Every finding on record at Evergreen Nursing Home

Based on observation, interview, a facility policy titled, Assisting the Impaired Resident with In-Room Meals and a facility document titled, Inservice Dignity and Respect, the facility failed to ensure a CNA (Certified Nursing Assistant) did not stand while feeding RI (Resident Identifier) #46 the lunch meal on 03/10/20. This deficient practice affected RI #46, one of four sampled residents who required assistance with feedings. Findings Include: A review of a facility policy titled, Assisting the Impaired Resident with In-Room Meals, with no date revealed the following: Policy: The purpose of this procedure is to provide a well-balanced meal to the resident who needs assistance with eating . Procedure: . 3 . be seated during the feeding, position a chair where it will be convenient for you and the resident, providing resident dignity . A review of a facility document titled, Inservice Dignity and Respect, with no date, revealed the following: . the facility must promote care for residents in a manner . that maintains or enhances each resident's dignity . Promoting resident . dignity in dining such as avoidance of: . Staff standing over residents while assisting them to eat: . RI #46 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #46's Care Plan revealed the following: Problem Onset 10/3/14 . ADL's (activities of daily living) Resident requires assist w/(with) . eating . Approaches .* Provide assistance with meals . On 03/10/20 at 12:20 p.m., the surveyor observed EI (Employee Identifier) #1 standing up while feeding RI #46, while the resident was sitting on the side of the bed. On 03/10/20 at 12:39 p.m., an interview was conducted with EI #1, a CNA. EI #1 was asked did she feed EI #46 his/her lunch meal. EI #1 said yes. EI #1 was asked what position was she feeding RI #46. EI #1 said she was standing. EI #1 was asked what was she taught about feeding residents. EI #1 said to sit down on the side of them (resident), pay attention to them and make sure they are offered everything on the tray. EI #1 was asked what position should she have been in when feeding the resident. EI #1 said she should have been sitting in front of, or on the side of RI #46. EI #1 was asked why was she standing feeding RI #46. EI #1 said there was no chair so she just stood up. EI #1 was asked what was the concern with standing up feeding a resident, would it be a dignity concern. EI #1 said yes it would be a dignity issue. On 03/12/20 at 2:25 p.m., an interview was conducted with EI #2, RN (Registered Nurse), Staff Development Coordinator. EI #2 was asked how were CNAs trained to assist the residents with feeding. EI #2 said they were trained to sit down to feed residents, for safety purposes of the residents. EI #2 was asked what position should the CNA be in when feeding residents. She said sitting down facing the resident. EI #2 was asked should staff be standing feeding a resident. She said no. EI #2 was asked what was the concern with the CNA standing while feeding a resident. EI #2 said it is a dignity concern.

Based on observations and interviews, the facility failed to ensure Resident Identifier (RI) #6 had an isolation sign outside of the door. This affected RI #6, one of one resident observed on isolation. Findings include: RI #6 was admitted to the facility on [DATE] and readmitted on [DATE]. RI # 6 had a [DIAGNOSES REDACTED]. On 03/10/20 at 3:29 p.m., an observation was made of RI #6's room, an isolation cart containing gloves, mask, and gowns were outside of the room. No observed isolation sign on the door indicating the type of isolation such as contact, airborne, or droplett the resident was on, or what staff/visitors should do before entering the room. On 03/11/20 at 9:09 a.m., an observation was made of RI #6's room, an isolation cart (remained) outside of the room. Still no observed isolation sign on the door indicating the type of isolation the resident was on, or what staff/visitors should do before entering the room. On 03/12/20 at 8:09 a.m., an observation was made of RI #6's room, an isolation cart remained outside of the room. No observed isolation sign on the door indicating the type of isolation the resident was on, or what staff/visitors should do before entering the room. On 03/12/20 at 1:29 p.m., an interview was conducted with Employee Identifier (EI) #3, Unit Manager. EI #3 was asked, who was the unit manager on the hall where RI #6 was. EI #3 replied, she was. EI #3 was asked, what kind of precautions was RI #6 on. EI #3 replied, on contact isolation. EI #3 was asked, why was the resident on these precautions. EI #3 replied, the resident had ESBL positive urine. EI #3 was asked how staff knew what precautions the resident was on. EI #3 replied there was a sign, it was on the care plan, it was in the books. The resident had a door hanger and they changed it out, she thought that they must have taken it off when they took it because it was attached to it. EI #3 was asked, how do visitors know what to do. EI #3 replied, usually the only visitor the resident had was her/his sister and she came once or twice a week and has been told what to do. EI #3 was asked, was there a sign on the door. EI #3 replied, no. EI #3 was asked, where was the sign for the door. EI #3 replied she did not know but it had been there. EI #3 was asked, should there be a sign. EI #3 replied, yes. EI #3 was asked, why was there not a sign for the door. EI #3 replied it obviously came off the door. EI #3 was asked, who was responsible for ensuring there was a sign on the door. EI # 3 replied that would be every personnel in this building. EI #3 was asked what was the potential concern of not having a sign outside of a resident's room that was on transmission-based precautions. EI #3 replied, that someone may come in and get contaminated and expose it to someone else. On 03/12/20 at 1:46 p.m., an interview was conducted with EI #4, Infection Control Nurse. EI #4 was asked, what kind of precautions was RI #6 on. EI #4 replied, on contact isolation. EI #4 was asked, why was the resident on these precautions. EI #4 replied the resident had ESBL in the wound and urine. EI #4 was asked, how did staff know what precautions the resident was on. EI #4 replied it was posted on the door, and every time they put residents on precautions they did in-services. EI #4 was asked, how did visitors know what precautions the resident was on. EI #4 replied when they first put the resident on precautions they contacted them and let them know. EI #4 was asked, where was the sign for the door. EI #4 replied usually they put it on the door and it was under the resident's name. EI #4 was asked, should there be a sign. EI #4 replied yes. EI #4 was asked, why was there not a sign for the door. EI #4 replied, she did not know if it fell off, she really did not know, but there was a sign on the door. EI #4 was asked, who was responsible for ensuring there was a sign on the door. EI #4 replied all staff really, she was the infection control person, so she initiated it. EI #4 was asked, what was the potential concern of not having a sign outside of a resident's room that was on transmission-based precautions. EI #4 replied that someone entering into that room without the proper Personal Protective Equipment (PPE) could cause a visitor or another resident to get what that resident had.

Based on observation, interview, and review of the facility's policy titled, Medication Administration - General Guidelines, the facility failed to ensure a licensed nurse washed her hands after returning to the medication cart to continue preparing medication for Resident Identifier (RI) #21. Further, the facility failed to ensure a licensed nurse did not place a contaminated blister medication card into the medication cart after it had fallen on the floor. This affected one of four residents and one of three nurses observed during medication pass administration. Findings Include: A review of the facility's policy titled, Medication Administration - General Guidelines, dated 01/12 revealed: . Procedures . 6. Cleanse hands with soap and water before handling medication . RI #21 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 1/16/19 at 8:14 a.m., the surveyor observed Employee Identifier (EI ) #1, Licensed Practical Nurse, leave the medication cart to go to the medication room to retrieve more insulin. EI #21 was observed touching items in the medication room, such as the door handle, the refrigerator, and the emergency medication box. EI #1 did not wash her hands when she returned to the medication cart to continue preparing RI #21's medication. EI #1 then placed a medication blister card that had fallen on the floor into the medication cart. An interview was conducted on 1/16/19 at 4:04 p.m. EI #1 was asked, what should be done after returning to the medication cart and before continuing to prepare medication. EI #1 stated, I should have . washed my hands in the sink at the nursing station. EI #1 was asked, what should be done after the nurse picked up the medication blister pack off the floor and handed it to you. EI #1 stated, I should have used a kleenex to take the blister pack from her. EI #1 was asked, should the blister pack have been placed into the medication cart. EI #1 stated, No, it should have been placed in the drug destruction box. EI #1 was asked, what was the potential for harm. EI #1 stated, Germs, . can cause other residents to get sick. An interview was conducted on 1/16/19 at 4:12 p.m. with EI #2, Registered Nurse/ Quality Assurance, Infection Control. EI #2 was asked, what should be done after a nurse returns to the medication cart to continue preparing medications. EI #2 stated, Wash her hands. EI #2 was asked, if a blister pack of medications falls on the floor, what should the nurse do. EI #2 stated, She must throw the medication away after it hits the floor because it is contaminated.

Based on observations, interviews, and a review of the 2013 Food Code, the facility failed to ensure a dietary worker washed her hands after handling soiled dishes and prior to handling clean dishes. This had the potential to affect all fifty-seven residents that were served meals from the kitchen. Findings Include: A review of the 2013 FDA (Food and Drug Administration) Food Code revealed: 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms . immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and . (E) After handling soiled EQUIPMENT or UTENSILS; . (I) After engaging in other activities that contaminate the hands . An observation was made on 01/31/18 at 9:18 AM of EI (Employee Identifier) #3, a Dietary Aide, washing silverware. EI #3 was observed to send the silverware through the dishwasher flat, then removed the washed silverware and stacked the silverware in holders with the tines up without washing her hands between handling the soiled silverware then the clean silverware. EI #3 then removed a clean rack and changed tines to down and re-washed silverware without her hands being washed. EI #3 washed and wiped multiple surfaces in the dirty dish-washing area with a wash cloth. Without washing her hands, EI #3 then gripped the rack of clean utensils, shook it, and continued to clean the dirty side of the dish-washing area. EI #3 had not washed her hands. At 9:30 AM, EI #3 wiped her hands on her apron and retrieved a cart from the dining room with her unwashed hands. At that time, EI #3 washed her hands and put her hands back on the bar she handled with unwashed hands. An interview was conducted with EI #3 on 01/31/18 at 9:47 AM. EI #3 was asked how should clean dishes and silverware be handled and she answered with her hands. EI #3 was asked when should hands be washed during dishwashing and she answered before washing the dirty silverware and after. EI #3 was asked if she did that. EI #3 initially answered yes then added she had washed them before handling the dirty. EI #3 was asked what was the concern of handling clean dishes or silverware with unwashed hands and she answered bacteria contamination. EI #3 was asked if she usually worked both the clean and dirty side of dishwashing and she answered yes. An interview was conducted with EI #2, the Dietary Manager, on 02/01/18 at 1:32 PM. EI #2 was asked when should hands be washed during dishwashing and she answered after contact with dirty dishes. EI #2 was asked what was the facility's policy regarding staff handling both soiled and clean dishes and silverware. EI #2 answered after staff handled the soiled, they were supposed to go wash their hands before they handled the clean. EI #2 was asked what was the concern of staff handling soiled dishes or silverware, then handling the clean dishes without washing their hands. EI #2 answered it could cause germs to be transferred.

Based on observation, interviews, and a review of a smoking assessment, the facility failed to ensure a smoking assessment was accurately completed for RI (Resident Identifier) #157. This affected RI #157, one of twenty-one sampled residents. Findings Include: A review of a facility policy titled, NURSING PR(NAME)EDURES MANUAL, with an effective date of 03/08, revealed: PURPOSE: The resident has the right to smoke, if desired. However, smoking is generally supervised to protect the resident from fire hazards. PR(NAME)ESS: 1. Upon admission, quarterly, and a significant change, the resident's smoking desires should be determined, along with their ability to smoke unattended. A review of the medical record revealed RI #157 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the care plan for RI #157 revealed, . Problem/Need . SMOKER Res (Resident) has the potential for injury r/t (related to) smoking due [MEDICAL CONDITION] w/(with) right-sided wkns (weakness) . Apply smoking apron whenever smoking . A review of a facility document titled, Smoker's Assessment, revealed a section for Cognitive Assessment, Motor Skills Assessment, and Safety Assessment. In the Safety Assessment section, the following abilities were to be assessed: .Wears apron when smoking Put ashes in proper container Lights cigarette on right end Knows when cigarette is finished Puts cigarette in proper container when finished. A review of the Smoking Assessment for RI #157 was dated 1/25/18, and revealed the ability, Wears apron when smoking, had not been checked. An observation was made on 02/01/18 at 2:33 PM of EI (Employee Identifier) #4, a CNA (Certified Nursing Assistant), asking if RI #157 was ready to go out to smoke. EI #4 got a storage bag with cigarettes and a smoking apron and walked down the hallway with RI #157. EI #4 put the smoking apron on RI #157. EI #4 passed a cigarette and lighter to RI #157. RI #157 lit the cigarette with a steady hand. At 2:52 PM, RI #157 extinguished their second cigarette, stood up, and EI #4 detached the smoking apron. An interview was conducted on 02/01/18 at 3:30 PM with EI #5, the Social Services Director. EI #5 was asked who completed the smoking assessment for RI #157. EI #5 answered a trainee and herself. EI #5 was asked what the assessment indicated related to RI #157 needing a smoking apron. EI # 5 answered it was not checked, EI #5 was asked what it meant when the line by need for apron was left blank. EI #5 answered that would say there was no need for an apron. EI #5 was asked what did the care plan indicate related to RI #157's use of a smoking apron and she answered to apply a smoking apron whenever smoking. EI #5 was asked should the plan of care match the assessment and she answered it should. EI #5 was asked which one was correct and she answered the care plan. EI #5 was asked what was the facility policy regarding the assessment and plan of care correlating and she answered they should match. EI #5 was asked what was the concern of the plan of care not matching the assessment. EI #5 answered she would be concerned that it may not match what the resident needs. An interview was conducted with EI #1, the Administrator, on 02/01/18 at 3:39 PM. EI #1 was asked if the care plan and assessment should match and she answered yes. EI #1 was asked what was the facility's policy regarding the assessment and plan of care correlating and she answered they should match. EI #1 was asked what was the concern of the plan of care not matching the assessment. EI #1 answered staff might not meet a resident's needs.

Based on observations, interviews, and a review of the manufacturer's descriptions of the divided plates residents' were served on, the facility failed to ensure residents were not served meals on divided plates that did not appear homelike. This affected all fifty-seven residents who were served meals from the kitchen. Findings Include: A review of the description of the Three-Compartment Plate, from the manufacturer's website revealed: . Item Details An excellent addition to any restaurant or food service establishment . A review of the description of the 3-Compartment Deep Plate, from the manufacturer's website revealed: . For use indoors and outside; dress up a table for everyday entertaining or use worry free for school, church, parties, poolside or barbecues . An observation was made on 01/30/18 at 12:04 PM of trays being served to residents in the dining room. The plates served to the residents were divided plates. An observation was made on 01/30/18 at 12:19 PM of seventeen residents who had been served meals on divided plates. An observation was made on 01/31/18 at 8:02 AM of residents on the hallways eating in their rooms. The residents' meals were served in divided plates and deep divided plates. An observation was made on 01/31/18 at 12:27 PM of all residents in the dining room being served in divided plates. An interview was conducted with EI (Employee Identifier) #2, the Dietary Manager, on 02/01/18 at 01:32 PM. EI #2 was asked why were residents served meals in divided plates. EI #2 answered she could only answer that those were the plates they had been using. EI #2 was asked were divided plates consistently used in a home setting and she answered that she did not use them at home. EI #2 was asked if that meant the divided plates were not homelike. EI #2 answered they were not like the ones she used at home. EI #2 was asked what were the expectations of the facility to provide a homelike atmosphere. EI #2 answered to make it look like things used at home. EI #2 was asked what was the policy for providing a homelike atmosphere for the residents. EI #2 answered they try to make it comfortable, quiet, and more like home, as if they were dining at home. EI #2 was asked what was the concern of residents being served meals in plastic divided plates and she stated one would wonder if they were satisfied. An interview was conducted with EI #1, the Administrator, on 02/01/18 at 3:39 PM. EI #1 was asked why were residents served meals in divided plates. EI #1 stated to prevent spillage, food juices mixing with other foods. EI #1 was asked were residents always served on divided plates. EI #1 answered yes, except for a period of time ceramic dinnerware was used, a more home-like type. EI #1 was asked if divided plates were consistently used in home settings and she answered no. EI #1 was asked what were the expectations of the facility to provide a homelike atmosphere. EI #1 answered they wanted to provide a homelike atmosphere. EI #1 was asked what was the policy for providing a homelike atmosphere for the residents and she answered none.

Based on observations, interviews, and document reviews, the facility failed to ensure a certified nursing assistant did not use the same gloves to apply a skin protectant to the buttocks, and then to the perineal area. This had the potential to affect RI (Resident Identifier) #9, a resident with a history of Urinary Tact Infection, one of three residents sampled for incontinence care. Findings include: A review of the facility's document titled, "Incontinent Care and Catheter Care Using Disposable Wipes," dated 12/2012, revealed, "... 2. Wash hands. Apply gloves. ... 4. Female - clean entire perineal area (outer and inner labia) with disposable wipe. ... 6. Turn resident on their side. Clean the buttocks and anal area, moving upwards toward the back in the same manner that you cleaned the perineal area." A review of the facility's document titled, "Handwashing Policy and Procedures," dated 2/10 revealed, "Purpose: The use of appropriate handwashing and hand antisepsis practices are recommended to promote improved hand-hygiene practices and reduce the transmission of microorganisms to patient and personnel in the health-care setting. Procedure: 1. Wash hands after touching blood, body fluids, secretions, excretions, mucous membranes, non-intact skin and contaminated items, regardless of whether gloves are worn. 2. Wash hands when they are visibly soiled or contaminated with proteinaceous material or are visibly soiled with blood or bodily fluids. 3. Wash hands...when otherwise indicated, such as performing personal hygiene, to avoid transfer of microorganisms to other residents or environments. ... 5. It may be necessary to wash hands between tasks and procedures on the same resident to prevent cross contamination of different body sites." A review of the medical records revealed RI #9 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Significant Change of Status MDS (Minimum Data Set) for RI #9, with an ARD (Assessment Reference Date) of 9/25/2014, revealed a BIMS (Brief Interview for Mental Status) score of 7 out of a possible 15 points. This indicated RI #9 was severely impaired for daily decision making skills. This MDS also indicated RI #9 required extensive assistance for ADLs (Activities of Daily Living). RI #9 was frequently incontinent of bowel and bladder. On 11/5/2014 at 2:50 PM, an observation was made of incontinence care for RI #9. The incontinence care was performed by EI (Employee Identifier) #1, and assisted by EI #2, both CNAs (Certified Nursing Assistants). After incontinence care was performed, RI #9 was still positioned on the left side. EI #1 returned from washing her hands and donning her gloves. EI #1 applied the skin protectant to RI #9's buttocks and anal areas. EI #2 positioned RI #9 onto the back. EI #1 applied the skin protectant onto the perineal and urethral areas of RI #9 with the same pair of contaminated gloves used to apply the skin protectant to RI #9's buttocks and anal area. On 11/5/2014 at 4:50 PM, an interview was conducted with EI #1, a CNA. EI #1 was asked when gloves should be changed, while applying skin protectant. EI #1 stated, "I should have changed the gloves after wiping the back, and before going to the front." EI #1 was asked should the same pair of gloves be used to wipe the buttocks and then the perineal area when applying skin protectant. EI #1 stated, "No." On 11/6/2014 at 11:45 AM, an interview was conducted with EI #3, the Infection Control Nurse/DON (Director of Nursing). EI #3 was asked how were CNAs inserviced about applying skin protectant creams. EI #3 stated, "They go from front to back." EI #3 was asked should the same pair of gloves be used to wipe the buttocks and then the perineal area, when applying skin protectant. EI #3 stated, "No." EI #3 was asked why the same pair of gloves should not be used to wipe the buttocks and then the perineum. EI #3 stated, "Cross contamination is possible."

Based on interviews and record review, the facility failed to ensure a resident's sponsor was provided written information of the facility's bed hold policy, prior to, or within 24 hours of transfer to the hospital. This had the potential to affect RI (Resident Identifier) #10, one of fifteen sampled residents. Findings include: A review of the facility's undated policy titled, "Bed Hold Policy and Procedure," revealed, "I. Purpose To inform every resident and/or family member or legal representative of the opportunity to hold a bed in the event of temporary, medically necessary hospitalization or exhausted leave. II. Policy Each resident and/or family member or legal representative will be given a written copy of our bed hold policy upon admission, changes to the policy, hospitalization or in the event of an exhausted leave. At the time or within 24 hours of discharge to another facility, the Social Service Director or designee will provide the resident and/or family member or legal representative of the bed hold policy. A written notification may also be included in the paperwork accompanying a resident to the hospital in cases of emergency discharge. ..." A review of medical records revealed RI #10 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the documentation on RI #10's admission agreement indicated RI #10's son was the responsible party. A review of RI #10's Quarterly MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 01/15/2014, revealed a BIMS (Brief Interview for Mental Status) score of 15 out of a possible 15 points. This indicated RI #10 was cognitively intact for daily decision making skills. A review of the Nurse's Notes for RI #10, revealed, "3-4-14 (at) 15:30 (3:30 PM) Transferred to (Named Facility) per (named entity) accompanied by 2 staff members. Resident cooperative at time of transfer. Reason for transfer is due to (symbol for increase) in behaviors unresponsive to medication changes - failed of treatment. Sponsor aware & (and) in agreement. ..." On 11/6/2014 at 9:22 AM, an interview was conducted with RI #10's son. RI #10's son was asked if he was involved in RI #10's admission to the facility, and he replied that he was, because he took care of RI #10's personal affairs. RI #10's son was asked if the facility provided him with a written notice of the bed hold policy prior to or within 24 hours of RI #10 being transferred to the hospital on [DATE]. RI #10's son stated he had been informed the facility could hold the bed for 21 days, he thought, but that he had not received nor signed anything recently. An interview was conducted with EI #4, the Social Services Designee, on 11/6/2014 at 10:40 AM. EI #4 was asked what the facility's policy was on bed holds. EI #4 stated, "... An agreement is in the Admissions Agreement and in the Resident Handbook. The sponsors usually signs the bed hold agreement." EI #4 was asked when was RI #10's son/sponsor notified of the bed hold policy. EI #4 replied, "Always on admission. We do all sponsors on admission. I only do them on admission. ..." EI #4 went on to say she initiated RI #10's Admissions Agreement with the sponsor who was out of town, and he signed the agreement. EI #4 was asked how the bed hold agreement was handled, if the sponsor was out of state. EI #4 replied, "He and I did everything via fax. There was only one communication from me regarding bed hold with (named person). Financial may have done something else." On 11/6/2014 at 1:00 PM, an interview was conducted with EI #5, the Bookkeeper. EI #5 was asked when RI #10's son/sponsor was notified of the facility's bed hold policy, and by whom. EI #5 replied, "On admission by the Admissions Coordinator, (EI #4). I don't know if he was notified when (RI #10) was sent out. I didn't notify him." An interview was conducted with EI #6, the Administrator, on 11/6/2014 at 2:47 PM. EI #6 was asked what the facility's policy was on bed holds. EI #6 stated, "Our policy says we will ask if you want to hold the bed before you go to the hospital. In the ideal world, it's to ask prior to sending out, if they want us to hold the bed." EI #6 was asked when RI #10's son/sponsor was notified of the bed hold policy. EI #6 stated, "(EI #4) does admissions, so I'm assuming it was on admissions. I don't know if (RI #10's son) was given the bed hold policy prior to (RI #10) going out. He lives out of town. ..." In a subsequent interview with EI #6 on 11/6/2014 at 4:20 PM, EI #6 was asked what the facility's policy stated on bed holds when a resident was sent to the hospital. EI #6 stated, "Each resident or sponsor/family member or legal representative will be given a copy of our bed hold policy upon admission, changes to the policy, hospitalization or in the event of an exhausted leave." EI #6 was asked if they followed their policy in providing RI #10's sponsor with a written copy of the bed hold policy at the time of, or within 24 hours of RI #10'S transfer to the hospital on [DATE]. EI #6 replied, "Not to my knowledge." EI #6 was asked why not. EI #6 stated, "Because we were automatically holding the bed and anticipating (RI #10's) return when (RI #10) was stabilized."

Based on observation, interview, and document review, the facility failed to ensure food was stored, prepared and served in a sanitary manner and in a manner to prevent the potential for cross-contamination by the following: 1) the range/grill grease trays contained a large accumulation of food debris and black residue; 2) two boxes of the commercial milkshakes were not dated with a thaw date and use-by date per manufacturer's instructions; 3) a large portion of pre-cooked ham was not completely sealed; 4) the interior and exterior of the dishmachine contained an accumulation of residue; 5) a pitcher of tea was placed with clean dishes that were air drying; 6) two dietary staff members did not know how to calibrate a dial thermometer; and 7) the milk temperature was not checked at lunch on 02/12/14 before some was served to residents. This had the potential to affect all 56 of 56 residents who receive meals from the kitchen. Findings include: 1) A review of the facility policy titled, "Cleaning Instructions: Cleaning Ranges" (dated 2008) revealed: "...4. Wash the drip pans as needed and/or according to the cleaning schedule. ..." A review of the "Cook Cleaning Responsibility" (not dated) revealed: "Clean range top each shift and as needed." On 02/11/14 at 9:30 AM, during the initial tour of the kitchen, the Dietary Manager, EI (Employee Identifier) #2, was asked to pull out the grease tray on the side of the range grill. EI #2 pulled on it, but the tray would not come out. EI #2 asked a Dietary Aide/Cook (EI #7) to pull the tray out. EI #7 had to pull on it, but was able to get the tray out. There was a large amount of food particles and black residue in the tray (about 2 inches thick of debris and residue). The other grease tray under the eyes of the stove was pulled out. It contained oily residue and black residue. EI #2 was asked if the grill was used that morning for the breakfast meal. She said it was not. On 02/13/14 at 10:12 AM, the Dietary Manager (EI #2) was asked how often the grease trays were supposed to be cleaned. She said as needed, after they cook on it; so daily if they use it. EI #2 was asked who was supposed to clean the grease trays. She said whoever uses the range/grill, and the Cook cleans it on Sunday whether or not she uses it. EI #2 was asked what the potential harm was with having a build-up of food and grease. She said it could attract rodents. 2) A review of the manufacturer's instructions on one of the boxes of commercial milkshakes revealed: "...After thawing, keep refrigerated. Use within 14 days after thawing. Date thawed _____" On 02/11/14 at 9:30 AM, during the initial tour of the kitchen, the walk-in cooler contained two boxes of commercial milkshakes. There were no thaw or use-by dates on the boxes or the individual cartons. EI #2 was asked if they should be dated. She said they should be dated on the boxes with the thaw date and the use-by date. EI #2 confirmed that there were no dates on the boxes or cartons. EI #2 was asked who was supposed to write the dates on them. She said whoever pulled them out of the freezer. On 02/13/14 at 10:12 AM, EI #2 was asked if she knew how long the boxes of milkshakes had been thawed. She said she did not. EI #2 was asked what the potential problem was in having milkshakes not dated. She said they were potentially hazardous due to being a milk product, and they had fourteen days to be used. 3) A review of the facility policy titled, "Use of Leftovers" revealed: "...Leftovers will be covered...then stored appropriately..." On 02/11/14 at 9:30 AM, during the initial tour of the kitchen, there was a large portion of pre-cooked ham in a plastic box, which was not completely closed. EI #2 picked up the ham and it was only partially covered with aluminum foil, exposed to air and contaminates. On 02/13/14 at 10:12 AM, EI #2 was asked what the potential problem was with the ham not being completely sealed. She said air could have gotten on it. 4) On 02/12/14 at 8:13 AM, during the observation of dishwashing using the dishmachine, the exterior top and top edges of the dishmachine contained an accumulation of white and yellow residue. The two sprayers on the interior of the dishmachine contained a build-up of white residue. On 02/13/14 at 10:12 AM, EI #2 was asked if she noticed the dishmachine had white residue on the sprayers. She said she did not, but they clean it with a degreaser and de-lime it once a week (on Saturday or Sunday). EI #2 was asked who was responsible for cleaning the dishmachine. She said whoever uses the machine. EI #2 was asked who cleans the exterior of the dishmachine. She said whoever is washing dishes or whoever she assigns to clean it. EI #2 was asked if she noticed the top of the dishmachine contained residue. She replied, "No." EI #2 was asked when the top of the machine should be cleaned. She said at the end of each shift and the end of the day. 5) On 02/12/14 at 8:13 AM, during an observation of dishwashing in the three compartment sink, there was a pitcher of tea on the counter where clean dishes were air drying. EI #2 was asked why the pitcher of tea was placed with clean dishes. She said somebody probably just put it there. On 02/13/14 at 10:12 AM, EI #2 was asked what the problem was with the tea being placed with clean dishes. She said it could spill on the dishes and contaminate them. 6) A review of the facility policy titled, "Calibrating a Thermometer" (not dated) revealed: "...To use the ice water method, fill a large glass with ice. Add clean, cold tap water to the top of the ice and stir well. Immerse the food thermometer stem a minimum of 2 inches into the mixture, touching neither the sides nor the bottom of the glass. Wait a minimum of 30 seconds before adjusting. (For ease in handling, the stem of the food thermometer can be placed through the clip section of the stem sheath and, holding the sheath horizontally, lowered into the water.) Without removing the stem from the ice, hold the adjusting nut under the head of the thermometer with a suitable tool and turn the head so the pointer reads 32 (degrees) F." On 02/12/14 at 11:23 AM, during the observation of lunch trayline, the Cook (EI #4) used a dial thermometer to check the temperatures of the food on the steamtable. After she completed this, EI #4 was asked how she knew the thermometer was reading accurate temperatures. She said they calibrate the thermometer once a week and adjust it to 32 degrees (Fahrenheit). EI #4 was asked to calibrate the thermometer. She obtained a styrophoam cup, filled it with ice and water, then placed the thermometer in it. The thermometer registered 38 degrees F (Fahrenheit). EI #4 placed more ice into the cup. The thermometer registered 36 degrees F. EI #4 just looked at the thermometer. She said it needed to be adjusted, but did not turn the dial head to 32 degrees with the adjusting tool. EI #3 (a Dietary Aide/Cook) was then asked to calibrate the thermometer. She obtained a fresh cup of ice water. The thermometer registered 38 degrees F. EI #3 was asked what she should do to get it to 32 degrees. She replied, "Adjust it." However, EI #3 did not turn the dial head to 32 degrees with the adjusting tool. The Dietary Manager (EI #2) was asked what the potential problem was with the thermometer not reading 32 degrees F. She said the food temperatures were not accurate and they needed to be re-checked. A review of a training class attendance record for calibrating thermometers in July 2013 revealed EI #3 and EI #4 were both in attendance. 7) A review of the Food and Drug Administration's 2009 Food Code revealed: "3-501.16 Potentially Hazardous Food (Time/Temperature Control for Safety Food), Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, ... potentially hazardous food (time/temperature control for safety food) shall be maintained: (1) At 57oC (135oF) or above, ... or (2) At 5?C (41?F) or less." On 02/12/14 at 11:23 AM, during the observation of lunch trayline, EI #4 was observed taking temperatures of the food on the steamtable. The temperature of the milk was not checked. At 12:03 PM, the first cart went out to the hall, which contained two cartons of fat free milk and two cartons of whole milk. The second cart was being prepared and it contained milk on some of the trays as well. The surveyor asked the Dietary Manager to check the temperature of a milk on the second cart. She checked a carton of whole milk, and it was 44 degrees Fahrenheit. EI #2, EI #3, EI #4, and EI #8 (another Dietary Aide) were all asked if they checked the temperature of the milk for that meal. They said they did not. EI #2 was asked who was responsible for checking the temperature of the milk. She said it was whoever took the milk out of the refrigerator. On 02/13/14 at 10:50 AM, the Administrator (EI #1) was informed of the concerns in the kitchen. She said she acknowledged that they were legitimate concerns and they would fix them so it would not happen again.

Based on observation, interview, and document review, the facility failed to ensure the interior and exterior of the dryers in the laundry department were free of a build-up of lint. The facility also failed to ensure the exterior of the washing machines and the area behind the washing machines were free of a large accumulation of dust-like residue and trash. The facility further failed to ensure the walk-in freezer compressor in the kitchen was free of a large build-up of ice. These failures had the potential to affect all 60 residents in the facility. Findings include: A review of the facility's "Job Description" (not dated) for "Laundry - 6:00AM - 4:00PM Shift" revealed: "...3:30-4:00 Clean all laundry areas, organize shelves, wipe equipment, and mop floor." A review of the "Director Of Maintenance Job Description" (not dated) revealed: "General Purpose: To plan, organize and direct the overall operation of the department in accordance with current federal, state and local standards, ensuring that the facility is maintained in a safe, comfortable condition. ... Plan, develop and direct the Maintenance Department; coordinate maintenance services with other departments...ensure proper maintenance of the facility including...equipment...regularly inspect equipment...to ensure a safe and comfortable environment. ..." 1) On 02/11/14 at 3:55 PM, the laundry department was observed. There were two washing machines in one room. They were not operating at this time. There was a large accumulation of dust-like residue on the tops of the washers, the hoses and pipes connected to the washers, and the floor behind the washers. There were sticky note papers on the floor, as well as paper, paper towels, a screw, a black pipe, and pieces of plastic. There was also a plastic container lid on top of the right washer. There was a separate room where three dryers were located. The dryers were not operating at this time. The lint compartment of the left and middle dryer contained an accumulation of lint on the inside top. The middle dryer contained a large clump of lint on an electrical box on the inside top and a large clump hanging next to the electrical box. The left dryer had a clump of lint next to the electrical box, lint on the electrical box, and lint accumulated on the back and in corners inside the top. There was an accumulation of dust-like residue on the back of the dryers, on the pipes, and the floor behind the dryers. The Laundry Aide, EI (Employee Identifier) #6, was asked if she usually cleaned around the electrical box. She said she did not, that maintenance took care of that. EI #6 was asked what she does when she sees lint on the electrical box. She said she would get maintenance. EI #6 was asked when she last cleaned the lint compartments. She said 2:55 PM (one hour ago). EI #6 was asked how often she cleaned the lint compartments. She said four times a day and as needed. EI #6 was asked if she noticed the lint up underneath where the electrical boxes are located. She said she did not. On 02/11/14 at 4:10 PM, the Housekeeping Manager (EI #5) was asked what the potential harm was with having lint build-up in the dryers. She said it could catch on fire. EI #5 was asked who was responsible for making sure the Laundry Aides completed their tasks. She said that was her responsibility. EI #5 was asked if she checks the lint compartments to make sure they are clean. She said she did and she documented it on a check-off sheet. EI #5 was asked when she last checked the lint compartments. She said at 9:00 AM that morning (02/11/14). EI #5 was asked if she noticed the accumulation of lint around the electrical box. She responded, "No ma'am." EI #5 was asked who was responsible for cleaning the top and behind the washing machines. She replied, "Maintenance." On 02/11/14 at 4:30 PM, the Administrator (EI #1) was asked who the facility Maintenance Director was. She said they had a new Director who was in his second day of orientation. EI #1 explained that they had been without a Maintenance Director since January 10th or 11th of 2014, but a Maintenance Director from a sister facility would come when she called him, or she would call a contract worker if needed. EI #1 said she had not been made aware of any concerns in the laundry department, so she had not called anyone for anything in laundry. EI #1 was asked what maintenance cleaned in the laundry department. She said the only thing she was aware of was they would take off the front of the dryers to clean around the drums. EI #1 was informed of the accumulation of lint on the upper part of the lint compartments of the dryers. EI #1 was asked what the potential harm was with having lint build-up in the dryers. She said if there was a large accumulation of lint, there would be a risk for a fire. EI #1 was asked who was responsible for cleaning on top, the sides, and behind the washers. She said she thought laundry staff would clean it if it involved dusting and sweeping. She said maintenance took care of the area behind the washers because of the electrical lines. EI #1 said she had not called anyone for that. EI #1 was asked if there was a facility policy regarding the cleaning of the lint and laundry areas. She said there was not. At 4:58 PM, the surveyor and EI #1 observed the laundry area. EI #1 got down on the floor and removed the clumps of lint out of the middle dryer with her hand. EI #1 said the laundry workers could have cleaned that off. A review of the Housekeeping Manager's check-sheet dated 02/10/14 revealed a check mark for "Washing Machine Area...Machines clean" and a check mark for "floors" indicating these area were clean. The section for "Dryer Room (Clean)" had a check mark for "Dryers clean" and "Floor" indicating these areas were clean. 2) On 02/11/14 at 9:30 AM, during the initial tour of the kitchen, the walk-in freezer was observed. There was a large accumulation of frozen droplets on the ceiling around the compressor. There was water on the front edge of the compressor. Two pipes contained a large accumulation of ice. There was also build-up of ice on the top of a box of commercial milkshakes underneath the compressor. On 02/12/14 at 9:25 AM, the walk-in freezer was observed. The accumulation of ice continued to be on the compressor and ceiling. The Dietary Manager (EI #2) was asked if she had noticed the ice build-up. She said she had not. EI #2 explained that maintenance usually cleaned the ice off the compressor. EI #2 was asked if the freezer compressor had accumulated ice like that before. She said about two or three years ago ice built up on the compressor and the Maintenance Director took care of it. EI #2 was asked who was responsible for checking for ice build-up. She said usually the maintenance department checked that, but they had not had a Maintenance Director in a while. On 02/12/14 at 10:12 AM, the Administrator (EI #1) was asked if she was aware of the ice build-up on the freezer compressor. She said she was not. EI #1 was asked who was responsible for monitoring to ensure the compressor is working properly. She said she was uncertain about that, but if dietary workers notice something that needs to be addressed, they inform her or maintenance. EI #1 was informed of the ice build-up on the compressor. She said she would add that to maintenance's responsibility.

Based on observation, interview, and record review, the facility failed to ensure RI (Resident Identifier) #3 was given morning care in a timely manner so that she could attend activities without being late. This affected one of eight residents attending the Resident Council Meeting. Findings include: On 03/20/13 from 3:00 PM to 4:00 PM a resident group meeting was held with eight residents in attendance, including RI #3. RI #3 mentioned that the staff members could not get everyone ready in the mornings to make it on time to the activity programs. She was asked how often she is late to activities because of this. She said every now and then. A review of RI #3's Annual Minimum Data Set (MDS) with an Assessment Reference Date of 06/26/12 revealed she scored a 15 out of 15 for mental status, indicating she was cognitively intact. The MDS showed that listening to music, doing things with groups of people, doing her favorite activities, and participating in religious services were "very important" to her. The MDS also showed she was totally dependent on staff for transfers and locomotion on and off the unit. A review of RI #3's "Activity Assessment" (07/10/12) revealed her preference of time for activities included morning, mid morning, afternoon, and evening. RI #3's current interests included: sports, cooking, crafts, music, news/current events, groups, cultural, games, exercise, writing, movies, conversing, reading, TV/radio, and religious activities. A review of RI #3's current care plan for "Depression" (12/14/09) contained an approach of: "Offer and assist to small group activities or activities of interest." The current care plan for "Activities" (12/14/09) had approaches including: "Remind resident of large group religious or social groups, bingo, parties and resident council prior to the event. Transport assist resident to and from activities." On 03/21/13 at 9:25 AM, RI #3 was in her wheelchair, dressed and being transported to the activity program by the Activity Director, EI (Employee Identifier) #4. The activity calendar on the wall across the hall from the living room where the activity was being held showed the activity was "small group" and the time listed was 9:00 AM. EI #4 was asked what time the small group started. She said 9:00 AM. RI #3 went into the small group activity after it had already been in progress for 25 minutes. On 03/21/13 at 10:38 AM, RI #3 was asked if small group activities were something she enjoyed. She responded, "Yes." RI #3 was asked if she was up and ready to go by 9:00 AM. She said EI #6 (CNA) got her up and dressed this morning, but EI #6 had to go help another resident twice in the middle of getting her ready. RI #3 explained that before EI #6 could get her up with the lift she had to get another CNA to help (EI #5), and they transferred her to the wheelchair at 9:00 AM. RI #3 explained that she then had to get her breathing treatment, which took about ten minutes. RI #3 said EI #6 then brushed her hair, left the room to help someone else, EI #4 walked by the room and RI #3 called to EI #4 to take her to the activity. RI #3 was asked how it made her feel to be late to the activities. She replied, "I've gotten used to it." RI #3 was asked if it bothered her to be late. She responded, "Well, I would like to be there from the start." RI #3 was asked how often she is late to activity programs. She said it happened about twice a week. On 03/21/13 at 2:12 PM, EI #5 was asked how much she works with RI #3. She said RI #3 was not on her regular assignment, but she helps EI #6 with RI #3 about three to four times a day. EI #5 was asked what activities RI #3 enjoys attending. EI #5 replied, "She basically likes to go to all of them." EI #5 was asked who was responsible for making sure RI #3 was up and ready for activities on time. She said all of them - CNAs and activity staff. EI #5 explained that RI #3 was usually one of the first ones because they know she likes to attend the activities. EI #5 was asked why RI #3 was late to the small group that morning. She said she had to get EI #6 to help her transfer another resident, then EI #6 had to answer another call light then they transferred RI #3. EI #5 was asked if any resident had complained about not getting up in time for activities. She said every now and then. EI #5 was asked if she was aware that RI #3's care plan showed that she enjoyed small groups. She replied, "No." On 03/21/13 at 2:36 PM, EI #6 was asked how often she works with RI #3. She said she had RI #3 every day; RI #3 was on her regular assignment. EI #6 was asked what time she normally gets RI #3 up in the mornings. She said by 10:00 AM. EI #6 said she normally gets RI #3 up first. EI #6 was asked what activities RI #3 enjoyed. She said singings, games, Bible study, Sunday school, church, and 10:00 activities. EI #6 was asked if she was aware that RI #3 enjoys small group activities, and that it was on her care plan. She replied, "No." EI #6 was asked if RI #3 had ever complained about not getting up in time to get to activities on time. She said RI #3 had complained, but it was days when she did not work. EI #6 was asked who was responsible for getting the residents up on time for activities. She said she was. On 03/21/13 at 11:01 AM, EI #4, the Activity Director was asked if any residents had been late to activities. She said they are late sometimes. EI #4 was asked why they are usually late. EI #4 said they are usually in the midst of their bath or getting their hair combed. On 03/21/13 at 3:06 PM, EI #4 and EI #10 (Assistant Activity Director) were asked if RI #3 enjoyed small group activities. EI #4 responded, "Yes. She likes them." EI #4 and #10 were asked what RI #3's care plan meant by "small group activities." EI #4 said it was any time the calendar showed "small group." EI #10 was asked if she had noticed RI #3 coming in late to activities. She said it did happen, but not very often. On 03/21/13 at 3:25 PM, EI #1 (Administrator) was asked who was responsible for making sure residents were up and ready to be at activities on time. She said CNAs get the residents dressed, but it was a team effort and the charge nurse was supposed to make sure the CNA does what she is supposed to. EI #1 was asked how the CNAs know when to get the residents up and who wants to attend which activity. She said the CNAs know the residents, they offer all the activities to everyone, and the CNAs can look at the activity calendar and make plans accordingly. EI #1 was asked what the potential harm was for staff to get a resident up too late and being late to an activity. She said they would miss out on part of something they enjoy.

Based on record review and interviews, the facility failed to follow their abuse policy and procedure for suspending a staff member pending completion of an investigation of an allegation of abuse. This affected one of three abuse investigations reviewed. The facility further failed to ensure an abuse registry check was completed for a newly hired employee prior to being employed. This affected one of six personnel records reviewed. Findings Include: A review of the facility's policy and procedure titled, "Abuse Policy" revised 03/09/01, revealed: "Procedure for Documentation and Investigation of Resident Abuse ... 9. If abuse is alleged/suspected, the employee(s) involved will be suspended until completion of the investigation. ..." The facility's policy and procedure titled, "Abuse Policy" revised 03/09/01, also revealed the following: "...Prior to employment and annually thereafter, (Name of Nursing Home) will contact the Alabama Board of Nursing to determine whether such applicant/employee is ... not listed on the Nurse Abuse Registry. ... Abuse Prevention Policy... 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. ..." 1. A review of the facility report of the allegation of abuse to the State Department of Public Health dated September 10, 2012 revealed the following: "...Select Category: Verbal Abuse...Name of perpetrator(s) or alleged perpetrator(s): (Employee Identifier (EI) #2) (housekeeper) based on physical description given by caller. Stated the employee was a ... housekeeper (physical description of the housekeeper) ..." A review of the completed investigation dated 09/11/12 submitted to the State Complaint Unit did not reveal EI #2 was suspended pending investigation of the allegation of abuse per the facility's abuse policy. On 03/21/13 at 11:50 AM, during an interview with EI #1 (Administrator), the surveyor asked if EI #2 was suspended pending the results or conclusion of the investigation. EI #1 said no. The surveyor asked what was the policy and the procedure regarding an abuse allegation involving staff, pending completion of the investigation. EI #1 stated, "I'm gonna read #9 (referring to entry #9 of the facility's Abuse Policy and Procedure). If abuse is alleged/suspected, employee(s) involved will be suspended until completion of investigation. If investigation does not substantiate abuse, the employee will be allowed to return to work." EI #1 further stated, "I allowed her (EI #2) to return to work while I continued to conduct investigation with staff members and residents to see if any abuse or anything occurred on day in questions." 2. A review of (name of company) form titled, "Confidential Employee Profile" for EI #3 (floor tech) revealed a hire date of 03/11/13. A review of (name of company) form titled, "New Hire Checklist" dated 03/14/13 revealed a check mark by "Nurse's Aide Abuse Registry." The checklist further revealed the HR (Human Resource) Director's signature, the Payroll Manager's signature and a date of 03/14/13 was noted next to each signature. This indicated that the nurse aide registry check was not completed until three days after the employee was hired. A review of the Certified Nurse Aide Registry check for EI #3, given to the surveyor by (name of company) District Manager and Compliance Officer, did not reveal a date as to when the registry was checked for EI #3. On 03/21/13 at 2:20 PM, during an interview with (name of company)'s District Manager and the Compliance Officer, the surveyor asked how did they ensure registry checks were completed prior to hire. The Compliance Officer stated when the background checks are done, the online registry checks are completed also. The surveyor asked what documentation did they have to reflect when registry checks were completed. The District Manager stated those two items (background and registry checks) are completed during the application process. The surveyor asked what documentation they had to reflect the date and/or time the nurse aide registry was checked for EI #3. The Compliance Officer stated, "None, because all we have is what we gave you yesterday."

Based on observation, interview and record review, the facility failed to ensure an LPN (Licensed Practical Nurse) washed her hands before and after dispensing and administering residents' medication. This affected one of three nurses observed during medication pass. Findings include: A review of the facility's policy and procedure titled, "Medication Administration" dated 01/12 revealed the following: "... 6. Cleanse hands with soap and water before handling medication ..." On 03/19/13 at 5:10 PM, the following observation was made: Employee Identifier (EI) #7 (LPN) dispensed and administered medications to a resident. EI #7 exited the room and proceeded to dispense medications for the other resident in the same room. EI #7 entered the resident's room and administered the residents medications. EI #7 did not wash her hands after administration of medications to a resident and before dispensing and administering medications to another resident. On 03/19/13 at 5:35 PM, during an interview with EI #7, the surveyor asked what should be done regarding handwashing when going from one resident to the other. EI #7 stated, "Wash between residents." The surveyor asked after administration of a resident's medication when did she wash her hands. EI #7 stated, "When I went back in for (name of other resident) for her nebulizer treatment." The surveyor asked if she washed her hands before or after the nebulizer treatment. EI #7 responded, "After." The surveyor asked if her hands were clean or contaminated. EI #7 stated contaminated. The surveyor asked what she should have done prior to the preparation and administration of medications. EI #7 stated, "I guess wash my hands."

Based on observations, record record and interviews: 1) The facility failed to follow the pre-planned menu approved by the Registered Dietitian (RD). 2) The facility failed to follow the facility procedure by not documenting what was actually served and the reason for the change on the back of the menu. 3) The menu failed to provide variety which resulted in four resident complaints in resident group meeting and an individual resident interview with Resident Identifier (RI) #10. RI #10 said that peaches or pears were served three times per week. This had the potential to affect all fifty of fifty residents who received meal trays from dining services. Finding include: 1) The facility failed to follow the pre-planned menu approved by the Registered Dietitian (RD). A review of the WAG (Week At a Glance) menu for Sunday (3/17/2013) through Saturday (3/23/2013) revealed for the evening meal on 3/17/2013 a menu plan for Peaches as the dessert. The written planned menu for 3/19/2013 documented the dessert as Fruit Cup. A review of the recipe indicated to use Fruit Cocktail or mix any fruits. An observation of the dessert served was not according to the recipe. Sliced peaches were served. On 3/21/2013 at 11:00 AM, the Dietary Manager (DM), Employee Identifier (EI) #8 was asked if the menu had been followed. EI #8 responded no, that the menu was not followed. EI #8 was asked why the menu was not followed, but she did not respond. At 11:15 AM, the Cook, EI #9 was asked the same question. EI #9 said that there was no Fruit Cocktail and that is the only reason she could think of. 2) The facility failed to follow the facility procedure by not documenting what was actually served and the reason for the change on the back of the menu. A review of the pre-planned menus for Week 4 of the cycle revealed the menu failed to document what was served. There were no cross outs or changes to indicate a Fruit Cup was not served. On 3/21/2013 at 11:15 AM, the DM (EI #8) was asked what she should do when there is a menu change. EI #8 responded that she should have put on the back of the menu the date and what the change was and the reason for changing. 3) The menu failed to provide variety which resulted in four resident complaints in resident group meeting and an individual resident interview with RI #10. RI #10 said that peaches or pears were served three times per week. On 03/20/13 at 3:00 PM, a resident group meeting was held with eight residents in attendance. The residents were asked if they are served too much of any item. Four of the residents said they are served peaches too often. On 03/21/13 at 10:00 AM, RI #10 was asked if she was served food she liked to eat. RI #10 stated that peaches or pears are served three times a week. Principles of menu planning include ABCV (Adequacy, Balance, Color and Variety).

Based on observation, record review and interview the facility failed to ensure privacy was maintained for Resident Identifier (RI) #7 during the performance of personal care. This affected one of twelve sampled active residents. Findings include: RI #7 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] revealed RI #7 was incontinent of bowel and bladder and was dependent upon staff bathing, hygiene and dressing. RI #7 had Brief Interview of Mental Status score of 9 out of a possible 15. During the initial facility tour on 7/19/2011 at 9:30 AM, the surveyor was told to enter RI #7's room. Upon entering the room the surveyor noted the privacy curtain to be partially drawn around the resident. Since care was being provided, the surveyor went to talk to RI #7's room mate, who was dressed and sitting in a wheelchair at the side of the bed. Upon entering that area, RI #7 was observed receiving personal care since the curtain had not been pulled completely around the resident. When the Certified Nursing Assistant (CNA) saw the visitors were a surveyor and a facility Employee Identifier (EI) #6, Registered Nurse (RN), she immediately pulled the curtain to middle of the bed space but again did not completely shield RI #7 from being in plain view. RI #7 was undressed except for a shirt and the pubic area was exposed during this time. EI #1 acknowledged RI #7 was exposed to the room mate as well as the surveyor and EI #6 when there was a gap in the curtain. In an interview on 7/20/2011 at 5:10 PM, EI # 6 stated the curtain should have been pulled all the way around. When asked what was wrong with that she stated, it should have peen pulled all the way around. It was exposing the resident and that could be a privacy or dignity issue. A review of the facility policy entitled "Dignity and Respect", revealed the entry "...respect their privacy..." A review of the CNA's competency check-off identified the following concerns to be completed by the CNA: "...Close the door and blinds, Pull privacy curtain completely closed so that it encircles the bed, As care provided, expose only the body involved in the procedure." The CNA failed to follow the guidelines thereby failed to provide privacy during the personal care.

Based on observation, interview and record review the facility failed to develop a comprehensive care plan to address an alarm and seat belt worn by RI (Resident Identifier) #4. This affected 1 of 12 sampled residents. Findings Include: RI #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set assessed RI #4 as having moderately impaired cognitive skills for daily decision making. He was also assessed as needing total assistance with all activities of daily living. During initial tour of the facility on 7/19/11 at 10:40 AM, RI #4 was observed to be sitting in his wheelchair with an alarming style seatbelt fastened around him. On 7/20/11 at 9:40 AM, RI #4 was observed to be in his room sitting in his wheelchair with an alarm style seatbelt fastened around him and lying in his lap. On 7/20/11, a review of RI #4's care plans was completed. There were no care plans developed to address the alarm or seat belt fastened around the resident. A review of the Functional Maintenance Plan dated 6/20/11, revealed no information about the alarm seatbelt used with RI #4. A review of the therapy notes dated 6/21/11, documents "...Current Week...High back recliner with alarm and seat belt..." A review of the "Physician Orders" for July 2011, revealed no orders were written for an alarm or seatbelt. In an interview on 7/20/11 at 3:35 PM, with EI (Employee Identifier) #1, Restorative Nurse, she was asked is there a care plan that addresses the alarm and/or the seatbelt attached to RI #4's wheelchair? She answered, No. When asked how do the certified nurse aids know how to take care of RI #4 regarding his alarm and seatbelt, she responded he should have had a care plan, but there is not one. In an interview on 7/20/11 at 4:00 PM, with EI #2, Certified Occupational Therapy Assistant, she was asked was there any communication to nursing documented by the Occupational Therapist addressing the alarm and seatbelt. She responded, no.

Based on observation, record review and interview the facility failed to ensure a safe transfer, when transferring RI (Resident Identifier) #12 with a mechanical lift from the bed to the wheel chair. This affected 1 of 12 sampled residents. Findings Include: RI #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Quarterly Minimum Data Set with Assessment Reference Date of 6/2/11, assessed RI #12 as having a score of 10 on the Brief Interview of Mental Status, 15 being the highest functional level. She was also assessed as needing extensive and total assistant for all Activities of Daily Living, including transfer. During initial tour on 7/19/11 at 10:05 AM, two CNAs (Certified Nurse Aides) were observed to transfer RI #12 from her bed to the wheelchair using a mechanical lift. EI (Employee Identifier) #3, CNA, was observed to put the wheelchair in front of the resident and mechanical lift, tilt the wheelchair back on the back wheels and place the front wheels on the base of the mechanical lift. The CNAs then lowered the resident into the wheelchair, slowly rolling the chair back while lowering the resident into the chair. The CNAs never locked the brakes to the wheelchair. During observation on 7/20/11 at 9:15 AM, the same CNAs were observed to transfer RI #12 from her bed to the wheelchair using the same mechanical lift. EI #3, again placed the wheelchairbetween the open legs of the lift and in front of the resident, tilting the chair back onto back wheels and lowering the front wheels onto the base of the lift. EI #4, CNA, lowered the resident down while EI #3 slowly rolled the unlocked wheelchair back until RI #12 was fully seated in the chair. A review of the Care Plan with the problem "Falls" with an onset date of 2/24/11 revealed the following approach: "...*During normal daily care routines be especially observant of resident's safety status..." A review of the policy titled "Lifting Machine, Using a Portable" with no review or revision date revealed, "...3. To transfer a resident from a bed to a chair, you should: a. Position the chair. If it is a wheelchair, be sure the wheels are locked..." In an interview on 7/20/11 at 9:45 AM, with EI #5, Staff Development, she was asked to explain the process of the mechanical lift and transfer from the bed to the wheelchair. She explained to make sure the wheelchair wheels are locked and then lower the resident down.