Every finding on record at Elite Nursing and Rehabilitation Care Center

Based on interviews, resident record review, review of the facility investigative file, review of a Facility Reported Incident (FRI), and review of a facility policy titled Abuse, Neglect and Exploitation, the facility failed to conduct a thorough investigation of an allegation of physical abuse on 09/13/2024 to include determining the time the alleged incident occurred. This citation resulted from the investigation of complaint/report number AL00048805 and had the potential to affect Resident Identifier (RI) #1, one of six residents sampled for abuse. Findings include: A facility policy titled Abuse, Neglect and Exploitation, reviewed 01/2024, documented: . Definitions: Abuse means the willful infliction of injury . Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. V. Investigation of Alleged Abuse, Neglect and Exploitation . 6. Providing complete and thorough documentation of the investigation. RI #1 was readmitted to the facility on [DATE] and had diagnoses to include Dementia. RI #1's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 07/11/2024 noted a Brief Interview for Mental Status (BIMS) score of three of 15 which indicated severe cognitive impairment. On 09/13/2024 at 3:10 PM the State Agency received an Online Incident Report from the facility alleging physical abuse occurred on 09/13/2024 at 1:15 PM when Floor Technician (FT) #7 observed Certified Nursing Assistant (CNA) #8 push RI #1 in the back of the head. On 10/02/2024 at 9:50 AM, FT #7 said the incident on 09/13/2024 occurred in the hallway outside of the shower. FT #7 said, he must have misunderstood what he saw when CNA #8 had a towel drying RI #1's hair. FT #7 did not remember what time the incident occurred or what time he reported the incident. The facility's investigative file was reviewed, and a report titled Investigation Summary dated 09/16/2024 for RI #1 documented: . On 9-13-24 it was reported . by . (FT #7) that (CNA #8) was observed pushing . (RI #1) on the back of (his/her) head. Upon interviewing (CNA #8) informed that she and another CNA were assisting (RI #1) with a shower . (CNA #8) denied pushing the resident in the back of (his/her) head, stating that she only dried residents' hair with a towel. Resident stated, they was messing with me, when asked how resident stated, they washed my hair. yea its ok. The Investigation Summary did not indicate what time the incident occurred and did not include documentation of efforts made to determine when the incident occurred. FT #7's witness statement included in the facility's investigative file was reviewed and it did not include documentation of when the alleged incident occurred. CNA #8's witness statement included in the facility's investigative file was reviewed and it did not include documentation of when the alleged incident occurred or when the statement was written. Further review of the facility investigative file revealed no documented evidence of efforts made by the facility to confirm when the abuse allegedly occurred. On 10/02/2024 at 11:11 AM CNA #8 was interviewed and reported she and CNA #9 showered RI #1 around 6:30 AM the morning of 09/13/2024 and RI #1 became upset during hair washing while in the shower. CNA #8 said, she tried to calm RI #1 and said she would get RI #1's coffee. On 10/02/2024 at 11:47 AM CNA #9 was asked about the incident on 09/13/2024. CNA #9 said, she assisted CNA #8 with RI #1's shower the morning of 09/13/2024 around 6:30 AM when RI #1 became upset and requested to go back to bed before breakfast. On 10/02/2024 at 2:02 PM Human Resources Director (HRD) #5 was interviewed and said he/she was notified around 12:45 or 1:00 PM on 09/13/2024 by FT #7 of the allegation of abuse. On 10/02/2024 at 3:45 PM the Director of Nursing (DON) was asked about the incident involving RI #1. The DON said she was notified of the alleged abuse allegation on 09/13/2024 around 1:00 PM. When asked what the process was for investigating an abuse allegation, the DON said, to protect the resident and start the investigation process of obtaining witness interviews and statements. The DON said, witness statements would include names, dates, and times. When asked what time the alleged incident occurred, the DON said she assumed right then when they were notified which was around 1:00 PM. The DON said, she was not aware of a time discrepancy of when the incident occurred. When asked why she was not aware, she said she just assumed it happened at that time it was reported. CNA #8 and CNA #9's facility witness statements were reviewed with the DON and she said, CNA #8's statement did not have a date or time documented, and CNA #9's statement did not have a time documented that the incident occurred. The DON said, the importance of obtaining times and verifying when an incident occurred would be for resident protection and for the integrity of the investigation. When the DON was asked if the facility completed a thorough investigation of the allegation, she said no.

Based on record reviews, interview, facility's policies titled Notification of Changes, and Information and Communication the facility failed to ensure residents' families were notified when the facility was unable to maintain the first floor's residents' right to a safe and homelike environment when the facility's air conditioning system failed to maintain temperatures less than 81 F (degrees Fahrenheit) in the residents' common areas and residents' rooms on the first floor. Due to the elevated temperatures, the facility initiated an enhanced hydration round program. The facility did not notify residents' families or representatives of the elevated temperatures or the enhanced hydration round program. This deficient practice had the potential to affect all 98 residents residing on the first floor of the facility. This deficient practice was cited as a result of the investigation of complaint/report numbers AL00048537 and AL00048538. Findings Include: Cross-Reference F 584. The facility's policy titled Information and Communication with a revised date of 12/23 revealed: Policy: The purpose of this policy is to assure that all residents are informed of their rights . during their stay at the facility. Residents will receive notices orally and in writing in a format and language they understand. Compliance Guidelines: . 5. The facility will notify the resident and/or family of any changes/violation of rights. 6. The facility will require the resident and/or resident representative to acknowledge receipt of information by signing. The facility's policy titled, Notification of Changes with a revised date of 12/23 revealed: Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: . 3. Circumstances that require a need to alter treatment. On 08/12/2024 at 6:34 PM, an interview was conducted with the Administrator (ADM). When asked what issues the facility had experienced with the long-term care residents in the facility. The ADM stated abnormal temperature ranges secondary to the chiller only functioning at 60% (percent) of its' capacity. The ADM said the abnormal temperatures affected the first floor of the facility. The ADM said the problems with the chiller began on August 1, 2024 and the Medical Director was notified on August 2, 2024. The ADM said the facility began an enhanced hydration round program that included stationary hydration carts on each hall which included popsicles, ice creams, watermelon slices, and strawberries. The ADM said the hydration carts were also taken room to room to provide residents with additional hydration. The ADM said the facility in-serviced the staff on 08/02/2024 regarding keeping their residents hydrated due to the heatwave and the air conditioning system being repaired. The ADM said all of the residents' families were not notified, but she should have sent out written communication to each of them. The ADM was asked what was the concern with the families not being notified of the facility's concern regarding elevated ambient temperatures, and she said that they would not be aware of the temperatures being increased and the changes to their homelike environment. The ADM said 98 residents resided on the first floor and could have been affected by the chiller not performing efficiently.

Based on observations, interviews, record reviews, and the facility policy titled, Safe and Homelike Environment, the facility failed to maintain safe and comfortable temperatures in residents' common areas and residents' rooms on the first floor. The facility failed to ensure temperatures in residents' common areas and residents' rooms were not above 81 degrees from 08/09/2024 through 08/13/2024. The temperatures on the first floor were recorded above 81 F (degrees Fahrenheit) during all five days of the survey. This deficient practice had the potential to affect all 98 residents residing on the first floor of the facility. The deficiency was cited as a result of the investigation of complaint/report number AL00047537 and AL00047538. Findings Include: On 08/07/2024, the State Survey Agency received an anonymous complaint alleging the facility had no air conditioning. On 08/08/2024, the State Survey Agency received a complaint alleging the facility had no air conditioning for four days, and it was 83 F in the complainant's family member's room. A review of a facility policy titled, Safe and Homelike Environment with a revised date of 12/23, revealed: .'Comfortable and safe temperature levels' means that the ambient temperature should be in a relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia/hyperthermia and is comfortable for the residents. Policy Explanation and Compliance Guidelines: . 7. The facility will maintain comfortable and safe temperature levels. a. The facility should strive to keep the temperature in common resident areas between 71 and 81 degrees Fahrenheit. On 08/09/2024, the Lead Maintenance Tech (LMT), measured the temperatures on the first floor of the facility with the highest ambient temperature recorded as 84 F in an unoccupied dining room at 10:33 AM. On 08/09/2024 at 10:39 AM the LMT measured the temperature in Resident Identifier (RI) #1's room. The temperature in RI #1's room was 81.3 F. RI #1 denied concerns with the temperature in his/her room. On 08/09/2024 at 10:48 AM, an interview was conducted with the LMT. The LMT stated that the problems with the air conditioning system had been going on for about a week. The LMT said the highest ambient temperature that he obtained during temperature rounds earlier that morning was 84 F. The LMT stated that the facility was not in compliance since the temperature was higher than 81 F. The LMT said that the residents could get too hot and get sick when temperatures were increased. On 08/10/2024 at 9:17 AM three residents were observed in the first floor hallway. The LMT measured the temperature in the hallway and said the temperature was 84 F. On 08/10/2024 at 11:49 AM the temperature in RI #5's room was 83.6 F. RI #5 denied concerns with the temperature. On 08/10/2024 at 11:53 AM five residents were observed in the hallway of the men's secured unit. The LMT measured the temperature and said it was 83.8 F in the hallway. The highest ambient temperature measured by the LMT on 08/10/2024 was 85 F. On 08/10/2024 at 12:08 PM, an interview was conducted with the Maintenance Tech (MT). The MT said that he checked room temperatures in the morning and after lunch usually, and that the temperatures had been up to 85 F or 86 F at the highest so far on the first floor. On 08/11/2024 at 12:58 PM, RI #11 and RI #12's room temperature was measured by the LMT and noted to be 86 F. Both residents denied concerns with the room's temperature. The highest ambient temperature measured by the LMT on 08/11/2024 was 86.7 F. On 08/12/2024 at 2:01 PM RI #17 was observed in his/her room and he/she denied concerns with the temperature in the room. The LMT measured his/her room's temperature and said it was 87.6 F. The highest ambient temperature measured by the LMT on 08/12/2024 was 88.9 F. On 08/13/2024, RI #18 was observed in his/her room and denied concerns with the temperature. RI #18 said he/she felt ok with the fan blowing on him/her. The LMT measured the temperature in RI #18's room and said the temperature was 87.7 F. The highest ambient temperature measured by the LMT on 08/13/2024 was 90.3 F. On 08/13/2024 at 5:47 PM, a telephone interview was conducted with the Regional Maintenance Director (RMD). The RMD said the ambient temperature should ideally be 71 F to 81 F per regulation and said the temperatures on the first floor of the facility were not within that regulation. The RMD said the temperatures were higher than 81 F. An interview was conducted with the Administrator (ADM) on 08/12/2024 at 6:34 PM. The ADM said that she had been dealing with abnormal temperature ranges secondary to the chiller only functioning at 60 percent of its' capacity. She stated that the issue began on the morning of 08/01/2024. She further stated that the HVAC company checked the chiller (Air Conditioning Unit), gauged it, and said that it was only functioning at 60 percent. She said from there they developed a plan to replace and update the system. The ADM said the facility rented the larger portable heat pump/air conditioner/dehumidifiers, purchased several portable air conditioners, and began utilizing the fan-controlled air purifying units. The ADM said that ambient temperatures should be 71 F to 81 F in residents' rooms and care areas, but said that the temperatures were 78 F to 88 F and up to 90 F. The ADM said 98 residents resided on the first floor and could have been affected by the chiller not performing efficiently. The ADM said that the concern with the temperatures being above 81 F was a homelike environment was not provided and potential for dehydration or overall decline in residents' health.

Based on observations, interviews, and a review of the United States (U.S.) Food and Drug Administration (FDA) 2022 Food Code, the facility failed to ensure 1) Two ovens in the kitchen had exposed electrical wiring and were in working condition 2) The walk-in freezer was free from excessive ice buildup on two fans, the floor, ceiling, and boxes containing food products. This was observed on the initial tour of the kitchen on 03/26/2024. This had the potential to affect 129 of 130 residents receiving meals from the facility kitchen. Findings Include: The 2022 U.S. Food and Drug Administration documents the following: . Maintenance and Operation 4-501.11 Good Repair and Proper Adjustment A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements . On 03/26/2024 at 2:31 PM during the initial kitchen tour, two ovens were observed with exposed wiring at the base of both ovens. The Dietary Manager (DM) was interviewed and asked why the ovens had exposed wiring. The DM stated that the ovens were not working. When asked how long the ovens had not been working, she said that the ovens went out several times last year. The DM stated they had been completely out since around December 2023 or January 2024. On 03/26/2024 at 2:41 PM during the initial kitchen tour, the walk-in freezer was observed with excessive ice buildup on two fans, the floor, ceiling, and boxes containing food products. When asked how long the heavy ice buildup had been there, she said since January. When asked if this had been reported, she said yes both the oven and freezer had been reported to corporate office. She further stated a repair company was at the facility in February to work on the freezer. On 03/27/2024 at 8:41 AM a review of local repair company documentation with a work order date of 02/02/2024 revealed: . walk in freezer accumulating condensation and freezing- checked door seal and any pass thus. Foamed two opening in top of box. Insulation for box is likely compromised due to age of box. Replacement would be only permanent solution .

Based on observations, interviews, the 2022 United States (U.S.) Food and Drug Administration (FDA) Food Code, and a facility's policy titled Sanitation Inspection, the facility failed to ensure the stove top, knobs, handles, and drip pans were free of a heavy grease build up. This had the potential to affect 129 of 130 residents who received meals from the facility's kitchen. Findings Include: A review of 2022 United States (U.S.) Food and Drug Administration (FDA) Food Code, documented: (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean . A review of policy titled Sanitation Inspection dated 12/23 documented: .It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary .1. All food service areas shall be kept clean, sanitary . On 03/26/2024 at 2:31 PM, the initial kitchen tour was conducted by the Surveyor with the Dietary Manager. During the tour, it was observed that there was a significant accumulation of grease on the stove top, knobs, and handles. Additionally, the drip pans had a grease build up on the aluminum foil in both pans. The Dietary Manager mentioned that the cleaning schedule for these areas was on Wednesdays and Fridays. When questioned about the reason behind the grease build up, the Dietary Manager explained that there was an employee who was not cleaning properly and had been terminated the previous day. The Dietary Manager said that the problem with grease accumulation would be cross-contamination. This deficiency was cited as a result of AL00047294

Based on observations, interviews, and facility policies titled Hand Hygiene, Standard Precautions Infection Control, Handling Clean Linen, and Water Management Program the facility failed to ensure: 1) Laundry Staff (LS) #7 washed her hands after leaving Resident Identifier (RI) #54 and RI #10's room with contaminated laundry hangers and touching clean clothing for RI #74. 2) LS #9 kept clean sheets off the floor and off her clothing while folding clean laundry on 03/28/24. 3) Clean blankets for the residents were stored in a clean dust free area and ensured the blankets were not touching the wall. 4) Certified Nursing Assistant (CNA) #10 washed or sanitized her hands after leaving RI #115's room and before picking up RI #23's meal tray while delivering meals on 3/28/24. 5) Maintenance Director (MD) implemented a water management program to prevent and identify Legionella This affected five of 26 sampled residents and had the potential to affect all residents residing in the facility. Findings Include: 1) Review of the facility policy titled Hand Hygiene with an implemented date of 12/22 and a reviewed date of 12/23 revealed: . Policy: . All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. Review of the facility's undated table titled Hand Hygiene Table revealed: . Between resident contacts .Before performing resident care procedures . RI #10 was admitted to the facility on [DATE]. RI #54 was admitted to the facility on [DATE]. RI #74 was admitted to the facility on [DATE]. An observation on 03/27/24 at 10:23 AM of LS #7 coming out of RI #54 and RI #10's room with 3 dirty hangers in her hand then placing the dirty hangers on the left side of the clean clothes hanging cart. Then LS #7 pushed the laundry hanging cart in front of RI #74's room. LS #7 then picked up pants that were on a hanger from the right side of the laundry hanging cart and went into RI #74's room without washing or sanitizing her hands. On 03/27/24 at 10:25 AM an interview with LS #7 was conducted. LS #7 stated that she was hanging clothes for RI #54 and RI #10 in the closet. LS #7 stated that she brought used clothes hangers from RI #54 and RI #10's closet. LS #7 stated the hangers had been used and were contaminated. LS #7 stated she picked up RI #74's clothes and went into his/her room and hung them in the closet. LS #7 stated that she should have washed her hands after touching the contaminated hangers. LS #7 stated that there was a risk of passing germs after touching contaminated items and then touching clean clothing. LS #7 stated that she should have washed her hands before picking up the clean clothes. On 03/29/2024 at 10:52 AM a follow-up interview was conducted with ADM/IP. ADM/IP stated that staff should not pick up dirty hangers until they are done passing out clean laundry to residents. She stated that when staff picks up the dirty laundry hangers, they should put them in a bag and take them to laundry to be disinfected. ADM/IP stated that staff should wash or sanitize their hands after handling laundry hangers that had been used. She stated there would be a risk of cross contamination if staff did not wash or sanitize their hands after touching a contaminated item. ADM/IP stated that facility policy for hand hygiene was to wash or sanitize hands after coming in contact with anything contaminated, before and after entering a room, and before picking up meal trays. 2) Review of the facility policy titled Handling Clean Linen with an implemented date of 12/22 and a reviewed date of 12/23 revealed: . Policy: It is the policy of this facility to handle, store, process, and transport clean linen in a safe and sanitary method to prevent contamination of the linen, which can lead to infection. 2. Linen can become contaminated with pathogens from contact with intact skin or body substances, or from environmental contaminants or contaminated hands. On 03/28/24 at 10:55 AM an observation of LS #9 folding sheets in the clean area of the laundry room. LS #9 picked up a top sheet from the clean laundry basket and the other side of the sheet touched the floor. Two personal phones and personal glasses were on the clean laundry folding table and at the end of the clean folding table was a box fan. LS #9 had long braids that touched the clean laundry when she turned or bent down. LS #9 picked up a sheet out of the basket and another sheet fell to the floor. LS #9 picked up the sheet off of the floor with her left hand and put it back into the clean cart. LS #9 folded the other sheet she was holding in her right hand touching her clothing, she was wearing a blue zipper jacket. LS #9 put the folded sheets on the blue covered cart in stacks. LS #9 picked up another sheet dropping one end of the sheet on the floor and put it on the clean folding table. LS #9 picked up another sheet out of the clean laundry basket and put it on the table. LS #9 picked up another sheet dropping one end of the sheet on the floor and then folded the sheet and put it on the clean folding table. On 03/28/24 at 11:00 AM an interview was conducted with LS #9. LS #9 stated that the sheets she folded touched, the table, the floor and her clothing. LS #9 stated that the sheets should not have touched the floor or her clothing. LS #9 stated that the sheets had a risk of getting dirt on them if the sheet touched the floor. LS #9 stated the sheets should be held away from her clothing and not touching the floor. On 03/28/24 at 11:30 AM an interview with ADM/IP was conducted. ADM/IP stated that clean linen should be handled away from the body and not to touch the floor. She stated that if clean linen were to touch the floor or touch a staff member's clothing it should be rewashed. On 03/29/2024 at 10:52 AM a follow-up interview was conducted with ADM/IP. ADM/IP stated that staff were supposed to keep clean laundry away from their body and clothing, and/or any other contaminated surfaces. ADM/IP stated that staff should hold clean laundry away from their body and off of the floor. She stated clean laundry is considered contaminated when touching the floor. ADM/IP stated there would be a risk of cross contamination if staff did not wash or sanitize their hands after touching a contaminated item. She stated that facility policy for hand hygiene was to wash or sanitize hands after coming in contact with anything contaminated, before and after entering a room, and before picking up meal trays. ADM/IP stated that clean laundry was considered contaminated/dirty if it touched the floor. She said that there was a risk of contamination of putting a sheet back into the clean laundry basket that had touched the floor. 3) Review of the facility policy titled Handling Clean Linen with an implemented date of 12/22 and a reviewed date of 12/23 revealed: . Policy: It is the policy of this facility to handle, store, process, and transport clean linen in a safe and sanitary method to prevent contamination of the linen, which can lead to infection. . 5. Guidelines for the storage of clean linen include, but are not limited to, the following: . c. A separate room, closet or other designated space with a closing door will be used to store clean linen to reduce the risk of accidental contamination. On 03/28/24 at 10:34 AM an observation was made in the laundry room of shelves adjacent to the entrance. The surveyor observed white blankets not covered and touching the wall. On 03/28/24 at 10:38 AM an interview was conducted with Laundry Aide (LA). LA has worked at the facility for four years. LA stated that blankets should be away from the wall. LA stated that according to facility policy the blankets should be in a place free of dust and dirt. She stated that the blankets touching the wall could cause contamination. On 03/29/24 at 10:52 AM an interview was conducted with Infection Preventionist/Administrator (ADM/IC). She stated that the Laundry Supervisor had only been in that position a couple of weeks. ADM/IC stated that there was a risk for contamination with the blankets being uncovered and stored on the shelves by the door in the laundry room. She stated that the blankets should not have touched the wall in the laundry room due to cross contamination. 4) Review of the facility policy titled Hand Hygiene with an implemented date of 12/22 and a reviewed date of 12/23 revealed: . Policy: . All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. Review of the facility table titled Hand Hygiene Table revealed: . Between resident contacts .Before performing resident care procedures . RI #23 was admitted to the facility on [DATE]. RI #115 was admitted to the facility on [DATE]. On 03/28/24 at 11:40 AM an observation was made of CNA #10 on unit 2 passing out lunch trays. CNA #10 brought a lunch tray into RI #115's room and set up the tray for the resident. CNA #10 lifted the plate cover, opened the straw and put the straw in the tea, CNA #10 put sugar in the tea for the resident. CNA #10 then walked out of the room without washing or sanitizing her hands. CNA #10 without washing or sanitizing her hands picked up the lunch tray for RI #23. CNA #10 set the lunch tray on the bedside table next to RI #23. On 03/29/2024 at 10:52 AM a follow-up interview was conducted with ADM/IP. ADM/IP stated that the risk of not washing or sanitize hands was cross contamination. ADM/IP stated staff should wash or sanitize hands after coming in contact with anything contaminated before and after entering a room and before picking up meal trays. She stated that there would be a risk of cross-contamination. On 03/28/24 at 12:20 PM an interview was conducted with CNA #10. CNA #10 stated that she did not wash or sanitize her hands. CNA #10 stated that she did not wash her hands after coming out of RI #115's room, and further stated she should have washed her hands. 5) Review of the facility policy titled Water Management Program with an implemented date of 12/22 and a reviewed date of 12/23 revealed: . Policy: It is the policy of this facility to establish water management plans for reducing the risk of legionellosis and other opportunistic pathogens . in the facility's water systems based on nationally accepted standards . Policy Explanation and Compliance Guidelines: 1. A water management team has been established to develop and implement the facility's water management program, including facility leadership, the Infection Preventionist, maintenance employees, safety officers, risk and quality management staff, and Director of Nursing. 2. The Maintenance Director maintains documentation that describes the facility's water system. 3. A risk assessment will be conducted by the water management team annually to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the faclitiy's water systems. The risk assessment will consider the following elements: . b. Clinical equipment: This includes medical devices and other equipment utilized in the facility that can spread Legionella through aerosols or aspiration. On 03/29/2024 at 10:52 AM an interview was conducted with the Maintenance Director (MD). MD stated that he had a plan typed up for Legionella prevention, but it had not been implemented at that time. On 03/29/24 at 10:52 AM an interview with ADM/IP was conducted. ADM/IP stated that the facility was working on a plan for legionella prevention. She stated the facility had not yet implemented a plan or procedure. ADM/IP stated they were not monitoring for legionella. ADM/IP stated that she did not have an answer for why the faclitiy did not have a plan for prevention of Legionella. ADM/IP stated that the risk of not testing for legionella is the residents could become exposed to Legionella.

Based on interviews, record review, and facility's policy titled Infection Prevention and Control Program the facility failed to ensure the facility employed a certified infection preventionist from 1/5/2022 until 3/29/2024. This deficient practice affected 130 residents in the facility. Findings Include: A review of a facility policy titled Infection Prevention and Control Program with an implemented date of 12/22, and a reviewed date of 12/2023 revealed: . Policy Explanation and Compliance Guidelines. 1. The designated Infection Preventionist is responsible for oversight of the program and serves a consultant to our staff on infectious diseases. A review of the facility's employment record for the previous certified infection preventionist revealed a hire date of 03/27/2020 and last day of employment as 01/05/2022. A review of TRAIN TRAINING PLAN PROOF OF COMPLETION for ADM/IC revealed: . (ADM/IC) has successfully completed Nursing Home Infection Preventionist Training Course as of 03/29/2024 On 03/29/2024 at 10:52 AM an interview was conducted with Administrator/Infection Control (ADM/IC). ADM/IC stated that she worked at the facility for [AGE] years. ADM/IC stated that she had been the infection preventionist for four years but really for just the last year. ADM/IC stated that she did not have all the modules completed for the infection preventionist. ADM/IC stated that the Previous Infection Preventionist (PIP) had been a Certified Infection Preventionist. On 03/29/2024 at 03:59 PM a follow up interview with ADM/IC was conducted. ADM/IC stated the last Certificated Infection Preventionist in the facility had a last day of 01/05/2022. ADM/IC stated that she thought she had completed her Infection Preventionist Certificate, but she had not finished the training. ADM/IC stated that it was the facility's policy to have a Certified Infection Preventionist in the facility.

Based on observations, interviews, review of a facility policy titled Safe and Homelike Environment, the facility document titled Plan of correction for torn floors and complaint/report number AL00046076, the facility failed to ensure Resident Identifier (RI) #128's room's floor covering was not torn, ceiling tiles were not stained in RI #128's room, and that RI #128's room did not have a urine odor. This affected RI #128. The torn floors had the potential to affect residents in 47 rooms. Findings Include: Review of a facility policy Safe and Homelike Environment with a revised date of 12/2023 documented Policy: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, . A review of a facility document titled Plan of correction for torn floors dated 03/28/2024 documented the floor replacements started on 02/14/2024 and would be completed by 05/01/2024. The plan indicated 52 rooms floors were to be replaced. The plan indicated five of the 52 rooms had been completed. A review of Complaint/Report number AL00046076 received to the State Agency 10/31/2023 documented . there are leaks all over the building. the floors are coming up and some are taped down. RI #128 was admitted to the facility on [DATE]. On 03/26/2024 at 5:07 PM and on 03/27/2024 at 9:08 AM the surveyor observed the floor covering in RI #128's room was torn in six places and the areas were taped. The tapes on covering the torn floor was rolling up. The room also had a strong smell of urine and three ceiling tiles were stained. On 03/28/2024 at 9:07 AM, during an observation and interview with the Director of Nursing (DON). The DON said the odor may have gotten into the floor; he said the facility was in the process of replacing all the floor covering on the unit. When asked about the floor covering in RI #128's room, the DON said it had been torn and covered with the tape. The DON said he was not sure how long the flooring had been torn and taped as he had only been there a few months. The DON said it was not homelike when the room smelled like urine and the floor covering torn. On 03/28/2024 at 9:21 AM, observations were made of RI #128's room with The Director of Maintenance (DOM). An interview with the DOM was conducted at the same time. The DOM said the floor covering was torn and tape was used to repair it. He said there were several rooms on the unit the same way. The DOM said RI #128's room smelled like urine. The DOM said other rooms also smelled like urine and he felt it was in the floor covering which was due to be replaced. The DOM said the ceiling tiles were stained or broken. The DOM said it was not homelike when the room smelled like urine, the ceiling tiles were stained, and the floor covering was torn. This deficiency was cited as a result of AL00046076.

Based on interview ,record review and a facility policies titled Comprehensive Care Plans and Oxygen Administration, the facility failed to ensure a care plan was developed for Resident Identifier (RI) #13's use of oxygen therapy. This affected RI #13, one of 26 sampled residents whose plans of care were reviewed. Findings Include: A facility policy titled Comprehensive Care Plans revised 01/2023 indicated: .Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . 8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made . A facility policy titled Oxygen Administration revised 12/23 indicated . 4. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as but not limited to: a. The type of oxygen delivery system. b. When to administer, such as continuous or intermittent and or when to discontinue. c. Equipment setting for the prescribes flow rates . RI #13 was readmitted to the facility on [DATE], with a diagnosis of Failure to thrive and COVID 19. A Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 01/19/2024, identified RI #13 as having received oxygen therapy during this assessment period. A review of RI #13's Active March 2024 Physicians Orders documented: . O2/2L via nasal cannula (N/C) , 02 Sat <90%. every shift for shortness of breath (3/6/2024 ) . On 03/28/2024 at 4:40 p.m., the surveyor reviewed RI #13's care plans. There were no care plan noted for the use of oxygen. On 03/29/2024 at 8:30 AM., the surveyor conducted an interview with the MDS Coordinator (MDSC). The MDSC looked in the computer and RI #13's medical records and stated she could not find that RI #13 had been care planned for the use of oxygen. The surveyor asked the MDSC should RI #13 be care planned for the use of oxygen and she replied yes. 29671 An interview was conducted with the Director of Nursing (DON) on 03/29/2024 at 11:43AM. The DON said a resident who received oxygen should have a care plan in place to ensure proper care was provided. The DON did not know why RI #13 did not have a care plan for use of oxygen but said he/she should have one in place.

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 Version 1.18.11, the facility failed to ensure Section N, Medications, of Resident Identifier (RI) #124's quarterly Minimum Data Set (MDS) was accurately coded for anticoagulant and antiplatelet medication. This deficient practice affected RI #124 one of twenty-six sampled residents whose MDS was reviewed during the survey. Findings Include: The Centers for Medicare &Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11 October 2023 Section N documented: . N0415: High-Risk Drug Classes: Use and Indication .E. Anticoagulant ( . warfarin, heparin, or low-molecular weight heparin) . Do not code antiplatelet medications such as aspirin . or clopidogrel as N0415E, Anticoagulant. N04151I Check if an antiplatelet medication (e.g., aspirin . clopidogrel) was taken by the resident at any time during the 7-day observation period (or since admission/entry or reentry if less than 7 days) . RI #124 was admitted to the facility on [DATE] with diagnoses of Cerebrovascular Disease, Nontraumatic Subdural Hemorrhage, Unspecified, and Essential (Primary) Hypertension. A review of RI #124's Order Summary Report revealed an order for Plavix (clopidogrel) Oral Tablet 75 Milligrams (MG) give one tablet by mouth one time a day related to Essential Hypertension ordered on 10/25/2023 and started on 10/26/2023. A review of Section N of RI #124's quarterly MDS with an Assessment Reference Date (ARD) of 01/26/2024 indicated RI #124 was coded as taking an anticoagulant and was not coded as taking an antiplatelet. On 03/29/24 at 09:23 AM an interview with the Minimum Data Set Coordinator (MDSC) was conducted. The MDSC stated RI #124's MDS with ARD of 01/26/2024 was inaccurately coded for an anticoagulant, because RI #124 did not have an order for an anticoagulant. The MDSC said RI #124 had an order for Plavix, an antiplatelet, and it was not coded accurately on the MDS. The MDSC the care plans would not be correct when the MDS was coded inaccurately. The MDSC stated she did not know why RI #124 was coded for anticoagulant instead of an antiplatelet.

Based on record review, interview and review of the facility policy Resident Assessment - Coordination with PASARR Program, the facility failed to submit for a new Level I for Resident Identifier (RI) #14 when a new diagnosis for Psychotic Disorder was given on 07/07/2021. This affected RI #14 one of two residents reviewed for PASARR (Pre-admission Screening Annual Resident Review). Findings Include: Review of a facility policy Resident Assessment - Coordination with PASARR Program with a revised date of 12/2023 documented . Policy Explanation and Compliance Guidelines: 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions . a. PASARR Level I i. Negative Level I Screening - permits admission to proceed and ends the PASARR process unless a possible serious mental disorder arises later. 9. any resident who exhibits a newly evident or possible serious mental disorder, . or related condition will be referred promptly to the state mental health . c. A resident transferred, admitted , or readmitted to the facility following an inpatient psychiatric stay or and equally intensive treatment . RI #14 was admitted to the facility 05/07/2009 and readmitted [DATE]. A review of RI #14's diagnoses information indicated Psychotic Disorder with Delusions with an onset date of 07/08/2021 and Dementia with Behavioral Disturbances with an onset date of 10/01/2022. On 03/28/2024 at 9:44 AM while reviewing the resident's record a Level I or II was not found in the record. On 03/28/2024 at 10:30 AM the Social Worker (SW) was asked for RI #14's PASARR, she said RI #14 had been in the facility for a long time and she would find it. On 03/29/2024 at 9:25 AM, the SW brought two pages of the Level I screening for RI #14 dated 03/29/2009, when asked where was the second page she said she could not find it because the resident had been there for some time. The SW said she called the OBRA office but had not received a return call. On 03/29/2024 at 10:07 AM, during an interview with the Social worker (SW), she said RI #14 was admitted to the facility 05/07/2009. The SW said RI #14 received the diagnosis of Psychotic Disorder with Delusions on 07/08/2021. When asked what was the date of the current PASARR, she said 03/23/2009. The SW said a submission for a new level I should have been done with the new diagnosis of the Psychotic Disorder with Delusions on 07/08/2021. The SW said she should have submitted for a new Level I when RI #14 returned with a new diagnosis dated 07/08/2021. The SW said the facility process for identifying residents with a possible Mental Disorder, Intellectual Disability or a related condition prior to admission to the facility was to review the admitting diagnosis, and it should match the Level I that comes with the resident. The SW said if the resident went to the hospital or had a new diagnosis a new Level I should be submitted. The SW said she did not submit for a new Level I. The SW said social services was responsible for making the referrals to the appropriate state designated authority when a resident was identified as having an evident or possible Mental Disorder, Intellectual Disability or related condition. The SW said it was an oversight that RI #14 was not submitted for a updated Level I.

Based on record review and interview the facility failed to ensure Resident Identifier (RI) #483 had a physician's order for a urinary catheter when he/she was admitted to the facility with a Catheter on 08/20/2022. This affected one of three residents sampled for urinary catheter use. Findings Include: RI #483 was admitted to the facility on [DATE]. A review of RI #483's Physician Orders for August 2022 revealed no order for the use of a catheter. A review of RI #483's progress notes from 08/28/2022 documented that RI #483's catheter was removed. A telephone interview with the Medical Director revealed that he gave a verbal order to remove the catheter on 08/28/2022. On 03/28/2024 at 10:54 AM an interview was conducted with the Admissions Nurse (AN). The AN stated that RI #483 was admitted to the facility on [DATE] with a foley catheter. On 03/29/2024 at 11:43AM an interview was conducted with the Director of Nurse (DON). The DON said that if a resident was admitted with a catheter a physician's order for the use of the catheter was needed. He said that an order was needed to ensure proper care. When asked about RI #483 the DON said the facility should have called and gotten a physician's order when he/she was admitted to the facility with a catheter on 08/20/2022. This deficiency was cited as a result of complaint AL00045866 ,

Based on record reviews, interviews, a review of the facility's investigation, police report, a review of the facility's policy titled, Abuse Neglect Exploitation Mistreatment and Misappropriation or Property Prevention and a review of the facility's policy titled Cell Phone Policy, the facility failed to ensure a staff member did not post on social media a video of Resident Identifier (RI) #1 naked while laying in bed on 12/29/2021. This affected RI #1, one of three sampled residents for abuse. Findings Include: The facility's policy titled Abuse Neglect Exploitation Mistreatment and Misappropriation of Property Prevention dated 11/17/2021, documented INTENT: The facility will develop and operationalize policies and procedures for .protection of residents .DEFINITIONS: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment, or deprivation .Residents of this facility shall be protected from occurrences of abuse, exploitation, misappropriation of property, mistreatment or neglect . An acknowledgement dated 11/05/2021 and signed by Employee Identifier (EI) #3, Housekeeper documented she read and understood the above Abuse of Prevention Policy and Reporting Procedure. The facility's policy titled Cell Phone Policy with a date of 01/01/2010, revealed It is the policy of Mount Royal Towers to protect the dignity, privacy, and confidentiality of the .residents. Without prior written permission from the Executive Director of the facility . the following are prohibited activities: videotaping of the facility, staff or residents . An acknowledgement dated 11/03/2021 and signed by EI #3 documented she read and understood the Cell Phone Policy. A written undated statement by EI #1, Administrator included in the facility's investigation, documented, On 12/29/21, anonymous call received at the front desk informing the attendant that a staff member had posted a resident on Facebook. The Administrator made aware and informed the attendant to transfer the call. The caller identified self as [NAME] to the Administrator and stated that she works with someone that is snapchat friends with an CNA that works at this facility. In addition, the name was unknown, however, the CNA did post/expose a resident on snapchat. I provided an email address and a phone number and ask for the information to be forwarded. Investigation initiated, and the employee investigated was (name of EI #3) who worked in Housekeeping .Call received at 9:30pm, from (name of EI #3) who admitted that it was her phone and that it was her snap chat account. Employee terminated for violation of company policy related to cell phone use and resident rights and privacy . An ALABAMA UNIFORM INCIDENT/OFFENSE REPORT dated 12/29/2021, documented, .Narrative on 12/29/21, I (Name of Officer) was dispatched to (address of facility) to speak with (name of EI #1), the Administrator or Royal Towers, about abuse of a patient by an employee of the facility. (name of EI #1) stated that an employee, (name of EI #3), took a video of a patient, (name of RI #1), naked while laying on the bed and posted it to her snapchat account (name of EI #3s snapchat account). (Name of RI #1) has medical reasons that render him/her incapable of consenting to such a video .(Name of EI #1) asked (name of EI #3) about the video on her snapchat and she stated that she had given her phone to another employee, (name of EI #6, Housekeeper), who had taken the video and uploaded it to her snapchat . RI#1 was readmitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #1's Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 12/07/2021, listed the resident's Brief Interview for Mental Status (BIMS) as 6, which indicates the resident is cognitive impaired. A telephone interview was conducted with EI #3 on 02/17/2022 at 12:14 PM. EI #3, housekeeper stated her, EI # 4,5, 6 and 7 (all housekeepers) were cleaning RI #1's room. EI #3 stated, she sat her phone down and walked out of the room. EI #3 said when she walked back in the room RI #1 was naked and they (housekeepers) were laughing. EI #3 stated, she told RI #1 he/she didn't need to be in here naked and he/she needed to put some clothes on. EI #3 stated she informed EI #8, Licensed Practical Nurse (LPN) RI #1 was naked and he informed that he would go down there and tend to him. EI #3 said she went to lunch and when she returned she was called to the office and asked about a video and that's when she became aware that a video was made and posted. EI #3 stated, later EI # 7 told them she was the one that took the video because she was upset that EI #3 got the lead position and not her. EI #3 stated she does not keep her phone lock. EI #3 admits it was her phone used to make the video and video was posted to her snapchat. An interview was conducted with EI #8, Licensed Practical Nurse (LPN) on 02/17/2022 at 4:15 PM. EI #8 stated, EI #3 did not tell him that RI #1 was naked on 12/29/2021. He stated, she on the hall with him and the other housekeepers were near RI #1's room. A telephone interview was conducted with EI #4, housekeeper on 02/17/2022 at 5:24 PM. EI #4 stated she found out about the video from EI #3. EI #4 stated, she remembers cleaning the room and RI #1 was naked, they (housekeepers) told RI #1 to put some clothes on. She said EI #3 and EI #6 were in the room with her. When asked who had EI #3's phone that day, EI #4 stated, I don't know, I thought EI #3 had her own phone that day. A telephone interview was conducted with EI #5, housekeeper on 2/18/2022 at 7:50 AM. EI #5 stated RI #1 was naked on 12/29/2021 when she went into the room. She said RI #1 was laying in bed saying he/she was hot. EI #5 stated, EI #3, 4 and 6 came into room and told her that room had already been cleaned and someone told RI #1 to put on some clothes, you can't be in here naked. EI #5 stated, she doesn't know who took the video, but it had to be between EI #3 and EI #6. An interview was conducted with EI #2, Director of Nursing (DON) on 2/18/2022 at 10:15 AM. EI #2 stated, EI #3 posting video of RI #1 could be considered a form of abuse (emotional). EI #2 stated staff members are not to have cell phones on while working. EI #2 admitted that facility's abuse and cell phone policies were not followed when EI #3 posted a video of RI #1 naked to her snapchat. An interview was conducted with EI #1, Administrator/Abuse coordinator on 2/18/2022 at 3:50 PM. EI #1 admitted that EI #3 did not follow facility's abuse and cell phone policy when she posted a video of RI #1 naked on her snapchat.

Based on record reviews, interviews, a review of the facility's investigation and a review of the facility's policy titled, Abuse Neglect Exploitation Mistreatment and Misappropriation or Property Prevention, the facility failed to ensure an allegation of abuse was thoroughly investigated when a staff member posted a video of Resident Identifier (RI) #1 naked while laying on the bed on her social media on 12/29/2021. This affected RI #1, one of three sampled residents for abuse. Findings include: The facility's policy titled Abuse Neglect Exploitation Mistreatment and Misappropriation of Property Prevention dated 11/17/2021, documented INTENT: The facility will develop and operationalize policies and procedures for .protection of residents .Investigation: Investigate different types of incidents; and Identify the staff member responsible for the initial reporting, investigation of the alleged violations and reporting of results to the proper authorities .Reporting/Response: .In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility will: .2. Have evidence that all alleged violation are thoroughly investigated . A written undated statement by Employee Identifier (EI) #1, Administrator included in the facility's investigation, documented, On 12/29/21, anonymous call received at the front desk informing the attendant that a staff member had posted a resident on Facebook. The Administrator made aware and informed the attendant to transfer the call. The caller identified self as Name to the Administrator and stated that she works with someone that is snapchat friends with an CNA that works at this facility. In addition, the name was unknown, however, the CNA did post/expose a resident on snapchat. I provided an email address and a phone number and ask for the information to be forwarded. Investigation initiated, and the employee investigated was (name of EI #3) who worked in Housekeeping .Call received at 9:30pm, from (name of EI #3) who admitted that it was her phone and that it was her snap chat account. Employee terminated for violation of company policy related to cell phone use and resident rights and privacy . RI #1 was readmitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #1's Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 12/07/2021, listed the resident's Brief Interview for Mental Status (BIMS) as 6, which indicates the resident is cognitive impaired. A telephone interview was conducted with EI #4, Housekeeper, on 02/17/2022 at 5:24 PM. EI #4 stated she was not interviewed by facility staff about the video of RI#1. An interview was conducted with EI #1, Administrator on 2/18/2022 at 6:10 PM. EI #1 was asked about identity of voices, gloved hand and what looked to be others in room on video; EI #1 stated, she didn't think those were staff from the facility, but people from University of Alabama in Birmingham (UAB). EI #1 admitted that she did not interview all housekeepers that were mentioned to be in the room on that day due to them quitting.

Based on observation, interviews, resident record review and review of a facility policy titled WOUND MANAGEMENT PROGRAM, the facility failed to ensure Employee Identifier (EI) #3 Licensed Practical Nurse (LPN), the previous facility Treatment Nurse, 1.) completed an accurate and complete assessment of pressure ulcers on Resident Identifier (RI) #4's left hip and sacrum when wounds were reported to her on 12/29/21. EI #3 failed to assess the measurement of RI #4's pressure ulcers and failed to identify the correct pressure ulcer location for RI #4's left hip pressure ulcer on the weekly wound assessment, and 2.) completed an assessment of Resident Identifier (RI) #5's sacral pressure ulcer on 12/31/21 and 1/18/22 to include the assessment of measurements. This affected two of six residents sampled for pressure wounds. Findings Include: A facility policy titled WOUND MANAGEMENT PROGRAM, dated 11/17/21 documented the following: . PURPOSE: The purpose of this program is to assist the facility in the care, services, and documentation related to the occurrence, treatment, and prevention of pressure . related wounds. 1) RI #4 was admitted to the facility on [DATE]. RI #4's Weekly Wound assessment dated [DATE] which documented a pressure ulcer was present to RI #4's sacrum did not include assessment of the measurement of the wound. RI #4's Weekly Wound assessment dated [DATE] which documented a pressure ulcer was present on RI #4's right buttock, did not include assessment of the measurement of the wound. A review of RI #4's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/19/22 at 2:40 PM RI #4's pressure ulcers were observed during a body audit and observations were made of treatments provided to pressure ulcers on RI #4's sacrum and left hip. RI #4 had no other open areas or wounds. On 1/19/22 at 8:05 PM, an interview was conducted with EI #3, LPN and previous treatment nurse. EI #3 was asked, what she could recall about RI #4's wounds. EI #3 replied, RI #4 had wounds on the left hip and sacrum, both were found by Certified Nursing Assistant (CNA) EI #5 and reported to her on 12/29/21. EI #3 was asked what were the measurements of the wounds identified. EI #3 replied, she did not measure them. EI #3 was asked why did she not measure the wounds. EI #3 replied, she did not know. EI #3 was asked what stage were RI #4's wounds. EI #3 said, one was a stage three and one was unstageable. EI #3 was asked what was the policy for measuring wounds. EI #3 replied, measure wounds when they were identified and enter the assessment on the flow sheet. EI #3 was asked if she entered the measurements on the flow sheet. EI #3 replied, she did not assess the measurement. When asked why she recorded the would location of the right buttock on the Weekly Wound Assessment form, EI #3 stated, she was not sure but the wounds were on the left hip and the sacrum. On 1/20/22 at 3:30 PM, an interview was conducted with EI #5, CNA. EI #5 was asked what skin concerns she identified. EI #5 replied, she found an open area on RI #4's left hip and sacrum during the shower on 12/29/21 and reported her findings to EI #3, the previous treatment nurse. On 1/21/22 at 7:30 AM, a follow up interview was conducted with EI #3, LPN the previous treatment nurse. EI #3 was asked how she could have staged pressure ulcers and not assessed the measurement. EI #3 said she was looking at the type of wound. EI #3 was asked what was the potential harm in not assessing measurements of the wounds. EI #3 said, she did not follow the policy and others would not be able to follow the progress of the wound. On 1/21/22 at 12:30 PM, an interview was conducted with EI #1, the Administrator. EI #1 was asked to review the wound assessment sheets dated 12/29/21 (for RI #4) and was asked about the measurements. EI #1 replied, the form did not have measurements recorded. EI #1 was asked why no measurements were recorded, to which she replied, she did not know. EI #1 was asked what was the policy for assessing and identifying wounds. EI #1 replied, new wounds should be assessed. EI #1 was asked what was included in the assessment. EI #1 replied, a full description including measurements, staging, drainage, and color. EI #1 was asked who should assess the measurements if a wound was identified. EI #1 replied, the one identifying it. EI #1 was asked if EI #3 assessed the measurements. EI #1 replied, no. EI #1 was asked what were the concerns if wound measurements not assessed and entered on the assessment sheet. EI #1 replied, no one could determine the progress or decline in the wounds. 2) RI #5 was originally admitted to the facility on [DATE] and readmitted on [DATE]. RI #5's Progress Notes documented a readmission skin assessment dated [DATE] that included a stage three pressure ulcer to the sacrum. No further assessment of the pressure ulcer to the sacrum was documented. RI #5's Weekly Skin Check sheet dated 12/31/21 documented RI #5's skin was not intact, but did not document evidence measurements were assessed. RI #5's Weekly Skin Check sheet dated 1/10/22 documented RI #5's skin was not intact, but did not document evidence measurements were assessed. On 1/20/22 at 4:01 PM, the surveyor conducted an interview with EI #2, the LPN (Licensed Practical Nurse)/MDS (Minimum Data Set) nurse. When asked when wounds were initially identified, where the information was documented, EI #2 said it should be in the nurses notes and there was a skin assessment sheet in the computer used by the wound care nurse. The surveyor asked EI #2 who was responsible for documenting and measuring the assessment of the wounds. EI #2 said the wound care nurse. When asked how often were wounds assessed, EI #2 said weekly. EI #2 said the assessments were documented on the Weekly Skin Check sheets. On 1/21/22 at 8:59 AM, the surveyor conducted a telephone interview with the former Wound Care Nurse, EI #3. EI #3 said when wounds were initially identified she would make a note on the skin and wound assessment sheet. When asked what would that documentation consist of, EI #3 said where the wound was, the stage of the pressure ulcer and the measurement. The surveyor asked EI #3 how often wounds were assessed for measurement. EI #3 said every week. These deficiencies were cited as a result of the investigation of complaint/report number AL 664.

Based on interviews, record reviews, facility policy with the subject, INFECTION CONTROL-COVID-19 and the Centers for Medicare and Medicare Services (CMS) QSO (Quality Safety and Oversight)-20-38-NH memo dated August 26, 2020, titled Interim Final Rule (IFC), CMS-3401-IFC, Additinal Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements and ., revealed the facility failed to conduct outbreak testing for all residents after an identified COVID-19 outbreak on September 24, 2020. This deficient practice had the potential to affect 102 out of 119 residents that were not tested . Findings include: A review of facility policy with the subject, INFECTION CONTROL-COVID-19, dated 04/15/2020, documented, .An outbreak is defined as a new COVID-19 infection in any healthcare personnel (HCP) . In an outbreak investigation, rapid identification and isolation of new cases is critical in stopping further [MEDICAL CONDITION] transmission. The CMS, August 26, 2020, QSO 20-38 memo section: Testing of Staff and Residents in Response to an Outbreak states, An outbreak is defined as a new COVID-19 infection in any healthcare personnel (HCP) or any nursing home-onset COVID-19 infection in a resident. In an outbreak investigatin, rapid identification and isolation of new cases is critical in stopping further [MEDICAL CONDITION] transmission. A resident who is admitted to the facility with COVID-19 does not constitute a facility outbreak. Upon identification of a single new case of COVID-19 infection in any staff or residents, all staff and residents should be tested , and all staff and residents that tested negative should be retested every 3 days to 7 days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since themost recent positive result . A review of the results dated 9/24/2020 of EI #7's, (Licensed Pracitical Nurse) COVID-19 test performed at AFC (American Family Care) revealed a positive test result for COVID-19. A review of an untitled two-page spreadsheet provided by EI # 1, Executive Director, with a Collection Date of Week Four and handwritten Residents across the top of the table revealed a total of 119 residents. One resident was tested on [DATE] and sixteen (16) residents were tested on [DATE]. On 11/07/2020 at 03:29PM, in an interview with EI #2, Administrator, EI #2 reported that she was the Infection Preventionist. When asked when the facility should conduct COVID testing, EI #2 responded in accordance with HHS (Department of Health and Human Services), the positivity rate, signs and symptoms and with any outbreak. When asked who should be tested , EI #2 responded staff are tested weekly and residents are tested with signs and symptoms or with an outbreak. When asked what was considered an outbreak, EI #2 responded anytime someone gets COVID. When asked when should you test during an outbreak, EI #2 stated immediately. When asked who should be tested after an outbreak, EI #2 stated residents and staff. When asked if all residents were tested after the 09/24/2020 positive test of EI #7, EI #2 responded no, there were some holes according to the spreadsheet. When asked if the facility had a list of residents who refused the COVID-19 testing, EI #2 responded there was a list. There were no documented refusals for testing on 09/24/2020. On 11/07/2020 at 05:20PM, in an interview with EI #8, Quality Assurance Nurse, EI #8 stated that she did the COVID testing. When asked about testing for 09/24/2020, EI #8 stated she did not recall if she was working on 09/24/2020. EI #8 could not say whether or not she completed testing on all residents after the outbreak on 09/24/2020.

Based on observations, interviews and review of facility policy, Infection Control-Covid 19, the facility failed to ensure standard precautions were taken during a pandemic by not ensuring residents engaged in communal activities were social distancing and wearing a facial covering that covered their nose and mouth. This affected one out of five units observed during 7 of 8 days of the survey. Findings include: A review of a facility policy and procedure titled, INFECTION CONTROL- COVID 19 dated 04/15/2020, revealed: . Small -group activities Group activities may be considered for activities that improve the quality of life for residents. With a maximum of ten (10) residents at an activity. To conduct activities on a limited basis: . *Maintain 6-foot separation, mask or face covering and hand hygiene . On 11/04/2020 at 06:20PM, the men's locked unit common area was observed and it was noted that there were 16 men sitting watching television. There was no social distancing and no face covering/masks worn. On 11/05/2020 at 09:35AM, the men's locked unit common area was observed and it was noted that there were 14 men sitting watching television. There was no social distancing and no face covering/masks were worn. On 11/06/2020 at 10:03AM, the men's locked unit common area was observed and it was noted that there were 18 men, with no masks and sitting next to each other. On 11/07/2020 at 01:30PM, the men's locked unit common area was observed and it was noted that there were approximately 10 men, sitting in chairs, with no social distancing and no face covering/masks. On 11/17/2020 at 01:17PM, the men's locked unit common area was observed and it was noted that there were five residents sitting watching television. Two residents were in wheelchairs. No residents were wearing face masks. On 11/17/2020 at 01:22PM, the men's locked unit was observed residents in hallway walking around without face masks. On 11/17/2020 at 01:24PM, the men's locked unit was observed with RI #18 in a wheelchair going into Room Locator (RL) #1 with no face mask. When asked about wearing face mask, RI #18 stated, ain't got one. When asked if facility gave one; RI #18 stated no. RI #18 stated nope when asked if facility had spoken with residents about wearing face masks. On 11/18/2020 at 06:35PM, the men's locked unit common area was observed with seven residents, one with a face mask on. Four residents sitting next to each other, with no social distancing. On 11/19/2020 at 09:27AM, the men's locked unit common area observed with 10 men watching television. Seven residents were without face masks. On one side of the room, two residents were sitting side by side, there was no social distancing. On the other side of the room, three residents were sitting side by side, with no social distancing. On 11/19/2020 at 11:17AM, the men's locked unit, EI # 19, the Maintenance Lead, measured the common area/television room on the men's locked unit. Width was 11 feet, 3 inches and length was 23 feet, 11 inches. On 11/06/2020 at 03:12PM, an interview with EI #10, Licensed Practical Nurse (LPN), was conducted. He was asked what size was the day area on the men's locked unit. EI #10 stated it was about 16 feet across and about 24 feet deep. EI #10 was asked was it large enough for 15-17 people in wheelchairs and /or chairs to be socially distanced. He stated no. When asked how far apart should the residents be for social distancing, EI #10 stated six feet. EI #10 was asked what was the concern with residents not being socially distanced six feet apart, he stated infection control. When EI #10 was asked if any of the residents in the day area were wearing face masks, he stated no. When asked should residents be wearing face masks, EI #10 stated yes. When asked why the residents were not wearing face masks, EI #10 stated he assumed the residents were care planned not to wear them. EI #10 was asked should there be a care plan for residents refusing to wear face masks, EI #10 stated yes. When asked the concern for residents not wearing face masks, EI #10 stated infection control. On 11/06/2020 at 05:45PM, an interview was conducted with EI #14, LPN/Minimum Date Set (MDS) coordinator. EI #14 was asked were any residents care planned for not wearing a face mask; she stated, I'm not sure. EI #14 was asked during morning meetings, had any staff discussed residents being care planned for not wearing a face mask or social distancing; EI #14 stated not that she was aware. On 11/06/2020 at 06:06PM, an interview was conducted with EI #15, Registered nurse (RN)/MDS coordinator. EI #15 was asked were any residents care planned for not wearing masks or social distancing; EI #15 stated no. On 11/07/2020 at 01:00PM, an interview was conducted with EI #9, Activity Director. EI #9 was asked what social distancing was. EI #9 stated social distancing was when people are at least six feet apart. EI #9 was asked why residents wore face coverings. She stated to keep from spreading germs and Covid. When asked if residents were wearing masks, EI # 9 stated, Some do and some don't, but it's their choice. EI #9 was asked according to facility's policy should residents wear face masks, EI #9 stated when they leave off their unit. When asked should residents on a locked hall wear masks in group settings, EI #9 stated by guidelines they should, but their behavior makes it difficult for them to wear. On 11/07/2020 at 03:29PM, an interview was conducted with EI #2, Administrator. When asked do residents wear masks during communal activities covering mouth and nose, EI #2 stated after much encouragement. EI # 2 was asked if residents were social distanced during communal activities. She stated yes. EI #2 was asked what was considered communal activities, EI #2 stated when you have a group of residents and they are sharing the same area. EI #2 was asked when 16 men on the locked unit are in the television area, would this be considered social distancing. EI #2 stated no. On 11/17/2020 at 02:08PM, an interview was conducted with EI #17,Certified Nursing Assistant (CNA). EI #17 was asked did she encourage residents to wear face masks. EI #17 stated when residents go off locked unit. On 11/17/2020 at 02:16PM, an interview was conducted with EI #18,CNA. EI #18 was asked did they encourage residents to wear face masks. EI #18 stated no, unless they go off locked unit. On 11/19/2020 at 03:02PM, an interview was conducted with EI #16, LPN, On the men's locked unit. EI #16 was asked were the chairs social distanced in the common area/television room on the men's locked unit on 11/04/2020 and 11/17/2020. EI #16 stated no. On 11/19/2020 at 03:19PM, an interview was conducted with EI #17, CNA, On the men's locked unit. EI #17 was asked were the chairs social distanced in the common area/television room on the men's locked unit on 11/04/2020 and 11/17/2020. EI #17 stated no. On 11/19/2020 at 03:32PM, an interview was conducted with EI #10, LPN, On men's locked unit. EI #10 was asked were the chairs social distanced in the common area/television room on the men's locked unit on 11/04/2020 and 11/17/2020. EI #10 stated no, chairs were not six feet apart.

Based on interviews, review of a facility policy with the subject, Abuse Neglect Exploitation Mistreatment and Misappropriation of Property Prevention, review of facility documents titled, Incident Report, Progress Notes and Declaration and a review of the Alabama Department of Public Health Complaint Tracking System, the facility failed to report nine out of 11 incidents of either injuries of unknown origin or resident to resident abuse affecting Resident Identifier (RI) #'s (numbers) 2, 8, 11, 12, 15, 16, 17, 20, 22 and 23 to the State Agency. This deficient practice was evident in the 10 out of 12 reportable incidents reviewed. Findings include: A review of a facility policy with the subject, Abuse Neglect Exploitation Mistreatment and Misappropriation of Property Prevention, dated 11/17/2017, documented, .VII. Reporting/Response: Report all alleged violations .to the state agency .In response to allegations of abuse, .the facility will: 1. Ensure that all alleged violations involving abuse, .or mistreatment, including injuries of unknown source . are reported immediately, but not later than 2 hours after the allegation is made .or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. 1. RI #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a facility document regarding RI #2 titled, INCIDENT REPORT dated 02/19/2020, documented, .WHAT HAPPENED? Area was noted during shower .DESCRIBE INJURY? Lg (large) bruise covering top of Lt (left) foot . On 11/07/2020 at 3:29PM, during an interview with EI #2, Administrator, EI #2 was asked if reports of injuries of unknown origin, such as bruises were reported to State Survey Agency. EI #2 responded she would not report a bruise but would investigate the cause of the bruise. When asked what she would do if she could not determine the cause, EI #2 stated she would make a report. EI #2 was asked should injuries of unknown origin be reported to State Survey Agency. EI #2 responded, Yes. EI #2 was asked if all injuries of unknown origin were reported to State Survey Agency. EI #2 responded, To my knowledge, yes. When asked who was primarily responsible, EI #2 responded EI #3, Director of Nursing (DON). When asked who was responsible to make sure EI #3 completed duties, EI #2 responded, Administrator. A review of the Alabama Department of Public Health Complaint Tracking System for Mount Royal Towers revealed this bruise/injury of unknown origin was not reported to the State Survey Agency. 2. RI #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a facility document regarding RI #8 titled, INCIDENT REPORT dated 10/21/2020, documented, .WHAT HAPPENED? Resident was hit in the face causing a scratch . A review of a facility document titled, DECLARATION EI #5,Certified Nursing Assistant (CNA), documented, .(RI #8) was in the doorway and (RI #11) ask (him/her) to move and (RI #8) refused and we heard (RI #8) said you hit me and we didn't notice the mark until this morning. A review of a facility document titled, DECLARATION of EI #6,CNA, documented, (RI #8) was in the doorway and (RI #11) was standing behind (him/her) they then had words. (RI #8) with back in the hall and that's when we heard (RI #8) say you hit me in my face call the authority. Didn't notice a scratch until this morning at 5:15am. On 11/07/2020 at 11:30AM, EI #3, DON, was asked the name of the Abuse Coordinator. EI #3 stated it was her, the Administrator (EI #2) and the Executive Director (EI #1). When asked about the incident with RI #8 and RI #11, EI #3 stated she heard about the incident around 6:30-7:00AM by EI #4, Nurse. When asked what EI #3 did when told about an abuse allegation, EI #3 stated she had to investigate and then tell EI #1 and EI #2. When asked if she reported the allegation to EI #1 and EI #2 before or after the investigation, EI #3 stated after. When asked why she investigated prior to reporting the incident, EI #3 responded she based it on policy. When asked for clarification, EI #3 stated allegations get reported if the action was willful. EI #3 further stated when she received a report she had to investigate what happened and report it to EI #1 and EI #2 if she determined it was willful. When asked why she did not think the action was deliberate, EI # 3 stated because both of the residents were confused. When asked if she reported the incident to EI #1 or EI #2, EI #3 stated yes. When asked about their response, EI #3 stated EI #2 told her to send RI #11 out. When asked who reported allegations to State Survey Agency, EI #3 responded EI # 1 or EI #2 since she did not have the capabilities. On 11/07/2020 at 3:29PM, during an interview with EI #2, Administrator, EI #2 was asked if the allegation of RI #11 hitting RI #8 in the face was reported to the State Agency. EI #2 responded that the allegation was not reported to her knowledge. When asked if the facility's policy on reporting allegations of abuse was followed, EI #2 responded that policy was not followed if the allegation was not reported. When asked who was responsible for reporting to the State Agency, EI #2 responded EI #3, DON or herself or EI #1, Executive Director. A review of the Alabama Department of Public Health Complaint Tracking System for Mount Royal Towers revealed this resident on resident altercation was not reported to the State Survey Agency. 3. RI #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a facility document regarding RI #12 titled, INCIDENT REPORT dated 02/09/2020, documented, .WHAT HAPPENED? Resident was hurt on right wrist, from agitating co-resident. WHAT CAUSED IT? Co-resident became agitating and strikes out .NURSE REVIEW: (Signature of EI #2, Administrator) . On 11/20/2020 at 09:56AM, during an interview with EI #2, EI #2 was asked if all resident to resident altercations were reported to State Survey Agency. EI #2 responded, .No. When asked who was primarily responsible, EI #2 responded EI #3, the DON. When asked who was responsible to make sure EI #3 completed duties, EI #2 responded, Administrator. A review of the Alabama Department of Public Health Complaint Tracking System for Mount Royal Towers revealed this resident on resident altercation was not reported to the State Survey Agency. 4. RI #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a facility document regarding RI # 15 titled, INCIDENT REPORT dated 11/17/2020, documented, .WHAT HAPPENED? 'Fighting' hitting room mate & visa versa per resident .HOW DID IT HAPPEN? Resident got up from bed @ (at) confronted roommate hitting him face/chest area per CNA (Certified Nursing Assistant). A review of a facility document regarding RI # 16 titled, INVESTIGATION OF INCIDENT dated 11/17/2020, documented, .Witness/Resident description of incident Fighting, hitting (RI # 15) while holding against wall . On 11/20/2020 at 09:56AM, during an interview with EI #2, Administrator, EI #2 was asked if all resident to resident altercations were reported to State Survey Agency. EI #2 responded, .No. When asked who was primarily responsible, EI #2 responded EI #3, DON. When asked who was responsible to make sure EI #3 completed duties, EI #2 responded, Administrator. When asked if the incident involving RI #15 and RI #16 was reported to the State Survey Agency, EI #2 stated she did report it on 11/17/2020. EI #2 stated she did not get a confirmation because she reported it on her telephone. A review of the Alabama Department of Public Health Complaint Tracking System for Mount Royal Towers revealed this resident on resident altercation was not reported to the State Survey Agency. 5. RI #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of facility document regarding RI #17 titled, INCIDENT REPORT dated 05/25/2020, documented, .WHAT HAPPENED? Resident was attempting to remove shoes from co-residents feet and co-resident struck resident . A review of a facility document regarding RI #17 titled, Progress Notes dated 10/08/2020 written by EI #16, Licensed Practical Nurse (LPN), documented, .Effective Date: 10/8/2020 11:58 .Type: General Nursing Note .Resident noted to be in altercation with co-resident today. Residents face-to-face with each other and gripping each other's arms. In an interview with EI #2 on 11/20/2020 at 09:56AM, EI #2 was asked if the incident with RI #17 was reported to State Survey Agency. EI #2 responded, No. When asked who was primarily responsible, EI #2 responded EI #3. When asked who was responsible to make sure EI #3 completed duties, EI #2 responded, Administrator. A review of the Alabama Department of Public Health Complaint Tracking System for Mount Royal Towers revealed these resident on resident altercations were not reported to the State Survey Agency. 6. RI #20 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a facility document regarding RI #20 titled, INCIDENT REPORT dated 04/02/2020, documented, .WHAT HAPPENED? Resident unable to answer .DESCRIBE INJURY? Large laceration to middle finger (with) purple bruising and bloody drainage present. On 11/20/2020 at 09:56AM, during an interview with EI #2, Administrator, EI #2 was asked should injuries of unknown origin be reported to State Survey Agency. EI #2 responded, Yes. EI #2 was asked if all injuries of unknown origin were reported to State Survey Agency. EI #2 responded, To my knowledge, yes. When asked who was primarily responsible, EI #2 responded EI #3, DON. When asked who was responsible to make sure EI #3 completed duties, EI #2 responded, Administrator. A review of the Alabama Department of Public Health Complaint Tracking System for Mount Royal Towers revealed this injury of unknown origin was not reported to the State Survey Agency. 7. RI #22 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a facility document regarding RI #22 titled, INCIDENT REPORT dated 04/14/2020, documented, .WHAT HAPPENED? Resident unable to answer .DESCRIBE INJURY? ST (skin tear) to L (left) forearm (with) purplish bruising to surrounding tissue . On 11/20/2020 at 09:56AM, during an interview with EI #2, Administrator, EI #2 was asked should injuries of unknown origin be reported to State Survey Agency. EI #2 responded, Yes. EI #2 was asked if all injuries of unknown origin were reported to State Survey Agency. EI #2 responded, To my knowledge, yes. When asked who was primarily responsible, EI #2 responded EI #3, DON. When asked who was responsible to make sure EI #3 completed duties, EI #2 responded, Administrator. A review of the Alabama Department of Public Health Complaint Tracking System for Mount Royal Towers revealed injury of unknown origin was not reported to the State Survey Agency. 8. RI #23 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a facility document titled, INCIDENT REPORT dated 08/31/2020, documented, .WHAT HAPPENED? CNA .noticed skin tear after undressing resident .HOW DID IT HAPPEN? Resident unable to tell what happened due to being cognitive impaired .DESCRIBE INJURY? Skin tear to lower right leg . In an interview with EI #2, Administrator, on 11/20/2020 at 09:56AM, EI #2 was asked if the incident with RI #23 was reported to State Survey Agency. EI #2 responded, No, I do not send a skin tear . When asked who was primarily responsible, EI #2 responded EI #3, DON. When asked who was responsible to make sure EI #3 completed duties, EI #2 responded, Administrator. A review of the Alabama Department of Public Health Complaint Tracking System for Mount Royal Towers revealed this injury of unknown origin was not reported to the State Survey Agency.

Based on interview and review of Resident Identifier (RI) #8's medical record, the facility failed to timely collect a urinalysis for RI #8 as ordered by the physician. This failure caused a delay in the administration of an antibiotic for a Urinary Tract Infection. This deficient practice affected RI #8, one of three sampled residents. Findings include: RI #8 was admitted to the facility on [DATE]. The resident has a medical history to include a [DIAGNOSES REDACTED]. RI #8's physician's orders [REDACTED]. However, RI #8's progress notes indicated the UA C&S was collected until 9/21/2020. After the UA C&S results were reviewed, on 9/29/2020, RI #8 was ordered Cipro, an antibiotic, for a Urinary Tract Infection. On 11/20/2020 at 2:13 PM, an interview was conducted with Employee Identifier (EI) #2, a Registered Nurse (RN). EI #2 was asked when should she receive the results if a resident had a UA C&S collected on 9/21/2020. EI #2 said not long, there is usually a 24-hour turnaround time. EI #2 was asked when should a UA C&S that was ordered on [DATE] have been collected. EI #2 replied on 9/9/2020, if possible. EI #2 was asked why would it have not been collected until 9/21/2020, 11 days later. EI #2 stated there should have been some documentation in there as to why it was not collected and possibly another order besides the 9/9/2020 order. When asked what was the concern when a doctor's order was received on 9/9/2020 and not followed until 11 days later, EI #2 responded mainly a delay in treatment for [REDACTED].

Based on observation, interview, and review of the facility's policy titled Three Compartment Sink Sanitization, the facility failed to ensure a kitchen aide did not sanitize a knife in the three compartment sink containing food particles in the sanitizing compartment. Further, the kitchen aide removed the knife from the sink using bare hands and placed it on the wall with other clean knives for future use. This had the potential to affect 122 residents receiving meals from the facility's kitchen. Findings include: A review of the facility policy titled Three Compartment Sink Sanitization, dated 5/2018, revealed: .It is the policy of this facility to use the three-compartment sink to clean and sanitize pots, pans and serving utensils as part of the infection control program and eliminate the possibility of spreading harmful microorganisms in the ware washing process. Purpose: To prevent the spread of bacteria that may cause food borne illnesses .Procedure .: 1. First Sink-Wash Dishes . b. Scrape pots/pans as needed, wash pots, pans & utensils thoroughly removing all debris .3. Third Sink-Sanitizing .e.Inspect all pots, pans & utensils for any residue or debris or moisture before storage . On 11/17/19 at 3:05 p.m., the surveyor along with Employee Identifier (EI) #4, a Dietary Manager (DM), observed EI #5, Prep Pot Kitchen Aide, removed a knife from the sanitizing compartment of the three compartment sink. EI #5 touched the blade of the knife with her bare hands and placed it on the wall with other clean items to hang dry. The surveyor, along with EI #4, observed food particles in the sanitizing compartment of the three compartment sink. The surveyor asked EI #4 what did she observe happen. EI #4 stated EI #5 did not properly sanitize the knives because she took the knife out of the sanitizing sink with food particles, touched the blade with her hand and placed it back on the wall with the clean utensils. The surveyor asked EI #4 what was the potential harm in having food particles in the sanitizing sink and touching the blade with her bare hand. EI #4 stated cross contamination. On 11/19/19 at 2:38 p.m., a follow up interview was conducted with EI #4. EI #4 was asked should there have been food particles in the sanitizing sink. EI #4 stated no. EI #4 was then asked why there should not have been food particles in the sanitizing sink. EI #4 stated it meant something was left there and the process needed to be restarted. EI #4 was then asked if she considered the water in the sanitizing sink dirty. EI #4 stated yes. EI # 4 was asked what the aide did with the knife in the sanitizing sink. EI #4 stated the aide retrieved the knife out of the sink, touched the blade on the cutting side, and placed it on the wall with the clean knives. EI #4 was then asked if EI #5 should have put the knife back on the wall with the clean knives. EI #4 stated no. EI #4 was then asked why the aide should not have put the knife back on the wall with the clean knives. EI #4 stated she contaminated the clean knife storage area. On 11/20/19 at 7:30 a.m., EI #5 was interviewed. EI #5 was asked what she observed in the sanitizing compartment of the three compartment sink on 11/17/19 at 3:05 p.m EI #5 stated there were food particles in the sanitizing sink. EI #5 was then asked if there should have been food particles in the sanitizing sink. EI #5 stated no. EI #5 was asked why not, and EI #5 stated cross contamination. EI #5 was then asked if she considered the water in the sanitizing sink dirty. EI #5 stated yes. When EI #5 was asked what she did with the knife in the sanitizing sink, EI #5 stated she put it back on the wall with the clean knives. EI #5 stated she touched the blade on the sharp side with her bare hands and had made a mistake in doing that. EI #5 was asked should she have put the knife back on the wall with clean knives. EI #5 stated she should not have put the knife back on the wall with clean items because it would contaminate the other items and the knife could have been used to cut food for residents.