Every finding on record at Englewood Health Care Center

Based on interviews, review of Resident Identifier (RI) #14's medical record, the facility's ABUSE POLICY and the investigation file, the facility failed to ensure Employee Identifier (EI) #1, a Certified Nursing Assistant (CNA) did not verbally abuse and neglect RI #14 on 3/17/2021. On 3/17/2021, EI #1, a CNA cursed and neglected to change the resident's wet incontinence brief when asked. This affected RI #14, one of four sampled residents reviewed for abuse/neglect. Findings include: The facility's ABUSE POLICY dated November 2016, documented, . It is the policy of <<Facility>> to insure that each resident is free from verbal . abuse, neglect . Definitions . Verbal abuse is the use of oral, written or gestured language that includes disparaging and derogatory terms to residents . Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress . RI #14 was readmitted to the facility on [DATE]. RI #14's Annual Minimum Data Set with an assessment reference date of 2/5/2021 indicated the resident was cognitively intact with a Brief Interview for Mental Status of 15. The resident was assessed as requiring extensive assistance with toilet use and always continent of bowel and bladder. On 3/18/2021, the facility reported an allegation of neglect to the State Agency involving RI #14 and EI #1, a CNA. According to the report, (RI #14) alleged (EI #1) would not change (his/her) in a timely manner when asked to be changed. Also reported (EI #1) was fussing at (him/her). According to the undated facility's investigation summary, On the night of 3-17-202 (2021), (RI #14), resident, reported to (EI #2), LPN (Licensed Practical Nurse), that (he/she) was upset with (EI #1), CNA. (RI #14) told (EI #2) that (EI #1) entered (his/her) room at approximately 3:15 a.m. fussing at (him/her) because (he/she) had wet (him/herself), turned the call light off and left (him/her) in a wet diaper. (RI #14) stated (EI #1) returned to the room at approximately 5:00 a.m. still fussing about the resident's wetting (him/herself) stating you know damn good and well I asked you at 2:00 a.m. did you have to go to the bathroom.Upon conclusion of the investigation I have determined through resident and witness interviews that the allegation of neglect . is substantiated. (EI #1) will be terminated from Englewood Healthcare. In an interview on 5/26/2021 at 9:12 AM, RI #14 stated at the time of the incident, he/she reported his/her concerns to the nurse on duty. RI #14 stated this was the first and only time a staff member had been rude to him/her. According to RI #14, the staff was fired and the Administrator and other staff were very fast in taking care of the issue and making him/her feel safe. RI #14 stated he/she has not had any other issues with any other staff. On 5/26/2021 at 12:37 PM, an unsuccessful attempt was made to contact EI #1, a CNA by way of the telephone; EI #1's telephone number was no longer is service. EI #1's EMPLOYEE CORRECTIVE ACTION REPORT indicated on 3/25/2021, EI #1's employment with the facility was terminated for Class A: Immediate Discharge #3 Resident Abuse . During an interview on 5/27/2021 at 11:35 AM, EI #2, a LPN stated when she entered RI #14's room (on 3/18/2021), RI #14 appeared to look as if he/she had been crying. EI #2 stated she asked RI #14 what was wrong; RI #14 reported what EI #1 said and done. EI #2 stated she immediately reported the allegation to the Registered Nurse Supervisor, who then informed the (Regional) Administrator. In an interview on 5/26/2021 at 2:45 PM, EI #3, the Regional Administrator stated the facility does not tolerate abuse or neglect towards the residents. He stated abuse/neglect is discussed frequently with the staff and the expectation of the facility was to ensure all residents are free from abuse of any kind. He stated when he completed the investigation into the allegation, he was hurt to know what RI #14 had endured. According to EI #3, the staff member, EI #1, was immediately suspended and once the investigation was completed, EI #1 was terminated. On 6/14/2021 at approximately 5:15 PM, the facility's Administrator returned a telephone call to the State Survey Agency regarding corrective actions taken as the result of the substantiated allegation of neglect involving RI #1 and EI #1. ************************* The following corrective actions were implemented: On 3/18/2021, the facility reported an allegation of neglect to the State Survey Agency. On 3/18/2021, the facility suspended EI #1, a CNA depending the results of the investigation. On 3/18/2021, the facility began an investigation into the allegation of neglect. From 3/18/2021 to 3/25/2021, the facility provided education to their staff related to Resident Rights and Abuse. On 3/25/2021, the facility terminated the employment of EI #1, a CNA. On 3/25/2021, the facility concluded their investigation and submitted their investigative summary to the State Survey Agency. ************************* After review of the facility's corrective actions, observations during the survey, interviews with residents and staff, and no further allegation of abuse and/or neglect, the facility implemented corrective actions from 3/18/2021 to 3/25/2021, thus past noncompliance was cited. This deficiency was cited as a result of the investigation of complaint/report number AL 372.

Based on observations, interview and review of facility policies titled Food Storage and Hand Washing, the facility failed to ensure: 1. Three half pint cartons of milk were not expired in the refrigerator; and 2. Staff properly washed hands when changing tasks in the kitchen, including preparing a meal and throwing trash in the garbage can. These deficient practices had the potential to affect all residents receiving meals from the kitchen. Findings include: 1) Review of the facility policy titled Food Storage, sated 2013, revealed: .Procedure: .14. Refrigerated Food Storage: . f. All foods should be . labeled and dated. All foods will be checked to assure that foods . will be consumed by their safe use by dates . or discarded. On [DATE] at 2:15 PM, the Surveyor observed the facility's milk refrigerator contained a total of three fat free skim milk (half pint cartons) with an expiration date of [DATE]. Employee Identifier (EI) #1, the Dietary Manager, was interviewed on [DATE] at 05:10 PM. EI #1 confirmed the presence of three expired milk cartons on [DATE]. When asked what the potential harm was in having expired milk in the refrigerator, EI #1 replied, it can make somebody sick. 2) Review of the facility policy titled, Hand Washing, dated 2013, revealed: . Procedure: .1. When to Wash Hands: . * After handling soiled equipment or utensils. * During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. . *After engaging in other activities that contaminate the hands. On [DATE] at 10:41 AM, the surveyor observed EI #2, a Cook, use bare hands (no gloves) to roll soiled, used tin foil from the pan the cooked chicken was prepared on. EI #2 picked up the rolled tin foil, walked to the trash can, lifted the lid to the trash can, and threw the rolled up tin foil away. EI #2 then walked to the ice chest and picked up a scoop on top of the chest. EI #2 dipped ice out with the scoop and placed it onto exposed raw chicken in a pan. EI #2 did not wash hands or have gloves on. EI #2 then picked up a tray of bowls with lids covering them. EI #2 placed the tray on top of another tray of bowls that was labeled puree fruit. EI #2 also took a pan of rolls from the shelf below and placed them on the counter. EI #2 began placing wrapped rolls into another pan using bare hands (no gloves on), without washing hands. She again touched the garbage can lid to throw an item away, proceeded to take a dirty pan to the sink, and then entered the storage room. After leaving the storage room, EI #2 then walked to the stove and touched a pan on it. EI #2 still had not washed hands. She then walked to a metal rack and removed tongs, placed them in a pan, and stirred a pot of gravy. The surveyor interviewed EI #2 on [DATE] at 4:38 PM. When asked what the facility's policy was regarding hand washing while working in the kitchen, EI #2 replied, before putting on gloves, before and after dealing with food, when coming in and out of the kitchen, and when leaving the dishwashing room and restroom. The Surveyor asked, if you touch a soiled pan that chicken was cooked in should you wash your hands before you handle a pan of rolls that was being served for lunch. EI# 2 replied, yes. When asked what the potential harm was if a staff member touched the trash can and soiled items and then touched the food being served to the residents, EI #2 replied, bacteria. EI #1, the Dietary Manager, was interviewed on [DATE] at 5:13 PM. When asked what the policy was for handwashing for staff in the kitchen, EI #1 said staff were supposed to wash hands before putting gloves on. The Surveyor asked, should staff wash hands after touching the trash can lid in the kitchen and before touching ice scoop or rolls in bags being served to residents for lunch. EI# 1 replied, yes, due to cross contamination.

Based on observations, record review, interviews, review of a facility policy titled, Diet Orders, and review of a facility form titled Mechanical Soft Diet, the facility failed to ensure Resident Identifier (RI) #40, received a mechanical soft diet as ordered by the physician. This affected one of three residents for whom meals were observed. Findings include: Review of a facility policy titled, Diet Orders, dated 2013, revealed: Policy: When there is a nutritional indication, the facility will provide a therapeutic diet that is individualized to meet the clinical needs and desires of the patient/resident to achieve outcomes/goals of care. These diets coincide with the therapeutic diets on the facility menus. Procedure: . 3. Diets will be offered as ordered by the physician. Review of the facility document Mechanical Soft Diet, dated 2011, revealed: A Mechanical Soft or Dental Soft Diet is used for individuals who have difficulty chewing regular textured foods.Foods that are difficult to chew are chopped, ground, shredded and/or soft cooked to facilitate chewing and ease of swallowing. Mechanical Soft (Dental Soft) Diet . Foods Allowed . Protein Foods . Must be very tender, small pieces, shredded, chopped or ground, and well moistened with gravy or cream sauce . Foods to Avoid . dry/tough meats, whole pieces of meat . RI #40 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of RI #40's (MONTH) 2019 Physician order [REDACTED]. On 04/16/19 at 2:44 PM, RI #40 stated that the meat was too tough, and stated he/she has a hard time chewing meat. An observation was made of the resident's meal tray sitting on the over bed table. The resident had a whole piece of meat, mashed potatoes, and butterbeans. On 04/17/19 at 05:34 PM, the dinner tray for RI #40 was observed to have two hot dogs with cheese. The hot dogs were whole and not mechanically soft. The meal ticket on the tray had his/her diet as mechanically soft. The resident had not eaten any of the hotdogs. RI #40 said he/she could not eat that . On 04/18/19 at 07:49 AM, an observation was made of RI #40's breakfast tray; it was observed to have a piece of sausage on it, that was not mechanically soft. On 04/17/19 at 05:58 PM, an interview was conducted with Employee Identifier (EI) #3, Certified Nursing Assistant (CNA) . EI #3 was asked, what does the diet card say on RI #40's tray. EI #3 replied, mechanical soft. EI #3 was asked if RI #40 received a mechanically soft diet. EI #3 replied, no. EI #3 was asked, what kind of diet is it. EI #3 replied, solid. EI #3 was asked, what is the potential concern of serving a regular diet to someone who requires a mechanically soft diet. EI #3 replied, malnutrition. On 04/18/19 at 01:34 PM, an interview was conducted with EI #1, Dietary Manager. EI #1 was asked, what is the purpose of a diet for a resident. EI #1 replied, to make sure they get adequate nutrition, and you don't want anything to make them sick. EI #1 was asked, who is responsible for making sure a diet is followed. EI #1 replied, the kitchen staff and me. EI #1 was asked, how do dietary staff ensure a resident receives the correct diet. EI #1 replied, it is printed out on their tray card, and as soon as we get the diet changes we upgrade or down grade their diet. EI #1 was asked, what is a mechanical soft diet. EI #1 replied, being able to mash with a fork.

Based on observation, interviews, and review of a facility policy, titled, Hand Hygiene Policy and Procedure, the facility failed to ensure a licensed staff member did not perform a finger stick blood sugar (FSBS) on a resident and place his/her soiled gloved hand into a cup and bag containing clean items, and place them back on the medication cart. This affected one of four nurses observed during medication pass. Findings include: A facility policy titled, Hand Hygiene Policy and Procedure, revised 6/17, revealed, Purpose: Hand hygiene is recommended to reduce the transmissions of infection to residents,staff, and visitors in the health-care setting. Procedure: . 3. Perform hand hygiene after contact with blood, body fluids, mucous membranes, non-intact skin, . when handling invasive devices .and when otherwise indicated to avoid transfer of microorganisms to other residents or environment. On observation was made on 4/17/19 at 4:46 PM during medication pass with Employee Identifier (EI) #5, Licensed Practical Nurse (LPN). EI # 5 performed a FSBS on a resident, then reached her contaminated gloved hand into a cup filled with cotton balls and glucometer strips, and into a bag containing Sani-wipes. She then removed her gloves and washed her hands and placed the cup of items and the bag of Sani-wipes back into the medication cart. On 04/17/19 at 05:22 PM an interview was conducted with EI # 5, LPN. EI # 5 was asked, what should you do after performing a FSBS, before reaching your soiled gloved hand into a cup with cotton balls and glucometer strips, and before reaching your soiled gloved hand into a bag of Sani-wipes. EI #5 replied, wash hands. When asked if she put those items back into the medication cart, EI #5 replied, yes. EI #5 was asked, what is the potential concern for reaching your soiled gloved hand in a cup with cotton balls and glucometer strips and your soiled gloved hand in a bag of Sani-wipes. EI #5 replied, contamination. EI # 5 was asked, what is the potential concern for placing these items back on the medication cart. EI #5 replied, contamination. On 04/18/19 at 10:50 AM, an interview was conducted with EI #4, Infection Control. EI #4 was asked, what should a nurse do after performing a FSBS, before reaching her gloved hand into a cup with cotton balls and glucometer strips, and before reaching her gloved hand into a bag of Sani-wipes. EI #4 replied, she should have taken her gloves off and washed her hands. When asked what the potential concern was of not removing the gloves and washing her hands first, EI #4 replied, spread of infection, exposing someone else to a blood pathogen.

Based on an observation, interviews, record reviews, and review of the facility's policy titled, Medication Administration Procedures Enteral Tube Administration, the facility failed to ensure the privacy curtain was pulled around for RI (Resident Identifier) #5, during medication administration by G (Gastrostomy)-tube. This was observed on RI #5, one of one sampled residents observed for medication administration via [DEVICE]. Findings include: A review of the facility's policy titled: Medication Administration Procedures Enteral Tube Administration dated 01/12 revealed: .Procedures 1. Explain the procedure and screen the resident for privacy. A review of RI #5's medical record revealed the resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #5's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 01/06/17, revealed RI #5 had severe cognitive impairment. During a medication pass observation via [DEVICE] on 01/31/17 at 4:50 p.m., the following was observed. EI (Employee Identifier) #1, an LPN (Licensed Practical Nurse) administered the medication to RI #5, in full view of the resident's roommate. The privacy curtain was not pulled between the two residents. On 02/1/17 at 5:25 p.m., an interview was conducted with EI #1. The surveyor asked EI #1 what was not done to ensure privacy was provided for the resident. EI #1 stated, I did forget to pull the privacy curtain, and (his/her) roommate was in the room. The surveyor asked EI #1 what was the concern with the above observation. EI #1 stated, Number one, it is a violation of HIPAA (Health Insurance Portability and Accountability Act). The other resident should not know what is going on. It could also be a dignity issue for (RI #5). On 2/2/17 at 2:45 p.m., an interview was conducted with EI #2, the DON(Director of Nursing) of the facility. EI #2 was asked how staff should provide privacy while administering [DEVICE] medications. EI #2 stated, They shut the door, close the blinds, and pull the privacy curtain. The surveyor asked EI #2 what was the concern when privacy was not provided during medication administration via [DEVICE], and the resident's roommate was present and observed the procedure. EI #2 stated, It is a dignity issue. The resident is exposed with someone watching. It is a privacy and dignity issue.

Based on observations, interviews, and record reviews, and review of the facility's policy on Handwashing the facility failed to ensure a licensed nurse washed her hands between residents and after touching contaminated items while administering medications. This deficient practice affected Resident Identifier #11, one of eight residents observed for medication pass. Findings include: A review of the Handwashing Policy and Procedure, revised 2/10 revealed, Purpose: The use of appropriate handwashing and hand antisepsis practices are recommenced to promote improved hand-hygiene practices and reduce the transmission of microorganisms to patient and personnel in the health-care setting . 1. Wash hands after touching . contaminated items, regardless of whether gloves are worn . On 02/01/17 at 12:01 p.m., a medication pass observation was performed by EI (Employee Identifier) #4, an LPN (Licensed Practical Nurse). EI # 4 attempted to administer a medication to an unsampled resident. After this resident refused the medication, EI #4 disposed of the medication into a sharp's container. EI #4 went into the medication cart with her bare hands and obtained a container of powdered thickener. EI #4 scooped 30 milliliters into a plastic medication cup, poured it into a cup, and added juice. EI #4 knocked on the door, pulled the privacy curtain, and administered the solution with medications to RI #11 without washing her hands before providing RI #11's medication. On 02/01/17 at 6:00 p.m., an interview was conducted with EI #4. The surveyor asked EI #4 when she should wash her hands while administering medications. EI #4 stated, before and after administering medications. On 02/02/17 at 2:40 p.m., an interview was conducted with EI #2, the facility's DON (Director of Nursing). The surveyor asked EI #2 when should staff wash their hands during medication pass. EI #2 stated before they start, between residents, between eye drops, and with mixing medications.

Based on observations, record reviews, interviews, and review of Potter and Perry Medication Administration, the facility failed to ensure: 1. The licensed nurse flushed with 5 ml (milliliters) of water between medication administrations by G (Gastrostomy)- tube. This affected RI (Resident Identifier) #5 one of one resident observed receiving medication by [DEVICE]. 2. The licensed nurse did not administer the [MEDICATION NAME] IV (intravenously), outside of the ordered time frame. This affected RI #6 one of one resident observed receiving IV therapy. These deficiencies affected RI #5 and RI #6, two of eight residents observed for medication pass. Findings include: 1. A review of Potter and Perry Fundamentals of Nursing Ninth Edition, with a copyright date of 2013 revealed: Chapter 32, Medication Administration . page 635 . When administering more than one medication at a time, give each separately and flush between medications with 15 to 30 mL(milliliters) of water. A review of the facility's policy titled, Medication Administration Procedures Enteral Tube Administration, dated 01/12 revealed: .Procedures . 6. Administer medications separately using a syringe. Medications can be diluted with water and flushed with approximately 5-10 mL's of water. A review of RI #5's medical record revealed the resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #5's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 01/06/17 revealed RI #5 had severe cognitive impairment. The MDS also revealed RI #5 required the use of a feeding tube for nutritional needs. A review of RI #5's medical record had an order dated 05/08/10, that revealed: FLUSH W/(with) 30 CC'S (cubic centimeters) H2O (water) BEFORE & AFTER MEDICATION ADMINISTRATION & 5 CC'S BETWEEN EACH MED (medication). (In addition to routine flush) . During a medication pass observation via [DEVICE] on 01/31/17 at 4:50 p.m., the following was observed. EI (Employee Identifier) #1, an LPN (Licensed Practical Nurse) crushed, diluted, and administered, five medications to RI #5 via [DEVICE]. EI #1 did not flush between each medications with 5 cc's of water. An interview was conducted with EI #1 on 2/1/17 at 5:25 p.m The surveyor asked EI #1 how she was instructed to flush the [DEVICE] during medication administration. EI #1 stated, I am instructed to flush with 5 cc before and after the medications are given. The surveyor asked EI #1 how she flushed the [DEVICE] while administering medications for RI #5. EI #1 stated, I did flush it with each medication with 30 cc of water. I flushed it with 30 cc before and after. The surveyor discussed the above observation with EI #1, and asked if she flushed between medications with water. EI #1 stated, Not with plain water. I mixed the 30 cc with the medication, but I did flush with 30 cc before and after I administered the medications. The surveyor asked EI #1 what the concern was when the [DEVICE] was not flushed between medications with 5 cc's of water. EI #1 stated, Basically to make sure the medications go down the tube with not clogging it up. It is to ensure the medications goes through the tube. On 2/2/17 at 2:45 p.m., an interview was conducted with EI #2 the DON (Director of Nursing) of the facility. EI #2 was asked how nurses were instructed to flush the [DEVICE] while administering medications via [DEVICE]. EI #2 stated, You are going to check placement with air, Auscultate, and we flush with water, 30 cc before, flush between medications with 5 cc, and at the end of the medication administration with 30 cc. The surveyor asked EI #2 what the concern was, when the [DEVICE] was not flushed with 5 cc between medications. EI #2 stated, Well the tube can get stopped up. The flushing helps to get the pills through the tube. 2. A review of Potter and Perry Fundamentals of Nursing Ninth Edition, with a copyright date of 2013 revealed: Chapter 32, Medication Administration .page 635 .Chapter 32 . Right Time . Give antibiotics 30 minutes before or after they are scheduled .to maintain therapeutic blood levels. A review of RI #6's medical record revealed the resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #6's medical record had an order dated 01/25/17, that revealed: .[MEDICATION NAME] ([MEDICATION NAME])80 mg (milligram) IV Q Every 12 hrs (hours)X (times) 10 days . at 9:00 AM and 9:00 PM. During a medication pass observation on 2/01/17 at 7:45 a.m., an Empty IV bag of [MEDICATION NAME] 80 mg was observed hanging in RI #6's room. EI #3, a Registered Nurse stated that she had already administered the medication to RI #6. EI #3 stated she arrives at 5:30 a.m., to administer medications because she had to administer medications on three different halls. An interview was conducted with EI #3 on 2/2/17 at 1:10 p.m The surveyor asked EI #3 what the standard time frame was allowed for administering medications. EI #3 stated, One hour before and one hour after. The surveyor asked EI #3 what time she administered RI #6's [MEDICATION NAME]. EI #3 stated, I hung it at 7:40 a.m The surveyor asked what time was the medication ordered to be given. EI #3 stated, 9 a.m. The surveyor asked EI #3 why it was administered more than one hour prior to the ordered administration time. EI #3 stated, I hung it early so that I can get to the back hall to administer medications. The surveyor asked EI #3 what was the concern when medications are not administered at the ordered times. EI #3 said she understood the concern. She stated that she was only one person and she did the best that she could do in the eight hours she was there. On 2/2/17 at 2:45 p.m., an interview was conducted with EI #2 the DON (Director of Nursing) of the facility. EI #2 was asked what was the standard time frame allowed for administering medications. EI #2 stated, One hour before and one hour after, if the medication is due at 9 a.m., you have from 8 a.m. to 10 a.m The surveyor asked EI #2 what the concern was, when medications were not administered at the ordered time. EI #2 stated, If it is not given at that time it would be too early or too late, for instance if it is ordered three times a day, it would not be given in the correct time frame. It is also not following doctor's orders.

Based on record review and interviews, the facility failed to implement their abuse policy and procedure by not ensuring a background check and reference check was completed prior to Employee Identifier (EI) #8's employment and further failed to ensure the facility provided training to EI #8 during orientation on the facility's abuse policy and procedure. hire for the facility's Beautician. This affected one of seven personnel files reviewed. Findings include: The facility's policy and procedure titled "Abuse Prevention Policy" with a revised date of 12/13/2013, documented "It is the policy of Englewood Health Care Center, LLC to insure ... *Applications for employment will contain questions relating to criminal felony convictions and/or felony charges ... The supervisor responsible for hiring shall make a reasonable effort to contact the applicants prior employers in an effort to uncover positive and/or negative work behavior. *An applicant for a non professional position will be investigated through the State Registry to determine if reports of abuse, neglect, mistreatment or misappropriation of property exist as to the applicant ... a drug screen shall be administered to each prospective employee ... *A criminal background check will be conducted on each prospective employee prior to employment and annually thereafter on the employee's anniversary date ... *As a part of the orientation procedure, each new employee will receive education regarding the facility policies concerning resident rights and physical, neglect, verbal and sexual abuse, corporal punishment, involuntary seclusion, and misappropriation of resident's personal property to include methods of properly reporting any such alleged violation of resident rights. Training will also be provided on appropriate intervention methods that may become necessary to remove a resident from potential harm in the event that a resident or visitor exhibits aggressive or catastrophic behavior. Additionally, this facility shall provide annual training for all employees regarding these policies ... ." During an interview on 02/25/15 at 8:45 AM, Employee Identifier (EI) #8, the beautician, was asked, what would she do if she witnessed an employee inappropriately touch a resident. EI #8 stated she didn't know. When asked, what would she do if she was aware an employee took a resident's credit card and used it for their own purposes, EI #8 stated she didn't know. The surveyor asked EI #8, if a resident was in need of something and a staff member refused the resident, what type of abuse would that be. EI #8 stated she did not know. When asked when was the last abuse in-service she attended, EI #8 stated a couple of years ago. In an interview on 02/25/15 at 9:30 AM, EI #1, the Administrator was asked if he had any in-service training records for EI #8. EI #1 stated no. When asked was there a background check, reference check or Nurse Aide Registry check done on EI #8 prior to her employment, EI #1 said no. A typed letter on facility letterhead dated 02/25/15 written by EI #1 documented " ... To whom it may concern: The only documentation that Englewood Health Care Center has on (EI #8), Beautician is her current Alabama Board of Cosmetology and Barbering License. On 2/25/2015, we did not have a background investigation, drug screen, reference check, abuse registry check or in-service training on (EI #8) ... ." In an interview on 02/25/15 at 10:10 AM, EI #2, the Staff Development Nurse acknowledged that she was responsible for training new staff on abuse and for providing ongoing staff training on abuse. When asked what training did she provide to EI #8, EI #2 stated she had not provided any training to EI #8. The surveyor asked, was the abuse policy and procedure followed for EI #8 and EI #2 stated no.

Based on observation, interviews and record review, the facility failed to discard two 1-gallon containers of milk by the stamped use-by dates, seal bagged bread after use and before storage, and ensure staff did not handle ready-to-eat food with bare hands. This had the potential to affect all 78 residents for whom meals were prepared and served at the time of the survey. Findings included: FOOD STORAGE During the initial kitchen tour on 05/29/13 between 10:20 and 10:40 AM, the following was observed: 1) Two 1-gallon containers of whole milk were stored in the milk box with stamped use-by dates of May 24 and May 26 (three to five days past their recommended use). The facility policy related to "Food Storage" (Policy & Procedure Manual, Becky Dorner & Associates, 2010) specifies: "14. Refrigerated Food Storage: ...f. ...All foods will be checked to assure that foods... will be consumed by their safe use by dates or frozen (where applicable) or discarded." 2) A bag containing one loaf of cinnamon raisin bread was left open to air on the storage shelf. The facility policy related to "Food Storage" (Policy & Procedure Manual, Becky Dorner & Associates, 2010) specifies: "8. e. Foods will be stored and handled to maintain the integrity of the packaging until ready for use." FOOD PREPARATION 3) On 05/30/13 at 10:50 AM, the surveyor noticed a basket of fried chicken tenders resting atop the grill adjacent to the deep fat fryer. The cook (Employee Identifier/EI #1) got a 1/3-size steam table pan, and with her bare hands transferred several pieces of fried chicken tenders from the fryer basket to the steam table pan. On 05/30/13 at 10:52 AM, the surveyor watched as EI #1 obtained and donned a pair of gloves. The surveyor then asked EI #1 why she put the gloves on. EI #1 explained she was about to chop some meat for the lunch trayline. When asked why she needed gloves, EI #1 said she was told to wear them, but she did not know why. The surveyor mentioned the observation of EI #1 not using gloves to transfer the fried chicken tenders from the basket to the pan. EI #1 explained she had been in a hurry. The facility policy regarding "Food Handling and Serving" specifies: "Food is to be handled in such a manner consistent with established safety and sanitation regulations and in a manner that is designed to minimize the potential of cross contamination." "Procedure: 1. Food shall be served with clean tongs, scoops, forks or other suitable implements so as to avoid manual (hand) contact with prepared food."

Based on observation, interview, and record review the facility failed to ensure: 1. Ice cream received frozen, remained frozen during storage on 04/10/2012 and 04/11/2012, two of two days of the survey. ( Food Code - 3-501-11) 2. Large serving pans were not stored in a manner to prevent wet nesting in the facility's kitchen during the tour on 04/10/2012. These deficiencies had the potential to effect 73 of 73 residents being served from the kitchen. Findings Include: A review of the facility's policy on food storage with the date of 2010, revealed: " FOOD STORAGE...Refrigeration temperatures should...maintain food temperatures at or below 41 degrees F (Farenheit) and freezer temperatures to keep food frozen solid." 1. Food Storage: During the tour on 04/10/2012 at 12:51 PM, the inside temperature of the walk in freezer was 10 degrees F. Ice cream was stored in a carton on the shelf they were very soft to the to the touch. At 1:05 PM during the tour, 2 ice cream cup containers and 2 magic cups containers were observed in the freezer in the pantry area. The surveyor lifted the lids and the items were extremely soft and melted. The temperature inside the freezer was 17 degrees F. On 04/11/2012 at 10:05 AM, the inside temperature was 7 degrees F in the walk in freezer, the ice cream was very soft to touch and easy to squeeze. This observation was observed by the surveyor and EI #2. During an interview with the Assistant Dietary Manager, EI(Employee Identifier) #2 on 04/12/2012 at 9:15 AM, the surveyor asked what temperature should ice cream be stored, and what negative effect could occur when soft melting ice cream was served to residents. EI #2 said, the freezer temperature should be 0 degree F and spoilage could occur if ice cream was not kept at the proper temperature. 2. Wet nesting observations: A review of the facility policy dated 2010 reveled, "...Manual Dishwashing...Check all dishes to be sure they are clean and dry prior to storing..." During the tour of the kitchen on 04/10/11 at 1:22 PM, the surveyor observed 4 of 6 large serving pans stacked on a storage rack. The pans had water and grease films on the inner surfaces. At 1:24 AM, during the tour additional pans were observed in the kitchen. Four of four large serving pans were stacked wet on a different rack in the kitchen. All 8 pans were stored in a manner for wet nesting to occur on the inner surface areas.

Based on observations, interviews and record review, the facility failed to ensure the south hall's whirlpool tub, its seat and frame were free of rust, rough and jagged areas. This had the potential to affect ten of ten residents who used the south hall's tub room, and one of three facility tub rooms. Findings Include: On 04/10/12 at 1:02 PM, during initial tour the following were observed in the south hall's tub room: 1. Whirlpool tub -top front noted with open jagged area -inside of door near top noted with a chipped, vertical grooved area -slightly above the door handle/latch, located on the outside of the tub, noted with a chipped horizontal grooved area 2. Seat -front section noted with two jagged areas -top back section noted with jagged areas 3. Frame of seat -chipped paint, rusted and rough areas On 04/11/12 at 11:00 AM, during an interview with Employee Identifier (EI) #11(Certified Nursing Assistant (CNA)), the surveyor asked what was the bath on the south hall used for. EI #11 stated to give baths in the tub and the shower. The surveyor asked how often did she use the room from baths, tub and shower. EI #11 stated everyday except Sunday. The surveyor requested EI #11 to look at the whirlpool tub. The surveyor and the EI #11, observed the whirlpool tub and the surveyor asked to whom did she report the jagged edges on the tub, the chair and the peeling paint to. EI #11 stated she had not reported the areas to maintenance. The surveyor asked how long had she (EI #11) been aware of the jagged areas, peeling paint and rough areas. EI #11 said, for about four months. She also stated maintenance worked on the tub to fix the water and that she was sure they saw the areas. The surveyor asked with these jagged and rough areas to the tub and the chair, what would the potential for harm be to the residents. EI #11 stated skin tear or injury. On 04/11/12 at 11:26 PM, during an interview with EI #3 (Director of Maintenance), the surveyor asked who was responsible for checking facility equipment, tubs in the shower room. EI #3 stated he was responsible. The surveyor asked what did he check when he made rounds and how often. EI #3 stated all hardware for proper functioning, water temperatures, leaks, any missing parts, and make sure everything is in good working condition on a monthly basis. The surveyor asked about the peeling paint and jagged edges on the tubs and chairs in bath rooms. EI #3 stated he did monthly rounds and also communicated by work orders through nursing and CNAs, if any repairs were needed. The surveyor requested monthly maintenance reports and work orders. On 04/11/12 at 11:40 AM, maintenance reports reviewed. A review of the facility's form titled "Preventative Maintenance Inspection Checklist" dated March 2012 revealed the following: "Check each item on each unit monthly...Check each item off once the check is completed if no concerns. You are looking that items are in working order and not needed to be repaired/painted /stained as well. Any concerns found or items needing repair are to be addressed in the comments section...Area to check...Apollo tubs/seat secure with no broken parts;...South Hall (checked)...Comments (if item needing repair briefly describe and how corrected)..." No comments noted on the March 2012 monthly maintenance check for the Apollo tub. The surveyor requested the EI #3 to observe the bath room and asked what areas were potential problems. EI #3 responded: 1. The right side top door fiberglass is broken with jagged areas. 2. The bottom right door opening slightly above the door latch is broken with a jagged area. 3. The upper inside section of the door opening has a worn place with a slightly grooved area. 4. The chair has a chipped place on the front seat section that is rough, worn areas and the coating is off. 5. The top back section of the chair is gouged, broken and jagged. 6. The frame paint is peeling, rusted and has rough edges. The surveyor asked what was the potential for harm to the resident. EI #3 stated the jagged edges and the rough areas, would be a potential for skin tears. The surveyor asked when was the maintenance check completed for March. EI #3 stated March 22, 2012. The surveyor asked what did he check. EI #3 stated he only observed the peeling paint to the frame. The surveyor asked why hadn't he done any thing with the frame. EI #3 stated only thing to do was to replace the frame. When the surveyor asked why the frame had not been replaced. EI #3 said he could not tell me why the frame had not been replaced. The surveyor then asked how long had the peeling paint and the rust been there. EI #3 stated for about two months. The surveyor requested a list of residents who used the whirlpool tub on south hall. A review of the list revealed, ten resident's on the list, used the south hall whirlpool tub. RI(Resident Identifier) #17 was readmitted to the facility 01/06/12. The Minimum Data Set with the Assessment Reference Date of 01/13/12 revealed RI #17 had a BIMS (Brief Interview of Mental Status) score of 10 out of 15. On 04/12/12 at 2:20 PM, during an interview with RI #17, the surveyor asked how often did he use the south hall bath room. RI #17 stated every Monday and Thursday. The surveyor asked when he used the tub, was anything wrong with the tub. RI #17 stated yes, the frame was rusted and rough. The surveyor asked how did he know the frame was rough. RI #17 stated he could look at it and see it was rough. The surveyor asked who did he report this to. RI #17 stated he did not report it.

Based on observation and interview, the facility failed to ensure: 1. Waste was properly contained in 2 of 3 dumpsters and the surrounding areas were free of trash. 2. 1 of 3 dumpsters had a build up dirt and grease. This had the potential to affect all 78 residents in the facility. Findings include: On 04/11/2012 at 07:55 AM, 3 dumpsters were observed. The one on the right side had one lid partially lifted with stacked boxes observed propping it open. This dumpster also had trash, that included a dirty bed linen saver that was partially stuck under the dumpster. The middle dumpster had a torn garbage bag and juice cups, that were partially underneath the dumpster. This dumpster's side door was open. All 4 sides of this dumpster had a build up of grease and dirt. On 04/11/2012 at 4:20 PM, an interview was conducted with (Employee Identifier)EI #3, the Maintenance Director. The surveyor asked when were the dumpsters last emptied. EI #3 said that the dumpsters on left and in the middle were probably emptied this morning. He stated that the dumpster on the right would probably be emptied tomorrow (this was the dumpster with the linen saver stuck partially underneath). EI #3 explained that the dumpsters were suppose to be emptied weekly, but sometimes they were emptied every 2 weeks. When the surveyor said that the dumpster on the right had the linen saver partially underneath it, EI #3 stated, "It (the linen) saver had to come out (fallen out of the dumpsters) when it was last emptied." The surveyor questioned EI #3 regarding how often the dumpsters were to be cleaned. EI #3 said they generally wash them down with bleach once a week. When asked when was the last time the dumpsters were washed down, EI #3 stated, "Oh, it's been about a month. They (the company that empties the dumpsters) take them to a landfill sometimes and they come back real dirty." The surveyor asked if the facility had a cleaning log for the dumpsters. EI #3 said, no.