Every finding on record at Forest Manor Health and Rehab

Based on observation, interview, the facility's policies for Maintenance Service and Cleaning and Disinfection of Environmental Surfaces, and the facility's Housekeeper job description; the facility failed to ensure 3 of 4 shower rooms in the long term care building were in good repair and free of grime build-up. In addition, the hallway at the entrance to the Station #2 Shower Room had water pooling under the linoleum tile, which was stained and peeling. This affected the shower rooms on Station #1, Station #2, and Station #3 and had the potential to affect 134 of 162 residents in the facility. Findings include: The facility's policy for Maintenance Service, with a revised date of December 2009, included the following: Policy Statement Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation 1. The maintenance department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to: . b. maintaining the building in good repair and free from hazards. j. others that may become necessary or appropriate. The facility's policy for Cleaning and Disinfection of Environmental Surfaces, with a revised date of August 2019, included the following: Policy Statement Environmental surfaces will be cleaned and disinfected according to current CDC (Centers for Disease Control and Prevention) recommendations for disinfection of healthcare facilities and the OSHA (The Occupational Safety and Health Administration) bloodborne pathogens standard. Policy Interpretation and Implementation . 9. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. 10. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled. 11. Walls . will be cleaned when these surfaces are visibly contaminated or soiled. The facility's job description for Housekeeper, dated 01/01/2018, included the following: . Generally Reports to: Housekeeping Supervisor . SUMMARY Provides housekeeping services to ensure a safe, sanitary, and comfortable environment for residents . ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned. Cleans (dust, dry mop, wet mop, sanitize, scrub) assigned resident rooms, bathrooms, and common areas daily . Cleans walls . Disposes of trash and waste . An observation of the Station #2 Shower Room was made on 06/28/2023 at 4:20 PM. The linoleum floor tiles in the hall just in front of the shower room door were stained and peeling. Water was pooled beneath the linoleum floor tiles. Seventeen linoleum floor tiles, each approximately one-foot square, were affected by the standing water. In addition, the metal door frame at the entrance to the shower room was rusted and eroded at varying heights from the floor level, approximately one to three inches up the frame. Water also appeared to be pooled up under the ceramic tile of the shower room near the doorway. When the door sill/threshold was stood upon by an individual, water was pushed out onto the linoleum tiles in the hallway. Inside the shower room, there were two ceramic floor tiles missing by the floor drain and three more missing near the shower room doorway. In addition, there was a build-up of dark residue/grime around the ceramic floor tiles and the lower ceramic wall tiles. An observation of the Station #1 Shower Room was made on 06/28/2023 at 4:30 PM. Employee Identifier (EI) #4, an Licensed Practical Nurse, (LPN) said the residents on Station #1 were using both the Station #1 Shower Room and one on the [NAME] hallway, the Station #3 Shower Room. The Station #1 Shower Room had 29 missing ceramic floor tiles. The Station #1 Shower Room's floor drain had a build-up of grime and the room had a musty odor. The shower room contained a shower chair and a shower bed. The pad on the shower bed had five long cuts and some additional smaller cuts in the vinyl, which exposed the beige pad underneath. There was a build-up of black residue visible on the beige pad at the vinyl cut sites. An observation of the Station #3 Shower Room was made on 06/28/2023 at 4:42 PM. The framework for the ceiling tiles was rusted and there was one missing ceramic wall tile at a corner near the floor. In addition, there was a build-up of dark residue between the floor tiles. On 06/28/2023 at 4:48 PM, a tour of the shower rooms was conducted with EI #3, the Housekeeping Supervisor and Maintenance Director, beginning with the Station #3 Shower Room. EI #3 said the Station #3 Shower Room was used by the residents from both Stations #1 and #3. Upon viewing the shower floor with EI #3, it was observed that grout had eroded from between the actual shower area floor tiles. EI #3 said skin tears would be a concern due to the exposed tile edges. Upon viewing the status of the floor, the rusted ceiling framework, and the missing wall tile; EI #3 said the Station #3 Shower Room was not homelike. At 5:00 PM, the Station #1 Shower Room was viewed with EI #3. Upon seeing the missing floor tiles, the grime build-up, and the cuts with the dark residue in the shower bed pad; EI #3 said the Station #1 Shower Room was not sanitary, clean, or homelike. At 5:07 PM, the Station #2 Shower Room was viewed with EI #3. Upon viewing the damaged linoleum tile in the hallway, EI #3 said there had been a previous issue with drainage, but he did not know what was causing the water build-up beneath the tiles. After seeing the missing floor tiles, the ceiling rust, and the dark grime build-up between the ceramic floor and wall tiles; EI #3 said the Station #2 Shower Room had not been cleaned properly and that it was not sanitary or homelike. On 06/28/2023 at 6:10 PM, EI #1, the Administrator, said he was aware of the water under the linoleum tile building up, but he had not seen the crack in the tile until today. On 06/29/2023 at 9:25 AM, EI #8, a Housekeeper, was interviewed. EI #8 said the Station #1 Shower Room was currently in use. EI #8 said she knew the floor was a bit of a mess, and that the floor tiles needed to be replaced. On 06/29/2023 at 11:07 AM, EI #10, an LPN, was interviewed. EI #10 said she had known about the issue with the linoleum tile in the hall outside of the Station #2 Shower Room for about a week and a half. EI #10 said she reported it to (Name of EI #3), the Maintenance Director. On 06/29/2023 at 11:30 AM, EI #2, the Director of Nursing was interviewed while viewing the Station #1 Shower Room. EI #2 said the shower bed/stretcher pad had tears in the cushion and needed to be replaced. EI #2 said she would expect the CNAs to report to her or to Maintenance that the shower bed/stretcher pad needed to be looked at or replaced. EI #2 said the torn shower bed/stretcher pad was an infection control issue. EI #2 further said it could be a safety issue due to the potential for skin tears and skin breakdown.

Based on interviews, record review and a facility policy titled, Care Plans, Comprehensive Person-Centered, the facility failed to ensure a comprehensive care plan was developed and implemented for RI (Resident Identifier) #1 a resident who resided in the facility from [DATE] through 11/04/21. This deficient practice affected RI #1, one of seven residents whose care plans were reviewed. Findings Include: A review of a facility's policy titled, Care Plans, Comprehensive Person-Centered, with a revised date of December 2016 revealed, . Policy Interpretation and Implementation 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. RI #1 was admitted to the facility on [DATE]. On 07/07/22 at 12:25 PM, Surveyor reviewed the electronic records and there was no documentation of RI #1's comprehensive care plan. On 07/07/22 at 12:30 PM an interview was conducted with EI (Employee Identifier) #1, Minimum Data Set (MDS) Coordinator. EI #1 was asked who was responsible for developing RI #1's comprehensive care plan. EI #1 stated she was responsible. EI #1 was asked was RI #1's comprehensive care plan developed and implemented including his/her care plan for at risk for falls. EI #1 said no it was not done. EI #1 was asked why a comprehensive care plan was not developed and implemented for RI#1. EI #1 said it was an error on her part. EI #1 was asked when should a newly admitted resident's comprehensive care plan be developed and implemented. EI #1 said 21 days from admission to complete and implement the care plan. EI #1 was ask should a comprehensive care have been done for RI#1. EI #1 said, yes it should have been completed on 11/02/21. EI #1 was asked why it was important to have a comprehensive care plan developed and implemented for a resident. EI #1 said so you will know how to provide their care. On 07/07/22 at 3:45 PM an interview was conducted with EI #2, Registered Nurse, Director of Nursing. EI #2 was asked should a comprehensive care plan have been developed and implemented for RI #1. EI #2 said, yes it should have. EI #2 was asked was a comprehensive care plan developed and implemented for RI #1. EI #2 said no it was not. EI #2 was asked what was the concern with RI #1 not having a care plan developed and implemented. EI #2 said the staff would not know the individualized accommodations that the resident may need.

Based on observations, interviews, record review and review of POTTER and PERRY'S FUNDAMENTALS OF NURSING, the facility failed to ensure Employee Identifier (EI) #4, the Licensed Practical Nurse (LPN)/Treatment Nurse, removed her gloves, sanitized her hands, and put on clean gloves after cleaning Resident Identifier (RI) #9 and #11's pressure ulcers, and before applying clean dressings to resident's pressure ulcers on 08/18/2021. This deficient practice affected RI #9 and #11, two of three residents sampled for pressure ulcers. Findings Include: Page 1225 of Chapter 48 titled Skin Integrity and Wound Care of POTTER and PERRY's FUNDAMENTALS OF NURSING with a copyright date of 2017, revealed the following: . IMPLEMENTATION . 3. Clean ulcer thoroughly with normal saline or cleaning agent . RATIONALE . Removes wound debris. 4. Remove gloves, perform hand hygiene, and apply clean or sterile gloves. Aseptic technique must be maintained during cleaning and all phases of pressure ulcer treatment . RI #11 was admitted to the facility on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] RI #11's August 2021 Order Recap Report (physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . CLEAN PRESSURE WOUND OF THE RIGHT, LATERAL HEEL WITH NS (Normal Saline), APPLY SANTYL AND COVER WITH BORDER GAUZE EVERY T (Tuesday)-TH (Thursday)-SAT (Saturday) . On 08/18/2021 between 2:26 and 2:50 p.m., EI #4, the LPN Treatment Nurse, was observed providing wound care to RI #11's Stage 4 pressure ulcer on the resident's right lateral heel. The surveyor observed a dressing to RI #11's right outer heel. During care observed, EI #4 washed her hands and applied a new pair of gloves. EI #4 cleaned the right heel wound, picked up the clean dressing with Santyl on it, and with the contaminated gloves still on, placed the dressing over the wound bed. RI #9 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #9's August 2021 Order Recap Report revealed the following: . Clean open area to right lateral foot with wound cleanser, apply antibiotic ointment and cover with border gauze to area BID two times a day . Hydrogel Gel . Apply to Lt (left) Buttocks topically every day shift for wound care . On 08/18/2021 between 2:57 p.m. and 3:50 p.m., EI #4, the LPN Treatment Nurse, was observed providing wound care to the excoriated area to RI #9's left buttocks and right lateral foot. EI #4 gloved and cleaned the excoriated areas to RI #9's left and right inner buttocks. EI #4 placed the gauze in a plastic bag and removed her gloves. EI #4 put on clean gloves without sanitizing her hands, picked up the border dressing with hydrogel on it and placed it over the excoriated areas to RI #9's buttocks. EI #4 then removed her gloves and washed her hands in the bathroom before removing the heel protector from RI #9's right foot. EI #4 described the wound to RI #9's right lateral foot as beefy red with granulation tissue present. EI #4 gloved and cleaned the wound bed, then placed gauze in the plastic bag. With the contaminated gloves still on, EI #4 picked up the border dressing with antibiotic ointment on it and placed the dressing over the wound bed. On 08/19/2021 at 1:55 p.m., the surveyor conducted an interview with EI #4. EI #4 said she had been the treatment nurse since December of 2020. The surveyor asked EI #4, after cleaning a wound, what should the nurse do with their gloves before picking up a clean dressing and placing the clean dressing over the wound bed. EI #4 said the gloves should be removed and disposed of. EI #4 also said your hands should be washed. When asked why she did not do those things when she provided wound care for RI #11 and RI #9 on 08/18/2021, EI #4 said she made herself nervous. The surveyor asked EI #4 what was there a potential for when contaminated gloves were not changed when providing wound care, EI #4 said infection. On 08/19/2021 at 3:39 p.m., the surveyor conducted an interview with EI #2, the Director of Nursing. The surveyor asked EI #2 when should the nurse performing wound care change their gloves. EI #2 said after the nurse has cleaned the wound. When asked what was there a potential for when this was not done, EI #2 said infection. This deficiency was cited as a result of the investigation of complaint/report number AL 488

Based on interviews, record review, review of a facility policy titled Abuse Prevention Program, and review of a facility report from the Alabama Department of Public Health Online Incident Reporting System, the facility failed to ensure their five day summary was submitted to the State Agency in a timely manner when Resident Identifier (RI) #12 alleged Mistreatment on 08/11/2021. This deficient practice affected RI #12, one of four residents reviewed for incidents reported to the State Agency by the facility. Findings Include: RI #12 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a policy titled Abuse Prevention Program, with a revised date of 04/2019, revealed the following: . Abuse of any kind is to be reported to the appropriate State agency or agencies, with in the allowed reporting timeframe by the facility . Policy Interpretation and Implementation As part of the resident abuse prevention, the administration will: . 7. Investigate and report any allegations of abuse within timeframes as required by federal requirements . A review of an Alabama Department of Public Health Online Incident Reporting System report revealed the following: Confirmation of Receipt of Online Incident Report . Date/Time Submitted: Wednesday, August 11, 2021 . Selected Category: Mistreatment . Names(s) of resident(s) involved: (name of RI #12) . Narrative summary of incident: Resident (RI #12) reported to (Employee Identifier [EI] #3, Social Services staff) that staff mistreated (him/her) by refusing to provide a bed bath. Resident stated (he/she) was told it is not (his/her) bath day . On 08/19/2021 at 9:31 a.m., the surveyor conducted an interview with EI #3. EI #3 said RI #12 did voice a concern to her on 08/11/2021 that he/she had not received his/her baths. When asked what was done when RI #12 voiced this concern, EI #3 said she reported this to EI #1, the Administrator. On 08/19/2021 at 5:06 p.m., the surveyor conducted an interview with EI #1. The surveyor asked EI #1 when was the report, concerning RI #12 not receiving his/her baths, sent in to the State Agency. EI #1 said on 08/11/2021. When asked what would be considered the five working days to submit the investigation from a report, EI #12 said Monday through Friday. The surveyor asked EI #1 to review the August 2021 calendar and tell the surveyor when the five day summary from the investigation would be due. EI #1 said the report should have been submitted on the 18th (08/18/2021). When asked why the five day summary had not been submitted to the State Agency, EI #1 said the facility was attempting to do a thorough investigation. This deficiency was cited as a result of the investigation of complaint/report number AL 488.

Based on interviews, record review, and review of a facility policy titled Activities of Daily Living (ADLs), Supporting, the facility failed to provide evidence Resident Identifier (RI) #12, a resident totally dependent on staff for bathing/showers, was provided bed baths as requested by the resident. This deficient practice affected RI #12, one of four residents sampled for ADL care. Findings Include: RI #12 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a policy titled Activities of Daily Living (ADLs), Supporting, with a revised date of 03/2018, revealed the following: Policy Statement . Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good . personal . hygiene. Policy Interpretation and Implementation . 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing . care) . RI #12's care plan titled The resident had an ADL self-care performance deficit r/t (related to) decreased mobility, non-ambulatory, limited ROM (Range of Motion) BUE (Bilateral Upper Extremity)/BLE (Bilateral Lower Extremity), with an initiated date of 03/03/2021, revealed the following intervention: *BATHING/SHOWERING: The resident is totally dependent on x (times) 1 staff to provide bath/shower daily and as necessary . A review of the Daily BEDBATH/SHOWER ASSIGNMENT SHEET for the Unit RI #12 resided on revealed RI #12's bed baths/showers were scheduled for the 3-11 shift. RI #12's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 06/21/2021, assessed RI #12 as scoring a 15 on the Brief Interview for Mental Status (BIMS) and was totally dependent on staff for bathing. On 08/18/2021 at 10:40 a.m., the surveyor conducted an interview with RI #12. RI #12 said he/she used to get showers but he/she now preferred bed baths. When RI #12 was asked when he/she had not gotten his/her baths as scheduled, EI #12 said on the 6th, 7th and 8th of August (2021). RI #12 said she told the nurse who cared for her and the nurse informed RI #12 he/she would have to speak with someone else. RI #12 said he/she did talk to Employee Identifier (EI) #3, a Social Service staff member. On 08/19/2021 at 9:31 a.m., the surveyor conducted an interview with EI #3. EI #3 said RI #12 did voice a concern to her on 08/11/2021 that he/she had not received a bed bath in three days. The surveyor asked EI #3, according to RI #12's ADL plan of care, when was RI #12 scheduled to receive bed baths. EI #3 said RI #12 was to receive bed baths daily and as necessary. On 08/19/2021 at 3:39 p.m., the surveyor conducted an interview with EI #2, the Director of Nursing. The surveyor asked EI #2 where would there be evidence RI #12 had received her baths as scheduled. EI #2 said it would be documented on the Bathing: Self Performance sheet. When asked if she saw where the evidence was documented on the sheet, EI #2 said no. The surveyor asked EI #2 when a resident was scheduled for a bath or shower should it be provided to them. EI #2 said yes. This deficiency was cited as a result of the investigation of complaint/report number AL 488.

Based on observations, interviews and a review of a facility policy titled, Labeling and Dating Foods (Date Marking), the facility failed to ensure food items in the cooler, freezer and dry storage area were labeled. This had the potential to affect 121 of 121 residents who received meals from the kitchen. Findings Include: A review of a facility policy titled, Labeling and Dating Foods (Date Marking) with no effective date, revealed: Guideline: . 1. Date marking for dry storage food items . dry food items will be dated with the date the case was received into the facility and will be using, first in-first out .3. Frozen food packages removed from the case will be dated with the date, the item was received into the facility and will be stored using the first in-first out .4. Prepared food or opened food items should be discharged when: . the food item is older than the expiration date . On 5/11/21 at 8:26 AM, the surveyor observed in the dry storage area, two packages of taco shells out of the original container on shelves, with no date. The surveyor noted a discolored soft taco shell and the bottom of the taco package was hard. The surveyor also observed there to be tomatoes cut in half in a box with other tomatoes wrapped with saran wrap with no label in the cooler. In the freezer, the surveyor observed French fries out of the original container in a medium bag wrapped with saran wrap with no label on it. On 5/12/21 at 4:08 PM, an interview was conducted with EI (Employee Identifier) #5, Dietary Manager. EI #5 was asked, what was in the dry storage with no label on it. EI #5 said, tortilla wraps. EI #5 was asked, what was in the freezer with no label on it. EI #5 replied, French fries. EI #5 was asked, what was in the cooler with no label on it. EI #5 replied, a tomato. EI #5 was asked, why was there no label on the food items. EI #5 said, they did not date it. EI #5 was asked, what was the facility's policy on labeling food items in dry storage, the cooler and the freezer. EI #5 replied, label it as you open it. EI #5 was asked, who was responsible for labeling food items in dry storage, the cooler and the freezer. EI #5 said, the person that was utilizing the product. EI #5 was asked, when should food items be labeled. EI #5 replied, when they come in. EI #5 was asked, why was it important that food items be labeled. EI #5 said, do not want it to go bad, or get anyone sick.

Based on observation, interview, record review and review of a facility policy titled Administering Medications through a Small Volume (Handheld) Nebulizer, the facility failed to ensure Resident Identifier (RI) #112's nebulizer mask was stored as per facility policy when not in use. This affected one of one resident sampled for respiratory care. Findings include: A review of the facility policy titled Administering Medications through a Small Volume (Handheld) Nebulizer with a revised date of October 2010 revealed, Purpose The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway.Steps in the Procedure .29. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. RI #112 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #112's order summary report with a date of May 12, 2021 revealed, [MEDICATION(S)]-[MEDICATION(S)] Solution 0.5-2.5 (3) MG (milligrams)/3 ML (milliliters) 3 ml inhale orally three times a day for bronchodilator . order date 4/14/21 . On 5/11/21 at 8:43 AM, an observation was made of RI #112's nebulizer mask sitting upright in the holder on a nebulizer machine. The nebulizer mask was not covered. On 5/12/21 at 9:37 AM, an observation was made of RI #112's nebulizer mask lying beside the nebulizer machine that was sitting on the bedside table. The mask was not covered and there was residue in the mask. On 5/12/21 at 9:40 AM, an interview was conducted the Employee Identifier (EI) #7, Registered Nurse (RN). EI #7 was called to RI #112's room. EI #7 was asked, what should the nebulizer mask be stored in. EI #7 replied, the mask was supposed to be stored in a plastic bag. On 5/13/21 at 8:17 AM, an interview was conducted with EI #2, Director of Nursing. EI #2 was asked, how should nebulizer masks be stored. EI #2 replied, in a plastic bag that was dated. EI #2 was asked, what was the risk to the resident when a nebulizer mask was not stored in a plastic bag. EI #2 replied, infection.

Based on interviews, medical record review, and a review of Potter and Perry's Fundamentals of Nursing, Ninth Edition, the facility failed to ensure RI (Resident Identifier) #1, a resident admitted to the facility on [DATE] and discharged on [DATE], then readmitted on [DATE] and discharged again on 01/31/21, received the ordered medication Clonazapam (Klonopin) on 01/14/21, 01/15/21, 01/16/21, 01/22/21, 01/23/21, 01/24/21, and 01/25/21, as ordered by the physician. RI #1 did not receive the Klonopin on 7 of 15 total days the resident was in the facility. This deficient practice affected RI #1, one of five sampled residents whose physician's orders [REDACTED]. Findings Include: A review of Potter and Perry's Fundamentals of Nursing, Ninth Edition, revealed the following: Chapter 23 Legal Implications in Nursing Practice .Health Care Provider's Orders. The health care provider (physician .) is responsible for directing medical treatment. Nurses follow health care provider's orders unless they believe that the orders are in error . RI #1 was originally admitted to the facility on [DATE]. The resident was discharged out to the hospital on [DATE] and re-admitted on [DATE] with final discharge on 01/31/2021. A review of RI #1's Physician order [REDACTED]. Give 2 tablets by mouth two at bedtime for anxiety. Order dated 01/13/21 with start date 01/14/2021 at 8:00 pm. A review of the Medication Administration Record [REDACTED]. On 02/03/21 at 3:15 p.m., an interview was conducted with Employee Identifier (EI) #1, Registered Nurse (RN). EI #1 was asked if she worked on Saturday 1/23/21. She replied yes. EI #1 was asked if RI #1 received their Klonopin on 01/23/21. EI #1 answered no. EI #1 was asked why RI #1 did not receive the Klonopin. EI #1 responded that the Klonopin was not on the medication cart in the morning. EI #1 was asked what was the potential harm of a missed dose of Klonopin. EI #1 replied that the resident can be more anxious. When asked what do you do when a medication is not on your cart, EI #1 answered call the pharmacy. She said she ordered it from the pharmacy when she realized the resident did not have the Klonopin. An interview with EI #2, Director Of Nursing (DON), was conducted on 02/21/21 at 4:45 p.m. When asked who was responsible for making sure the pharmacy gets the script for a controlled substance, EI #2 answered the admissions nurse. Regarding RI #1, EI #2 was asked when a nurse discovered that the Klonopin was not in the med cart, what should they have done. EI #2 responded they she should have called the pharmacy to see why it had not been shipped, then when the pharmacy said that they have no hard script, the nurse should have taken care of it. If the call is not returned in 2 hours, they are to notify her (DON). She would notify the Medical Director to get a back up prescription. EI #2 was asked who was the first person that should have caught that the med was needed. EI #2 responded, the first nurse to give medication. She looked it up and said, it was EI #6, LPN. When asked who should be following up to see that meds are given, EI #2 replied her. EI #2 was asked when did she become aware that the resident did not receive the Klonopin for 7 days/doses. EI #2 responded day 6. When asked what did she do about it. EI #2 stated, she notified their Medical Director. EI #2 was asked who signed the prescription. EI #2 replied their Medical Director on 01/25/21. When asked did she do an investigation. EI #2 replied, she did, she went through the whole process: why it was done the way it was and what they could do to fix it. EI #2 was asked what did she find was the reason why it happened. EI #2 replied there was no hard script in the beginning, it was overlooked by the admission nurse, so they did send a FAX to the original prescribing doctor, but he did not respond. It was the weekend and no one followed up. On 02/23/21 at 11:07 a.m., a telephone interview was conducted with the Pharmacy Tech. She was asked to explain the process of facilities ordering medications from their pharmacy. She replied, when they first come in they (facility) send the orders the patient came with and new orders. The pharmacy keys them in and they will be at the facility later that night if sent in before 5:00 pm. When asked if the process varies at different times of day, the tech replied that as long as they get it to us before cut off time, they should get the medication the same day. When asked what are the cut-off times, she replied 5:00 p.m. The tech was asked what orders did their receive from the facility on 01/13/21 for RI #1. She responded hospital orders and orders from the nursing home. When asked did they received those on 01/13/21. She replied yes. When asked what did the orders say, the tech responded that the hospital orders were for [MEDICATION NAME] ([MEDICATION NAME]) 875/125, [MEDICATION NAME] 10 mg, [MEDICATION NAME] 5 mg, Clonazapam 1 mg (listed on hospital order, cannot and did not send until they received a valid prescription), [MEDICATION NAME] 500 mg, Xarelto 15 mg, [MEDICATION NAME] 20 mg (2 tablets), [MEDICATION NAME] 5 mg, Atovastatin 10 mg and Vitamin B12 1000mcg. The tech further stated they also received matching orders from the facility. She was asked when did they receive a valid prescription for the Clonazapam 1 mg, on the hospital orders. She responded that the prescription that she had was dated 01/25/21. The tech was asked when was that order filled. She replied on 01/26/21. When asked why did they need a prescription in addition to the orders, she stated it is a controlled substance and they need a written prescription that is signed by the doctor with quantity, date, patient's name, and directions to fill the order. On 02/23/21 at 3:47 pm, a interview was conducted with EI #4, Licensed Practical Nurse (LPN) to verify the information that was originally provided to a surveyor on 02/03/21. EI #4 was asked did RI #1 receive his/her Klonopin on 01/22/21. EI #4 replied no. When asked why the Klonopin was not administered, EI #4 responded it was not on the cart. When asked when there is no medication on the cart who do you tell. EI #4 responded that you log in and put in the code that it was not on the cart or fill out an order sheet for that medication. EI #4 was asked if she filled out an order sheet. She replied she did not remember. When asked what happened when she filled out an order sheet. EI #4 responded, then you FAX it to the pharmacy. When asked what do you do with an order sheet then. She replied that you wait on a confirmation sheet and file it by date or month. EI #4 was asked who did the follow up on medications when it had been more than one day with missing medication, EI #4 responded the Registered Nurse (RN) supervisor. EI #4 was asked did she contact the supervisor. EI #4 responded no she was not there at 8:00 p.m. EI #4 was asked how did they communicate with the supervisor. She said generally they page overhead. On 02/23/21 at 4:04 p.m., an interview was conducted with EI #6, LPN, the nurse who admitted RI #1 on 01/13/21. EI #6 was informed, that according to the Progress Notes she was the nurse that admitted RI #1 on 01/13/21. A Copy the the progress notes was shown to EI #6. When asked what time was RI #1 admitted on [DATE], EI #6 replied 5:14 p.m. is when the admission note was made. When asked did RI #1 have orders for Klonopin on admission. EI #6 stated there was an order for [REDACTED].#6. On 2/24/21 at 10:10 a.m., a telephone interview was conducted with the Pharmacist. The Pharmacist was asked what was the pharmacy process for when they get an order for [REDACTED].#1. The Pharmacist said he was not sure if they did or not, sometimes there is a delay on the prescription after the orders are received. He also stated the hospital normally sends everything they need with the packet. The Pharmacist was asked what was the process on the weekend. He said they (facility) call the pharmacy first to get the pharmacist on call and let them know of a new admission, they look for the fax, then try to get the meds to the facility. Sometimes the pharmacists will bring the medications to the facility. The Pharmacist was asked where RI #1's Klonopin script came from. He said it was received on 01/26/21 from Forest Manor Station 1, but not sure of the time either 6:38 or 8:38. The Pharmacist was asked were orders faxed from the hospital and the facility with RI #1's new admission on 01/22/21. He said they did get them around 3:11 p.m, no prescription with the orders, and the hospital orders were received by the pharmacy on 01/22/21 at 3:11, Klonopin was on orders but there was no script with order. He was asked when was the order filled. The Pharmacist said he was not sure why it did not get done (filled) on the 22nd, no one called about it from the facility, and the pharmacists on call came in and filled it on Saturday the 23rd. The Pharmacist was asked who was responsible for getting the prescription from the MD. He said the pharmacy calls the facility to let them know. This citation was written as a result of the investigation of complaint/report number AL 101.

Based on observation, staff interviews, a review of an undated facility document titled: Diet Spreadsheet . Menu: Nursing Home Week: 2 Day: 2, and a review of an undated facility document titled . Menu Week 2 the facility failed to ensure the breaded chicken breast portion served on 10/21/19 for supper was equal to the portion size of chicken breast listed on the menu and approved by dietitian. This affected 79 of 160 residents who received the breaded chicken breast with the meal from the kitchen on 10/21/2019. Finding include: A review of an undated facility document titled Diet Spreadsheet . Menu: Nursing Home Week: 2 Day: 2 revealed . SUPPER . Chicken, On Bun (C) 3 ounces . A review of an undated facility document titled . Menu Week 2 revealed . SUPPER . Breaded Chicken Sandwich . Beginning on 10/21/2019 at 5:47 PM, an observation was made of resident's supper meal trays being plated with a breaded chicken breast on white bread. The chicken being served was noted to be about one-half the size of a standard piece of bread. The small portion size of the chicken being served prompted an immediate interview with Employee Identifier (EI) # 8, Certified Dietary Manager (CDM). EI #8 reported, the breaded chicken breast being served was purchased pre-breaded and was three ounces. On 10/23/19 at 9:40 AM, the surveyor requested EI #8 to show the surveyor the box of 3 ounce pre-breaded chicken breasts served on 10/21/19 at supper. EI #8 presented a box of pre-breaded chicken breast with a label indicating each piece was 2.4 ounces. The chicken breast in the box was observed and noted to be the same size as chicken breast served on 10/21/19 dinner meal. EI #8 was asked, when was breaded chicken breasts served that week. EI #8 reported, the pre-breaded chicken breast was served on Monday's supper meal for chicken sandwich and again on Tuesday's lunch meal for the chicken parmesan. EI #8 was asked, what was the portion size for chicken breast. EI #8 replied, 2.4 ounces chicken breast was served. EI #8 was asked, what should the portion size have been for chicken breast. EI #8 replied, normally four ounce chicken breast was served, but the minimum size was three ounces. EI #8 was asked, what was the potential harm to residents when portion sizes served was less than recommended portion size by the dietitian. EI #8 replied, residents did not get a full meal of protein or calories On 10/23/19 at 10:24 AM, an interview was conducted with EI #6, Registered Dietitian Nutritionist (RDN), Licensed Dietitian (LD). EI #6 was asked, why were the 2.4 ounce chicken breasts served instead of four ounce chicken breasts. EI #6 replied, the boxes were identical and the cook made a mistake. EI #6 was asked, what was the harm to residents when they receive less than the recommended portion size. EI #6 replied, inadequate protein was the concern which could lead to other issues like skin break down. On 10/23/19 at 11:30 AM a second interview with EI #6, RDN, LD was conducted. EI #6 was asked, on Monday 10/21/2019, what size chicken breast should have been served for supper. EI #6 replied, four ounce chicken breast should have been served with chicken sandwich. EI #6 was asked, when the 2.4 oz chicken breast was served instead of four ounce chicken breast, was she notified. EI #6 replied, No.

Based on record review, interviews and review of a facility policy titled, Notification of Changes in Resident Condition with a revision date of 12/10/18, the facility failed to ensure that a licensed staff member notified Resident Identifier (RI) #9's sponsor of a change in medication order. This affected RI #9, one of three residents sampled for notification. Findings Include: A review of a facility policy titled, Notification of Changes in Resident Condition with a revision date of 12/10/18 revealed, . Policy: It is the policy of this facility to notify the resident, the Resident's Physician, and the resident's legal representative as soon as possible when there are any changes in care needs. Procedure: 1. The facility must notify the resident, . and the resident's legal representative when there is a change in the following areas: . D. A need to alter treatment significantly. A review of the medical record revealed RI #9 was admitted to facility on 12/04/2009 and re-admitted on [DATE] with a [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. Allow Patient to Decide What (He/She) wants for Pain. either [MEDICATION NAME] or [MEDICATION NAME] - Not Both (symbol for change) [MEDICATION NAME] to PRN (as needed) muscle pain (Due to Sedation & (symbol for increased) Fall Risk) . (Signed by prescriber) . 10/8/19 (name of RI #9) states (he/she) will keep [MEDICATION NAME] . D/C (discontinue) [MEDICATION NAME] . An interview was conducted with Employee Identifier (EI) #2, a Registered Nurse/Unit Manager on 10/24/2019 at 10:10 AM. EI #2 was asked where she sent prescriptions to be filled for RI #9. EI #2 named the pharmacy they used. EI #2 was asked when the order for RI #9's [MEDICATION NAME] and [MEDICATION NAME] was changed. EI #2 answered the order was changed on the 8th (October). EI #2 was asked what was the facility policy for notifying the sponsor about medication changes and/or changes in condition. EI #2 answered the nurse that takes off the order was supposed to notify the family of all medication changes. EI #2 was asked if they were supposed to notify the sponsor even if the resident was cognitive and made the decision. EI #2 answered they were supposed to notify the sponsor even if the resident made the choice and let them know which one the resident chose. EI #2 was asked if the sponsor was notified of the medication changes for RI #9. EI #2 answered the sponsor said she was not notified but the nurse stated that she did notify the sponsor. EI #2 added she could not verify that because she did not take off the order. EI #2 was asked who was responsible for notifying sponsors of changes. EI #2 answered the nurse that notes the order. An interview was conducted with EI #1, a Licensed Practical Nurse on 10/24/2019 at 1:11 PM. EI #1 was asked what was the facility policy for notifying a sponsor about medication changes. EI #1 answered they were to notify the sponsor of any or all changes with medication. EI #1 was asked who took the order off to discontinue RI #9's [MEDICATION NAME] and to change the [MEDICATION NAME] to as needed. EI #1 answered she thought she was the one that actually wrote the order. EI #1 was asked who notified the sponsor that the [MEDICATION NAME] was discontinued and the [MEDICATION NAME] was changed to as needed for RI#9. EI #1 answered she did not remember. EI #1 was asked if she notified the sponsor about the medication change. EI #1 answered she had talked to the sponsor about something but she was not sure if it was about the medication change. EI #1 was asked who was responsible for notifying the sponsor about the medication changes. EI #1 answered she would have been the one to notify them.

Based on observation, interviews and review of a facility policy titled, Dining Room Policy and Procedure with a revised date of 12/4/18 the facility failed to ensure Resident Identifier (RI) #9's meal preferences were honored. This affected RI #9 one of four residents sampled for meal observations. Findings Include: Review of facility policy titled Dining Room Policy and Procedure with a revised date of 12/4/18 revealed, Objective: . Meals will be prepared by dining room staff in accordance with diet orders and food preferences. Procedure: . 2. Nursing/Dining staff responsibilities for dining: . G. Resident's meals will be provided according to their preferences. A review of the medical record revealed RI #9 was admitted to facility on 12/04/2009 and re-admitted on [DATE] with a [DIAGNOSES REDACTED]. A review of the Menu with RI #9's choices selected for 10/20/19 through 10/26/19 revealed, . Thursday 10/24/19 . (hand-written Turkey cheese sandwich - veg. (vegetable) soup cottage cheese & (and) peaches . A review of the tray card for the evening meal for RI #9 on 10/24/19 revealed, . 10/24/19 Thursday Supper . ***SELECT MENU**** . Tea, Iced 12 Oz. (Ounces) Water 8 Oz. Pudding Parfait 4 Oz. (hand-written as follows:) Turkey cheese sandw (sandwich) veg soup cottage cheese & peach (RI #9's name) . An observation was made of the supper meal for RI #9 on 10/24/19 at 5:42 PM. The items delivered were as follows: Sandwich with shredded lettuce, vegetable soup, a white creamy substance without curds with a sweet smell and a carton of fat free milk. RI #9 was asked was that the meal they ordered. RI #9 said the daughter ordered their meals. On 10/24/19 at 6:48 PM, a phone interview was conducted with EI #8, the Certified Dietary Manager. EI #8 was asked what condiments he would expect to be put on a tray when a turkey sandwich was served. EI #8 answered he would expect to see mayonnaise and mustard on the tray. EI #8 was asked if RI #9 had tea chosen on her ticket, but no tea was in the glass of ice, what would be the concern. EI #8 answered he/she should have been served tea and they were not getting what they ordered. On 10/24/2019 at 7:18 PM an interview was conducted with EI #9, a Dietary Aide. EI #9 was asked what her duties on the tray line were. EI #9 answered the initial set up of the tray, if they have cold foods like a turkey and cheese sandwich, she puts the ticket on the tray and whatever utensils they are supposed to get on a napkin. EI #9 was asked what else should be on the tray. She answered mayonnaise and mustard. (The surveyor showed EI #9 the tray card for RI #9) EI #9 was asked what condiments should have been on the tray. EI #9 answered mayonnaise and mustard. EI #9 was asked why RI #9 did not have condiments on their tray. EI #9 answered she thought she did (put them on the tray). On 10/24/19 at 7:29 PM an interview was conducted with EI #10, a Dietary Aide. EI #10 was asked who was responsible on the evening of 10/24/19 for serving the cottage cheese with fruit. EI #10 answered he was. EI #10 was asked what RI #9 was supposed to be served. EI #10 answered cottage cheese and peaches. EI #10 was asked what RI #9 got, he answered pudding parfait. EI #10 was asked why. EI #10 answered he did not look the ticket all the way over.

Based on observation, interview and review of facility policies titled, HANDWASHING-EMPLOYEE with a revised date of 10/19/17 and ICE HANDLING POLICY AND PR[NAME]EDURE the facility failed to ensure: 1) a Certified Nursing Assistant (CNA) did not change gloves without performing hand hygiene while providing incontinent care on Resident Identifier (RI) #4. This affected RI #4, one of two residents observed for timely incontinent care; 2) a CNA removed her gloves and washed her hands while going from room to room removing pitchers, dispensing ice, and returning the pitchers to the rooms. This was observed on 10/23/19 for five of 42 resident rooms on Station 2. Findings Include: 1) A review of a facility policy titled HANDWASHING-EMPLOYEE, with a revised date of 10/19/17 revealed .KEY POINTS: 1. Appropriate hand hygiene must be performed under the following conditions: . i. After removal of gloves; . 2. The use of gloves does not replace hand hygiene. RI #4 was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. On 10/23/19 at 5:42 AM, the surveyor observed incontinent care performed by Employee Identifier (EI) #4, CNA to RI #4. EI #4 put on gloves, turned RI #4 and began wiping stool from the buttock. EI #4 stopped cleaning, removed her gloves, did not wash hands, and walked outside the doorway to summon assistance. EI #3, Licensed Practical Nurse (LPN) and EI #4 entered the resident's room and both put on gloves. RI #4 was turned with assistance provided by EI #3. EI #4 began cleaning stool from RI #4's buttocks with a moist wash cloth. EI #4 removed her gloves and did not perform hand hygiene. EI #4 retrieved clean wash cloths from across the resident's room and put on clean gloves. EI #4 cleaned stool from the buttocks, removed her gloves, and did not perform hand hygiene. EI #4 retrieved clean linen, put on clean gloves without washing her hands, and placed the clean brief and linen. On 10/23/19 at 3:30 PM, an interview was conducted with EI #5, LPN, Infection Control Nurse. EI #5 was asked, when should staff performing resident care perform hand hygiene after removing gloves. EI #5 replied, always. EI #5 was asked, when should a staff member providing incontinent care not perform hand hygiene after removing gloves. EI #5 replied, never. EI #5 was asked, when should a staff member providing incontinent care not perform hand hygiene after removing gloves and before putting on new gloves. EI #5 replied, never. EI #5 was asked, what was the potential harm to residents when staff did not perform hand hygiene between glove changes. EI #5 replied, infection control, could spread germs. On 10/24/19 at 12:20 PM, a phone interview was conducted with EI #4, CN[NAME] EI #4 was asked, did she assist EI #3 when she provided peri-care for RI #4. EI #4 replied, no, EI #3 assisted her. EI #4 was asked, how often should she wash her hands when she changed her gloves during incontinence care. EI #4 replied, every time. EI #4 added, she was not organized. EI #4 was asked, did she perform hand hygiene every time she changed gloves while providing incontinent care to RI #4. EI #4 replied, No. EI #4 added, RI #4 was being uncooperative, she had two more bathes to do before the end of her shift. EI #4 was asked, what was the concern of changing gloves after removing stool and not washing her hands. EI #4 replied, hand hygiene decreased the spreading of germs. EI#4 was asked, what did the facility policy indicate when staff remove stool and change their gloves. EI #4 replied, staff must wash their hands between each glove change. On 10/24/19 at 1:23 PM, a phone interview was conducted with EI #3. EI #3 was asked, was she present during an observation of peri-care of RI #4 with EI #4, CNA performing the care. EI #3 replied, Yes. EI #3 was asked, what could she report about EI #4 changing gloves after removing stool and not washing her hands prior to putting on clean gloves. EI #3 replied, EI #4 was supposed to perform hand hygiene between glove changes. EI #3 was asked, how many times did EI #4 not perform hand hygiene between glove changes while performing incontinent care to RI #4. EI #3 replied, at least twice. EI #3 was asked, what was the concern with removing gloves that were worn while removing stool and not washing hands prior to putting on clean gloves and continuing the peri-care. EI #3 replied, Contamination. 2) A review of a facility policy titled, ICE HANDLING POLICY AND PR[NAME]EDURE, with a last revised date of 8/23/18, revealed, . POLICY: It is the policy of this facility to ensure safe handling of ice during distribution. PR[NAME]EDURE: 1. Place glove on dominant hand. 5. If filling water pitch with ice replace pitcher lid and carry to the resident's room. 6. Remove glove and wash hands/use hand sanitizer. 7. Repeat procedure for other residents On 10/23/2019 at 6:30 AM, a surveyor observed (EI) #11, a CNA, passing out ice. EI #11 used a cart which contained a green ice chest with a white lid. Attached to the cart was a holder for the ice scoop. The CNA was wearing gloves. EI #11 entered room A, came out of the room carrying a water pitcher, picked up the ice scoop, lifted the lid of the ice chest, got a scoop of ice, put the ice in the water pitcher, placed the ice scoop back into the holder, closed the lid on the ice chest, placed the lid on the water pitcher, walked back into room A carrying the water pitcher filled with ice. EI #11 was observed coming out of room B still wearing the same gloves. The CNA then went into room B, still wearing the same gloves, came out of the room carrying a water pitcher, picked up the ice scoop, lifted the lid of the ice chest, got a scoop of ice, put the ice in the water pitcher, placed the ice scoop back into the holder, closed the lid on the ice chest, placed the lid on the water pitcher and walked back into room B carrying the water pitcher filled with ice. Came out of room B still wearing the same gloves. The CNA repeated the same steps for rooms C, D and [NAME] while wearing the same gloves. The CNA did not remove the gloves or wash nor sanitize her hands between water pitchers. On 10/23/2019 at 6:35 AM, an interview was conducted with EI #11. EI #11 was asked, what was wrong with passing ice and going from room to room without changing gloves. EI #11 replied, she should have taken her gloves off and washed her hands between rooms. EI #11 was asked, did she change gloves between rooms and wash her hands. EI #11 replied, no. EI #11 was asked, why should she change gloves and wash her hands between rooms/water pitchers while passing ice. EI #11 replied, to prevent the spread of germs. EI #11 was asked, what was the potential harm to the residents by not changing gloves between water pitchers. EI #11 replied, the residents could catch something. EI #11 was asked, when was it acceptable to use the same gloves she touched a contaminated watch pitcher with, then touch the ice chest lid, the ice scoop and another resident's water pitcher. EI #11 replied, it is not. On 10/23/19 at 3:30 PM, and interview was conducted with EI #5, the Infection Control Nurse. EI #5 was asked, when staff are passing ice, when should hand hygiene be performed. EI #5 replied, staff should perform hand hygiene when leaving a resident's room. EI #5 was asked, should staff wear gloves while passing ice without changing the gloves and performing hand hygiene between each resident. EI #5 replied, no. EI #5 was asked, when should staff wear gloves while passing ice without changing gloves between each resident. EI #5 replied, never. EI #5 was asked, what was the potential harm to residents when staff wear gloves while passing ice to multiple residents without changing gloves. EI #5 replied, infection control and spreading of germs.

Based on observations, interviews, medical record review and a review of the facility's policy titled, Staffing, the facility failed to ensure there was sufficient staff available on a twenty four hour basis to meet the needs of the residents related to: 1. compression dressings not being applied to RI #197's bilateral legs as ordered; 2. baths and care not being provided for RI #s 140, 93 and 86 as care planned and 3. staff, residents and family members reporting the inability of staff to meet the needs of residents. This affected four of thirty-one sampled residents on 2 of 6 halls. Findings Include: A review of the facility's policy titled, Staffing, dated 3/27/19, revealed: . Policy Statement Our facility provides adequate staffing to meet the needed care and services for our resident population. Policy Interpretation and Implementation 1. Our facility maintains adequate staffing on each shift to ensure that our resident's needs and service are met. 2. Certified Nursing Assistants are available on each shift to provide the needed care and services of each resident as outlined on the resident's comprehensive care plan. 5. Inquires or concerns relative to our facility's staffing should be directed to the Administrator or his/her designee. 1) Resident Identifier (RI) #197 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. 3-layered COMPRESSION DRESSING FROM BASE OF TOES TO KNEES BILATERAL LEGS FOR ONE WEEK. Discontinued Date: 12/31/18 . A review of RI #197's TAR (Treatment Administration Record) revealed RI #197 did not receive the compression dressing from the bilateral base of toes to the knees on 12/29/18, 12/30/18 and 12/31/18. On 3/27/19 at 11:57 AM, a phone interview was conducted with Employee Identifier (EI) #8 the Licensed Practical Nurse/Wound Nurse. EI #8 was asked, what was her position at the facility. EI #8 replied, she was the Wound Nurse at the Rehab (Rehabilitation Unit). EI #8 was asked, was there a reduction in the amount of staff assigned to the units. EI #8 responded, yes. EI #8 was asked if she recalled when the reduction started. EI #8 response was, it was a gradual process since the first of the year (2019). EI #8 was asked if she thought the reduction in staff affected the care the resident's received. EI #8 replied, yes, she did. EI #8 was asked how many residents were on each station. EI #8 responded, up to fifty four per nurse on the 11-7 shift, depending on the census. EI #8 was asked if she remembered RI #197. EI #8 replied, no. EI #8 was asked, if she performed a task regarding wound care, where would it be documented to verify it was completed. EI #8 responded, it would be on TAR in the computer. EI #8 went on to say if she was pulled to work on the medication cart to give medications, then she was unable to perform her duties as a wound care nurse. The responsibility would then be transferred to the nurse on that specific cart. EI #8 was asked why there was no documentation on the TAR that the compression dressing was applied to RI #197's legs on 12/29/18, 12/30/18, and 12/31/18. EI #8 replied, 12/29/18 and 12/30/18 were during the weekend and she did not work the weekend, it would be the responsibility of the nurse working the medication cart to apply the dressing. EI #8 stated she was probably working a medication cart on 12/31/18 because it was a holiday. 2) RI #140 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #140's care plan documented the following: . Problem Onset: 09/06/2018 I NEED ASSISTANCE WITH ACTIVITIES OF DAILY LIVING (ADL) *ASSIST X 1 (person) WITH BATHING, . PERSONAL HYGIENE . An interview was conducted with the sponsor for RI #140 on 3/26/19 at 11:05 AM. The sponsor reported RI #140's toe nails needed attention. The sponsor added RI #140's hair looked greasy and RI #140 has had a body odor. The sponsor reported she came at lunch often because she was not sure if there was enough staff to feed RI #140. An observation was made to follow up on the sponsor's concerns on 3/26/19 at 2:56 PM with EI #6, a Certified Nursing Assistant (CNA). After the CNA washed her hands and put on gloves she exposed both of RI #140's feet. There was an excessive amount of dead skin that the CNA rubbed loose with her gloved hand. EI #6 reported, It's dead skin. All dead skin. It could come off during a bath. EI #6 was asked when should RI #140's feet be cared for. EI #6 answered every day, each shift. EI #6 was asked when should RI #140 be bathed. EI #6 answered on the 11p-7a shift. EI #6 was asked why would the bath not be done. EI #6 probably did not have enough workers, that was the only reason. EI #6 added when staff were rushing and trying to get things done, some things were neglected. EI #6 was asked what she was aware of regarding residents not getting baths on 11-7 shift. EI #6 answered CNAs have said they were not able to give all the baths they were supposed to. EI #6 was asked which residents. EI #6 answered RI #86 and RI #93 both told her they had not had baths on Sunday. EI #6 reported she gave RI #93 a bath after she got to work on Sunday. She added RI #93 had said someone came in there and dried him/her and turned him/her, but just did not have time to give him/her their bath. EI #6 was asked what she was trained regarding ADL care for dependent residents. EI #6 answered we are to do everything for them that they(residents) cannot do. An interview was conducted on 3/27/19 at 6:58 AM with EI #7, a CNA. EI #7 was asked if she was assigned to care for RI #140 last shift and she answered yes. EI #7 was asked when RI #140 was supposed to get a bath and she answered on the 11-7 shift. EI #7 was asked to observe RI #140's feet and was asked why there was a heavy build-up of dead flaky skin. EI #7 answered because they did not have time to give a thorough bath and lotion them up. EI #7 added that on Monday (MONTH) the 3rd she had 48 residents by herself and she was expected to provide baths. EI #7 was asked why she had difficulty giving residents baths during her shifts. EI #7 answered they have to many residents with usually only two CNAs. EI #7 was asked were the residents needs being met and she answered no. EI #7 was asked how many residents she was responsible for on a regular basis during her shift. EI #7 answered 22, with 48 one time. EI #7 was asked if she had enough time to complete her required assignments each day and she answered no. EI #7 was asked what assignments she was not able to complete. EI #7 answered she had to give rushed baths, could not put ice out, some residents are a 2 person assist and they could not do 2 person assist when they were the only aides. An interview was conducted on 3/27/19 at 7:19 AM with EI #5, a Licensed Practical Nurse. EI #5 was asked what other ADL tasks were CNAs expected to perform on the 11-7 shift. EI #5 answered to check and change (incontinent residents), check vital signs, turning residents, clean up the utility room and pantry, put out ice, empty trash and other duties. EI #5 was asked who she notified that 11-7 CNAs were unable to complete ADL care tasks on that shift. EI #5 answered she had told EI #3, the Director of Nursing, and EI #2, the Unit Manager/RN for Unit 2. EI #5 added she passed the information on to the oncoming shift staff. EI #5 was asked how could CNAs perform the same number of baths when staffing had been cut from 4 to 2. EI #5 answered they could not, it was impossible. EI #5 was asked how could CNAs check and change incontinent residents when they have half the staff of what they used to have, EI #5 answered they could not, it was impossible for them to do it effectively. EI #5 was asked how could residents be turned as routinely with half the staffing. EI #5 answered that was impossible. EI #5 was asked how CNAs handled residents that required 2-person assistance. EI #5 answered they work together but when you have anything going on, it was almost impossible. EI #5 was asked what was the most number of residents a CNA has had to provide care for on her shift. EI #5 answered 49 and that she helped the CNA. RI #93 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #93's care plan documented the following: . Problem Onset: 08/02/2016 REQUIRES ASSISTANCE IN ADL PERFORMANCE . EXTENSIVE/TOTAL ASSIST X 1 WITH BATHING UPPER & LOWER BODY . An interview was conducted on 3/27/19 at 10:23 AM with RI #93. RI #93 reported he/she got a baths on the 11-7 shift. RI #93 was asked if he/she got a bath or shower on the prior Saturday night (3/23/19). RI #93 reported a CNA did it on Sunday morning. RI #93 was asked if the 11-7 CNA ever said they did not have time. RI #93 answered they said they were short of help on 11-7, so he had to wait for the 7-3 shift. RI #93 was asked how often he/she did you not get baths on 11-7 shift. RI #93 answered it has happened but he/she could not say how many times. RI #93 added the supervisors were aware. RI #86 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #86's care plan documented the following: . Problem Onset: 4/5/17 (RI #86) Requires total care for ADL's: Dressing, Grooming, Hygiene & Bathing R/T Quadriplegic. Goal .To be clean, groomed . Approaches: . Bathing & Hygiene daily . An interview was conducted on 3/26/19 at 2:06 PM with RI #86. RI #86 stated that was the first day she/he had had a bath in four days. She/he said she/he was supposed to have a bath on the 11-7 shift, but the morning shift had to do it. 3) An interview was conducted on 03/24/19 at 4:32 PM, with EI #16 a Certified Nursing Assistant (CNA). EI #16 was asked, how many CNAs did she normally have on Station 3 on the 3-11 shift. EI #16 replied, just two, it used to be three. EI #16 was asked, when was staffing cut. EI #16 replied, (MONTH) (2019), when the new owners took over. EI #16 was asked if she was able to meet the needs of the residents. EI #16 replied, sometimes, she had four feeders (eight feeders on the hall) and four baths (two bed baths and two showers). EI #16 further stated that one resident was a fall risk and took extra monitoring, some days were more hectic than others. There was just not enough help. An interview was conducted on 3/24/19 at 4:47 PM, with EI #17 CNA. EI #17 was asked, how many CNAs worked Station three on the 3-11 shift. EI #17 stated, It started out with three until January. EI #17 was asked if she was able to get all of her work done. EI #17 stated, To be honest, not like I should. EI #17 was asked, did the facility management ask her about staffing. EI #17 replied, I think they know, sometimes I feel like this is how it's going to be. It's hard, a lot of patients require two CNAs. EI #17 went on to say they asked her to stay over that day because they did not have anyone to work 3-11. Seven to three shift was her normal shift. EI #17 was asked, did they ask her to work over, stay late or come in early a lot. EI #17 stated, Yes, not just me, everyone. EI #17 was asked what happened if she did not get all her work done. EI #17 replied, It's passed on to the next shift. An interview was conducted on 3/27/19 at 07:46 A.M. with EI #15. EI #15 was asked, did she have difficulty giving residents their baths during her shift. EI #15 replied, she needed more time on the shift. EI #15 was asked did she know of any residents to miss their baths. EI #15 replied, it depended on how short they were. EI #15 was asked had anyone missed a bath. EI #15 replied, yes, when it was just her. An interview was conducted on 3/27/19 at 8:14 AM, with EI #4, the Unit Manager/ RN for Unit 2. EI #4 was asked what she was aware of regarding one CNA caring for 48 residents. EI #4 answered she had seen it on a staffing sheet when she came in at 7 AM. EI #4 was asked what day she observed one (1) CNA on the schedule for 48 residents. EI #4 answered she could not tell the exact day and would need to look at the book. EI #4 was asked what she was aware of regarding ADL care not being provided because staffing had gone from three to four CNAs on Unit 2, down to one or two. EI #4 answered residents had told her they had not had their shower. EI #4 was asked how many residents were scheduled for baths on the 11-7 shift on Unit 2. EI #4 answered on Monday, Wednesday and Friday, nine residents were scheduled for baths. EI #4 added on Tuesday, Thursday and Saturday nine residents were scheduled for baths. EI #2 was asked how could one or two CNAs give 9 baths and provide all other ADL care and housekeeping for the residents on Unit 2. EI #4 answered they could not. EI #4 answered they (nurses) have petitioned to upper management that staffing was inadequate several times. EI #4 was asked how could 7-3 shift CNAs perform the ADL tasks they had scheduled and also the baths that night shift CNAs were unable to finish because of not having time. EI #4 answered they could not either, that she has even had to help herself. EI #4 was asked who she had notified that 11-7 CNAs were unable to complete ADL care tasks on the shift. EI #4 answered upper management, as in EI #3, the DON, EI #2, the Administrator and EI #1, the Owner. EI #4 was asked when they were notified. EI #4 answered she was not sure. EI #4 was asked how management responded after they were made aware of staffing inadequacy. EI #4 answered EI #1 said he had looked around and the staffing should be adequate but were trying to hire more staff. EI #4 was asked how could CNAs check and change incontinent residents when they have half the staff of what they used to have. EI #4 answered they could not, they try. EI #4 was asked what was the concern of not having enough staffing to provide care for residents. EI #4 answered they are not getting the care they are used to or need. An interview was conducted on 3/27/19 at 10:59 AM, with EI #3, Director of Nursing. EI #3 was asked what was the difference in the number of Nurses and CNAs for each shift in the Facility Assessment from (YEAR) to 2019. EI #3 reported in the year (YEAR) for all stations for a 24 hour period it was: 7-3 shift 23-30 staff, 3-11 shift 19-23 staff and 11-7 shift 11-16 staff. EI #3 then reported for the year 2019 it fell to 7-3 shift 19-21 staff, 3-11 shift 14-16 staff and 11-7 shift 11 staff. EI #3 reported the difference in the total number of CNA's between (YEAR) Facility Assessment and the 2019 Facility Assessment was fourteen to twenty-one CNAs. EI #3 stated they had a big change in the number of CNAs with the same number of residents and saw very quickly that it was not going to work. They had disgruntled employees, they had a lot of resident falls. EI #3 was asked what was the concern of care not being provided. She replied, resident decline. This regulatory violation was cited as the result of the investigations of Complaints # AL 202, # AL 205 and # AL 206.

Based on observation, interviews and review of the facility policy titled, . Basic Care Protocol the facility failed to ensure baths were provided for Resident Identifier's (RI) #86 and #140, according to the individualized plan of care for these residents. This affected RI #s 86 and 140, two of thirty-one residents whose care plans were reviewed. Findings Include: A review of a facility policy titled, Basic Care Protocol, last revised date 12/5/18, revealed the policy was to provide basic care daily for all residents. The procedure included: . 7. Tub bath/shower as scheduled and as needed. 12. Nail care provided . as needed. 1) RI #86 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #86's care plan documented the following: . Problem Onset: 4/5/17 . Requires total care for ADL's: Dressing, Grooming, Hygiene & Bathing R/T (related to) Quadriplegic. Goal: . To be clean, Groomed . Approaches: . Follow Basic Care Protocol . Assist for Grooming, Bathing & Hygiene Daily . An interview was conducted on 3/26/19 at 2:06 P.M. with RI #86. RI #86 stated that day was the first day he/she had had a bath in four days, since the resident had moved to that unit a week ago. RI #86 said he/she was supposed to have a bath on the eleven to seven shift, but the morning shift had to do it. The facility provided documentation to show that RI #86 had only received a bath on 3/20/19, plus the one provided on 3/26/19, on the 7-3 shift. 2) RI #140 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed RI #140 was totally dependent on staff for bathing. RI #140 was coded as requiring extensive assistance for all ADLs with the exception of eating, that required limited assistance. A review of RI #140's care plan documented the following: . Problem Onset: 09/06/2018 I NEED ASSISTANCE WITH ACTIVITIES OF DAILY LIVING DUE . Approaches . Follow Basic Care Protocol . ASSIST X 1 (person) WITH BATHING, DRESSING, TOILETING, BED MOBILITY AND PERSONAL HYGIENE . An observation was made of RI #140 on 3/26/19 at 2:56 PM with Employee Identifier (EI) #6, a Certified Nursing Assistant (CNA). After the CNA washed her hands and put on gloves she exposed both of RI #140's feet. There was an excessive amount of dead skin that the CNA rubbed loose with her gloved hand. EI #6 reported, It's dead skin. All dead skin. It could come off during a bath. EI #6 was asked when should RI #140's feet be cared for. EI #6 answered every day, each shift. EI #6 was asked what she was trained regarding ADL care for dependent residents. EI #6 answered they are to do everything for them that they cannot do. EI #6 was asked what was the concern of ADL care not being provided for dependent residents. EI #6 answered possible breakdown, body odor or being depressed about the lack of care. EI #6 was asked what was the facility policy regarding following the plan of care. EI #6 answered. do what it says. On 03/27/19 at 10:33 AM, an interview was conducted with EI #23, a Registered Nurse/Care Plan Coordinator. EI #23 was asked what was the purpose of the person-centered plan of care. EI #23 answered to be individualized for the wants and needs of the resident. EI #23 was asked how was it supposed to be utilized. EI #23 answered it was supposed to be known and used for staff to care for the resident. EI #23 was asked what was the concern of not following the plan of care. EI #23 answered the residents needs and wants may not be adequately met.

Based on interviews, medical record review, review of the facility's policy titled, PHYSICIAN'S ORDER POLICY AND PR[NAME]EDURE, and review of POTTER PERRY NINTH EDITION, the facility failed to: 1. ensure physician's orders were followed by applying a three layer compression dressing from base of the toes to the knees for Resident Identifier (RI) #197 on the dates of 12/29/19, 12/30/19, and 12/31/19; 2. ensure a Physician's Order was complete with a route and frequency for RI #61 and 3. ensure RI#198 did not take an unsampled resident's medication home upon discharge from the facility. This had the potential to affect one of two resident's who were ordered compression dressing application, one of thirty-one residents whose physician's orders were reviewed for care and one discharged residents. Findings Include: 1. A review of the facility's policy titled, PHYSICIAN'S ORDER POLICY AND PR[NAME]EDURE, revealed: . PHYSICIAN'S ORDERS ARE CARRIED OUT UNLESS THE NURSE OR OTHER LICENSED PERSONNEL BELIEVE THE ORDER TO BE INACCURATE, NON EFFICACIOUS, OR CONTRAINDICATED. IN THIS CASE, THE NURSE OR OTHER LICENSED PERSONNEL WILL SEEK CLARIFICATION BY CONSULTING WITH THE PHYSICIAN. RI #197 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Physician's order dated 12/27/18 revealed: . 3-layered COMPRESSION DRESSING FROM BASE OF TOES TO KNEES BILATERAL LEGS FOR ONE WEEK. Discontinued Date: 12/31/18 . A review of RI #197's TAR (Treatment Administration Record) revealed RI #197 did not receive the compression dressing from the bilateral base of toes to the knees on 12/29/18, 12/30/18 and 12/31/18. A phone interview was conducted on 3/27/19 at 11:57 a.m. with Employee Identifier (EI) #8, a former employee and Licensed Practical Nurse/Wound Nurse. EI #8 was asked what was her position at the facility. EI #8 responded, Wound Nurse at the Rehabilitation Center. EI #8 was asked, did she remember RI #197. EI #8 replied, no. EI #8 was asked, where would a task regarding wound care be documented. EI #8 replied, it would be on the TAR in the computer. EI #8 went on to explain that if she had been pulled to work a medication cart and had to give medications, then she was unable to perform her duties as a Wound Care Nurse as listed in her job description. EI #8 explained the responsibilities of the wound treatments would be transferred to the nurse working on that specific cart. EI #8 was asked why there was no documentation on the TAR that the 3 layer compression dressings were applied on 12/29/18, 12/30/18 and 12/31/18. EI #8 responded, the 29 th and 30th were both on the weekend and she did not work the weekend, so it would be the responsibility of the nurse on the medication cart to provide the treatment. EI #8 further explained, she was probably on a medication cart on the 31 st because it was a holiday. 2. A review of Potter Perry Fundamentals of Nursing Ninth Edition, Chapter 32, page 626, revealed: . STANDARDS Standards are actions that ensure safe nursing practice. Standards for medication administration are set by health care agencies and the nursing profession. Professional standards such as Nursing: Scope and Standards of Practice . apply to the activity of medication administration. To prevent medication errors, follow the six rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to and inconsistency in adhering to these six rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation . RI #61 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the MEDICATION ORDERS FOR [REDACTED]. Interval Code PRN (as needed) Time Code PRN [MEDICATION NAME] 20 MG (Milligrams) TABLET-([MEDICAL CONDITION]) ****NOT TO EXCEED 2 TIMES PER WEEK***** MAKE SURE TO CHECK LAST ADMINISTRATION . An interview was conducted on 3/27/19 at 9:31 AM with EI #4, a Registered Nurse. EI #4 was asked who transcribed the PRN [MEDICATION NAME] order for RI #61. EI #4 answered she did. EI #4 was asked what were the components of a complete medicine order. EI #4 answered dose, time, patient, route, [DIAGNOSES REDACTED].#4 was asked what was missing from that order. EI #4 answered a frequency and the route. EI #4 was asked what was the concern of an incomplete medication order. EI #4 answered could possibly cause a medication error. 3. A review of the facility's policy titled, Medication Administration, revealed .12. Remember the 7 RIGHTS of medication administration. A. Right resident B. Right drug C. Right dose D. Right route E. Right time F. Right reason G. Right documentation . RI#198 was admitted to the facility on [DATE] and discharged on [DATE]. A review of RI# 198 chart revealed the following: Nurses notes dated 2/25/2019 that the resident discharged with incorrect medication. A MEDICATION ERROR REPORT Date of error: 2/25/19. RI#198 CONTROLLED SUBSTANCE RECORD . [MEDICATION NAME]-APAP 5-325mg .amount remaining 34. Unsampled Resident Number #1 (USR#) CONTROLLED SUBSTANCE RECORD .[MEDICATION NAME]-APAP 7.5-325mg .amount remaining 10. RI#198 Discharge Summary dated 2/22/19 was documented the resident was discharged with [MEDICATION NAME]/ [MEDICATION NAME] ([MEDICATION NAME]) 5mg/325 mg, (46) was handwritten beside the medication. An phone interview was conducted with the complainant 4/11/19 at 8:25 am. The complainant, stated they were sent home with USR #1(she named the resident's name) medication of [MEDICATION NAME] 7.5 mg. The complainant reported she discarded the medication and kept the package. On 4/11/19 at 10:29 the surveyors interview with EI #3, Director of Nursing. The surveyor asked what was the facility's policy regarding discharging a resident and dispensing medication or medication sent home with a resident. EI #3 responded, follow the order that was given for discharge. The surveyor asked did she have a system in place to document the medication sent home with a resident. EI #3 responded yes. The surveyor asked what was that system. EI #3 responded it was a print out of the meds sent, a computer print out. The surveyor asked where was that documented. EI #3 responded the family signs the control substance record and the other was a printed discharge summary. The actual number that was sent home with the resident was handwritten on the discharge summary beside each drug. The surveyor asked, regarding the control record for [MEDICATION NAME] 5mg for RI #198, how many tablets ere verified remaining that was signed by complainant. EI #3 replied thirty-four. The surveyor asked was that the record for RI #198's discharge. EI #3 replied yes, RI #198. The surveyor asked was the signature of RI# 198's family member on the control record for [MEDICATION NAME] 5 mg document. EI #3 replied it was RI #198's sponsor signature. The surveyor asked would that indicate that was the medication amount and dosage RI #198 took home. EI #3 responded yes. The surveyor asked what number was handwritten on RI #198 discharge summary of [MEDICATION NAME] 5 mg. EI #3 replied 46 tablets. The surveyor asked who was responsible for ensuring the resident was discharged with the correct medication. EI #3 responded the nurse discharging the resident. The surveyor asked how was that insured. EI #3 responded, the nurse should compare the actual medication to the discharge print out of medications ordered. The surveyor asked, was the medication compared and verified for RI #198. EI #3 responded, she was going to assume not because it was not correct. The surveyor asked was there a difference in the number of pills actually sent than what was documented. EI #3 replied, yes, she assumed the actual difference was the other resident's pills that were sent home with RI #198. The surveyor asked, what was the name on the other narcotic record. EI# 3 responded, USR #1(she gave resident's name). The surveyor asked what was the medication. EI #3 responded, [MEDICATION NAME] 7.5 mg. The surveyor asked what was the total amount remaining. EI#3 stated, ten tablets. She was asked whose signature was on the record. EI # 3 stated sponsor/ complainant. The surveyor asked, was the complainant the sponsor for USR #1. EI# 3 responded, no. The surveyor asked, was there a date for the signature documented on USR #1 narcotic record. EI# 3 responded, no. The surveyor asked why did she document the investigation on 2/26/19 (Medication Error Report). EI# 3 stated, because the wrong resident's medication was sent home with another resident. The surveyor asked, what did their investigation determine was the cause of sending the wrong medication home with RI #198. EI# 3 responded, failure to compare medication to the orders. The Surveyor asked, what was the potential harm for sending the wrong medication home with a resident. EI# 3 responded, resident receiving the wrong medication. The surveyor conducted a phone interview with EI #14 at 11:57 am. EI #14 was the nurse who discharged RI #198 home with another resident's medication. The surveyor asked did she remember the incident regarding RI #198's discharge. EI #14 responded yes. The surveyor asked what did she remember about it. EI #14 stated, she did RI #198 discharge, when she pulled the resident's medication, she pulled the wrong person's medication that had the same last name. The surveyor asked, what did she do with wrong the medication. EI #14 stated, she gave it to RI #198's family to take home. The surveyor asked did the facility have a policy regarding discharging residents. EI #14 responded, EI #3 gave her a policy and refresher on discharging residents and she did a write up on it. The survyeor asked, was the wrong medication she sent home with RI #198 a narcotic. EI #14 said yes, but it was the same medication RI #198 was taking, it was just the wrong person, the last name was the same. The surveyor asked, what was the potential harm for sending home the wrong resident's medication to another resident. EI #14 responded, anything from minor to reaction to death, depending on the resident's condition and the medication. This regulatory violation was cited as the result of the investigation of Complaint # AL 204 and #AL 205.

Based on observation, interviews and review of the facility policy titled, Basic Care Protocol, the facility failed to ensure Activities of Daily Living (ADLs) care was provided regarding bathes for RI #140 and and RI #86. This affected RI #140 and #86, two of two residents who were not provided complete baths as scheduled. Findings Include: A facility policy titled, Basic Care Protocol, revised on 12/5/18, revealed, Objective: To maintain physical, mental and psychosocial well-being of residents. Policy: Basic care will be provided daily for all residents. Procedure: .7. Tub bath/shower as scheduled and as needed. 12. Nail care provided . as needed. 1) RI #140 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed RI #140 was totally dependent on staff for bathing. RI #140 was coded as requiring extensive assistance for all ADLs with the exception of eating, that required limited assistance. A review of RI #140's care plan documented the following: . Problem Onset: 09/06/2018 I NEED ASSISTANCE WITH ACTIVITIES OF DAILY LIVING . Approaches *ASSIST . WITH BATHING . PERSONAL HYGIENE . An interview was conducted with the sponsor for RI #140 on 3/26/19 at 11:05 AM. The sponsor reported RI #140's toe nails needed attention. The sponsor added RI #140's hair looked greasy and RI #140 had a body odor. The sponsor also came often at lunch to assist with the resident's feeding, if staff were not available. On 3/26/19 at 2:56 PM, an observation was made of RI #140 being provided with care by Employee Identifier (EI) #6, a Certified Nursing Assistant (CNA). After EI #6 washed her hands and put on gloves she exposed both of RI #140's feet. There was an excessive amount of dead skin that the CNA rubbed loose with her gloved hand. On the end of the left small toe there was a piece of thick dead skin about the size of a pencil eraser that the CNA dislodged with her gloved finger. EI #6 reported, It's dead skin. All dead skin. It could come off during a bath. The CNA was asked about the condition of the toe nails. She reported the left great toe, third toe and fourth toe nails needed to be trimmed. The right fifth toe nail needed to be trimmed. EI #6 was asked when should RI #140's feet be cared for. EI #6 answered every day, each shift. EI #6 was asked when should RI #140 be bathed. EI #6 answered on the 11 PM - 7 AM shift. EI #6 was asked why would the bath not be done. EI #6 said, probably did not have enough workers, that was the only reason. EI #6 added when staff are rushing and trying to get things done, some things are neglected. EI #6 was asked what she was aware of regarding residents not getting baths on 11-7. EI #6 answered CNAs have said they were not able to give all the baths they were supposed to. An interview was conducted on 3/27/19 at 6:58 AM with EI #7, a CNA. EI #7 was asked if she was assigned to care for RI #140 the last shift and she answered yes. EI #7 was asked when RI #140 was supposed to get a bath and she answered on the 11-7 shift. EI #7 was asked to observe RI #140's feet and was then asked why there was a heavy build-up of dead flaky skin. EI #7 answered because they did not have time to give a thorough bath and lotion them up. EI #7 was asked why she had difficulty giving residents baths during her shifts. EI #7 answered they have to many residents with usually only two CNAs. EI #7 was asked what assignments she was not able to complete. EI #7 answered she had to give rushed baths. 2) RI #86 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #86's care plan documented the following: . Problem Onset: 4/5/17 (RI #86) Requires total care for ADL's . Approaches: .Follow Basic Care Protocol . Bathing & Hygiene daily . An interview was conducted on 3/26/19 at 02:06 P.M. with RI #86. RI #86 stated that day was the first day he/she had had a bath in four days. He/she said he/she was supposed to have a bath on the 11-7 shift, but the morning shift had to do it. The facility provided documentation to show that RI #86 had only received a bath on 3/20/19, plus the one provided on 3/26/19, on the 7-3 shift. An interview was conducted on 3/27/19 at 07:46 A.M. with EI #15. EI #15 was asked, did she have difficulty giving residents their baths during her shift. EI #15 replied, she needed more time on the shift. EI #15 was asked did she know of any residents to miss their baths. EI #15 replied, it depended on how short they were. EI #15 was asked had anyone missed a bath. EI #15 replied, yes, when it was just her. This regulatory violation was cited as the result of the investigations of Complaint # AL 092.

Based on observation and interviews the facility failed to serve a palatable food to the residents on 3/24/19 for the evening meal This had the potential to affect 8 of 139 residents who received meals from the kitchen. Findings Include: On 03/19/2019 the State Agency received a complaint that the facility food is awful. No other detail was given. On 03/24/19 at 5: 53 PM, the surveyor conducted a test of a food tray that was taken to the Station Two hall. The served country fried steak was noted to be tough and very bland to taste. On 03/24/19 at 6:16 PM, Resident Identifier #71 stated he/she did not like the food because it had no flavor. On 3/25/19 at 8:20 AM, an unsampled resident reported the food was not the quality it use be. She reported the food was good last (MONTH) but in the last two months the food had changed. On 03/25/2019 at 10:30 AM, a Resident Council Meeting was conducted with nine residents in attendance. Of the nine, seven residents voiced there was no flavor to the food. On 03/27/2019 at 9:13 AM, an interview was conducted with Employee Identifier (EI) #20, the cook. EI #20 was asked if she tried the country fried steak on Sunday night. EI #20 answered, It was ok. She was asked if it was bland and she stated, some what. EI #20 was then asked if it was tough and she replied Not too tough. This regulatory violation was cited as the result of the investigation of Complaint # AL 205.

Based on observations, review of the (YEAR) Food Code, review of the chemical manufacturer's Quat (chemical sanitizer) Sanitizer Technical Data Sheet, review of the facility's daily temperature log and staff interviews, the facility failed to assure: 1. a) chicken salad was not determined to be 49 degrees F (Fahrenheit) on the tray line and 52 degrees F stored in the refrigerator, b) milk temperature was monitored/documented when served from the tray line, 2. thawing of frozen diced pork was done per standards of practice, 3. facility staff followed correct manual dishwashing procedures (i.e. correct water temperature), 4. a) a male employee with a mustache working in the Dishroom wore a beard cover, b) eyeglasses were not placed on the cook preparation counter and 5. ice cream received frozen remained frozen. These failures had the potential to affect 147 of 156 residents who received meals from dining services. Findings Include: 1. a) A review of the Food and Drug Administration Food Code (YEAR) Section 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding revealed the following: . (A) Except during preparation, cooking, or cooling . TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (2) At 5 degrees C (Celsius) (41 degrees F) or less . An observation on 8/21/18 at 11:00 AM, of the noon meal tray line temperatures, revealed chicken salad was documented as 40 degrees F. A request to re-measure revealed the chicken salad placed on the tray line measured 49 degrees F. Croissants filled with chicken salad and stored in the refrigerator measured 52 degrees F and a pan with chicken salad (no Croissant) measured 59 degrees F. b) On 8/21/2018, during a review of the facility's noon meal temperature log (prior to the plating), it was revealed staff failed to record/document the tray line temperature of milk. During an interview on 8/21/2018 at 11:20 AM, EI (Employee Indentifer)#1, CDM (Certified Dietary Manager) was asked to show the surveyor where staff had recorded the tray line temperature of the milk. EI #1 said she did not see it (temperature). EI #1 was asked should they have recorded it (temperature). EI #1 responded, Yes, ma'am. EI #1 was asked why staff should record/document temperatures and EI #1 replied, to make sure (milk) was served at (the) designated temperature. 2. A review of the Food and Drug Administration Food Code (YEAR) revealed: .Section 3-501.13 Thawing Except as specified .TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be thawed: .(b) completely submerged under running water . An observation on 8/21/2018 at 11:15 AM, revealed frozen diced pork packages in a sink filled with water. The faucet was turned off. At the above time, an interview with EI #2, the Cook, revealed someone must have turned the water off. 3. An observation on 8/21/2018 at 8:25 AM, revealed the facility used Oasis 144, a quaternary (Quat) ammonia chemical sanitizer in the manual dishwashing area for sanitizing in the pots/pan sink. The Quat Sanitizer Technical Data Sheet written by the chemical manufacturer revealed: . Quat test strips should be read at room temperature: (75 degrees F), higher temperatures will result in inaccurate readings. (A limit of the test strip, not the product) . On 8/22/2018 at 10:30 AM, in the pots/pan sink, manual dishwashing was observed by the surveyor. EI #1, CDM, was also observing. Staff used a test strip. EI #1 was asked, what was the water temperature. EI #1 stated 89.4 degrees F in the 3rd (sanitizing) sink. The water mixture flowing from the faucet measured 84 degrees F per facility digital thermometer. EI #1 was asked, what did the placard on the wall indicate. EI #1's response was water (measuring) between 65-75 degrees F. During the above time frame, EI #2 the Cook, who had been standing nearby was asked, did she ever add hot water to the 3rd compartment sink. EI #2 responded, Yes ma'am, sometimes she added a little bit. 4. a) A review of the (YEAR) Food Code revealed: .Hair Restraints Section 2-402.11 Effectiveness. (A) .FOOD EMPLOYEES shall wear hair restraints . beard restraints .worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, . During an observation on 8/21/2018, of the delivery of meal carts, a male staff member with a mustache was observed with his mustache not restrained. The male staff member had been observed to work both the dirty and clean side of the dishmachine. EI #1 was observed to direct the male staff member to cover the mustache. EI #1 was asked why the employee should cover the mustache and EI #1 said to prevent cross contamination. b) On 8/21/2018 at 8:25 AM, the surveyor observed a pair of eyeglasses laying on the cook's preparation table that was located opposite of the range. During the above time, EI #1 was asked about the eyeglasses found on the cook's preparation table across from the range. EI #1 said that staff should not place glasses on counters due to potential cross-contamination. 5. A review of the (YEAR) Food Code revealed: .Temperature and Time Control 3-501.11 Frozen Food. Stored frozen FOODS shall be maintained frozen . On 8/22/2018 at 9:45 AM, during an observation of ice cream in a walk-in freezer, the following was revealed: A cup was selected and when squeezed (pressure applied) finger indentations were left. The internal temperature was soft and measured +7 degrees F. At this time, an interview with the Cook, EI #2, who had accompanied the surveyor was asked if the ice cream frozen solid. EI #2 responded, No ma'am.

Based on observation, review of the (YEAR) Food Code and interview, the facility failed to assure a dumpster door was not left open and 1/2 of a lid cover was not missing on one of three dumpster units. This had the potential to affect all 156 residents who reside in the facility by potentially attracting the harborage and feeding of pests and rodents. Findings include: A review of the (YEAR) Food Code revealed: .Section 5-501.15 Outside Receptacles .shall be designed and constructed to have tight-fitting lids,doors, or covers . 5-501.113 Covering Receptacles .waste handling units for REFUSE .shall be kept covered . An observation on 8/21/2018 at 2:30 PM, of the facility outside receptacles, revealed three dumpster units. One of the three units had the sliding door fully opened and white bagged waste was exposed. The units had flip tops and 1/2 of a unit top covering was missing. A few seconds later, the surveyor encountered the Consultant Dietitian, Employee Identifier (EI) #4. EI #4 was asked what were the regulatory requirements related to doors/lids. EI #4 said, they should be closed. .

Based on record reviews, interviews and review of facility policy Care Plan Process Policy and Procedure, the facility failed to ensure the fall care plan for Resident Identifier (RI) #1 was updated with an intervention after a fall on 10/9/17. This affected one of three residents sampled for falls. Findings Include: A review of a facility policy Care Plan Process Policy and Procedure with a revised date of 8/27/17 revealed .Procedure: . 2. The preliminary Care Plan will be updated by the nursing staff on the unit along with other members of the interdisciplinary team as information becomes available. 4. Any time any intervention is added or changed in any way it should be dated and initialed by the staff making the addition or the change. RI #1 was admitted to the facility 9/27/17 with [DIAGNOSES REDACTED]. A review of a Quality Assurance Report dated 10/9/17, revealed RI #1 was found sliding out of the wheelchair at 5:40 p.m. An intervention was to place a towel over wheelchair cushion and remove clear covering from cushion. The report was written by Employee Identifier (EI) #2, Registered Nurse, (RN). A review of RI #1's Preliminary Care Plan with an initial date of 9/28/17 revealed Potential for falls . No intervention was reviewed for fall on 10/9/17. A review of Departmental Notes dated 10/17/2017 revealed: Falls meeting: Resident found on floor on 10/9/17. Staff reported to finding resident sliding out of wheelchair on to the floor. Staff assessed wheelchair and noted that resident had a foam cushion in wheelchair. However plastic covering noted on cushion which could have aided in resident sliding . Staff removed plastic covering . On 11/1/17 at 6:00 p.m., a phone interview was conducted with EI #2, RN. EI #2 was asked what was the intervention after RI #1's fall on 10/9/17. EI #2 replied the plastic on the wheelchair cushion was to be taken off and a towel put over the cushion, but it did not get done. EI #2 was asked who was responsible to carry through the intervention. EI #2 replied, she was and she was disciplined for not assuring it was done. EI #2 was asked what was the potential harm in not following through with adding an intervention to the care plan. EI #2 replied another fall or sliding from the wheelchair. EI #2 added the intervention was done it just was not added to the care plan. On 11/2/17 at 5:55 p.m., an interview was conducted with EI #1, Director of Nursing. EI #1 was asked if the care plan was updated after RI #1's fall on 10/9/17. EI #1 replied no. EI #1 was asked who was responsible for updating the care plan. EI #1 replied, the nurse assigned when occurred. EI #1 was asked what was the harm in a care plan not being updated. EI #1 replied, could have another fall.

Based on interview and record review the facility failed to ensure a Licensed Practical Nurse (LPN) followed Resident Identifier (RI) #1's "At Risk for Side Effects/Adverse Reaction/Compromised Safety from use of [MEDICAL CONDITION] Meds (Medications)" care plan. The LPN failed to monitor RI #1 for adverse/side effects of [MEDICAL CONDITION] medications. On 02/22/14 at 5:45 PM, Employee Identifier (EI) #2 administered RI #1's medications, scheduled to be given at 8:00 PM, in conjunction with the medications scheduled to be given at 6:00 PM. The medications administered Klonopin, [MEDICATION NAME] have the side effect of causing drowsiness. EI #2 stated RI #1 was positioned in her wheelchair (w/c) at her bedside when she administered the medications. EI #2 admitted leaving RI #1 unattended in her wheelchair, in her room without monitoring for side effects of the medications. Around 6:30 PM, forty five minutes after the medications given, RI #1 fell from her wheelchair, sustaining an injury. RI #1 was sent to the emergency room for evaluation and was admitted to the hospital with [REDACTED]. Findings Include: RI #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed RI #1's Brief Interview for Mental Status (BIMS) score was 12, indicating RI #1 was moderately impaired in cognition. The MDS documented RI #1 required a one person physical assist with Activities of Daily Living except eating, she required set up help and was independent in toileting. The MDS also documented RI #1 was not steady, only able to stabilize with staff assistance with balance: moving from seated to standing position and surface-to-surface transfer. A review of RI #1's Fall Risk assessment dated [DATE] revealed a score of 95, indicating a high risk for falls (high risk 50 or >). A review of RI #1's care plan with a Problem Onset of 08/24/11 titled "At Risk for Side Effects/Adverse Reaction/Compromised Safety from use of [MEDICAL CONDITION] Meds ... Approaches Assess for side effects of meds ... Assess for: drowsiness, disorientation, lethargy, limp, hard to arouse, out of it, confusion ... restlessness, poor balance (worsening), can't sit still, slowed movement of upper or lower extremities, tremors ... " The facility's Investigative Summary, sent in to the State Agency on 2/25/14 revealed the following: "Date and time of occurrence: 02/22/14 Time: 6:30 PM Narrative summary of the incident: "(name of RI #1) fell from her wheelchair at approx. (approximate) 6:30pm (PM). (Name of EI #1) LPN had given the resident her 6:00pm and 8:00pm Medications together upon resident's request. which included Ambin (Ambien) 10mg, Klonopin 0.5 mg, [MEDICATION NAME] ([MEDICATION NAME]) 50mg, [MEDICATION NAME] 15mg These are 8:00pm meds that were given at 5:45pm. ... Describe the adverse outcome to the resident(s): It is a possibility that the medication could have contributed to the fall ... " A review of the "Mosby's 2013 Nursing Drug Reference" 26th edition, revealed the medications, Ambien, Klonopin, [MEDICATION NAME] ([MEDICATION NAME]) and [MEDICATION NAME] that RI #1 received could cause "dizziness", "drowsiness" or "confusion". A review of RI #1's "Incident/Accident Report" dated 02/22/14 at 6:30 PM, revealed the following: "... Injury exact location: ... Hematoma & (and) Ecchymosis to forehead ... Equipment involved ... Wheelchair... Head Injury with fall: (Yes checked)... Moderate Injury (checked)... Describe exactly what happened: Resident was found by CNA (Certified Nursing Assistant) lying on floor in front of bed. Unclear how she fell or what she was trying to do. Assisted resident to bed and performed skin assessment, neuro (neurological) checks and physical assessment ... " A review of the facility's "Departmental Note" dated 02/22/14 at 8:45 PM, revealed the following: " ...6:30 PM writer was called to residents room by CNA who found resident lying on floor, face down in front of bed and wheelchair. Resident fell out of chair but would not tell writer how or what happened. Resident had hit forehead ... Signed by (name of EI #1 (LPN)" During an interview with EI #1 on 03/18/14 at 3:50 PM, the surveyor provided EI #1 nurses note and a hand written note 02/22/14 and asked EI #1 to recall what happened. EI #1 stated around 4:30 or 5:00, the resident was in her w/c in her room. Her roommate was trying to assist her up and she had instructed both residents not to get up without staff assistance. She also stated before 7:00 PM, she administered RI #1 her 6:00 PM and 8:00 PM medications, because RI #1 had requested her bedtime medications. The surveyor asked what medications she administered. EI #1 stated she administered [MEDICATION NAME] the Klonopin, which were scheduled for 8 PM and [MEDICATION NAME], Potassium, [MEDICATION NAME], [MEDICATION NAME] and [MEDICATION NAME]. The surveyor asked was RI #1 put to bed before the medications were administered. EI #1 stated no. The surveyor asked why not. EI #1 stated it was before dinner and she explained to RI #1 as soon as they (staff) could, they would put her (RI #1) to bed. The surveyor asked why she administered the medications early. EI #1 stated it was, "Just a bad mistake." The surveyor asked at what point did she review the type of medications she administered. EI #1 stated it was a "Bad night" and she did not think she did. The surveyor asked where the resident was when she administered her medications. EI #1 stated RI #1 was in her w/c in her room. The surveyor asked what happens if those medications are given too close together and outside of the time frame. EI #1 stated you "Get too much of drug." The surveyor asked EI #1 what were the side effects of [MEDICATION NAME], Klonopin, [MEDICATION NAME] and Ambien. EI #1 stated, "I don't know." The surveyor asked what were the indications for the use of these medications. EI #1 stated anxiety and depression. The surveyor asked what effect they have on the body. EI #1 stated the drugs cause the body to "relax." The surveyor asked what could potentially happen to a resident when these medications are given together. EI #1 stated, the resident "could go to sleep and fall out of the chair ..." This citation was written as a result of complaint/report number AL 644.

Based on interviews and record reviews, the facility failed to ensure the Licensed Practical Nurse (LPN) monitored Resident Identifier (RI) #1 for adverse/side effects of psychotropic medications after administering medications that caused drowsiness. On 02/22/14, RI #1 medications, Klonopin 0.5 mg (milligram), Buspar 15 mg, Trazodone 50 mg and Ambien 10 mg, scheduled to be administrated at bedtime (8:00 PM), were administrated at 5:45 PM by the medication nurse, Employee Identifier (EI) #2. EI #2 admitted leaving RI #1, a resident assessed as being a high risk for falls, alone and unattended in her room in a wheelchair (w/c). Around 6:30 PM, forty five minutes after the medications given, RI #1 fell from her wheelchair, sustaining an injury. RI #1 was sent to the emergency room for evaluation and was admitted to the hospital with [REDACTED]. Findings Include: RI #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed RI #1's Brief Interview for Mental Status (BIMS) score was 12, indicating RI #1 was moderately impaired in cognition. The MDS documented RI #1 required a one person physical assist with Activities of Daily Living except eating, she required set up help and was independent in toileting. The MDS also documented RI #1 was not steady, only able to stabilize with staff assistance with balance: moving from seated to standing position and surface-to-surface transfer. A review of RI #1's Fall Risk assessment dated [DATE] revealed a score of 95, indicating a high risk for falls (high risk 50 or >). A review of review of RI #1's care plan titled Short Term Memory Impairment with an onset of 04/30/12 revealed RI #1 "... skull plate missing from the (L) (left) side of head, mental function varies ... " A review of RI #1's care plan titled Potential for Falls/Trauma R/T (related to) ... Use of Psychotropic meds, ... with an onset date of 05/03/11 revealed the following: "... Approaches ... Monitor more closely when having increased restlessness, more confused, or having acute illness. Provide more assist as needed ... Q (every) 1 hour safety checks ..." A review of RI #1's care plan with a Problem Onset of 08/24/11 titled "At Risk for Side Effects/Adverse Reaction/Compromised Safety from use of Psychotropic Meds ... Goals ... Will have reduced risk for undiagnosed side effects/adverse reaction to psychotropic meds aeb (as evidence by): ... Change in mental function ... Approaches Assess for side effects of meds ... If any noted. Assess for: drowsiness, disorientation, lethargy, limp, hard to arouse, out of it, confusion ... restlessness, poor balance (worsening), can't sit still, slowed movement of upper or lower extremities, tremors, ..." A review of the "Mosby's 2013 Nursing Drug Reference" 26th edition, revealed the medications, Ambien, Klonopin, Desyrel (Trazodone) and Buspar that RI #1 received could cause "dizziness", "drowsiness" or "confusion". A review of RI #1's "Incident/Accident Report" dated 02/22/14 at 6:30 PM, revealed the following: "... Exact Location of incident/accident: Resident's room, end of bed Contributing Factors to fall: noncompliance (with) use of call light Injury exact location: ... Hematoma & (and) Ecchymosis to forehead Equipment involved ... Wheelchair ... Head Injury with fall: (Yes checked) ... Moderate Injury (checked) ... Describe exactly what happened: Resident was found by CNA (Certified Nursing Assistant) lying on floor in front of bed. Unclear how she fell or what she was trying to do. Assisted resident to bed and performed skin assessment, neuro checks and physical assessment. ... Interventions: Educate resident & roommate on compliance (with) call lights and getting help to get up. ..." A review of RI #1's February [DATE](Medication Administration Record) revealed EI #1 administered the following medications on 02/22/14: Buspar 15 MG PO TID - 8 AM, 12 PM & 8 PM Klonopin 0.5 MG PO TID - 8 AM, 12 PM & 8 PM Trazodone 50 MG PO QHS (at bedtime) - 8 PM Ambien 10 MG PO QHS - 8 PM A review of the facility's "Departmental Note" dated 02/22/14 at 8:45 PM, revealed the following: " ...6:30 PM writer was called to residents room by CNA who found resident lying on floor, face down in front of bed and wheelchair. Resident fell out of chair but would not tell writer how or what happened. Resident had hit forehead ... Signed by (name of EI #1 (LPN)" A review of the facility's "Departmental Note" dated 02/23/14 at 3:05 AM, revealed the following: "... writer called (initial of hospital) ED (emergency department) to check on resident. Resident was admitted to hospital on [DATE] at 12:40 A.M (AM)..." A review of the hospital's "Discharge Summary" dated 02/25/14, revealed the following: "...Diagnoses: [REDACTED]. ..." During an interview with EI #2 on 03/17/14 at 5:50 PM, the surveyor provided her a copy of the incident/accident report dated 02/22/14 and asked what happened. EI #2 stated she heard an alarm and as she approached where the alarm was sound, RI #1's room, the resident was laying on the floor face up, in front of her closet. She also stated RI #1's w/c was at the foot of the bed, upright with the seat facing towards the doorway. The surveyor asked what did she do after she found the resident. EI #2 stated she went to the door and called for help. EI #1 came in and assessed the resident. The surveyor asked had the resident had an incontinent episode. EI #2 responded, no. During an interview with EI #1 on 03/18/14 at 3:50 PM, the surveyor provided EI #1 a nurse's note and a hand written note 02/22/14 and asked what happened. EI #1 stated around 4:30 or 5:00, the resident was in her w/c in her room. Her roommate was trying to assist her up and she had instructed both residents not to get up without staff assistance. She also stated before 7:00 PM, she administered RI #1 her 6 PM and 8 PM medications, because RI #1 had requested her bedtime medications. The surveyor asked what medications did she administer. EI #1 stated she administered the Ambien and the Klonopin, which were scheduled for 8 PM and Coreg, Potassium, Zocor, Bethanechol, Mucinex, Keppra, Depakote, Namenda, Buspar, Trazadone and Advair. The surveyor asked was RI #1 put to bed before the medications were administered. EI #1 stated no. The surveyor asked why not. EI #1 stated she it was before dinner and she explained to RI #1 as soon as they could, they would put her (RI #1) to bed. The surveyor asked what was the policy and procedure for medication administration regarding the time frame. EI #1 stated one hour before and one hour after scheduled time. The surveyor asked was policy and procedure followed. EI #1 stated no. The surveyor asked why did she administer the medications early. EI #1 stated, "Just a bad mistake." The surveyor asked at what point did she review the type of medications she administered. EI #1 stated, "Bad night, I didn't think." The surveyor asked where was the resident when she administered her medications. EI #1 stated RI #1 was in her w/c in her room. The surveyor asked what happens if those medications are given too close together and outside of the time frame. EI #1 stated the resident, "Get too much of drug." The surveyor asked what were the side effects of Buspar, Klonopin, Trazodone and Ambien. EI #1 stated, "I don't know." The surveyor asked what were the indications for the drug use. EI #1 stated anxiety and depression. The surveyor asked what effect do they have on the body. EI #1 stated it causes the body to, "relax." The surveyor asked what was the potential to a resident when these medications are given too close to a previous dose, outside of the time frame and sitting in a wheelchair. EI #1 stated the resident, "could go to sleep and fall out of the chair ..." During an interview on 03/20/14 at 4:10 PM with EI #7 (LPN/Investigator) she stated after she interviewed EI #1 and reviewed the cameras to see what time EI #1 administered the medications. EI #7 stated EI #1 admitted giving the medications to RI #1 at that time (5:45 PM). EI #7 stated the facility felt the medications could have possibly been a factor for RI #1's fall. A Investigative Summary sent in to the State Agency by the facility on 2/25/14. Documented in the Investigation Summary was a narrative summary of the incident. Documentation revealed, "...(name of RI #1) fell from her wheelchair at approx. (approximate) 6:30pm (PM). (Name of EI #1) LPN had given the resident her 6:00pm and 8:00pm Medications together upon resident's request. which included Ambin (Ambien) 10mg, Klonopin 0.5mg, Desyrel (Trazodone) 50mg, Buspar 15mg These are 8:00pm meds that were given at 5:45pm. ... Describe the adverse outcome to the resident(s): It is a possibility that the medication could have contributed to the fall ..." This citation was written as a result of complaint/report number AL 644.

Based on record review, interview and review of the facility's employee handbook, the facility failed to preserve Resident Identifier (RI) #2's and RI #3's dignity. On 06/22/2012, a Licensed Practical Nurse (LPN) discovered the word, "bath" written in ink on RI #2, a cognitively impaired residents', lower left abdomen. EI #2, a Certified Nurse Assistant (CNA), admitted to writing the word on RI #2. RI #2's brother, the sponsor for RI #2, stated in an interview this act was undignified and embarrassing. RI #2's brother, stating he was disturbed by what occurred and stated the staff member could have written a note instead of writing on the resident. The 11:00 PM- 7:00 AM, Registered Nurse Supervisor who was informed of this incident stated staff members was upset saying the word written on the resident in ink appeared to be saying RI #2 was nothing. A Volunteer Ombudsman, while visiting resident in the facility, was informed by RI #3 that she needed to use the bathroom but needed staff's assistance. The Volunteer Ombudsman stated he activated the resident's call light system and staff did not responded. He stated he went into the hallway and notified a CNA Employee Identifier (EI) #10 of RI #3's request. The Volunteer Ombudsman stated EI #10 came to RI #3's room and de-activated the call light system and stated she had informed the resident's assigned CNA of her request to go to the bathroom. EI#10, failing to assist the resident, stated to the Volunteer Ombudsman in the presence of the resident, "...it's OK, she wears a diaper ..." then left the room. This deficient practice affected RI #2 and RI #3, two of four sampled resident's. Findings include: RI #2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. RI #2's Significant Change in Status Minimum Data Set (MDS) with an Assessment reference date of 5/29/2012, assessed RI #2 as having long and short term memory problems and of being severely impaired for cognitive skills of daily living. The MDS has RI #2 assessed as being totally dependent of two with bed mobility and turning. RI #2 is assessed as requiring the total assist of one with dressing, eating, bathing and personal hygiene. RI #2's Care Plan for Activities of Daily Living dated 1/24/2012 documents that RI #2 requires assistance with ADL's related to RI #2 having numbness and tremors in his hands, Central Cord Syndrome and impaired cognition. The interventions listed for RI #2 includes "STAFF TO BATHE RESIDENT" and "PROVIDE CARE IN MANNER THAT PROMOTES DIGNITY." RI #2's Nurse's Notes dated 6/22/2012 at 6:53 AM, signed by EI #1 documents, "LPN FROM PREVIOUS SHIFT REPORT THAT DURING SKIN ASSESSMENT SHE FOUND THE WORD BATH WRITTEN ON RESIDENT'S LEFT LOWER ABD. (Abdomen) WRITER ENTERED RESIDENT'S ROOM TO ASSESS SKIN AND FOUND BATH WRITTEN IN WHAT APPEARED TO BE INK PEN ON RESIDENT'S LEFT LOWER ABD. WRITER NOTIFIED RN SUPERVISOR, (EI #3's name). ..." On 11/28/2012, three attempts were made by the surveyor to reach EI #1 at three different numbers. The surveyor was unable to leave a message at either number. On 11/29/2012 the facility's Administrator, EI #5 was asked for the last known number for EI #1. EI #5 provided the surveyor with the same numbers attempted earlier by the surveyor. On 11/28/12 at 7:58 a.m., EI #3, the Registered Nurse (RN) Supervisor for night shift, was interviewed by the surveyor. EI #3 stated she was told by EI #1 that RI #2 had the word "bath" written on his abdomen. EI #3 did not know if it was found by the nurse doing the body audit or a CNA giving a bath. EI #3 stated that the staff was upset and she had to calm the staff down then decide what to do. EI #3 stated she believed it was written under the diaper. EI #3 stated she had staff to wash it off then she reported the incident to EI #4, the former (DON), and EI #6, the former RN Unit Manager. EI #3 stated she told EI #4 and EI #6 that someone had written the word bath on the abdomen of RI #2. EI #3 stated she did not know who wrote it. EI #3 stated she did not know what it meant but knew it was wrong and inappropriate. EI #3 stated staff was upset because they took the work to be personal against them because 11- 7 shift always gave the bath. EI #3 stated some staff was emotional because it appeared to be written in ink like he was nothing. EI #3 stated the writing was big enough to see, about an half an inch or an inch. On 11/27/2012, EI #5 gave the surveyor an undated and unsigned typed statement with the name of the Former DON, EI #4. The statement has documented, "...On 6-22/12 it was reported to me that (RI #2's name) was found with the word "bath" on him. (EI #3 name) reported that staff had found the resident with this word on his lower abdomen. Staff removed this word. They are unsure of how this word got on his abdomen. When I arrived at the building I spoke with the resident's usual CNA (EI #2's name) to determine whether or not he knew about this word being written on him. He (EI #2) said that he wrote the word there because there had been confusion between our staff and the Hospice CNA about his bath. He said that he wrote it so they would make sure and bath him. I told him this was a very inappropriate action and that he should never do anything like this again. He was very apologetic and said that he would not ever do this again but he expressed his frustration with the bath situation. I told him that we probable needed to contact Hospice and infomr them that we did not need them to bath the resident any more but that our staff should provide his baths. Written warning was given to him by his Supervisor and this is placed in his file... " On 11/28/2012 at 2:23 p.m., an phone interview was conducted with the local Hospice agency who cared for RI #2. The Director of the local Hospice agency stated RI #2 only received a bath twice by a Hospice aide on 5/24/2012 and 6/04/2012. The Director stated the facility called and declined the hospice aides because RI #2 received his bath on night shift. The local Hospice Director faxed a document titled, "SUPPLEMENTAL ORDER" to the surveyor after the conversation, which documented, "... PATIENT ... (RI #2's name) ... ORDER 06/14/2012 Reason: Facility requests we D/C (discontinue) HHA (Hospice Health Aide) due to pt (patient) receives bath on 11-7 shift ..." On 11/28/2012 at 3:32 p.m., EI #4, the former DON was interviewed by phone by the surveyor. EI #4 stated she remembered the incident when an employee wrote the word bath on RI #2. EI #4 stated it was a Certified Nurse Assistant, EI #2, who wrote the word bath. EI #4 was read an unsigned and undated statement provides by the facility about the incident to the surveyor and confirmed that she did write the statement. EI #4 was asked why she wrote the statement. EI #4 stated that after the person who was doing investigation felt as though it was not abuse she felt like something needed to happen. EI #4 stated after she found out that had done it she talked to him and had the Unit Manager EI #6 to counsel him. On 11/27/2012 at 3:40 p.m., the surveyor reviewed the employee file for RI #2. Contained within the personnel record was a form titled, "Employee Warning Notice," completed by EI #6, the facility's RN Unit manager at the time of the incident, and dated 6/22/2012. This form documented, " Employee name (RI #2's name) Type of Violation... Unsatisfactory Performance Description of Violation Date of incident: 6/21/12 Description: Staff member wrote "bath ..." on resident in room (RI #2's room number). ... I have read and understand this Employee Warning Notice. (EI #2's signature)" Documented on page 19 of the facility's employee handbook, signed by EI #2 on 1/17/2012, "...RESIDENT RIGHTS Residents residing in the facility are entitled to retain their dignity and self respect, and the Facility and its employees have a moral and legal responsibility to communicate and preserve their rights. ..." On 11/28/12 at 2:47 pm, a phone interview was conducted with RI #2's Family Member (FM) by the surveyor. RI #2's FM was asked if he was aware of a staff member writing the word bath on RI #2's abdomen. RI #2's FM responded by saying, "What?" RI #2's FM stated he was not aware of this incident asked, "When did it happen. Why would they do that. Do you mean write on the skin like a piece of paper?" The surveyor informed RI #2's FM of the finding related to this incident. RI #2's FM stated he was "dumbfounded" and did not know what to say. RI #2's FM asked the surveyor who had done this and why. Surveyor explained to RI #2's family member that based on documentation in the facility it was an employee who was attempting to communicate that RI #2 had not received a bath from Hospice staff. RI #2's FM stated he was upset and angry. RI #2's FM stated they could have told someone or written it on a piece of paper, but they did not have to write on RI #2. RI #2 FM stated he wasn't sure if his brother would have known it was there, but you just did not treat people that way. The surveyor asked RI #2's FM, if his brother could have know how it would have made him feel. RI #2's FM stated, "Like me angry, it would be embarrassing." 2. RI #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #3's Bowel and Bladder Assessment, dated 11/26/2012 documents, "... RESIDENT IS FREQUENTLY INCONTINENT OF BLADDER, AND OCCASIONALLY INCONTINENT OF BOWEL. WEARS ADULT BRIEFS FOR CONTAINMENT. STAFF TO OFFER TOILETING, TO THE BSC (bed side commode), ON ROUTINE ROUNDS AND AS NEEDED. RESIDENT WILL ASK FOR TOILETING AT TIMES. STAFF WILL ALSO CHECK AND CHANGE AND PROVIDE PERI-CARE PER PROTOCOL ..." RI #3's Care Plan for Potential for UTI (Urinary Tract Infection), dated 11/15/2012 documents as approaches "wears adult briefs" and "will ask to use BSC at times." RI #3's Admission Minimum Data Set, with an ARD date of 11/22/2012, which had not been submitted to the state, documents RI #3's Brief Interview for Mental Status (BIMS) as being 9 ( a score of 8-12 suggest the resident is moderately impaired in cognitive skills for daily decision making). RI #3 is assessed as requiring extensive assist of two wit transfer and ambulation. RI #3 is assessed as being frequently incontinent of bladder and occasionally incontinent of bowel. On 11/27/2012 at 11:25 a.m., during a phone conversation, the local Ombudsman informed the surveyor of an incident that occurred while a Volunteer Ombudsman was visiting RI #3. The Volunteer Ombudsman had informed the local Ombudsman that RI #3 was not taken to the bathroom. On 11/29/2012 at 12:36 p.m., an interview was conducted with the Volunteer Ombudsman by the surveyor. The Volunteer Ombudsman stated that he was making rounds at the facility. He stated when he entered RI #3's room to speak to her the first thing she told him was she been up since 7 a.m. and had not been checked. He stated RI #3 told him she had to go to the bathroom. The Volunteer Ombudsman stated that sounded strange to him so he pushed the call light for staff assistance. The Volunteer Ombudsman stated he waited a few minutes and when no one responded to the call light he went into the hallway. The Volunteer Ombudsman stated he saw three staff members. He told EI #10 that RI #3 needed to go to the bathroom and needed someone to assist her. The Volunteer Ombudsman stated he returned to RI #3's room and shortly after EI#10 entered the room and told RI #3 she had spoken with her CNA (EI #9) and she would be with her shortly. The Volunteer Ombudsman stated the CNA (EI #10) stated to him "its ok she wears a diaper", then cut the light off then left the room. On 11/27/2012 at 2:01 p.m., the surveyor interviewed EI #10; the CNA who answered RI #3's call light. EI #10 was asked what assistance RI #3 needed. EI #10 stated that RI #3 needed assistance and there was a man in the room saying she needed assistance. EI #10 was asked what type of assistance RI #3 stated she needed. EI #10 stated RI #3 stated she needed to go to the toilet. EI #10 stated she told the Volunteer Ombudsman that was in the room that RI #3 "wears a diaper and that's what she uses." EI #10 was asked if it was appropriate to tell anyone or encourage a resident to use the diaper. EI #10 stated, no. EI #10 stated she did not know who the man was but he kept telling her that RI #3 had to go to the toilet. EI #10 stated she did not think about it and probably should not have said that. This citation is being written as a result of AL 871.