Every finding on record at Diversicare of Riverchase

Based on interviews, record review, facility document titled POSITION DESCRIPTION for Social Services Supervisor, and facility policy titled Transfer & (and) Discharge the facility failed to ensure an individualized discharge plan of care which was a part of the comprehensive care plan was created for Resident Identifier (RI) #3, RI #10 and RI #16. This affected three of three residents sampled for discharge planning. Findings Include: A review of facility policy titled Transfer & Discharge with an effective date of November 1, 2016, revealed . PROCEDURE . Orientation for Transfer or Discharge . 7. In accordance with Federal and State law, (name of facility) will provide and document sufficient preparation and orientation to the Resident to ensure a safe and orderly . discharge from the Center and will be provided in a form and manner the Resident can understand. A review of facility document titled POSITION DESCRIPTION for Social Services Supervisor signed by Employee Identifier (EI) # 13 on 11/03/2022 revealed .KEY RESPONSIBILITIES . 6. Ascertains potential and develops discharge plans when clients are admitted . RI #3 was admitted on [DATE] with diagnoses that included End Stage Renal Disease. RI #3 was discharged on [DATE]. On 04/27/2023 RI #3's Care Conference Person and family reported that they were not informed a final discharge plan. RI #3 did not have an individualized discharge plan of care. RI #10 was admitted on [DATE] with diagnoses that included Infection Following a Procedure, Other Surgical Site, Subsequent Encounter. RI #10 was discharged on [DATE]. On 04/26/2023 at 2:45 PM RI #10 Care Conference Person and family reported that they were not informed of final discharge plan or when wheelchair for home would be delivered. RI #10's comprehensive care plan did not include an individualized discharge plan of care. RI #16 was admitted on [DATE] with diagnoses that included Cerebral Infarction Due to Unspecified Occlusion or Stenosis of Right Middle Cerebral Artery. RI #16 was discharged on [DATE]. RI #16's comprehensive care plan did not include an individualized discharge plan of care. On 04/26/2023 at 5:00 PM an interview was conducted with EI #11, Minimum Data Set and Care Plan Assistant. EI #11 said EI #4 or EI #13 was responsible for developing resident individualized discharge care plans. On 04/27/2023 at 10:20 AM an interview was conducted with EI #14, Licensed Practical Nurse, Regional Nurse, Unit Manager. EI #14 said EI #4 or EI #13 developed residents' discharge plan of care. EI #14 was asked, discharge planning was the process of creating an individualized discharge care plan, which was part of the comprehensive care plan, who was responsible for creating the individualized discharge care plan. EI #14 replied, EI #4. On 04/27/2023 at 10:40 AM an interview was conducted with EI #4, Director of Care Coordination who said social services was responsible for discharge plan of care and she was not sure what the process included. On 04/27/2023 at 10:50 AM an interview was conducted with EI #13, Social Services Director. EI #13 said he talked to the family and resident to ascertain and develop a discharge plan when residents are admitted . EI #13 did not know who was responsible for developing and updating resident discharge care plan. EI #13 was asked, discharge planning was the process of creating an individualized discharge care plan, which was part of the comprehensive care plan, who was responsible for creating the individualized discharge care plan. EI #13 replied, social services was not doing that and was not aware that it needed to be initiated by social services. EI #13 continued and said that EI #11 developed the comprehensive care plans. On 04/27/2023 at 12:15 PM an interview was conducted with EI #2, Registered Nurse, Director of Nursing. EI #2 said the discharging nurse should provide resident and family with any documentation to clarify and educate the family and resident on discharge, but it could be done better. EI #2 said MDS staff, EI #11, was responsible for developing resident's individualized discharge care plan. EI #2 said it was important to create a discharge plan of care to see if facility was meeting goals to allow resident to progress to other levels of care. EI #2 said RI #3, RI #10, and RI #16 did not have a discharge plan of care developed. ************************** This deficiency was cited as a result of the investigation of complaint/report number AL00042883.

Based on observations, interviews, record reviews, review of the Director of Social Services Job Description, review of facility policies titled, Medication Administration General Guidelines and Oxygen Guideline, and review of Potter and Perry's Fundamentals of Nursing, the facility failed to ensure: 1) Resident Identifier (RI) #1's Admission Physician Orders were followed, as RI #1 was admitted with an order for a cardiologist appointment for 4/10/23, that was missed. This affected one of three residents sampled for appointments; and was cited as a result of investigation of complaint/report number AL00043987, 2) licensed nurses did not leave medications unattended at the bedside of RI #2, this affected one of 17 resident's sampled, 3) RI #3's Physician Order for Oxygen Use for 3L(liters)/MIN (minute) via nasal cannula continuously was followed, this affected one of 17 resident's whose orders were reviewed; and 4) provide evidence RI #4's Scopolamine patch was removed and reapplied on 02/13/2023 as ordered by the physician. This deficient practice affected RI #4, one of one resident having a Physicians Order for a Scopolamine patch; and was cited as a result of investigation of complaint/report number AL00043925. Findings include: 1) A review of Social Service Job Description, revealed. POSITION DESCRIPTION POSITION TITLE: Social Services Director . Key Responsibilities . 4. Arranges transportation, makes appointments and acts as liaison between all departments, residents' families and outside agencies. RI #1 was admitted to the facility on [DATE] with a diagnosis of Acute on Chronic Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure. A review of RI #1's discharge orders from the hospital revealed . Recommendations . At discharge . should follow up in CHF (Congestive Heart Failure) clinic on 4/10/23. Discharge Planning: (name of Hospital) CHF Discharge Instructions . CHF clinic 04/10/2023 10:40 . A review of the Order Summary Report for RI #1 revealed . Order Summary APPOINTMENT WITH . CHF CLINIC 4/10/23 at 10:40 AM . On 4/26/23 at 11:50 AM, during an interview with Employee Identifier (EI) #7, Social Service Director she was asked how she found out about resident appointments; she said the Nurse Practitioner (NP) or Director of nursing would tell her, and she did not know about RI #1's appointment. EI #7 was asked why she would not know about the appointment if she was the one who set up transport. EI #7 said once she knew about an appointment, she would set it up. When she was asked about the appointment and realized RI #1 had missed it, she called and rescheduled. EI #7 was asked what the problem could be if a resident missed an appointment. EI #7 said it varies depends on the type of appointment, she recalled the NP telling RI #1's family RI #1 missed the appointment and another was scheduled for the 4/18. EI #7 was asked where the appointment sheet was for 4/18/23; EI #7 said she did not make one, as RI #1's family was taking the resident out of the facility that day which was 4/11/23. On 4/28/23 at 8:00 AM during an interview with EI #9, the admitting nurse she was asked how did the facility get orders for RI #1. she said admit orders were faxed to the facility the day before RI #1 came. EI #9 was asked when was the cardiology appointment made known to the facility; EI #9 said with admission orders so she put it in the facility Physician Orders. When EI #9 was asked when was the appointment to be; she said on 4/10/23 at 10 something in the morning. EI #9 said she did not know if RI #1 went to the appointment or why the appointment was missed. When EI #9 was asked who was responsible for making transport arrangements; she said social service does that if they know about it. EI #9 was asked if the appointment was a doctor's order; she said yes. When EI #9 was asked how doctor's orders were followed if the appointment was missed; she said orders were not followed. On 4/28/23 at 8:20 AM during a follow up interview with EI #7, Social Services, she was asked how did she find out about resident appointments on current or new residents. EI #7 said in the morning meeting they discussed new admits and new orders and it was usually at that time she was told of appointments. EI #7 was asked what she recalled about RI #1 in the morning meeting on 4/6/23. EI #7 said honestly, she could not recall any discussion about an appointment, if she had she would have arranged transport and placed a sheet in the appointment book. EI #7 was asked why was the appointment for RI #1 on 4/10/23 missed. EI #7 said, Oversight. EI #7 was asked how did she find out about appointments. EI #7 said the Nurse Practitioner will call, nurses will call and in morning meetings if it was a new resident. When EI #7 was asked who was responsible for setting up appointments; she said she was and she got the appointment instructions and would arrange for transport. EI #7 said she then placed an appointment sheet in the appointment book; the staff would go to the book and see who had appointments and when and where and have the resident ready. EI #7 was asked what could the concern be in a resident missing an appointment. EI #7 said the problems may vary. When EI #7 was asked if the appointment was a doctor's order; she said yes. EI #7 was asked what was the concern with the appointment being missed; EI #7 said the facility did not follow doctor's orders. On 4/28/23 at 12:10 PM during an interview with EI #2, the Director of Nursing she said RI #1 had a follow up appointment on the admission orders for the Congestive Heart Failure Clinic. When asked who should have been notified of the appointment EI #2 said she should have told about it in the morning meeting the day after RI #1 was admitted , we discuss new admits and review the orders, and social services would have arranged transportation and placed paper in appointments book. EI #2 said they had determined the appointment was missed. EI #2 was asked why was the appointment missed; she said an oversight on our part. EI #2 was asked if the appointment was a doctors' order; she said yes. When EI #2 was asked how were doctors orders followed if the appointment was missed; she said the orders were not followed. 37292 2) A review of Potter and Perry's FUNDAMENTALS OF NURSING with a copyright date of 2017, Chapter 32 Medication Administration, page 657, revealed the following STEP . l. Do not leave medications unattended . RATIONALE . Nurse is responsible for safekeeping of drugs. Review of a facility policy titled, Medication Administration General Guidelines, with a reviewed/updated date of 04/2022, revealed the following: POLICY: Medications are administered . in accordance with good nursing principles and practices . RI #2 was admitted to the facility on [DATE] and has a diagnosis of Cognitive Communication Deficit. RI #2's April 2023 Order Review Report (Physician's Orders) revealed RI #2 was receiving Gabapentin 300MG two capsules (600MG) at bedtime and Norco 7.5-325MG every 4 (four) hours as needed for pain. On 04/27/2023 at 9:41 AM, the surveyor observed RI #2 take an amber-colored bottle without a label out of his/her nightstand drawer. The bottle had a plastic medicine cup in the opening at the top of the bottle. The surveyor observed six medications in the bottom of the bottle. When asked what they were and how he/she got the medication, RI #2 stated that five of the pills were Norco and one of them was Gabapentin and that most of the nurses just left them on his/her overbed table with a cup of water and then left the room. RI #2 said that Norco caused constipation, so he/she did not take it unless he/she was in a lot of pain, but some of the nurses brought it to him/her whether it had been requested or not, so he/she would take out the Norco and put it in the bottle to take when he/she really needed it. When asked which nurse left the medications, RI #2 said that he/she did not recall any specific nurse and stated that several of them left his/her medications. The surveyor explained that staff would have to be notified that the medication was in the room and RI #2 said that the Administrator could come, and he/she would tell him about the medications, and it was explained that a management nurse would also have to be in the room to get the medication and RI #2 agreed. The surveyor stepped to the door and asked a staff member to ask the Administrator to come to RI #2's room and also asked her to get a nurse manager. On 04/27/2023 at 9:57 AM, Employee Identifier (EI) #1, the Administrator, entered RI #2's room, along with EI #3, Registered Nurse (RN)/Assistant Director of Nursing (ADON). When asked, RI #2 explained to them that nurses had left his/her medications on the overbed table and that they brought the Norco whether he/she had asked for it or not and it caused constipation, so he/she would take it out of the medicine cup and put it in the bottle and then take it when he/she really needed it later. RI #2 said he/she did not know why the Gabapentin was in there because he/she usually took it when the nurses left it. The surveyor asked EI #3 to get RI #2's medication cards to verify the medications in the bottle matched what was in the cards in the medication cart. EI #3 left the room and returned with RI #2's medication card of Norco 7.5MG and Gabapentin 300MG. She donned gloves and took a white caplet out of the bottle on RI #2's overbed table and held it beside the card of Norco 7.5MG with imprint M366 and compared it to white pills in bottle and stated that they matched the Norco 7.5 in the card. EI #3 then picked the yellow capsule out of the bottle and compared it to the card of Gabapentin with imprint of IP102 and stated that it matched the Gabapentin in the card. EI #3 was asked to describe the appearance of the pills and she said that they were intact, and she could read the imprint on them. When asked if she could determine if the pills had been administered to RI #2, she said it did not look like it to her because they were dry and intact and admitted that it was consistent with what RI #2 was reporting about the pills being left in the medication cup on the overbed table. On 04/27/2023 at 10:24 AM, an interview was conducted with EI #1, Administrator. EI #1 said that he was notified by a staff member that a state surveyor had requested for him and a registered nurse to come to RI #2's room. When asked, EI #1 said that he observed what appeared to be a prescription bottle container with a total of six medications and what appeared to be a medication cup with a hole in the top covering the prescription bottle. He said that RI #2 indicated that five of them were Norco and one was Gabapentin and that he/she was being given PRN (as needed) medication without him/her asking for them and that they would be left in the medication cup on his/her table and that he/she knew what those medications were for and they were constipating so he/she chose to hold on to the medication in the drawer and take them at a later time when he/she felt that the medication was needed. EI #1 further stated that the nurses should ensure that when they give medications that they stay with the residents to see the residents swallow the medications, but since RI #2's medications were intact he would have to say that they did not do that with him/her. On 04/28/2023 at 7:33 AM, an interview was conducted with EI #15, Licensed Practical Nurse (LPN). She stated that the only medications that should be left at a resident's bedside was if they had an order for an inhaler or something like that that could be kept at bedside. When asked how RI #2 would have been able to put his/her Norco 7.5 MG and Gabapentin 300 MG in a bottle in his/her nightstand, EI #15 said someone would have had to leave the medication in his/her room for that to happen, but she did not recall leaving either of those medications in RI #2's room. On 04/28/2023 at 8:47 AM, an interview was conducted with EI #3, RN/ADON. When asked how PRN narcotics should be administered, EI #3 said she did not give out a PRN unless the resident asked for it and she made sure that they took it while she was in there. She stated she became aware that there were narcotic medications in RI #2's room because EI #1, Administrator, had told her that State needed a nurse in his/her room, and she saw it when she entered the room. She further stated that she observed one Gabapentin 300 MG and five Norco 7.5-325 MG pills and that they were intact and did not appear to have been in RI #2's mouth. She said RI #2 told them that the nurses brought the Norco in and would just set them on the table and leave them even though he/she had not asked for it so he/she would take them out and put them in a bottle and would take them later when he/she needed them. When asked what the concern was with narcotics being left in RI #2's room, EI #8 said he/she could overdose or somebody else could go in there and take them so either way nothing good was going to come from it. On 04/28/2023 at 5:03 PM, an interview was conducted with EI #2, RN/Director of Nursing (DON). EI #2 was asked how should nurses administer PRN narcotics and she said if a resident requests a PRN, the nurse should assess them, validate the order, punch it out of the blister pack, sign it out on the narcotic book, take it in and then go back to the cart and document it on the MAR so that they can follow up and document the effectiveness of it. When asked what was determined about why RI #2 had five Norco and one Gabapentin in a bottle in his/her room that were still intact, EI #2 stated some of the nurses might have left them in there like RI #2 said, but they should have stayed with him/her until they were taken. 3) Review of a facility policy titled, Oxygen Guideline, with an effective date of 01/01/2022, documented: POLICY Medical oxygen is classified by the Food and Drug Administration as a drug and therefore it is provided in accordance with a health care provider's order and in accordance with acceptable standards of practice. RI #14 was readmitted to the facility on [DATE]. RI #14's April 2023 Order Summary Report (Physician's Orders) revealed RI #14 had an order for Oxygen Use: 3L (liters)/MIN (minute) via (by way of) nasal cannula continuously every day and every night. Review of RI #14's April 2023 Weights and Vitals Summary documented that RI #14 was on Room Air from 04/01/2023 - 04/17/2023, and from 04/19/2023 - 04/26/2023. On 04/26/2023 at 2:48 PM, the surveyor observed that there was no oxygen infusing and there was no concentrator in RI #14's room. The surveyor noted that RI #14 did not appear to be in any distress and he/she was able to talk and answer questions with no obvious signs or symptoms of shortness of breath. When asked, RI #14 said that he/she was on oxygen when he/she readmitted to the facility at the end of last month, but he/she had not used the oxygen, but a few days and he/she did not recall when the last time there was any oxygen in his/her room. On 04/27/2023 at 7:43 AM, the surveyor observed that there was no oxygen infusing and there was no concentrator in RI #14's room. On 04/28/2023 at 8:47 AM, an interview was conducted with EI #3, RN/ADON. When asked EI #3 said that she remembered seeing RI #14 with a cannula in his/her nose when he/she came back from the hospital after hip surgery, but she did not recall seeing it since then. She said she was not aware that RI #14 had an order for continuous oxygen but agreed that the order was not being followed since he/she did not have an oxygen concentrator in his/her room. On 04/28/2023 at 11:41 AM, an interview was conducted with EI #5, Licensed Practical Nurse (LPN). EI #5 said she was not aware that RI #14 had an order for continuous oxygen and had not seen an oxygen concentrator in his/her room. She stated that all doctor's orders should be followed and the concern with not following them would be that the resident was not getting what the doctor wanted them to have and RI #14 could have become short of breath if he/she needed the oxygen and was not getting it. On 04/28/2023 at 5:03 PM, an interview was conducted with EI #2, Registered Nurse (RN)/Director of Nursing. When asked if RI #14's Physician's Order to receive Oxygen at 3L/MIN continuously had been followed, EI #2 said no, but stated that all doctor's orders should be followed. She admitted that the concern with not following doctor's orders was that the resident was not receiving his/her prescribed care. 21055 4) Page 311 of Chapter 23 titled Legal Implications in Nursing Practice of POTTER and PERRY's FUNDAMENTALS OF NURSING, with a copyright date of 2017, documented: . Health Care Providers' Orders . Nurses follow health care providers' orders unless they believe that the orders are in error . RI #4 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include Alzheimer's Disease, Adult Failure to Thrive and Encounter for Palliative Care. RI #4's Order Summary Report (Physicians Orders) revealed RI #4 had an order, with a start date of 02/14/2022, for Scopolamine Patch 72 Hour 1 MG (milligram)/3 DAYS Apply 1 patch transdermally every 72 hours for secretion and remove per schedule . On 04/26/2023 at 6:57 PM, the surveyor conducted a telephone interview with RI #4's representative. The resident representative alleged RI #4's Scopolamine patch was off for four days. A review of RI #4's February 2023 e-MAR (electronic Medication Administration Record) revealed on 02/13/2023, there was no evidence RI #4's Scopolamine patch had been removed and a new one applied as ordered by the physician. Further review of the eMAR revealed the next time there was evidence the Scopolamine patch had been replaced was on 02/16/2023, three days later. On 04/28/2023 at 11:55 AM, the surveyor conducted an interview with Employee Identifier (EI) #12, the CNA (Certified Nursing Assistant)/Medication Aide administering medications to RI #4 on 02/13/2023. When asked where there would be evidence RI #4's Scopolamine patch had been removed and a new one applied as ordered by the physician, EI #12 said that would be on the eMAR. The surveyor asked EI #12, looking at EI #4's February 2023 eMAR, did she see evidence RI #4's Scopolamine patch was removed and applied on 02/13/2023. EI #12 said no. The surveyor asked EI #12 how she as a Medication Aide would show the Physicians Orders had been carried out. EI #12 said by documenting on the eMAR. On 04/28/2023 at 6:30 PM, the surveyor conducted an interview with EI 10, the Registered Nurse (RN)/Unit Manager of the unit RI #4 resided on. When asked where there would be evidence RI #4's Scopolamine patch had been removed and a new one applied as ordered by the physician, EI #10 said that would be documented on the eMAR. The surveyor asked EI #10, looking at RI #4's eMAR, did she see evidence the Scopolamine patch was removed and a new one applied on 02/13/2023, EI #10 said no.

Based on interviews, record review, and facility document titled POSITION DESCRIPTION for Social Services Supervisor the facility failed to ensure the care planning process facilitated the inclusion of resident and resident's representative for Resident Identifier (RI) #3 and RI #10 when the facility did not schedule a care plan meeting with resident or resident's representative. This affected two of three residents sampled for the right to participate in care planning. Findings Include: A review of facility document titled POSITION DESCRIPTION for Social Services Supervisor which was signed by Employee Identifier (EI) #13 on 11/03/2022 revealed .KEY RESPONSIBILITIES . 3. Documents progress and updates plans of care at the interdisciplinary care conference . RI #3 was admitted on [DATE] with diagnoses that included End Stage Renal Disease. RI #3 was discharged on [DATE]. On 04/26/2023 at 10:45 AM an interview was conducted with RI #3's responsible party and care conference person. He/she reported the facility did not communicate anything with them regarding a care plan meeting and he/she did not attend a care plan meeting. RI #10 was admitted on [DATE] with diagnoses that included Infection Following a Procedure, Other Surgical Site, Subsequent Encounter. RI #10 was discharged on [DATE]. On 04/26/2023 at 2:45 PM an interview was conducted with RI #10's family and care conference person. He/she reported the facility did not communicate anything with them regarding a care plan meeting and he/she did not attend a care plan meeting. On 04/26/2023 at 5:00 PM an interview was conducted with EI #11, Licensed Practical Nurse, Minimum Data Set (MDS) and Care Plan Assistant. EI #11 said that through interviews with residents and care plan meetings, she incorporated the residents and resident representative's goals and preferences into resident's care plans. EI #11 said social services should schedule care plan meetings with residents and sponsors upon admission and quarterly. EI #11 said it was important to include the resident and sponsor in care plan meetings to ensure the residents needs were met and the care plan was individualized. EI #11 continued, the care plan meeting was to address any specific concerns or request. On 04/27/2023 at 10:40 AM an interview was conducted with EI #4, Director of Care Coordination who said social services was responsible for scheduling care plan meetings and inviting resident and resident's representative. On 04/27/2023 at 10:50 AM an interview was conducted with EI #13, Social Services Director. EI #13 said social services, himself, was responsible for scheduling care plan meetings with residents and resident's representative. EI #13 said he scheduled the care plan meeting whenever it was determined to be necessary for residents or family. EI #13 said the care plan meeting should be within seven days of admission and then quarterly but were not being done at that frequency. EI #13 said he did not know when a care plan meeting was held for RI #3 or his/her representative. EI #13 said there was not an actual care plan meeting with RI #10 or his/her representative. EI #13 said when a care plan meeting was held it was documented on a sign-in sheet if held in-person and entered into resident notes in the electronic health record when representatives participated via phone. On 04/27/2023 at 12:15 PM an interview was conducted with EI #2, Registered Nurse, Director of Nursing. EI #2 said the EI #11, EI #13, or EI #4 was responsible for scheduling care plan meeting with residents and resident's representatives. EI #2 said nurse representative, therapy representative, social services, and other disciplines based on resident's needs or request should attend the meeting with resident and resident's representative. EI #2 said it was important to include the resident and representative in care plan meetings to update them on the care, changes, and communicate expectations and goals. ************************** This deficiency was cited as a result of the investigation of complaint/report number AL00042883.

Based on record reviews, interviews, and review of a policy titled, Abuse, Neglect, Misappropriation, Exploitation Policy, the facility failed to protect Resident Identifier (RI) # 5, from misappropriation of resident property when his/her bag with personal belongings were placed in an unlocked closet when he/she was out of the facility. RI # 5 transferred to the hospital on 12/20/2022 and on 12/27/2022 when his/her Power of Attorney came to retrieve his/her belongings the bag was missing from the unlocked closet. This affected RI #5, one of three residents sampled for abuse concerns. Findings Include: A review of the abuse policy titled, Abuse, Neglect, Misappropriation, Exploitation Policy, dated January 2019, revealed, .Purpose: To prohibit and prevent .misappropriation of resident property . RI # 5 was admitted to the facility on [DATE] and discharged to the hospital on 12/20/2022. On 12/28/2022 at 6:44 PM, the State Survey Agency received an initial report from the facility regarding an allegation of possible Misappropriation of Resident Property involving RI # 5. According to this initial report, RI # 5 was sent to the hospital on 12/20/2022. RI # 5's phone, phone charger and watch were locked up for safe keeping. On 12/23/2022 the remaining personal items were placed into a linen closet for storage. On 12/27/2022 RI # 5's Power of Attorney came to get his/her personal items and stated a wallet was missing. An interview was conducted with Employee Identifier (EI) # 4, Director of Care Coordinator on 4/26/2023 at 11:30AM. EI #4 stated that on 12/23/2022 she was instructed to removed RI # 5's personal items from his/her room due to a new admission. EI # 4 stated she placed clothing items and ball cap in a black carry-on suitcase. She said she looked in the black bag before placing the items and did not see a wallet, credit cards or state issued identification. She said she put the bag with the items in the west wing linen closet. She reported the linen closet was not locked and employees had access to the room. She further stated on 12/27/2022 an employee went to retrieve the bag and it was not in the linen closet. The clothes and ball cap were on a shelf in the linen closet. EI # 4 said several employees looked for the bag, but it was never located. She said she had no idea what happened to the bag. She further stated if asked now to remove personal items from a resident's room she would place them in a locked secure area. An interview was conducted with EI #2, Director of Nursing (DON) on 4/26/2023 at 12:00PM. EI # 2 recalled the incident involving RI # 5's missing items. She said in December of 2022 RI # 5 was discharged to the hospital. She said she became aware of the missing suitcase on 12/27/2022 when the sponsor came to retrieve RI #5's items. EI #2 stated during the time that RI #5 was gone, EI #4 had placed some of RI #5's items, including the black bag in the West wing linen closet. When RI #5's sponsor came to collect the items staff went to get items but the black bag was not there. EI # 2 said at that time the sponsor said a wallet, identification and credit cards were in the bag and were missing. EI # 2 said RI # 5's bag with personal items were placed in an unlocked closet on 12/23/2022 and if it had been locked it would have been harder for the suitcase to go missing due to limited people having access to a locked closet. On 4/26/2023 at 4:45PM, an interview was conducted with EI # 1, Administrator. EI # 1 stated he was not employed at the facility in December but had reviewed the report concerning RI #5. He stated the bag and wallet went missing and was never found. When asked what could have been done to prevent the bag from being misplaced, he said it could have been put in a secure area with a lock. He further said residents' personal items should be kept in a secure location until they are retrieved to ensure they are not misplaced. ********************************* This deficiency was cited as a result of the investigation of complaint/report number AL00042818.

Based on interviews, record review, and review of facility policies titled Medication Administration and Oxygen Guideline, the facility failed to ensure: 1) licensed staff documented pain medication on the Electronic Medication Administration Record as administered when administering pain medication to Resident Identifier (RI) #2 and 2) did not document administration of oxygen for RI #14 when it was not being administered. This affected two of 17 residents sampled for documentation. Findings Include: A review of a facility policy titled Medication Administration with an effective date of 11/1997 and revised date of 04/2022 revealed: Policy: Medications are administered as prescribed, in accordance with good nursing principles and practices . Procedure: . This individual records the administration of medication on the resident's MAR (medication administration record)/EHR (electronic health record) at the time the medication is given. 1) RI #2 was admitted to the facility on [DATE] with diagnoses including Unspecified Pain. A review of RI #2's CONTROLLED SUBSTANCE INVENTORY RECORD (narcotic log/book/record) and Medication Administration Record (MAR) revealed that 76 doses of Norco were recorded as administered on the CONTROLLED SUBSTANCE INVENTORY RECORD between 03/18/2023 and 04/27/2023; and 13 doses were documented on the MAR from 03/18/2023 through 04/27/2023. On 04/28/2023 at 7:33 AM an interview was conducted with Employee Identifier (EI) #15, Licensed Practical Nurse (LPN). When asked, EI #15 stated the process for administering and documenting narcotics was to sign it out on the narcotic log when she takes out the medication and then after they actually take the medication and put it in their mouth she went back to the computer and click on the EMAR (electronic medication administration record) that they have taken it. EI #15 said that the biggest concerns with signing the medication out of the narcotic log and not signing it out on the MAR would be possible diversion and the log not matching the MAR. When asked EI #2 confirmed that RI #2's Norco was signed out on the narcotic log 29 times from March 18 - 31, 2023, however, it was only signed out on the [DATE] times. She then confirmed that RI #2's Norco was signed out on the narcotic log 47 times from April 1 - 27, 2023, but only eight (8) times on the MAR which made RI #2's MAR inaccurate. EI #15 then confirmed that she had signed out RI #2's Norco several times on the narcotic log but had not signed it out on the MAR because things got so hectic, she probably just forgot to do it both places. On 04/28/2023 at 10:07 AM, a telephone interview was conducted with EI #16, Registered Nurse (RN). When asked where should the administration of RI #2's Norco be documented, EI #16 said on the narcotic log and on the MAR, but they sign it out on the log when they pull it and then document it on the MAR when the residents take it so sometimes we may get busy and forget to sign the MAR if something happens and we get interrupted, but we are supposed to sign both places. On 04/28/2023 at 11:41 AM, an interview was conducted with EI #5, LPN. When asked the process for administering a PRN (as needed) narcotic, EI #5 said that they have to ask for it since it is as needed, and the nurse should ask about their pain level, where the pain is located, make sure that it is in time frame, sign it out on the narcotic log, give the resident the medication and click it on the MAR in PCC (Point Click Care). She said that she was going to be honest and say that it gets hectic, and she sometimes forgets to document it in PCC, but she documents on the narcotic log to make sure the count is accurate. When asked if she had ever administered RI #2's PRN Norco, EI #5 said she had and he/she tried to get her to leave it on his/her table, but she said she told him/her no. EI #5 confirmed that RI #2's Norco was signed out on the narcotic log in March 18-31, 2023, 29 times but was only documented on the MAR five (5) times. She further confirmed that his/her Norco was signed out on the narcotic log from April 1 - 27, 2023 47 times but was only documented on the MAR eight (8) times, so the MAR was not accurate. On 04/28/2023 at 5:03 PM, an interview was conducted with EI #2, RN/Director of Nursing. When asked, EI #2 said that nurses should sign out narcotics on the narcotic logbook when it is prepared and after the medication is taken, they should document the administration on the MAR. It was explained to EI #2 that from March 18 through April 27, 2023, RI #2 had 76 doses of Norco were signed out on the CONTROLLED SUBSTANCE INVENTORY RECORD, but only 13 doses were documented on the MAR. EI #2 stated that the nurses should have documented the administration of the Norco in both places because not signing it out on the MAR made RI #14's MAR/medical record inaccurate. 2) Review of a facility policy titled, Oxygen Guideline, with an effective date of 01/01/2022, documented: POLICY Medical oxygen is classified by the Food and Drug Administration as a drug and therefore it is provided in accordance with a health care provider's order and in accordance with acceptable standards of practice. RI #14 was readmitted to the facility on [DATE]. RI #14's April 2023 Order Summary Report (Physician's Orders) revealed RI #14 had an order for Oxygen Use: 3L(liters)/MIN (minute) via (by way of) nasal cannula continuously every day and every night with a start date of 03/28/2023. Review of RI #14's April 2023 MAR revealed documentation that the resident was receiving continuous oxygen via nasal cannula at 3L/MIN. On 04/26/2023 at 2:48 PM, the surveyor observed that there was no oxygen infusing and there was no concentrator in RI #14's room. On 04/27/2023 at 7:43 AM, the surveyor observed that there was no oxygen infusing and there was no concentrator in RI #14's room. On 04/28/2023 at 8:47 AM, an interview was conducted with EI #3, RN/ADON. When asked EI #3 said that she remembered seeing RI #14 with a cannula in his/her nose when he/she came back from the hospital after hip surgery, but she did not recall seeing it since then. She reviewed the documentation in RI #14's medical record and said that the nurses were falsifying documentation about him/her receiving oxygen which made his/her medical record inaccurate. On 04/28/2023 at 11:41 AM, an interview was conducted with EI #5, Licensed Practical Nurse (LPN). EI #5 said she was not aware that RI #14 had an order for continuous oxygen and had not seen a oxygen concentrator in his/her room. She stated when asked that documenting something that the resident was not receiving would be false documentation. On 04/28/2023 at 5:03 PM, an interview was conducted with EI #2, Registered Nurse (RN)/Director of Nursing. When asked why the nurses were documenting that RI #14 was receiving oxygen when there was no oxygen concentrator in his/her room, EI #2 said she was not sure, but they should not be documenting it if he/she was not getting it. She further stated the concern was RI #14's medical record was not accurate if the nurses were documenting that he/she was receiving oxygen when he/she was not.

Based on observations, interviews, and a review of medical records, the facility failed to ensure interventions were implemented for Resident Identifier (RI) #14 when RI #14 developed a Stage II pressure ulcer on his/her left heel on 04/24/2023. This deficient practice affected RI #14; one of three sampled residents reviewed for pressure ulcers. Finding include: RI #14 was readmitted to the facility on [DATE] with a diagnoses including Fracture of Unspecified Part of Neck of Left Femur, Initial Encounter for Closed Fracture, Other Reduced Mobility, and Moderate Protein-Calorie Malnutrition. Review of RI #14's Order Summary Report (Physician's Orders) for April 2023, revealed the following order: . CLEAN LEFT HEEL WITH WOUND CLEANSER COVER WITH XEROFOAM, 4X4 AND WRAP WITH KERLIX SECURE WITH TAPE CHANGE MWF (MONDAY, WEDNESDAY, FRIDAY). ONE TIME A DAY EVERY MON, WED, FRI . Order Date 04/24/2023 . On 04/26/2023 at 2:48 PM, the surveyor observed RI #14 lying in bed with yellow non-skid socks on his/her feet and his/her heels were lying flat on the bed with no booties or pillows being utilized to relieve pressure to the left heel area. On 04/27/2023 at 7:43 AM, RI #14 was observed lying in bed with yellow non-skid socks to bilateral feet and his/her heels were lying flat on the bed with no booties or pillows being utilized to relieve pressure to the left heel area. On 04/27/2023 at 3:26 PM, RI #14 was lying in bed with yellow non-skid socks to bilateral feet and his/her heels were lying flat on the bed with no booties or pillows being utilized to relieve pressure to the left heel area. On 04/27/2023 at 3:41 PM, an interview was conducted with Employee Identifier (EI) #8, Nurse Practitioner. EI #8 was asked if he had been made aware of RI #14's left heel pressure ulcer and he said that they did not tell him, but he saw it in the chart where they documented that he/she had a blister. EI #8 looked into his computer and further stated that he would enter an order to elevate RI #14's heels because he did not see where he/she had elevation as an intervention, but that it should be done for the area to heal. On 04/28/2023 at 7:31 AM, RI #14 was lying in bed with yellow non-skid socks to bilateral feet and his/her heels were lying flat on the bed with no booties or pillows being utilized to relieve pressure to the left heel area. On 04/28/2023 at 8:47 AM, an interview was conducted with EI #3, Registered Nurse (RN)/Assistant Director of Nursing (ADON)/Interim Treatment Nurse. When asked how she became aware that RI #14 had a pressure area on his/her left heel, EI #3 said she was called at home late Friday or Saturday by the Director of Nursing (DON), and she told her about it. She further stated that the DON described it like a popped blister and that they discussed the treatment, and that she would assess the area on Monday. She said that a dressing was placed on the area by the DON, and she thought that they would have elevated RI #14's heels, but she had seen where EI #8, NP, had put in an order to elevate heels on 04/27/2023. EI #8 said the heel wound measured 5.4 cm (centimeters) in length and 3.2 cm in width and the wound bed was dry and pink with no slough, eschar, or drainage. On 04/28/2023 at 11:14 AM, surveyor into resident's room with EI #3, RN/ADON/Interim Treatment Nurse, to observe wound care to RI #14's left heel wound. RI #14 was lying in bed on back with yellow non-skid socks to bilateral feet and no booties or pillows being utilized at this time. Surveyor observed a Stage II pressure ulcer to RI #14's heel during dressing change. Upon completion of the dressing change, EI #3 went to the nurse's desk and asked a staff member to go get a pillow to elevate RI #14's heels from the bed. The surveyor asked EI #3 should RI #14's heels have been elevated when we entered his/her room and EI #8 said yes, they should have. On 04/28/2023 at 3:18 PM, an interview was conducted with EI #14, Licensed Practical Nurse (LPN)/Unit Manager. EI #14 was asked if she was aware that RI #14 had a wound on his/her left heel, and she said no. When asked what interventions should have been implemented when it was determined that RI #14 had developed a heel wound, EI #14 said contact the provider for an order for treatment and elevate the heels because the wound could get worse without the heel being elevated. On 04/28/2023 at 5:03 PM, an interview was conducted with EI #2, RN/Director of Nursing. When asked what intervention should be implemented when a resident develops a pressure ulcer on his/her heel, EI #2 stated to elevate the heels because the wound could worsen if the heels were not being elevated.

Based on interviews and record review the facility failed to ensure Resident Identifier (RI) #3's comprehensive care plan was developed timely. This affected RI #3; one of three residents sampled for timely development of comprehensive care plans. Findings Include: RI #3 was admitted on [DATE] with diagnosis that included End Stage Renal Disease. RI #3 was discharged on [DATE]. A review of RI #3's chart revealed only a base line care plan was in place for RI #3 and comprehensive care plans were never developed. On 04/26/2023 at 5:00 PM an interview was conducted with Employee Identifier (EI) # 11, Minimum Data Set (MDS) and Care Plan Assistant. EI #11said all residents should have a Comprehensive Care Plan developed by day 21 of each resident's stay. EI #11 said RI #3 did not have a Comprehensive Care Plan developed or implemented. EI #3 said RI #3's care plan should have been developed by 12/05/2022. EI #11 said it was important for residents to have a Comprehensive Care Plan because if the care plan was not created, the Kardex could not be created, and direct staff would not have instructions on how to best care for the resident. On 04/27/23 at 12:15 PM an interview was conducted with EI #2, Registered Nurse, Director of Nursing. EI #2 said RI #3 did not have a Comprehensive Care Plan developed. EI #2 said the Comprehensive Care Plans are developed based on resident's assessment and informed staff on how to provide care to each resident. ************************** This deficiency was cited as a result of the investigation of complaint/report number AL00042883.

Based on observations, interviews and record review, the facility failed to ensure: 1) Resident Identifier (RI) #4's intervention for padded side rails was implemented; and 2) an Oxygen care plan was developed for RI #14 when he/she was readmitted to the facility on [DATE]; and a pressure ulcer care plan was developed and implemented when RI #14's left heel wound was identified on 04/24/2023. These deficient practices affected RI #4 and RI #14, two of 17 residents whose plans of care were reviewed. Findings include: 1) RI #4 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include Alzheimer's Disease and Impulsiveness. A review of RI #4's At risk for falls related to: use of psychotropic medications impaired mobility, dependent for all transfers, impaired vision care plan, with an initialed date of 03/16/2021, revealed the following intervention: . Padded side rails for positioning . RI #4's Order Summary Report (Physicians Orders) revealed RI #4 had an order, with a start date of 10/14/2022, for padded enablers. On 04/25/2023 at 5:59 PM, the surveyor observed RI #4 lying in bed with 1/2 upper side rails in use. There was no padding observed on the side rails. On 04/26/2023 at 7:49 AM, RI was again observed in bed with no padding on his/her 1/2 upper side rails. On 04/27/2023 at 7:33 AM, RI #4's side rails remained without padding. On 04/28/2023 at 7:51 AM, RI was again observed in bed with no padding on his/her 1/2 upper side rails. On 04/28/2023 at 6:30 PM, the surveyor conducted an interview with Employee Identifier (EI) #10, the Registered Nurse (RN)/Unit Manager of the unit RI #4 resided on. The surveyor asked EI #10, according to RI #4's plan of care, should RI #4's side rails be padded. EI #10 said yes. When asked why that intervention was put in place, EI #10 said RI #4's skin was fragile and the padding was to prevent skin tears and bruising to RI #4's knees. The surveyor asked EI #10 who would be responsible for ensuring RI #4's side rails were padded. EI #10 said nursing staff. When asked if RI #4's side rails were not padded was the intervention on the care plan being implemented, EI #10 said no. On 04/28/2023 at 6:39 PM, EI #10 escorted the surveyor to RI #4's room. EI #10 said she did not see any padding on RI #4's side rails at that time. 37292 2) RI #14 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include Fracture of Unspecified Part of Neck of Left Femur, Initial Encounter for Closed Fracture and Other Reduced Mobility. A review of RI #14's care plans revealed no care plans were found for potential for altered skin integrity due to decreased mobility or for the use of continuous oxygen. RI #14's Order Summary Report (Physician's Orders) revealed RI #14 had an order, with a start date of 03/28/2023, for Oxygen Use: 3L(liters)/MIN (minute) via (by way of) Nasal Cannula Continuously every day and night shift and an order with a start date of 04/24/2023, to clean left heel with wound cleanser cover with Xerofoam, 4x4 and wrap with Kerlix secure with tape change MWF (Monday, Wednesday, Friday) one time a day every Mon, Wed, Fri. On 04/28/2023 at 4:39 PM, an interview was conducted with Employee Identifier (EI) #11, Licensed Practical Nurse (LPN)/Minimum Data Set (MDS) Assistant. When asked who was responsible for initiating, implementing, and developing care plans, EI #11 said she does them on admission and updates them quarterly. EI #11 said that she looked at RI #14 when he/she was readmitted from the hospital and put in a fracture care plan, but she missed the oxygen. EI #11 admitted that if RI #14 was on oxygen when he/she was readmitted that an oxygen care plan should have been initiated when she initiated the fracture care plan. She stated the purpose of the care plan was to guide the resident's care. EI #11 was asked when a risk for altered skin integrity should be initiated and she said on admission and that RI #14 should have had one on readmission for potential for pressure ulcers. When asked what the potential for or risk for pressure ulcer care plan interventions would be, EI #11 said pressure reduction mattress, wheelchair cushion, turn and reposition resident as they will allow, and incontinent care were the ones that she recalled, but she could not recall everything at the moment. EI #11 stated that if she were developing a care plan for an actual heel wound such as the one RI #14 had developed, she would add for the heels to be floated as an approach. On 04/28/2023 at 5:03 PM, an interview was conducted with Employee Identifier (EI) #2, Registered Nurse (RN)/Director of Nursing (DON). EI #2 was asked when a care plan for oxygen should be initiated. EI #2 said when the order for oxygen was received. EI #2 said that RI #14 did not have a care plan for oxygen when he/she was readmitted with the order on 03/28/2023. She stated that a care plan should have been initiated at that time because a care plan directs staff to provide optimal care for the residents. She further stated that a resident should receive a care plan for potential for altered skin integrity on admission and it should be updated with any changes or if the resident developed an actual wound. When asked if RI #14 had a care plan implemented when a blister on his/her heel was identified on 04/24/2023, EI #2 said no, and the concern was that the care plan directs the care and not having a care plan could result in the pressure ulcer not improving or could even cause the area to worsen.

Based on interview, record review, and review of the Centers for Medicare & (and) Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, the facility failed to ensure Resident Identifier (RI) #15's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 03/22/2023 was accurately coded to reflect RI #15 used continuous oxygen during this assessment period. This deficient practice affected RI #15, one of 17 sampled residents for whom MDS assessments were reviewed. Findings include: RI #15 was admitted to the facility on [DATE], and has diagnoses to include Shortness of Breath (SOB). A review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, dated October 2019, revealed: . Section O0100: Special Treatments, Procedures, and Programs . O0100C, Oxygen therapy Code continuous or intermittent oxygen via (by way of) mask, cannula, etc., delivered to a resident to relieve hypoxia in this item. A review of RI #15's Order Summary Report (Physicians Orders) revealed RI #15 had a Physicians Order, with an order date of 02/28/2023, for Oxygen at 2 liters/minute via NC (nasal cannula) to maintain saturations greater than 90% (percent) every shift for SOB. RI #15's Quarterly MDS assessment, with an ARD of 03/22/2023, did not code RI #15 as using oxygen during this assessment period. A review of RI #15's March 2023 e-MAR (electronic-Medication Administration Record) revealed RI #15 had received oxygen at 2 liters/minutes from 03/01/2023 through 03/31/2023. On 04/28/2023 at 4:23 PM, the surveyor conducted an interview with Employee Identifier (EI) #11, the MDS Assistant. When asked should RI #15 be coded on his/her most recent MDS assessment dated [DATE] for oxygen use, EI #11 said if RI #15 used the oxygen between 03/16/2023 - 03/22/2023 he/she should be coded for oxygen use. The surveyor asked EI #11 where it would be found if RI #15 had used oxygen during those time frames. EI #11 said on the eMAR or in the nurse's notes. EI #11 said looking at RI #15's e-MAR the oxygen was used during those time frames and should have been coded on the 03/22/2023 MDS assessment. The surveyor asked EI #11 was the 03/22/2023 MDS assessment accurate. EI #11 said no. EI #11 said the importance of a resident having an accurate MDS assessment was to ensure the plan of care would be correct.

Based on observation, interviews, record review, review of a facility policy titled, Medication Administration General Guidelines and review of Potter and Perry's FUNDAMENTALS OF NURSING, the facility failed to ensure the licensed nurse did not leave medications unattended at the bedside of Resident Identifier (RI) #15 on 03/17/2022. This deficient practice affected RI #15, one of 15 sampled residents. Findings Include: A review of Potter and Perry's FUNDAMENTALS OF NURSING with a copyright date of 2017, Chapter 32 Medication Administration, page 657, revealed the following STEP . l. Do not leave medications unattended . RATIONALE . Nurse is responsible for safekeeping of drugs. Review of a facility policy titled Medication Administration General Guidelines, with a reviewed/updated date of 07/2021, revealed the following: POLICY: Medications are administered . in accordance with good nursing principles and practices . RI #15 was admitted to the facility on [DATE] and has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] RI #15's Annual Minimum Data Set assessment, with an Assessment Reference Date of 12/28/2021, assessed RI #14 as scoring a 12 on the Brief Interview for Mental Status, indicating RI #15 had moderately impaired cognition. RI #15's March 2022 Order Summary Report (physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03/17/2022 at 10:11 AM, the surveyor observed RI #15 in bed with a medication cup, containing five pills in it, on top of the over the bed table in front of the resident. There was no nurse observed in the room at this time. A CNA (Certified Nursing Assistant) was in the room and said the nurse left the medications and said she would be back. On 03/17/2022 at 6:35 PM, the surveyor conducted an interview with Employee Identifier (EI) #29, the Licensed Practical Nurse (LPN) assigned to care for RI #15 on the 7 AM - 7 PM shift on 03/17/2022. When asked should medications be left at a resident's bedside, EI #29 said you did not leave medications at the bedside. The surveyor asked EI #29 what happened that morning when she left RI #15's medications at his/her bedside. EI #29 said it was a mistake. EI #29 when she went in the room to give RI #15 the medications and a CNA was providing care to RI#15. EI #29 said she sat the medications down and was going back to administer them to RI #15 when the CNA was finished. The surveyor asked EI #29 what could be a consequence of leaving medications at the bedside. EI 29 said someone else could take the medications. On 03/18/2022 at 3:49 PM, the surveyor conducted an interview with EI #4, the RN (Registered Nurse) unit manager for the wing RI #15 resided on. The surveyor asked EI #4 what should the nurse do when administering medications. EI #4 said stand with the patient and make sure they take the medications. When asked should the nurse leave medications at the bedside, EI #4 said no. The surveyor asked EI #4 what was there a potential for when medications were left at the bedside. EI #4 said you were not sure if the patient took them or not. EI #4 also said a wandering resident could go in the room and get hold of the medication cup if the patient did not take the medications on time. This deficiency was cited as a result of the investigation of complaint/report #AL 749.

Based on observations, interviews, record review and review of facility policies titled Nebulizer Therapy and Resident Self-Administration of Medication, the facility failed to ensure the licensed nurse remained with Resident Identifier (RI) #14, a resident not assessed to self-administer his/her nebulizer breathing treatment, when RI #14 received a nebulizer treatment on 03/17/2022. This deficient practice affected RI #14, one of one sampled resident observed receiving a nebulizer breathing treatment. Findings Include: Review of a facility policy titled Nebulizer Therapy, with a reviewed/updated date of 07/2021, revealed the following: POLICY: Medications are administered . in accordance with good nursing principles and practices . PROCEDURE: . 5. Instruct patient to breath slowly and deeply throughout the treatment. Review of a second facility policy, with a reviewed/updated date of 07/2021, revealed the following: POLICY: Each resident who desires to self-administer medications may be permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer. Self-administration should be written in the care plan once safety has been established . PROCEDURE: If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive (including orientation to time), physical, and visual ability to carry out this responsibility during the care planning process. The results of the interdisciplinary team assessment are recorded on the Self-Administration Assessment Form, which is placed in the resident's medical record. RI #14 was admitted to the facility on [DATE] and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #14's Admission Minimum Data Set assessment, with an Assessment Reference Date of 12/21/2021, assessed RI #14 as having impaired vision and scoring a 9 on the Brief Interview for Mental Status, indicating RI #14 had moderately impaired cognition. RI #14's March 2022 Order Summary Report (physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03/17/2021 at 10:21 AM, the surveyor observed RI #14 sitting in a wheelchair in his/her room. RI #14 was observed to have on a nebulizer mask with a breathing treatment in progress. There was no nurse observed in the room at this time. On 03/17/2021 at 10:27 AM, RI #14's nebulizer breathing treatment continued to infuse; and still there was no nurse observed in the room. On 03/17/2022 at 6:54 PM, the surveyor conducted an interview with Employee Identifier (EI) #10, the RN (Registered Nurse) assigned to care for RI #14 on the 7 A - 7 P shift on 03/17/2022. The surveyor asked EI #10 did RI #14 receive a nebulizer treatment. EI #10 said yes, once or twice a day. When asked by the surveyor what should the nurse do when administering a resident a nebulizer treatment, EI #10 said after she sets up the treatment she would set the timer on her cell phone for about 15-18 minutes, leave the room and check back in about that time. The surveyor asked EI #10 had RI #14 been evaluated to self-administer his/her nebulizer treatments. EI #10 said she did not think so. When asked when administering a resident their nebulizer treatment, when should the nurse leave the room, EI #10 said she did not know of anybody that stayed in the room. On 03/18/2022 at 2:06 PM, the surveyor conducted an interview with EI #5, the Interim unit manager for the wing RI #14 resided on. The surveyor asked EI #5 what should be done when a resident requested to self-administer their medications. EI #5 said you would have to have an order from the physician that the resident could self -administer the medication and an assessment done to ensure they could self-administer their medication. The surveyor asked EI #5, when looking at RI #14's physician orders, did RI #14 have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked if there was no order, what should the nurse do when administering a resident their nebulizer treatments, EI #5 said the nurse should be in the room the entire time the patient was receiving that nebulizer treatment and checking the 02 saturations as well. On 03/21/2022 at 3:30 PM, the surveyor reviewed RI #14's medical records and could not locate a Self-Administration Assessment Form indicating RI #14 had been assessed to self-administer his/her medications.

Based on observations, interviews, record review and a review of the facility's Bath and Shower's Schedule, the facility failed to ensure Resident Identifier (RI) #7 received a bath/shower as scheduled. This deficient practice affected RI #7 one of five residents sampled for activities of daily living (ADL's). Findings include: RI #7 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility's Bath and Shower's schedule revealed RI #7 was to receive a bath on Tuesday, Thursday and Saturday on the 3:00 PM to 11:00 PM shift. RI #7's Admission Minimum Data Set (MDS) assessment, with an ARD (Assessment Reference Date) of 1/18/22, revealed RI #7 was totally dependent on staff for bathing. A review of the resident's Care Plan, with a start date of 1/25/2022, indicated RI #7 had a physical functioning deficit and require assistance with ADLs. A review of RI #7's Documentation Survey Report v2 for January 2022 revealed one documented bath during January 14, 2022 through February 3, 2022. On 3/21/2022 at 3:52 PM an interview was conducted with Employee Identifier (EI) #22, Certified Nursing Assistant (CNA). EI #22 was asked, how long did she work here. EI #22 replied, two months. EI #22 was asked, what shift did she work. EI #22 replied, three to eleven. EI #22 was asked, what were your job duties during that shift. EI #22 replied, caring for the resident, feeding, changing, and bathing. EI #22 was asked, how often should baths be given. EI #22 replied, it should be three times a week, every other day. EI #22 was asked, how often was she giving a bath to residents. EI #22 replied, maybe once or twice a week on one or two residents was all she had time for. EI #22 was asked, about how many residents was that a week. EI #22 replied, maybe three residents EI #22 was asked, how many baths was she able give RI #7. EI #22 replied, she only remembered giving a partial bed bath once or twice. EI #22 was asked, what was considered a partial bed bath. EI #22 replied, just washing the face and under the arms. EI #22 was asked, what was the risk of baths/showers not being given. EI #22 replied, skin break down. On 3/21/2022 at 4:13 PM an interview was conducted with EI #23 CNA. EI #23 was asked, did you give a bath or partial bed bath to RI #7. EI #23 replied, no. EI #23 was asked, should you have given RI #7 a bed bath or shower. EI #23 replied, yes. EI #23 was asked, what was the risk of bath/showers not being done. EI #23 replied, skin issues. This was cited as a result of the investigation of complaint/report number AL 748.

Based on interviews, review of Resident Identifier (RI) #5's and #3's medical records, review of the facility's investigative file and review of the facility's policy titled Abuse, Neglect, Misappropriation, Exploitation Policy, the facility failed: 1) to ensure when RI #5 was identified with a bruised eye on 02/06/2022, staff immediately informed the Administrator and an investigation was conducted; and 2) to ensure the Administrator was immediately notified when RI #3's family made an allegation to Employee Identifier (EI) #7, the facility's Admission Liaison, staff cursed at RI #3. These deficient practices affected RI #5 and RI #3, two of five residents sampled for abuse/neglect. Findings Include: Review of the facility's policy titled Abuse, Neglect, Misappropriation, Exploitation Policy with an effective date of January 2019, documented; Purpose: To prohibit and prevent abuse, neglect . and to ensure reporting and investigation of alleged violations (to include injuries of unknown source .) in accordance with Federal and State Laws. Definitions: . Injuries of Unknown Source: When both of the following criteria are met: the source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury . 6. Investigation . The administrator, or designee will oversee the center in conducting an internal investigation against any violation/alleged violation of abuse, neglect, exploitation, injury of unknown source . investigations will be prompt, comprehensive . 7. Reporting/Response Alleged violations/violations will be reported to the Administrator, designee immediately. 1) RI #5 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #5's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 02/03/2022, indicated the resident was Moderately impaired in cognitive skills for daily decision making with a Brief Interview for Mental Status (BIMS) score of 11. RI #5's progress note dated 02/06/2022 at 9:30 AM, signed by EI #28, a Licensed Practical Nurse documented: Situation: Upon arrival to shift this nurse notified by CNA (Certified Nursing Assistant) that resident eye is bruised. Upon assessment resident is noted with discoloration/bruising to L (left). eye. Resident verbalized I don't know what happened it doesn't hurt when asked what happened .Response: Notified NP (name of Nurse Practitioner) . Attempted to notify (name of son of RI #5) via phone call no answer at this time, voicemail left to call back to facility. Will continue plan of care to resident. A telephone Interview was conducted with EI #28 on 03/16/2022 at 10:02 AM. EI #28 stated, she came in the morning of 02/06/2022 and EI #18, a CNA informed her RI #5 had a black eye. EI #28 stated she went in to assess resident and the eye was black. EI #28 stated she worked the day before and RI #5 didn't have any injuries. EI #28 said she called staff that worked the night shift and they didn't know anything about it. EI #28 admitted because RI #5 had a bruised/black eye and no one knew how he/she got it, therefore the bruised/black eye was considered an unknown accident or unknown bruise. When asked what was the facility policy for unknown injuries, EI #28 stated to report it and document it. EI #28 stated she reported it to the nurse practitioner, but no one else because it was the weekend. EI #28 stated the abuse coordinator was the Administrator and if she was not available to notify the Director of Nursing. When asked if an incident/allegation happened on the weekend who would she notify, EI #28 stated Administrator and Director of Nursing. She stated their cell numbers were available. A telephone interview was conducted with EI #18, Certified Nursing Assistant (CNA) on 03/16/2022 at 11:15 AM. EI #18 stated on 02/06/2022, she was taking RI #5 his/her breakfast tray. EI #18 said upon entering the room, she turned on the light and opened the curtains and that's when she saw the black eye. EI #18 stated she called EI #28 into the room. EI #18 stated, EI #28 asked RI #5 some questions, but RI #5 could not tell what happened to his/her eye. An interview was conducted with EI #5, the Licensed Practical Nurse (LPN) Interim Unit Manager for the West Unit on 03/17/2022 at 5:15 PM. EI #5 was asked what should have been done once EI #28 observed RI #5 with a bruised/black eye. EI #5 stated, notify the Administrator and let her know it was an injury of unknown source, so she could investigate. EI #5 admitted that a bruised/black eye should be reported and investigated. EI #5 stated, that an injury of unknown source should be reported to the Administrator as soon as possible. EI #5 said if observed on a weekend, it should be reported to the Administrator. EI #5 stated, the Administrator's number is posted on the unit and most staff have her number. EI #5 admitted the facility's abuse policy was not followed when EI #28 did not report RI #5's bruised/black eye to Administrator. An interview was conducted with EI #1, the Administrator/Abuse Coordinator on 03/17/2022 at 7:46 PM. EI #1 was asked what should have happened when EI #28 observed RI #5 with a bruised/black eye on 02/06/2022. EI #1 stated EI #28 should have called her immediately to report it, because of the location and it could not be explained. A Follow-up interview was conducted with EI #1 on 03/22/2022 at 10:50 AM. When asked what she would have done if she had been notified about RI #5's bruised/black eye on 02/06/2022, EI #1 stated she would have reported it immediately and started an investigation. EI #1 admitted an investigation was not conducted and the Facility's abuse policy was not followed for reporting and investigating. 2) RI #3 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #3 Admission MDS assessment, with an ARD of 02/21/2022, assessed RI #3 as scoring a 15 on the BIMS, indicating RI #3 was cognitively intact. A review of the facility's investigative file revealed a Progressive Disciplinary Form for EI #7, dated 02/28/2022, which revealed the following: . Summary of Incident: As a member of the Riverchase team, you are expected to uphold the Mission and Service Standards of Diversicare, as well as be responsible for exhibiting excellent performance and following guidelines and procedures to ensure appropriate care for our residents and patients. On February 23, 2022, you sent an email to the Administrator advising her of a complaint received from a family member regarding a possible allegation of verbal abuse. This incident was reported to you the previous day, February 22, 2022. An investigation has been completed from which the allegation was unsubstantiated However, according to Diversicare abuse reporting guidelines, you are to immediately report suspected abuse to the Administrator. This process was not followed appropriately . On 03/17/2022 at 3:56 PM, the surveyor conducted an interview with EI #7. EI #7 said the daughter of RI #3 informed her a nurse stood over RI #3 and cursed her. The surveyor asked EI #7 what was the facility's policy or procedure staff follow when an allegation of abuse was made. EI #7 said the Administrator, who was the Abuse Coordinator, should be notified. When asked was that done, EI #7 said she forgot to. The surveyor asked EI #7 what type abuse would cursing be considered. EI #7 said verbal. When asked when should verbal abuse be reported to the Administrator, EI #7 said immediately after you become aware it had occurred. On 03/17/2022 at 7:19 PM, the surveyor conducted an interview with EI #1. The surveyor asked EI #1 when she was made aware RI #3's family made an allegation someone was verbally abusive to RI #3. EI #1 said she received an email on 02/23/2022. EI #1 said the email was sent by EI #7. EI #1 said EI #7 said in the email she had talked to the RI #3's daughter the day before, and the daughter had stated something along the line of the nurse was standing over RI #3 cursing at her. EI #1 said it triggered to her it could be verbal abuse, so she called EI #7 and got her statement. EI #1 said EI #7 admitted she had gotten the information the day before (03/22/2022). These deficiencies were cited as a result of investigation of complaint/report number AL 741 and AL 743.

Based on observation, interviews, and review of a facility policy Handwashing/Hygiene, and a facility tool titled Peri Care Audit Tool, the facility failed to ensure the Certified Nursing Assistant (CNA) washed or sanitized her hands between glove changes and did not place a clean cloth and clean brief under the resident with the same gloves she had on to clean bowel movement from the resident. This was observed on 6/30/21 and affected Resident Identifier (RI) #84 one of two residents observed for incontinent care. Findings Include: A review of a facility policy Handwashing/Hand Hygiene, with an effective date of 11/1/17, revealed . POLICY INTERPRETATION AND IMPLEMENTATION . 5. Use an alcohol based rub or, alternatively, soap . and water for the following situations: . h. before moving from a contaminated body site to a clean body site during resident care; . j. after handling contaminated equipment ect.; k. after removing gloves; . A review of an undated facility tool titled Peri Care Audit Tool revealed Action . 3. Remove soiled brief, wash front to back . 6. buttock, washes sides first then middle. 7. STOP! Remove gloves, washes/sanitizes hands and re-gloves. 8. Applies clean brief . 9. Removes gloves. RI #84 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 6/30/21 at 7:10 PM, Employee Identifier (EI) #3, CNA was observed to perform incontinent care for RI #84. EI #3 gathered the needed supplies, sanitized her hands and put on gloves. EI #3 pulled RI #84's pants down and loosened the brief. EI #3 wiped the front area three times using a new wipe each time. EI #3 turned RI #84 to the left side, rolled the soiled brief under the resident, the resident had a bowel movement. EI #3 wiped the buttocks area five times, using a clean wipe each time. EI #3 removed the soiled brief from under the resident and discarded in a trash bag. EI #3 removed her gloves and put on clean gloves, without sanitizing or washing her hands. EI #3 wiped the buttocks area two more times using a clean wipe each time; EI #3 discarded the wipes in the trash bag. EI #3 placed a clean cloth pad, and the clean brief under the resident with the same gloves she clean bowel movement from RI #84. EI #3 secured the brief and covered the resident. On 6/30/21 at 7:24 PM an interview was conducted with EI #3. EI #3 was asked how should you wash or sanitize your hands during incontinent care. EI #3 replied, when she changed gloves, after she remove the soiled and before putting the clean under the resident. EI #3 was asked when did she wash her hands. EI #3 replied, she did not. EI #3 was asked when should you place a clean cloth pad and clean brief with same gloves you had on to clean bowel movement from a resident. EI #3 replied she should not, she should have washed her hands after she wiped the resident and put on clean gloves to put the cloth pad and clean brief. EI #3 was asked when did she change her gloves and wash her hands before placing the clean cloth and brief. EI #3 replied she did not. EI #3 was asked what would the harm be in not washing her hands between glove changes. EI #3 replied she could have some of the bowel movement on her gloves and transfer it to the resident. EI #3 was asked what would the harm be in not changing gloves and sanitizing hands before placing a clean cloth pad and the clean brief. EI #3 replied, touching the clean things with her gloves that were dirty, she could pass germs and contaminate causing infection. On 7/1/21 at 11:09 AM, an interview was conducted with EI #2, Director of Nursing (DON), Infection Preventionist. EI #2 was asked when should staff wash their hands. EI #2 replied when going in to provide care and when taking gloves off. EI #2 was asked what was the facility policy for hand washing with glove changes. EI #2 replied, they can use sanitizer between each glove change and with resident contact. EI #2 was asked what was the policy for hand washing or sanitizing during incontinent care. EI #2 replied, when taking gloves off, when going from dirty to clean, wash hands put on a clean pair, handle what you are doing, then remove the gloves and wash your hands before new gloves. EI #2 was asked when should a CNA change gloves and not wash or sanitize her hands. EI #2 replied, they should not. EI #2 was asked when should a CNA clean bowel movement from a resident then with the same gloves place a clean cloth pad and a clean brief. EI #2 replied, she should not do that. EI #2 was asked, what would the harm be in the CNA not sanitizing or washing her hands between glove changes. EI #2 replied, it could cause contamination. EI #2 was asked what would the harm be in the CNA cleaning bowel movement from a resident then placing the clean cloth and brief with those same gloves. EI #2 replied, they could spread those germs and cause contamination.

Based on interviews, review of Resident Identifier (RI) #1's medical and hospital record, and the facility's investigation, the facility failed to ensure RI #'1 bed was correctly positioned on 2/28/2021. On 2/28/2021, RI #1, who is totally dependent on staff for all activities of daily living, was found in the floor. RI #1 sustained a laceration to the back of his/her head that required right staples to close and a skin tear to the left knee. The facility's investigation concluded positioning of the resident's bed contributed to the fall. This deficient practice affected RI #1, one of three sample residents reviewed for falls. Findings include: RI #1 was admitted to the facility on [DATE]. RI #1 has a medical history to include diagnoses of Alzheimer's Disease, Dementia and Abnormal posture. RI #1's care plan titled At risk for falls . initiated on 1/23/2019 had an intervention of . * Bed in low position to allow for safer transfers . An unlabeled facility report dated 2/28/2021 prepared by Employee Identifier (EI) #3, a Licensed Practical Nurse (LPN) indicated RI #1 was observed on the floor between the resident's and roommate's bed. RI #1 was not able to give a description of what occurred. Immediate Action Taken Description: Resident was immediately assessed for injuries, laceration to back of head noted and skin tear to left knee noted. Neurological assessment was performed, right pupil sluggish . Contacted 911 . Resident was transported to (local hospital) The facility's undated INVESTIGATION TEMPLATE documented On 2-21-21 at appropriately (approximately) 23:10 (11:10 PM) (RI #1) was observed on the floor in (his/her) room between (his/her) and (his/her) roommates bed . Conclusion: (RI #1) . is bedridden and is totally dependent for ADL (activities of daily living) care. (RI #1) is physically contracted in (his/her) lower extremities; however, (he/she) does rock and scoot at times in (his/her) bed . (RI #1) sustained a fall from (his/her) bed and was observed on the floor by the staff . (RI #1) did sustain a laceration to (his/her) head requiring 8 staples . Due to resident cognitive status (he/she) was unable to relay what happened causing the fall. During the investigation, It was determined that positioning contributed to the occurrence . RI #1's hospital records revealed the residen arrived in the local emergency roiagnom on [DATE] at 11:51 PM. The chief complaint was listed as . pt presents from Diversicare (Riverchase) for fall out of bed, unwitnessed by staff. EMS (Emergency Medical Services) noted post head lac-bleeding . pt is demented and unable to provide a history . IMPRESSION: 1. Left frontal scalp laceration without acute intracranial abnormally . On 4/6/2021 at 7:22 AM, an interview was conducted with EI #1, the Certified Nursing Assistant who found RI #1 on the floor on 2/282/2021. EI #1 stated she worked the 11:00 PM to 7:00 AM shift on 2/28/2021. EI #1 stated about 10 minutes after arriving on duty, she entered RI #1's room didn't see the resident in the bed. According to EI #1, RI #1 on the floor between both beds in the room. RI #1 was balled up with his/her head was at the foot of the bed, and the resident's foot was at the head of the bed. EI #1 stated she didn't see any injuries, so she called RI #1's name and the resident opened his/her eyes. When asked was RI #1's bed in the low position, EI #1 said she didn't know if the bed was in the low position. When asked should RI #1's bed have been in the low position, EI #1 said yes. On 3/17/2021 at 7:49 AM, an interview was conducted with EI #2, a CNA. EI #2 stated she worked in the facility during the 11:00 PM to 7:00 AM shift on 2/28/2021. When asked who found RI #1 on the floor on 2/28/2021, EI #2 said, EI #1 and when she was coming through the double doors on the East Wing, EI #1 called her in RI #1's room. EI #2 was asked what she saw when she entered the room. EI #2 said, RI #1 was lying on the floor on the opposite side of the bed in between both beds. EI #2 was asked did she observed any injuries. EI #2 said she saw some blood under the resident's head. EI #2 was asked what position the bed was in. EI #2 said it was medium height. On 3/18/2021 at 11:27 AM, an interview was conducted with EI #3, a LPN. EI #3 stated when she entered RI #1's room, there were two CNAs in the resident's room. RI #1 was on the floor between both beds. EI #3 stated RI #1 was in the fetal position on the floor with his/her head at the foot of the bed and his/her feet at the head of the bed. RI #1 had a laceration to the back of the head, there was a small pool of blood under the resident's head and a skin tear to the left knee. When asked what position was RI #1's bed in, EI #3 said it was between her hip and knee. When asked was the resident's bed in the low position, EI #3 said no. When asked how was RI #1's head of bed, EI #3 said it was raised between 75 to 80 degrees approximately. In a follow-up interview on 4/6/2021 at 8:22 AM, EI #3 was asked should the bed have been in a low position. EI #3 said yes it should have. When asked what contributed or caused RI #1's fall on 2/28/2021, EI #3 said the bed position, the air mattress how it redistributes air and gravity. When asked what she meant by bed position, EI #3 said the way the head of the bed was raised. On 4/6/2021 at 2:14 PM, an interview was conducted with EI #4, the Director of Nurses (DON). EI #4 acknowledged she completed the investigation into RI #1's fall on 2/28/2021. When asked what she determined was the cause of RI #1's fall on 2/28/2021, EI #4 stated because the resident was not able to tell what happened, and it was not witnessed by anyone, she concluded positioning was a contributing factor to the fall. EI #4 stated based on the interviews with LPN and CNAs, they stated the head of bed was elevated and the height of the bed was elevated. EI #4 stated RI #1's bed should have been in the low position. EI #4 acknowledged RI #1's care plan was not followed. On 4/6/2021 at 3:20 PM, an interview was conducted with EI #5, the facility's Administrator. EI #5 was asked what the facility determined was the cause of RI #1's fall on 2/28/2021. EI #5 said, positioning contributed to the occurrence of the fall. EI #5 was asked what was meant by positioning. EI #5 said, the way RI #1 was positioned in the bed, the head of RI #1's bed was elevated, and the height of the bed was elevated. EI #5 was asked what position the bed should have been in. EI #5 said it should be in the low position. This deficiency was cited as a result of the investigation of complaint/report number AL 296

Based on observations, interviews, and a facility document titled . COVID-19 Education, Prevention & Response Guide the facility failed to ensure: 1) a licensed staff member did not enter a resident's room on the COVID Unit without putting on a gown or N95 respirator. This affected Resident Identifier (RI) #1, one of fifteen residents on the COVID Unit. 2) licensed staff cleaned a blood pressure cuff between resident use. This affected RI #3 and RI #4, two of four residents observed for blood pressure measurement. Findings Include: 1) A facility document titled . COVID-19 Education, Prevention & Response Guide with a revised date of December 30, 2020 revealed: .Guidance for Limiting the Transmission of COVID-19 . 8. Ensure all staff are using appropriate Personal Protective Equipment (PPE) . Full PPE should be worn per Center for Disease Control (CDC) guidelines for the care of any resident with known . COVID-19 . .Checklist for Establishing and Running a COVID-19 Positive Unit (Zone 3) .Place signage at the entrance to the COVID-19 care unit that instructs Health Care Personnel (HCP) they must wear . N95 . at all times while on the unit. Gown and gloves should be added when entering resident rooms. Appendix H. Use of Respiratory Protection (N95 Respirators) during COVID-19 . Suggested Use of N95 Respirators vs. Regular Facemask . 2. Use an N95 respirator when in the presence of a confirmed (or highly suspected) COVID patient. Resident Identifier #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the facility daily census indicated that RI #1's room was in Zone Three and indicated Zone Three was COVID Positive. An observation was made on 1/4/21 at 6:12 PM of Employee Identifier (EI) #3, Licensed Practical Nurse (LPN) entering Resident Identifier (RI) #1's room on the COVID Unit while wearing a face shield and surgical mask and not wearing an N95 respirator, gown, or gloves. Signage was observed on RI #1's room indicating Contact and Droplet Precautions. On 1/4/21 at 6:15 PM EI #3 exited RI #1's room. On 1/4/21 at 6:15 PM an immediate interview was conducted with EI #3. EI #3 was asked, was she wearing a N95. EI #3 replied, no. EI #3 was asked, what type of PPE is worn for COVID -19 isolation rooms. EI #3 replied, face shield, gown, gloves, and mask. EI #3 added, if she was going in an out, she did not have to wear an N95 and she knew a N95 was appropriate mask when providing care. EI #3 was asked, what type of PPE was she wearing in RI #1's room. EI #3 replied, she put on full PPE to answer her call light and RI #1 asked for something to drink. EI #3 added, she took off the PPE and washed her hands and the went to the kitchen and got the drink; when she returned, she did not see the PPE station and entered the room with a face shield and surgical mask. EI #3 continued and stated, she did not touch anything, and she did not normally work on COVID Unit. EI #3 was asked, why did she not wear a N95 respirator, gown, or gloves. EI #3 replied, she was just answering the call light and if she was entering the room as the wound care nurse, then she would have known. EI #3 was asked, was RI #1's room on the COVID isolation unit. EI #3 replied, she did not know. EI #3 was asked, was there a plastic barrier separating the unit in which RI #1's room is on. EI #3 replied, yes. On 1/5/21 at 6:00 PM and interview was conducted with EI #2, Director of Nursing/ Registered Nurse (RN). EI #2 was asked, had the facility had any issues acquiring adequate numbers of PPE. EI #2 replied, no. EI #2 was asked, while on the COVID unit, when should staff wear N95. EI #2 replied, all the time. EI #2 was asked, while on the COVID unit, when should staff wear gown and gloves. EI #2 replied, before going into a resident's room. EI #2 was asked, who was responsible for wearing appropriate PPE when entering a COVID Positive resident's room. EI #2 replied, the person going into the room. EI #2 was asked, when should a staff member enter a resident's room on the COVID unit while wearing a surgical mask and face shield without wearing a N95, gown, or gloves. EI #2 replied, they should not. EI #2 was asked, what was the potential harm when staff do not wear N95, gown, or gloves while in a resident's room on the COVID unit. EI #2 replied, they could get infected and infect other staff or residents and cause an outbreak. On 1/5/21 at 7:36 PM an interview was conducted with EI #1, Administrator. EI #1 was asked, were there sufficient PPE supplies available and accessible to use by staff. EI #1 replied, yes. EI #1 was asked, what PPE were the staff wearing on the COVID unit. EI #1 replied, N95 and face shield or goggles; gown and gloves when entering a patient's room. EI #1 was asked, while on the COVID unit, when should staff wear a N95. EI #1 replied, all the time. EI #1 was asked, while on the COVID unit when should staff wear gown and gloves. EI #1 replied, before going into a resident' room. EI #1 was asked, while on the COVID unit, where should staff put on gown and gloves. EI #1 replied, the gown should be worn before entering the unit. The gloves should be changed between each resident. EI #1 was asked, who was responsible for wearing appropriate PPE when entering a COVID positive resident's room. EI #1 replied, the employee. EI #1 was asked, when should a staff member enter a resident's room on the COVID unit while wearing a surgical mask and face shield without wearing a N95, gown, or gloves. EI #1 replied, they should not. EI #1 was asked, what was the potential harm when staff did not wear N95, gown, or gloves while in the resident's room on COVID unit. EI #1 replied, they could take it home with them and infect themselves or community. 2) A facility document titled . COVID-19 Education, Prevention & Response Guide with a revised date of December 30, 2020 revealed: .Equipment and Department Cleaning/Maintenance Policy . Effective Date: April 2020 . Each piece of equipment used for patient/resident care is to be cleaned with a center approved surface disinfectant before and after each resident use. This includes: . blood pressure cuffs, . On 1/5/21 at 10:12 AM EI #4, RN was observed performing blood pressure measurement for RI #4. EI #4 wrapped the blood pressure cuff on RI #4's left lower arm. During observation, the blood pressure cuff and six inches of the tubing were noted to be touching the resident's bed. At 10:18 AM EI #4 exited RI #4's room and did not clean the blood pressure equipment or cuff. On 1/5/21 at 10:19 AM EI #4 entered RI #3's room and wrapped the same blood pressure cuff around RI #3's left upper arm. During observation, a portion of the blood pressure machine's hose touched RI #3's bed. EI #4 exited RI #3's room and did not clean the blood pressure equipment or cuff. On 1/5/21 at 10:25 am the surveyor began continuous observation of the blood pressure equipment which was in the hallway beside EI #4's medication cart. On 1/5/21 at 10:42 AM EI #5, LPN was observed as she took the same blood pressure equipment from beside EI #4's medication cart to the nurses' desk and did not clean it. On 01/05/21 at 10:43 AM an observation was made of EI #5, who took the blood pressure equipment to RI #2's room. EI #5 did not clean the blood pressure equipment and wrapped the cuff around the RI #2's left upper arm. On 1/5/21 at 12:07 PM an interview was conducted with EI #4, RN. EI #4 was asked, whose blood pressure was measured using the rolling blood pressure equipment while the surveyor observed. EI #4 replied, RI #4 and RI #3 was attempted. EI #4 was asked, where did the blood pressure cuff or hose contact the residents or objects in the resident's room. EI #4 replied, RI #4 and RI #3's left lower arm. EI #4 was asked, why was the blood pressure cuff not cleaned after each use or before using on RI #3. EI #4 replied, she just forgot. EI #4 was asked, when should a blood pressure cuff be used for multiple residents without cleaning the cuff between each resident. EI #4 replied, it should always be cleaned. EI #4 was asked, what was the standard of practice for cleaning equipment, like a blood pressure cuff, between usage on different residents. EI #4 replied, they clean it between resident's use. EI #4 was asked, what training did she have related to COVID-19. EI #4 replied, infection control, handwashing, cleaning equipment, what PPE to wear for COVID-19, how and where to put on PPE, and lots more. On 1/5/21 at 2:55 PM an interview was conducted with EI #5, LPN. EI #5 was asked, whose blood pressure was measured using the rolling blood pressure equipment while surveyor observed. EI #5 replied, RI #2. EI #5 was asked, where did the blood pressure cuff or hose contact the resident. EI #5 replied, left arm. EI #5 was asked, when was the blood pressure cuff cleaned. EI #5 replied, she cleaned it after she checked RI #2's blood pressure. EI #5 was asked, why was the blood pressure cuff not cleaned before using. EI #5 replied, she probably should have. EI #5 was asked, when should a blood pressure cuff be used for multiple residents without cleaning the cuff between each resident. EI #5 replied, they should always clean it. EI #5 was asked, what was the Standard of Practice for cleaning equipment, like a blood pressure cuff, between usage on different residents. EI #5 replied, it should be cleaned using an anti-microbial cleaner. On 1/5/21 at 6:00 PM and interview was conducted with EI #2, RN, Director of Nursing. EI #2 was asked, how should equipment, like a blood pressure cuff be cleaned. EI #2 replied, between residents they use the wipes that are approved to kill COVID-19 that are supplied by our company. EI #2 was asked, what was the facility's policy regarding cleaning equipment between residents. EI #2 replied, they clean it between each resident of course. EI #2 was asked, why was it important to clean blood pressure cuffs between resident use. EI #2 replied, so germs and bacteria are not transferred from patient to patient. EI #2 was asked, what was the potential harm when staff do not clean blood pressure cuff between uses on residents. EI #2 replied, transmitted germs. On 1/5/21 at 7:36 PM an interview was conducted with EI #1, Administrator. EI #1 was asked, how should equipment, like a blood pressure cuff be cleaned. EI #1 replied, after each use. EI #1 was asked, what was the facility's policy regarding cleaning equipment used on multiple residents. EI #1 replied, it should be cleaned between each resident. EI #1 was asked, why was it important to clean blood pressure cuffs between each use. EI #1 replied, so that it was not contaminated. EI #1 was asked, what was the potential harm when staff do not clean blood pressure cuff between usage on residents on the non-COVID unit. EI #1 replied, contamination.

Based on interviews with residents and staff, a review of the, Certified Nursing Assistant (CNA) Position Description, Care Giver Information Sheet and a review of the ADL (Activities of Daily Living) bath sheets, the facility failed to routinely provide showers as scheduled to residents who required ADL assistance. This deficient practice affected RI (Resident Identifier)'s #1, RI #2 and RI #3, three of three residents sampled for assistance with ADL care. Findings include: The position description for the POSITION TITLE: CNA, with no effective date, documented: KEY RESPONSIBILITIES: 1. To perform or assist the resident with completing Activities of Daily Living (ADL) . RI #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/02/20 revealed his/her Brief Interview for Mental (BIMS) Score was a 13, which indicated the resident was cognitively intact. Also, in Section G of the MDS the resident was totally dependent on staff for bathing. RI #1's Care Giver Information Sheet documented, ADL/Assist/Shower .TTS (Tuesdays, Thursdays and Saturdays) 7/3 . On 09/15/20 at 10:05 a.m. an interview was conducted with RI #1. RI #1 was asked if he/she had received a shower. RI #1 said no, he/she had not. RI #1 was asked when was the last time he/she received a shower. RI #1 said it had been a while, about a couple of weeks ago. The ADL Bathing records revealed RI #1 had received two showers out of thirteen scheduled for the month of July 2020, and three showers out of thirteen scheduled for the month of August 2020. On 9/16/20 at 10:55 a.m. an interview was conducted with EI (Employee Identifier) #3, CNA. EI #3 was asked if she was assigned to provide care to RI #1. EI #3 said she provided care for the resident sometimes. EI #3 was asked what type of care did RI #1 require. EI #3 said RI #1 was total care. EI #3 was asked if she had provided RI #1 a shower. EI #3 said she had not given RI #1 a shower. EI #3 was asked if she had washed RI #1's hair prior to it being cut. EI #3 said no that she only took it down, RI #1 had som plaits and she took the rubber bands off her hair. EI #3 was asked what did she do after taking RI #1's plaits down. EI #3 said, she tried to comb RI #1's hair but is was matted up bad, so she left it alone. On 09/15/20 at 12:16 p.m. an interview was conducted with EI #4, CNA. EI #4 was asked if she was assigned to provide care to RI #1. EI #4 said she had provided care to RI#1. EI #4 was asked what type of care did RI #1 require. EI #4 said she/he was total care. EI #4 was asked if she had provided RI #1 a shower. EI #4 said she gave RI #1 a shower about a month ago. EI #4 was asked if she washed RI #1's hair. EI #4 said yes, she washed RI #1's hair and in the process of washing his/her hair it was matted and she could not comb it. On 9/16/20 at 3:49 p.m. an interview was conducted with EI #2, Registered Nurse (RN), Supervisor. EI #2 was asked what type of care did RI #1 require. EI #2 said she/he required assistance with all ADLs including bathing. EI #2 was asked when was RI #1's shower days. EI #2 said Tuesday, Thursday, and Saturday. EI #2 was asked to review RI #1's ADL sheet for July 2020 and see how many times it was indicated she/he received a shower. EI #2 said it was documented 2 times. EI #2 was asked how many times was it indicated she/he received a shower for August 2020. EI #2 said three times. RI #2 was re-admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #2's Quarterly MDS with an ARD date of 09/02/20 revealed the resident was totally dependent on staff for bathing. RI #2's, Care Giver Information Sheet documented, ADL/Assist/Shower .TTS 3-11 . During the initial tour on 09/14/20 at 5:49 p.m., an interview was conducted with RI #2. RI #2 was asked if she/he had received a shower. RI #2 said she/he only received a shower on Thursdays. RI #2 was asked when was the last time she/he had received a shower. RI #2 said about a month ago. RI #2's ADL's bathing record revealed she/he had received four showers out of seven scheduled between September 1-September 16. On 09/16/20 at 3:49 p.m., an interview was conducted with EI #2. EI #2 was asked when was RI #2's shower days. EI #2 said Tuesday, Thursday, and Saturday's, 3-11 p.m. EI # 2 was asked how many times was it indicated RI #2 was provided a shower between September 1-16. EI #2 said four. RI #3 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #3's Annual MDS with an ARD date of 08/05/20 revealed a BIMS score of 15 indicating the resident was cognitively intact. Also, Section G revealed the resident was totally dependent on staff for bathing. RI #3's Care Giver Information Sheet, documented, ADL/Assist/Shower .MWF (Mondays, Wednesdays and Fridays) 3/11 . On 09/14/2020 at 4:15 p.m. an interview was conducted with RI #3. RI #3 was asked if she/he had any concerns with receiving a shower. RI #3 said she/he needed a shower. RI #3's ADL bathing record revealed she/he had received one shower out of thirteen scheduled for the month of July 2020 and received two showers out of seven scheduled between September 1-September 16. On 9/16/20 at 3:49 p.m. an interview was conducted with EI #2. EI #2 was asked when was RI #3's shower days. EI #2 said Monday, Wednesday, and Friday's on 3-11 shift. EI #2 was asked how many times was it indicated that RI #3 received a shower in July 2020. EI #2 said one time. EI #2 was asked how many times was it indicated RI #3 received a shower for September 2020, between September 1-16. EI #2 said 2. On 9/16/20 at 3:49 p.m. an interview was conducted with EI #2. EI #2 was asked when providing ADL care to residents, would that include washing a resident's hair. EI #2 said when a resident got a shower their hair should be washed too. EI #2 was asked if the resident refused a shower, what was the protocol. EI #2 said, the CNA would go tell the charge nurse. The charge nurse would talk with resident to see why she/he refused and document it on the shower sheet. EI #2 was asked if she had documentation of RI #1, RI #2 and RI #3 refusing to take a shower. EI #2 said she did not see any documentation. EI #2 was asked when should showers be provided. EI #2 said as scheduled three times a week. EI #2 was asked who was responsible for ensuring ADL care was provided in accordance with the plan of care. EI #2 said nursing. On 09/16/20 at 5:36 p.m., an interview was conducted with EI #1, Administrator. EI #1 was asked if a resident was total assistance with ADL care, was he/she dependent on staff for care. EI #1 said yes. EI #1 was asked when should showers be provided. EI #1 said three times a week. EI #1 was asked where would the CNA document if the resident received a shower. EI #1 said in the Kiosk on the shower sheet. EI #1 was asked if there was no documentation the for showers provided, how would you know if the resident received a shower. EI #1 said you would not know. EI #1 was asked who was responsible for ensuring ADL care was provided in accordance with the plan of care. EI #1 said the nursing staff. This citation was written as a result of the investigation of complaint/report number AL 009

Based on observation, interview, the (YEAR) Food and Drug Administration (FDA) Food Code, the facility's policy on Dry Storage, and the facility's policy on Team Member Sanitary Practices, the facility failed to ensure: 1.) the food preparation sink's drain pipe did not extend into the floor drain, 2.) the ceiling of the Walk-in Cooler was free of removable dark matter, 3.) the shelving in the dry storage area was at least six inches from the floor, 4.) shredded chicken salad was discarded by the manufacturer's expiration date, 5.) staff with facial hair wore beard guards in the kitchen and food preparation areas, and 6.) staff did not chew gum in the kitchen area. This had the potential to affect 108 residents receiving meals from the kitchen, 108 of 111 residents in the facility. Findings include: 1.) The (YEAR) FDA Food Code included the following: . 5-402.11 Backflow Prevention. (A) . a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD . are placed. During the initial tour of the kitchen on 10/01/19 at 11:26 AM, the drain pipe under the food preparation sink was observed to be extended down into the floor drain. Employee Identifier (EI) #5, the Registered Dietitian (RD), was asked what was the problem with the food preparation sink's drain pipe going into the floor drain. EI #5 replied you do not want to have backflow from the floor drain. On 10/01/19 at 11:36 AM, EI #4, the Administrator, measured the distance from the top of the floor drain to the end of the food preparation sink's drain pipe and found the drain pipe extended into the floor drain by 1/16 inch. During an interview on 10/03/19 at 9:10 AM, EI #5 was asked what was the potential negative affect for residents if there was not an air gap between the drain pipe and the floor drain. EI #5 replied they did not want backflow from drainage or sewage to get into the clean water in the food preparation sink. EI #5 was asked what would be the potential affect on residents if backflow occurred. EI #5 responded residents could get sick by cross-contamination from what could come up with the backflow. 2.) The (YEAR) FDA Food Code included the following: . 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. On 10/02/19 at 9:00 AM, dark spots were observed on the ceiling of the Walk-in Cooler. Some of the spots were black and some were brown. The surveyor touched a brown spot on the ceiling, which transferred residue to the surveyor's fingers and felt gritty. EI #5, the RD, was able to wipe some black spots from the ceiling using a paper towel. When asked what was the concern with debris/residue on the ceiling, EI #5 responded they did not want any foreign objects in food. 3.) The (YEAR) FDA Food Code included the following: . 3-305.11 Food Storage. (A) . FOOD shall be protected from contamination by storing the FOOD: . (3) At least 15 cm (centimeters) (6 inches) above the floor. The facility's policy titled Dry Storage, effective 01/01/2017, included the following: . POLICY It is the policy of this center to store, prepare and serve food that is stored in accordance with federal, state, and local sanitary codes. PR[NAME]EDURE . 4. Construction for shelving should be . designed to assure ease in cleaning. Food must be stored 6-11 inches off the floor . During the initial kitchen tour on 10/01/19 at 11:12 AM, an observation was made of a nutritional supplement carton on the floor in the corner underneath the bottom shelf of the dry storage area and the adjacent shelf appeared to be less than six inches from the floor. On 10/02/19 at 8:57 AM, the shelf in the dry storage area still appeared to be less than six inches from the floor and the nutritional supplement carton was still on the floor in the corner. The surveyor pointed out to EI #5, the RD, that one shelf in the dry storage room was crooked and appeared to be less than 6 inches from floor. Two cases of apple juice and a plastic container with packets of ground coffee were stored on the shelf that appeared to be less than 6 inches from the floor. When asked if the shelf appeared to be at least six inches from floor, EI #5 responded that it did not. When asked why was it important for the shelf to be at least six inches from floor, EI #5 said to keep everything dry and clean. Upon being asked how often the storage room was swept, EI #5 referred the question to EI #6, the Dietary Manager (DM), who said it was swept every night by the night (PM) Cook and last night it was (name of EI #8). The surveyor noted that the nutritional supplement carton from yesterday's observation was still on floor underneath shelving in the corner. On 10/02/19 at 10:42 AM, EI #4, the Administrator, measured the pantry shelf from the top of the bottom shelf to the floor as five inches. On 10/02/19 at 1:31 PM, EI #8, the PM Cook, was interviewed. EI #8 said he swept last night, but did not see the nutritional supplement carton on the floor in corner under the shelf when he swept. 4.) The (YEAR) FDA Food Code included the following: . 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (B) . refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PR[NAME]ESSING PLANT shall be clearly marked, . to indicate the date or day by which the FOOD shall be consumed on the PREMISES . or discarded . (2) The day or date marked . may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. During the initial tour on 10/01/19 at 11:18 AM, a commercially packaged container of shredded chicken salad was observed in the Walk-in Cooler with an opened date of 9/21/19 and a manufacturer's expiration date of 10/01/19. On 10/02/19 at 9:02 AM, the shredded chicken salad with the opened date of 9/21/19 and the manufacturer's expiration date of 10/01/19 was observed to still be in the Walk-in Cooler. EI #5, the RD, was asked when should the chicken salad be tossed out. EI #5 said they go by the manufacturer's date, so on the first of (MONTH) it should have been thrown out. When asked how often products with use-by dates were being checked, EI #5 referred the question to EI #6, the DM, who said she checked every day. During an interview on 10/03/19 at 9:10 AM, EI #5 was asked what was the potential negative affect on residents of having shredded chicken salad with a manufacturer's expiration date of 10/01/2019 still located in the Walk-in Cooler on 10/02/19. EI #5 said they did not want residents getting sick from consuming food that was past the manufacturer's expiration date. 5.) The (YEAR) FDA Food Code included the following: . Hair Restraints . 2-402.11 Effectiveness. (A) . FOOD EMPLOYEES shall wear hair restraints such as . beard restraints . that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, . The facility's policy entitled Team Member Sanitary Practices, effective (MONTH) 1, (YEAR), included the following: . POLICY It is the policy of this center to promote guidelines for employee sanitary practices. PR[NAME]EDURE . 3. Wear hairnets or restraints . All hair including any facial hair must be completely covered. On 10/01/19 at 12:30 PM, EI #8, the PM Cook, was observed plating food for lunch from a portable steam table in the dining room. EI #8 was observed to have noticeable facial hair and was not wearing a beard guard. On 10/02/19 at 11:55 AM, EI #9, a Dietary Aide, was observed in the kitchen with noticeable hair above his upper lip and no beard guard covering the facial hair. When EI #9 opened the reach-in cooler, the surveyor asked him if he had a mustache. EI #9 responded, did he need one (a beard guard). EI #6, the DM, told EI #9 that he needed a beard guard. During an interview on 10/03/19 at 8:54 AM, EI #6, the DM, was asked if EI #9, the Dietary Aide, had a mustache. EI #6 said she knew he has a light mustache. When asked if EI #8, the PM Cook, had a beard, EI #6 responded yes and said he also had sideburns and a light mustache. EI #6 was asked why did EI #8 not wear a beard guard on Tuesday, 10/01/19 and why did EI #9 not wear one on Wednesday, 10/02/19. EI #6 said she could not give an answer because they (EI #8 and EI #9) knew the policy and beard guards were available. On 10/03/19 at 9:10 AM, EI #5, the RD, was asked why it was important for facial hair to be covered while in the kitchen preparing food/plating food. EI #5 said they did not want foreign objects in food or on clean utensils or on anything in contact with food surfaces. 6.) The (YEAR) FDA Food Code included the following: . 2-401.11 Eating, Drinking, or Using Tobacco. (A) . an EMPLOYEE shall eat, drink . only in designated areas where the contamination of exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS . can not result. The facility's policy entitled, Team Member Sanitary Practices, effective (MONTH) 1, (YEAR), included the following: . PR[NAME]EDURE . 13. Do not eat, drink, chew gum . in kitchen areas. On 10/01/19 at 11:38 AM, EI #9, a Dietary Aide, was observed chewing gum while removing trays of clean dishes from the dish room. When asked if he was chewing gum, EI #9 responded, Oh and spit the gum out of his mouth and into the trash can. During an interview on 10/03/19 at 8:54 AM, EI #6, the DM, was asked why should staff not chew gum in the kitchen. EI #6 said because staff could spit on food, contaminate the food, or the gum could fall out of their mouth. EI #5, the RD, was interviewed on 10/03/19 at 9:10 AM and asked why should kitchen staff not chew gum in the kitchen while preparing food/plating food. EI #5 said due to the potential for cross contamination from bodily fluid to food or food contact surfaces. When asked what was the potential negative affect on residents if kitchen staff chewed gum while preparing food/plating food, EI #5 said residents could potentially get sick.

Based on observations, and interviews the facility failed to ensure the call system was working properly on the east wing. This affected 60 of 60 residents residing on the east wing. Findings Include: On 10/01/19 at 02:47 PM, Resident Identifier (RI) #44 had the call light on. The call light was answered at 03:32 PM, by Employee Identifier (EI) #10 Unit Manager (UM). She was asked where the call bell rang to and she said the front nurse's station. On 10/01/19 at 05:14 PM, RI #44 was asked to push the call light and the surveyor walked up to nursing station and a light was lighting up on the call light box, but there was no sound. room [ROOM NUMBER] came on as well and it was not sounding. On 10/01/19 at 05:27 PM, room [ROOM NUMBER] light came on box and was not beeping. On 10/01/19 at 05:32 PM, a maintenance staff was asked to push all the call lights on the light board. On 10/01/19 at 05:48 PM, all lights on the board lit up, but none were making the beeping sound. An interview was conducted on 10/01/19 at 05:24 PM, with EI #10 RN UM. EI #10 was asked, how long had the call light box at the nurse's station not been beeping. EI #10 replied, she did not know, normally it sounded. EI #10 was asked, who had she told about it. EI #10 replied, when they discovered it, it was not working, she and the DON were trying to figure out why it was not working. EI #10 was asked, when was that. EI #10 replied, she was not sure what time. EI #10 was asked, what happened after she and the DON found out the call light system was not beeping at the desk. EI #10 replied, she went to take care of something else and she did not know what she (DON) did. EI #10 was asked, had she known it was not working before that day. EI #10 replied, no. EI #10 was asked, what rooms did the box serve. EI #10 replied 171, 91, 1-35. On 10/01/19 at 06:16 PM, an interview was conducted with EI #4, the Administrator. EI #4 was asked, what was being done for the residents on the east wing while the call system was not working. EI #4 replied, he was just made aware of it and there was a lose wire in the wall and they should be working now. EI #4 was asked, did he know how long they had not been working. EI #4 replied he was just made aware; they were going to call the company. He said they were going to hand all of the resident's bells until it was fixed. On 10/03/19 at 08:02 PM, an interview was conducted with EI #4 Administrator. EI #4 was asked, how often was maintenance done on the call bell system. EI #4 replied he was checking it every day or if something came up in the meantime. EI #4 was asked, when was he notified the system was not working. EI #4 replied on 10/1/19, he just knew it was in the afternoon. EI #4 was asked, how long had the system not been working. EI #4 replied, he did not know, he knew it had been working that morning because he heard it. EI #4 was asked, how many residents lived on the east wing. EI #4 replied 60 people. EI #4 was asked, what was the potential concern of the call system not working properly. EI #4 replied, it could delay having someone's needs met.

Based on observations, interviews, the facility's recipe for Pureed Asian Chicken, and the facility's recipe for Pureed Oriental Vegetables, the facility failed to prepare pureed foods per recipe instructions in order to maintain the nutritional content and flavor at lunch on 10/2/19. This had the potential to affect all residents on puree diets in the facility, 16 of 108 residents receiving meals from the kitchen. Findings include: The facility's recipe for Pureed Asian Chicken, dated 2019, required the ingredients of Asian Chicken, water, and chicken base and included the following instructions: . Combine chicken base and water to make chicken broth. Place prepared chicken in a washed and sanitized food processor. Gradually add broth and blend until smooth. Note: . 1. If product needs thinning, gradually add an appropriate amount of liquid (NOT WATER) to achieve a smooth, pudding or soft mashed potato consistency. 2. If the product needs thickening, gradually add a commercial or natural food thickener . to achieve a smooth, pudding or soft mashed potato consistency . Top pureed foods with appropriate sauces or gravies, as needed, to ensure adequate moisture for safe consumption and enhance flavor. The facility's recipe for Pureed Oriental Vegetables, dated 2019, required the ingredients of Oriental Blend Vegetables and margarine and included the following instructions: . Place prepared vegetables and margarine in a washed and sanitized food processor; blend until smooth. Note: . 1. If product needs thinning, gradually add an appropriate amount of liquid (NOT WATER) to achieve a smooth, pudding or soft mashed potato consistency. 2. If the product needs thickening, gradually add a commercial or natural food thickener . to achieve a smooth, pudding or soft mashed potato consistency . On 10/02/19 at 11:06 AM, Employee Identifier (EI) #7, the AM Cook, was observed preparing the Pureed Oriental Vegetables. When asked how many pureed diets she had to prepare for, EI #7 said 18 to 19. EI #7 added water (at least 8 to 10 ounces) from a pitcher to the vegetables in the [NAME]ot Coupe (food processor) and then added a commercial thickening agent (no measure) by using a large bin-style scoop (approximately 1 1/2 cups). After taking the lid off of the [NAME]ot Coupe and looking at the pureed mixture, EI #7 added more water. She pureed those ingredients and visually checked the mixture. EI #7 then added more commercial thickening agent and pureed the mixture again. When asked if there was a guide for preparing pureed foods, EI #7 said no. EI #7 said she eyeballed it to the desired consistency, like mashed potatoes. EI #6, the Dietary Manager (DM), who was icing cake on the other side of the preparation table told EI #7 that there was a guide. On 10/02/19 at 11:48 AM, EI #7 was observed preparing the Pureed Asian Chicken. EI #7 stated she was pureeing 18 chicken breast portions with 1/2 cup commercial thickening agent and 1 cup water to make 18 to 19 servings. When asked how many servings she was preparing, EI #7 said about 19 and that the commercial thickening agent stretched it. EI #7 then added 8 more chicken breast portions and approximately two tablespoons water to the [NAME]ot Coupe. On 10/02/19 at 1:27 PM, a plate of pureed items, which included Oriental Vegetables and Asian Chicken, was tasted by the surveyor, EI #7, and EI #6. The Pureed Oriental Vegetables tasted watered-down. EI #7 said the Pureed Oriental Vegetables tasted very watery. The Pureed Asian Chicken had no flavor. During an interview on 10/03/19 at 8:54 AM, EI #6, the Dietary Manager, was asked what was the guide for cooks to follow for pureeing foods. EI #6 replied the recipe. EI #6 further said if they follow the recipe, they can enhance it with salt, gravy, etcetera after tasting. EI #6 said if they follow the recipe, it should be fine. EI #6 was asked if it was common for the cooks to taste the food. EI #6 responded yes and said they are to taste the food. When asked how did cooks know where to find the recipe guide, EI #6 said the recipe book was kept on top of the counter at their station. EI #6 was asked how could not following the recipe negatively affect the residents. She said the food may not taste good, nutrients may be left out, and the texture may not be correct. EI# 6 stated staff are to follow the recipe instructions first. When asked if there was a reason why EI #7 would not follow the recipe or be able to locate the recipe. EI #6 responded no and said EI #7 knows where the recipes are located. EI #5, the full-time Registered Dietitian, was interviewed on 10/03/19 at 9:10 AM. EI #5 was asked how did cooks know how to prepare pureed foods. EI #5 stated they have a recipe book with instructions on portions. When asked what was the importance of preparing pureed foods according to recipes, EI #5 said to maintain proper consistency, texture, nutritional value, and taste. EI #5 further said they want it to be as palatable and aesthetically pleasing as possible. When asked what was the potential negative affect on residents if pureed foods were not prepared correctly, EI #5 said residents may not get the nutrition they are supposed to receive.