Every finding on record at East Glen

Based on record review, interviews, and review of a facility policy titled Cardiopulmonary Resuscitation (CPR) Compression Airway Breathing (CAB), The American Heart Association (AHA) current website for CPR & First Aid Emergency Cardiovascular Care, and the AHA Adult Basic Life Support (ABLS) Algorithm for Health Care Providers the facility failed to initiate CPR in accordance with facility policy and in accordance with the AHA, ABLS for Resident Identifier (RI) #1 on [DATE], when Employee Identifier (EI) #4, a Licensed Practical Nurse (LPN), determined RI #1 was unresponsive and had no palpable pulse upon returning to the facility. On [DATE], RI #1 was transferred by a transport van contracted by the facility to and from a medical appointment. RI #1's spouse and transport van driver stated RI #1 slid onto the van's floor from his/her wheelchair. The van driver informed RI #1's spouse that she needed to pull over and assess RI #1 but was directed by the spouse to continue driving to the facility. The van driver stated while driving she called the facility to alert them what occurred. Upon arrival to the facility, EI #4, LPN responded and observed RI #1 lying on his/her back with his/her legs between driver seat and passenger seat. EI #4 stated he assessed RI #1 and found him/her to be unresponsive and without a carotid pulse. EI #4 stated he provided sternal rub but failed to initiate CPR, activate Emergency Medical System (EMS), or summon additional assistance from facility staff. EI #4 stated he instructed the van's driver to transport RI #1 to the emergency room across the street instead of immediately performing CPR. Upon arrival at the emergency room (ER) RI #1 was found to be apneic and without a pulse. The ER staff performed Advanced Cardiac Life Support (ACLS) for twenty (20) minutes but was unsuccessful in reviving RI #1. The ER pronounced the death of RI #1 at 6:13 PM. This deficient practice placed RI #1, one of three sampled residents reviewed for the provision of CPR, in immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment or death. This had the potential to affect 18 full code residents of 26 residents under the care of EI #4 on [DATE]. On [DATE] at 3:37 PM, EI #1, the facility Administrator and EI # 2, the Director of Nursing (DON) were given a copy of the Immediate Jeopardy (IJ) template and notified of the findings of substandard quality of care at the IJ level in the area of Quality of Life, at F678-Cardio-Pulmonary Resuscitation (CPR). The immediate jeopardy began on [DATE] and continued until [DATE] when the facility implemented corrective actions to address the identified deficient practice, including ongoing monitoring; thus, immediate jeopardy past noncompliance was cited. Findings include: On [DATE] the State Survey Agency received an Online Incident Reporting System from East Glen Nursing Facility at 4:11 PM. East Glen submitted to the Alabama State Survey Agency an allegation labeled as other. The report identified, Resident left the facility with (spouse) in transport van, for a follow up appointment transported by (name) transportation. During the return trip driver reports resident slid out of chair. Upon return to facility resident was assessed in the van and noted to be unresponsive and without pulse. Nurse prompted (spouse) and driver to take resident to the emergency room . The facility timeline dated [DATE] for RI #1 identified the following: Approximately 2:45 pm (RI #1) left facility with (Name) Transport, accompanied by (his/her) spouse to go to a scheduled follow-up appointment . Approximately 5:36 pm (Name) Transport service called (EI #3, Director of Admissions) and informed her that RI #1 had slid out of (his/her) chair and they were pulling up to East Glen. Approximately 5:37 pm (EI #4) received phone call from (Name) Transport letting him know (RI #1) was unresponsive and could not wake (him/her) up and they were outside at front. (EI #4) immediately gathered staff and went to assess (RI #1). (RI #1) was found lying in the floor of van . (EI #4) went in the van and checked pulse. After not finding a pulse (EI #4) instructed the driver transport (RI #1) across the street to (Name of hospital) for evaluation . The facility's policy titled Cardiopulmonary Resuscitation (CPR)/Compression Airway Breathing (CAB), dated ,d+[DATE], documented: PURPOSE: To circulate oxygenated blood through the body until advanced medical support arrives. STANDARD: CPR is initiated when indicated on residents who do not have DNR (Do Not Resuscitate) orders. PROCESS: (Some of these actions may occur simultaneously and / or by persons other than the first person responding to the scene) 1. Assess the resident's breathing and pulse. 2. Activate EMS system-call 911. 3. Begin compressions at a rate of 100 to 120 per minute at a depth of approximately 2 inches. Avoid excessive chest compressions depths of more than 2 inches. 4. Give 2 rescue breaths after 30 compressions. 5. Notify physicians/family/sponsor. 6. Continue compressions/breath cycle until EMS arrives or resident regains consciousness . The American Heart Association (AHA) Adult Basic Life Support (ABLS) Algorithm for Health Care Providers, dated 2020, documents the following sequence of response should be initiated in the event Health Care Providers respond to a person in need of CPR and EMS: . Verify scene safety. Check for responsiveness. Shout for nearby help. Activate emergency response system via mobile device (if appropriate). Get . emergency equipment (or send someone to do so). Look for no breathing or only gasping and check pulse (simultaneously). No breathing or only gasping, pulse not felt . By this time in all scenarios, emergency response system or backup is activated . and emergency equipment are retrieved, or someone is retrieving them. Start CPR Perform cycles of 30 compressions and 2 breaths . Check . (for a pulse if no AED). Resume CPR immediately . Continue until ALS (advanced life support) providers take over or victim starts to move. The AHA current website for CPR & First Aid Emergency Cardiovascular Care documents Science-based Guidelines . All recommendations below are based on the AHA Guidelines Update for CPR and Emergency Cardiovascular Care (ECC) . CPR . is an emergency lifesaving procedure performed when the heart stops beating. Immediate CPR can double or triple chances of survival after cardiac arrest . RI #1 was admitted on [DATE] with diagnoses including: Metabolic Encephalopathy, Altered Mental Status, and Malignant Neoplasm. A review of RI #1's Physician Orders for the month of [DATE] revealed an order dated [DATE] for FULL CODE STATUS. A review of the facility's NON-WITNESS STATEMENT . dated [DATE] completed by EI #4 (LPN) identified that . At 5:46 PM the . driver called my personal phone and stated the Resident was unresponsive and not moving, and she was parked in the front of the facility. I then called both of my CNAs .and told them we have an emergency .I then went into the van to assess the resident. (He/She) was lying on (his/her) back with .legs in between the driver and passenger seat . Resident was pale in color .I checked the carotid for pulse and couldn't find one a sternal rub was performed also; I then instructed the driver to take (him/her) across the street to the Hospital . An interview was conducted on [DATE] at 10:30 AM with RI #1's spouse who reported he/she accompanied RI #1 to an appointment. RI #1's transportation was scheduled by the facility with a contracted company for non-emergency van transport. After the appointment and during the transport back to the facility he/she (spouse) was sitting behind RI #1. The resident's spouse said halfway to East Glen RI #1 slid out of the wheelchair onto the floor of the minivan. The spouse said when they arrived at the facility things happened quite fast. He/she continued to say several staff came to the van and a nurse assessed RI #1, but the nurse did not do anything and said take him/her to the ER. RI #1's spouse said the nurse did not perform CPR. RI #1's spouse was asked, did he/she agree that RI #1 needed to be transported to the ER in the van. He/she replied that he/she did not but what else was he/she going to do; it was out of his/her hands and sounded like the appropriate thing to do. RI #1's spouse said it took three to four minutes to transport RI #1 to ER from facility. An interview was conducted on [DATE] at 11:55 AM with the contracted van transport driver. The van driver reported when she picked up RI #1 from the doctor's appointment, he/she looked asleep and tired. The van driver said during the return trip RI #1 did not say anything and RI #1 kept sliding down in the chair. The van driver said RI #1 slid out of the wheelchair to the van's floor before arriving at the facility. The van driver said when they arrived at the facility it took staff about five to ten minutes to respond to their arrival. The van driver said staff got into the van and just stood there looking. The nurse said RI #1 was pale and instructed her to take RI #1 to the hospital. The van driver said she took RI #1 to the ER. When she arrived at the ER several staff came out and a nurse started CPR. The van driver said then ER staff brought a stretcher, removed RI #1 from the van, and continued CPR. The van driver stated that she was CPR certified and thought EI #4 should have at least entered the van and started CPR. An interview with EI #4 (LPN) was conducted on [DATE] at 1:00 PM. EI #4 was asked how he knew when to start CPR/BLS (Basic Life Support) for a resident. EI #4 replied, he would check for carotid pulse, rise and fall of chest, whether the skin color was normal, talked with patient to make sure patient could not respond. EI #4 said, he would check the airway and pulse, and if absent CPR would definitely be started. EI #4 was asked, what happened when RI #1 arrived at the facility in the transport van. EI #4 said the van driver called to report she could not wake RI #1 and RI #1 was not moving. EI #4 said he immediately summoned two CNAs, went out to the van, and then got into the van to assess RI #1. EI #4 said he performed a sternal rub with no response and was unable to palpate the carotid pulse. EI #4 said he told the van driver that RI #1 was in very critical condition, and she needed to get RI #1 to the hospital. EI #4 stated he did not know how long RI #1 had been non-responsive. EI #4 stated in an emergency response his role was to take the crash cart and perform CPR. EI #4 was asked, according to BLS and facility policy, what actions should have been taken based on his assessment. EI #4 stated, when breathing and pulse were not present, CPR should have been initiated. EI #4 stated he did not activate EMS and made the decision to send RI #1 to the ER. An interview was conducted on [DATE] at 6:10 PM with EI #8, CNA. EI #8 said EI #4 said he needed her because RI #1 was not responding. EI #8 said they went to the van. EI #8 said RI #1 was lying flat on his/her back wedged between the driver seat and the passenger seat. EI #8 stated the van driver said, (she/he) been down there for a while. EI #8 said EI #4 climbed into the van, assessed RI #1, and realized he/she did not have a pulse. EI #8 said RI #1 was very pale as white as a piece of paper. EI #8 said EI #4 told the van driver to take the resident to the hospital immediately and said RI #1 did not have a pulse. EI #8 said the driver asked where was the hospital; EI #8 and EI #4 pointed across the street. An interview was conducted on [DATE] at 3:25 PM with the emergency room physician who provided care to RI #1. The emergency room physician stated RI #1 arrived at the ER near 6:00 PM and did not have a pulse. He stated that the ER staff performed ,d+[DATE] minutes of ACLS according to protocol before death was pronounced. The ER physician stated when a resident was found to be pulseless nursing staff should immediately initiate CPR. An interview was conducted on [DATE] at 1:00 PM with EI #2 (Director of Nursing). EI #2 stated the code status for all residents was documented on the front of the resident's chart and in the Electronic Health Record (EHR). EI #2 stated the steps in determining if a resident requires CPR was to check code status, once identified if the resident was a full code status, then CPR would be initiated by assessing breathing and pulse. EI #2 stated when a resident was without a pulse, the nurse should initiate CPR and activate EMS. EI #2 stated EI #4 did not initiate CPR according to facility policy. EI #2 stated it was not standard policy and procedure to send a resident to ER without initiating CPR. EI #2 stated all licensed nurses were CPR certified. An interview was conducted on [DATE] at 11:45AM with EI #1, Administrator who stated all licensed staff (LPN's and RN's) were trained on BLS through AHA and they know what to do in emergency. EI #1 stated she was told RI #1 went out to a medical appointment and on the way back to the facility he/she slid out of the wheelchair. EI #1 stated the van driver called the facility and notified the nurse RI #1 slid out of the chair. EI #1 stated when the van arrived, RI #1 was on the floor of van according to the nurse's statement. EI #1 stated EI #4, LPN assessed RI #1 and immediately sent him/her to the emergency room across the street. EI #1 stated according to facility policy, staff should have verified code status and initiated CPR. EI #1 stated that a resident requiring emergency care prior to the arrival of emergency medical personnel should receive basic life support, including CPR. EI #1 stated on [DATE] RI #1 was assessed by EI #4 to be pulseless and was not provided CPR by EI #4 nor was emergency services contacted. EI #4 instructed the van driver to take RI #1 to the ER by non-emergent transport. This deficient practice was cited as a result of the investigation of complaint/report number AL00044244 ****************************************************************** The facility took the following immediate action to correct the deficient practice; thus, past non-compliance was cited: 1) Reported the incident to ADPH Online Reporting System on [DATE] and investigation completed. 2) Notified Medical Director, audit conducted on all resident's code status and care plans on [DATE]. 3) Terminated contract with transport company on [DATE]. 4) Held a QA held and QAPI (Quality .) on [DATE]. 5) On [DATE] EI #4 was provided 1:1 education/in-servicing on the facility CPR policy and code status. 6) Completed in-servicing for all licensed staff on Code Status and performance of CPR on [DATE]. 7) Completed Mock Codes on [DATE] and [DATE]. 8) Completed audit for licensed staff to verify CPR on [DATE]. 9) DON monitoring all unusual occurrences beginning on [DATE].

Based on interviews, resident record reviews, and review of the Centers for Medicare & (and) Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure Resident Identifier (RI) #24's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/17/2023 was accurately coded for Dialysis and Oxygen Therapy and RI #7's quarterly MDS with an ARD of 02/12/2023 was accurately coded for Hospice services. This affected two of 18 sampled residents for whom MDS assessments were reviewed. Findings Include: The Centers for Medicare & (and) Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, dated October 2019, documented: . SECTION O: SPECIAL TREATMENTS, PROCEDURES, AND PROGRAMS Intent: The intent of the items in this section is to identify any special treatments, procedures, and programs that the resident received during the specified time periods. O0100C, Oxygen therapy Code continuous or intermittent oxygen administered via mask, cannula, etc., delivered to a resident to relieve hypoxia in this item. O0100J, Dialysis Code peritoneal or renal dialysis which occurs at the nursing home of at another facility . O0100K, Hospice care Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions. RI #24 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses to include Chronic Respiratory Failure with Hypoxia, Stage Four (4) Chronic Kidney Disease, and Shortness of Breath. RI #24's March 2023 physician orders documented an order dated 01/10/2023 instructing that RI #24 was to receive Oxygen (02) at three (3) liters per minute (l/m) by nasal cannula (n/c) for Shortness of Breath and low oxygen saturation. Another physician order dated 01/10/2023 documented RI #24 was to receive Dialysis on Mondays, Wednesdays, and Fridays. RI #24's quarterly MDS with an ARD of 01/17/2023 was not coded to reflect RI #24 received Dialysis Treatments or Oxygen Therapy in the last 14 days. In an interview on 03/15/2023 at 3:10 PM, Employee Identifier (EI) #3, a Registered Nurse (RN)/MDS Coordinator, stated RI #24 received dialysis at the time of the most current MDS. EI #3 stated the MDS was not coded for dialysis. EI #3 stated the MDS should have been coded for receiving dialysis while a resident. EI #3 stated the MDS was not complete and accurate. EI #3 stated the MDS should be an accurate reflection of the resident. In a follow-up interview on 03/16/2023 at 02:32 PM, EI #3, RN/MDS Coordinator, stated RI #24 received oxygen therapy at the time of the most current MDS. EI #3 stated the MDS indicated the resident was not receiving oxygen therapy. EI #3 stated the MDS should have been coded that the resident was receiving oxygen therapy. EI #3 stated RI #24's MDS was not complete and accurate. EI #3 stated the MDS did not capture the full picture of the resident's care. 44165 RI #7 was admitted to the facility on [DATE]. A review of RI #7's physician orders revealed, . Compassus Hospice to evaluate and admit . on 11/09/2022. RI #7's quarterly MDS with an ARD of 02/12/2023 was not coded to reflect RI #7 received hospice services. In an interview on 03/16/2023 at 10:48 AM, EI #3, RN/MDS Coordinator, stated RI #7 received hospice at the time of the most current MDS. EI #3 stated the MDS was not coded for hospice. EI #3 stated the MDS should have been coded for receiving hospice while a resident. EI #3 stated the risk of the MDS not being coded correctly was, it would not reflect the care of the resident. On 03/16/23 at 02:41 PM, an interview was conducted with EI #2, RN/Director of Nursing (DON). EI #2 was asked, what was the procedure when a resident was placed on hospice. EI #2 replied, an order was obtained for a consult, the resident was evaluated and the service was added to the care plan and the MDS assessment. EI #2 was asked, where should hospice have been addressed on the MDS dated [DATE]. EI #2 replied, Section O, Letter K. EI #2 was asked, what was the risk of hospice not being addressed on the MDS. EI #2 replied, the information was needed to appropriately update the care plan according to the needs. EI #2 was asked, when was the order for RI #7's hospice written. EI #2 replied, 11/09/2022. EI #2 was asked, where was hospice coded on RI #7's MDS for 02/12/2023. EI #2 replied, it was not coded.

Based on observations, interviews, resident record review, and review of Potter and Perry, Fundamentals of Nursing, NINTH EDITION, the facility failed to ensure licensed staff, Employee Identifier (EI) #10, Licensed Practical Nurse (LPN)/Wound Care Nurse, followed physician orders for treatment for Resident Identifier (RI) #24. This was observed on 03/16/2023 when dressings on RI #24's legs had not been changed the night before as ordered. This deficient practice had the potential to affect RI #24, one of three residents for whom wound treatments were reviewed. Findings Include: A review of Potter and Perry's 2017, Fundamentals of Nursing, NINTH EDITION, Chapter 23, Legal Implication in Nursing Practice, page 311, revealed the following: . Health Care Providers' Orders. The health care provider (physician or advanced practice nurse) is responsible for directing medical treatment. Nurses follow health care providers' orders unless they believe the orders are in error, . or are harmful to the patient. RI #24 was readmitted to the facility on [DATE] and had diagnoses to include: Peripheral Vascular Disease, Swelling of Bilateral Lower Legs, and Chronic Peripheral Venous Insufficiency. RI #24's March 2023 physician orders documented an order dated 01/31/2023 for RI #24's legs to be wrapped with Ace wrap (elastic bandage) twice a day for swelling. On 03/14/2023 at 8:20 AM RI #24 was observed sitting in a wheelchair in his/her room. RI #24 said, he/she had cellulitis in his/her legs, and venous stasis in his/her feet. RI #24 said, he/she was supposed to have his/her legs wrapped, but the facility had not been doing that as ordered, and only sometimes he/she got them wrapped. RI #24's legs were observed not wrapped, and blisters were observed on each leg, weeping fluid onto the floor. On 03/15/2023 at 9:26 AM RI #24 was up in a wheelchair and RI #24's legs were covered with Ace wrap. Later that same day, 03/15/2023 at 5:35 PM, RI #24 marked the Ace bandages with a yellow X on the left lower leg. The next morning, on 03/16/2023 at 7:46 AM, an observation was made of Ace wraps on RI #24's legs with the yellow X mark on the left lower leg, that RI #24 had placed there the previous day. RI #24 said, the staff had not changed the Ace bandages since yesterday morning. RI #24's March 2023 Electronic Medication Administration Record (EMAR) documented both of RI #24's legs were to be wrapped with Ace wrap twice a day for swelling. The EMAR documented the wraps were to be done at 9:00 AM and 9:00 PM. The EMAR documented the treatment entry on 03/15/2023 at 9:00 PM as N, which meant RI #24's legs had not been wrapped by the nurse at that time. The entry was documented by EI #10 LPN. On 03/16/2023 at 11:19 AM EI #10, the Licensed Practical Nurse (LPN)/Treatment Nurse was asked, how often were the Ace wraps ordered to be changed for EI #24. EI #10 replied, 9:00 AM and 9:00 PM. EI #10 was asked, why she charted N for the Ace wrap changes on 03/15/2023. EI #10 replied, because RI #24 was sitting up and she asked RI #24 to lie down, and RI #24 was not ready to lie down. EI #10 was asked, what did N mean on the EMAR. EI #10 answered, it meant EI #10 did not administer the treatment. EI #10 was asked, what she should have done. EI #10 replied, she could have called the Director of Nursing (DON) and let her know that RI #24 would not get in the bed. EI #10 was asked, how many times on her shift did the Ace wrap get changed. EI #10 replied, none. EI #10 was asked, what was the risk of not following physician orders. EI #10 replied, it all depended on what the order was. On 03/16/2023 at 12:37 PM, RI #24 was observed still wearing the Ace wraps with the yellow X mark on the left leg. RI #24 told the surveyor, no one had been in his/her room to change the wraps and no one had asked about changing the Ace wraps, and they wraps had been on RI #24's legs since yesterday morning around 8:00 AM. A phone interview was conducted on 03/16/2023 at 8:29 AM with EI #8, Certified Registered Nurse Practitioner (CRNP). EI #8 was asked, what she been told about RI #24's skin. EI #8 replied, RI #24 had weeping legs. EI #8 said, RI #24 had orders for his/her legs to be wrapped two times a day because of the weeping to keep them as dry as possible. EI #8 said if RI #24's legs were not wrapped twice a day there was a risk of the areas on RI #24's legs turning into cellulitis. EI #8 stated, she would like for RI #24's legs to be wrapped twice a day. On 03/16/2023 at 2:25 PM a follow up phone interview with EI #8 was conducted. EI #8 was asked about the purpose of the Ace wraps for RI #24 legs. EI #8 replied, to help control the moisture. EI #8 said other types of dressings could get wet and soggy. EI #8 was asked what the risk would be of Ace wraps being left on for over 24 hours without being changed. EI #8 replied, the bandages could be wet. EI #8 said if the Ace wraps were kept on too long, it would keep in moisture and could cause skin breakdown. On 03/16/2023 at 2:41 PM an interview was conducted with EI #2 RN/DON (Director of Nursing). EI #2 was asked, who should have been wrapping RI #24's legs. EI #2 replied, the nurse. EI #2 was asked, what was her concern of RI #24's legs having the same Ace wraps on since around 8:00 AM on 03/15/2023. EI #2 replied, RI #24's wraps needed to be changed. When asked about why it would the required for RI #24 to be back in the bed to have the wraps changed, EI #2 replied, it was not a requirement, but it would be easier for the nurse and the resident.

Based on observations, interviews, resident record review, and review of a facility policy titled Call Light, the facility failed to ensure Resident Identifier (RI) #41's call light was positioned within reach of the resident on 03/14/2023 while RI #41 was in a wheelchair in his/her room. This affected one of 18 sampled residents. Findings include: A facility policy titled Call Light effective 12/2016, documented: . PURPOSE: Call lights serve as notice to the staff the resident has a need or request. Prompt answering of call lights provides a sense of security to the resident. 4. Place the call light within reach of the resident before leaving the room. RI #41 was readmitted to the facility on [DATE]. On 03/14/2023, the surveyor made the following observations of RI #41: At 8:56 AM RI #41 was sitting in a wheelchair in his/her room. RI #41 had finished the breakfast meal and said, he/she wanted to get back in bed. RI #41 said, he/she could not reach his/her call light to call for staff assistance. At 9:03 AM Employee Identifier (EI) #6 Certified Nursing Assistant (CNA) went into RI #41's room to pick up the breakfast tray and RI #41 asked for assistance to get back in the bed. EI #6 told RI #41, she would be right back. At 9:04 AM another staff member went into RI #41's room, picked up a cup, and came out of the room. At 9:09 AM RI #41 still in the wheelchair, did not have a call light within reach, and was still requesting to get into bed. At 9:23 AM RI #41 began yelling out for help. At 9:26 AM RI #41 yelled out nurse, nurse, help, help. At 9:27 AM RI #41 yelled out help, help. At 9:28 AM a staff member walked by RI #41's room and did not look into RI #41's room as RI #41 called out for help. At 9:33 AM RI #41 called out, help, while EI #7 Registered Nurse (RN), was at the medication cart in the hallway. At 9:34 AM EI #7 pushed the medication cart in front of RI #41's room, entered RI #41's room, and told RI #41 someone would come to assist him/her. At 9:37 AM staff went to assist RI #41. On 03/14/2023 at 9:42 AM EI #6 CNA was asked where RI #41's call light was. EI #6 said, it was on RI #41's bed under RI #41's blanket. EI #6 said, RI #41's call light was too far from RI #41, out of RI #41's reach. EI #6 said, the risk of RI #41's call light being out of reach was that RI #41 could have fallen, and RI #41, not being able to reach the call light, could not call for help. EI #6 said, the policy for call lights was to make sure the call light was within reach for residents to be able call for help. EI #6 was asked, why she did not check RI #41's call light placement when she went in the room to pick up the breakfast tray. EI #6 replied, she was in a rush to pick up the trays. EI #6 said, she was supposed to check on the resident's call light positioning whenever she went in the room. On 03/14/2023 at 9:47 AM EI #7 RN was asked why she entered RI #41's room. EI #7 said, she heard RI #41 asking for help. When asked where RI #41's call light was, EI #7 said, she did not notice. When asked if RI #41 uses the call light, EI #7 answered, RI #41 uses the call light. When asked what the risk was of a resident not having the call light within reach, EI #7 said, not receiving care in a timely manner or the resident could fall. When asked the reason she did not check to see where RI #41's call light was, EI #7 said, she was doing her medication pass and she heard RI #41 call out so she checked on him/her. When asked where RI #41's call light should have been, EI #7 said, always within reach. On 03/16/2023 at 2:41 PM EI #2, Director of Nursing (DON) was asked what her concern was of a resident's call light not being within reach. EI #2 said, if the call light was not in reach it would make it difficult for the resident to notify staff if they needed something or if they had an emergency. EI #2 said, if the staff went into the resident's room because the resident was yelling, the staff should have placed the call light in reach of the resident before they left the room.

Based on interviews, record review and review of facility policies titled Guidelines Wound Management and Prescriber Medication Orders, the facility failed to ensure Resident Identifier (RI) #1's wound care order to the right groin incision was transcribed with the accurate duration of administration, 14 days, to RI #1's Treatment Administration Records (TAR) as ordered by the physician. This deficient practice affected RI #1, one of three residents sampled for dressing change documentation. Finding Include: Review of a facility policy titled Guidelines Wound Management, with an effective date of 11/2019, revealed the following: . DOCUMENTATION . · Treatment Administration Record (TAR's) - include treatment orders and/or daily notation of the condition of dressing/ wound site per physician's orders [REDACTED]. Review of another facility policy titled Prescriber Medication Orders, with a reviewed date of 04/2020, revealed the following: . Procedures 1. Elements of the Medication Order A. Medication orders specify the following . (6) .duration (length) of therapy . 2. Documentation of the Medication Order A. Each medication order is documented in the resident's medical record with the date, and a record of the person receiving the order. The order is recorded on the physician's orders [REDACTED]. RI #1 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. RI #1's physician's orders [REDACTED]. . (3) incision (R) (right) groin - clean c (with) alcohol prep pad - allow to air dry & (and) cover c dry island dressing q (every) day - Reassess 14 days . The physician's orders [REDACTED].#3, Registered Nurse (RN) Supervisor. However, review of RI #1's October 2020 TAR revealed RI #1's order to receive care to the right groin surgical incision had not been been transcribed to the TAR for a duration of 14 days. The text of the order stated 14 days, but was entered into the electronic system with a start date of 10/07/2020, and discontinuation date of 10/16/2020, for a total of only nine days. On 11/05/2020 at 11:13 a.m., the surveyor conducted an interview with EI #1, the Treatment Nurse. When asked how many days was treatment to be provided the RI #1's right groin incision, EI #1 said 14. EI #1 said looking at RI #1's TAR it looked like whoever took the order off (transcribed the order into the electronic system) may not have placed the 14 days duration on the TAR. On 11/05/2020 at 3:09 p.m., the surveyor conducted an interview with EI #2, RN Unit Manager. EI #2 said when RI #1 was admitted to the facility there was a treatment order to clean RI #1's right groin incision with alcohol prep and air dry and cover with an island dressing and reassess in 14 days. EI #2 said according to the TAR, it looked like whoever placed the order on the TAR stopped the treatment at nine days, instead of 14. When asked who would have been responsible for ensuring the duration of the treatment order was placed on the TAR as ordered by the physician, EI #2 said EI #3 would have been responsible if she wrote the orders. On 11/05/2020 at 5:55 p.m., the surveyor conducted an interview with EI #3, RN Supervisor. EI #3 said when RI #1 was admitted to the facility on [DATE] there were orders for daily treatment to the right groin every day for 14 days, then reassess. Upon reviewing RI #1's TAR, EI #3 said the TAR only reflected nine days of treatment. EI #3 further stated the person who took the order off would have been responsible for ensuring the treatment order was placed on the TAR as ordered by the physician. This deficiency was written as a result of complaint/report #AL 404.

Based on observation, interview, the (YEAR) Food and Drug Administration (FDA) Food Code, and the facility's Food and Nutrition Department cleaning logs for AM Cook, PM Cook, AM Aide, AM Dining Room (DR) Aide, PM Aid, PM DR Aid, Part Time (PT) Aide, and Helper for the week of 10/27/2019, the facility failed to ensure: 1.) the dishwashing machine drainpipe did not extend into the floor drain by three inches and thereby create the potential for backflow, 2.) the standing table mixer was clean and without any dried chocolate-colored residue, 3.) the floors in the dry storeroom, behind the trayline's reach-in cooler, and between the backs of the major pieces of cooking equipment were clean, 4.) the interior of the trayline's reach-in cooler was clean and dry, 5.) the ice cream was frozen solid in the ice cream freezer, 6.) there was not a dark residue build-up on the two water spray heads and the interior housing of the coffee machine, 7.) the convection oven did not have a heavy build-up of dark residue inside the oven, and 8.) the griddle drip pan was not one-third full of grease. This had the potential to affect all residents receiving meals from the kitchen, 101 of 103 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, portable EQUIPMENT, or UTENSILS are placed. On 10/29/19 at 10:47 AM, an observation was made of the dishwashing machine drainpipe extending down into the floor drain with Employee Identifier (EI) #2, the Registered Dietitian (RD)/Director of Food and Nutrition, and EI #4, the Director of Maintenance/Housekeeping. EI #4 was asked if he could measure the drain. EI #4 said yes and went to get a measuring device. On 10/29/19 at 10:48 AM, EI #2 was asked what was the concern with the drain from the dishwasher extending into the floor drain. EI #2 said Backflow. On 10/29/19 at 10:49 AM, EI #4 measured the metal dishwasher drainpipe from the top of the floor drain to the end of the drainpipe. EI #4 said it extended three inches into the floor drain. EI #4 agreed that backflow could be a concern since the drainpipe extended into the floor drain. 2.) The (YEAR) FDA Food Code included the following: . 4-601.11 Equipment, Food-Contact Surfaces, Nonfood Contact Surfaces, and Utensils. (A) . EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) . The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. During a kitchen observation on 10/29/19 at 10:35 AM, the mixer was seen covered with a plastic bag. When asked if that meant the mixer was clean, EI #2, the RD/Director of Food and Nutrition, said yes. When the mixer was uncovered, dried spots of chocolate-colored residue were observed underneath the top frame of the mixer and on the cage above the mixer bowl. EI #7, a Dietary Aide who was also present, was asked when was the last time the mixer was cleaned. EI #7 stated it was possibly cleaned last weekend. EI #2 stated it should have been cleaned on Sunday (10/27/19) after they made brownies. When asked if the mixer was clean, EI #2 said it had debris on it and it was not clean. During an interview on 10/30/19 at 4:27 PM, EI #2 was asked what was the potential concern with the mixer being left dirty with dried spots of chocolate-colored residue underneath the top frame of the mixer and on the cage above the mixer bowl. EI #2 replied debris, bacteria, food borne illness, and pests. 3.) The (YEAR) FDA Food Code included the following: . 6-501.12 Cleaning, Frequency and Restrictions. (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. On 10/29/19 at 10:57 AM, the floor to the dry storage room was observed dirty, with more than a 24-hour accumulation of debris, especially under the shelving areas. In one section of the storeroom, under the shelving, there was an area of dark residue where the wall and floor met. EI #2, the RD/Director of Food and Nutrition, was asked how often the storeroom was swept and mopped. EI #2 went to check the posted cleaning logs for the week of 10/27/19 and then said the staff had not been signing off on them. Seven of eight cleaning logs included the task of Floor area-swept and cleaned. Only one cleaning log had anything initialed as being done, and that was the PM Cook's cleaning log for duties completed on 10/28/19 (Monday). On 10/29/19 at 11:05 AM, an observation was made of the reach-in cooler for the line. Something had leaked from the reach-in cooler onto the floor behind it. On 10/29/19 at 11:14 AM, an observation was made of the floor between the backs of the convection oven, the stove, and the other major cooking equipment. The floor was very dirty with debris and had a build-up of dark, grease-like residue. On 10/30/19 at 9:37 AM, an observation again revealed a buildup of debris on the floor behind and between the backs of the pieces of major cooking equipment, which were the stove, the ovens, the steamer, the fryers, and the tilt skillet. On 10/30/19 at 9:43 AM, there was a dried spill observed behind the reach-in cooler. During an interview on 10/30/2019 at 4:27 PM, EI #2 was asked if the cleaning logs were properly completed for AM Cook Cleaning, AM Aide Cleaning, AM DR Aide Cleaning, Helper Cleaning, PT Aide Cleaning, PM DR Aid Cleaning, and PM Aide Cleaning for 10/27/19 (Sunday) through 10/28/19 (Monday). At this time, EI #2 was shown copies of the cleaning logs, which she had provided on 10/29/19. EI #2 replied no. When asked what does not completing the logs indicate and why is that a concern, EI #2 said it indicated no one did their cleaning assignments and the concern was not having a clean and sanitized kitchen and the potential for food borne illness. When asked what was the potential problem with the floors in the dry storage room accumulating dust and being dirty, EI #2 said attracting pests. EI #2 was asked what was the potential problem with drainage of fluid on the floor behind the reach-in cooler being present on 10/29/19 and 10/30/19. EI #2 said significant debris, bacteria, and pests. When asked what was the potential concern with a buildup of grease and debris on the floor between the cooking equipment, EI #2 said cleanliness and attracting pests. 4.) The (YEAR) FDA Food Code included the following: . 4-601.11 Equipment, Food-Contact Surfaces, Nonfood Contact Surfaces and Utensils. (C) . NONFOOD FOOD CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other residue. On 10/29/19 at 11:05 AM, an observation made of the reach-in cooler for the tray line revealed something was leaking and had pooled at the base of the interior of the cooler. It had not been cleaned, but rags were soaking up the leak inside the cooler. There were pink and yellow stains on the rags. The fluid had dripped down the front interior of the cooler and onto the interior gasket of the cooler door. EI #2, the RD/Director of Food and Nutrition, was interviewed on 10/30/19 at 4:27 PM. EI #2 was asked what was the potential problem with the reach-in cooler for the tray line having pooled liquid at the base of the interior of the cooler, having rags soaking up the liquid inside the cooler that were stained pink and yellow, and having fluid which had dripped down the front interior of the cooler and onto the interior gasket of the cooler door. EI #2 said issues with cleanliness, potential for bacteria, and potential for pests. 5.) The (YEAR) FDA Food Code included the following: . 3-501.11 Frozen Food Stored frozen Foods shall be maintained frozen. On 10/29/19 between 10:57 AM and 11:11 AM , the ice cream inside the chest freezer was mushy/soft when squeezed and was not frozen solid. Both sides of the chest freezer had mushy ice cream, including containers in a box that had not been previously opened. On 10/30/19 at 9:42 AM , the ice cream was checked and was again found to not be frozen solid. During an interview on 10/30/2019 at 4:27 PM, EI #2, the RD/Director of Food and Nutrition, was asked what was the problem with the ice cream not being frozen solid. EI #2 replied it's not at temp (temperature), so that means it could potentially be in the danger zone. 6.) The (YEAR) FDA Food Code included the following: . 4-601.11 Equipment, Food-Contact Surfaces, Nonfood Contact Surfaces and Utensils. (C) . NONFOOD FOOD CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other residue. On 10/29/19 at 11:11 AM , a buildup of dark residue was observed on and around the two water spray heads on the interior housing of the coffee maker over each of the coffee filter baskets/pots. During an interview on 10/30/2019 at 4:27 PM, EI #2, the RD/Director of Food and Nutrition, was asked what was the potential concern with built up dark residue around the two water spray heads and on the interior housing of the coffee maker. EI #2 said significant buildup leads to significant bacteria, which can lead to food borne illnesses. 7.) The (YEAR) FDA Food Code included the following: . 4-601.11 Equipment, Food-Contact Surfaces, Nonfood Contact Surfaces and Utensils. (C) . NONFOOD FOOD CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other residue. On 10/29/19 at 11:13 AM , the convection oven was observed with a buildup of dark, heavy residue over entire interior of the oven. EI #6, the AM Relief Cook, was asked who cleaned the ovens. EI #6 shook her head and said they did not have anyone. EI #2, the RD/Director of Food and Nutrition, was interviewed on 10/30/2019 at 4:27 PM. EI #2 was asked which oven or ovens were supposed to be cleaned per the PM Cook cleaning log, which documented there was to be a monthly cleaning of the oven, oven racks, and a deep cleaning of the stove eyes. EI #2 said if it did not specify, it should be all three ovens, to include the convection oven and the stove range ovens. When asked how did she ensure this happens, EI #2 said she would have to follow up with the Dining Service Manager (EI #3) to ensure he was monitoring if the responsible staff members were doing their cleaning assignments. EI #2 was asked what was the potential problem with the convection oven having buildup of dark residue inside and not being cleaned on a regular basis. EI #2 said if there is buildup, there is more than likely bacteria growing which is going to lead to food borne illness and also attract pests. On 10/30/19 at 5:02 PM, EI #3, the Dining Service Manager, was interviewed. EI #3 was asked how he monitored to see if the oven had been cleaned. EI #3 said they wiped down the outside surfaces every day, but a good job was not done inside the ovens. When asked how long it had been since the inside of the ovens were cleaned, EI #3 said it had been several months. 8.) The (YEAR) FDA Food Code included the following: . 4-601.11 Equipment, Food-Contact Surfaces, Nonfood Contact Surfaces and Utensils. (C) . NONFOOD FOOD CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other residue. On 10/29/19 at 11:14 AM, the stove griddle's drip pan was observed to be at least one-third full of grease and it appeared to be more than a 24-hour accumulation. During an interview on 10/30/2019 at 4:27 PM, EI #2, the RD/Director of Food and Nutrition, was asked how often should the griddle drip pan be emptied and cleaned. EI #2 said they should do it everyday after significant spills and after production. When asked if it was acceptable for the griddle drip pan to be one-third full of grease, EI #2 said no. Upon being asked the potential concern, EI #2 said significant buildup leads to significant bacteria and pests, which could lead to food borne illness.

Based on observation, interview, review of the facility's policy for Smoking/Tobacco/Electronic Cigarette Free Facility and review of the (YEAR) Food and Drug Administration (FDA) Food Code, the facility failed to ensure waste was not strewn about the area designated for the compacting dumpster and the grease refuse container. The waste included cigarette butts, pepper packets, gloves, a pie box, a plastic food container lid, unidentifiable clumps of white residue, and dirty mop water This had the potential to affect 103 of 103 residents currently residing in the facility. Findings include: A facility policy dated 11/08/99 titled, Smoking/Tobacco/Electronic Cigarette Free Facility, included the following: (name of company) facilities are tobacco-free and electronic cigarette free in an effort to contribute to a safe, healthful, and comfortable work environment for employees and visitors. Smoking, tobacco products, and/or electronic cigarettes are prohibited in all workplace areas throughout all . (name of company) facilities . The (YEAR) FDA Food Code included the following: . 5-501.15 Outside Receptacles. (B) Receptacles and waste handling units for REFUSE and recyclables such as an on-site compactor shall be installed so that accumulation of debris and insect and rodent attraction and harborage are minimized and effective cleaning is facilitated around and . under the unit. 5-501.115 Maintaining Refuse Areas and Enclosures. A storage area and enclosure for REFUSE . shall be maintained free of unnecessary items . and clean. An initial tour of the dumpster/refuse area of the facility was conducted on 10/29/19 at 11:17 AM with Employee Identifier (EI) #2, the Registered Dietitian (RD)/Director of Food and Nutrition. At this time, EI #5, a Housekeeping Floor Tech, was observed dumping mop water with some suds from the loading dock onto the pavement between the compacting dumpster and the grease refuse container. EI #5 responded to questions about correct disposal of dirty mop water by stating, I'm new. At 11:18 AM, the initial tour of the dumpster/refuse area revealed: at least 16 cigarette butts, pepper packets, a small plastic food container lid, and multiple clumps of an unidentifiable white residue underneath and around the grease refuse container. In addition, a pie box and two plastic gloves were observed under the dumpster compactor. The dumpster compactor was located next to the grease refuse container. Both the dumpster compactor and the grease refuse container were directly adjacent to the loading dock for the facility. On 10/29/19 at 12:00 PM, EI #4, the Maintenance Director/Housekeeping Director, was asked how were workers supposed to dispose of dirty mop water. He answered in the janitorial closet. EI #4 further said there were four janitorial sinks and that one of the four was in the kitchen. EI #4 also said it was not appropriate to dump the mop water off the loading dock. When asked what was the policy on cleaning around the dumpster, EI #4 said it was cleaned really well every two weeks when the compacting dumpster was removed for emptying. During an interview on 10/30/19 at 04:27 PM, EI #2, the RD/Director of Food and Nutrition, was asked what was the potential concern with trash accumulating around and under the grease refuse container and the compacting dumpster. EI #2 said, It would attract pests and rodents. When asked how this could affect residents, EI #2 said pests and rodents could get in the kitchen. Upon being asked who was responsible for cleaning around the dumpster, EI #2 said she was not sure who was responsible for cleaning around the dumpster. During an interview on 10/30/19 at 5:11 PM, EI #4, the Maintenance Director/Housekeeping Director, was asked what was the potential concern with trash accumulating around and under the grease refuse container and the compacting dumpster; to include a pie box, gloves, unidentified white clumps, and cigarette butts. EI #4 said the drain could get clogged. When asked if he was able to determine that the white clumps were, EI #4 responded it could be chemicals or paper; he was not really sure. EI #4 was asked who was responsible for cleaning the area around the dumpster. He said housekeeping was responsible, and they do a walk-through everyday. When asked what was the problem with dumping mop water off the loading dock onto the pavement, EI #4 said chemicals go right down into the earth through the drain. EI #4 further said a floor tech should use the service sink because it provided more control and protected the soil.

Based on interview and review of the ALABAMA BOARD OF NURSING ADMINISTRATIVE CODE, the facility failed to develop standardized procedures for wound assessment and care that were approved by the Alabama Board of Nursing. This had the potential to affect all 103 of 103 residents currently residing in the facility identified by Employee Identifier, EI #1, the Administrator, as being considered at risk for pressure ulcer development. Findings include: Review of the ALABAMA BOARD OF NURSING ADMINISTRATIVE CODE, dated 3/31/19, revealed the following: . 610-X-6-.12 Practice Beyond Basic Nursing Education: Standardized Procedures. (1) For practice beyond basic education that has not been previously approved by the Board, a standardized procedure is required for the licensed nurse in any practice setting. . (b) Practice beyond basic education in . other locations outside a licensed hospital requires approval by the Board prior to implementation. (2) A complete Standardized Procedure Application shall be submitted to the Board for practice beyond basic education preparation required in rule, practice not previously approved by the Board, and shall include: (a) Approval from the submitting facility, as evidenced by signatures on the application form of: 1. The chief nursing officer or, if no such position exists within a facility, an Alabama-licensed registered nurse who has oversight responsibility for the procedure. 2. The Alabama-licensed chief medical officer or an Alabama-licensed physician. 3. The chief executive officer for the Alabama organization. (b) The policy and procedure. (c) The organized program of study by a qualified instructor with the method of evaluation of learning specified. (d) The plan for supervised clinical practice. (e) The plan for demonstration of competence, initially and at periodic intervals, during which the nurse demonstrates the knowledge, skills, and ability to perform the procedure safely and to manage any complications. . 610-X-6-.13 Standards For Wound Assessment And Care. (1) It is within the scope of a licensed nurse practice to perform wound assessments, including but not limited to staging of a wound and making determinations as to whether wounds are present on admission to a healthcare facility, pursuant to an approved standardized procedure, outlined in Rule 610-X-6-.12, Standardized Procedures, including supervised clinical practice and demonstrated clinical competence, initially and at periodic intervals . On 11/06/19 at 10:01 AM Employee Identifier (EI) #1, the Administrator, EI #9, Director of Nursing (DON), and EI #10 ,Director of Clinical Operations, were present with the surveyor and were asked about the facility's standardized procedures for pressure ulcer assessment and care, approved through the Alabama Board of Nursing. Their collective answer was, that was not something they had done. On 11/08/19 at 12:02 PM, EI #9, DON, was interviewed to discuss the concern of the facility not having a standardized procedure in place for pressure ulcer assessment and care that had been approved by the Alabama Board of Nursing. EI #9 was asked why had standardized procedures for pressure ulcer assessment and care not been submitted to the Board of Nursing. EI #9 said, she was unsure of the reason. EI #9 was asked if she would be using it to train nurses if the facility had one. EI #9 said, yes. EI #9 was asked why it would be important to have a standardized procedure, submitted to and accepted by the Alabama Board of Nursing for standards for wound assessment and care. EI #9 replied, to make sure the wounds were assessed and treated to provide appropriate care. When asked what elements would be included in the standards for wound assessment and care, EI #9 stated, scheduled body audits, reporting of concerns, identifying concerns, treatment, and documentation. On 11/08/19 at 12:42 PM, EI #10, Director of Clinical Operations, was asked about the facility's standardized procedures for wound care. EI #10 said, she had not submitted standardized procedures for pressure ulcer assessment and care to the Alabama Board of Nursing. When asked why not, EI #10 said, when she reviewed the standard she did not see anything that led her to believe that she needed to send one.

Based on interview, record review, review of Fundamentals of Nursing, Ninth Edition, and review of a facility policy titled, Guidelines Wound Management, the facility failed to ensure Employee Identifier (EI) #11, the Treatment Nurse, did not document a wound assessment for Resident Identifier (RI) #393 on 10/2/19 without indicating it was for a prior assessment date. This affected one of five residents sampled for pressure ulcers. Findings include: Review of Fundamentals of Nursing, Ninth Edition, copyright (YEAR), Chapter 26 Documentation and Informatics, page 362, revealed the following: GUIDELINES FOR QUALITY D[NAME]UMENTATION .Current Timely entries are essential in patient's ongoing care. Delays in documentation lead to unsafe patient care . Review of the facility policy titled Guidelines Wound Management with an effective date of 1/2017 revealed the following: . D[NAME]UMENTATION . Update wound assessment module weekly . RI #393 was admitted to the facility on [DATE] with Pressure Ulcer of the Sacral Region. Review of RI #393's ADMISSION BODY AUDIT form, dated 9/20/19, revealed an open area to the sacrum. Review of RI #393's wound assessments revealed EI #11, Registered Nurse/Wound Treatment Nurse, failed to document a weekly assessment of RI #393's wound in the wound assessment module between 9/20/19, the day RI #393 was admitted to the facility and the date the wound was identified, and 10/2/19. The first documented Wound Assessment Report listed a Date of Assessment of 10/2/19, but indicated the wound was identified on 9/20/19. On 10/31/19 at 12:30 PM, EI #11, Treatment Nurse, provided an undated handwritten wound report with RI #393's name and a measurement. EI #11 was asked when the measurement was taken. EI #11 said, he did not know. On 11/01/19 at 9:21 AM, EI #11 was asked what training he received on the documentation process for the electronic system for wounds. EI #11 stated, wounds must be updated weekly. EI #11 was asked why it was important to assess and document the details of the wound, with measurements and a description. EI #11 said, to know the baseline of the wound and a proper assessment was the foundation of accurate treatment. When asked how he was assessing and documenting if he was not using the wound assessment manager, EI #11 said, he would handwrite notes about the wounds, and then later went in and entered the information into the system on 10/2/19. When asked why his assessments were not documented in the resident's record prior to 10/2/19, EI #11 replied, the demand for treatment superseded the demand for documentation. On 11/02/19 at 1:51 PM, EI #11 was asked how he would record a nursing entry for a previous date. EI #11 said, it would be a late entry. EI #11 was asked why he did not document a late entry for the documentation of the wound assessment for RI #393 that was entered into the system on 10/2/19. EI #11 said, it was difficult learning to integrate clinical treatments and clerical technical documentation.

Based on observation, staff interview and review of the facility's policy titled, Food Receipt and Storage, the facility failed to ensure a bag of dry gelatin dessert was sealed and stored properly in the dry storage area. This had the potential to affect 106 of 109 residents receiving meals from the kitchen. Findings Include : A review of the facility's policy titled, Food Receipt and Storage with an effective date of 06/2017, revealed the following: PURPOSE: Food should be received and stored properly to prevent food borne illnesses. STANDARD: Foods should be checked in and inspected upon receipt and stored in accordance with FDA (Food and Drug Administration) Food Code recommendations. PR(NAME)ESS: 1. Receipt: . b. All items delivered should be inspected as follows: . Cartons, bags and containers are sealed. On 10/17/17 at 8:05 a.m., during the initial tour of the kitchen with EI #4, Registered Dietician, an open bag of dry gelatin dessert was observed inside of an open plastic bag dated 10/10/2017. During an interview with EI #4 on 10/19/2017 at 3:50 p.m., EI #4 was asked there was an open food item in dry storage on kitchen tour on 10/17/2017. EI #4 stated yes, the gelatin. When asked who was responsible for storing items in dry storage, EI #4 stated that ultimately she was, but the dietary manager makes daily rounds. EI #4 also stated food-borne illnesses could be a potential impact when there are open food items in the dry storage.

Based on observations, staff interviews, record review and review of the facility's policy titled Snacks, the facility failed to ensure bedtime snacks were offered to residents on 10/18/17. This affected RI #4, RI #17 and #18, three of three sampled residents with a [DIAGNOSES REDACTED].#8, RI #13 and RI #16. Findings Include: A review of the facility's policy titled, Snacks with an effective date of 7/2014, revealed the following: PURPOSE: Snack foods are made available at each nursing unit for residents between meals and at bedtime (hs-hour of sleep). STANDARD: Dietary Management, in conjunction with the Nursing Department, should establish . foods and beverages for the nursing unit . for bedtime snacks. PR(NAME)ESS: . 5. Nursing personnel should verify the resident's diet order prior to providing a snack or beverage. 6. Resident specific snacks should be labeled and dated including the use by date (UBD). On 10/17/17 at 11:00 a.m., a total of 12 residents attended the group meeting. When asked if facility offered bedtime snacks, 12 of 12 residents stated no bedtime snacks were being offered and had not been offered. On 10/18/17 beginning at 8:53 p.m.-9:15 p.m., the surveyor entered four residents' room, and asked had snacks been offered that night. Each resident stated they had not been offered a snack. The surveyor asked how often were snacks offered. Three of the four residents stated they had never been offered a snack and one stated only once since December of 2016. 1. RI #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #8's current Quarterly Minimum Data Set assessment dated [DATE] revealed RI #8 's Brief Interview for Mental Status score of 15, indicating cognition intact. On 10/17/17 at 9:18 p.m., during an interview with RI #8 regarding snacks, RI #8 stated since December of last year, the facility had never, ever offered snacks. On 10/18/17 at 9:00 p.m., the surveyor observed EI #9, a Certified Nursing Assistant, entered a resident's room. The surveyor asked what did she ask the resident. EI #9 stated she asked the resident if the resident wanted a late night snack. The surveyor asked how often are snacks offered and when. EI #9 replied every other night and snacks should be offered at eight p.m. EI #9 also stated snacks should be offered every night at eight. EI #9 replied all residents are not offered a bedtime snack and she did not know why. The surveyor asked how long had she been employed at the facility. EI #9 stated she had been at the facility for a year and snacks are only offered every other night. 2. RI #4 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/18/2017 at 9:13 p.m. the surveyor asked RI #4 if he/she received a snack at bedtime. RI #4 stated, I never ever have a bedtime snack. 3. RI #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #17's current Quarterly Minimum Data Set assessment dated [DATE] revealed RI #17's Brief Interview for Mental Status score of 15, indicating cognition intact. On 10/18/17 at 7:15 p.m., during an interview with RI #17 regarding snacks. The surveyor asked RI #17 if he/she was offered snack. RI #17 said he/she was never offered a snack. RI #17 said he/she had been in the facility since April 2017. The surveyor asked RI #17 if he/she was a diabetic. RI #17 said yes. RI #17 asked if the facility was suppose to offer him/her a snack, because he/she had never been told that. 4. RI #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #18's Quarterly Minimum Data Set assessment dated [DATE] revealed RI #18's Brief Interview for Mental Status score of 10, indicating cognition moderately impaired. On 10/18/17 at 7:35 p.m., during an interview with RI #18 regarding snacks. The surveyor asked RI #18 if he/she was a diabetic . RI #18 said yes. The surveyor asked RI #18 if he/she would like a bedtime snack. RI #18 said not really, but he/she would take it if it was offered. 5. RI #13 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #13's Significant Change Minimum Data Set assessment dated [DATE] revealed RI #13's Brief Interview for Mental Status score of 13, indicating cognition intact. On 10/18/17 at 7:38 p.m., during an interview with RI #13 regarding snacks. The surveyor asked RI #13 if he/she was offered a snack. RI #13 said no, but he/she would like a snack at bedtime snack of peanut butter and jelly sandwiches and crackers. On 10/18/17 at 7:45 p.m., the surveyor conducted an interview with EI #13, Certified Nursing Assistant (CNA). The surveyor EI #13 where were the bedtime snacks kept for the diabetic residents and any other resident who wanted a late night snack. EI #13 said in the nutritional kitchen. The surveyor and EI #13 went to the nutritional kitchen and observed in the refrigerator health shakes, supplements and pudding. The surveyor and EI #13 returned to the nursing station and observed 8 - peanut butter cracker, 7 - cheddar cheese crackers and 6 honey buns. The surveyor asked EI #13 how did she know which resident was a diabetic. EI #13 said she would not know. 6. RI #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #16's current Quarterly Minimum Data Set assessment dated [DATE] revealed RI #16''s Brief Interview for Mental Status score of 15, indicating cognition intact. On 10/18/17 at 7:45 p.m., during an interview with RI #16 regarding snacks, RI #16 stated that he/she had never had a evening snack offered since he/she had been here, not never.

Based on staff interviews, record review and review of the facility's policy titled Notification of a Change in Medical Condition of Residents, the facility failed to ensure licensed staff notified Resident Identifier (RI) #15's physician after RI #15 had a change in condition. This affected one of 14 residents reviewed for a change in condition. Findings Include: A review of the facility's policy titled Notification of a Change in Medical Condition of Residents, with an effective date of 03/2017, revealed the following: . STANDARD Notification of the physician, . when there is a change in the resident's condition. This would include but is not limited to: . A change in the resident's physical, mental or psychosocial status . RI #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #15's current Significant Change Minimum Data Set assessment dated [DATE], revealed RI #15's Brief Interview for Mental Status score of 9, indicating moderate impairment in cognition. A review of the facility's Departmental Notes revealed the following: . 9/21/2017 10:10 PM Role: Licensed Practical Nurse . 3-11p shift .Weekly summary . noting that resident having difficulty swallowing meds whole, . gave resident some chocolate pudding though it took awhile to swallow still . (signed by Employee Identifier (EI) #2, Licensed Practical Nurse/LPN) . 9/28/2017 2:01 PM Role: Licensed Practical Nurse . This nurse entered residents room to administer am PO (by mouth) medications, resident stated I feel SOB (short of breath) .(signed by EI # 3, LPN) . 09/28/2017 10:16 PM Role: Licensed Practical Nurse . is now taking meds crushed in pudding . (RI #15) answers are slower to come when asking (RI #15) questions, slower to raise (RI #15) fluids to (RI #15) mouth. (signed by EI #2) . There was no documentation in the Departmental Notes for the above entries to indicate the physician was notified. On 10/18/17 at 10:10 a.m., during an interview with EI #1, the Director of Nursing/DON, the surveyor provided a copy of the nurses notes (departmental notes) for RI #15. The surveyor asked EI #1, for the entries dated 09/21/17 at 10:10 p.m., 09/28/17 at 2:01 p.m., and 09/28/17 at 10:16 p.m., what should have been done. EI #1 stated the physician should have been notified because this was a change in the resident's condition. On 10/18/17 at 4:05 p.m., during an interview with EI #5, the Medical Director, the surveyor asked would he have wanted the nurse to notify him of the above changes. EI #5 stated yes, if RI #15's symptoms were progressing.

Based on observation, interviews and review of the facility's policy titled, SPECIFIC PR(NAME)EDURES FOR ALL MEDICATIONS, the facility failed to ensure a Licensed Practical Nurse (LPN), Employee Identifier (EI) #11, did not document her initials on the Medication Administration Record (MAR) before she administered medications to Resident Identifier (RI) #13. This deficient practice affected RI #13, one of five residents observed during the Medication Administration Observation. Findings Include: The facility's policy titled SPECIFIC PR(NAME)EDURES FOR ALL MEDICATIONS, documented: . Procedures . G. Identify resident before administering medication . K. After administration, return to cart and document administration in the MAR . On 10/17/17 at 5:00 p.m., during the evening Medication Administration Observation, the surveyor observed EI #11, a LPN pour up EI #13's medications. EI #11 signed her initials on the MAR and went in RI #13's room and administered the medications to the resident. Upon returning to the cart, the surveyor asked EI #11 if she was finish with RI #13. EI #11 said yes. On 10/18/17 at 5:00 p.m., the surveyor conducted an interview with EI #11. The surveyor asked EI #11 why did she sign RI #13's MAR before she administered the medication. EI #11 said it was not a standard practice she did. EI #11 said it was just an error. The surveyor asked EI #11 should she sign the MAR before she give the medication. EI #11 said no. The surveyor asked EI #11 what did the facility's policy instructs her to do as far as documentation when she administer medications. EI #11 said sign the MAR after the medication been administered. On 10/18/17 at 6:55 p.m., the surveyor conducted an interview with EI #12, a Unit Manager. The surveyor asked EI #12 when should the nurse (EI #11) sign for routine medications. EI #12 said when she returned to the medication cart from administering the medication to the resident. The surveyor asked EI #12 should the nurse (EI #11) document her initials on the MAR before she administered the medication. EI #12 said no.

Based on observation of incontinent care, review of Potter and Perry's Fundamentals of Nursing, review of a facility policy titled, Isolation, Types of (Infection) and staff interviews, the facility failed to ensure staff removed their soiled gloves and washed their hands before touching the clean brief of Resident Identifier (RI) #4 during incontinent care on 10/18/17. The facility further failed to ensure an Isolation sign were posted and viewable for RI #23. This affected #4, one of one residents observed during incontinent care and RI #23, one of one sampled residents identified by the facility on isolation Findings Include: A review of Potter and Perry's Fundamentals of Nursing Chapter 28, Infection Prevention . page 419, documented: . Gloves. Change gloves and perform hand hygiene between tasks and procedures on the same patient after contact with material that contains a high concentration of microorganisms. A review of a facility's policy titled, Isolation, Types of (Infection) with an Effective Date: 05/2017, documented: . PURPOSE: To prevent the spread of infection from residents known to have infectious diseases. PR(NAME)ESS: Isolation signs should be placed on the door of rooms where residents receive isolation precautions. The sign should inform visitors, Report to the Nurses Station Before Entering for instructions. 1. RI #4 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #4's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/01/2017, revealed RI #4's Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment. The MDS further revealed that RI#4 was totally dependent for all Activities of Daily Living (ADL) and was always incontinent of bladder and bowel. An observation was made on 10/18/2017 at 10:45 a.m., during incontinent care on RI #4. Employee Identifier (EI) #7, Registered Nurse (RN) and EI #8, Certified Nursing Assistant (CNA) washed their hands and donned gloves. EI #7 rolled RI #4 to the left side and EI #8 removed the soiled brief. EI #8 stated, The brief had a moderate amount of urine and no feces. EI #8 then performed pericare. EI #8 then obtained a clean brief and placed underneath RI #4. EI #8 did not change her gloves or wash her hands before touching the clean brief. An interview was conducted on 10/18/2017 at 12:32 p.m., with EI #8. EI #8 was asked after removing the soiled brief and before touching the clean brief what did she do. EI #8 said she did not change her gloves or wash her hands. EI #8 was asked what was the potential harm in not changing gloves or washing hands before touching the clean brief. EI #8 said contamination. On 10/19/2017 at 6:36 p.m., an interview was conducted with EI #1, Director of Nursing (DON) Infection Control. EI #1 was asked during incontinent care when should gloves be changed and hands be washed. EI #1 said anytime when going from dirty to clean. EI #1 was asked what was the potential harm with going from dirty to clean without changing gloves. EI #1 said bacteria could be introduced. 2. RI #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Diff). A review of the Discharge Summary (Hospital Name) dated 10/12/2017 documented: . HOSPITAL COURSE: . After surgery, . (he/she) developed a [DIAGNOSES REDACTED] infection . A review of RI #23's physician's orders [REDACTED]. (3) Contact Isolation . An observation was made on 10/17/2017 at 8:05 a.m., and 4:59 p.m., RI #23's door to the room had no Isolation sign on the door. An observation was made on 10/18/2017 at 7:00 a.m., RI #23's door to the room had no Isolation sign on the door. An interview was conducted on 10/17/2017 at 8:13 a.m., with EI #10, RN/Unit Manager. EI #10 was asked was RI #23 on Isolation. EI #10 said yes, Contact Isolation because he/she had [DIAGNOSES REDACTED]icile. EI #10 was asked why was there not a sign on the door. EI #10 said she was not sure how it got missed. EI #10 was asked why was it important to have an Isolation sign on the door. EI #10 said to prevent the [DIAGNOSES REDACTED]icile from spreading. An interview was conducted on 10/19/2017 6:36 p.m., with EI #1, DON, Infection Control. EI #1 was asked why should there be a sign on RI #23's door. EI #1 said to notify staff and visitors of isolation precautions. EI #1 was asked what was the potential harm in not having a isolation sign/check at nursing station on the resident's door. EI #1 said staff/visitors could come in contact with [DIAGNOSES REDACTED]icile and then it could be spread.

Based on observations, interview and review of a facility form titled NURSING STAFFING and review of a facility policy and procedure titled, Nurse Staffing Information .,, the facility failed to ensure nurse staffing was posted prior to the beginning of shift on two of three days of the survey. This had the potential to affect all 107 residents residing in the facility and all visitors. Findings Include: A review of the facility's policy and procedure titled, Nurse Staffing Information ., with an effective date of 06/2014, revealed the following: . PR(NAME)ESS: 1. The facility shall post the following information on a daily basis: . c) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: . 2. Posting guidelines: a) The facility shall post the . nurse staffing information on a daily basis at the beginning of each shift . The following was observed: 10/17/17 at 7:40 a.m. - no 7 a.m. nurse staffing and hours posted 10/17/17 at 3:30 p.m. - no nurse staffing and hours posted for 2nd shift, 10/18/17 at 7:10 a.m. - no 2nd shift nurse staffing and hours documented and posted for 10/17/17 and no nurse staffing and hours posted for 10/18/17 10/18/17 at 7:20 a.m., EI #6, Staffing Coordinator, posted NURSE STAFFING form dated 10/18/17 On 10/18/17 at 7:25 a.m., during an interview with EI #6, the surveyor requested a copy of the NURSE STAFFING form dated 10/17/17, and asked what area did she just complete for 10/17/17. EI #6 replied the 2nd shift actual staffing. EI #6 further stated she did not know why the 2nd shift for 10/17/17 had not been completed. The surveyor asked when should the staffing form be completed. EI #6 stated first shift is posted between 8-8:30 a.m., 2nd shift is posted between 3:30-4:00 p.m. and 3rd shift is posted around 11:30 p.m., after staff comes on shift and is counted. EI #6 further stated the NURSE STAFFING form is posted after the shift comes in. EI #7, a Licensed Practical Nurse, who previously was responsible for posting staffing stated the NURSE STAFFING form is completed and posted after each shift comes on. The facility's policy on Nurse Staffing form was provided to EI #6 and EI #7 to review and the surveyor asked based on the facility's policy on nurse staffing posting, when should actual hours for staffing be posted. EI #6 stated at the beginning of each shift, but that was not being done.

Based on observation, interview, and record review, the facility failed to ensure on the evening of 12/5/2016 the kitchen was free from: 1. food debris on counters, carts, inside a sink, cooktops and ovens to prevent attraction of pests; 2. a package of grits left open and not sealed on a cart without a date; 3. the flour bin containing a bowl resting on top of the flour, a potential of cross contamination; 4. meat inside the walk in cooler not labeled and dated with use by dates; and 5. silverware wet nested in trays located in the dish washing room. These failures had the potential to affect all 92 residents receiving meals from the kitchen. Findings include: A facility policy titled: Cleaning Schedules with an effective date of 7/2014 revealed: PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses.PROCESS: . 5. The Dietary Management should . assure duties are completed . A facility policy titled: Service ware/Silverware, Handling with an effective date of 8/2014 revealed: PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses. STANDARD: Service ware and silverware should be . handled according to methods that provide effective sanitization and reduce potential contamination. PROCESS: . 2. Silverware should be placed in a flat rack, no more that one layer deep . 3. Silverware should then be placed loosely, business end up, in a cylinder or silverware basket/caddy to prevent nesting of each piece . 4. Silverware should then be place business end down . and allowed to air dry. The Food and Drug Administration (FDA) Food Code 2013, page 92, revealed: . on-premises preparation . hold cold 3-501.17 . Date Marking (A) . shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, . or discarded . The FDA Food Code 2013, page 148, revealed: . Drying 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and sanitizing, . UTENSILS: (A) Shall be air-dried or used after adequate draining . On 12/5/2016 at 9:08 p.m., an initial tour of the kitchen was conducted and observations were made of the following: 1. Food debris was seen in and around three of four ovens. One oven had foil on the bottom of the oven with baked on food. In the fry area, three of four fry baskets contained food debris and the right fry basket contained a fry scoop with food debris. Food debris was also observed on the griddle or cook top with a spatula left on top with food debris and a grease-like substance. On the plate holder cart, food debris was observed on the left side of the cart. The three shelves of a rolling cart beside the six burner stove was covered with paper and was noted to have food debris. Food debris was also observed in the right side of the two compartment sink. Four of thirteen pans on a tray cart was observed to be covered in parchment paper with residual food debris from baking. On the six burner stove top, the front left burner had an uncovered pot that contained a butter-like substance and two cooking utensils. 2. On the rolling cart beside the stove top there was a bag of Grits that was not contained and was gapped open. 3. The flour storage bin contained a white plastic like bowl that was resting on top of the flour. 4. Observations of the walk-in cooler revealed a large pan with two round, foil wrapped meats on a cart in the front of the cooler and a small rectangle pan of cooked chicken legs, covered with plastic wrap on the shelf on the right side of the cooler. Neither was dated with a use by date. 5. In the dish washing area there were two trays that contained wet nested silverware, more that one layer deep with water stains on the silverware. On 12/8/2016 at 9:00 a.m., an interview was conducted with EI (Employee Identifier) #9, Dietary Manager. EI #9 was asked when the kitchen should be cleaned. EI #9 said it was supposed to be cleaned after each meal and before they go home. EI #9 was asked who was responsible for cleaning the kitchen. EI #9 said the evening shift crew. EI #9 was asked if it was an acceptable practice for staff to leave the kitchen with food debris left on surfaces and in a sink, cooked-on parchment paper left in pans, a bowl inside of the flour bin and resting on top of the flour, silverware wet nesting in trays to dry, and meat in the walk in cooler not dated. EI #9 said it was not acceptable. EI #9 was asked what should have been done before the staff left for the night. EI #9 said: 1. The surfaces should have been wiped down and sanitized before they left. 2. The parchment paper should have been disposed of. 3. The bowl should not have been in the flour and should have been taken out. 4. The silverware should have been run (washed) business side down first and then business side up and left to dry. 5. The meat should have been dated before putting it in the fridge. EI #9 was asked why was it important to date items that are covered. EI #9 said they would know the end date, know it was not bad and how long it had been in the fridge. EI #9 was asked why should silverware not be allowed to dry resting on top of one another. EI #9 said it prevents bacteria and allows air flow. EI #9 was asked what should be labeled and dated. EI #9 said anything that has been opened. EI #9 was asked what was the potential harm to the residents when these things are not done. EI #9 said they could get sick. On 12/8/2016 at 10:50 a.m. an interview was conducted with EI #10, Cook. EI #10 was asked what did the facility's policy indicate about when the kitchen should be cleaned. EI #10 said every shift. EI #10 was asked who was responsible for ensuring the kitchen was cleaned on 12/5/2016. EI #10 said she was. EI #10 was asked it was an acceptable practice for staff to leave the kitchen with food debris left on surfaces and in a sink, cooked-on parchment paper left in pans, a bowl inside of the flour bin and resting on top of the flour, silverware wet nesting in trays to dry, and meat in the walk in cooler not dated. EI #10 said no. EI #10 was asked why was it important to date items that are open or covered. EI #10 said would know how long something has been there. EI #10 was asked what should be labeled and dated. EI #10 said anything that was open. EI #10 was asked what was the potential harm to residents when open and covered foods were not dated, food debris remained on surfaces, silverware was wet nested, and a bowl was left inside the flour bin and resting on top of the flour. EI #10 said undated food could cause food poisoning, debris could cause cross contamination and roaches, silverware could be contaminated, and a bowl left inside the flour could cause cross contamination.

Based on observation, record review and interview, the facility failed to ensure refrigerator temperatures for the Long Term Care medication room were consistently obtained and were within 36 and 46 degrees per facility policy as evidenced by monitoring logs not completed and temperatures below 36 degrees. This affected one of two medication rooms located within the facility. Findings Include: A review of a facility policy dated 08/16/2016 and titled MEDICATION STORAGE IN THE FACILITY revealed: .Procedures .K. Medications requiring refrigeration or temperatures between 2 degrees Celsius (36 degrees Fahrenheit) and 8 degrees Celsius (46 degrees Fahrenheit) are kept in a refrigerator with a thermometer to allow temperature monitoring. On 12/8/2016 at 8:30 a.m., the surveyor observed 1 of 2 medication refrigerators. The refrigerator temperature was 32 degrees. A review of the Refrigerator Log, December 2016 revealed that the facility had not recorded temperatures on 2 days (12/6 and 12/7). The log further revealed on 12/2, 12/3, 12/4 and 12/5 the temperatures recorded were all below the 36 degrees. The surveyor observed Aplisol and Pneumovax with recommended temperature ranges of 36 to 46 degrees. On 12/08/2016 at 3:20 p.m., an interview was conducted with Employee Identifier (EI) # 2, Director of Nurses (DON). She was asked why it was important to keep a log of refrigerator temperatures in the medication room and she said to make sure it is not too hot or too cold and stated that these had not been maintained or kept in the recommended range. When asked about the potential negative outcome since the medications were not kept in the recommended range, she stated it could affect what is stored in the refrigerator.

Based on observation, interviews, and record review, the facility failed to ensure signs were posted throughout the facility identifying where the survey results, with the availability of survey results for the past three years, were located. This had the potential to affect all 97 residents in the facility, their family members, and visitors. Findings Include: A review of a facility document titled Resident Handbook with no revision date revealed the following on page 11: . Survey Results .You have the right to examine the results of the most recent standard survey of East(NAME)conducted by federal or state surveyors, and any plan of correction . On 12/5/2016 at 9:00 p.m., the surveyor toured all halls in the facility. There was no availability notice posted on any of the halls to inform residents of the location of the survey results or availability of the past three years of results. The surveyor located the survey results for 3/3/2016 in the left hallway just past the front lobby inside a binder on the wall. On 12/6/2016 at 3:45 p.m., during the resident group meeting, the surveyor asked the 10 residents in attendance if they knew where the survey inspection results were located. The residents voiced that they were unaware of results and did not know where the results were located. On 12/8/2016 at 10:35 a.m., an interview was conducted with EI (Employee Identifier) #8, LBSW (Licensed Bachelor of Social Work). When asked where in the facility it was posted to let residents and visitors know the location of the survey results, EI #8 said, it was only posted in the foyer hallway. When asked where it was posted to let residents and visitors know they can access three years of survey inspection results, EI #8 replied, I don't think it is posted anywhere. When asked why it was not posted, EI #8 said, she did not know it should have been posted. When asked why it was important for residents and visitors to have access to reports of survey inspection results, EI #8 said, it was part of their rights to see the results and see how the facility had done.

Based on observations, interviews and record reviews the facility failed to ensure: 1. staff wore a hair net and hair was completely inside a hair net while working in the kitchen. 2. water was not in plates while plating 3. food items in the freezer were labeled 4. an expired milk and a milk without a date on the carton was not in the refrigerator This had the potential to affect 104 residents who receive meals from the kitchen Findings Include: A review of a facility policy titled, . Policy: Employee Personal Hygiene . with an Effective Date: 7/2014 revealed: .PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses. PROCESS: . 4. Hair and Beard restraints-must be worn while in kitchen production areas. Dietary staff must wear hair restraints ( . hair net, hair bonnet, hat, and/or beard restraint, .) to prevent their hair from contacting exposed food. A review of a facility policy titled, . Policy: Service ware/Silverware, Handling . with an Effective Date: 8/2014 revealed: . PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses. Process: 8. Service ware should be air dried and stored turned upside down, or covered. A review of a facility policy titled, .Policy: Food, Leftover-Storage and Use . with an Effective Date: 7/2015 revealed: . Purpose: To assure that food borne illnesses are avoided. 2. Leftover foods should be covered, labeled and dated. (1) On 3/2/2016 at 11:20 AM, the surveyor observed hair hanging from the dietary manager net. There were hairs hanging out on the net from the side and neck area. The surveyor observed the dietary manager with hair hanging from under her net again at 11:46 AM. At 12:00 PM, the dietician was observed in the kitchen with no hair net on. On 3/3/16 at 1:34 PM, an interview was conducted with EI #3 (Employee Identifier) Dietary Manager. EI #3 was asked what does the facility policy say about wearing a hair net in the kitchen. EI #3 replied, they have to have a hair net on in the kitchen. EI #3 was asked what was the potential harm when hair was not completely inside of the hair net. EI #3 replied hair may fall in the food. On 3/3/2016 at 1:39 PM, an interview was conducted with EI #4. EI #4 was asked what was the importance of wearing a hair net in the kitchen. EI #4 replied, to be sure hair does not get on any food items when working. EI #4 was asked when should hair nets be worn in the kitchen. EI #4 replied, anytime you are in the kitchen. EI #4 was asked what does the facility policy say about wearing hair nets in the kitchen. EI #4 replied, hair net should be worn while in the kitchen. EI #4 was asked did she have a hair net on in the kitchen on 3/2/2016. EI #4 replied she thought she did it must have fallen off. EI #4 was asked what was the potential harm when hair nets are not worn in the kitchen. EI #4 replied when working with food hair can fall into the food. (2) On 3/2/2016 at 12:20 PM, the surveyor observed a worker plating plates. There was water in the plates. After five plates left the kitchen area, the surveyor asked the worker what was in the plate and she stated water. The worker stopped using the plates near her and turned the plates over. She started using plates from the right side of the steam table. At 12:40 the surveyor observed the worker using another plate from the wet stack of plates. On 3/3/2016 at 1:49 PM, an interview was conducted with EI #6. EI #6 was asked did she see water in the plates on 3/2/2016. EI #6 replied, yes. EI #5 was asked why did she turn the plates over. EI #6 replied, to make sure no water was in the plates. EI #6 was asked who was responsible for making sure the plates were dry. EI #6 replied, the staff in dishwashing. EI #6 was asked how should plates be allowed to dry. EI #6 replied, the plates are placed on a rack to air dry. EI #6 was asked what was the facility policy on wetnesting of plates. EI #6 replied, they are suppose to air dry. EI #6 was asked what was the potential harm when plates are stacked on top of each other and water was in the plates. EI #6 replied, do not use them. EI #6 was asked did she observe water in the plates prior to plating. EI #6 replied, no. (3) On 3/1/2016 at 5:45 PM, during initial tour the surveyor and the dietary manager observed in the freezer 12 hush puppies in a Ziploc bag and 14 cornbread in a Ziploc bag with no label on the bags. On 3/3/2016 at 1:30 PM. an interview was conducted with the dietary manager. EI #3 was asked why were there hush puppies and cornbread in the freezer with no label of what it was. EI #3 replied, the cook did not date it when it was put in the freezer. EI #3 was asked why was there no preparation date or use by date on the cornbread and hush puppies. EI #3 replied, the cook did not write it on there. EI #3 was asked who was responsible for labeling items in the freezer. EI # 3 replied everyone that use food out of the kitchen. EI #3 was asked when should food items be labeled. EI #3 replied, before they are placed back in the cooler or freezer. EI #3 was asked why should items in the freezer be labeled. EI #3 replied if there was no use by date it may be out of date. EI #3 was asked what was the potential harm when food items are not labeled with a use by date. EI #3 replied, it there was no use by date it maybe out of date. (4) On 3/1/2016 at 5:45 PM, on initial tour the surveyor observed 1 plain white milk in a crate container with 15 other white milks dated 2/26/2016. There was a trumood chocolate milk in a crate container with 25 other milks with no date on it. On 3/3/2016 at 1:25 PM, interview was conducted with EI #3. EI # 3 was asked why was there an expired milk on 3/1/2016 in the refrigerator. EI #3 replied, it was in the crated and they do not check every milk in the crate. EI #3 was asked why was there no date on one of the milk in the refrigerator. EI #3 replied it came that way from the manufacture. EI #3 was asked what was the importance of removing expired milk from the refrigerator. EI #3 replied, they can not serve expired milk because it was a health hazard. EI #3 was asked who was responsible for removing expired milk from the refrigerator. EI #3 replied, every one in dietary. EI #3 was asked what was the potential harm when a resident received milk that was expired. EI #3 replied, it may make them sick.

Based on interviews, record review and review of a facility policy titled Notification of a Change in Medical Conditions of Residents, the facility failed to notify Resident Identifier (RI) #1's sponsor/family when RI #1 was prescribed a treatment to the right posterior leg; and [MEDICATION NAME] ointment was ordered to be applied to RI #1's buttocks. This affected RI #1, one of five residents sampled for notification. Findings Include: A facility policy titled Notification of a Change in Medical Conditions of Residents, with an effective date of 2/2016, documented: PURPOSE To keep the . family members/legal representatives, responsible for health care decisions, informed of the resident's medical condition so they may direct the plan of care as needed. STANDARD Notification of . legal representative or interested family member, should occur promptly, according to federal regulations, when there is a change in the resident's condition. This would include but is not limited to: . · A need to alter treatment ( . or to commerce to a new form of treatment) . 1. RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's Admission Body Audit, dated 08/28/15, revealed RI #1 did not have any skin issues to the back of the right posterior leg and the buttocks. RI #1's physician's orders [REDACTED]. Clean right posterior leg c (with) wound cleanser pat dry Apply Antibiotic ointment and Dry Dressing. 2) A review of RI #1's Treatment Record, with charting for 09/01/15 through 09/30/15, documented the following: . Apply [MEDICATION NAME] ointment to buttocks daily & (and) PRN (as needed) . On 03/03/16 at 2:23 p.m., the surveyor conducted an interview with a Registered Nurse (RN) supervisor, Employee Identifier (EI) #5. The surveyor asked EI #5, when RI #1 was admitted to the facility did RI #5 have any skin concerns to the back of his right leg. EI #5 said she did not see anything on RI #5's admission body audit. The surveyor asked EI #5 who wrote the order for the treatment to the back of RI #1's leg on 08/31/15. EI #5 said EI #7 did. The surveyor asked EI #5 did writing the order mean RI #1 developed skin concerns to the back of the right leg. EI #5 replied, I would think so. The surveyor asked EI #5, according to RI #1's nurses notes, was the family notified. EI #5 said No Ma'am. The surveyor asked EI #5 should the family have been notified. EI #5 replied, Yes Ma'am. You are to call when there is a change in condition. The surveyor asked EI #5 , when RI #5 was admitted did RI #1 have any skin concerns to the resident's buttocks. EI #5 said she did not see anything (referring to RI #1's body audit). The surveyor asked EI #5, on 09/01/15, why was the order for [MEDICATION NAME] ointment to RI #1's buttocks written. EI #5 said, possible because RI #1 had redness to the buttocks. The surveyor asked EI #5 should the family have been notified of that. EI #5 replied, Yes. The surveyor asked EI #5, according to RI #1's nurses notes, were they. EI #5 replied, no. The surveyor asked EI #5 whose responsibility would it have been to notify the family. EI #5 said the person who wrote the order. On 03/03/16 at 3:41 p.m., the surveyor conducted an interview with EI #7, the Licensed Practical Nurse writing the order for the treatment to the back of RI #1's leg on 08/31/15. The surveyor asked EI #7, on RI #1's admission body audit dated 08/31/15, did RI #1 have any skin concerns to the back of the right leg. EI #9 said no, not at that time. The surveyor asked EI #7, on 08/31/15, why was the order written for a treatment to the back of RI #1's right leg. EI #7 said, probably a scratch or some sort. The surveyor asked EI #7 was the family notified of this. EI #7 said she did not see where she had put in her nurses notes that the family was notified. The surveyor asked EI #7 who would have been responsible for notifying the family. EI #7 said for the notification it should have been her. On 03/03/16 at 4:07 p.m., the surveyor conducted a interview with the sponsor of RI #1. The surveyor asked The sponsor was she ever informed or notified that RI #1 developed skin issues to the back of the right leg and [MEDICATION NAME] ointment was ordered for redness to the resident's buttocks. The sponsor replied, No.

Based on interviews, record review, and review of the facility policy and procedure titled "Pain Management" effective date 11/2010, the facility staff failed to provide Resident Identifier (RI) #1 with pain managment interventions after she complained of pain. RI #1 was admitted to the facility on [DATE] at 07:20 PM, during the 3:00 PM - 11:00 shift after having surgery for [REDACTED]. While the CNA, Employee Identifier (EI) #2, was transporting RI #1 in the wheelchair, RI #1's feet and legs were caught under the wheelchair. The resident's feet were hyper flexed (bending beyond its normal range), causing the toes to drag on the floor. RI #1 stated she complained to pain to EI #2 and EI #2 notified the licensed nurse, EI #1. The licensed nurse, EI #1 assigned to provide care to RI #1, failed to assess RI #1's level of pain at the time of the incident to determine the severity level according to the facility's policy and procedure for pain management; provide non-pharmacologic pain management (measures that do not require the use of medication); and failed to provide prescribed pain medication ([MEDICATION NAME] 5 milligrams) when RI #1 continued to complain of the pain throughout this shift. RI #1 stated it wasn't until the oncoming licensed nurse, EI #3, on the 11:00 PM -07:00 PM shift provided relief of her pain by putting a brace on her leg and providing her with pain medication. This deficient practice affected one of 3 sampled residents, RI #1. Findings Included: RI #1 was admitted to the facility on [DATE] at 06:14 PM, with [DIAGNOSES REDACTED]. A hospital record for RI #1 titled,"Transfer Summary" dated 4/15/2011, documented the following: "Diagnosis: [REDACTED]. History: The patient is a [AGE] year old with chronic left knee pain. She has had a scope. She has had injections. She has had medications. She is no longer relieved with conservative care. She is admitted for left total knee arthroplasty (surgical repair of the joint). Past medical history is otherwise noncontributory. The left knee was painful with crepitus (a grating sound or sensation produced by friction between bone and cartilage) on range of motion ... She was taken to the operating room on 4/12/2001. She had a left total knee arthroplasty... She was fitted for a brace for ambulation because of some hyper-extension of the knee ... She is transferred to a skilled nursing facility on 4/15/2011 with [MEDICATION NAME] 5 for pain and one aspirin a day. She will follow up in the office 4/27/2011 for suture (stitches holding together the surgical incision) removal." Nurses Notes dated 04/15/11 at 7:20 p.m., written by EI #1 documented, "Resident arrived via (by way of) private car accompanied by family member, alert and able to make needs known, required one person assistance to exit vehicle, VS (vital signs) 132/68 (blood pressure), 18 (respirations), 62 (heart rate), 97.1 (temperature). Breathing unlabored & (and) even, alert & oriented, able to make needs known." RI #1's Physician's orders dated 04/15/11, that included Aspirin 325 mg (milligrams) PO (by mouth) daily, [MEDICATION NAME] 5 mg 1 (one) tab (tablet) q4hr (every 4 hours) PRN (as needed) and [MEDICATION NAME] 5 mg 2 (two) tab PO Q4hr PRN. RI #1's care plan for Pain, documented, "(RI #1) has potential for pain... Goal & Target Date Resident will exhibit no unrelieved pain thru (through) next review 7/15/11 Approaches Assess for pain prn. Notify MD of unrelieved pain. Meds (Medications) as ordered. Notify family. Reposition resident using pillows." On 07/11/11, the Division of Health Care Facilities (DHCF) received a complaint that included the following allegation: "The complainant, resident (RI #1), sustained 3 fractured toes to her right foot and a swollen left knee as the result of a wheelchair incident caused by a staff member during a transport on April 15, 2011. The resident reports she was in extreme pain for four days after the incident. She reports the facility failed to provide pain relieving measures during her stay in the facility." On 07/13/11 at 4:49 p.m., the surveyor conducted an interview with EI #1, the LPN (Licensed Practical Nurse) who was assigned to care for RI #1 on 4/15/11, the day RI #1 was admitted to the facility. The surveyor asked EI #1 who transferred RI #1 from the cab to the wheelchair? The surveyor asked EI #1 did anything happen during the transfer from the car to RI #1's room, while RI #1 was in the wheelchair? EI #1 stated, "... I was behind her ... I heard (RI #1) say ouch. Then (EI #2) stopped in the hall. (RI #1) said that hurt her knee. I checked her knee for any signs and symptoms of injury to see if she had staples or stitches that had came open. There was no signs and symptoms of any injury what so ever to her left knee ... she (RI #1) said it hurt and she was in a lot of pain and she wanted me to look at it; her left leg." The surveyor asked EI #1 what are you suppose to do when a resident complain of pain? EI #1 stated, "Do an assessment, rate the pain; It depends on the resident and the reason for the pain." The surveyor asked EI #1 did she assess and rate the pain. EI #1 stated, "No, I did not." The surveyor asked EI #1 the reason for not assessing and rating the pain. EI #1 stated, "I just didn't do it." EI #1 stated, "(RI #1) said her left knee hurt, she had just had got out of the hospital." The surveyor asked EI #1 did she medicate RI #1 for pain on 4/15/11 after RI #1 complained of pain. EI #1 stated, "I would like to say I did, but without documentation, I did not do it." EI #1 was asked if she recalled the number of times RI #1 complained of pain on 04/15/11 on the 3:00 PM - 11:00 PM shift. EI #1 stated, "I don't know." The surveyor asked EI #1 was RI #1's feet dragging the floor/ground when she was transported? EI #1 stated, "No, she had them lifted up and crossed over, the right leg over the left leg." The surveyor asked EI #1 did RI #1 scream when her feet were bent under the wheelchair. EI #1 stated, "Scream, no." The surveyor asked EI #1 what did she hear RI #1 say at the time of the incident? EI #1 stated, "Ouch, my knee. I didn't see her knee under the wheelchair. She (RI #1) pulled it out when I got to her. I was about ten feet behind them (EI #2 and RI #1)..." The surveyor asked EI #1 were both legs (of RI #1) under the wheelchair at the time of the incident? EI #1 stated, "I don't know ...?" A review of EI #1's personnel file revealed she had received training (Continue Education) CE - Pain Assessment and Management on 3/08/11. The facility's policy titled "Pain Management" effective date 11/2010, documented the following: "Purpose: Adequate treatment of [REDACTED]. Standard: Pain assessment presents unique problems in the elderly, as these residents may exhibits physiologic, psychologic and cultural changes associated with aging. Many health care providers and residents alike mistakenly consider pain to be normal part of aging. Process: 1. Pain Assessment a) The resident pain should be assessed using a standardize scale. b) If able, have the resident show you the location and radius of the pain. c) If able, ask the resident if anything makes the pain better or worse d) Pain assessment may be such as restless, agitation, groaning or holding of an area. 2. Pain management may consist of tiered levels a) Nonpharmacologic management may include: ... Immobilization of a body part ... c) Opioid [MEDICATION NAME], with or without an NSAID (Nonsteroidal Anti- [MEDICAL CONDITION] Drug) d) If the resident's pain is not controlled by the current treatment regime, the physician should be notified 3. Documentation a) The resident's response to pain medication should be documented in the medical record." On 7/13/11 at 6:25 p.m., the surveyor conducted an interview with EI #2, a CNA assigned to care for RI #1 on 4/15/11, on the 3:00 PM - 11:00 PM shift. The surveyor asked EI #2 when she transferred RI #1 from the front of the facility to her room by way a wheelchair did anything happen to her? EI #2 said, when she got (RI #1) out of the cab, (RI #1) said she wanted her pain pill. EI #2 said she put (RI #1) in her wheelchair. RI #2 stated RI #1 kept saying she was hurting, she wanted a pain pill, and wanted to see the nurse. The surveyor asked EI #2 did the wheelchair have footrest. EI #2 stated, "No, it did not. When she (RI #1) got in the wheelchair. I told her to cross her legs. She put the right leg over the left leg and she lifted her legs. I pulled her (RI #1) backward from the front of the entrance pass the nursing station and her legs were still crossed. (RI #1) asked for the nurse. She wanted her medicine for pain. She (RI #1) had a bag of medicine with her. I don't know what kind it was." The surveyor asked EI #2 did RI #1 say what level her pain was on the plain scale of 1-10? EI #2 stated, "No, she (RI #1) just said her left knee hurt and she just had surgery." The surveyor asked EI #2 when did the resident (RI #1's) feet fall or drop to the floor? EI #2 stated, "When we got half way to her room, I turned the chair (wheelchair) around and started pushing her (RI #1) forward. Her feet came down, her left foot got caught under the wheelchair, then I stop pushing the wheelchair." The surveyor asked EI #2 what did the resident say when her foot got caught under the wheelchair. EI #2 stated, "She didn't say anything. But she yelled out like she was in pain. One of the patients (RI #4) came out of her room and said who is that screaming / hollering? I told (RI #4) everything was all right and (RI #1) told (RI #4) 'I am all right.' When we got to her (RI #1's) room ... (RI #1) stood up with assistance of me. I told her (RI #1) she did good. (RI #1) said, 'yea I can do it when I want to.' Then (RI #1) told me she had surgery on her left leg. Also, I saw that she (RI #1) had a brown shopping bag full of medicine of pills in the bottles. She (RI #1) was holding the bag of medicine, this was about 7:15 p.m. when I got her (RI #1) in the room, ... I was trying to get her (RI #1) settled." The surveyor asked EI #2 did RI #1 take any of the medicine for pain. EI #2 stated, "No, because I gave the bag of medicine to the nurse (EI #1, the LPN). (RI #1) kept saying she wanted her pain medicine. I went back to her room about five times that evening... I told (EI #1, the LPN) about four times (RI #1) wanted her pain medicine. (EI #1, the LPN) went in (RI #1's) room each time trying to explain to (RI #1) that she didn't have her pain medicine. (EI #1) did tell her (RI #1) she had ordered the medication ..." The surveyor asked EI #2 did (RI #1) yell out 'you are killing me' when her feet got caught under the wheelchair? EI #2 stated, "No, she (RI #1) just yelled out loud. She (RI #1) said she was in pain. She was in pain from the taxi to the room. She (RI #1) complained of her left knee hurting and she wanted something for pain." The surveyor asked EI #2 did (RI #1) complain of pain in her right great toe (big toe)? EI #2 replied, "She (RI #1) said she hurt all over. She (RI #1) complain of pain until the end of the shift." On 7/14/11 at 1:50 p.m., the surveyor conducted a telephone interview with RI #1. The surveyor asked RI #1 if the nurse on the duty on 04/15/11, during the 3:00 PM -11:00 PM shift, did the nurse (EI #1) give her anything for pain? RI #1 stated, "No, she (EI #1) did not give her any medicine on her shift ..." The surveyor asked RI #1 what time did she receive something for pain on 4/15/11. RI #1 said she did not get anything for pain. RI #1 said she got some other medicines from EI #1. RI #1 said she hurt the rest of the shift, until the EI #3; the nurse from the other shift came on duty. RI #1 said EI #3 gave her something and she does not remember what it was. RI #1 said (EI #3) put her brace on and that help ease the pain, positioning. The surveyor asked RI #1 which knee did she have a total knee replacement? RI #1 said the left knee. The surveyor asked RI #1 did she cross her right leg over the left leg while she was being transported in the wheelchair by EI #2. RI #1 said yes, because that is what EI #2 told her to do. RI #1 further commented (EI #1) did not do an assessment on her or give her pain medicine, she had to hurt. The surveyor asked RI #1 did she have pain in her right great toe (big toe) when her feet got caught under the wheelchair on 4/15/11. RI #1 said she hurt real badly all over her knees, legs and feet. RI #1 said she told EI #1 she was hurt and needed pain medication and that EI #1 never gave her any pain medication on her shift (3-11). RI #1 stated "the pain was very strong, very bad." EI # 3, the 11:00 PM - 7:00 AM shift licensed nurse, was interviewed on 07/14/11 at 4:00 PM. The surveyor asked if RI #1 complained of pain at the begining of his shift. EI #3 stated "She complained of pain at the beginning of the shift. I thought I gave her something for pain. I believe it was Tylenol. I apparently did not document it on her chart." The surveyor asked if EI #3 assessed RI #1's knees and legs for injuries or swelling. EI #3 stated, "I didn't assess her. I did go in her room when she complained of pain. I put her brace on her left leg. She told me that helped ease the pain. I do remember charting that in her nursing notes. She didn't complain of pain the rest of the shift." EI #3 documented in the nursing note on 04/16/11 at 1:00 AM, "Resident resting quietly in bed, alert, speech clear able to make needs known. Resident has dsg (dressing) to L (left) knee, and brace placed on knee per (by) nurse." On 7/15/11 at 9:30 a.m., the surveyor conducted an interview with the Director of Nursing (DON), EI #7. The surveyor asked the DON where can the licensed nurses go in the facility to obtained common used narcotics such as [MEDICATION NAME]. The DON stated, "From our EDK (Emergency Drug Kit) Box, it's on (name of the nursing station) under double lock and key." The surveyor asked the DON was the EDK Box available to (EI #1) on 4/15/11, to get [MEDICATION NAME]? EI #7 replied, "Yes." On 7/15/11 at 12:00 noon, the surveyor conducted an interview with the facility's Medical Director, EI #9. The surveyor asked the Medical Director if he ordered a PRN narcotic such as [MEDICATION NAME] and it had not been sent to the facility by the pharmacy, where could the licensed nurses go to get the [MEDICATION NAME] in the facility. The Medical Director said the facility has a stat box with narcotic to tie people over so they won't hurt over the weekend. RI #1's "CONTROLLED DRUG RECORD" for [MEDICATION NAME]-APAP 5-500, [MEDICATION NAME] 5/500 tablet, has documented a facility nurse recieved 30 tablets on 4/16/11. The record has documented that RI #1 recieved the first [MEDICATION NAME] on 4/16 at 9:00 AM. NN dated 4/16/11 at 10 a.m. documented, "Resident reports her L leg where she had a total L knee on 4/12/11, was pulled under the wheelchair as she was transported the previous evening. She reports there is swelling and redness to the knee that was not evident prior to this event. Nurse did note swelling and redness upon examination of the extremity. Resident reports knee becoming very painful. Dr. (name) notified and orders received to send resident to (name of hospital) ER (emergency room ) to have knee x-rayed and evaluated. Family notified." RI #1's X-Rays from Orthopedic Surgeon dated 4/18/11, revealed the following: "Fracture right great toe. status [REDACTED]. The right toe is tender swollen closed. The left knee as 0-90 (degrees) range of motion, the incision the calf is soft. Xray's left knee AP (Antero-Posterior) lateral and sunrise are good. Her right foot AP lateral oblique, show fractured at the joint the great toe. We buddy taped 1 2 and 3 and he exercises 4 the knee and keep her regular appointment." This deficiency was written as a result of the investigation of complaint #AL 688

Based on observations, interviews, record review, and review of the facility's policy titled "Event Reports/Incident Reports", the facility failed to provide Resident Identifier (RI) #1 with a wheelchair that had footrests to maintained her legs and feet in a safe position during transport. On 04/15/11, RI #1 was pushed in a wheelchair from the front entrance of the facility to her assigned room by Employee Identifier (EI) #2. RI #1 was being admitted to the facility due to having a total knee replacement to her left leg on 04/12/11. EI #2, a Certified Nursing Assistant (CNA) instructed RI #1 to place her right leg on top of her left leg, for support during the transport, due to the wheelchair not having the footrest. RI #1's feet and legs were caught under the wheelchair causing RI #1's feet to be hyper flexed (bending beyond its normal range), resulting in her toes dragging on the floor. According to x-rays on 04/18/11, RI #1 sustained a fracture to her right great toe as a result. This deficient practice affected one of three sampled residents. Findings included: The facility's policy titled: "Event Reports/Incident Reports" Guidelines For Investigation of Incidents and Completion of Reports rev (revised) 07/01/2009." Documented the following; " The following steps should be taken when an accident or incident occurs. It is understood that the severity of the situation will dictate staff ' s response, and that the nurse assessing the resident will need to exercise judgment when determining the order in which the items are to be completed. Procedure ? Assess resident and provide treatment and/or take appropriate steps to address the needs of the resident. Assessment is to be completed by licensed personnel... ? Transport resident to hospital if indicated. ? Assess the environment in which the accident occurred, i.e., is the wheelchair behind resident, is there urine or other liquid on the floor, etc. Observe the clothing and shoes that the resident was wearing at the time of the incident... ? Determine what interventions need to be implemented... ... Determine if the incident was witnessed. Can the resident tell you what happened? Did the roommate observe the event? Identify staff that was, or may have been in the area of the accident/incident and obtain statements. ? Initiate paperwork, i.e., complete the occurrence report, note event on 24 hour report, obtain witness/resident statements, talk to resident's roommate if applicable or individuals in the immediate vicinity; document facts of situation and description of the injury in medical record; note any new orders received, etc. ? Conduct follow up on resident as indicated, i.e., 24, 48, 72 hours. Continue to assess and evaluate patient's condition. Note if there are significant changes, and communicate changes to the physician and the family, and document same in the medical record... ? Evaluate resident as to the appropriateness of level of care. Update care plan to reflect new interventions, and communicate new approaches to staff, including CNAs. If new equipment or supplies need to be ordered, communicate such at morning stand-up meeting. Assign responsibility for follow-up. The Charge Nurse is responsible for ensuring that interventions are implemented." RI #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #1's care plan for "Falls" included the following: "Approaches" documented "...Provided assistance devices as needed." Nurses Notes dated 4/15/11 at 7:20 p.m., documented, "Resident arrived via (by way of) private car accompanied by family member, alert and able to make needs known, required one person assistance to exit vehicle, VS (vital signs) 132/68 (blood pressure), 18 (respirations), 62 (heart rate), (temperature) 97.1 (degrees Fahrenheit). Breathing unlabored & (and) even, alert & oriented, able to make needs known." Nursing Notes dated 4/16/11 at 10 a.m. documented, "Resident reports her L leg where she had a total L knee on 4/12/11, was pulled under the wheelchair as she was transported the previous evening. She reports there is swelling and redness to the knee that was not evident prior to this event. Nurse did note swelling and redness upon examination of the extremity. Resident reports knee becoming very painful. Dr.(name) notified and orders received to send resident to (name of hospital) ER (emergency room ) to have knee x-rayed and evaluated. Family notified." Nursing notes dated 04/16/11 at 10:00 AM documented, "Resident reports her L (left) leg where she had a total knee on 4/12/11, was pulled under the wheelchair as she was transported the previous evening. She reports there is swelling and redness to the knee that was not evident prior to this event. Nurse did note swelling and redness upon examination of the extremity. Resident reports knee becoming very painful. Dr. (name) notified and orders received to send resident to (name of hospital) ER (emergency room ) to have knee x-rayed and evaluated. Family notified." Nursing notes dated 04/16/11 (no time) documented, "Resident readmitted back to facility. Resident received PRN Lortab. Incision was assessed. X-ray showed not damage to L knee. Physician recommend resume previous orders." Nursing notes dated 04/17/11 at 11:00 AM documented, "Resident alert and verbally responsive ... Resident went to occupational therapy (OT). Dressing intact to left knee ... PRN pain meds given. Meds (medications) and meals well tolerated. No S&S (signs and symptoms) of infection noted. No distress noted. Will continue to monitor." Nursing notes dated 04/17/11 at 9:30 PM documented, "Resident say her left leg hurts and that is more swollen & hotter than it was yesterday ... Contact Dr. (Medical Director name) & he said for her to see the doctor who did her knee surgery or one of the doctors in his group ..." RI #1's X-Rays from Orthopedic Surgeon dated 4/18/11, revealed the following: "Fracture right great toe. status [REDACTED]. The right toe is tender swollen closed. The left knee as 0-90 (degrees) range of motion, the incision the calf is soft. Xray's left knee AP lateral and sunrise are good. Her right foot AP lateral oblique, show fractured at the joint the great toe. We buddy taped 1 2 and 3 and he exercises 4 the knee and keep her regular appointment." On 7/7/11, the Division of Health Care Facilities (DHCF) received a complaint that included the following allegation: " ... resident, (RI #1) she was admitted to the facility on [DATE], post surgery for [REDACTED]. She had to drag her feet because of no footrest. During the transport her legs caught under the wheelchair with two popping sounds heard. Her legs were under the wheelchair for 10 to 15 seconds at which time the resident was in extreme pain, hollering "you are killing me," and crying ... reports she had pain in both knees and feet at the time and following the incident. As a result of the incident the resident reports her left leg swelled and she sustained 3 fractured toes on her right foot. The resident is alleging the facility failed to provide safety measures to prevent injury during transport in the wheelchair." On 7/14/11 at 1:50 p.m., the surveyor conducted a telephone interview with RI #1. The surveyor asked RI #1 if the nurse on the duty on 04/15/11, during the 3:00 PM -11:00 PM shift, did the nurse (EI #1) give her anything for pain? RI #1 stated, "No, she (EI #1) did not give her any medicine on her shift ..." The surveyor asked RI #1 what time did she receive something for pain on 4/15/11. RI #1 said she did not get anything for pain. RI #1 said she got some other medicines from EI #1. RI #1 said she hurt the rest of the shift, until the EI #3; the nurse from the other shift came on duty. RI #1 said EI #3 gave her something and she does not remember what it was. RI #1 said (EI #3) put her brace on and that help ease the pain, positioning. The surveyor asked RI #1 which knee did she have a total knee replacement? RI #1 said the left knee. The surveyor asked RI #1 did she cross her right leg over the left leg while she was being transported in the wheelchair by EI #2. RI #1 said yes, because that is what EI #2 told her to do. RI #1 further commented (EI #1) did not do an assessment on her or give her pain medicine, she had to hurt. The surveyor asked RI #1 did she have pain in her right great toe (big toe) when her feet got caught under the wheelchair on 4/15/11. RI #1 said she hurt real badly all over her knees, legs and feet. RI #1 said she told EI #1 she was hurt and needed pain medication and that EI #1 never gave her any pain medication on her shift (3-11). RI #1 stated "the pain was very strong, very bad." On 07/13/11 at 4:49 p.m., the surveyor conducted an interview with EI #1, the LPN (Licensed Practical Nurse) who was assigned to care for RI #1 on 4/15/11, the day RI #1 was admitted to the facility. The surveyor asked EI #1 who transferred RI #1 from the cab to the wheelchair? The surveyor asked EI #1 did anything happen during the transfer from the car to RI #1's room, while RI #1 was in the wheelchair? EI #1 stated, "... I was behind her ... I heard (RI #1) say ouch. Then (EI #2) stopped in the hall. (RI #1) said that hurt her knee. I checked her knee for any signs and symptoms of injury to see if she had staples or stitches that had came open. There was no signs and symptoms of any injury what so ever to her left knee ... she (RI #1) said it hurt and she was in a lot of pain and she wanted me to look at it; her left leg." The surveyor asked EI #1 what are you suppose to do when a resident complain of pain? EI #1 stated, "Do an assessment, rate the pain; It depends on the resident and the reason for the pain." The surveyor asked EI #1 did she assess and rate the pain. EI #1 stated, "No, I did not." The surveyor asked EI #1 the reason for not assessing and rating the pain. EI #1 stated, "I just didn't do it." EI #1 stated, "(RI #1) said her left knee hurt, she had just had got out of the hospital." The surveyor asked EI #1 did she medicate RI #1 for pain on 4/15/11 after RI #1 complained of pain. EI #1 stated, "I would like to say I did, but without documentation, I did not do it." EI #1 was asked if she recalled the number of times RI #1 complained of pain on 04/15/11 on the 3:00 PM - 11:00 PM shift. EI #1 stated, "I don't know." The surveyor asked EI #1 was RI #1's feet dragging the floor/ground when she was transported? EI #1 stated, "No, she had them lifted up and crossed over, the right leg over the left leg." The surveyor asked EI #1 did RI #1 scream when her feet were bent under the wheelchair. EI #1 stated, "Scream, no." The surveyor asked EI #1 what did she hear RI #1 say at the time of the incident? EI #1 stated, "Ouch, my knee. I didn't see her knee under the wheelchair. She (RI #1) pulled it out when I got to her. I was about ten feet behind them (EI #2 and RI #1)..." The surveyor asked EI #1 were both legs (of RI #1) under the wheelchair at the time of the incident? EI #1 stated, "I don't know ...?" On 7/13/11 at 6:25 p.m., the surveyor conducted an interview with EI #2, a CNA assigned to care for RI #1 on 4/15/11, on the 3:00 PM - 11:00 PM shift. The surveyor asked EI #2 when she transferred RI #1 from the front of the facility to her room by way a wheelchair did anything happen to her? EI #2 said, when she got (RI #1) out of the cab, (RI #1) said she wanted her pain pill. EI #2 said she put (RI #1) in her wheelchair. RI #2 stated RI #1 kept saying she was hurting, she wanted a pain pill, and wanted to see the nurse. The surveyor asked EI #2 did the wheelchair have footrest. EI #2 stated, "No, it did not. When she (RI #1) got in the wheelchair. I told her to cross her legs. She put the right leg over the left leg and she lifted her legs. I pulled her (RI #1) backward from the front of the entrance pass the nursing station and her legs were still crossed. (RI #1) asked for the nurse. She wanted her medicine for pain. She (RI #1) had a bag of medicine with her. I don't know what kind it was." The surveyor asked EI #2 did RI #1 say what level her pain was on the plain scale of 1-10? EI #2 stated, "No, she (RI #1) just said her left knee hurt and she just had surgery." The surveyor asked EI #2 when did the resident (RI #1's) feet fall or drop to the floor? EI #2 stated, "When we got half way to her room, I turned the chair (wheelchair) around and started pushing her (RI #1) forward. Her feet came down, her left foot got caught under the wheelchair, then I stop pushing the wheelchair." The surveyor asked EI #2 what did the resident say when her foot got caught under the wheelchair. EI #2 stated, "She didn't say anything. But she yelled out like she was in pain. One of the patients (RI #4) came out of her room and said who is that screaming / hollering? I told (RI #4) everything was all right and (RI #1) told (RI #4) 'I am all right.' When we got to her (RI #1's) room ... (RI #1) stood up with assistance of me. I told her (RI #1) she did good. (RI #1) said, 'yea I can do it when I want to.' Then (RI #1) told me she had surgery on her left leg. Also, I saw that she (RI #1) had a brown shopping bag full of medicine of pills in the bottles. She (RI #1) was holding the bag of medicine, this was about 7:15 p.m. when I got her (RI #1) in the room, ... I was trying to get her (RI #1) settled." The surveyor asked EI #2 did RI #1 take any of the medicine for pain. EI #2 stated, "No, because I gave the bag of medicine to the nurse (EI #1, the LPN). (RI #1) kept saying she wanted her pain medicine. I went back to her room about five times that evening... I told (EI #1, the LPN) about four times (RI #1) wanted her pain medicine. (EI #1, the LPN) went in (RI #1's) room each time trying to explain to (RI #1) that she didn't have her pain medicine. (EI #1) did tell her (RI #1) she had ordered the medication ..." The surveyor asked EI #2 did (RI #1) yell out 'you are killing me' when her feet got caught under the wheelchair? EI #2 stated, "No, she (RI #1) just yelled out loud. She (RI #1) said she was in pain. She was in pain from the taxi to the room. She (RI #1) complained of her left knee hurting and she wanted something for pain." The surveyor asked EI #2 did (RI #1) complain of pain in her right great toe (big toe)? EI #2 replied, "She (RI #1) said she hurt all over. She (RI #1) complain of pain until the end of the shift." On 07/13/11 at 12:36 p.m., during the initial tour of the facility the surveyor observed a storage area that had 6 wheelchairs. Four of the six wheelchair did not have foot rests. These wheelchairs were stored near room 8 and room 9. On the opposite side of the hallway three of five wheelchairs were stored without foot rests near room 20 and room 21. The surveyor returned on 07/14/11 at 8:05 a.m., with the EI #10, the Administrator, EI #7, the DON and EI #11, the Cooperate Nurse and showed them the wheelchairs that needed foot rests. On 07/15/11 at 9:30 a.m., the surveyor conducted an interview with EI #7, the Director of Nursing. EI #7 was asked if EI #2 transported RI #1 correctly when the resident was transported on 04/15/11. The stated, EI #7 stated, "Yes and no". She (EI #2) said she turned the resident around and transported her backward because she didn't have the footrests . She didn't want to take a chance of injuring the resident." The surveyor asked EI #7 if the incident/accident that happened to RI #1 could have been prevented. EI #7 stated, "Yes, it could have been prevented if she (EI #2) had footrests on the wheelchair." On 07/14/11 at 2:15 p.m. a phone interview was conducted with the EI #8, the Orthopedic Surgeon who treated RI #1. The surveyor asked the surgeon did RI #1 receive a fracture as a result of her foot being caught under her wheelchair on 4/15/11. EI #8 stated RI #1 relayed to him that her foot got caught under the wheelchair. EI #8 stated this caused the foot to be hyperextended. EI #8 stated the resident explained this incident occurred at the facility when she was admitted on [DATE]. EI #8 stated X-rays were done that revealed a fracture of the big toe. On 07/15/11 at 10:00 a.m., the surveyor conducted an interview two staff member from the Therapy Department. The surveyor asked EI #5, the Occupational Therapist (OT) and EI #6, the Licensed Physical Therapist Assistant how the incident that occurred with RI #1 on 04/15/11 could have been prevented. The OT stated, "First of all don't pull her backward if there is no leg rest available. She (EI #2) should have instructed the resident to crossed or place the affected leg over the non-affected leg for better support." A review of EI #1's personnel file revealed she had received training CE (Continue Education) - Accident Prevention and Managment 05/3/2011. This deficiency was written as a result of the investigation of complaint #AL 688