Every finding on record at Florala Health and Rehabilitation LLC

Based on observations, interviews, record review, facility policies, Infection Prevention and Control Officer- Job Duties, and Infection Prevention & (and) Control Program Overview, and facility forms titled, Weekly Infection Analysis, and Outbreak Investigation Form, the facility failed to investigate and implement appropriate control measures when Resident Identifiers (RI) #'s 12, 4, 7, 6, 8 and Employee Identifiers (EI) #'s 8, 7, 6, 4 were identified to have possible scabies, the facility further failed to investigate after RI #3 was identified with a rash and treated with [MEDICATION(S)] cream. This had the potential to effect 73 of 73 residents residing in the facility. Findings include: A review of the facility policy titled, Infection Prevention and Control Officer- Job Duties, with an Effective Date of June 11, 2020, revealed, . POSITION TITLE: Infection Prevention and Control Officer/Designee . JOB SUMMARY: Evaluates quality of resident/guest care and resident/guest outcomes as they relate to healthcare-associated infections; collects, prepares and analyzes healthcare-associated infection data; . implements programs to protect the healthcare workers, visitors, and others in the healthcare environment; . promotes compliance with regulations and guidelines . DUTIES AND RESPONSIBILITIES: . 6. Conducts outbreak investigation and initiates control measures . 10. Initiates follow-up on employee/resident/guest exposures . A review of the facility policy titled, Infection Prevention & Control Program Overview, with an Effective Date of September 14, 2020, revealed, . GOALS The goals of the Infection Prevention & Control Program are to: A. Decrease the risk of infection to resident/guest(s) and personnel by breaking the chain of infection, preventing development and transmission of communicable diseases B. Monitor for occurrence of infection and implement appropriate control measures, including when and how isolation should be used. A facility document titled, Weekly Infection Analysis dated 9/06/2022, revealed: . Were there any observations of educational opportunities related to infection control identified this week? Yes. If yes, please explain: Monitor Resident for possible scabies - (RI #12 named) . Actions recommended: no Were any changes implemented in facility related to infection control this week? No . Signed by EI #1, the DON (Director of Nursing)/Infection Preventionist. No tracking or investigation of the rash was performed by the Infection Preventionist. No tracking analysis or investigation was found in the Infection Control Log regarding the findings above for RI #12. A document titled, Weekly Infection Analysis dated 9/13/2022, revealed: . Were there any observations of educational opportunities related to infection control identified this week? Yes. If yes, please explain: Monitor Residents for possible scabies - (RI #'s 12, 4, 7, 6, and 8 named) . Actions recommended: Hydrate skin moisturizing Vaseline applied to skin [MEDICATION(S)] cream ordered . Were any changes implemented in facility related to infection control this week? No . Signed by Employee Identifier 1, the DON/Infection Preventionist. No tracking or investigation of the rash was performed by the Infection Preventionist. No tracking analysis or investigation was found in the Infection Control Log regarding the findings above for RI #'s 12, 4, 7, 6 or 8. A document titled, OUTBREAK INVESTIGATION FORM , dated 10/26/2022, revealed: . 1. Verify the diagnosis; identify the agent. Describe the initial magnitude of the problem and what symptoms got the facility's attention. Itching Rash What diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] ? Rash What agent . has been identified? Possible scabies . 4. Characterize the cases by person, place, time. Person: . (Lists the names of EI #'s 8, 7, 6, and 4 were listed. EI #4 was the only one with [MEDICATION(S)] 5% cream listed) Place: (Consider ward, hall, room, outside exposures. May use facility maps.) Halls 1 & 2 Time: What is the period of the outbreak? What is the probable source of exposure: Source - unknown 10/24 Record dates of onset and demonstrate the progress and digress of the outbreak Bumps to side of face, staff members arms & side 5. Attempt to determine where outbreak began. Review data to determine common host factors and exposures. Develop a best guess on the: System Involved Itching, Rash Redness Source . Unknown . 6. Institute preliminary control measures. Initiate control measures based on what you know. (Hand hygiene, isolation, cohorting, etc. {Et Cetera}) Determine if you need outside assistance. Control measures Hand hygiene, contact, monitoring - treatment in progress Date implemented 10/25/2022-cream order .7. Add additional control measures. Control Measure Additional order - may see workmen comp (compensation) physician if needed Date added 10/25/2022. 8. Monitor and evaluate the control measures. Date: 10/26/2022 Signed by Employee Identifier 1, the DON/Infection Preventionist. No tracking of resident caregivers or of residents that the staff had cared for prior to presenting with scabies was conducted by the DON/Infection Preventionist in the Infection Control Log. No complete treatment and follow-up of cases and prophylactic treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Infection Control Log had no monitoring of the possible scabies rash. A review of RI #12's medical record revealed he/she had been admitted to the facility on [DATE] and readmitted on [DATE]. The Nurse's note on RI #12 dated 9/14/2022 and timed 4:42 PM, revealed: . SKIN ASSESSMENT COMPLETED ON RESIDENT WITH UNIT MANAGER PRESENT RESIDENT HAS RASH TO CHEST AND ABD (ABDOMEN) AREA UNKNOWN SOURCE NO OTHER AREA AFFECTED TREATMENT IN PROGRESS RESIDENT WAS TREATED WITH [MEDICATION(S)] ON 9/6/2022 . SECOND APPLICATION DUE 9/20/2022 . A body audit was performed on RI #12 with the DON on 11/15/2022 at 4:16 PM. Findings include: three red raised spots on the left shoulder, 2 red raised spots on the left upper chest, six red raised spots on the right upper shoulder and four on the right chest wall. Four of the spots were pustular. A review of RI 4's medical record revealed he/she had been admitted on [DATE]. The Nurse's note on RI #4 dated 9/14/2022 at 4:59 PM revealed: . SKIN ASSESSMENT COMPLETED WITH UNIT MANGER (MANAGER) RESIDENT HAS RASH TO ABD (ABDOMEN) AND UPPER AND LOWER EXTS (EXTREMITIES) UNKNOWN ORIGIN RESIDENT . A review of RI #6's medical record revealed he/she had been admitted to the facility on [DATE] and readmitted on [DATE]. A review of RI #7's medical record revealed he/she had been admitted to the facility on [DATE] and readmitted on [DATE]. On 11/14/22 at 5:36 PM RI #7 was observed with raised reddened areas - one on the right wrist and two on the front of the right upper arm. A body audit was performed on RI #7 with EI #1, the DON on 11/15/2022 at 4:30 PM. Findings include: two reddened, raised areas on the left shoulder and one on the right side of the abdomen. All of the areas were scratched and scabbed. A review of RI #8's medical record revealed he/she had been admitted to the facility on [DATE] and readmitted [DATE]. A review of RI #3's medical record revealed he/she had been admitted to the facility on [DATE] and readmitted on [DATE]. A review of a copy of RI #3's face sheet that EI #12, a Licensed Practical Nurse, had sent to the doctor revealed: . * red bumps all over body. resident states (he/she's) miserable from itching. Please let me know what I need to do about that. [MEDICATION(S)] 25 mg (milligrams) (1) PO (by mouth) TID (three times a day) PRN (as needed) itching signed by EI #12 and dated 10/21/2022 hydrocortisone 0.5% cream bid (twice daily) to affected area . An initial interview was conducted with EI #1, the DON/Infection Preventionist (IP), on 11/15/22 at 1:08 PM. EI #1 said she had not determined the root cause of the rashes. When asked what her Weekly Infection Analysis indicated, she answered possible scabies. As related to staff skin issues, EI #1 reported EI #8, a Certified Nursing Assistant (CNA), was given some scabies cream ([MEDICATION(S)]) ordered on 10/25/22. EI #1 reported EI #8 improved after using the cream. EI #1 was asked if any residents or family were treated regarding EI #8 and she said no. EI #1 stated EI #8 worked on hall 1 and 2. EI #1 also named EI #7, CNA, as having received the cream she ordered on 10/25/22. EI #7 worked on hall 1. EI #4, a CNA, received her cream on 10/25/22. She works on both halls 1 and 2. EI #1 reported EI #6, a CNA, got her cream on 10/25/22. These are the four CNAs that presented to the DON/Infection Preventionist with bumps on their neck, arms and side that itched really bad. EI #1 said no one else assessed the CNAs but the house doctor ordered the [MEDICATION(S)]. EI #1 was asked if all four CNAs continued providing care for residents while treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #1 was asked what she put in place to prevent the spread of possible scabies and she said nothing. An interview was conducted with EI #4, a CNA, on 11/16/22 at 5:59PM. This CNA was listed on the Outbreak Investigation EI #1 had written. EI #4 described the rash she observed on RI 3 as red, pimple-like bumps that itched until the resident clawed their skin. EI #4 described her own rash as red, pimple-like bumps that itched so bad. She did not think she had ever itched that bad. EI #4 reported EI #1 told her it was scabies and gave her [MEDICATION(S)] cream. The red, pimple-like bumps on her went away after she used the cream. EI #4 was asked if scabies was contagious, and she reported it was very contagious. When EI #4 was asked how to ensure it did not spread, she answered, isolation but there was not any. EI #4 was asked if she had worked before she presented to the DON with the red, pimple-like bumps and given the scabies cream and she answered yes. EI #4 was asked what the Infection Control Protocol was for staff that were contagious. She answered they were supposed to isolate. EI #4 was asked what EI #1 did to prevent the spread of the red, itchy, pimple-like bumps by staff. She answered nothing, adding she kept them working. An interview was conducted with EI #6, a CNA on 11/17/22 at 10:34 AM. This CNA was listed on the Outbreak Investigation EI #1 had written. EI #6 was asked about her rash. She described it as red, itchy raised bumps. She reported EI #1 gave her some cream and it was effective. EI #6 was asked what management had instructed her to observe for in residents, after staff had worked with residents, before being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #6 was asked what EI #1 told her to do to prevent the spread of the rash. She reported EI #1 just said to put the cream all over her body and wash it off the next day. She added EI #1 did not say what it was, or to stay home. EI #6 was asked what the Infection Control protocol was for staff when they were contagious. She answered to stay home, that way you don't spread it. EI #6 was asked what EI #1 did to prevent the spread of the red, itchy, pimple-like bumps. She answered the cream that EI #1 gave her, but they still had to work. An interview was conducted with EI #7, a CNA, on 11/17/2022 at 11:10 AM. This CNA was listed on the Outbreak Investigation EI #1 had written. She reported she observed red bump pimples in tracks and patches on the arms, thighs, and the back of RI #3. She reported she, herself, had red bumps that itched like crazy on her arms. She admitted they looked like the same tiny, red, raised bumps. She was asked if scabies was contagious, and she answered yes. When asked what she was supposed to do if she was contagious and she answered call in, let them know. Adding, don't come in and chance exposing residents or other staff members. EI #7 was asked about staff getting treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #7 reported that no Infection Control precautions were put in place while she had the rash. She added they just gave them the cream. EI #7 was asked what EI #1 told her to do to prevent the spread of scabies and she answered nothing. EI #7 was asked if she was working before, she went to the DON/IP with the red, pimple-like bumps and given scabies cream. She answered yes, she was on the clock. She added the DON/IP had to order the [MEDICATION(S)] and she came and got it the next day. EI #7 added the DON/IP did not look at her. She just told her she was itchy and had a rash on her arms and needed the cream for scabies. EI #7 was asked what the Infection Control protocol was for staff when they are contagious. She answered you don't come to work if you are contagious. When asked why she came to work after she had went to get treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked what the DON/IP did to prevent spread of the red, itchy, pimple-like bumps. She answered they gave her the cream. An interview was conducted with EI 10, the Pharmacist on 11/17/2022 at 1:52 PM. EI 10 reported the medical director ordered [MEDICATION(S)] 5% cream for staff on 7/3/2022, 10/25/2022 and 11/3/2022. When asked what [MEDICATION(S)] 5% cream was used to treat, he answered it is used for skin rashes and scabies. He added they would normally treat everyone in the surrounding area or unit or the entire facility. An interview was conducted with EI #8, a CNA, on 11/17/2022 at 2:27 PM. This CNA was listed on the Outbreak Investigation EI #1 had written. EI #8 reported she had observed residents with a red, itchy rash. She described it as red, rash, bump raised, and very itchy. EI #8 reported she has had it a few times since she has been here, in the last three years. EI #8 was asked to describe the rash she had, and she answered it was the same as the residents. EI #8 was asked if it was a recurring problem and she answered off and on. When asked what the cause was, she answered she thought it was scabies. EI #8 was asked if scabies was contagious, and she answered yes. EI #8 was asked how to ensure it does not spread and she answered avoid contact. When EI #8 was asked about staff being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . They asked for something to prevent the bumps and they all showed them to her. EI #8 reported she had the bumps on her chest, both sides, her arms, her thigh and between fingers. EI 8 was asked what the DON/IP's response was. She answered that EI #1 said how did they know they got it from the facility. EI #8 told her she only goes to work, goes to get her child, and goes home. Then the DON/IP said she would get them some cream. EI #8 was asked what Infection Control precautions were put in place while she had a rash, after you told the DON/IP. She answered EI #1 said the cream would be delivered. She added EI #1 just told them to put on gloves and wash their hands. EI #8 was asked if her rash/spots were covered by the gloves and she answered, no. EI #8 reported she had worked hall 1 before she presented to the DON/IP with the red, itchy rash. EI #8 was asked what the Infection Control protocol was for staff when they are contagious. She answered to stay home. She admits she should have stayed home. EI #8 was asked what the DON/IP did to stop the spread of the red, itchy pimple-like bumps by staff. She answered the DON/IP only gave them the cream and told them to wash their hands. An interview was conducted with EI #9, a CNA, on 11/17/2022 at 2:45 PM. EI #9 was asked if she had reported red, itchy bumps to the DON/IP, and she said yes. EI #9 was asked when this happened, and she answered on 10/24/2022. She added that the DON/IP gave them some [MEDICATION(S)] cream. EI #1 said she would order the cream but kept saying it was not scabies. EI #9 added when she came to the facility to get her cream, the DON/IP wanted to see the spots. EI #9 was asked if the DON/IP said why she was treating her for scabies if that was not what it was. She answered that she did not, but she felt like the DON/IP wanted them to keep their mouths shut. EI #9 was asked if she had worked prior to presenting to the DON/IP with the bumps, and she said yes, and every day since we reported it, and the DON/IP visibly saw the bumps. EI #9 was asked if scabies was contagious, and she answered yes. EI #9 was asked if she was supposed to come to work when she was contagious. She answered no. EI #9 was asked what Infection Control precautions were put in place while you had the rash and she answered, nothing. An interview was conducted with EI #13, a CNA, on 11/17/2022 at 3:18 PM. EI #13 was asked about residents with red, itchy rashes. She responded it had occurred, it was ongoing since about July and then showed back up in September or October. She described what she saw on residents as a dot-to-dot streak and then it spreads as the resident's scratch until the area was covered. EI #13 reported when she and three other CNAs went in to tell the DON/IP that they felt like they were exhibiting the same symptoms as the residents, the DON/IP said nobody in the building had scabies and told us she had to order some more [MEDICATION(S)], the scabies cream. EI #13 was asked what the CNA's rashes looked like. She answered they had the dot-to-dot with itching just like the residents. EI #13 said that scabies was contagious. EI #13 was asked what Infection Control precautions were put in place while she had the rash and she answered nothing but the cream, wear gloves and hand washing. EI #13 was asked what the Infection Control protocol was for staff when they are contagious. She answered not coming to work, but that doesn't happen because of staffing, they are short staffed. EI #13 was asked if that meant it was okay to expose residents and she said she did not think so. EI #13 was asked what the DON/IP did to prevent the spread of the red, itchy pimple-like bumps by staff. She answered nothing. She added the DON/IP said the residents did not have scabies and did nothing to keep us from giving it to residents. A follow-up interview was conducted with EI #1, the DON/Infection Preventionist on 11/17/2022 at 6:25PM. EI #1 reported her duties as Infection Preventionist were to monitor infections, any outbreaks and investigate them. She said she was supposed to track and trend anything infectious or possibly infectious. EI #1 was asked what she had tracked for 9/6/22 through 9/13/22 and she answered five residents for possible scabies as she had documented. EI #1 was asked if she ruled out scabies for RI #'s 12, 4, 7, 6, and 8 and she said only for RI #4. EI #1 admitted she just tried to treat the rashes and reviewed medications, but there was no change and she had not ruled out scabies. EI #1 was asked what caregivers the identified residents had in common and where it was documented. She said she did not document. EI #1 was asked what she did to try to contain what she had identified as possible scabies and she said she did not investigate; she went in to nurse mode and was trying to treat the condition. EI #1 was asked what the CDC recommended regarding surveillance, when possible, scabies was identified, and she said she did not know. EI #1 was asked what the root cause analysis of the possible scabies was, and she answered she did not do one. EI #1 described the red itchy bumps on the residents as raised, red, little bumps, some of which you could tell had been scratched. EI #1 described the red, itchy bumps on the CNAs as red, raised bumps that itched. EI #1 was asked what interventions she put in place to address the spreading (of the red, itchy bumps) to other residents, and she answered, none. EI #1 was asked if she should have tracked the spreading and she answered she did not track the possible scabies rash. EI #1 was asked if a pattern was identified, and she said yes. EI #1 said the similarities were the caregivers. EI #1 was asked if the CNAs that were treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #1 was asked how many residents were treated with [MEDICATION(S)] 5% cream and she answered one. EI #1 was asked what preventative measures were put in place after CNAs presented to her with itchy, red, pimple-like bumps and she answered, nothing. EI #1 was asked which residents, the infectious CNA's provided care for, had been isolated or monitored. She replied none. When EI #1 was asked what the policy indicated for staff when they are contagious, she answered they need to stay home. EI #1 was asked if that happened, and she said no. When asked why, she answered short staffing. EI #1 was asked how she determined the rash identified on RI #'s 12, 4, 7, 6, and 8 was not contagious and she stated she did not make that determination. EI #1 reported RI #7's possible scabies rash was identified on 9/13/22, they hydrated his skin, and she had no root cause. EI #1 reported she did not know when RI #3's rash was identified, they treated her 1 time with [MEDICATION(S)] 5%, she did not know about it, her condition was not tracked, and there was no root cause because it was not investigated. EI #1 was asked when RI #6's rash was identified (that she had documented as possible scabies on 9/13/22) and she answered when she started working in the facility in the spring. She reported he/she was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #1 reported RI #12's rash was identified 9/13/22 and admitted he/she had been treated with [MEDICATION(S)] 5% cream. EI #1 was asked if RI #12 was being monitored (listed on list of possible scabies rash), and what did she do after he/she was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #1 was asked why she did not do that, and she answered she just did not. EI #1 admitted she did not do a root cause analysis. EI #1 was asked if EI #8 cared for any of the listed residents after she complained of scabies and she said yes. She also reported EI #'s 4, 7, and 6 also cared for residents after coming to her office with complaints of scabies or red, itchy bumps, being treated with [MEDICATION(S)] 5% cream and being included in her outbreak investigation. She admitted two other CNAs came to her and complained of red, itchy rash after 10/24/2022. When asked what she did with them regarding her investigation, she said she did nothing. EI #1 admitted this was an increase in staff cases. EI #1 was asked from her investigation protocol did that indicate additional actions should have taken place and she answered yes, an outbreak was possible. EI #1 was asked why she implemented an outbreak investigation dated 10/26/2022 for staff with red, itchy bumps, but not for RI #12 on 9/6/2022 and RIs 4, 7, 6 and 8 on 9/13/2022. EI #1 answered she did not know, but she should have. This deficiency was cited as a result of the investigations of complaint/report #'s Al 185 and Al 165.

Based on review of the medical record, an interview and a review of a facility policy titled, Charting and Documentation Guidelines, the facility failed to ensure a treatment was documented that had been provided to Resident Identifier (RI) # 3. This affected one of twenty resident's charts reviewed for documentation. Findings include: Review of the facility policy titled, Charting and Documentation Guidelines with and Effective Date of April 24, 2019, revealed: . PROCESS: I. Rules for Charting and Documentation a) Chart all pertinent changes in the resident's condition, reaction to treatments, medication, as well as routine observations. d) Chart sufficient information to identify . services provided . A review of RI # 3's medical record revealed he/she had been admitted to the facility on [DATE] and readmitted on [DATE]. A review of a copy of RI #3's face sheet that Employee Identifier (EI) #12, a Licensed Practical Nurse, had sent to the doctor revealed: . * red bumps all over body. resident states (he/she's) miserable from itching. signed by EI #12, a Licensed Practical Nurse. The MAR (Medication Administration Record) revealed no documentation of [MEDICATION(S)] 5% cream ordered or given. An interview was conducted with EI #3, a Licensed Practical Nurse on 11/17/2022 at 2:08 PM. EI #3 was asked what she could tell the surveyor about a treatment that she had provided to RI #3. She responded yes, she did do that. She came in to work at 1:00 AM. She reported it was before RI #3 went out to the hospital. EI #3 was asked what medication she put on the resident, and she answered [MEDICATION(S)]. EI #3 was asked had she asked for the [MEDICATION(S)] for RI #3, and she answered yes. EI #3 was asked why. She responded RI #3 was itching and had a couple of red spots that were a little raised. She added RI #3's scratching was what made her notice them. EI #3 was asked where she documented the treatment, she provided for RI #3. She answered she did not remember if she did document it. EI #3 was asked what was the facility policy regarding documentation of treatments provided. She answered they were supposed to document whatever they do for residents. EI #3 was asked what was the concern of not documenting treatments that she provided. She answered the record would not show what was done and could be duplicated.

Based on observations, interviews, record reviews and review of a facility check sheet titled PERINEAL CARE, the facility failed to ensure Certified Nursing Assistants (CNAs) performed incontinent care for Resident Identifier (RI) #37 with handwashing and glove changes to prevent the spread of infection. Employee Identifier (EI) #2 and EI #3 cleaned RI #37's perineum, then applied a clean brief to RI #37, while wearing the same soiled gloves. This was observed on 8/23/22 and affected one of two residents observed for incontinent care. Findings Include: Review of an undated facility check sheet titled, PERINEAL CARE revealed, . Washes hands before applying gloves and after removing gloves. Removes any fecal matter thoroughly or urine . Remove gloves, wash hands and re-apply gloves. RI #37 was admitted to the facility on [DATE]. Review of RI #37's quarterly Minimum Data Set with an Assessment Reference Date of 7/13/22 revealed RI #37 to be totally dependant on staff for toileting needs. On 8/23/22 at 4:10 PM EI #2 CNA and EI #3 CNA provided incontinent care to RI #37. EI #2 loosened RI #37's brief and folded it down, then EI #3 wiped the front of RI #37's perineum. Both CNAs assisted the resident to turn to the left side. EI #2 wiped RI #37's buttocks and removed the soiled brief from under RI #37. EI #2 placed a clean brief under RI #37 and EI #3 pulled the brief in place and both secured the brief. Both EI #2 and EI #3, without performing hand hygiene and while wearing the same soiled gloves, cleaned RI #37's perineum and buttocks, then placed and secured a clean brief on RI #37. On 8/23/22 at 4:20 PM, both EI #2 and EI #3 were interviewed. Both were asked, what was the policy for glove changes during incontinent care. EI #3 replied, they should change gloves after cleaning the resident's perineal area, before they place the clean brief. Both were asked, when should staff change gloves during incontinent care. EI #2 replied, after touching dirty, then before touching a clean item like the brief. EI #3 was asked, when did she and EI #2 change gloves after cleaning RI #37, but before placing the clean brief. EI #3 replied, they did not change their gloves and had on the same gloves worn while they cleaned the perineum and buttocks. Both were asked, what would be the harm in not changing gloves when going from a dirty area before touching and placing a clean brief on the resident. EI #3 replied, the resident could get an infection like a [CONDITION(S)] (Urinary Tract Infection). On 8/24/22 at 4:01 PM, an interview was conducted with EI #1, Director of Nursing and Infection Control Nurse. EI #1 was asked, what was the policy regarding glove changes during incontinent care. EI #1 replied, if soiled, when going from dirty to clean, and before touching clean items such as the brief. EI #1 was asked, when should staff change gloves during perineal care. EI #1 replied, after cleaning the resident, if soiled if cleaning bowel movement from a resident, and before placing the clean brief. EI #1 was asked, what would the harm be in the staff not changing gloves during the provision of incontinent care. EI #1 replied, cross contamination, spread contaminates, and could cause a [CONDITION(S)].

Based on observation, interview, record review and a review of the facility's policy titled, Medication Administration Procedures Eye Drops, the facility failed to ensure a licensed staff member did not put Resident Identifier (RI) #63's eye drop (gtt) container in her pocket prior to the administration of the eye gtts to RI #63. This affected RI #63, one of 14 residents observed during medication administration who received eye drops. Findings Include: A review of the facility's policy titled, Medication Administration Procedures Eye Drops dated 03/11, revealed the following: .Opthalmic solutions are to be administered into .the eye in a safe .manner . RI #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #63's current Quarterly Minimum (MDS) data set [DATE], revealed RI #63's Brief Interview for Mental Status score was 9, indicating moderate impairment in cognition. On 12/12/18 at 11:45 AM, Employee Identifier (EI) #7 was observed preparing medication for RI #63. EI #7 removed the [MEDICATION NAME] (eye gtt medication) container/bottle out of the box and placed the [MEDICATION NAME] container in the right pocket of her scrub top. EI #7 entered RI #63's room. EI #7 reached inside of the right pocket of her scrub top with a gloved hand and obtained the [MEDICATION NAME] bottle. EI #7 removed the cap and administered the [MEDICATION NAME] to RI #63's right and left eye. EI #7 placed the [MEDICATION NAME] container back in her right scrub pocked with her gloved right hand. EI #7 removed her gloves and washed her hands. EI #7 exited RI #63's room, and removed the [MEDICATION NAME] container from her right scrub pocket and placed the medication in the medication cart drawer. On 12/12/18 at 12:20 PM, during an interview with EI #7, the surveyor asked why was RI #63 receiving [MEDICATION NAME] eye gtts. EI #7 said for irritation in both eyes. The surveyor asked EI #7 where did she place the eye gtt bottle after she took it out of the medication box. EI #7 said she put it in her scrub pocket. The surveyor asked EI #7 why she put the eye gtt bottle in her scrub pocket. EI #7 said to keep the bottle from becoming contaminated, and because she was going into the bathroom to wash her hands. The surveyor asked EI #7 was her scrub pocket considered clean. EI #7 said no the scrub pocket was dirty. The surveyor asked EI #7 what was the potential harm in placing the eye gtt medication bottle in her scrub pocket, reaching in the pocket with her gloved hand to obtain the bottle, and administering the eye gtt medication. EI #7 said contamination. On 12/13/18 at 7:22 PM, during an interview with EI #6, Director of Nurses (DON) Infection Control, the surveyor asked what was the facility's policy for handling the eye gtt medication container during medication administration. EI #6 said place a barrier on the overbed table. The surveyor asked why should staff not place an eye gtt bottle in their scrub pocket. EI #6 said that would be contamination. The surveyor asked what was the potential harm in placing the eye gtt container in a scrub pocket, reach in the pocket with gloved hand, take the eye gtt bottle out and administer the eye gtt medication to the resident. EI #6 said that would be contamination and infection.

Based on interviews, record reviews, and a review of the facility's policy titled, Voting, the facility failed to ensure residents were provided absentee ballots and voted in the (MONTH) (YEAR) election. This affected six of eight residents, Resident Identifier (RI) #12, #13, #41, #48, #61, and RI #74, who attended the Resident Council meeting. Findings Include: A review of the facility's policy titled, Voting with an effective date of 05/01/2002, revealed the following: PURPOSE: To assist residents in the exercise of their rights as a citizen of the United States . On 12/12/18 at 3:13 PM, during the Resident Council meeting, RI #12, #13, #41, #48, #61, and RI #74 voiced the following: 1. staff did not remind them of the voting day; 2. they were not provided with absentee ballots to vote; and 3. they did not participate in the (MONTH) (YEAR) election. 1. RI #12 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #12's current Quarterly Minimum Data Set (MDS), dated [DATE], revealed RI #12's Brief Interview for Mental Status (BIMS) score of 9, indicating moderate impairment in cognition. 2. RI #13 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #13's Significant Change MDS, dated [DATE], revealed RI #13's BIMS score of 14, indicating intact cognition. 3. RI #41 was re-admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #41's current Annual MDS, dated [DATE], revealed RI #41's BIMS score of 13, indicating intact cognition. 4. RI #42 was re-admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #42's current Quarterly MDS, dated [DATE], revealed RI #42's BIMS score of 15, indicating intact cognition. 5. RI #61 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #61's current Quarterly MDS, dated [DATE], revealed RI #61's BIMS score of 15, indicating intact cognition. 6. RI #74 was re-admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #74's current Quarterly MDS, dated [DATE], revealed RI #74's BIMS score of 14, indicating intact cognition. On 12/12/18 at 4:30 PM, during an interview Employee Identifier (EI) #1, Licensed Social Worker, the surveyor asked who was responsible to ensure residents voted, whether by transportation or by absentee ballots. EI #1 stated, I do the absentee ballots. The surveyor asked did all the residents who wanted to vote get to vote in the last election. EI #1 stated, We had two residents who voted . The surveyor asked EI #1 what happened with the other residents. EI #1 stated, (RI #74) was only one that brought the voting concern to me that I had spoken with. The surveyor asked what about (RI #12, #13, #41, #48, and #61), who did not vote, ballots were not brought to them nor were they reminded of the voting day. EI #1 stated, I did not have any concerns or grievances with them regarding voting. The surveyor asked EI #1 how did he ensure all residents who wanted to vote absentee were provided that opportunity. EI #1 stated, I asked each cognitive residents if they would like to vote. The surveyor asked did he speak with those residents (RI #12, #13, #41, #48 and #61). EI #1 stated, I only spoke to (RI #74). The surveyor asked EI #1 should he have spoken with all of the cognitive residents regarding voting for the last election. EI #1 stated, Yes. The surveyor asked was that the facility's policy regarding voting, and was he responsible to ensure all cognitive residents were asked by him if they wanted to vote. EI #1 stated, Yes. The surveyor asked EI #1, regarding this last election, what was it for and when. EI #1 stated, November, (YEAR), we had a general election voting for house and senate. The surveyor asked for this last general election in (MONTH) (YEAR), was policy and procedure followed. EI #1 stated, Not in full.

Based on observations, record reviews, interviews and a review of the facility's policies titled, Cleaning of Miscellaneous Equipment and Utensils, Employee Personal Health and Hygiene, and Handling Serviceware/Silverware, the facility failed to ensure: 1. plates were free of water and food substances; 2. a dietary worker's hair was completely enclosed within her hairnet and 3. silverware was not placed in silverware bags wet, to be given to the residents. This had the potential to affect 70 of 71 residents who received meals out of the kitchen. Findings Include: 1) A facility policy titled, Cleaning of Miscellaneous Equipment and Utensils, with an effective date of (MONTH) 23, (YEAR), revealed: .8. Dishes: . allow dishes to air dry .9. For dishes with heavy soil, loosen soil with brush . On 05/16/18 at 10:44 a.m., an observation was made. The surveyor observed the cook plating food. The cook touched one plate that was ready for food to be placed in it. The surveyor asked EI (Employee Identifier) #9, the Cook, to pull the plate out of the line. A red, dirty spot was on the plate. The surveyor observed one wet plate going out. The cook pulled five dirty plates. One plate that was pulled had a large orange, grease like substance on it. Four plates that were pulled by the cook had spots on them. Three plates had food substances in them. The surveyor observed six stained plates, stained spoons, knives, and forks. One dirty plate was wiped out by EI #11, the Dietician. EI #11 used a dish cloth to wipe the plate out and the spot was removed. On 05/17/18 at 10:44 a.m., an interview was conducted with EI #9. EI #9 was asked, what did she observe on some of the plates on 5/16/18. EI #9 replied, she did not see any plates that were dirty. EI #9 was asked, did she observe plates with spots and water. EI #9 replied, she did not see the water till the surveyor showed it to her. EI #9 was asked, what was on five plates that she pulled from the line. EI #9 replied, the plates were stuck together but she did not know what it was. EI #9 replied, it looked like a piece of food or syrup. EI #9 was asked, who was responsible for making sure plates were clean. EI #9 replied, everyone in the kitchen was responsible for checking the plates. EI #9 was asked, should food be served on dirty plates. EI #9 replied, no. EI #9 was asked, what was the facility policy on serving food on dirty plates. EI #9 replied, its unacceptable. EI #9 was asked what was the large orange grease looking substance on a plate. EI #9 replied, she had no idea. EI #9 was asked, what was the potential harm when food was served on dirty plate. EI #9 replied, resident's would get sick. On 05/17/18 at 11:04 a.m., an interview was conducted with EI #11. EI #11 was asked, what was in the plate that he scraped. EI #11 replied, he had no idea. EI #11 was asked, did it come out after wiping it. EI #11 replied, yes. EI #11 was asked, did he observe dirty plates on 05/16/18. EI #11 replied, the one that he wiped. EI #11 was asked, what was the potential harm when food was served on dirty plates. EI #11 replied, food borne illness. 2) A review of facility policy titled, Employee Personal Health and Hygiene with an effective date of (MONTH) 29, (YEAR), revealed: PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses. PR[NAME]ESS: d. Hairnets-Hair must be neatly styled and completely covered . On 05/16/18 at 10:44 a.m., the surveyor observed the EI #9's hairnet had hair hanging out from the front and side of the hairnet. The cook was serving food during the lunch tray-line. There were two or three stands of hair on the cook's left shirt sleeve. On 05/17/18 at 11:11 a.m., an interview was conducted with EI #9, the Cook. EI #9 was asked, when should staff hair be enclosed within a hair net. EI #9 replied, at all times. EI #9 was asked, how often should she check her hairnet while in the kitchen. EI #9 replied, every time she went to the bathroom or every time she felt like it was on her face. EI #9 was asked, what was the potential harm when hair was exposed in the kitchen and she was serving food. EI #9 replied, it could get hair in the food. On 05/17/18 at 11:16 a.m., and interview was conducted with EI #8, the Dietary Manager. EI #8 was asked, when should staff's hair be enclosed in a hairnet. EI #8 replied, at all times. EI #8 was asked, did she observe a worker's hair hanging out of the hairnet and on her shirt sleeve. EI #8 replied, only when the surveyor pointed it out. EI #8 was asked, what was the potential harm when hair was exposed in the kitchen, and food was being served. EI #8 replied, it can get into the food. 3) A review of a facility policy titled, Handling Serviceware/Silverware with an effective date of (MONTH) 1, 2002, revealed: .PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses. PR[NAME]ESS: .h. Serviceware should be air dried . On 5/16/18 at 10:44 a.m., the surveyor observed utensils in silverware bags. The surveyor pulled some of the silverware out of the bags and observed three spoons and a knife with water on them. The silverware bags were taken to another area in the kitchen and was checked for dryness. The surveyor observed EI #10, an aide, taking silverware out of the silverware bags. The surveyor observed spoons, forks and knives with water on them and the silverware was dull looking. On 5/17/18 at 11:29 a.m., the surveyor conducted an interview with EI #11. EI #11 was asked, what did he see on some of the spoons and forks in the kitchen on 5/16/18. EI #11 replied, water. EI #11 was asked, why was there water on the utensils. EI #11 replied, there was no rinse aid and negligence on the workers' part. EI #11 was asked what did the facility policy say about wet utensils. EI #11 replied, they were suppose to air dry before using them. EI #11 was asked who was responsible for making sure utensils were dry. EI #11 replied the second dish washer. EI #11 replied, the person who was pulling the dishes. EI #11 was asked what was the potential harm when residents were served wet utensil. EI #11 replied, food borne illness. On 5/17/18 at 2:00 p.m., the surveyor conducted an interview with EI #12, Dietary Aide. EI #12 was asked who was responsible for bagging utensils in the kitchen on 05/17/18. EI #12 replied, she was when she worked. EI #12 was asked, did she bag utensils on 5/16/18. EI #12 replied, yes. EI #12 was asked, why did she bag wet utensil. EI #12 replied, she did not know the jet drier was not working in the machine. EI #12 was asked, what did the facility policy say about wet utensils. EI #12 replied, all dishes must be air dried. EI #12 was asked did she bag wet utensils. EI #12 replied, yes. On 5/17/18 at 2:04 p.m., an interview was conducted with EI #10. EI #10 was asked, when taking utensils out of the silverware bags, what did she see on them. EI #10 replied, spots of water. EI #10 was asked, were the silverware bags ready to go to the residents. EI #10 replied, yes they were. EI #10 was asked, why were the utensils wet in the silverware bags. EI #10 replied, they were not completely dry. EI #10 was asked, who was responsible for making sure utensils were dry. EI #10 replied, whoever washed the dishes were responsible for bagging the silverware. EI #10 was asked, what was the potential harm when the residents were given wet utensils. EI #10 replied, it could cause mildew bacteria. EI #10 was asked, what did the facility policy say regarding putting wet utensils in silverware bags. EI #10 replied, we were not supposed to bag silverware until it was completely dry.

Based on observation, interview and a review of RI (Resident Identifier) #41's MAR (Medication Administration Record), the facility failed to ensure a licensed staff member documented the administration of PRN (As Needed) O2(Oxygen) to RI #41 on 05/16/18. This affected one of one sampled resident who received PRN O2. Findings Include: RI #41 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #41's most recent Annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 02/02/18, revealed RI #41 was severely impaired for daily decision making. The MDS further revealed the resident used O2 while a resident at the facility. On 05/16/18 at 3:34 p.m., an observation was made of RI #41. RI #41 was observed in bed with the head of the bed elevated. RI #41 was observed with O2 on and in use. A review of RI #41's (MONTH) (YEAR) MAR indicated [REDACTED]. A review of RI #41's (MONTH) (YEAR) Physician order [REDACTED]. On 05/17/18 at 10:24 p.m., an interview was conducted with EI (Employee Identifier) #3, Unit Manager RN(Registered Nurse). EI #3 was informed of the surveyor's observation of RI #41's use of O2 on 5/16/18 at 3:34 p.m. EI #3 was asked, when PRN O2 was used by a resident, why should the nurse document the administration on the resident's MAR. EI #3 said, the nurse should check what had been given to the resident on the MAR. EI #3 was asked, when the nurse administered RI #41's O2, why should the staff member have placed the use of the O2 on RI #41's MAR. EI #3 explained it should have been documented as used on RI #41's MAR. EI #3 was asked when she reviewed RI #41's MAR, was there proof the nurse administered the resident O2 on 5/16/18. EI #3 said there was not. EI #3 was asked, should RI #41's MAR indicated [REDACTED]. EI #3 was asked, what was the potential harm for a nurse not to document the administration of a PRN Medication such as O2 on a resident's MAR. EI #3 replied, if it was not documented, it was not done.

Based on observation, interview, and record review, the facility failed to ensure Resident Identifier(RI) #7 was placed in a scoot chair on 3/4/15 as care planned. RI #7 was placed in a recliner chair, with no alarm and sustained a right [MEDICAL CONDITION] on 3/4/15. The facility further failed to ensure the care plan for RI #4 was followed. A two handle sippy cup was not provided for one of three meals observed and a right angled fork was not provided for three of three meals observed. This deficient practice affected two of 14 residents whose care plans were reviewed. Findings Include: A review of the facility's policy titled: "Care Plans" with an effective date of 10/1/10 documented: "PURPOSE: Plans of Care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals for the the resident. STANDARD: According to federal regulations, the facility develops a comprehensive plan of care for each resident that included measurable objectives and timetables to meet a resident's medical, nursing and mental/psychosocial needs ..." 1) RI #7 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #7's most recent Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/19/15 documented RI #7 had both short and long term memory problems and was severely impaired in cognitive skills for decision making. The MDS also revealed RI #7 required extensive assistance for transfers, and walking in room and on corridor on unit. The MDS documented RI #7 was not steady, only able to stabilize with staff assistance with walking, surface to surface transfer and moving from seated to standing positions. A review of RI #7's Care Plan with a Problem/Onset date of 06/15/2013 documented: "... Potential for falls R/T (related to) WEAKNESS, IMPAIRED MOBILITY,[MEDICAL CONDITION](Hypertension), WANDERING, [MEDICAL CONDITIONS] Approaches ... 3/3/15...RESIDENT TO USE SCOOT CHAIR WHEN UP..." On 3/5/15 at 8:30 AM, EI #12 (CNA) was asked if she worked with RI #7 when the fall occurred on 3/4/15 and she said she did. The surveyor asked EI #12 what happened on 3/4/15 with RI #7's fall. EI #12 said another CNA gave RI #7 a shower around 5:30 AM and placed RI #7 in a scoot chair. EI #12 said as the resident was walking off, RI #7 began to get out out of the chair. EI #12 said she asked the resident to sit back down and the resident would not and tried to walk off. EI #12 said she grabbed RI #7's hand and walked RI #7 over to the recliner and helped RI #7 sit down. EI #12 said she went to get another resident up and make beds. EI #12 said when she was in a another resident's room, she saw RI #7 walking. EI #12 said she took off running to assist the resident. EI #12 said by the time she got to the resident, RI #7 had fallen. EI #12 was asked if RI #7 was wandering prior to the fall and she said yes, RI #7 had gotten out of the recliner that she had put the resident in. The surveyor asked EI #12 what type of chair should RI #7 use. EI #12 said the red chair that is low to the floor (scoot and go chair). The surveyor asked EI #12 why did she put RI #7 in a recliner without an alarm. EI #7 said, "Because she would not stay in (scoot and go) chair." EI #12 was asked if the recliner was reclined back. EI #12 said, "No, (RI #7) does not like (the) feet up."EI #12 was asked if RI #7 was supposed to be in any type of chair when the resident was up according to the resident's care plan. EI #12 said she thought it was the red one low to the floor (scoot and go). EI #12 was asked was RI #7 in the scoot and go chair when the resident fell . EI #12 said no. EI #12 was asked after she walked RI #7 the first time, was RI #7 placed in the red chair low to the floor (scoot and go). EI #12 said, "No, I put (the resident) in the pink recliner." EI #12 further stated the scoot and go had an alarm, but the recliner did not. On 3/4/15 at 4:30 PM, EI #7 Licensed Practical Nurse (LPN) was asked if she was working on 3/4/15 when RI #7 had a fall, and EI #7 replied, yes. EI #7 was asked what was she doing. EI #7 said she was passing medicines on the 100 to 107 hall. EI #7 said she did not witness the fall, but the Certified Nursing Assistant (CNA) alerted her by walkie talkie. The surveyor asked EI #7 how many CNA's worked on the locked unit. EI #7 said one at night. EI #7 said RI #7 had been trying to get up all night. EI #7 said she guessed staff had gotten RI #7 up and had taken the resident to a recliner. EI #7 was asked if RI #7 had a chair alarm. EI #7 replied, "(The resident) did not have one this morning (3/4/15)." EI #7 said the resident would have had an alarm if RI #7 had been in the Broda chair. EI #7 was asked if RI #7 should have been in a Broda chair. EI #7 said RI #7 may have been. EI #7 was asked what fall interventions were currently in place for RI #7. EI #7 said they used the mat on both sides of the bed, alarm on the bed, alarm in scoot chair and the resident is to wear hipsters. On 3/5/15 at 2:10 PM, EI #2, Director of Nursing (DON/RN) was asked what type of chair was RI #7 supposed to be in according to the care plan. EI #2 said in a Broda chair (gray chair with slats). EI #2 was asked why did the care plan for 3/3/15 document "scoot chair when up." EI #2 said she was not sure. EI #2 was asked what type of interventions were in place for RI #7 to prevent falls. EI #2 said hipsters, chair evaluations, fall mats and chair alarms EI #2 further stated she would have to check to see if the resident had a bed alarm. EI #2 was asked if RI #7 had sustained a fracture from her fall on 3/3/15. EI #2 said RI #7 had a right [MEDICAL CONDITION]. The surveyor asked EI #2 if she would expect staff to follow the care plan and use the correct chair as ordered. EI #2 said yes. EI #2 was asked if RI #7 was supposed to have an alarm in the chair and in the bed. EI #2 said, "Yes, (the resident) does." EI #2 was asked if she knew why there was a difference in the care plan stating scoot chair and staff thinking Broda chair. EI #2 said they were evaluating the resident on 3/3/15, and the unit manager would have to answer that question. On 3/5/15 at 3:20 PM, EI #11, a RN (Registered Nurse) Unit Manager was asked what type of chair was RI #7 in. EI #11 said RI #7 had been in a broada chair, but she talked with the therapist during their morning meeting on 3/3/15, and she asked the PTA (Physical Therapist Assistant) about a scoot chair; the PTA said it was okay. EI #11 said she thought RI #7 could get hurt from trying to get out of the Broda chair. EI #11 was asked if she updated the care plan, and she said she did. The surveyor asked if staff were aware of the change. EI #11 said, yes she made the LPN and the CNA's aware. The surveyor asked EI #11 if she expected staff to follow the care plan and put RI #7 in the scoot chair. EI #11 said, "Yes." The surveyor asked EI #11 if RI #7 was a one or two person assist. EI #11 said RI #7 was a two person assist for transfers and walking. EI #11 was asked if RI #7 was supposed to have an alarm in the scoot chair and she said, "Yes." EI #11 was asked if it would be appropriate for staff to sit RI #7 down in any chair without an alarm. EI #11 replied, "No." EI #11 was asked how did the staff know what to do with the residents. EI #11 said they go by the CNA nursing sheet that is on the resident's closet door (she provided a blank form to the surveyor for review). EI #11 said she was just told the forms were not on all resident's doors, and she was working on that. EI #11 was asked if the CNA sheet was not on the resident's doors, how would CNAs know what to do. EI #11 replied, "They could ask." EI #11 was asked what interventions were put into place for RI #7 to prevent falls. EI #11 said they had mats on the floor by the bed, hipsters on the resident, staff should use a gait belt when walking the resident, and a bed and chair alarm should be used with the resident. On 3/5/15 at 4:05 PM, EI #10, PTA (Physical Therapy Assistant)was asked what type of chair was RI #7 supposed to be in. EI #10 said RI #7 had been in a Broda chair, but it had not worked, and they had tried the scoot chair. EI #10 was asked if he had attended a meeting on 3/3/15. EI #10 said he had. EI #10 was asked if RI #7's chair was changed to a scoot chair on that date. EI #10 said it was. EI #10 was asked if staff should be using the scoot chair per care plan. EI #10 stated, "Yes." 2) RI #4 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #4's most recent Annual MDS with an Assessment Reference Date of 01/25/15 revealed under, "Section C-Cognitive Patterns" a BIMS (Brief Interview for Mental Status) summary score of 15, indicating the resident was cognitively intact. A review of RI #4's Care Plan titled "Potential for weight loss..." with an onset date of "07/20/2010" revealed the following: "... Approaches ... TWO HANDLE SIPPY CUP WITH MEALS ..." A review of "RI #4's Tray Cards for Breakfast, Dinner and Supper for "Eating Devices" revealed: "2 handle sippy cup" and "Rt. (right) Angled Fork". On 3/04/2015 and 3/05/2015 the surveyor observed the resident eating three meals. The following observations were documented: -On 3/04/2015 at 8:15 AM, breakfast was observed; one sippy cup with water was included on the tray; there was no angled fork on the tray -On 3/04/2015 at 11:45 AM, lunch was observed; there was no sippy cup or angled fork on the tray -On 3/04/2015 at 5:00 PM, an additional observation was made of RI #4's room. No sippy cup was observed on the resident's bedside table. RI #4 was asked if there was a sippy cup for drinking fluids. RI #4 stated was supposed to have one, but did not have a sippy cup. -On 3/05/2015 at 9:15 AM, RI #4 was observed eating breakfast. There was one sippy cup with coffee on the resident's tray; there was no angled fork. When EI #4 was asked if an angled fork had ever be provided with meals, the resident answered, "No." When asked if an angled fork would make it easier to eat, RI #4 replied, "It might." The surveyor then observed the resident drop a bite of scrambled eggs from the fork onto the resident's chest. The hand was observed to jerk as the resident tried to remove the eggs from the chest area. RI #4 was then asked if a sippy cup was provided at lunch the previous day on 3/04/2014. RI #4 said, "No, and I'm supposed to." When asked if a sippy cup made it easier for the resident to drink fluids, RI #4 answered, "Yes." On 3/05/2015 at 9:30 AM, during an interview with EI (Employee Identifier) #9, the RN (Registered Nurse) Unit Manager, the care plan for RI #4 was reviewed. EI #9 was asked what adaptive eating equipment was required per RI #4's care plan. EI #9 stated a two handle sippy cup and a plate guard. After a review of the eating devices specified on RI #4's "Tray Cards", the surveyor conducted an additional interview with EI #9 at 1:05 PM on 3/5/2015. EI #9 was shown the "Tray Card" sheet from the Dietary Department and asked who discontinued the right angled fork on the care plan, and who should inform the Dietary Department when there is a change in a resident's adaptive eating equipment. EI #9 then told the surveyor the 2/20/2014 discontinued approach for the right angled fork on the care plan may not have been correct. EI #9 stated she was unable to find out who had discontinued it, or if it actually had been discontinued. EI #9 stated they did not know whether the approach was still active. EI #9 further stated she would have angled forks sent to the kitchen for the resident, and update the care plan to show the approach had not been discontinued. A review of RI #4's Care Plan titled "Requires assistance to complete daily activities of care safely ..." with an onset date of "07/20/2010" revealed the following: "... Approaches ... DC'D (discontinued) ... 2-20-14 RT (right) ANGLED FORK WITH MEALS ..." On 3/05/2015 at 4:45 PM, EI #9 was asked what was the potential for harm when a resident does not get the adaptive eating devices they require with their meals. EI #9 stated they may not get the nutrition needed, which could lead to the possibility of bed sores; she further stated dehydration could be the result of not getting the sippy cup.

Based on interview and record review, the facility failed to ensure Resident Identifier (RI) #7 did not sustain a fall on 03/04/15, which resulted in a right hip fracture. RI #7 was left unsupervised and unattended in a recliner. RI #7 was transferred to the hospital's emergency room (ER) on 3/4/15 and was admitted to the hospital with [REDACTED]. RI #7 was identified by the facility to have a history of falls. This affected one of four sampled residents identified with falls. Findings Include: A review of the facility's policy titled: "Incidents and Accidents" with an effective date of August 26, 2013 documented: "PURPOSE: The residents environment remains as free of accidents hazards as is possible ..." RI #7 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #7's most recent Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/19/15 documented RI #7 had both short and long term memory problems and was severely impaired in cognitive skills for decision making. The MDS also revealed RI #7 required extensive assistance for transfers, and walking in room and on corridor on unit. The MDS documented RI #7 was not steady, only able to stabilize with staff assistance with walking, surface to surface transfer and moving from seated to standing positions. A review of RI #7's Resident Incident Reports revealed RI #7 sustained a fall on 01/02/15 at 1:10 PM. RI #7 was sent to the (name of the hospital) for evaluation for a possible fracture. A review of the (name of hospital's) Radiology Report dated 01/02/15 revealed the following: "... IMPRESSION: PROXIMAL HUMERUS FRACTURE. ..." "Problem/Onset: 06/15/2013 Potential for fracture R/T WEAKNESS, DEMENTIA AND HX OF RECENT FX TO RT HIP AND RT SHOULDER ... REVIEWED ... 1-27-15... Approaches ... 1-19-15 WASH RT HIP SURGICAL SITE DAILY ..." A review of RI #7's Care Plans revealed the following: "Problem/Onset: 06/15/2013 Potential for falls R/T (related to) WEAKNESS, IMPAIRED MOBILITY, HTN (Hypertension), WANDERING, GLAUCOMA, NEUROPATHY... reviewed ... 1-27-15 Approaches ... 3/3/15 ... RESIDENT TO USE SCOOT CHAIR WHEN UP..." A review of the facility's "Resident Incident Report" for RI #7 revealed RI #7 fell on [DATE] at 9:20 PM, 03/03/15 at 10:15 AM and 3/04/15 at 5:31 AM. A review of RI #7's Resident Incident Report dated 03/04/15 at 5:31 AM revealed the following: "... Narrative of incident and description of injuries: CNA (Certified Nursing Assistant) SAW RESIDENT WALKING IN HALLWAY. CNA STATED SHE TRIED TO GET TO RESIDENT BUT RESIDENT BECAME UNSTEADY AND fell AGAINST WALL AND THEN ON TO FLOOR BEFORE SHE COULD GET TO HER. ABRASION ON RIGHT HAND AND C/O (complaining of) SEVERE PAIN IN RIGHT HIP AREA. UNABLE TO STRAIGHTED RIGHT LEG. ... Immediate Actions Taken: ASSESSED RESIDENT FOR INJURY. SUSPECTED FRACTURE RIGHT HIP. ...Additional Follow-ups ... 3/4/2015 RESIDENT SENT TO (NAME OF HOSPITAL'S) ER FOR EVALUATION..." A review of the (name of hospital's) Radiology report dated 03/04/15 revealed RI #7 had an acute right hip fracture. The report also documented RI #7 had a right hip prosthesis. A review of the (name of hospital's) "PHYSICIAN'S PROGRESS NOTES" dated 03/04/15, revealed the following: "Dx: (Diagnosis) ... fx (fracture) (right) hip Plan: Revision (right) femoral hemiarthroplasty ... ORIF (Open reduction internal fixation) right proximal femur fracture ..." On 3/5/15 at 8:30 AM, EI #12 (CNA) was asked if she worked with RI #7 when the fall occurred on 3/4/15 and she said she did. The surveyor asked EI #12 what happened on 3/4/15 with RI #7's fall. EI #12 said another CNA gave RI #7 a shower around 5:30 AM and placed RI #7 in a scoot and go chair. EI #12 said as she was walking off, RI #7 began to get out out of the chair. EI #12 said she asked the resident to sit back down and the resident would not and tried to walk off. EI #12 said she grabbed RI #7's hand and walked RI #7 over to the recliner and she helped RI #7 sit down. EI #12 said she went to get another resident up and make beds. EI #12 said when she was in a another resident's room, she saw RI #7 walking. EI #12 said she took off running to assist the resident. EI #12 said by the time she got to the resident, RI #7 had fallen. EI #12 said she saw RI #7 make about seven steps past the recliners in the hall, and the left foot crossed in front of the right foot causing the resident to fall sideways. EI #12 said RI #7 was trying to reach for the recliner, but couldn't. EI #12 said RI #7 bumped the right side of the wall with the head and scraped the pinkie finger which began to bleed. EI #12 was asked if RI #7 was wandering prior to the fall and she said yes, RI #7 had gotten out of the recliner that she had put her in. The surveyor asked EI #12 what type of chair should RI #7 use. EI #12 said the red chair that is low to the floor (scoot and go chair). The surveyor asked EI #12 why did she put RI #7 in a recliner without an alarm. EI #7 said, "Because she would not stay in (scoot and go chair) chair." EI #12 was asked if the recliner was reclined back. EI #12 said, "No, (RI #7) does not like (the) feet up."EI #12 was asked if RI #7 was supposed to be in any type of chair when the resident was up according to her care plan. EI #12 said she thought it was the red one low to the floor (scoot and go). EI #12 was asked was RI #7 in the scoot and go chair when the resident fell . EI #12 said no. EI #12 was asked after she walked RI #7 the first time, was RI #7 placed in the red chair low to the floor (scoot and go). EI #12 said, "No, I put (the resident) in the pink recliner." EI #12 further stated the scoot and go had an alarm, but the recliner did not. EI #12 further stated after the resident fell she called for the LPN. On 3/4/15 at 4:30 PM, EI #7, Licensed Practical Nurse (LPN) was asked what hall did she work on. EI #7 said she worked on hall one which included the locked unit. EI #7 was asked if she worked on 3/4/15 when RI #7 had a fall and she said she did work, but did not witness the fall. EI #7 said she was passing medicines on the 100 to 107 hall (outside of the locked unit) and EI #12 (CNA) alerted her by walkie talkie. EI #7 said when she entered the unit she saw RI #7 laying on floor and hollering, on her right side next to the recliner chair. EI #7 said they moved the chair and she felt the resident's right leg and RI #7 screamed. EI #7 said they did not move RI #7 after she assessed the resident. EI #7 said she called the physician, the family and the Emergency Medical Service. EI #7 said RI #7 had been trying to get up all night. EI #7 further said she could hear the resident's alarm when she was at the nurses' station. EI #7 stated RI #7's room was near the locked unit's entrance by the nurses' station. The surveyor provided RI #7's MDS dated [DATE] for reviewed and asked what did it document for assistance with transfers, ambulation and bed mobility. EI #7 said "3/3 Extensive Assistance." EI #7 was asked did RI #7 have a chair alarm. EI #7 replied, "(The resident) did not have one this morning." EI #7 was asked what fall interventions were currently in place for RI #7. EI #7 said they used the mat on both sides of the bed, alarm on the bed, alarm in scoot chair and the resident was to wear hipsters.

Based on observations, record review and an interview, the facility failed to ensure leftover food and commercially prepared foods in the walk-in and reach-in refrigerators were labeled with a Use-By (or discard) date, and ensure all food was discarded by the Use-By date. This had the potential to affect 75 of 75 residents who received meals from Dietary Services. Findings include: 1) Review of the Food and Drug Administration Food Code 2013, Chapter 3 Food, pages 92 and 94, revealed the following: "... 3-501.17 Ready-to-eat, Time/Temperature Control for Safety Food, Date Marking on-premises preparation · prepare and hold cold ... (A) ... refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, ... or discarded when held at a temperature of 5 degrees C (Celsius) (41 degrees Fahrenheit) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. commercially processed food · open and hold cold ... B) ... refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and packaged by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, ... or discarded ... ... 3-501.18 Ready-to-eat, Time/Temperature Control for Safety Food, Disposition. A) A FOOD specified in 3-501.17 (A) or (B) shall be discarded if it: ... (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is appropriately marked with a date or day that exceeds the temperature and time combination ..." During the initial tour of the kitchen on 03/03/2015 beginning at 1:00 PM, the following observations were made in the walk-in refrigerator: -A covered plastic container labeled, "Diet Choc (chocolate) Pudding UB (Use By) 3/2" (the day before) -An open bag of commercially prepared Swiss cheese cubes with no Use-By (or discard) Date -An open bag of commercially prepared Cheddar cheese cubes with no Use-by (or discard) Date, and -An open container of commercially prepared pimento cheese spread with no Use-by (or discard) Date. A review of the contents of the reach-in refrigerator at 1:30 PM on 03/03/2015 produced the following observation: -A half-full carton of commercially prepared "Easy Eggs" (a liquid egg product) with no Use-by (or discard) date. On 03/04/2015 at 8:50 AM, Employee Identifier (EI) #8, the Dietary Manager accompanied the surveyor during an additional tour of the walk-in refrigerator. An open bag of commercially prepared Cheddar cheese cubes with no Use-by (or discard) Date was observed stored in a box on a rack. A review of a facility policy titled "According to the 2013 Food Code:", dated 9/2014 and initialed, "KSS,RDLD", revealed: "All food items shall be labeled with the EXPIRATION DATE. Labels on all items will have USE BY DATE. You will no longer see thaw dates, open dates or date of preparation. You will ONLY SEE EXPIRATION (aka) (also known as) USE BY DATES." During an interview on 03/05/2015 at 8:55 AM, the Dietary Manager, EI #8 was asked how leftovers and open containers or bags of commercially prepared foods should be labeled. EI #8 answered, "With a use by date." EI #1, the facility Administrator then entered the Dietary Manager's office, interrupting the interview to ensure the surveyor had a copy of the above policy, and to ensure the surveyor knew that only Use-by dates are required. The surveyor assured EI #1, a copy of the policy had already been received, and that the surveyor was already aware of this fact. Proceeding with the interview, the surveyor then stated a container labeled, "Diet Choc (chocolate) Pudding UB (Use By) 3/2" was observed in the walk-in refrigerator on 03/03/2015, and asked EI #8 what staff should have done; EI #8 said, "It should have been discarded on 3/2." The surveyor then listed the commercially prepared cheese and egg products that were observed open, and asked how staff should have labeled these; EI #8 answered, "With the use-by date. Then EI #8 was asked what is the potential for harm if the labeling policy is not followed, and if food is not discarded by the "Use By" Date. EI #8 stated, "If it goes beyond the use-by date, it could cause the residents to be sick."

Based on observations, interviews and record reviews, the facility failed to ensure staff washed their hands after removing gloves and before applying clean gloves. This affected Resident Identifier (RI) #8, one of one resident observed during incontinent care. Findings Include: A review of the facility's policy and procedure titled, "Contact Precautions" with an effective date of December 1, 2009, revealed the following: "... GLOVES AND HAND HYGIENE Hand hygiene should be completed prior to donning gloves. ... B. Gloves should be changed after having contact with infective material ... C. Gloves should be removed ... and hand hygiene should be performed immediately. D. After glove removal and hand hygiene, ..." RI #8 was admitted to the facility on readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of RI #8's Admission Minimum Data Set ((MDS) dated [DATE] revealed RI #8's Brief Interview for Mental Status score was 12, indicating moderately impairment in cognition. The MDS also documented RI #8 required extensive assistance with toileting and hygiene. The MDS indicated RI #8 was frequently continent of bowel and bladder. A review of RI #8's care plan titled "Potential for skin breakdown" revealed the following: "...Problem Onset:12/05/2014...R/T (related to) FRAGILE SKIN, DECREASED IMMOBILITY ... Provide incontinent care after each episode ..." On 03/04/2015 at 4:00 PM, during incontinent care observation, the following were observed: Employee Identifier (EI) #13 (CNA) and EI #14 (CNA) washed their hands and applied gloves. RI was repositioned on her right side. EI #13 provided incontinent care to RI #8. EI #13 placed a clean brief underneath RI #8 by placing her gloved hands on the inner aspect of the clean brief and pushed the brief underneath the resident. EI #13 did not change her gloves. RI #8 was repositioned on the back. EI #13 provided incontinent care to RI #8. The resident was positioned on the left side. EI #14 removed the soiled brief. EI #13 removed her gloves and applied clean gloves. EI #13 did not sanitize her hands after she removed her gloves. EI #13 pulled the clean brief from underneath RI #8 and secured the brief. On 03/04/15 at 1:19 PM, the surveyor asked EI #13 what should be done when gloves are removed. EI #13 replied she did not change her gloves after she finished with the peri-care. EI #13 also stated after she wiped RI #8, she tucked the new brief underneath the resident before she removed the soiled brief. The surveyor asked what was the potential for harm to the resident. EI #13 replied contamination to the clean brief. EI #3 (Licensed Practical Nurse) stated EI #13 contaminated the clean brief when she touched the inside of the resident's clean brief, and the brief came into contact with the resident's skin. The surveyor asked what should be done when gloves are removed. EI #13 and EI #14 replied wash hands or use gel. EI #13 stated that was not what she had done.

Based on observation, interview and record review, the facility failed to ensure a right angled fork was supplied for Resident Identifier (RI) #4 during three of three meals observed, and a two-handled sippy cup was provided for one of three meals observed. This affected one of eight residents observed during meals on two of three days of the survey. FINDINGS INCLUDE: A review of "RI #4's Tray Cards for Breakfast, Dinner and Supper for "Eating Devices" revealed: "2 handle sippy cup" and "Rt. (right) Angled Fork". RI #4 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #4's most recent Annual MDS with an Assessment Reference Date of 01/25/15 revealed under, "Section C-Cognitive Patterns" a BIMS (Brief Interview for Mental Status) summary score of 15, indicating the resident was cognitively intact. A review of RI #4's Care Plan titled "Potential for weight loss..." with an onset date of "07/20/2010" revealed the following: "... Approaches ... TWO HANDLE SIPPY CUP WITH MEALS ..." On 3/04/2015 and 3/05/2015 the surveyor observed the resident eating three meals. The following observations were documented: -On 3/04/2015 at 8:15 AM, breakfast was observed; one sippy cup with water was included on the tray; there was no angled fork on the tray. -On 3/04/2015 at 11:45 AM, lunch was observed; there was no sippy cup or angled fork on the tray. -On 3/04/2015 at 5:00 PM, an additional observation was made of RI #4's room. No sippy cup was observed on the resident's bedside table. RI #4 was asked if there was a sippy cup for drinking fluids. RI #4 stated was supposed to have one, but did not have a sippy cup. -On 3/05/2015 at 9:15 AM, RI #4 was observed eating breakfast. There was one sippy cup with coffee on the resident's tray; there was no angled fork. When EI #4 was asked if an angled fork had ever be provided with meals, the resident answered, "No." When asked if an angled fork would make it easier to eat, RI #4 replied, "It might." The surveyor then observed the resident drop a bite of scrambled eggs from the fork onto the resident's chest. The hand was observed to jerk as the resident tried to remove the eggs from the chest area. RI #4 was then asked if a sippy cup was provided at lunch the previous day on 3/04/2014. RI #4 said, "No, and I'm supposed to." When asked if a sippy cup made it easier for the resident to drink fluids, RI #4 answered, "Yes." On 3/05/2015 at 9:30 AM, during an interview with EI (Employee Identifier) #9, the RN (Registered Nurse) Unit Manager, the care plan for RI #4 was reviewed. EI #9 was asked what adaptive eating equipment was required per RI #4's care plan. EI #9 stated a two handle sippy cup and a plate guard. After a review of the eating devices specified on RI #4's "Tray Cards", the surveyor conducted an additional interview with EI #9 at 1:05 PM on 3/5/2015. EI #9 was shown the "Tray Card" sheet from the Dietary Department and asked who discontinued the right angled fork on the care plan, and who should inform the Dietary Department when there is a change in a resident's adaptive eating equipment. EI #9 then told the surveyor the 2/20/2014 discontinued approach for the right angled fork on the care plan may not have been correct. EI #9 stated she was unable to find out who had discontinued it, or if it actually had been discontinued. EI #9 stated they did not know whether the approach was still active. EI #9 further stated she would have angled forks sent to the kitchen for the resident, and update the care plan to show the approach had not been discontinued. A review of RI #4's Care Plan titled "Requires assistance to complete daily activities of care safely ..." with an onset date of "07/20/2010" revealed the following: "... Approaches ... DC'D (discontinued) ... 2-20-14 RT (right) ANGLED FORK WITH MEALS ..." On 3/05/2015 at 4:45 PM, EI #9 was asked what was the potential for harm when a resident does not get the adaptive eating devices they require with their meals. EI #9 stated they may not get the nutrition needed, which could lead to the possibility of bed sores; she further stated dehydration could be the result of not getting the sippy cup.

Based on observation, record review and interview: 1) FOOD TEMPERATURES The facility failed to assure hot foods were maintained at 135 Degrees Fahrenheit (F) or above when served from the tray line. 2) TEMPERATURE MEASURING DEVICES The facility failed to assure temperature measuring devices were calibrated in accordance with manufacturer's specifications as necessary to ensure their accuracy. (Food Code) 4-203.11(B). The above practices posed the potential for food contamination and compromised food safety. The deficient practice had the potential to affect all 76 residents who received meals from dining services. Findings include: 1) FOOD TEMPERATURES The facility failed to assure hot foods were maintained at 135 Degrees Fahrenheit (F) or above when served from the tray line. Based on an observation made 6/18/11 at 11:40 AM, during the beginning of the noon tray line, it was noted, staff documented the temperature for (which was scheduled for 11:00 AM) of Pork Cutlets as 160 degrees F. A request was made for a recheck of the Pork Cutlet temperature. After obtaining two thermometers (one used by the cook) and recalibration of both thermometers, the Dietary Manager (DM), Employee Identifier (EI) #1 determined the temperature to be 124 degrees (substandard). Corrective action was taken. The temperatures were monitored again at the evening meal on 6/28/11. At 5:05 PM, it was noted that the cook (EI) #2 failed to determine the steam table temperature of the Vegetable Soup to assure it was 135 degrees F. The soup was tested and met standard. A review of the Consultant Registered Dietitian (RD,) EI #3 documented Reports for the past year revealed a 5/16/11 report with written information relative to taking temperatures: "...some alternate tempt (temperatures) were missing." Facility policy DS.IV-6 with an efective date of August 15, 2009, directs staff " to record food temperatures on the menu, after each food containeris placed in the steam table". 2) TEMPERATURE MEASURING DEVICES The facility failed to assure temperature measuring devices were calibrated in accordance with manufacturer's specifications as necessary to ensure their accuracy. (Food Code) 4-203.11(B). On 6/28/11 during the noon meal, EI #1 obtained a thermometer to recheck items on the tray line. When asked if she was sure it was calibrated, she obtained ice and water and found the instrument was inaccurate. EI #1 requested the cook on the tray line to allow her to use the thermometer in her pocket. It too was found to be inaccurately calibrated. One of the thermometers registered 42 degrees F. This would be a 14 degree F higher discrepancy. The DM (EI) #1 was asked the frequency of thermometer calibration. Her response was that it was done if dropped. Facility policy # DS.IV-6 dated August 15, 2009, directs staff: "A calibrated thermometer should be used for taking food temperatures ..."

Based on observation, record review and interview the facility failed to assure dietary personnel had knowledge, were properly trained and were competent to assure proper sanitary techniques were utilized in the preparation and distribution of food as evidenced by: 1.) There was a lack of evidence that all line staff had received orientation on job performance tasks. 2.) Problems identified in F 363, a failure to follow the preplanned menus. This resulted in food not being prepared with similar nutrient value per resident choice. 3.) Observations of food storage, preparation and distribution on two of three days of the survey, which resulted in deficient practices cited under F 371 (Store, prepare, distribute and serve food under sanitary conditions). Discrepancies were documented in 2 areas of concern, with a repeat in temperature monitoring and a failure to follow up on the Registered Dietitian's deficient practices. This has the potential to affect all 76 residents who received meals from dining services Findings include: 1.) A record review of the dietary staffing revealed a total of 11 employees (cooks and dietary aides). A review of personnel files revealed that one employee with a hire date of 8/16/03 and two recent hires 3/28/11 and 5/17/11. On 6/29/11 at 4:40 PM, a request was made for the DM to provide job specific orientation with return demonstration information. 2.) Problems identified in F 363, a failure to follow the preplanned menus. This resulted in repetition of items and resident complaints. On 6/30/11 at 2:00 PM, a request was made to the Administrator (EI) #4 to provided evidence of competency orientation for 3 of the eleven employees on staff for the past year. EI #2 , a cook was hired 8/16/03, EI #5, dietary aide, was hired 3/28/11 and EI #7, dietary aide, was hired 5/17/11. None of the 3 new hires above have competency checks as evidenced by record review and a lack of observed return demonstration, and failure of staff to provide additional information. . A request was made of the RD, EI #3, to provide in-service training for food service workers for the past year. A review of the data provided, revealed no training had been documented by the RD. The yearly plan contained a date of 2009 and failed to indicate the precentor for the above time frame. There was no summary of materials covered nor was there a time frame for amount of time spent. 3.) Observations of food storage, preparation and distribution on two of three days of the survey, which resulted in deficient practices cited under F371 (Store, prepare, distribute and serve food under sanitary conditions). Discrepancies were documented in 7 areas of concern. a. The facility failed to assure hot foods were maintained at 135 degrees F. or above when served from the tray line. Monitoring was not timely/consistent and there was a failure to document. b. Failure by staff to utilized accurately calibrated thermometers. Based on deficient practices identified and staff interviews it was determined the facility failed to comply with the demonstration of staff knowledge required in regulatory requirement and standards of practice documented in Food Code 2-102.11.

Based on observation, record review and interview: 1) The facility failed to assure the alternate menu for the noon meal on 6/28/2011 was followed (prepared) as planned. 2) The facility failed to adhere to the planned quantity (serving size) for the alternate menu item (peanutbutter/jelly sandwich) for the evening meal on 6/28/2011. This deficient practice had the potential to affect all 9 of 76 residents who frequently request an menu alternate. Findings include: An observation was made of the noon tray line on 6/28/2011 at 11:30 AM. According to the facility documented "Tray Service Schedule", the lunch meal service began at 11:00 AM. A review of the menu utilized by staff revealed the planned alternate was: Mini Pizza, Tossed Salad w/ (with) Dressing (1/2 C (cup)) Steamed Rice (1/2 C) and Green Beans (1/2 C). No prepared rice was observed. The Dietary Manager (DM) Employee Identifier (EI) #1, was standing nearby and was asked, where is the rice? Her response was: "I will ask (the cook) and let you know." She returned with the response: "She (the cook, EI #2) forgot (to prepare the item). The evening meal tray line delivery was observed on 6/28/2011 at 5:05 PM. A review of th menu revealed the planned menu alternate was: Vegetable Soup and Peanutbutter & Jelly Sandwich (4 T. (tablespoons) on 2 pieces of bread). Approximately 6 sandwiches were prepared and placed in individual baggies. A request was made for the DM to obtained measuring spoons and something to remove the peanutbutter/jelly from the bread. It was determined only 2 T. was used, not 4 T. as per menu plan. Therefore, the alternate provided failed to provide similar nutrient value. A review of the facility policy/procedures for menu changes, with an effective date of 2/1/02, revealed: "..changes should be indicated on the menu, prior to meal service. The reason for the deviation should be noted on the menu..." No documented changes were noted.