had been changed. EI #12 was asked, what would be the concern if the nasal cannula tubing was not changed per facility policy. EI #12 replied, risk of infection for the resident.

Based on medical record review, interview and review of a facility document titled, Medication error, the facility failed to ensure Resident Identifier (RI) #107's order for Eliquis 5 milligrams (MG) by mouth (PO) twice a day (BID) with no end date was not discontinued in error by a licensed nurse on 07/08/19. The medication error was significant due to the drug's classification as an anticoagulant. This affected RI #107, one of 24 sampled residents whose medications were reviewed. Findings Included: A review of a facility document titled, Medication error, with the Date: 7/17/2019, documented: .Incident Description Nursing Description: Resident's eliquis was discontinued in error by nursing caring for (him/her) on 7/8/19 . Immediate Action Taken Description: Contacted M.D., received verbal order for eliquis 5mg, 2 tabs(tablets) PO BID x (times) 7 days, then eliquis 5mg PO BID x 6 months . RI #107 was admitted to the facility on [DATE]. A review of RI #107's medical record revealed a Doppler Report with a Date of Service: 06/28/2019, revealed: .Conclusion: [MEDICAL CONDITIONS] involving the left profunda femoral vein. Further review of RI #107's medical record disclosed a physician's orders [REDACTED]. (2) Eliquis 5MG 1 tab twice a day by mouth . On 07/17/19 at 6:12 p.m., an interview was conducted with Employee Identifier (EI) #16, Registered Nurse (RN)/Director of Nursing. EI #16 was asked, to please look at RI #107's (MONTH) Medication Administration Record [REDACTED]. EI #16 said no, it was discontinued on 07/08/19. EI #16 was asked to look at RI #107's physician's orders [REDACTED].#107 should have still been receiving Eliquis 5MG PO BID. EI #16 stated yes. EI #16 was asked what was the concern with RI #107 not receiving Eliquis as ordered by the physician after being diagnosed with [REDACTED].#16 replied it could be very critical and could cause a [MEDICAL CONDITION] embolism.

Based on interview, and review of Resident Identifier (RI) #260's medical record, the facility failed to ensure that the Code Status for RI #260 matched through-out the medical record. This deficiency affected one of one resident reviewed for accurate code status. Findings include: RI #260 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 4:06 PM a more thorough investigation of RI #260's medical record revealed that the code status differed in multiple areas. The first page of the medical record had a page with a stop sign and DNR, the second page was the resuscitation order depicting No Cardiopulmonary resuscitation (CPR), and the third page noted was a bright green paper with big bold letters spelling Full Code. The Care Plan revealed that RI #260 was care planned for full code, while the Physicians orders dated [DATE] included Do not resuscitate (DNR) On [DATE] at 04:50 PM, an interview with Employee identifier (EI) #6 Registered Nurse, Unit Manager was conducted. EI #6 was asked, how and where should the code status be documented in the medical record. EI #6 responded they have orders and they have it inside the chart. EI #6 was further asked, what would be important regarding code status being documented in multiple areas in the medical record. EI #6 replied that all of the areas should be the same. EI #6 was then asked what would be the concern with all areas of the medical record not matching regarding code status. EI #6 answered that if someone was a DNR, they could code them and that would be against there wishes. EI #6 was asked, to look at the medical record for RI #260, and explain what the page, that read Stop/DNR, should mean to staff. EI #6 stated it tells the staff to pay attention that the resident is a DNR. EI #6 was then asked what the third page, that was bright green and read Full Code, should mean to staff. EI #6 stated that meant the resident is a full code. EI #6 was asked what the care plan for RI #260 reflected as code status. EI #6 responded that the care plan for RI #260 reflected a full code status. EI #6 was asked what the physician's orders [REDACTED]. EI #6 replied that RI #260 had a physician's orders [REDACTED].#6 was then asked if RI #260's medical record matched in all areas regarding code status. EI #6 responded, no, it did not match. EI #6 was further asked who was responsible for checking the charts for accuracy. EI #6 answered that the Nurse on every 3rd shift performed a chart check and there should be a 24 hour chart check sheet on the chart. EI #6 was asked if there was a 24 hour chart check sheet on RI #260's medical record. EI #6 replied no. EI #6 was asked if they checked just the physician's orders [REDACTED]. EI #6 replied that they should check the whole chart.

Based on observations, interviews, medical record reviews and review of a facility policy titled, Handwashing/Hand Hygiene, the facility failed to ensure: 1. a Certified Nursing Assistant (CNA) changed gloves after providing incontinence care for Resident Identifier (RI) #107 before touching the resident's bed covers and washed her hands after removing her gloves before leaving RI #107's room; and 2. a CNA washed her hands after removing her gloves and applying clean gloves during incontinence care for RI #34. These deficient practices affected RI #107 and #34, two of 24 sampled residents. Findings Included: A review of a facility policy titled, Handwashing/Hand Hygiene, with an Effective Date: (MONTH) 1, (YEAR), documented: . Policy Interpretation And Implementation . 2. All team members shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other team members, residents, and visitors.5. Use an alcohol-based hand rub or, alternatively, soap . and water for the following situations: . b. Before and after direct contact with residents; . h. Before moving from a contaminated body site to a clean body site during resident care; . k. After removing gloves; . General Infection Control Practices . 7. The use of gloves does not replace hand washing/hand hygiene. 1.) RI #107 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 07/17/19 at 9:48 a.m., the surveyor observed Employee Identifier (EI) #8, CNA, enter RI #107's room, apply gloves (without washing her hand), assist the resident from the wheelchair to the bed, remove the resident's sweatpants, check the brief and provide incontinence care for the resident. Then without changing her gloves, EI #8 repositioned the resident, pulled up the covers, removed her gloves and left the room, without washing her hands. The CNA was observed to not wash her hands until she went into the ice room, where she washed her hands. On 07/18/19 at 3:39 p.m., a telephone interview was conducted with EI #8, CNA. EI #8 was asked did she remove her gloves and wash her hands and apply clean gloves after providing incontinence care for RI #107 before repositioning and adjusting the resident's covers. EI #8 said, no she did not. EI #8 was asked should she have, she replied, yes. EI #8 was asked what was the concern with not changing gloves and washing hands after providing incontinence care and before touching other items. EI #8 answered cross contamination and infection control. On 07/18/19 at 7:31 p.m., an interview was conducted with EI #16, Registered Nurse (RN)/Director of Nursing/Infection Control. EI #16 was asked when should CNAs wash their hands when using gloves. EI #16 said when they remove them, in between residents or if they are soiled. EI #16 was asked should a CNA change gloves and wash her hands after providing incontinence care before positioning the resident and pulling up the covers. EI #16 replied yes. EI #16 was asked should a CNA wash her hands when changing gloves before applying clean gloves. EI #16 stated yes. EI #16 was asked what was the concern with those things. EI #16 answered infection control and cross contamination. 2. RI #34 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. On 07/17/19 at 11:40 AM, EI #8 CNA was observed providing incontinence care to RI #34. EI #8 entered RI #34's room, placed a package of wipes and a brief on the dresser. EI #8 then placed gloves on, adjusted the bed and informed RI #34 that they needed to check him/her. EI #8 then placed a plastic bag at the foot of the bed, along with the package of wipes and the clean brief. EI #8 then removed the blanket from RI #34, rolled RI #34 to their back, obtained several wipes, and wiped RI #34 from front to back. EI #8 then removed her gloves and placed cleaned gloves on without washing or using hand sanitizer. EI #8 then rolled RI #34 to their right side, wiped the backside of the resident, which was soiled. EI #8 then pulled more clean wipes from the package with the same soiled gloves on. EI #8 then pulled the soiled brief out from under the resident and placed a clean brief under RI #34 and affixed the brief. EI #8 rolled the resident to their left side and placed the soiled items in the plastic bag and put into the trash can in the room. EI #8 then removed her gloves and placed clean gloves on, without washing or using hand sanitizer. EI #8 adjusted the resident in the bed and turned RI #34 back to their right side. After washing her hands, EI #8 left the room. On 07/17/19 at 11:54 AM, an interview with EI #8 was conducted. EI #8 was asked, when should she wash her hands when providing incontinence care to a resident. EI #8 replied, before and after the care. EI #8 was asked how many times she changed her gloves with RI #34. EI #8 answered three times. EI #8 was asked if she should wash or gel her hands after removing gloves and before applying clean gloves. EI #8 replied, yes. EI #8 was then asked if she washed her hands or used hand sanitizer each time after removing her gloves and applying new gloves. EI #8 replied, no. EI #8 was further asked, how she was in-serviced on providing Peri care. EI #8 stated that as far as washing after removing gloves, it is not that they can't, they wash their hands, but they are kind of rushed.

Based on observation, interviews and review of the Food Code (YEAR), the facility failed to maintain the areas surrounding the dumpsters and grease vat free of debris. This had the potential to affect all 107 residents residing in the facility. Findings include: A review of the Food Code (YEAR), Page 529 documented the following: .Storage areas must be large enough to accommodate all the containers necessitated by the operation in order to prevent scattering of the garbage and refuse .Garbage containers should be available wherever garbage is generated to aid in the proper disposal of refuse .Removal .Refuse, recyclables, and returnable items,such as beverage cans and bottles, usually contain a residue of the original contents. Spillage from these containers soils .storage areas and becomes an attractant for insects, rodents and other pests .Alternative means of solid waste disposal must be conducted properly to prevent environmental consequences and the attraction of insects rodents and other pests . On 8/15/18 at 4:04 p.m., the surveyor observed the following items outside the kitchen near the dumpsters and grease vat area: 1) Stagnant green water in a container, 2) A one inch container with old towels used by maintenance, 3) one wheel chair, 4) wooden pallets, 5) four air conditioning units, 6) 20 cigarette butts, 7) pieces of unidentifiable plastic on the ground, 8) pieces of broken particle board, 9) pieces of trash to include plastic bottles and paper wrappers 10) one chair, 11) 19 crates, and 12) part of a steel, over bed table On 8/15/18 at 4:07 p.m., and interview was conducted with Employee Identifier (EI) #5, Dietary Manager. The surveyor and EI # 5 observed discarded items near the dumpster and grease vat. EI #5 was asked if deliveries were received near the area where the dumpster and grease vat were placed. EI #5 stated yes. EI #5 was asked how often the area was cleaned. EI #5 stated maintenance and house keeping were responsible for the entire grounds. EI #5 stated she comes out every other day and picks up thrash in the area. On 8/16/18 at 9:45 a.m. the surveyor observed the area outside the kitchen near the dumpster and grease vat and observed the same discarded items that were observed on 8/15/18. On 8/16/18 at 9:51 a.m. an interview was conducted with EI # 4, Maintenance staff. EI # 4 stated he was responsible for cleaning the area near the dumpster and outside the kitchen area. EI # 4 stated he tried to clean the area one time a week. EI # 4 was asked if he felt the area needed to be cleaned, and he stated yes. EI # 4 stated it was not clean now because he was the only employee responsible for the area. EI # 4 stated the potential risk of not keeping the area clean would be bugs, and confirmed he had observed bugs under a cardboard box near the grease vat on 8/15/18. EI # 4 was asked about the potential risk of the bugs being present near the grease vat. EI # 4 stated they could come inside the building. EI # 4 stated the area needed to be cleaned.

Based on observation, interviews, record review, and review of Potter and Perry, Fundamentals of Nursing, Ninth Edition, the facility failed to ensure Resident Identifier (RI) #40's nebulizer face mask and reservoir cup were rinsed and dried after receiving a nebulizer treatment from a Licensed Practical Nurse (LPN). This affected one of one resident observed receiving a nebulizer treatment and one of three nurses observed during medication pass. Findings Include: A review of Potter and Perry, Fundamentals of Nursing, Ninth Edition, Chapter 29, Infection Prevention and Control, page 455, documented: .Cleaning. Cleaning is the removal of organic material .from objects and surfaces .When an object comes in contact with an infectious or potentially infectious material, it is contaminated . RI #40 was readmitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. On 08/15/2018 at 10:14 a.m., Employee Identifier (EI) #3 , LPN, was observed during administration of a nebulizer treatment. The surveyor observed EI #3 place RI #40's nebulizer face mask and reservoir cup back in the nebulizer machine holder, without rinsing or drying. On 08/15/2018 at 03:07 p.m., an interview was conducted with EI #2, Registered Nurse/Infection Control Preventionist. EI #2 was asked what was the risk in putting a nebulizer face mask back in a breathing machine holder, in a plastic bag with wet moisture on the nebulizer face mask and reservoir cup, without rinsing and drying. EI #2 stated it could cause an upper respiratory infection to a resident. EI #2 further stated that you should rinse and dry the nebulizer face mask and reservoir cup, after a breathing treatment. On 08/16/18 at 07:39 a.m., an interview was conducted with EI #3, a Licensed Practical Nurse (LPN). EI #3 was asked what did she do with the nebulizer face mask and reservoir cup, when the resident was finished with the breathing treatment. EI #3 stated that she placed the nebulizer face mask and reservoir cup in the breathing machine holder and covered with a plastic bag. EI #3 was asked what was the facility standard of practice of care of the nebulizer face mask and reservoir cup after giving a resident a breathing treatment. EI # 3 stated that you should rinse and dry the nebulizer face mask and reservoir cup, prior to placing in the breathing machine holder. EI #3 was asked why she did not rinse and dry the nebulizer face mask and reservoir cup, after giving RI #40 the nebulizer breathing treatment. EI #3 stated she was unsure of the facility standard of practice. EI #3 was asked how could this affect the resident if the nebulizer face mask and cup were put back in a plastic bag without rinsing and drying these items. EI #3 replied that it could cause the resident to contract an infection. EI #3 was asked if there was wet moisture in the nebulizer face mask cup that was placed in the plastic bag. EI #3 stated yes.

Based on observation and interview, the facility failed to ensure signs were posted in the facility identifying where the survey results were posted. This had the potential to affect all residents, staff and visitors in the facility. Findings Include: On 8/15/18 at 8:41 a.m., the surveyor observed the survey results in a binder in the front lobby of the building. No sign was observed in the front lobby identifying what was in the binder. On 8/15/18 at 3:00 p.m., the surveyor toured the building and did not observe a sign identifying where the survey results were posted. An interview was conducted with Employee Identifier (EI) #1, Administrator, on 8/15/18 at 3:17 p.m EI #1 stated the survey results were posted in the front lobby. EI #1 further stated there was no sign identifying what was in the survey binder. EI #1 was asked if there was a sign in the facility identifying where the survey results were posted. EI #1 stated there was no sign in the building. EI #1 was asked why there should be sign identifying where the survey results were posted and what was in the binder. EI #1 said, so visitors, staff and residents would know where it was and what was in the binder

Based on observations, interviews and a review of facility policies Food Temperature by Meal, Leftover Foods, Refrigerated Storage, Dishwashing Procedures and Food Holding Temperatures on Food Service Line, the facility failed to ensure: 1. a dietary worker failed to take the temperature of a food item on the tray line, 2. shredded carrots, celery and lettuce was not expired in the cooler 3. spoons were free of water. Findings Include: 1. A review of a facility policy titled Food Holding Temperatures on Food Service Line with an effective date of January 1, 2017 revealed: POLICY .All foods will be served at appropriate temperatures to ensure resident/patient acceptance while reducing the risk of food foodborne illness.PROCEDURE .3. Once food is on the steam table, the temperature will be taken prior to each meal service .5. Temperatures will be recorded on the Food Temperature by Meal form in the Food Service Policy and Procedure Manual . A review of the 7/12/2017 Food Temperature by Meal form, there was no temperature recorded for the potato puff. On 7/12/2017 at 11:14 a.m., the surveyor observed the cook, EI #9 taking potato puff out of the stove to put on a plate and did not take the temperature of the food item or write down the food item on the menu. She closed the stove door and continue to plate food. On 7/13/2017 at 8:45 a.m., the surveyor conducted an interview with EI #7, the Dietician. EI #7 was asked what food item temperatures should be taken on the trayline. EI #7 replied, all food items that were being served to the residents. EI #7 was asked why should the temperatures be taken on the trayline. EI #7 replied, to make sure the food was safe to serve. EI #7 was asked what was the potential harm when the temperatures of food was not taken on the trayline. EI #7 replied, if they did not take the temperatures of the food there was no way for them to know the temperatures and to know if the food was safe to serve to prevent food borne illness. On 7/12/2017 at 3:00 p.m., the surveyor conducted an interview with EI #9 the cook. EI #9 was asked what was the facility policy on taking temperatures on the trayline. EI #9 replied, take temperatures of all the hot foods on the serving line. EI #9 was asked who was responsible for taking temperatures of the trayline. EI #7 replied, the cook; the aide takes the temperature of the milk. EI #9 was asked what was the temperature of the potato puffs. EI #9 replied, she did not take the temperature. EI #9 was asked where was it documented that the temperature was taken of the potato puff. EI #9 replied, it was not documented. EI #9 was asked what was the potential harm when food was served to the residents and it was not at the proper temperature. EI #9 replied, it can cause them to get sick. 2. A review of a facility policy titled, Refrigerated Storage with an effective date of January 1, 2017 revealed: POLICY .PROCEDURE .3. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates or frozen (where applicable) or discarded . A review of a facility policy titled, Leftover Foods with an effective date of January 1, 2017 revealed: .PROCEDURE . 2. Leftover cold foods should be completely labeled and dated. On 7/11/2017 at 10:45 a.m., the surveyor observed carrots wrapped in plastic wrap with a use by date of 7/3/2017, celery with a use by date of 7/1/2017, lettuce with a use by date of 7/7/2017 and diced tomatoes in a medium container with no use by date. On 7/13/2017 at 8:51 a.m., the surveyor conducted an interview with (Employee Indentifier) EI #7, Dietician. EI #7 was asked what items in the cooler were out of date. EI #7 replied, shredded carrots and celery. EI #7 was asked why was the expired items in the cooler. EI #7 replied, it was over looked. EI #7 was asked who was responsible for removing expired food items out of the cooler. EI #7 replied, everyone in the kitchen. EI #7 said if it was expired anyone can take it out. EI #7 was asked when should expired food be removed from the cooler. EI #7 replied, by the use by date. EI #7 was asked what food item had no use by date. EI #7 replied, diced tomatoes. EI #7 was asked why was there no use by date on the food item. EI #7 replied, whoever used it last failed to label it. EI #7 was asked what was the potential harm when expired food was cooked and served to the residents. EI #7 replied, potential for food borne illness. EI #7 was asked what was the potential harm when there was no use by date on food items. EI #7 replied, potential for food borne illness. 3. A review of a policy titled Dishwashing Procedures with an effective date of August 1, 2012 revealed: .PROCEDURE Proper sanitation of dishware and dishware equipment is essential to prevent the spread of illness from one resident to another.4. Cleaned dishes must be allowed to air dry . On 7/12/2017 at 11:02 a.m., the surveyor observed five spoons on five different residents trays with water in them and ready to go out to the residents. The surveyor observed the canister where the spoons were. There was water in the spoons, the bottom of the canister was wet and there was a food like substance on one spoon. On 7/12/2017 at 3:25 p.m., the surveyor conducted an interview with EI #16, dietary aide. EI #16 was asked what was on the spoon in the canister. EI #16 replied, not sure what it was. EI #16 said she took it back to the dish room. EI #16 was asked what was in some of the spoons on the resident's trays. EI #16 replied, specks of water. EI #16 was asked why was it there. EI #16 replied, too many spoons in the silverware holder. EI #16 was asked what was the facility policy regarding wet spoons. EI #16 replied, should not have wet nesting. EI #16 was asked was silverware wet nesting. EI #16 replied, yes. EI #16 was asked who was responsible for making sure utensil were dry. EI #16 replied, the person who was pulling the silverware. EI #16 was asked why should spoons be dry when serving to the residents. EI #16 replied, if they were wet it would make the napkin wet and may make someone sick. EI #16 was asked was the spoon with the spot clean or dirty. EI #16 replied, to her it was dirty and that was why she took all of them back to the dish room. EI #16 said one spoon could contaminate the others. EI #16 was asked what was the potential harm when residents were given spoons from a canister with water in them. EI #16 replied, they could get sick if water was on them. On 7/12/2017 at 3:40 p.m., the surveyor conducted an interview with EI #7, the Dietician. EI #7 was asked what was on the spoon in the canister. EI #7 replied, she did not know, it look like a piece of cabbage. EI #7 was asked did she observe water on some of the spoons. EI #7 replied, yes ma'am. EI #7 was asked why was it there. EI #7 replied, the spoons were not separated properly. EI #7 said the spoons were sticking together not allowing them time to dry. EI #7 was asked what was the facility policy regarding wet spoons. EI #7 replied, all silverware, plates, cups, and all dishes were to be air dried. EI #7 was asked who was responsible for making sure utensil were dry. EI #7 replied, the dish person. EI #7 was asked what was the potential harm when residents were given spoons from a canister with water on them. EI #7 replied, it can make them sick due to bacteria growth.

Based on observations and interview the facility failed to ensure Room Locators (RL) 1 - 8 were free of a closet door that was not intact, closet door free of scuffs and scrapes, commodes were free of uncapped bolts at the base and base boards were free of scrapes and peeling paint. This affected two of four units. Findings Include: 1. On 7/11/17 at 11:25 a.m., and 7/12/17 at 10:30 a.m., an observation was made of RL #1, the closet door was off and standing against the wall beside the free standing closet, the hot water faucet did not turn off and the screws at the base of the commode were exposed. 2. On 7/11/17 at 11:28 a.m., and on 7/12/17 at 10:32 a.m., an observation was made of RL #2 with exposed screws at the base of the commode. 3. On 7/11/17 at 11:35 a.m., and on 7/12/17 at 10:34 a.m., an observation was made of RL #3 of scuffed closet doors. 4. On 7/11/17 at 11:41 a.m., and on 7/12/17 at 10:36 a.m., an observation was made of RL #4 with exposed screws at the base of the commode. 5. On 7/11/17 at 11:42 a.m., and on 7/12/17 at 10:37 a.m., an observation was made of RL #5 with exposed screws at the base of the commode. 6. On 7/11/17 at 11:45 a.m., and on 7/12/17 at 10:40 a.m., an observation was made of RL #6 with exposed screws at the base of the commode and scuffs and peeling paint at the base board. 7. On 7/11/17 at 10:45 a.m., and on 7/13/17 at 11:15 a.m., an observation was made of RL #7 with exposed screws at the base of the commode. 8. On 7/11/17 at 10:45 a.m., and on 7/13/17 at 11:15 a.m., an observation was made of RL #8 with exposed screws at the base of the commode. On 7/13/17 from 12:00 p.m., until 12:30 p.m., a walk through in conjunction with an interview was conducted with Employee Identifier (EI) #5, Maintenance Assistant. EI #5 was asked at RL #1, where was the closet door. EI #5 replied, standing beside the closet. EI #5 was asked why there was not a closet door. EI #5 replied, it came off. EI #5 was asked what the harm was in not having a closet door. EI #5 replied, it looked bad. EI #5 was asked to turn on the water in the bathroom and then turn it off. EI #5 could not turn the hot water side off and replied it needed a new faucet. EI #5 was asked to explain what he noticed at the base of the commode in RL #1. EI #5 replied, about one inch of exposed screws at the base. EI #5 was asked what the harm was in the exposed screws. EI #5 replied, someone could get hurt. EI #5 was asked to describe the screws at the base of the commode in RL #2. EI #5 replied, one inch screws at the base were exposed. EI #5 was asked what the harm was in the exposed screws. EI #5 replied, someone could get hurt. EI #5 was asked to describe what he saw at the closet doors in RL #3. EI #5 replied, the closet doors were scuffed and needed painting. EI #5 was asked what the harm was in scuffed closet doors. EI #5 replied it looks bad. EI #5 was asked to describe was he saw at the base of the commode in RL #4. EI #5 replied exposed screws about one inch at the base of the commode and someone could get hurt. EI #5 was asked to describe what he saw at RL #5. EI #5 replied, one inch exposed screws at the base of the commode. EI #5 was asked what the harm was in the exposed screws. EI #5 replied, someone could get hurt. EI #5 was asked to describe what he saw at RL #6. EI #5 replied, exposed screws about one inch at the base of the commode and someone could get hurt. EI #5 was asked to describe what he saw at the baseboard. EI #5 replied, scuffed and peeling base. When EI #5 was asked what the harm was with the base peeling and scuffed; he replied aesthetics; looks. EI #5 was asked to describe what he saw at RL #7 and 8. EI #5 replied, about one inch exposed screws at the base of the commodes. When asked what harm there was with the exposed screws; EI #5 replied, someone could get hurt. EI #5 was asked who was responsible for ensuring screws at the base of the commodes were capped. EI #5 replied, the maintenance department. EI #5 was asked who was responsible for ensuring the closet door was intact. EI #5 replied, maintenance. EI #5 was asked who was responsible for ensuring the closet doors and baseboards were free of scuffs and peeling paint. EI #5 replied, maintenance.

Based on interviews, record review, a review of Physician's Orders, and review of Medication Administration Records, the facility failed to ensure licensed staff did treatment of [REDACTED].#2. This affected one of one residents sampled for bladder flush treatments. Findings Include: RI #2 was admitted to the facility 10/25/16 with [DIAGNOSES REDACTED]. A review of RI #2's October 2016 admit orders revealed .[MEDICATION NAME] 80 MG (milligram) /2 ML (milliliter) VIAL INSTILL 50MG INTO BLADDER DAILY, CLAMP FOLEY FOR 4 HRS (hours) THEN DRAIN. A review of RI #2's discharge Medication list revealed . DISCHARGE medications: [REDACTED]. Changes: X (times) 8 days . A review of RI #2's October Medication Administration Record [REDACTED]. In the block dated 10/26/16 revealed the letter N indicating as not given. Further review of the Medication Administration Record [REDACTED]. A review of RI #2's November Medication Administration Record [REDACTED]. The block dated 11/1/16 revealed the letter N with no indication of why the medication was not given. On 7/12/17 at 1:30 p.m., a phone interview was conducted with EI #6, Register Nurse, who no longer was employed by the facility. Her initials were in the block dated 10/26/16 with the letter N. When interviewed she voiced recalling the order, however, did not recall giving the medication. EI #6 was told by the surveyor that the block indicated an N; she was asked what the N indicated. EI#6 replied not given. EI #6 was asked if no reason was indicated why the medication was not given could that be a medication error. EI #6 stated I guess so. EI #6 was asked if the Physician orders indicated a total of eight doses to be given and two of the eight were not given were the Physicians orders followed. EI #6 stated, I suppose not. On 7/12/17 at 3:00 p.m., an interview was conducted with EI #2, Director of Nursing. EI #2 was asked if RI #2 had an order for [REDACTED].#2 stated Yes, by looking at the admission orders [REDACTED]. EI #2 replied, according to the Medication Administration Record [REDACTED]. EI #2 replied, there was an N in the block which indicated it was not given. EI #2 was asked why the medication was not given as ordered. EI #2 replied, according to the note entered by EI #6, it was not given pending provider clarification. EI #2 was asked if there was documentation of provider clarification. EI #2 replied no. EI #2 was asked according to the admitting physicians orders and according to the MAR for October and November 2016 was the [MEDICATION NAME] given as ordered. EI #2 stated. No, according to the MAR indicated [REDACTED]. EI #2 was asked if the [MEDICATION NAME] was given as ordered by the Physician. EI #2 replied, no the resident did not receive the eight doses as ordered. EI #2 went on to add on 11/2/16 the resident was out of the facility so two of the eight doses were not given as ordered. EI #2 was asked what was the harm in not following Physicians orders. EI #2 replied, if the Physician orders the medication, expectation was that the care should be done; not being done as ordered could result in a change in the resident's status. (This deficient practice was cited as a result of the investigation of complaint AL 860)

Based on record reviews, interviews and a review of a facility document titled, General Education: [MEDICAL TREATMENT], the facility failed to ensure RI (Resident Identifier) #1 received [MEDICAL TREATMENT] as scheduled. On 06/15/2017, RI #1 was not dressed and ready to be transported to [MEDICAL TREATMENT] to receive [MEDICAL TREATMENT] at the scheduled time of 7:00 a.m. This affected one of three residents sampled for [MEDICAL TREATMENT]. Findings include: A review of a facility document titled, General Education: [MEDICAL TREATMENT] with no date revealed the following: .Coordination between [MEDICAL TREATMENT] Unit and LTC (Long Term Care) Transportation- The LTC is responsible for transportation. Coordination with the resident's [MEDICAL TREATMENT] schedule is important to prevent excessive wait time. RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's Physician order [REDACTED]. .[MEDICAL TREATMENT] TUES (Tuesday) THURS (Thursday), SAT (Saturday) CHAIR TIME 7A . A review of a document titled, 24 HOUR REPORT/CHANGE OF CONDITION REPORT with a date of 06/14/2017 revealed resident was admitted to the facility from the hospital at 3:50 p.m. during the 2 p to 10 p shift. Further review of the 24 HOUR REPORT/CHANGE OF CONDITION REPORT dated 06/15/2017 revealed the resident was discharged to [MEDICAL TREATMENT] at 1:55 p.m., and returned on 06/15/2017 at 2:42 p.m., and was discharged to the hospital emergency room (ER) at 8:15 p.m. A review of a transportation document revealed arrangements for transportation were made on 06/09/2017 and faxed to the transportation agency on 06/12/2017. A review of RI #1's admission nurse's departmental notes dated 06/14/2017 at 4:30 p.m., did not reference to RI #1's [MEDICAL TREATMENT] for 06/15/2017 at 7:00 a.m. On 07/12/17/ at 7:53 a.m., a telephone interview was conducted with EI #6, LPN (Licensed Practical Nurse), the admitting nurse. EI #6 was asked was she familiar with RI #1. EI #6 stated she did not remember the name. EI #6 was asked when were orders reviewed for new residents. EI #6 explained once the initial nurse did the assessment the second nurse goes behind to ensure orders are put in correctly. EI #6 was asked when a resident was scheduled for [MEDICAL TREATMENT] who was responsible for ensuring transportation was arranged. EI #6 said social services to her knowledge. EI #6 was asked what was the nursing staff's responsibility to ensure residents were prepared to go to [MEDICAL TREATMENT]. EI #6 explained, once the arrangements were made for the resident to go to [MEDICAL TREATMENT], the nursing staff was to get the resident up to go. EI #6 was asked why should physician orders [REDACTED].#6 explained to ensure the best possible care of the resident. EI #6 was asked who was responsible for following physician orders. EI #6 said the nursing staff. EI #6 was asked if the physician's orders [REDACTED]. EI #6 said yes. EI #6 was informed RI #1 had orders to receive [MEDICAL TREATMENT] on 06/15/2017, Thursday, and was asked should the orders have been followed. EI #6 said yes. EI #6 was informed on 06/15/2017, Thursday, RI #1 was not up and dressed to be transported to [MEDICAL TREATMENT] by 7:00 a. m. EI #6 was asked would she say the orders were followed. EI #6 said she could not say. EI #6 was informed of her documentation and was asked should her documentation had indicated RI #1's need for [MEDICAL TREATMENT] for 06/15/2017 if it were on the physician orders. EI #6 stated if it was on the physician orders [REDACTED]. A review of a facility document titled, General Education: [MEDICAL TREATMENT] revealed: .Each treatment lasts approximately 3-4 hours. Residents are usually on .Tues-Thurs-Sat schedule. On 07/12/2017 at 9:52 a.m. the surveyor phoned the [MEDICAL TREATMENT] clinic. According to the clinical manager per an email, RI #1 was expected to present to the [MEDICAL TREATMENT] clinic on 06/15/2017 at 7:00 a. m. The clinical manager explained RI #1 was brought to the clinic at 2:00 p.m., which was two hours past the cut off time. She further explained when the resident presented to the clinic, they had a black out and their generator did not cross over to their power source, so due to both the power outage and the time the resident was brought to the clinic for [MEDICAL TREATMENT], he/she was sent back to the facility. On 07/12/2017 at 10:41 a.m., an interview was conducted with EI #10, Social Services Director. EI #10 was asked how was social services made aware of new admitted residents who were in need of [MEDICAL TREATMENT]. EI #10 explained admissions let them know prior to the resident coming. EI #10 was asked who was responsible for arranging transportation for residents to go to [MEDICAL TREATMENT]. EI #10 said social services. EI #10 was asked if she was familiar with RI #1. EI #10 said, Yes ma'am. EI #10 was asked when was RI #1 initially scheduled to go to [MEDICAL TREATMENT] on 06/15/2017. EI #10 said the orders said 7 a.m. EI #10 was asked when did she set up transportation for RI #1. EI #10 reviewed the paperwork completed for transportation and explained the form was completed on 06/09/2017 and faxed on 06/12/2017. EI #10 was asked if transportation arrived prior to RI #1's 7 a.m. [MEDICAL TREATMENT] time on 06/15/2017. EI #10 yes. EI #10 was asked was RI #1 up and dressed for transportation to [MEDICAL TREATMENT] on 06/15/2017 for his/her 7:00 a.m. time. EI #10 said No ma'am. EI #10 was asked why. EI #10 explained the nurse, EI #14 told her (EI #10) she was unaware RI #1 had to be ready for the appointment. EI #10 was asked should RI #1 have been up and dressed prior to transportation coming to transport him/her to [MEDICAL TREATMENT]. EI #10 said, Yes ma'am. On 07/12/2017 at 11:28 a.m., an interview was conducted with EI #13, LPN, Admissions. EI #13 was asked when RI #1 was admitted to the facility was he ordered to receive [MEDICAL TREATMENT]. EI #13 said yes. EI #13 was asked on what days and at what time was RI #1 to go to [MEDICAL TREATMENT]. EI #13 said Tuesday, Thursday and Saturday at 7:00 a.m. EI #13 was asked who made social services aware RI #1 would need to be transported to [MEDICAL TREATMENT] on 06/15/2017 at 7 a.m. EI #13 replied, I did. EI #13 was asked who was responsible for ensuring RI #1 would be up and dressed for transportation to take him/her to [MEDICAL TREATMENT] on 06/15/2017. EI #13 said the nurse and the CNA (Certified Nursing Assistant) that morning. EI #13 was asked in her opinion, if orders were for RI #1 to receive [MEDICAL TREATMENT] on 06/15/2017, Thursday at 7:00 a.m. and he/she did not go due to the resident not being up and dressed, was the physician orders [REDACTED].#13 said No. EI #13 further explained RI #1's chair time was 7:00 a.m. and it was on his/her orders. A review of nursing departmental notes dated 06/15/2017 at 3:04 p.m. revealed the following: Resident returned to facility at 2:45p .Was not able to have [MEDICAL TREATMENT] d/t (due/to) power outage . Appt (Appointment) has been rescheduled for 06/16/17 chair time at 6A .Addendum 06/15/2017 3:17 PM Spoke to daughter, she stated that (RI #1) is going to have problems b/c (because) (RI #1) won't be able to breathe over night. She stated she would rather him go to the hospital, but we can keep him here at the facility unless he wants to go to the hospital. Spoke with resident again, he was ok with staying until his [MEDICAL TREATMENT] appt in the morning. On 07/12/2017 at 12:41 p.m., an interview was conducted with EI #11, RN (Registered Nurse) and nurse who documented the 3:04 p.m. entry on 06/15/2017. EI #11 was asked was she familiar with RI #1. EI #11 said yes. EI #11 was asked why was RI #1 not taken to [MEDICAL TREATMENT] on 06/15/2017 for his/her 7:00 a.m. chair time. EI #11 said she did not know because she was not there at 7:00 a.m. EI #11 was asked when did she start care for RI #1. EI #11 said she started at 2:00 p.m. EI #11 was asked was she aware RI #1 was to be at the [MEDICAL TREATMENT] clinic at 7:00 a.m., on 06/15/2017. EI #11 said yes. EI #11 was asked how was she made aware this. EI #11 explained because she put the orders in on 06/14/2017. EI #11 was asked who notified the resident's daughter of the missed appointment on 06/15/2017. EI #11 stated social services. EI #11 was asked if anyone attempted to reschedule RI #1's [MEDICAL TREATMENT] appointment prior to 2:00 p.m. EI #11 stated not that she was aware of. The surveyor referenced to EI #11's documentation regarding her conversation with RI #1's daughter who stated RI #1 would have problems because he/she would not be able to breathe overnight. EI #11 was asked what was the daughter referencing to. EI #11 said RI #1 not having [MEDICAL TREATMENT]. The Surveyor referenced to EI #11's documentation of RI #1's daughter stating she'd rather have RI #1 sent to the hospital unless RI #1 wanted to go. EI #11 was asked did RI #1 have confusion and was lethargic at times. EI #11 explained RI #1 did have intermittent confusion. EI #11 was asked did the daughter request to have RI #1 sent to the hospital to receive [MEDICAL TREATMENT]. EI #11 explained the daughter made it to be RI #1's decision. EI #11 was ask in reviewing RI #1's physician orders [REDACTED]. EI #11 said Tues, Thurs and Sat. at 7 a.m. EI #11 was asked based on reviewing RI #1's physician orders [REDACTED].#11 said No. EI #11 was asked why not. EI #11 said she was not for sure why RI #1 did not go to the 7:00 a.m., time. A review of RI #1's departmental nursing notes, dated 06/15/2017 at 12:35 p.m., it was documented RI #1 was lethargic and was confused and agitated. RI #1 had labored breathing when attempting to dress him/her self and was able to eat breakfast with feeding. On 07/12/2017 at 1:17 p.m., an interview was conducted with EI #12, RN, the nurse who documented on 06/15/2017 at 12:35 p.m. EI #12 was asked which shift she worked on 06/15/2017. EI #12 said first shift. EI #12 was asked was she familiar with RI #1. EI #12 replied, I remember him. EI #12 was asked who was responsible for getting a resident up and dressed who had a [MEDICAL TREATMENT] time for 7 a.m. EI #12 said the CNA on the third shift. EI #12 was asked was she RI #1's first shift nurse on 06/15/2017. EI #12 said she was. EI #12 was asked was she aware RI #1 was to be at [MEDICAL TREATMENT] at 7 a.m. on 06/15/2017. EI #12 explained yes she was aware the day before as well. EI #12 was asked why RI #1 was not up and dressed when transportation came to pick him up for [MEDICAL TREATMENT]. EI #12 explained because the third shift nurse and CNA were not aware until the transportation called to confirm they were going to pick RI #1 up at that time. EI #12 was asked what time had her shift started. EI #12 said 5:45 a.m. EI #12 was asked when she reviewed RI #1's physician orders [REDACTED].#12 replied, No they were not. EI #12 was asked why were they not followed. EI #12 explained they failed to communicate RI #1 was to go to [MEDICAL TREATMENT] and there was a break down between second and third shift. EI #12 further explained it was not communicated or not communicated well. EI #12 was asked what was the potential harm of RI #1 not receiving [MEDICAL TREATMENT] as ordered by the physician. EI #12 explained, loss of electrolytes, things not being leveled, creatinine levels off, fluid overload and RI #1 had some [MEDICAL CONDITION] and labored breathing and congestion. On 07/12/2017 at 4:14 p.m., an interview was conducted with EI #14, RN, third shift nurse. EI #14 was asked how long had she been employed at the facility. EI #14 said 6 months. EI #14 was asked what shift did she work. EI #14 explained she worked the night shift, 10 pm-6 am which was the third shift. EI #14 was asked if she was familiar with RI #1. EI #14 said no. The departmental nursing notes were given to EI #14 to review regarding her documentation as well as her reviewing RI #1's physician orders. EI #14 was asked when residents were scheduled to go to [MEDICAL TREATMENT] at 7 a.m. who was responsible for ensuring the resident was up and dressed and ready to be transported. EI #14 explained it would have been her shift (third shift). EI #14 was asked why was it important for residents to receive [MEDICAL TREATMENT] as scheduled. EI #14 explained it would alter their condition if they did not have it. EI #14 was asked in reviewing RI #1's physician orders; on what days was he/she to receive [MEDICAL TREATMENT] and what time. EI #14 said Tuesday, Thursday and Saturday at 7 a.m. EI #14 further explained she was not aware RI #1 was to receive [MEDICAL TREATMENT]. EI #14 was asked why was that. EI #14 explained she did not remember the report. The surveyor asked what report. EI #14 said the report received from the previous nurse. EI #14 was asked when would she have looked at RI #1's physician orders. EI #14 explained she could not give a time. A review of departmental nursing notes revealed the following: 6/15/2017 1:03 AM 1100 Ambulance here coming down the hall with the stretcher. Report that the pt (patient) called 911 for help .States I need to get out of here, I have been kidnapped Called daughter about (RI #1) condition.Concerned about her (RI #1) getting [MEDICAL TREATMENT]. The surveyor informed EI #14 according to her documentation, she notified RI #1's daughter due to his calling 911 at 11:00 p.m. and the daughter voiced her concern about RI #1's [MEDICAL TREATMENT]. EI #14 was asked would this concern voiced by the daughter have signaled to her of RI #1 receiving [MEDICAL TREATMENT]. EI #14 stated she did not remember and it was probably busy that night and residents that currently go to [MEDICAL TREATMENT] usually did not go that early. EI #14 further explained she would have informed the on coming nurse of the resident and [MEDICAL TREATMENT]. EI #14 was asked when a new admit came to the facility with a physician order [REDACTED].#14 explained follow through with the next shift. EI #14 was asked was that what she had done. EI #14 stated she could not remember. On 07/12/2017 at 6:22 p.m., an interview was conducted with EI #2, DON (Director of Nursing). EI #2 was asked how did each shift LPN or RN communicate what was going on with a resident at the end of each shift. EI #2 explained they would give verbal reports and document on a 24 hour report. EI #2 was asked with new admits, how was it communicated to each shift nurse of a resident ordered to receive [MEDICAL TREATMENT]. EI #2 explained [MEDICAL TREATMENT] was a physician order [REDACTED]. EI #2 was asked why each nurse on each shift should be aware of a new resident who required [MEDICAL TREATMENT]. EI #2 explained if it is a new resident they would want to monitor the resident and get a baseline and they would want to know the day and times of [MEDICAL TREATMENT] to ensure they receive the [MEDICAL TREATMENT] treatment as ordered. EI #2 was asked why was it vital a resident not miss [MEDICAL TREATMENT] appointments as ordered by the physician. EI #2 explained they would not want any negative outcomes. A review of RI #1's departmental nursing notes dated 06/15/2017 revealed the following: 6/15/2017 8:16 PM Resident having difficulty breathing .Contacted MD (Medical Doctor) regarding status, was given order to send to .ER (emergency room ). Resident's daughter contacted regarding status and that resident was sent to ER.Addendum 6/15/2017 11:54 PM Informed daughter that resident was sent to (name of hospital) for observation over night d/t (due to) his change in status and will have [MEDICAL TREATMENT] in the morning. This deficient practice was cited as a result of the investigation of complaint #AL 206.

Based on record review and interview the facility failed to ensure the fall care plan was followed for RI (Resident Identifer) # 1 who had a fall from the bed on 4-6-14. This resulted in a laceration to the left scalp/eye. This affected 1 of 6 residents sampled for falls. Findings Include: A review of a policy titled "Comprehensive Plan of Care" with an effective date of August 1, 2012 documented: "...Purpose to provide an individualized Plan of Care, for each resident...All staff personnel who provide care...shall be knowledgeable of, and have access to, the resident's Plan of Care..." RI # 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. with [DIAGNOSES REDACTED]. A review of the most recent annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/25/14, documented RI # 1 had both long and short term memory loss. Section J1800 documented RI # 1 had had a fall. Section J1900 B. documented 1 injury to include skin tears, abrasions, lacerations, superficial bruises, hematoma's and sprains; or any fall-related injury that causes the resident to complain of pain. A review of the care plan for RI # 1 documented the following: "Focus RI #1 has the potential for falls r/t (related to) upper and lower extremity contractures...Date initiated 7/27/12...Interventions...keep adjustable bed in low position Date initiated 7/27/12...Res (resident) to have safety mats at both sides of bed Date Initiated 8/13/12..." A review of a document titled "Resident Fall Analysis RCA Worksheet" dated 4/6/14 documented RI # 1 had a fall on 4/6/14. The document stated Floor Mats/Landing strips were not in place. A review of a document titled "Performance Improvement Action" dated 4/6/14 documented the following. "Resident falls from bed to floor, and was found by CNA (Certified Nursing Assistant) lying on floor on Left side with...bleeding above/Left eye brow. Brusing also noted to Left face. ...Bed was also not in the lowest position, with no floor mats present..." A review of Physician note dated 4/6/14 at 3:59PM from local hospital documented RI # 1 had a 3 cm (centimeter) superficial laceration of the scalp...Laceration was approximated and repaired with x steristrips..." A review of a Nursing note dated 4/6/14 at 5:51PM documented the following: "...4/6/14...Resident returns from local hospital ER (emergency room )...Upon assessment it was noted to have laceration of left forehead with steri strips intact. Area noted to have large discoloration to it. Resident unable to express or acknowledge pain or discomfort..." An interview was conducted with EI (Employee Identifier) #6, CNA (Certified Nursing Assistant) on 5/14/14 at 9:40AM. EI # 6 was asked to explain what she knew about RI # 1's fall on 4/6/14. EI # 6 stated she was the CNA assigned and she turned her Q 2 hrs (hours). EI # 6 stated she did her last turn and left her. EI # 6 stated she was coming back around and found her on the floor. EI # 6 was asked what position her bed was in. EI # 6 stated it was in a low position, not the lowest position but a low position. EI # 6 was asked what was on the floor beside her bed and EI # 6 responded nothing. EI # 6 was asked if she reviewed RI # 1's care plan before she fell . EI # 6 stated she did not have access to the care plan so she did not review it. EI # 6 was asked when she found RI # 1 on the floor what was her condition. EI # 1 stated she was lying on her left side and there was blood on the floor by her head area. An interview was conducted with EI # 8, LPN (Licensed Practical Nurse) Charge Nurse on 5/14/14 at 12:30PM. EI # 8 was asked to explain what happened concerning RI # 1's fall on 4/6/14. EI # 8 stated she was called to the room by EI # 6 and RI # 1 was on the floor. EI # 8 stated she assessed her and saw a laceration above her eye and it was bleeding. EI # 8 stated RI # 1 was sent out to the hospital to get checked out. EI # 8 was asked what caused her to fall and she stated she was not quite sure, that she barely moves but can move around some. EI # 8 was asked if RI # 1 had any fall precautions in place prior to the fall. EI # 8 stated to my knowledge she didn't. EI # 8 was asked if she knew what her care plan said prior to her fall and she stated no. EI # 8 was asked was a fall mat in place when she fell when you entered the room and she stated no. EI # 8 was asked was the bed in the lowest position. EI # 8 stated in a low position but not lowest position. EI # 8 was asked if the care plan stated that RI # 1 should have fall mats in place and bed in lowest position, should they have been in place. EI # 8 responded yes, they should have been in place. EI # 8 was asked do you feel if the bed had been in the lowest position or a fall mat had been in place would it have prevented RI # 1's injury. EI # 8 stated yes it would have aided. An interview was conducted with EI # 10, LPN on 5/14/14 at 1:00PM. EI # 10 was asked to explain what happened concerning the fall on 4/6/14. EI # 10 stated when she went in the room RI # 1 had blood on the left side of her face and a laceration above the left eye brow. EI # 10 stated this happened at the end of the first shift. EI # 10 was asked when she went in the room was the bed in the lowest position. EI # 10 stated no because we had to lower it, so the stretcher could get in from the ambulance. EI # 10 was asked if fall mats were by the bedside and she stated no. EI # 10 was asked should the bed have been in the lowest position and fall mats in place. EI # 10 stated, " I know the lowest position, but (I am) unsure about fall mats". EI # 10 stated she thought fall mats should be in place but did not actually see a plan for the fall mats. EI # 10 was asked if the care plan specified bed in low position and fall mat in place. should they have been in place. EI # 10 stated yes. EI # 10 was asked if fall mats and bed in low position had been in place would it have prevented RI # 1's injury. EI # 10 stated, maybe not as bad, because the mat would have provided a cushion. An interview was conducted with EI # 9, CNA on 5/14/14 at 1:30PM. EI # 9 was asked if she recalled a fall RI # 1 had on 4/6/14. EI # 9 stated yes, I remember we found her but I don't remember the date. EI # 9 was asked to explain what happened to RI # 1 concerning the fall. EI # 9 stated EI # 6 came and got her ; RI # 1 was lying by the window on her left side and she was bleeding from her head. EI # 9 was asked when you went in the room was there any mats on the floor and she stated no. EI # 9 was asked was the bed in the lowest position. EI # 9 stated it was low but not in the lowest position. EI # 9 was asked if the mat had been in place and the bed in a low position, would that have prevented injury. EI # 9 stated, a little bit she would not have bumped her head as hard. An interview was conducted with EI # 2, DON (Director of Nursing) RN (Registered Nurse) on 5/14/14 at 4:50PM. EI # 2 was asked if she was aware RI # 1 fell on [DATE] and she stated yes. EI # 2 was asked why the mats were not in place and the bed in lowest position. EI # 2 stated the CNA just didn't do it (lower the bed) after changing RI # 1, and the mats should have been in place. EI # 2 was asked who is responsible for ensuring mats are by the bedside and the bed is in a low position. EI # 2 stated whoever is taking care of her should check the care card and follow it. EI # 2 was asked if the mats should have been in place, and the bed in the lowest position when RI # 1 fell on [DATE]. EI # 2 stated yes. EI # 2 was asked what type of injury did RI # 1 have after her fall. EI # 2 stated a laceration to her left forehead. EI # 2 was asked if it was a major injury. EI # 2 stated it was an injury but she unable to classify it. EI # 2 stated she noticed the bed was not in a low position; if it had been, her injury would not have been that bad. An interview was conducted with EI # 5, MDS Coordinator on 5/14/14 at 3:45 PM. EI # 5 was asked what interventions were in place on 4/6/14 concerning the falls for RI # 1. EI # 5 stated the bed was to be in a low position and mats on both sides of the bed. EI # 5 was asked why these interventions were in place. EI # 5 stated RI # 1 had a fall over two years ago and that is what caused us to put the mats in place. EI # 5 was asked how do staff know what is on the care plan. EI # 5 replied, the care cards in the bedroom closet. EI # 5 was asked if mats should have been on the floor, and the bed in a low position on 4/6/14 when RI # 1 fell . EI # 5 stated yes, according to the care plan that was in place. EI # 5 was asked when a care plan is written do you expect it to be followed and she stated yes. EI # 5 was asked what harm could come to a resident if the care plan is not followed. EI # 5 stated there was a potential for skin tears with RI # 1. An interview was conducted with EI # 7, MDS Coordinator, LPN on 5/14/14 at 4:00PM. EI # 7 was asked what care plan was in place on 4/6/14. EI # 7 stated the former owner of the facility's care plan was still in place; we were trying to get them switched over to the new system. EI # 7 was asked on 4/6/14 did the care plan for RI # 1 include the bed in the low position and mats at the side of bed. EI # 7 stated yes. EI # 7 was asked if the care plan was updated on 4/7/14 after the fall on 4/6/14. EI # 7 stated yes, we added staff education and we updated it due to the fall. EI # 7 was asked should fall mats and bed in the lowest position have been in place on 4/6/14 when RI # 1 fell . EI # 7 stated yes.

Based on record review and interview, the facility failed to ensure RI (Resident Identifier) # 1 was free of accidents by not placing fall mats on each side of the bed and maintaining the bed in the lowest position. This affected 1 of 6 residents sampled for falls. Findings Include: A review of an undated policy titled "Care System Guideline" documented the following: "...Purpose: To establish a process that identifies risk and establishes interventions to mitigate the occurrence of falls..." RI # 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. with [DIAGNOSES REDACTED]. A review of the most recent annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/25/14 documented RI # 1 had both long and short term memory loss. Section J1800 documented RI # 1 had had a fall. Section J1900 B. documented 1 injury to include skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains; or any fall-related injury that causes the resident to complain of pain. A review of care plan for RI # 1 documented the following: "Focus RI #1 has the potential for falls r/t (related to) upper and lower extremity contractures...Date initiated 7/27/12...Interventions...keep adjustable bed in low position Date initiated 7/27/12...Res (resident) to have safety mats at both sides of bed Date Initiated 8/13/12..." A review of a document titled "Resident Fall Analysis RCA Worksheet" dated 4/6/14 documented RI # 1 had a fall on 4/6/14. The document stated Floor Mats/Landing strips were not in place. A review of a document titled "Performance Improvement Action" dated 4/6/14 documented the following. "Resident fall from bed to floor, and was found by CNA (Certified Nursing Assistant) lying on floor on Left side with...bleeding above/Left eye brow. Brusing also noted to Left face. ...Bed was also not in the lowest position, with no floor mats present..." A review of Physician note dated 4/6/14 at 3:59PM from local hospital documented RI # 1 had a 3 cm (centimeter) superficial laceration of the scalp...Laceration was approximated and repaired with x steristrips..." A review of a Nursing Note dated 4/6/14 at 5:51PM documented the following: "...4/6/14...Resident returns from local hospital ER (emergency room )...Upon assessment it was noted to have laceration of left forehead with steri strips intact. Area noted to have large discoloration to it. Resident unable to express or acknowledge pain or discomfort..." An interview was conducted with EI (Employee Identifier), CNA #6 on 5/14/14 at 9:40 AM. EI # 6 was asked to explain what she knew about RI # 1's fall on 4/6/14. EI # 6 stated she was the CNA assigned and she turned her Q 2 hrs (hours). EI # 6 stated she did her last turn and left her. EI # 6 stated she was coming back around and found her on the floor. EI # 6 was asked what position her bed was in. EI # 6 stated it was in a low position, not the lowest position but a low position. EI # 6 was asked what was on the floor beside her bed and EI # 6 responded nothing. EI # 6 was asked if she reviewed RI # 1's care plan before she fell . EI # 6 stated she did not have access to the care plan so she did not review it. EI # 6 was asked when she found RI # 1 on the floor what was her condition. EI # 1 stated she was lying on her left side and there was blood on the floor by her head area. An interview was conducted with EI # 8, LPN (Licensed Practical Nurse) Charge Nurse on 5/14/14 at 12:30PM. EI # 8 was asked to explain what happened concerning RI # 1's fall on 4/6/14. EI # 8 stated she was called to the room by EI # 6 and she was on the floor. EI # 8 stated she assessed her and saw a laceration above her eye and it was bleeding. EI # 8 stated RI # 1 was sent out to the hospital to get checked out. EI # 8 was asked what caused her to fall and she stated she was not quite sure, that she barely moves but can move around some. EI # 8 was asked if RI # 1 had any fall precautions in place prior to the fall. EI # 8 stated to my knowledge she didn't. EI # 8 was asked if she knew what her care plan said prior to her fall and she stated no. EI # 8 was asked was a fall mat in place when she fell when you entered the room and she stated no. EI # 8 was asked was the bed in the lowest position. EI # 8 explained the bed was in a low position but not the lowest position. EI # 8 was asked if the care plan specified that RI # 1 should have fall mats in place and the bed in the lowest position, should they have been in place. EI # 8 responded yes, they should have been in place. EI # 8 was asked do you feel if the bed had been in the lowest position, or a fall mat had been in place, would it have prevented RI # 1's injury. EI # 8 stated yes it would have aided. An interview was conducted with EI # 10 on 5/14/14 at 1:00PM. EI # 10 was asked to explain what happened concerning the fall on 4/6/14. EI # 10 stated when she went in the room RI # 1 had blood on the left side of her face and a laceration above the left eye brow. EI # 10 stated this happened at the end of the first shift. EI # 10 was asked when she went into the room was the bed in the lowest position. EI # 10 stated "no, because we had to lower it so the stretcher could get in from the ambulance." EI # 10 was asked if fall mats were by the bedside and she stated no. EI # 10 was asked should the bed have been in the lowest position and fall mats in place. EI # 10 stated I know the lowest position but (I am) unsure about fall mats. EI # 10 stated she thought fall mats should be in place but did not actually see a plan for the fall mats. EI # 10 was asked if the care plan specified bed in low position and fall mat in place, should they have been in place. EI # 10 stated yes. EI #10 was asked if fall mats and bed in low position had been in place would it have prevented RI # 1's injury. EI # 10 stated, maybe it would not have been as bad, because the mat would have provided a cushion. An interview was conducted with EI # 9 on 5/14/14 at 1:30PM. EI # 9, CNA was asked if she recalled a fall RI # 1 had on 4/6/14. EI # 9 stated yes I remember we found her but I don't remember the date. EI # 9 was asked to explain what happened to RI # 1 concerning the fall. EI # 9 stated EI # 6 came and got her; RI # 1 was lying by the window on her left side and she was bleeding from her head. EI # 9 was asked when you went in the room was there any mats on the floor and she stated no. EI # 9 was asked was the bed in the lowest position. EI # 9 stated it was low but not in the lowest position. EI # 9 was asked if the mat had been in place and the bed in a low position, would that have prevented injury. EI # 9 stated, a little bit; she would not have bumped her head as hard. An interview was conducted with EI # 2, DON (Director of Nursing) RN (Registered Nurse) on 5/14/14 at 4:50PM. EI # 2 was asked if she was aware RI # 1 fell on [DATE] and she stated yes. EI # 2 was asked why the mats were not in place and the bed in lowest position. EI # 2 stated the CNA just didn't do it (lower the bed) after changing RI # 1, and the mats should have been in place. EI # 2 was asked who is responsible for ensuring mats are by the bedside and the bed is in a low position. EI # 2 stated whoever is taking care of RI # 1 should check the care card and follow it. EI # 2 was asked if the mats should have been in place, and the bed in the lowest position when RI # 1 fell on [DATE]. EI # 2 stated yes. EI # 2 was asked what type of injury did RI # 1 have after her fall. EI # 2 stated a laceration left forehead. EI # 2 was asked if it was a major injury. EI # 2 stated it was an injury, but she was unable to classify it. EI # 2 stated she noticed the bed was not in a low position; if it had been her injury would not have been that bad. EI # 2 was asked what type of treatment RI # 1 received at the hospital. EI # 2 stated glue to the wound.

Based on interview and record review, Employee Identifier (EI) #13, a Registered Nurse (RN) unit manager, fed Resident Identifier (RI) #1,a resident at risk for aspiration due to swallowing difficulty, a puree diet; even though, EI #1, a Certified Nursing Assistant (CNA), reported that RI #1 would not wake up to eat his lunch on [DATE], contrary to the facility's policies and procedures related to feeding residents with swallowing problems and at risk for aspiration. A facility document entitled, "SIGNS AND SYMPTOMS: DYSPHAGIA AND ASPIRATION" warn that a decreased level of awareness and poor positioning while eating may lead to dysphagia (swallowing difficulty) and/or aspiration (food /fluid going into the lungs instead of the stomach). This document identifies coughing before or after swallowing, and a gurgly voice during or after eating/drinking as signs of dysphagia and/or aspiration. Also, the document instructs staff to stop the meal if symptoms worsen and notify the nurse and the doctor if a problem with swallowing is suspected. During the lunch meal on [DATE], EI #1, the CNA assigned to feed RI #1, notified EI #13, a RN unit manager who was in the dining room feeding another resident, that RI #1 would not open his mouth to eat and had done the same at breakfast. The RN unit manager (EI #13) directed CNA (EI #1) to talk to RI #1 to wake him up. EI #1 offered RI #1 a spoonful of pureed food; but, the resident would not eat. Again, EI #1 notified EI #13 that RI #1 would not eat. EI #13 (RN unit manager) came over to the table where EI #1 was attempting to feed RI #1, spoke in the resident's right ear, rubbed his right arm and the fed the resident a spoonful of his pureed lunch. Immediately after swallowing, RI #1 began coughing. Within 3 to 5 minutes, EI #13 fed RI #1 five (5) spoonfuls of pureed food despite the resident's continuous gurgling, rattling coughing sounds. EI #13 left RI #1's table to resume feeding her (EI #13's) assigned resident in the dining room. Staff (EI #2, EI #4 and EI #6) present in the dining room reported that EI #1 (CNA assigned to fed RI #1) repeatedly informed EI #13 that RI #1 did not sound right. EI #13 directed EI #1 to reposition the resident up in his wheelchair and feed RI #1. EI #13 came and assisted EI #1 with pulling RI #1 up in the wheelchair. EI #1 said that she never fed RI #1 any of his lunch because the resident never stopped coughing and making the gurgling / rattling sounds. EI #13 reported that RI #1's gurgling sounded like it was coming from his lungs (respiratory) instead of from his mouth (oral). EI #13 further described the sound as being loud and sounding like a coffee maker. Approximately seven (7) minutes later (around 12:50 PM), EI #13 (RN unit manager) came over to RI #1's feeding table and said the resident was aspirating. She (EI #13) wheeled RI #1 out of the dining room and down the hallway, towards the resident's room. While wheeling RI #1 down the hallway to his room, EI #13 asked EI #34, the Director of Nursing (DON), the whereabouts of the Respiratory Therapist (EI #29), and stated she needed a suction machine. EI #34 (DON) instructed EI #13 to get the suction machine from the crash cart and accompanied EI #13 with RI #1 into the resident's room, where they suctioned the resident' oral cavity to remove visible pureed food from his mouth. During the suctioning, RI #1 clinched his teeth and gurgled while breathing in and out. After suctioning RI #1, EI #13 (RN unit manager) and EI #34 (DON) failed to immediately notify the physician of RI #1's suspected aspiration. EI #12 (the treatment nurse) entered the room to do the resident's wound care treatment. EI #12 reported seeing the back of RI #1's high back wheelchair, the suction equipment and EI #13 and EI #34. EI #13 and EI #34 explained to EI #12 (treatment nurse) that RI #1 had just been suctioned and that he needed to stay up in the wheelchair. EI #13 and EI #34 left the resident in his room and went outside to smoke, failing to notify staff to ensure that staffs were aware of the need to closely monitor RI #1 for complications associated with aspiration. Being unaware of RI #1's suspected aspiration and the need to monitor RI #1's condition, as well as being unable to perform wound care with RI #1 up in the chair, EI #12 left the room, leaving the resident alone. Around 1:00 PM, EI #29 (the Respiratory Therapist) returned to facility from lunch and heard an overhead page directing him by name to RI #1's room STAT (immediately). Without clocking in, EI #29 went to RI #1's room and found the resident sitting alone in his wheelchair. EI #29 attempted to assess RI #1's breathing by listening to the resident's breath sounds with a stethoscope. EI #29 could not hear anything; so, he (EI #29) stepped back and looked at RI #1. EI #29 (Respiratory Therapist) stated, "He (RI #1) looked like he passed away." About one (1) minute later, EI #13 entered the room. EI #13 asked if RI #1 was breathing. EI #29 answered he was not breathing. EI #13 left the room while EI #29 attempted to check RI #1 for the presence of a carotid pulse. EI #12, the treatment nurse, entered the room and assisted EI #29 with moving RI #1 from the wheelchair onto the bed. EI #13 returned to the room with a crash cart and CPR was initiated. In response to the 911 call, emergency medical staff arrived at the facility and took over the resuscitation efforts. RI #1 was transported to a local hospital with CPR in progress. Shortly after arrival at the emergency room , RI #1 was pronounced dead. This deficient practice affected RI #1, one of one sampled residents. On [DATE] at 4:55 PM, the facility's Administrator, DON, Assistant Director of Nursing (ADON), and District Directors of Clinical Operations for Alabama and Georgia were made aware that the survey team had identified deficient practice at an Immediate Jeopardy (IJ) level in the area of Quality of Care (F 309). The IJ began on [DATE], and was relieved on [DATE], when the facility implemented immediate corrective actions to remove the immediacy. Findings include: RI #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. RI #1's Annual Assessment, with an assessment reference date of [DATE], documented RI #1 had problems with his short and long term memory and his cognition for daily decision making was severely impaired. RI #1 was totally dependent on staff for eating, had chewing and swallowing problems and was on a mechanically altered diet. The "Admitting/Annual History & Physical" form (signed [DATE]), summarized RI #1's hospital course and reason for admission to the nursing home as: "...hx (history) [MEDICAL CONDITIONS], dementia, transferred to HH (Huntsville Hospital) ED (Emergency Department) [DATE] 2nd (secondary) to [MEDICAL CONDITION] ... . CXR (chest xray) ... pneumonia ... . " The physical exam section of this form documented that RI #1 presented to the hospital with cognitive impairment, pain, coughing with swallowing and prior [MEDICAL CONDITION]. Nutrition and swallowing were listed as problems for RI #1, with plans for ST (Speech Therapy) to evaluate. According to this form, RI #1 was at "High risk for aspirating again." RI #1's [DATE] physician's orders [REDACTED]. the"'Nursing Alert" section of the [DATE] physician's orders [REDACTED]. On ,[DATE], ST evaluated RI #1 and documents on the Dysphasia Evaluation/Swallowing Profile" form, "...follow some simple commands ... Pt (patient) able to coordinate breathing/swallow ... Pt able to manipulate & swallow pureed [MEDICATION NAME] ... intermittent cough c (with) honey thick liq (liquid) ... Pt able to clear oral cavity c double swallow (arrow down = decrease) bite size alt (alternate) bites/sips ... mildly (arrow down = increase) swallow trigger (arrow down) laryngeal excursion c palpation - Intermittent cough c honey thick liq Participates c meal c good po (by mouth) consumption ..." The "Dysphagia Evaluation" ([DATE]) from ST documents, " ...Pt assessed @ beside for clinical dysphasia eval- Pt presented c puree/honey thick liq [MEDICATION NAME] See supp (Supplemental) eval ..." The "Supplemental Evaluation" documented, "... Pt c intermittent cough/throat clear c honey thick liq primarily - Pt needs to be up in chair for all meals to (arrow down=decrease) r/o (risk of) aspiration with po (by mouth) intake. Pt req (requires) max (maximum) cues & laryngeal stim (stimulation) intermittently to clear oral cavity of pureed [MEDICATION NAME]. Pt cont (continue) c (arrow up = increase) r/o aspiration ..." The ST discharged RI #1 from her care on [DATE]. The "Dysphagia Discharge Summary" documents, "D/C (discontinued) as max render potential has been met ... Caregiver demonstrated understanding of strategies to promote pt's safety of swallow ...". Documented under the "Swallowing Strategies" section of this form were, "...Upright at 90 Degrees During and After Meals ... Size of Bite/Sip 1 tsp bite size clearing oral cavity before subsequent presentation of [MEDICATION NAME] ..." A facility form titled Signs and Symptoms: Dysphagia and Aspiration (no date) documented, "...Common signs of dysphagia and/or aspiration are: Coughing before or after swallowing Much drooling, especially during meals Pocketing food inside the cheek... Trouble chewing Trouble swallowing certain types of fluids Trouble swallowing certain types of food Taking a very long time to finish a meal Getting tired during a meal Refusals to eat certain foods or finish a meal... A gurgly voice during or after eating or drinking Much throat clearing after a meal Repeated episodes if choking, frequent colds, pneumonias or "allergies [REDACTED]. Conditions that may lead to dysphagia and/or aspiration: Aging Poor dental alignment or missing teeth.. Decreased level of awareness Fatique Some medication side effects that weaken ability to swallow Poor muscle function as in [MEDICAL CONDITION] Poor eating habits described as stuffing, or rapid eating Some medical conditions Poor positioning or posture while eating...". EI #13, the RN unit manager in the dining room on [DATE], during the lunch meal documented her account of the events surrounding RI #1's death in the resident's medical record. A progress form dated [DATE] at 12:45 P.M., documents: " ...Up to w/c (wheelchair) in DR (Dining Room) for noon meal. Total care resident c (with) feeding assist needed. Oral secretions noted to be collecting c poor swallowing due to positioning. Back of chair & (and) resident positioned to more upright angel. Resident responding to position change. Answers to verbal stimuli & clearing of oral secretions. Several bites of food administered assuring proper swallowing and clearing of oral cavity. CNA (Certified Nursing Assistant) to cont. feeding. Call back to resident when informed of increased secretions noted to change in tone c inspiration & exhalation. Immediately remove from DR. RT (Respiratory Therapist) paged & oral suctioning provided, DON at side observing procedure. Tolerated well, respirations improved c decreased audible respiration. Responsive to stimuli, ...MD (medical doctor) to be notified." A second progress noted dated [DATE] at 12:50 P.M., documents: "...R/T responds to overheard page and at side. Entered room to give report of which the resident noted to be absent of respirations. Code status verified, CPR initiated c assist of RT & DON. Ancillary staff @ bedside to assist. HEMSI (Huntsville Emergency Medical Services, Inc) & family noted ... ". A third progress noted dated, [DATE] at 1:10 P.M., documents: "... To Huntsville Hosp (Hospital) ER via (by) HEMSI, CPR continues via HEMSI staff. " Surveyors conducted the following interviews with all staff members involved in the incident described above. Interviews were as following: On [DATE] at 2:20 PM, EI #1, the CNA assigned to fed RI #1's breakfast and lunch meal on [DATE], was asked to describe where RI #1 was positioned in the dining room. EI #1 stated EI #1 was seated in the back section of the main dining room. EI #1 stated the back section and front section of the main dining room was separated by a doorway. EI #1 stated that RI #1 was positioned in a high back wheelchair, in the back dining room, facing the doorway entrance. EI #1 stated she was sitting next to RI #1 on his left side during this lunch meal. EI #1 stated she attempted to feed RI #1 his lunch, which he had a pureed diet consisting of a meat, mashed potatoes and turnip greens, but RI #1 would not opened his mouth. EI #1 stated RI #1 tighten his lips and would not open his mouth. So, EI #1 notified the unit manager, RI#13 that RI #1 would not open his mouth and had done the same at breakfast. EI #13 instructed EI #1 to talk to RI #1 to wake him up. Again, EI #1 attempted to feed RI #1 a spoonful of food; RI #1 would not eat. EI #13 came over from her assigned feeding table to RI #1's table, spoke in his right ear and rubbed his right arm. EI #1 said that EI #13 picked up the spoonful of food and gave it to the resident (RI #1). RI #1 began coughing after EI #13 fed him the first spoonful of food. EI #13 fed him a second spoonful; and, RI #1 continued to cough and started making gurgling sounds. EI #1 reported witnessing EI #13 (RN Unit Manager) administer five (5) spoonfuls of pureed food in about 3 to 5 minutes to RI #1, before returning to her (EI #13's) assigned feeding table. With RI #1 continuously coughing and making gurgling, rattling sounds, EI #13 instructed EI #1 to reposition RI #1 up in his chair. EI #1 recalled asking another CNA (EI #6) present in the dining room to help reposition the resident; however, EI #13 came and assisted with repositioning RI #1. Despite being repositioned up in the chair, RI #1 continued to cough and make gurgling, rattling sounds. EI #1 said that she never fed RI #1 any of the lunch meal because the resident never stopped coughing and making the gurgling, rattling sounds. According to EI #1, approximately seven (7) minutes later, EI #13 returned to RI #1's feeding table, said that RI #1 was aspirating and wheeled RI #1 out of the dining room because the resident never stopped coughing and making the gurgling, rattling sounds. EI #6 a CNA, in the dining room on [DATE], during the lunch meal, was interviewed on [DATE] at 3:33 PM. EI #6 stated she was sitting in the dining room on [DATE] during the lunch meal. EI #6 stated she recalled RI #1 coughing and making a gurgling sound. She stated she turned around towards RI #1 and EI #1 after hearing the sounds. EI #6 stated she saw EI #1 holding a spoon toward RI #1's mouth. EI #6 stated she observed EI #1 tapping the spoon against RI #1's mouth but RI #1 would not open his mouth. EI #6 was asked what RI #1 was doing at this time. EI #6 stated RI #1 was coughing. When RI #1 stopped coughing EI #1 attempted to feed RI #1 again, tapping his mouth to get RI #1 to open it. EI #6 stated RI #1 started coughing again. EI #6 stated EI #1 notified EI #13 stating RI #1 did not sound right. EI #6 stated EI #13 said let' s scoot him up. EI #6 stated EI #1 asked her to help reposition RI #1 however, before she was able to provide assistance to EI #1, EI #13 was helping EI #1 reposition RI #1 in his chair. EI #6 stated she had stood to walk over to RI #1 to help EI #1 reposition him and around the time she sat back down to feed a resident, after observing EI #13 assisting EI #1 in repositioning RI #1, she glanced over her shoulder in the direction of RI #1 and noticed EI #13 rolling RI #1 out of the dining room. EI #6 stated she overheard EI #13 instructs EI #1 to continue to feed RI #1. She stated she heard EI #13 say RI #1 was aspirating. EI #2, a CNA in the dining room on [DATE], during the lunch meal, was interviewed on [DATE] at 4:00 PM. EI #2 stated she was sitting in the dining room on [DATE] during the lunch meal. She stated she overheard EI #1 telling EI #13 that RI #1 was coughing and did not sound right. EI #2 stated she overheard EI #13 telling EI #1 to continue to feed RI #1. EI #2 stated she did not observed RI #1 from where she was seated because RI #2 stated she did not turn around. EI #4, a CNA in the dining room on [DATE], during the lunch meal, was interviewed on [DATE] at 4:30 PM. EI #4 stated she was sitting in the dining room on [DATE] during the lunch meal. EI #4 could only recall hearing EI #1 informing EI #13 that something was not right with RI #1, and that the resident was not eating. EI #4 recalled hearing EI #13 instructing EI #1 to reposition RI #1. EI #13, the RN/Unit Manager in the dining room on [DATE], during the lunch meal, was interviewed on [DATE] at 4:10 PM. EI #13 stated when she initially observed RI #1 he looked fine. EI #13 stated when she was called by EI #1 to observe RI #1 he was positioned in his chair and was heard making a gurgling noise. EI #13 stated RI #1 had slid down in his chair and the wheelchair was reclined. EI #13 stated his wheelchair was not up as high as it needed to be. EI #13 stated food was in EI #1's mouth. EI #13 stated RI #1 has a history of having food in his mouth. EI #13 stated she looked into EI #1's mouth and then, with the help of EI #1, she pulled RI #1 up in his chair. EI #13 stated she bent down to reposition RI #1; he coughed and made a gurgling noise. EI #13 stated she stood next to EI #13 and bent over jokingly to talk with RI #1. EI #13 stated she feed RI #1 three bites of food. She stated she gave him a bite of the pureed food and watched how he swallowed the food. EI #13 stated she watched his Adams's apple move and felt he was swallowing properly. EI #13 stated she made sure his mouth was clear of food and that he was not gurgling. EI #13 stated when RI #1 gurgled, based on a previous experience; he would be holding food in the back of his mouth. EI #13 was asked if she reported the resident gurgling to anyone. EI #13 stated this had been reported previously and an x-ray was performed on RI #1. EI #13 was asked the results of the x-ray. EI #13 stated after the x-ray, RI #1 had a [DIAGNOSES REDACTED].#1 called her name to informed her of RI #1's condition two times during this lunch meal. EI #13 stated the second time she assessed the resident she determined RI #1 was not making the "...typical noise that he makes ..." EI #13 was asked to explain what was different about EI #1. EI #13 stated based on her assessment there was a change in RI #1's respiratory sounds. EI #13 stated RI #1 sounded like a "...coffee maker ...". EI #13 stated she wheeled RI #1 from the dining room to his room to suction him. EI #13 stated, with the DON present, she suctioned RI #1's mouth. She stated she suctioned RI #1 until she could not longer hear a noise. EI #13 stated RI #1 was swatting at her and biting the suction yanker. EI #13 stated when she felt RI #1 was stable she left the room with the DON to provide the DON a report on the resident. EI #13 stated EI #12, the Treatment Nurse, was left in the room to monitor the resident, while she and DON left the resident's room and went outside the building. EI #13 stated when she and the DON returned back inside the building after 10 minutes, she went to the nursing station with the intent to call RI #1's doctor to obtain an x-ray. EI #13 stated while at the nursing station she heard an overhead page for EI #29, the Respiratory Therapist. She was informed by RI #7, an Licensed Practical Nurse, that EI #29 was in RI #1's room. EI #13 stated she left the nursing station and went to RI #1's room to find EI #29, the Respiratory Therapist, assessing RI #1. EI #13 stated she recalled EI #29 informing her that RI #1 was not breathing. EI #13 stated she ran down the hall to obtain the crash cart and told people in the hallway to verify RI #1's code status and call the code. EI #13 stated CPR was performed on RI #1 until the emergency response team arrived. She stated RI #1 was transported by the response team to the hospital. On [DATE] at 3:50 PM, EI #12, the Treatment Nurse was interviewed. EI #12 stated when she entered RI #1's room she noticed RI #1 was sitting in his wheelchair with his back facing the door entrance. She stated she noticed EI #13, RN, Unit Manager was holding a suction yanker and the suction canister in her hand and EI #34, DON, was standing beside RI #1. She informed EI #13 and EI #34 that she was there to provide wound care treatment to RI #1. EI #12 stated she could only see the back side of RI #1 and his wheelchair. She stated she recalled going to his bedside table to set-up her wound care supplies and noticed EI #13 and EI #34 were walking out the room. EI #12 stated EI #13 informed her that they had just suctioned RI #1. EI #12 stated she recalled EI #13 and EI #34 walking towards the doorway so she asked if RI #1 could be placed in a lying position so she could provide care to RI #1's wound. EI #34 stated to let RI #1 remind in a sitting position because he was able to breathe better (in that position). Being unable to perform wound care treatment on RI #1, EI #12 stated she collected her wound care supplies and left the room. Durning this interview with EI #12, she stated she wanted to inform the surveyor that she was never left in the room to monitor RI #1 at anytime. EI #29, the Respiratory Therapist, was interviewed on [DATE] at 2:55 PM. EI #29 stated he recalled around 1:00 PM, he walked into the building after returning from lunch. Upon entering the building, he heard an overhead page. EI #29 remembered hearing his entire name, a resident's room number and STAT (immediately) in the overhead page. EI #29 stated he remembers not being able to clock back in on the time clock because of the stat page; he went straight to RI #1's room. Upon entering RI #1's room, no one was in the room except RI #1. He recalled walking into RI #1's room and finding the resident sitting in the wheelchair alone. RI #1 looked at EI #29 and rolled his eyes. EI #29 stated he started to assess RI #1 by listening to his breath sounds with a stethoscope. He described RI #1 as breathing and said that RI #1 looked at him. As EI #29 listened, he did not hear anything; so, he stepped back and looked at RI #1. EI #29 stated, "he looked like he passed away." About a minute later, EI #13 entered the room. EI #29 stated he recalled EI #13 asking him if RI #1 was breathing. EI #29 stated he said he was not breathing. EI #29 stated EI #13 left the room while he was checking the resident for a carotid pulse. EI #29 stated while EI #13 was out of the room, EI #12, the Treatment Nurse, came in the room. According to EI #29, EI #12 said that RI #1 needed to be moved from the wheelchair onto the bed. While moving RI #1 to the bed, EI #29 stated he thought EI #13 had returned to the room with a crash cart. EI #29 recalled placing the back board underneath RI #1 so CPR could be initiated. On [DATE] at 5:00 PM, EI #34, the DON, was interviewed. EI #34 stated that she came down the hallway and EI #13(RN/Unit Manager) stated that she needed a suction machine. EI #34 instructed EI #13 to obtain the suction machine from the crash cart. EI #34 stated that she entered RI #1's room with EI #13 and there was no one else in the room with the resident. EI #34 stated that when she went to his room, EI #1 had visible pureed food in his mouth and his respirations were gurgley. EI #34 stated that the resident was not coughing or choking and he was never cyanotic. EI #34 stated that after the resident was suctioned that he was sitting up and looking at them. EI #34 stated that she felt that his airway was cleared, no distress. EI #34 was asked what was RI #1's vital signs prior to and after suctioning. EI #34 stated that no one had checked his vital signs. EI #34 stated that she did not listen to RI #1's lungs and that she had not observed RI #1's lungs being auscultated before or after suctioning. EI #34 was asked what did she do when she left RI #1's room. EI #34 stated that her intentions were to go get the Physician, but she and EI #13 went outside and took two (2) to three (3) puffs off of a cigarette instead. EI #34 stated she returned from outside of the facility and headed toward the Sub Acute Unit to the Physician's office. EI #34 said she never made it to the Sub Acute Unit to notify the physician because she responded to an overhead page directing her to go to RI #1's room STAT (immediately). EI #34 stated that right after that page, a Code Blue was called for RI #1's room. The surveyor asked EI #34 if it was sound judgement to instruct a CNA to continue feeding a resident who is classified as "High Risk for Aspiration", if that resident was drowsy. EI #34 stated that professionally, no. EI #34 stated you can not use the resident sleeping as an excuse not to feed the resident. EI #34 also stated that you have to attempt to arouse the resident and feed him. If the resident remains unarousable it would be in my professional judgement not to feed the resident. The surveyor then asked EI #34 what would have been the correct procedure to follow in the dining room with RI #1 on [DATE]. EI #34 stated that when the CNA voiced her concern, the Nurse should have stayed with that resident instead of going back to her scheduled resident. The facility policy titled Condition Change of a Resident, dated [DATE] documented, "Rationale: Resident change of condition is identified for proper treatment implementation. The physician is informed of resident events and/or change in resident's condition... Significant Change-A decline or improvement in a resident's status that: Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, is "self-limiting"; Impacts more than one area of the resident's health status...Procedure... 1. Assess Resident. 2. Take vital signs and include temperature. 3. Gather and organize the resident's information (chart, medication list, vital signs, etc.) for physician notification. 4. Designate someone to stay with resident while physician is notified, if necessary. 5. Notify the physician of the clinical problems. If attending physician is not available, notify the alternate physician on call then Medical Director... 11. Monitor and reassess resident's condition and response to interventions until stable or until emergency personal arrives and takes over care for transfer to acute care... Documentation Guidelines... 2. Document the time emergency personnel arrived and took over the care of resident, if applicable. a. Document the time resident was transferred to acute care, resident's condition at the time of transfer, method of transfer (i.e., stretcher) and transportation means (i.e., ambulance). b. Notification of resident's transfer and location...". EI #37, the Paramedic for HEMSI was interviewed on [DATE] at 4:05 PM. EI #37 stated they arrived to RI #1's room at 1:01 PM. EI #37 stated several people were in the room. She stated, the Huntsville Fire Department who was in the room, reported they had entered the room and the patient was still warm. Huntsville Fire Department stated the staff informed them that the resident was last seen ten minutes earlier. EI #37 stated she did not observe anything in RI #1's mouth and CPR was continued until they got the resident to the hospital. EI #37 stated they transported EI #1 to the hospital at 1:16 PM and arrived at the hospital, where the care of RI #1 was handed over to hospital staff at 1:18 PM. EI #30, the Speech Therapist, was interviewed on [DATE] at 10:50 PM. EI #30 stated she was familiar with RI #1 and stated she recalled him being impaired and was on a pureed diet with honey thick liquids. EI #30 stated she had assessed RI #1 and had made recommendation on how to feed RI #1. EI #30 stated she instructed staff to have RI #1 in an upright position during all meals and required maximum verbal tactile stimulation to get him to swallow. EI #30 stated RI #1 continued to be at risk for aspiration. EI #30 stated feeding should be discontinued should a resident start coughing continuously and is making gurgling sounds. EI #30 stated the resident should definitely not be fed if he or she is drowsy, sleepy or not alert. EI #13 was interviewed again on [DATE] at 11:10 AM. The surveyor asked in her opinion was it sound judgment to feed a resident who is at high risk for aspiration, and is observed coughing and gurgling. EI #13 stated if a resident is coughing and gurgling you should stop feeding. On [DATE] at 5:00 PM, EI #34, DON, was interviewed. EI #34 was asked what type of assistance did RI #1 require. EI #34 stated that RI #1 was a total care -resident and that he required feeding assistance from the staff. EI #34 stated EI #30 (Speech Therapy) had completed RI #1's treatment and left instruction regarding RI #1. EI #34 stated EI #30 instructions were to that RI #1 should be in the upright position and that he was an aspiration risk. EI #34 also stated that when RI #1 returned from the hospital on [DATE], it was reported to her that the resident had received therapy for swallowing and that he was not a candidate for a [DEVICE] (Gastrostomy tube). EI #34 was asked by the surveyor what type of instructions had been left by Speech Therapy. EI #34 stated that the instructions were written in the Progress Note and prior to the incident with EI #34, Speech Therapy had clarified the orders that RI #1 had to be upright. EI #34 stated that previous orders for RI #1 was for him to be upright in a chair. EI #34 stated that she thought the clarification orders was just stated as upright, not specifically in a chair. EI #34 stated that the CNAs were aware of the position the resident should be in by the Care Card. The Surveyor asked EI #34 if RI #1 had ever aspirated prior to [DATE]. EI #34 stated that she knew that he had Pneumonia, but to answer the question she would have to review the chart. EI #34 was then asked if RI #1 had aspirated on [DATE]. EI #34 stated that the resident had symptoms of aspiration, that he had food in his airway, but there was not a Chest X-ray performed to confirm aspiration. The facility policy titled Dining Skills Level, dated [DATE] documented, "Rationale: Residents are placed in the dining area that best meets their needs and skills, based on assessment and observation.... Dependent Dining-Residents who require total assistance due to extreme physical and/or cognitive impairment.... Procedure... 2. Notify OTR or SLP if there is a change of swallowing status or a decline-in dining skills noted... Specific Consideration for Restorative Dining 12. Assign staff trained and competent in restorative dining procedures and techniques... Specific Consideration for Assistive Dining... 20. Monitor safety of residents with specific swallowing needs/techniques (pocketing, double swallow, positioning)...". EI #33, the Administrator, was interviewed on [DATE] at 10:45 AM. EI #33 was asked if a resident is coughing or gurgling and at high risk for aspiration should the a staff member continue to feed this resident their meal. EI #33 stated he would not think that would be the thing to do given that description. This deficiency was cited as a result of complaint/report #AL 156. ********************************************** September, 15 2010 AOC 1. How corrective action will be accomplished for those affected: Immediate Action/ Corrections The resident involved in the citation was sent to the ER where he expired. Staff ( C.N.A, Unit Manager/Director of Nursing) involved in the care of R1 after his event have received education and training on documentation of care, identification of aspiration, patient assessments after acute event , monitoring of resident after an acute event. The RN unit manager has resi