Every finding on record at Diversicare of Greensboro

Based on observations, interviews, and review of a facility policy titled Resident's Rights and Quality of Life, the facility failed to ensure the 100 hall and Resident Identifier (RI) #52's room did not smell strong of urine on three of three days of the survey. This had the potential to affect RI #52 and other residents on the 100 hall, one of four halls in the facility. Findings include: Review of a facility policy titled Resident's Rights and Quality of Life with an effective date of 05/01/2012 revealed: POLICY STATEMENT . all residents have the right to a dignified existence . To receive services in a facility environment that is safe, clean, and comfortable with adequate space for all activities. RI #52 was admitted to the facility 06/07/2019 and had diagnoses to include Dementia. A review of a quarterly Minimum Data Set with an Assessment Reference Date of 12/18/2023 indicated a Brief Interview for Mental Status score of 9 which indicated RI #52 was moderately impaired in decision making abilities. The MDS further indicated RI #52 was occasionally incontinent of urine. On 01/30/2024 at 9:53 AM the surveyor observed a strong urine odor upon walking on the 100 hall. On 01/30/2024 at 9:59 AM RI #52's room was observed smelling strong of urine. On 01/30/2024 at 2:11 PM RI #52's room was observed with a urine odor. Housekeeper (HK) #4 was questioned and said RI #52 uses the bathroom and places soiled paper and briefs in the trash can and sometimes urinates on the floor. HK #4 said, they frequently clean up and empty the trash. During this observation the trash can was full of paper and the urine smell was strong in the bathroom. On 01/31/2024 at 8:57 AM a strong odor of urine was noticed on the 100 hall more noticeable at RI #52's room. On 01/31/2024 at 9:46 AM a strong urine odor was observed on the 100 hall. On 01/31/2024 at 11:30 AM a Certified Nursing Assistant (CNA) #5 said, she did work occasionally on the 100 hall. CNA #5 said, the hall smelled of urine quite often as RI #52 would take briefs off and hide them. When CNA #5 was asked what could be done to resolve the strong urine odor, she said, check the room often for hidden briefs, clean the room, and empty the trash. CNA #5 stated, a resident's room and the hall should not smell like urine, it should be homelike. CNA #5 said, the nursing and housekeeping staff were responsible to make sure resident's rooms and halls did not smell strong of urine. On 01/31/2024 at 2:51 PM there was still a strong odor of urine noted on the hall. On 02/01/2024 at 8:02 AM the 100 hall had a strong urine odor that increased closer to RI #52's room, which also had an odor of urine. On 02/01/2024 at 8:25 AM CNA #6 was asked what she smelled, she replied, urine. When CNA #6 was asked where the urine odor was coming from, she said, it was from RI 52's room. CNA #6 said, the resident would urinate in the trash can and the smell lingered out to the hall. CNA #6 said it was not homelike for resident's rooms and halls to smell like urine. On 02/01/2024 at 8:49 AM, the Housekeeping Supervisor (HKS) walked with the surveyor to the 100 hall. When asked what she smelled, she replied, urine. The HKS was asked why we smelled urine. She said it was a trail of urine odor from RI #52's room. The HKS stated, RI #52 placed briefs in the trash can and urinated in the trash can. The HKS said they mopped, emptied the trash, and cleaned frequently. The HKS said, the room was cleaned two times a day. The HKS stated, the 100 hall and RI #52's room should not smell of urine because it was not clean and homelike. On 02/01/2024 at 9:13 AM, the surveyor walked to the 100 hall with the Administrator (ADM), he was asked what he smelled. The ADM replied, urine. The ADM was asked why the hall smelled of urine, he said, he was not sure. When the ADM was asked what the concern was with the 100 hall smelling of urine, he said, it was not homelike.

Based on observations, interviews, resident record review, and a facility policy titled, NEBULIZER STORAGE, the facility failed to ensure Resident Identifier (RI) #26's nebulizer mask was covered when not in use. This affected RI #26, one of one resident sampled for respiratory care. Findings include: A facility policy titled NEBULIZER STORAGE, with an effective date of 8/2019 documented: . Policy: Storing of the nebulizer consist of dry storage in a zip loc bag. RI #26 was admitted to the facility on [DATE] and had diagnoses to include Asthma. RI #26 had a physician order dated 01/24/2023 for the administration of Ipratropium-Albuterol Inhalation Solution every six hours. On 01/30/2024 at 11:17 AM, RI #26's nebulizer machine was on the bedside dresser with a nebulizer mask uncovered. On 01/30/2024 at 4:45 PM, RI #26's nebulizer machine was on the bedside dresser with a nebulizer mask uncovered. On 01/31/2024 at 8:07 AM, RI #26's nebulizer machine was on the bedside dresser, with a nebulizer mask in a basket on the floor and not in a bag. On 01/31/2024 at 8:52 AM, an interview was conducted with the Director of Nursing (DON). RI #26's room was observed with the DON and she was asked, where the nebulizer mask was. The DON said, it was in a basket on the floor. The DON said, the nebulizer mask was not covered and not in a bag. The DON said the nurse on duty was responsible for storing the nebulizer mask. The DON said, the nebulizer mask should be covered to prevent infection.

Based on observation, interviews, record review, and the facility policy titled, Medication Administration, the facility failed to document respiratory treatments on Resident Identifier (RI) #26's Medication Administration Records (MAR). This deficient practice had the potential to affect RI #26, one of 19 residents for whom records were reviewed. Findings include: A facility policy titled Medication Administration, with a reviewed date of 07/2023, documented the following: . PROCEDURE: . Only licensed or legally authorized personnel who prepares a medication may administer it. This individual records the administration of medication on the resident's MAR/EHR (Medication Administration Record/Electronic Health Record) at the time the medication is given. RI #26 was admitted to the facility on [DATE] and had diagnoses to include Asthma. RI #26 had a physician order dated 01/24/2023 for the administration of Ipratropium-Albuterol Inhalation Solution every six hours. RI #26's January 2024 MAR had blank spaces where licensed nurses had failed to document administration of the inhalation solution every six hours on the following days and times: 01/01/2024 at 12:00 AM 01/04/2024 at 6:00 PM 01/05/2024 at 12:00 AM 01/10/2024 at 12:00 AM 01/14/2024 at 12:00 AM 01/15/2024 at 12:00 PM 01/18/2024 at 12:00 AM 01/19/2024 at 12:00 AM 01/21/2024 at 12:00 PM and 6:00 PM 01/23/2024 at 12:00 AM 01/24/2024 at 12:00 AM 01/28/2024 at 12:00 AM 01/30/2024 at 6:00 PM On 01/31/2024 at 3:19 PM, an interview was conducted with Licensed Practical Nurse (LPN) #7 and she was asked if she was working on 01/15/2024. LPN #7 said, yes. When asked about the respiratory treatment, LPN #7 said, the treatment was not documented but had been administered. LPN #7 said, she signed the MAR but it was not showing documented. LPN # 7 said, the concern of not documenting respiratory care for RI #26 on the MAR was the resident could receive too much medication if given twice. On 01/31/2024 at 3:34 PM an interview was conducted with LPN #8 and she was asked if she was working on 01/01/2024, 01/04/2024, 01/10/2024, 01/19/2024, and 01/30/2024. LPN #8 said, yes she was. LPN #8 said she performed the respiratory treatment for RI #26. LPN #8 said she signed the MAR and did not know why her initials were not there. LPN #8 was asked what the concern was of not documenting respiratory treatment for RI #26 on the MAR. LPN #8 said, the resident could receive too much medication if given twice. On 01/31/2024 at 3:57 PM a telephone interview was conducted with LPN #9 she said she was working on 01/24/2024 and completed the respiratory treatment for RI #26. LPN #9 was asked if the respiratory treatment was documented on the MAR on 01/24/2024 for RI #26. LPN #9 said, no she forgot to sign the MAR. LPN #9 was asked what was the concern of not documenting respiratory care on the MAR and she said, the resident could receive the medication multiple times. On 01/31/2024 at 04:05 PM a telephone interview was conducted with LPN #10 and she said she was working on 01/05/2024, 01/14/2024, 01/18/2024, 01/21/2024, 01/23/2024, and 01/28/2024. LPN #10 said, she performed the respiratory treatment for RI #26 on the above dates and forgot to document. LPN #10 was asked what was the concern of not documenting respiratory care on the MAR and she said if it was not documented, it was not given. An interview was conducted with the Director of Nursing on 01/31/2024 at 4:30 PM. The DON was asked, was there documentation of respiratory care being performed for RI #26 on 01/01/2024, 01/04/2024, 01/05/2024, 01/10/2024, 01/14/2024, 01/15/2024, 01/18/2024, 01/19/2024, 01/21/2024, 01/23/2024, 01/24/2024, 01/28/2024, and 01/30/2024, she said no. The DON was asked what was the concern of not documenting respiratory care on the MAR, she said it could cause a medication error.

Based on observation, interviews, record review, and a review of the facility policy titled, Enteral Nutrition, the facility failed to ensure Resident Identifier (RI) #19 received the nutritional requirements recommended by the Licensed Dietician. This affected RI #19, one of two residents sampled for enteral nutrition. Findings include: A facility policy titled, Enteral Nutrition, effective date: (MONTH) 01, (YEAR), included the the Policy statement . Adequate nutritional support . will be provided . as ordered. Policy Interpretation and Implementation: . 3. The Dietitian, . Physician and Nurse, will: . b. Determine whether the resident's current intake is adequate . 8. The Dietitian will monitor residents . and will make appropriate recommendations for . adequacy of enteral feedings. 14. Staff caring for the residents with feeding tubes will be trained . to recognize and report . b. Inadequate nutrition; . RI #19 was readmitted to the facility on [DATE]. A [DIAGNOSES REDACTED]. A review of RI #19's medical record revealed a physicians order to include: [MEDICATION NAME] at 80 (milliliter)ml/hour X 20 hours on at 4pm and off at 8am to provide 1600ml/2400 CAL(calorie) daily Water flush at 60 ml/hour X 20 hours from 4pm to 8am to provide 1440ml daily. On 12/10/19 at 04:36 p.m., an observation was made of the tube feed infusing per pump with [MEDICATION NAME] 1.5 (Fillable bag) at 80ml/hr dated 12/10/2019 at 4pm approx 675ml in bag; water flush at 60ml/hr dated 12/10/2019 full bag of H2O. On 12/10/19 at 04:42 p.m., Employee identifier (EI) # 7, a Licensed Practical Nurse (LPN), was asked how much [MEDICATION NAME] was placed in the fillable bag for the tube feed. EI #7 stated she had put 3 cartons of 237ml each (=711mls) at 4pm. On 12/11/19 at 08:33 a.m., an observation was made of RI #19's tube feeding(TF) pump and pole in the room with no TF infusing. Verifying the tube feed did not infuse for 20 hours as ordered. On 12/11/19 at 09:18 a.m., a review of RI #19's weights revealed a 4.8% weight loss in a 6 month period. On 06/05/2019 RI #19 had a weight of 185lbs and on 12/04/2019 RI #19 had a weight of 176lbs. On 12/11/19 at 11:46 a.m., EI #2 was asked what care she had provided to RI #19 that morning. EI #2 stated she had given RI #19 their crushed meds per tube. EI #2 was asked what time she had stopped the tube feed. EI #2 stated she did not know for certain, another nurse stopped it about 7:00-7:30 that morning because it was beeping. EI #2 was asked how much total nutrition and H2O the resident received. EI #2 replied she was not sure. EI #2 continued to state that when she first hang the feeding, she hung 3 cartons of 237ml each, but was not sure what they do during the night shift when that runs out. EI #2 was then asked where was it documented how much was hung to feed and flush. EI #2 stated they do not document it. EI #2 continued to state they just hang enough for the order. EI #2 was asked how much was the 3 cartons of feed. EI #2 replied the 3 cartons equal 711ml and continued that they would need to add more during the night. EI #2 was asked what the order was for RI #19's nutrition and hydration. EI #2 replied the order was 80ml/hr of [MEDICATION NAME] 1.5 for 20 hours and the H2O flush at 60ml/hr for 20 hours EI #2 continued to state they hang the nutrition and H2O at 4pm and stop it at 8am. EI #2 was then asked how many hours was 4pm to 8am and EI #2 stated that was 16 hours. EI #2 was asked if the resident received the amount of [MEDICATION NAME] 1.5 and H2O that was ordered. EI #2 stated the resident did not, according to those times. EI #2 was asked what would be the potential concern in not receiving the ordered amount of nutrition and H2O. EI #2 stated the resident could have weight loss and dehydration. On 12/11/19 at 04:09 p.m., an observation was made of RI #19's tube feed infusing at a rate of 80ml/hr with flush at 60ml/hr [MEDICATION NAME] 1.5 with approx 700 in fillable bag dated 12/11/19 at 3pm. A record review revealed a new order clarification was entered 12/11/19, infuse 80ml/hr X 20 hrs. start at 3pm, stop at 11 am. On 12/12/19 at 11:45 a.m. an interview with EI #1, Registered Nurse (RN), Director of Nursing, (DON) was conducted. EI #1 was asked who put in the order for the tube feed on RI #19. EI #1 stated the LPN on the hall entered the order per the dietitian recommendations. EI #1 was asked if the dietitian recommended the tube feed infuse 80 ml/hr for 20 hrs and the order read to hang at 4pm and remove at 8am, how many hours would the feeding infuse. EI #1 replied it would only infuse for 16 hours. EI #1 was asked if RI #19 received the recommended intake and calories in that time frame. EI #1 replied, no. EI #1 was asked where staff would document the actual amount of nutrition received. EI #1 stated they were not sure that there was a place to document actual amounts. EI #1 continued to state the computer system is fairly new to them and they were looking into correcting the issue. EI #1 was then asked what would be the potential concern with the resident not receiving the recommended nutrition and hydration. EI #1 stated the resident could possibly have weight loss and dehydration. On 12/12/19 at 12:21 p.m., an interview via phone, was conducted with EI #3, the Registered Dietitian/Nutritionist (RDN), Licensed Dietitian (LD). EI #3 was asked if she had written the recommendation for RI #19's tube feeding order that read 80ml/hr for 20 hours, hang at 4pm and remove at 8am. EI #3 stated yes, she had recommended the resident receive 1600 ml per day. EI #3 was asked if the resident received the amount of calories they had recommended with-in that time frame. EI #3 stated technically no, but the residents weight was stable and the labs were with-in a good range. EI #3 continued to state she felt the resident was at a good weight now with their condition and had ordered weekly weights to monitor closely. They felt they would have to reduce the feedings soon so the resident would not gain weight. EI #3 continued to state when this resident gains too much weight they have the risk to fall out of the wheelchair.

Based on observations, interviews, and a facility policy titled, Catheter Care, Urinary', the facility failed to ensure Resident Identifier (RI) #23's catheter bag was not touching the floor. This affected one of two residents observed with a catheter. Findings include: A facility policy titled, Catheter Care, Urinary, with a effective date of (MONTH) 1, (YEAR), revealed, . Infection Control . 2. b. Be sure catheter tubing and drainage bag are kept off the floor. RI #23 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #23 had a [DIAGNOSES REDACTED]. An observation was made on 12/10/19 at 02:44 p.m.; the resident was asleep in the bed. RI #23's catheter bag was observed lying flat on the floor face down, with the part that empties the urine touching the floor. On 12/11/19 at 03:29 p.m., an observation was made of RI #23's catheter bag. The bottom part of the catheter bag, where the urine is emptied, was touching the floor. On 12/11/19 at 03:39 p.m., an interview was conducted with Employee Identifier (EI) #5, Certified Nursing Assistant (CNA). EI #5 was asked, where was RI #23's catheter bag. EI #5 replied, hanging beside the bed. EI #5 was asked, was it touching the floor. EI #5 replied, the end part was. EI #5 was asked, should it be touching the floor. EI #5 replied, no. EI #5 was asked, what was the potential concern of a resident's catheter bag touching the floor. EI #5 replied, contamination. On 12/12/19 at 10:59 a.m., an interview was conducted with EI #4, Infection Control Nurse. EI #4 was asked, where should the catheter bag be placed when a resident was in bed. EI #4 replied, hanging on the bed frame. EI #4 was asked, should it be on the floor. EI #4 replied, no. EI #4 was asked, what was the potential concern of a catheter bag being on the floor. EI #4 replied, Urinary tract infection [MEDICAL CONDITION].

Based on observations, interviews and review of facility policies titled, Hand-washing Guidelines, Hand Sanitization During Dishwashing, and Food Preparation and Service, the facility failed to ensure the staff washed their hands when entering the kitchen and during dishwashing and staff wore a hair restraint when entering the kitchen. This deficit practice had the potential to affect 75 out of 75 residents receiving meals from the kitchen. Findings Include: A review of a facility policy titled, Hand-washing Guidelines, with an effective date of 4/1/16, documented the following: . PURPOSE To prevent the spread of bacteria that may cause food borne illnesses . PR[NAME]ESS: 1 Hands should be washed in the following situations: Every time an employee enters the kitchen; at the beginning of the shift, after returning from break; .After hands have touched anything unsanitary, . On 10/17/18 at 10:21 a.m., the survyor observed EI #2 putting away dishes. She then opened the door to the outside and stood outside. She then returned to the kitchen. During this observation EI #2 did not wash her hands or change her gloves. A review of a facility policy titled, Hand Sanitization During Dishwashing, with an effective date of 4/1/16, documented the following: . STANDARD: Hands should be sanitized between . the handing of clean dishes and utensils, and when leaving the dishwashing area and during dishwashing procedure . On 10/16/18 at 12: 41 p.m., the surveyor observed EI ( Employee Identifier) #2 enter the kitchen and put on a pair of gloves without washing her hands. EI #2 then began unloading clean dishes from the dishwashing. A review of a facility policy titled, Food Preparation and Service, with an effective date of (MONTH) 1, (YEAR), documented the following: Policy Statement Food service employees shall prepare and serve food in a manner that complies with safe food handing practices. Food Service /Distribution .7. Dietary staff shall wear hair restraints (hair net, hat, bear restraint, etc.) so that hair does not contact food. On 10/17/18 at 10:36 a.m, the surveyor observed EI #3, Maintance Assistant, enter and walk through the kitchen area where food was being prepared. He was not wearing a hair restraint. On 10/18/18 at 2:45 p.m., an interview was conducted with EI #3. EI #3 was asked if he was wearing a hair restraint when he entered the kitchen on 10/17/18. EI #3 said, no. EI #3 was asked what was the potential harm with not wearing a hair restraint when entering the kitchen. EI #3 said he guess you could spread it (hair) in the food. On 10/18/18 at 12:51 p.m., an interview was conducted with EI #1, Dietary Manager. EI #1 was asked what was the facility's policy regarding handwashing and wearing a hair restraint/net in the the kitchen. EI #1 said it was mandatory that everyone wear a hair net while in the kitchen. It was also mandatory that when they entered the kitchen they are supposed to wash their hands and wash their hands after changing gloves. EI #1 was asked what was the potential harm with not wearing hair restraints and not washing hands in the kitchen. EI #1 said cross contamination because hair particles could fall in the food and it was a potential for harm when someone is sick.

Based on observation, record review, interviews, and a review of the facility's policy titled, Care Plans - Comprehensive Person Centered Care Plans, the facility failed to ensure Resident Identifier (RI) #40's care plan was implemented to wear non-skid socks and a back brace . This affected one out of 18 residents whose care plans were reviewed. Findings Include: A facility's policy titled, Care Plans - Comprehensive Person Centered Care Plans, with an effective date of (MONTH) 28, (YEAR), revealed, Policy Interpretation and Implementation . 3. Each resident's comprehensive care plan is designed to : a. Incorporate identified problem areas; . g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels; . RI #40 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of RI #40's Quarterly Minimum Data Set (MDS) assessment, with a reference date of 8/22/18, indicated the resident had a fracture and had previous falls, going back to preadmission. Review of RI #40's care plans revealed a care plan, dated 11/22/17 for the problem of potential for falls, related to a history of poor balance and coordination. Interventions included an intervention that was added 4/28/18 for non-skid socks applied. Further review of the care plans revealed a problem for Potential Contractures related to functional strength/ ability/ mobility/ cognitive deficit. On 8/10/18 an intervention was added, To wear back brace when OOB (out of bed) with exception of toileting/ showering. On 10/16/18 at 12:34 p.m., the surveyor observed RI #40 sitting in the wheelchair with no back brace on. On 10/17/18 at 12:15 p.m., the surveyor observed RI #40 sitting on the bedside eating lunch with white socks on. On 10/18/18 at 11:24 a.m., the surveyor observed RI #40 sitting in the wheelchair with no back brace on. On 10/18/18 at 4:56 p.m., an interview was conducted with Employee Identifier (EI) #5, Certified Nursing Assistant (CNA). EI #5 was asked if RI #40 had on a back brace while up in the wheelchair that day. EI #5 said no, not when she got to work, around 1:54 pm, RI #40 did not have on his/her back brace. EI #5 was asked if RI #40 was care planned to wear a back brace. EI #5 said, yes ma'am. EI #5 was asked when should RI #40 wear his/her back brace. EI #5 said when he/she is up in his/her wheelchair. On 10/18/18 at 5:12 p.m., an interview was conducted with EI #6, MDS Coordinator. EI #6 was asked if RI #40 was care planned for a back brace. EI #6 said, yes. EI #6 was asked when should RI #40 wear the back brace. EI #6 said RI #40 was to wear the brace when he/she was out of the bed, except for toileting and showering. EI #6 was asked what was the potential harm with the resident not wearing the back brace as ordered. EI #6 said it was to prevent further injury. EI #6 was asked if R #40 was care planned for non skid socks. EI #6 said yes, the intervention dated 4/28/18. EI #6 was asked what was the potential harm with RI #40 not wearing non skid socks. EI #6 said he/she was at greater risk for slips and falls when he/she attempts to transfer self independently.

Based on observation, record review and staff interview and a facility policy titled, Medication and Treatment Orders, the facility failed to ensure Resident Identifier (RI) #40's physician's orders [REDACTED]. This affected one out of fourteen resident whose physician orders [REDACTED]. Findings Include: A review was conducted of the facility's policy titled, Medication and Treatment Orders , with an effective date of (MONTH) 1,2016. The document included, Policy Statement Orders for . and treatments will be consistent with principles of safe and effective order writing and following the MD (Medical Doctor) orders. RI #40 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of RI #40's Quarterly Minimum Data Set (MDS) assessment, with a reference date of 8/22/18, indicated the resident had a fracture. Review of RI #40's (MONTH) (YEAR) Physician order [REDACTED]. On 10/16/18 at 12:34 p.m., the surveyor observed RI #40 sitting in the wheelchair with no back brace on. On 10/18/18 at 11:24 a.m., the surveyor observed RI #40 sitting in the wheelchair with no back brace on. On 10/18/18 at 5:12 p.m., an interview was conducted with EI #6, MDS Coordinator. EI #6 was asked if RI #40 had a physician's orders [REDACTED]. EI #6 said, yes. EI #6 was asked when should RI #40 wear the back brace. EI #6 said RI #40 was to wear the brace when he/she was out of the bed, except for toileting and showering. EI #6 was asked what was the potential harm with the resident not wearing the back brace as ordered. EI #6 said it was to prevent further injury.

Base on observation, staff interviews, and a facility's policy titled Handwashing/Hand Hygiene, the facility failed to ensure Employee Identifier (EI) #7 did not turn off the faucet with her bare hands during handwashing after administering medication to a resident. This affected one out of eight nurses observed during medication administration. Findings Include: A facility's policy titled, Handwashing/Hand Hygiene, with a revised date of 7-5-17, revealed: Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation . 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, resident, and visitors Procedure Washing Hands 1. Vigorously lather hands with soap and rub them together, . 2. Rinse hands thoroughly under running water. 3. Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel. On 10/16/18 at 4:01 p.m. EI #7 was observed washing and drying her hands, then turning the faucet off with bear hands after medication administration. An interview was conducted on 10/17/18 at 5:24 p.m. with EI #7 a Registered Nurse (RN). EI #7 was asked how did she turn off the faucet. EI #7 replied, with her clean bare hands. EI #7 was asked how should she turn off the faucet after washing her hands. EI #7 stated with a clean dry paper towel. EI #7 was asked did she use a clean paper towel to turn off the faucet after washing her hands. EI #7 replied, no, but she should have. EI #7 was asked what was the concern with turning off the faucet with bare hands. EI #7 stated she put the germs back on her hand, and germs could be transferred to the resident, which could cause infection/ cross contamination. An interview was conducted on 10/18/18 at 4:35 p.m. EI #4 an Registered Nurse, Infection Control Nurse. EI #4 was asked what was the policy on hand hygiene for turning off the water faucet. EI #4 stated with a clean napkin or paper towel after drying your hands. EI #4 was asked why staff should not turn off the faucet with bare hands. EI #4 stated, you are recontaminating your hands.

Based on interview, resident record review, review of the facility policy titled Release of Information and review of the facility form titled Resident Rights, the facility failed to provide medical records to RI (Resident Identifier) #134's sponsor within 30 days as requested. This affected one of 4 residents sampled for access to medical records. The State Agency received a complaint on 11/14/2017 alleging RI #134's medical records had not been released to RI #134's estate executor within 30 days as ordered by a judge. Findings include: A review of the facility policy titled Release of Information with an effective date of 1/1/2016 revealed the following: . 3. All information contained in the resident's medical record . may only be released by the written consent of the resident or his/her legal representative . 10. A resident may obtain photocopies of his or her records by providing the facility with at least a forty-eight . hour . advance notice of such request. Review of a facility form titled . Resident Rights documented the following: . (g)(2)(ii) The facility must allow the resident to obtain a copy of the records or any portions thereof . upon request and 2 (two) working days advance notice to the facility. RI #134 was readmitted to the facility on [DATE] and discharged on [DATE]. RI #134's medical record request file was reviewed and contained documentation as follows: Documentation was reviewed from the county probate court/judge dated 10/2/2017 that granted RI #134's responsible party as administrator of the resident's estate. A copy of a medical record request dated 10/11/2017, from RI #134's estate executor to the facility, requested copies of the complete medical chart for the dates October 2016 through January 2, 2017. A copy of a letter dated 11/29/2017 from the facility to RI #134's estate executor acknowledged receipt of the record request and requested pre-payment for the records. A copy of a certified mail receipt dated 12/7/2017, the date RI #134's estate executor received the certified letter (dated 11/29/2017) from the facility, 57 days after the medical records were requested. On 3/1/2018 at 12:20 PM, EI (Employee Identifier) #3 Administrator, was asked, what the time frame was for the medical record request. EI #3 said, the request was for 30 days. EI #3 was asked if that was honored. EI #3 answered, no, the letter was mailed on 11/29/2017 and the records were picked up on 12/11/2017. EI #3 was asked why the records were not made available in the 30 days as requested. EI #3 replied, the records were at the facility's corporate/legal office and she made them available as soon as she could. This deficiency was cited as a result of the investigation of complaint #AL 439.

Based on observation, interviews and a review of preventative maintenance monitoring records and a policy related to Answering the Call Light, the facility failed to ensure a call light was positioned within the reach of Resident Identfier (RI) #19, and was in working condition on 02/27/18. This affected one of 12 sampled residents. Findings include: The facility's Preventive Maintenance Manual related to Resident Rooms dated 11/01/05, directs maintenance staff to Perform preventive maintenance as indicated . Monthly: 1. Inspect condition and operation of: . . g) Call light . The facility policy: Answering the Call Light dated 01/01/16, cites the purpose as .to respond to the resident's requests and needs. General Guidelines include: .5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. .7. Report all defective call lights to the nurse supervisor promptly . RI #19 has resided in the facility since 03/15/16 with [DIAGNOSES REDACTED]. The most recent completed Minimum Data Set assessment (Quarterly Review) with an Assessment Reference Date of 11/28/17, identified this resident as moderately impaired in cognition (with a Brief Interview for Mental Status score of 10 of a possible 15), in need of extensive assistance or totally dependent upon staff for all activities of daily living, impairments in range of motion in both the upper and lower extremities, and always incontinent of bowel and bladder, with a history of falling. On 02/27/18 at 3:50 PM, RI #19 was lying in bed, visiting with the surveyor. After a few minutes, he/she began to complain of acute pain in the abdomen. The call light was lying on the floor, behind the bed. The surveyor retrieved the light and tried to activate it. The push button portion of the call light was missing and the cavity cracked. Despite this, the surveyor attempted to push the remains of the bell. Nothing happened. The surveyor left the room and alerted a Licensed Practical Nurse (Employee Identifier/EI #1) at the neighboring unit, of RI #19's need. On 02/27/18 at 5:29 PM, the surveyor interviewed EI #1, and obtained the name of the Certified Nursing Assistant (CNA) responsible for RI #19. The surveyor interviewed the CNA (EI #2) responsible for the care of RI #19 during the second shift on 02/27/18 at 5:40 PM. When asked how long the resident's call light had been nonfunctional, EI #2 did not know. EI #2 explained the resident usually called out verbally, when needing assistance, or the staff would routinely check on her for any needs. On 02/28/18 at 12:15 PM, the day shift CNA (EI #4) responsible for RI #19 was interviewed. EI #4 explained RI #19 did use the call light, although not often. At this time, the call light was attached to the right side of the resident's bed. When asked why the light had been positioned on the right rather than the left side of the bed (the resident had no use of the right side of his/her body), EI #4 explained she had just made the resident's bed, but it was usually positioned on the left side. EI #4 had not noticed the call light was broken, but said she checked on RI #19 often. On 03/01/18 at 10:25 AM, the surveyor asked the facility Administrator (EI #3) whose responsibility it was to check placement of the call lights, as well as function. EI #3 explained the CNAs and facility nurses made rounds on each resident every two hours; the call light was supposed to be in the reach of the resident. EI #3 stated the Maintenance staff checked the call lights once a month to see if they worked, providing repairs as needed--and would replace with a manual, hotel bell if needed. EI #3 explained the nursing staff would additionally alert the maintenance staff of the need to fix call lights, as needed. When asked what potential harm the lack of a call light might pose, EI #3 responded the resident might not get the needed assistance for an hour or so.

Based on observation, record review and interview the facility failed to ensure RI (Resident Identifier) #5's physician's order was followed in order to keep the resident's O2 (oxygen) infusing at 3L ( Liters) per NC ( nasal cannula). RI #5 was observed on all three days of the survey with O2 infusing @2 L / NC. This affected one of two sampled residents observed utilizing O2. Findings Include: A review of the ALABAMA BOARD OF NURSING ALABAMA ADMINISTRATIVE CODE CHAPTER 610-X-6 STANDARDS OF NURSING PRACTICE revealed: .610-X-6-.05 Practice of Practical Nursing (Licensed Practical Nurse Practice) (1) The practice of practical nursing includes, but is not limited to: . (f) Administering medications and treatments when ordered by a legally authorized prescriber. A review of a facility policy titled, Oxygen Administration with an effective date of January 1, 2016 revealed: . Purpose: The purpose . is to provide guidelines for safe oxygen administration. Steps in the Procedure . 10. Adjust the oxygen delivery device so that it is . the proper flow of oxygen is being administered. A review of RI #5's January 2017 Physician's Order revealed: . O2 AT 3L/MIN (Minute) VIA N/C . RI #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #5's annual MDS (Minimal Data Set) with an ARD (Assessment Reference Date) of 11/15/2016 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15, which indicated the resident was cognitively intact for daily decision making. The MDS also revealed the resident was receiving oxygen. On 01/24/2017 at 10:10 a.m. , during the initial tour, RI #5 was observed wearing O2 @ 2 L/NC. On 01/25/2017 at 9:14 a.m. , RI #5 was observed wearing O2 @ 2 L/NC. On 01/26/2017 at 9:00 a.m. , RI #5 was observed wearing O2 @ 2 L/NC. On 01/26/2017 at 11:50 a.m., an interview was conducted with EI (Employee Identifier) #3, LPN (Licensed Practical Nurse). EI #3 entered RI #5's room with the surveyor and EI #3 observed the O2 @ 2 L/NC. EI #3 was asked what did the Physician order say. EI #3 said O2 @ 3L/NC. EI #3 was asked why was RI #3 receiving O2. EI #3 said for [MEDICAL CONDITION]. EI #3 was asked who was responsible for ensuring the resident received the correct amount of O2. EI #3 said the nurse. EI #3 was asked what was the potential harm in RI #3 receiving O2 @ 2 L/NC. EI #3 said possibly a decrease in O2 saturation.

Based on record review, observation and interview, the facility failed to ensure a CNA (Certified Nursing Assistant) wiped front to back (from the rectum up toward the back) during the incontinent care of RI (Resident Identifier) #4. RI #4 is a resident with a recent history of UTI (Urinary Tract Infection). This affected RI #4, one of one sampled residents observed during incontinent care. Findings Include: A review of a facility policy titled, Perineal Care with an effective date of January 1, 2016, revealed: Steps in the Procedure . e. Wash the rectal area thoroughly, wiping from the base of the (perineal area) towards and extending over the buttocks. RI (Resident Identifier) #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #4's 60-day MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 01/03/2017, revealed RI #4 had a BIMS (Brief Interview for Mental Status) score of 15, which indicated the resident was cognitively intact. The MDS also revealed RI #4 was incontinent of bowel and bladder. A review of RI #4's Bowel and Bladder assessment dated [DATE], revealed the resident was totally incontinent of bowel and bladder. A review of RI #4's Urine Culture with a date of 12/16/2016 revealed: .Result 1 Providencia stuartii (bacteria) Greater than 100,000 colony forming units per ml (milliliter) Result 2 Citrobacter amalonaticus (bacteria) Greater than 100,000 colony forming units per ml . On 01/26/2017 at 11:05 A.M., EI (Employee Identifier) #4, CNA, was observed performing incontinent care for RI #4. RI #4 had been incontinent of urine. EI #4 wiped from the top of the buttock (closest to the back) down toward the perineal area then back up toward the back again. EI #4 wiped RI #4's buttocks twice in that manner. On 01/26/2017 at 11:26 A.M., an interview was conducted with EI #4. EI #4 was asked in what direction she wiped RI #4's buttocks. EI #4 said U shape. I went all the way down and then I went up to the rectum part. EI #4 was asked how buttocks should be wiped. EI #4 said always go up. EI #4 was asked what the potential harm was in wiping a resident's buttocks from back to front (top of the buttock closest to the back downward toward the perineal area). EI #4 said it could cause an UTI infection. On 01/26/2017 at 12:05 P.M., an interview was conducted with EI #1, ADON (Assistant Director of Nursing). EI #1 was asked how the CNA's were taught to wipe the buttocks during incontinent care. EI #1 said up, not down then up. EI #1 was asked what the potential harm was in wiping down toward the perineal area and then back up toward the back. EI #1 said UTI and contamination period.

Based on record review, observation and interview, the facility failed to ensure the daily nurse staffing information was not posted for all three shifts at the same time on three of three days of the survey. This had the potential to affect all 79 residents who reside in the facility. Findings Include: A review of a facility policy titled, Posting Direct Care Daily Staffing Numbers with an effective date of January 1, 2016, revealed: .Policy Interpretation and Implementation 1.The beginning of each shift, the number of Licensed Nurses .and the number of unlicensed nursing personnel .directly responsible for resident care will be posted . On 01/24/2017 at 10:22 A.M., the daily nurse staffing information was observed and it was posted for all three shifts. On 01/24/2017 at 5:13 P.M., the daily nurse staffing information was observed and it was posted for all three shifts. On 01/25/2017 at 8:45 A.M., the daily nurse staffing information was observed and it was posted for all three shifts. On 01/25/2017 at 5:05 P.M., the daily nurse staffing information was observed and it was posted for all three shifts. On 01/26/2017 at 8:32 A.M., the daily nurse staffing information was observed and it was posted for all three shifts. On 01/26/2017 at 11:58 A.M., an interview was conducted with EI (Employee Identifier) #1, ADON (Assistant Director of Nursing). EI #1 was asked when the daily nurse staffing data should be posted according to regulation F356. EI #1 said at the beginning of each shift. EI #1 was asked if all three shifts of daily nurse staffing data should be posted at the same time. EI #1 said according to the regulation, no. EI #1 was asked if all three shifts were posted at the same time on 01/24/2017, 01/25/2017 and 01/26/2017. EI #1 said yes. EI #1 was asked if the facility was following the regulation guidelines set forth by CMS (Centers for Medicare and Medicaid Services) concerning posting daily nurse staffing data. EI #1 said no.

Based on observation, interview and record review, the facility failed to ensure a privacy curtain was large enough to provide adequate privacy during incontinence care for Resident Identifier (RI) #7 on 12/16/2015. This affected one of two residents observed for incontinence care. Findings include: The facility's policy titled Dignity with an effective date of 8/1/2005, revealed: . STANDARD: . must promote care . that maintains or enhances . resident's dignity . Respecting resident's private space . RI #7 was admitted to the facility on [DATE]. RI #7's care plan with a problem onset date of 10/16/2015 documented: . Provide privacy for bathing/dressing . During an observation on 12/16/2015 at 9:25 AM, RI #7's privacy curtain did not provide full visual privacy during the provision of incontinence care. RI #7's roommate was observed ambulating in the room. On 12/16/2015 at 12:20 PM, an interview was conducted with Employee Identifier (EI) #1, the Director of Nurses. EI #1 was asked to describe the curtain which provided privacy for RI #7. EI #1 stated the curtain was used for privacy and was not long enough to provide privacy if someone had walked into the room.

Based on observation, interview and record review, the facility failed to ensure a Certified Nurse Assistant (CNA) changed her gloves and washed her hands between touching a soiled brief and placing a clean brief on Resident Identifier (RI) #8. The CNA did not wash her hands or change gloves during the care. This affected one of two residents observed during incontinence care. Findings include: A review of the facility's policy and procedure titled, Infection Control Procedure - Handwashing, dated October 19, 2015, revealed the following: . STANDARD Handwashing should be performed before, after, and between certain procedures . RI #8 was admitted on [DATE] with [DIAGNOSES REDACTED]. RI #8's Quarterly Minimum Data Set (MDS), dated [DATE], indicated RI #8 required extensive assistance with toileting and was incontinent of bowel and bladder. During incontinence care observation on On 12/16/15 at 9:05 AM, Employee Identifier (EI) #2 removed a soiled brief from under RI #8. EI #2 placed it in a garbage bag and then placed a clean brief on the resident. EI #2 did not change gloves and perform hand hygiene during the care. EI #2 was interviewed on 12/16/15 at 10:05 AM. When asked when should she change gloves during incontinent care, EI #2 stated when going from dirty to clean. When asked if that was what she did, EI #2 stated, No. EI #2 explained that she should have removed her gloves and washed her hands after cleansing RI #8's dirty areas. When asked what was the potential harm in not performing proper hand hygiene during incontinent care, EI #2 stated, They can get urinary tract infections. An interview was conducted with EI #1, the Infection Control Coordinator/Director of Nurses on 12/17/15 at 2:00 PM. EI #1 was asked when should gloves be changed during incontinence care and what was the potential harm in not changing gloves after removing a soiled brief and before applying a clean brief. EI #1 stated gloves should be changed when going from dirty to clean and the potential harm is risk of infection (urinary tract infection) and exposure.

Based on observation, interview and record review, the facility failed to ensure food was stored, prepared and served in a sanitary manner and in a manner to prevent the potential for cross-contamination by the following: 1.) dietary staff members were wearing earrings during preparation and service of food which was not covered by a hair net; 2.) a pan was observed wet nested; 3.) cans of chicken that had been opened had a "use by" date and 4 Magic Cups were in the refrigerator with no "use by date;" 4.) sandwiches were dated that were observed in two separate refrigerators; 5.) cupcakes were observed with a date of 8/22/14. They had been opened and had no "use by" date; 6.) staff had a bottle of water in the refrigerator; 7.) a bottle of Nectar thickened water had been used and no dates were on the bottle; 8.) the thermometer probe was wiped off after food temperatures were taken and prior to placing in the Multi Quat sanitizer and after taking out of the sanitizer when food was observed on the top of the container; 9.) the thermometer was laid down in the cooked chicken with the dial touching the cooked chicken; and 10.) The air-conditioner (A/C) above the three compartment sink had a large accumulation of debris in the vents. This had the potential to affect all 78 residents who received meals from the kitchen. Findings Include: 1.) On 10/21/14 at 11:25 AM, EI #4 (Dietary Staff/Cook) was observed placing chicken in flour in the the kitchen. EI #4 had earrings that had stones in them that were not covered by her hair restraint. On 10/22/14 at 9:10 AM, EI #4 was observed to have earrings on that contained stones while in the kitchen preparing food. EI #5 (Dietary Staff), was also observed during this time to have large loop earrings on while in the kitchen that were not covered by her hair restraint. At 11:00 AM, EI #5 was observed putting ice in cups for the residents. EI #5 had large loop earrings on that were not covered by her hair restraint. The facility policy titled: "Dress and Grooming" (not dated) revealed: "... Since jewelry can harbor microorganisms, it is recommended that dietary staff keep jewelry to a minimum ..." A review of the 2013 Food and Drug Administration's Food Code revealed, "2-303.11 Except for a plain ring such as a wedding band, while preparing FOOD, FOOD EMPLOYEES may not wear jewelry..." On 10/22/14 at 2:15 PM, EI #2 (Dietary Manager) was asked if staff were supposed to wear jewelry in the kitchen. EI #2 said he knew there was a policy, but he was not sure about earrings. EI #2 was asked what was the facility's policy. EI #2 said, "I think it only refers to a wedding band." 2.) During initial tour on 10/20/14 at 6:25 PM, EI #8 (Dietary Staff) was asked to pick up a serving pan from the stack of pans. When EI #8 picked the pan up and turned it over, the inside was observed to be wet. EI #8 picked up a towel and wiped it out. The facility's policy titled: "Cleaning of Miscellaneous Equipment" with an effective date of August 1, 2005 revealed: "... 9. Dishes: ... Place dishes in dish rack; avoid overloading and nesting ..." A review of the 2013 Food and Drug Administration's Food Code revealed: "... Drying 4-901.11 Equipment And Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried..." On 10/22/14 at 2:15 PM, EI #2 was asked where were pots and pans supposed to be stored. EI #2 said they had an area in the middle where they would go and further stated, "They should be open to air upside down, air dryed." On 10/23/14 at 8:45 AM, EI #3 was asked how should pots and pans be dried when stored. EI #3 said, "Air-dryed." 3.) During initial tour on 10/20/14 at 6:25 PM, EI #8 toured with the surveyor. EI #8 opened the refrigerator and chicken base and beef flavored base had been opened and was observed with no "use by" date. Four Magic Cups were observed in the refrigerator with no "use by" date. EI #8 put the Magic Cups back into the freezer and replied, "They were not supposed to be in here." The facility's policy titled, "Food Receipt and Storage", dated 8/1/05 revealed, "... Storage of Foods: ... k. Refrigerated and frozen items should be labeled, dated and covered ..." A review of the 2013 Food and Drug Administration's Food Code 3-501.17 revealed: "... refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold or discarded ..." On 10/22/14 at 2:15 PM, EI #2 was asked if items were supposed to be dated that were in the refrigerator. EI #2 said they were. EI #2 was asked when an item is opened, should it be dated, EI #2 replied "Yes." EI #2 was asked if Magic Cups were supposed to be stored in the refrigerator or freezer. EI #2 said "In the freezer, they are an ice cream." On 10/23/14 at 8:45 AM, EI #3 was asked should foods be dated with a "use by" date. EI #3 replied, "Yes." 4.) During initial tour on 10/20/14 at 6:25 PM, EI #8 toured with the surveyor. EI #8 opened the refrigerator behind the kitchen and turkey sandwiches were observed with no date. EI #8 counted them and there were a total of 12 sandwiches. They had a small round sticker on them that had "Tues. (Tuesday)" on them. The small refrigerator near the serving area had 13 sandwich halves with a sticker that revealed, "Mon. (Monday)" on them. The facility's policy titled, "Food Receipt and Storage", dated 8/1/05 revealed, "... Storage of Foods: ... k. Refrigerated and frozen items should be labeled, dated and covered ..." On 10/22/14 at 2:15 PM, EI #2 was asked if items were supposed to be dated that were in the refrigerator. EI #2 said they were. EI #2 was asked if sandwiches were supposed to be dated that were in the refrigerator. EI #2 said they only make sandwiches every day and it is at 10:00 AM. EI #2 further replied "I don't see the need for a date since they are passed out as a 10:00 AM snack; if they are going to stay in the refrigerator they should date them." EI #2 was asked who was responsible for checking the refrigerators to make sure items were discarded that needed to be. EI #2 said everyone was responsible, but the cooks were supposed to date and name the items. 5.) During initial tour on 10/20/14 at 6:25 PM, EI #8 toured with the surveyor. EI #8 pulled out cupcakes that had been opened and were dated 8/22/14. EI #8 replied, "They are old." A review of the 2013 Food and Drug Administration Food Code 3-501.17 revealed: "... refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMESIS, sold, or discarded ..." The facility's policy titled, "Food Receipt and Storage", dated 8/1/05 revealed, "... Storage of Foods:...k. Refrigerated and frozen items should be labeled, dated and covered..." On 10/22/14 at 2:15 PM, EI #2 was asked if he was aware that there were cupcakes dated 8/22/14 in the refrigerator. EI #2 said, "No." EI #2 was asked if staff were supposed to label items with a "use by" date. EI #2 said "Yes." 6.) During initial tour on 10/20/14 at 6:25 PM, EI #8 toured with the surveyor. EI #8 opened the refrigerator behind the kitchen and a bottle of water that was not labeled or dated was in the refrigerator. EI #8 said it belonged to a staff member. On 10/22/14 at 2:15 PM, EI #2 was asked if staff were allowed to store their personal items in the refrigerators in the kitchen. EI #2 said, "No." On 10/23/14 at 8:45 AM, EI #3 was asked if staff were supposed to store their food or water in the refrigerators in the kitchen. EI #3 replied, "No." 7.) During initial tour on 10/20/14 at 6:25 PM, a bottle of Nectar thickened water that had been opened was observed in the refrigerator near the serving area. The bottle did not have a "use by" date on it. The facility's policy titled, "Food Receipt and Storage" dated, 8/1/05 revealed, "... Storage of Foods: ... k. Refrigerated and frozen items should be labeled, dated and covered ..." On 10/22/14 at 2:15 PM, EI #2 was asked if items were supposed to be dated that were in the refrigerator. EI #2 said they were. EI #2 was asked who was responsible for checking the refrigerators to make sure items were discarded that needed to be. EI #2 said everyone was responsible, but the cooks were supposed to date and name the items. On 10/23/14 at 8:45 AM, EI #3 was asked should foods be dated with a "use by" date. EI #3 replied, "Yes." 8.) On 10/21/14 at 11:10 AM, EI #2 was observed taking the temperatures of the food for tray line. EI #2 checked the pureed meat and placed the probe without wiping it into the sanitizing solution through the hole on the lid of the container. Food particles were observed on the lid. EI #2 then pulled the probe out of the sanitizer solution and placed it into another food item without wiping the probe. EI #2 looked at the surveyor and replied, "Should have wiped the probe off before putting it on top of the unit." A review of the facility's policy titled, "Calibrating and Sanitizing Thermometers" dated 08/01/05 revealed, "... Sanitization: ... d. Place the probe in sanitizing solution and agitate ... i. Wipe the food particles from the temperature probe ..." On 10/22/14 at 2:15 PM, EI #2 was asked if he was supposed to wipe the thermometer probe each time prior to placing it in the sanitizer. EI #2 replied, "Once I check the food, I am supposed to wipe it off." EI #2 was asked what were the manufacture's instructions for using it. EI #2 replied, "Of course it has to be wiped off." On 10/23/14 at 8:45 AM, EI #3 was asked what was the policy on the sanitizer used for the thermometer probe. EI #3 provided the policy and stated, "Wipe the food particles from the temperature probe." 9.) On 10/21/14 at 11:10 AM, EI #2 was observed taking the temperatures of the food for tray line. EI #2 checked the chopped chicken and the temperature was 130 degrees. The chicken was placed back into the stove to be re-heated. The surveyor asked EI #2 to re-check the temperature. EI #2 placed the probe (which was held in his un gloved hand) into the meat and dropped the head of the probe into the chicken. A review of the Food and Drug Administration's 2013 Food Code 4-702.11 revealed: "... UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT shall be SANITIZED before use after cleaning ..." On 10/22/14 at 2:15 PM, EI #2 was asked if he was aware he dropped the probe into the chicken that was re-heated. EI #2 said he did because he burned his finger checking the temperature. On 10/23/14 at 8:45 AM, EI #3 was asked what would be the potential harm if the thermometer dial touched the resident's food. EI #3 said "Potential cross-contamination." 10.) On 10/22/14 at 9:10 AM, the air-conditioner (A/C) over the three compartment sink was observed. The vents had some dust-like debris in the vents hanging down over the sink. On 10/22/14 at 2:15 PM, EI #2 was asked who was responsible for cleaning the A/C vents in the A/C over the three compartment sink. EI #2 replied, "It has to be cleaned whether is is dietary or maintenance." The surveyor asked EI #2 if he ever checked it. EI #2 said, "Of course." The surveyor asked EI #2 when was it checked. EI #2 replied, "Don't know." EI #2 was asked what would be the potential for particles/debris to fall into the three compartment sink. EI #2 said, "Yes, it is a potential." A review of the "Director of Dietary Services" job description with a revised date of 6/3/05 revealed, "... Basic Job Responsibility... Safety and Sanitation ... 4. Ensure cleanliness of dietary service work areas, storage rooms and preparation areas. 5. Report maintenance problems promptly to ensure equipment is maintained in good repair ..." On 10/23/14 at 8:45 AM, EI #3 was asked who was responsible for checking the A/C in the kitchen. EI #3 said she was not sure who was responsible at that facility. EI #3 was asked if she was aware the A/C vents had debris in them. EI #3 replied, "No, I know they should be cleaned, can't have them with dust/debris." On 10/23/14 at 10:45 AM, EI #1 (Administrator) was asked who was responsible for checking the A/C in kitchen over the three compartment sink. EI #1 said, "Maintenance." EI #1 was asked how often did maintenance check the A/C vents on the A/C in the kitchen. EI #1 replied, "Check all of them every month."

Based on observation, interview and document review, the facility failed to ensure garbage and refuse were contained in a manner to prevent the attraction of pests. This had the potential to affect all 83 residents at the facility. Findings Include: A review of the facility policy and procedure titled, "Garbage and Refuse" with an effective date of 8/1/05 revealed: "... e. Refuse containers and dumpsters kept outside the facility should have tightly fitting lids and should be kept covered when not being loaded. f. ... garbage should not accumulate or be left outside of the dumpster ..." On 10/21/14 at 12:20 PM, the surveyor along with EI (Employee Identifier) #2 (Dietary Manager) and EI #3 (Registered Dietitian) observed the dumpster area. The following was observed: 1.) The first dumpster door was not closed securely so items were exposed and accessible to pests. 2.) Large wooden crates were observed stacked by the dumpster. 3.) Napkins and straws were lying on the ground between the first and second dumpster. 4.) Four plastic lids were on the ground by the second dumpster. 5.) A broom was lying on the ground by the second dumpster, and 6.) Lids and straws were observed on the ground by the fourth dumpster. On 10/22/14 at 2:15 PM, EI #2 (Dietary Manager) was asked who was responsible for maintaining the dumpster area. EI #2 said "Dietary." The surveyor asked EI #2 should the doors be closed on the dumpster's. EI #2 said yes. EI#2 was asked if he observed the debris on the ground when he observed the dumpster area with the surveyor. EI #2 said he observed some lids (that he picked up) and some wooden crates. On 10/23/14 at 8:45 AM, EI #3 (Registered Dietitian) was asked who was responsible for checking and maintaining the dumpster areas. EI #3 said she was not sure, but it was dietary's in the end. EI #3 was asked if the dumpster doors should be closed and she said they should. EI #3 was asked what would be the potential harm if the doors were not closed. EI #3 replied, "Could attract bugs." On 10/23/14 at 10:45 AM, EI #1 (Administrator) was asked who was responsible for maintaining the dumpster's and making sure the area is clean. EI #1 said "Dietary." EI #1 was asked if anyone monitored the area to make sure the dumpster's were closed and the grounds were kept clean. EI #1 said it was monitored daily. The surveyor asked EI #1 if the dumpster doors and lids were supposed to be closed and she said they were.

Based on observation, interview, and review of a facility policy titled "MEDICATION STORAGE IN THE FACILITY ID3: Controlled Medication Storage", the facility failed to store a control medication, Marinol, in a locked permanently affixed compartment inside the refrigerator. This deficient practice affected one (1) of two (2) medication rooms in the facility. Findings Included: A facility policy with an Effective date of 16-Aug (August)-08 titled "MEDICATION STORAGE IN THE FACILITY ID3: Controlled Medication Storage" documented: "Policy Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and recording keeping in the facility in accordance with federal, state and other applicable laws and regulations. Procedures ... A. The director of nursing and the consultant pharmacist maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications ... B. Schedule III-V medication and other medications subjection subject to abuse are stored in a permanently affixed compartment separate from all other medications ..." An article from the Associated Press dated Friday July 2 (no year) at 8:15 PM ET (Eastern Time) documented: "... The Drug Enforcement Administration reclassified Marinol from a "Schedule 2'' drug to the less restricted "Schedule 3'' category. This essentially means that instead of being classified with drugs like morphine, Marinol is now classified with more widely used drugs like Codeine. Marijuana is classified as a "Schedule 1'' drug, and thus cannot be prescribed by doctors ..." On 10/23/14 at 2:15 p.m., the surveyor conducted an observation of the medication room with the Director Of Nursing (DON), Employee Identifier (EI) #6 and the Assistant Director of Nursing (ADON), EI #7. While conducting the observation of the medication room, the surveyor asked EI #6 if there were any controlled medications in the refrigerator. EI #6 said yes, Marinol 2.5 mg (milligrams) and EI #6 identified the resident whom the medication was prescribed for at this time. A total of 99 Marinol 2.5 mg caplets were observed in the refrigerator. The surveyor asked EI #7 to pull the rack with the box that contained the controlled medication. EI #7 was observed to easily remove the rack attached to the box from the refrigerator with very little effort. However, the box was not permanently affixed and secured to inside of the refrigerator to ensure the proper storage of controlled medications in the refrigerator. On 10/23/14 at 2:28 p.m., the surveyor conducted an interview with EI #6, the DON. The surveyor asked EI #6 how long had controlled medications been stored in the refrigerator. EI #6 said she had worked in the nursing home for seven years and it had been like that. EI #6 said no one had ever asked anything about the locked box being permanently affixed inside the refrigerator. EI #6 said this was the first time that this was mentioned. EI #6 said she thought as long as the controlled medications were under double lock and key, that was all that mattered. EI #6 said she did not know the box had to be attached to the refrigerator.

Based on observation and interview, the facility failed to ensure resident's rooms were maintained in a neat and orderly manner. Resident rooms and bathrooms on Station 1 and Station 2 were observed with nail holes in the walls, peeling paint and heavily scuffed wooden entry doors. This affected 7 resident's rooms on Station 1 and Station 2, and one Exit door, which is 2 of 4 stations in the facility. Findings include: The initial tour of Station 1 and Station 2 began on 10/21/13 at 5:05 PM. The following environmental concerns were identified: Room Locators (RL) RL #1 - The wooden entry door into the resident's room was heavily scuffed along the bottom third of the door. The wall paint was peeling behind the A & B beds. RL #2 - Nail holes over the A Bed and along the walls in the resident's room. RL #3 - Nail holes in the wall over the bathroom sink. RL #5 - Nail holes and rough, uneven caulk over the bathroom sink. RL #11 - The bathroom fan was extremely loud when the light switch is turned on. RL #13 - Nail holes in the wall above the bathroom sink. Multiple dried brown spots along that same wall. RL # 14 - Nail holes in the bathroom wall above the sink. The Exit Door at the end of the hall near RL #14 was heavily scuffed. On 10/24/13 at 11:20 AM, a walking tour of Station 1 and Station 2 was conducted with the facility Administrator, Employee Identifier (EI) #2 , and a Maintenance staff member, EI #3. They both acknowledged the identified environmental concerns. On 10/24/13 at 11:38 AM, an interview was conducted with EI #2. In the interview, EI #2 was asked what type of environmental concerns were identified when touring Stations 1 and 2. EI #2 said many nail holes in the walls were in need of being plugged and paint was needed in several rooms. When asked the importance of maintaining the resident's rooms in a neat and orderly manner, EI #2 said the areas need to be pleasing to the eye and the home needed to be maintained in good repair.