Every finding on record at Gadsden Health and Rehab Center

Based on record reviews, interviews, review of the facility's investigation file, review of the facility's report to Alabama Department of Public Health (ADPH) Online Incident Reporting System, and a review of the facility's policy titled, Abuse, Neglect and Exploitation, the facility failed to ensure a Certified Nursing Assistant (CNA)/Employee Identifier (EI) #4, did not verbally abuse Resident Identifier (RI) #1 on 12/13/2022, after RI #1 called EI #4, stupid and a bitch. CNA, EI #3, who witnessed the interaction between RI #1 and EI #4 on 12/13/2022, did not intervene even though she knew it was abuse when she overheard EI #4 calling RI #1 a mother fuc . EI #3 stated she was afraid of EI #4, due to EI#4's temper. This deficient practice affected RI #1, one of four residents sampled for abuse. Findings Include: Cross reference F 607. On 12/22/2022, the facility submitted a Facility Reported Incident through the ADPH Online Incident Reporting System. The report's summary of the incident documented that the incident was reported to the Director of Nursing (DON) that RI #1 was sitting at nurses desk in his/her chair when he/she called CNA, EI #4 a bitch and she called him/her a mother fuc . and kicked his/her wheelchair. A facility policy titled Abuse, Neglect and Exploitation dated 11/27/2017 documented: Policy: Each resident has the right to be free from abuse . Residents must not be subject to abuse by anyone, including . facility staff .Policy Explanation and Compliance Guidelines: . 3. Verbal Abuse means the use of oral . language that willfully includes disparaging and derogatory terms to residents . regardless of their age, ability to comprehend, or disability . RI #1 was admitted to the facility on [DATE] and had diagnoses to include Hemiplegia and Hemiparesis following Cerebral Infarction affection right dominant side and unspecified Dementia. A review of RI #1's Minimum Data Set, with an assessment reference date of 11/10/2022, documented a Brief Interview of Mental Status score of 4/15 which indicated RI #1 was cognitively impaired. The facility investigation summary documented that on December 22, 2022 at 3:30 PM (EI #3), CNA, reported to EI #2, DON/Abuse Coordinator, that she observed EI #4, CNA, on 12/13/2022, prior to midnight interacting inappropriately with RI #1 in the hallway near the nurses desk. EI #3 reported she witnessed RI #1 call EI #4 a bitch and then EI #4 called RI #1 a mother Fuc . and kicked at his/her wheelchair. RI #1was interviewed on 12/22/2022 at 6:00 PM, but he/she did not recall the incident. EI #4 was immediately placed on suspension and terminated on 12/23/2022. A witness statement handwritten by EI #3, CNA, documented on 12/13/2022 before midnight RI #1 was wanting to get out of bed and EI # 4, CNA, was told to get him/her up. EI #3 stated EI #4 was agitated when getting him/her up. When RI #1 was in the hall in his/her wheelchair he/she kept going to the nurses station door and trying to open it. EI #4 pulled RI #1 back and locked his/her wheelchair. RI #1 called her a bitch and she cussed back at him/her calling him/her a mother fuc . and kicked his/her wheelchair. An interview was conducted with EI #3, CNA, on 04/11/2023 at 2:00 PM. EI #3 was asked to recall the incident she observed between EI #4 and RI #1. EI #3 stated she was working the third shift on 12/13/2022, when the incident occurred. She stated EI #4 got RI #1 up from the bed to his/her wheelchair with no problem. EI #3 stated EI #4 rolled RI #1 in the hallway and RI #1 started cussing calling EI #4 a bitch and stupid. EI #3 stated EI #4 was acting like she was mad by her body language and her face was red. EI #3 stated RI #1 was attempting to go behind the nurses desk and EI #4 rolled him/her away from the desk and locked the wheelchair. RI #1 called EI #4 a bitch and then EI #4 called RI #1 a mother fuc . and kicked his/her wheelchair on the left wheel. EI #3 stated RI #1 had no injury and no further incidents were observed during the shift. She further stated RI #1 remained on the hall, ambulated around the unit in the wheelchair and remained calm. EI #3 was asked if she considered this incident to be abuse and she said she knew it was not right, but she had to think on it, due to being afraid of EI #4's temper and attitude. EI #3 stated she told her coworker EI #5 about the incident when they worked the third shift together and reported it to the facility on [DATE]. An interview was conducted with EI #2, Abuse Coordinator on 04/12/2023 at 11:00 AM. EI #2 said she became aware of the incident involving RI #1 on 12/22/2022 when EI #3 reported the abuse. EI #3 told EI #2 that on 12/13/2022 she witnessed EI #4 call RI #1 a mother fuc . and kick at his/her wheelchair after RI #1 called her a bitch. EI #2 said she considered this to be verbal abuse. EI #2 said she believed the incident happened and that is why EI #4 was terminated. She further said the only evidence she had the abuse occurred was the statement from EI #3 and EI #4's past behavior towards her coworkers and toward her work at the facility. EI #2 stated EI #4 was brought in for a statement on 12/23/2023 but she refused to provide a written statement and verbally denied the abuse occurred. An interview was conducted with EI #1, Administrator on 04/12/2023 at 5:26 PM. EI #1 was asked when she became aware of an incident involving RI #1. EI #1 said when the DON/Abuse Coordinator, was notified she EI #1 was notified. EI #1 said she was present when EI #3 and EI #5 were interviewed and was shocked they did not report the incident immediately. EI #1 said the allegation of verbal abuse should have been reported immediately after it was witnessed to protect the resident from further abuse ********************************* This deficiency was cited as a result of the investigation of complaint/report number AL00042761.

Based on record reviews, interviews, review of the facility's investigation file and a review of the facility's policy titled, Abuse, Neglect and Exploitation, the facility failed to ensure staff implemented one of the seven components of the abuse policy. A Certified Nursing Assistant (CNA) failed to report an allegation of verbal abuse to the abuse coordinator after she witnessed the abuse on 12/13/2023 in accordance with the facility policy. This affected RI #1 one of four residents sampled for abuse. Cross reference F600. Findings include: A facility policy titled Abuse, Neglect and Exploitation dated 11/27/2017 documented: . Each resident has the right to be free from abuse . Policy Explanation and compliance Guidelines: 1. The Abuse coordinator in the facility is the Director of Nursing. Report allegations or suspected abuse, neglect or exploitation immediately to: Director of Nursing . Administrator . Other Officials in accordance with State Law . Verbal Abuse mean the use of oral, written or gestured language that willfully includes disparaging and derogatory term to resident .regardless of their age, ability to comprehend, or disability . RI #1 was admitted to the facility on [DATE] with diagnoses to include Hemiplegia and Hemiparesis following Cerebral Infarction affection right dominant side and unspecified Dementia. A review of RI #1's 5-Day Minimum Data Set, with an assessment reference date of 11/10/2022 documented a Brief Interview of Mental Status score of 4/15 which indicated RI #1 was cognitively impaired. The facility investigation summary and conclusion documented that on December 22, 2022 at 3:30 PM (EI #3), Certified Nursing Assistant (CNA), reported to EI #2, Director of Nursing (DON)/Abuse Coordinator, that she observed EI #4, CNA, on 12/13/2022, prior to midnight interacting inappropriately with (RI #1) in the hallway near the nurses desk. EI # 3 reported she witnessed RI #1 call EI # 4 a bitch and then EI # 4 called RI # 1 a Mother Fuc . and kicked at his/her wheelchair. RI #1 was interviewed on 12/22/2022 at 6:00 PM, but he/she did not recall the incident. EI #4 was immediately placed on suspension and terminated on 12/23/22. During the investigation it was determined EI #3 made EI #5, CNA, aware of the incident involving RI #1 on 12/17/22 when they worked together. Both EI #3 and EI #5 were given verbal written warning for failing to follow the policy and procedure for reporting suspected abuse. A witness statement handwritten by EI #3, CNA, documented: .On 12/13/22 before midnight RI #1 was wanting to get out of bed and EI # 4, CNA, was told to get him/her up. EI #4 was agitated when getting him/her up. When RI #1 was in the hall in his/her wheelchair he/she kept going to the nurses station door and trying to open it. EI #4 pulled RI #1 back and locked his/her wheelchair. RI #1 called her a bitch and she cussed back at him/her, called him/her a mother fuc . and kicked his wheelchair . An interview was conducted with EI #3, CNA, on 4/11/23 at 2:00 PM. EI #3 was asked what she should do if she witnessed abuse of any type. EI #3 stated she should report the incident immediately. EI #3 was asked to recall the incident she observed between EI #4 and RI #1. EI #3 stated she was working the third shift on 12/13/22, when the incident occurred. She stated after RI #1 was gotten up from bed he/she was in the hallway and then near the nurses desk. RI #1 was attempting to go behind the nurses desk and EI # 4 rolled him/her away from the desk and locked the wheelchair. RI #1 called EI # 4 a bitch and then EI #4 called RI #1 a mother fuc . and kicked his/her wheelchair on the left wheel. EI #3 stated RI #1 had no injury and no further incidents were observed during the shift. She further stated RI #1 remained on the hall, ambulated around the unit in the wheelchair and remained calm with no new behavior observed the remainder of the shift. EI #3 was asked if she considered this incident to be abuse and she said she knew it was not right, but she had to think on it, due to being afraid of EI #4's temper and attitude. EI #3 stated she told her coworker EI #5 about the incident when they worked the third shift together on station one and then reported the incident to the facility two or three days later on 12/22/22. EI #3 said the abuse policy instructed her to report abuse and she should have reported the incident immediately to ensure abuse did not happen to other residents. An interview was conducted with EI #2, Abuse Coordinator on 4/12/23 at 11:00 AM. EI #2 said she became aware of the incident involving RI # 1 on 12/22/22 when EI #3 reported the abuse. EI #3 told EI #2 that on 12/13/22 she witnessed EI # 4 call RI # 1 a Mother Fuc . and kick at his/her wheelchair after RI #1 called her a bitch. EI #2 said she considered this to be verbal abuse and reported the abuse to the state agency and began the investigation. EI #2 said she felt like the incident happened and that is why EI #4 was terminated. EI #2 said EI #3 should have reported the abuse immediately after it happened. She said abuse should be reported immediately to stop future abuse and for the well being of the resident. When asked about EI #5's role in the incident involving RI # 1 she said when EI #3 told EI #5 about the incident involving RI #1 she should have reported the abuse allegation immediately. EI #2 said EI #3 and EI #5 did not follow the abuse policy of reporting abuse immediately after witnessing abuse and being told the abuse occurred. An interview was conducted with EI #1, Administrator on 4/12/23 at 5:26 PM. EI #1 was asked when she became aware of an incident involving RI #1. EI #1 said when EI #2 was notified she was notified. EI #1 said she was present when EI # 3 and EI #5 were interviewed and was shocked they did not report the incident immediately. EI #1 said the allegation of verbal abuse should have been reported immediately after it was witnessed to protect the resident from further abuse. EI #1 said the abuse policy was not followed because the policy instructed to report all abuse immediately. EI #1 further said both EI #3 and EI #5 were trained on the abuse policy and knew to report abuse. ********************************* This deficiency was cited as a result of the investigation of complaint/report number AL00042761.

Based on interview, record review and review of the Centers for Medicare & (and) Medicaid Services, Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure a Significant Change Minimum Data Set (MDS) was completed when Resident Identifier (RI) #23 was discharged from hospice on 5/1/21. This affected one of two residents sampled for Hospice. Findings Include: A review of the Centers for Medicare & (and) Medicaid Services, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, dated October 2019, reveled . An SCSA (Significant Change in Status Assessment) is required to be performed when a resident is receiving hospice services and then decides to discontinue those services (known as revoking of hospice care). The ARD (Assessment Reference Date) must be within 14 days from one of the following; 1) the effective date of the hospice election revocation (which can be the same or later than the date of the hospice election revocation statement, but not earlier than); 2) the expiration date of the certification of terminal illness; or 3) the date of the physician's or medical director's order stating the resident is no longer terminally ill. RI # 23 was admitted to the facility on [DATE] and readmitted on [DATE]. A review of RI # 23's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Hospice services . A review of RI # 23's medical record did not reveal a Significant Change MDS when RI # 23 was discharged from Hospice on 5/1/21. On 7/15/21 at 9:21 AM, an interview was conducted with the MDS coordinator Employee Identifier (EI) #1. EI #1 was asked, was RI # 23 on Hospice. EI #1 replied, RI #23 was discharged from hospice. EI #1 was asked, when was RI #23 discharged from hospice. EI #1 replied, 5/1/21 or 5/2/21. EI #1 was asked, did you complete a significant change MDS. EI #1 replied, we are in the process of doing one now for July, the ARD was open now. EI #1 was asked, when RI #23 was discharged should he/she have had a significant change. EI #1 replied, yes. EI #1 was asked, why did RI #23 not have a significant change. EI #1 replied, she just missed it. EI #1 was asked, what was the reason you would do a significant change. EI #1 replied, in case there was a decline or improvement, or need more care.

Based on interview, record review and review of the Centers for Medicare & (and) Medicaid Services, Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure Resident Identifier (RI) #36's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 05/02/2021, did not code RI #36 as receiving an Anticoagulant medication during this assessment period. This deficient practice affected RI #36, one of 31 residents whose MDS assessments were reviewed. Findings include: A review of the Centers for Medicare & (and) Medicaid Services, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, dated October 2019, revealed the following: . Coding Instructions . NO410E, Anticoagulant (e.g. (for example), [MEDICATION(S)], [MEDICATION(S)], or low-molecular weight [MEDICATION(S)]): Record the number of days an anticoagulant medication was received by the resident at any time during the 7-day look-back period . Do not code antiplatelet medications such as . [MEDICATION(S)] here . RI #36 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #36's Quarterly MDS assessment, with an ARD of 05/03/2021, revealed RI #36 received an Anticoagulant during this 7-day look back assessment period. A review of RI #36's April and May 2021 eMAR (electronic Medication Administration Record) revealed RI #36 received the following: . [MEDICATION(S)] 75 MG (milligrams) ([MEDICATION(S)] Bisulfate) Give 1 tablet by mouth one time a day related to [CONDITION(S)] OF NATIVE CORONARY ARTERY WITHOUT [CONDITION(S)] PECTORIS . According the Centers for Medicare & (and) Medicaid Services Long-Term Care Facility Resident Assessment Instruction 3.0 User's Manual [MEDICATION(S)] ([MEDICATION(S)]) should not be coded as an anticoagulant medication. On 07/15/2021 at 10:57 AM, the surveyor conducted an interview with Employee Identifier (EI) #1, the RN (Registered Nurse)/MDS Coordinator. The surveyor asked EI #1, when looking at RI #36's medical records, which anticoagulant medication was RI #36 receiving. EI #1 said RI #36 was on [MEDICATION(S)] but it is an Antiplatelet. When asked what the RAI classified [MEDICATION(S)] as, EI #1 said an Antiplatelet. The surveyor asked EI #1 why it would be important to code the MDS accurately. EI #1 said for accurate patient care and billing purposes. When asked was the [MEDICATION(S)] coded accurately, EI #1 said No.

Based on observations, record review, interviews, and review of Potter & Perry Fundamentals of Nursing, the facility failed to ensure Resident Identifier (RI) #99's tube feeding bottle and water bag were labeled. This affected one of five residents sampled for tube feeding. Findings Include: A review of Potter & Perry Fundamentals of Nursing, Ninth Edition, copyright 2017, Chapter 45 Nutrition, page 1082, revealed: . SAFETY GUIDELINES FOR NURSING SKILLS . When performing the skills in this chapter, remember the following points to ensure safe, individualized patient care. * Label enteral equipment with patient name and room number; formula name, rate, and date and time of initiation; and nurse initials . RI #99 was readmitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] RI #99's Order Summary dated Jul (July) 5,2021 revealed, .Enteral Feed Order every shift Glucerna 1.5 a@ (at) 40 mL/hr (milliliters per hour) over 23 hours . start date [DATE] . H2O flush at 23 ml/hr over 23 hours via peg tube per pump . start dated [DATE] . On [DATE] at 10:56 a.m., the surveyor observed RI #99's tube feeding infusing. There was no date, time or initials on RI #99's tube feeding or water bag. On [DATE] at 12:30 p.m. the surveyor observed RI #99's tube feeding infusing and noted there was no label with the date or time noted on RI #99's tube feeding or water bag. On [DATE] at 4:00 p.m., the surveyor again observed there was no label with the date and time noted on RI #99's tube feeding and water bag. On [DATE] at 4:04 p.m., an interview was conducted with Employee Identifier (EI) #2, Licensed Practical Nurse (LPN). EI #2 was asked what was wrong with the tube feeding and water bag hanging for RI #99. EI #2 replied, it did not have a label, date, or initials, on the tube feeding or water bag. EI #2 was asked should the tube feeding, and water bag be labeled prior to infusing. EI #2 replied, yes. EI #2 was asked, how could the unlabeled tube feeding, and water bag potentially harm the resident. EI #2 replied, RI #99 could receive expired tube feeding that could make him/her sick. EI #2 was asked what should have been done prior to infusing the tube feeding. EI #2 replied, both should have been labeled prior to infusing. On [DATE] at 4:20 p.m., an interview was conducted with EI #3, a Registered Nurse/ Unit Manager. EI #3 was asked, what she observed when looking at RI #99's tube feeding. EI #3 replied, there was no label with the date and time on either bag. EI #3 was asked, when was the tube feeding and water bag hung. RI #3 replied they were hung this morning. EI #3 was asked what was the potential concern with not having the bags labeled on the tube feeding. EI #6 replied, the tube feeding could go bad if it has not been dated and timed. The tube feeding could run too long causing the resident to get sick.

Based on record reviews, interviews and the nursing manual titled, Fundamentals of Nursing, the facility failed to ensure the physician orders [REDACTED].#75 for stool specimens to be collected times three for [MEDICAL CONDITION]. The deficient practice affected one of the 39 sampled residents whose physician's orders [REDACTED]. Findings include: A review of the nursing manual titled, Fundamentals of Nursing, Ninth Edition by Potter and Perry, Chapter 23 page 311, revealed . Health Care Providers' Orders. Nurses follow health care providers' orders . RI # 75 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Surveyor reviewed the resident's medical record and discovered the physician's orders [REDACTED]. The resident's Medication Administration Record [REDACTED]. There were no lab reports for stool specimens or documentation of collected stools for [MEDICAL CONDITION]. On 12/05/19 at 11:31 a.m., the Surveyor conducted an interview with Employee Identifier (EI) # 4 Licensed Practical Nurse. EI # 4 was asked, were the physician's orders [REDACTED].# 75. EI # 4 replied, she did not collect the specimens because RI # 75 wore adult diapers and when RI # 75 had a bowel movement the following day 11/25/19, it was just a smear. EI # 4 was asked, were any stool specimens collected since 11/24/19. EI # 4 replied, she had not collected any specimens and had not heard from the facility's 24 hour report of any specimens being collected. EI # 4 was asked, was medication administered to RI # 75 by her to stop loose stools. EI # 4 replied, she did give RI # 75 (one of the [MEDICATION NAME]); RI # 75 complained of having loose stool. EI # 4 was asked, what was the potential harm with the facility not following the physician's orders [REDACTED].# 4 replied, potentially delayed the resident's treatment and spread the [MEDICAL CONDITION] infection. On 12/05/19 at 11:57 a.m., the Surveyor conducted an interview with EI # 3, Registered Nurse Infection Control. EI # 3 was asked, what date was the order for RI # 75 stool for [MEDICAL CONDITION]. EI # 3 replied, 11/24/19. EI # 3 was asked, what was potential harm with the facility not following the physician's orders [REDACTED].# 75 for [MEDICAL CONDITION]. EI # 3 replied, possible delayed treatment for [REDACTED]. On 12/05/19 at 12:09 p.m., the Surveyor interviewed EI #1, Primary Physician. EI # 1 was asked, did he recall writing an order for [REDACTED].# 1 replied, yes he did. EI # 1 was asked, why did he write the order for RI # 75. EI# 1 replied, to ensure RI # 75 did not have any infection because RI # 75 recently was discharged from the hospital and complaining of diarrhea. EI # 1 was asked, what was the potential harm with the facility not following his physician order. EI # 1 replied, not following his physician order [REDACTED]. EI # 1 said, because they were unable to ensure they ruled out an infectious disease. EI # 1 continued to say [MEDICAL CONDITION] spreads quickly in a facility. EI # 1 also said, early [DIAGNOSES REDACTED]. On 12/05/19 at 12:38 p.m., the Surveyor conducted an interview with EI # 2 Registered Nurse/ Unit Manager of the Rehabilitation Department. EI # 2 was asked, (while she was viewing the facility's records) what did the order read dated 11/24/19. EI # 2 replied, stool for [MEDICAL CONDITION] times three. EI# 2 was asked, who signed the order off acknowledging it was received. EI # 2 replied, she did. EI # 2 was asked, what was meant by the order. EI # 2 replied, it meant they were ordered to collect stool specimens from RI # 75 for [MEDICAL CONDITION]. EI # 2 was asked, was the stools collected for [MEDICAL CONDITION] from RI # 75. EI # 2 replied, no. EI # 2 was asked, why were the physician's orders [REDACTED]. EI # 2 replied, there was not enough stool for a specimen. EI # 2 was asked, was the resident given (an as needed) medication to stop diarrhea/ stool on 11/24/2019. EI # 2 replied, yes ma'am. EI # 2 was asked, what time frame are stool specimens obtained once an order was received. EI # 2 replied, the facility liked to obtain specimens as soon as possible, within days. EI # 2 was asked, (while reviewing RI # 75 MAR indicated [REDACTED]. EI # 2 replied, 12/1 - 12/4/19. EI# 2 was asked, what shifts did RI # 75 receive an as needed medication to stop loose stools. EI # 2 replied, all shifts. EI # 2 was asked, what was the potential harm for RI # 75 that the facility did not follow the physician orders [REDACTED]. EI # 2 replied, if RI# 75 had [MEDICAL CONDITION] it could have spread to employees and other patients.

Based on observation, interviews and a review of the facility policy titled, Destruction of Unused Drugs, the facility failed to ensure one and one-half bottle of expired [MEDICATION NAME] (8 ounce) and an expired bottle of [MEDICATION NAME] 80 mg tablets were not left on medication carts beyond the expiration dates. This deficient practice was observed on two of nine total medication carts. Findings Include: A review of the facility policy's titled Destruction of Unused Drugs, dated 11/27/2017, revealed the following: . Policy Interpretation and Implementation . 3. Non-controlled medications will be audited and inspected for expiration dates on a monthly basis . if a medication is found to be expired the nurse will follow facility procedure on destruction of non-controlled medication. On 11/1/2018 at 11:34 AM, the surveyor conducted a medication cart review on the 800 Hall. Employee Identifier (EI) #2, Licensed Practical Nurse (LPN), was also present. One and one-half bottle of [MEDICATION NAME] (8 ounce bottle) was observed with an expiration date of (MONTH) (YEAR). The surveyor asked EI #2 who was responsible for checking the medication carts for expired medications. EI # 2 stated all nurses working the carts were responsible. EI #2 agreed the [MEDICATION NAME] was expired. The surveyor asked EI # 2 what was the potential harm for using expired medications. EI # 2 stated residents would probably not get their full dose since the medication is expired. On 11/1/2018 at 11:41 AM, the surveyor conducted a medication cart review on the 700 Hall. EI # 3, LPN, was also present. A bottle of [MEDICATION NAME] 80mg/milligram was observed with an expiration date of (MONTH) (YEAR). This medication bottle had an open date of 10/26 written on it. The surveyor asked who was responsible for checking medication carts for expired medications. EI # 3 stated the nurse working on the cart was responsible. EI #3 agreed the [MEDICATION NAME] was expired. The surveyor asked EI# 3, what was the potential harm of using expired medication. EI #3 said the medication may be ineffective. On 11/1/2018 at 12:50 PM , the surveyor asked EI #4, RN/DON (Registered Nurse/Director of Nursing), who was responsible for checking medication carts for expired medications. EI #4 stated the pharmacy technicians come monthly and check the carts and the nurses working on the carts should also catch any expired medications.

Based on observation and interview, the facility failed to ensure a Certified Nursing Assistant (CNA) did not drop a carton of milk onto the floor, then return it to the refrigerator. This had the potential to affect all residents receiving supplements from the refrigerator at Station 2. Findings Include: On 10/31/18 at 2:59 PM Employee Identifier (EI) #5, a CNA, was observed to drop a container of milk on the floor, pick it up and then return it to the refrigerator at Station 2. The surveyor asked EI #5 what should be done if a container of milk is dropped on the floor. EI #5 said she should have disposed of it because placing the milk back into the refrigerator could cause contamination.

Based on observation, interviews, record reviews and review of facility policy titled, Care Plans - Comprehensive, the facility failed to ensure staff implemented a care plan for Resident Identifier (RI) # 1 and RI #12's foley catheter. This affected two of two residents sampled for Foley catheters. Findings Include: A review of a facility policy titled, Care Plans - Comprehensive with a revised date of September 2010 revealed: Policy Statement An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Policy Interpretation and Implementation . 6. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident . RI #1 was admitted to the facility 02/04/2016, with a [DIAGNOSES REDACTED]. A review of RI #1's Order Summary Report dated October 18, 2017 revealed: .CHANGE FOLEY CATH (catheter) . Q (every) 30 days ON 3rd DAY OF Q month .Order Date 10/05/2017 . On 10/18/2017 at 12:00 p.m., RI #1 was observed with a foley catheter attached to a closed drainage bag inside a privacy bag hanging from the right side of RI #1's bed. Clear yellow drainage was observed in the tubing. A review of RI #1's Care Plans did not reveal a care plan for the Foley Catheter. On 10/18/2017 at 3:30 p.m., an interview was conducted with Employee Identifier (EI) #1, LPN (Licensed Practical Nurse). EI #1 was asked if RI #1 had a foley catheter. EI #1 replied, yes. EI #1 was asked how long had RI #1 had the foley catheter. EI #1 replied, it had been a while, since 2/7/2017. EI #1 was asked if RI #1 had a care plan for the foley catheter. EI #1 replied, no. EI #1 was asked if there should be a care plan for the foley catheter. EI#1 replied, yes. EI #1 was asked what was the [DIAGNOSES REDACTED]. EI #1 replied, Neuromuscular dysfunction of the bladder. EI #1 was asked what was the harm in not having a care plan for the foley catheter. EI #1 stated, Potentially it may not get done if it was not care planned for. RI #12 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of RI #12's Order Summary Report dated October 19, 2017 revealed: .Change foley catheter q 30 days and PRN as needed .Order Date 10/10/2017 . On 10/18/2017 at 3:40 p.m., RI #12 was observed with a foley catheter, attached to a closed drainage bag hanging in a privacy covered bag on side of RI # 12's bed. A review of RI #12's Care Plans did not reveal a care plan for the Foley Catheter. On 10/19/17 at 8:55 a.m., an interview was conducted with EI #2, RN (Registered Nurse)Unit Manager. EI #2 was asked if RI #12 had a care plan for the use of his/her foley catheter. EI #2 said no. EI #2 was asked should RI #12 have a care plan for the use of a foley catheter. EI #2 said yes he/she should have a care plan. EI #2 was asked what was the potential harm with not having a care plan for a resident with a foley catheter. EI #2 replied nursing staff would not know he/she had a foley catheter so they would not know to provide care for the foley catheter.

Based on observation, staff interviews, medical record review and a review of facility's policies titled, NURSING MEDICATIONS/ADMINISTRATING Standard Precautions and an unnamed policy and procedure, the facility failed to ensure a Licensed staff member did not touch the inside of a medication pill crush packet with her ungloved hand and did not take clean gloves from the top of the medication cart and place them in her uniform pocket, then later remove the gloves to perform an eye lid scrub for Resident Identifier (RI) #17. The facility further failed to ensure RI #14's nebulizer mask was stored properly on 10/17/17 and 10/19/17. This affected one out of seven nurses observed for medication administration and one of four sampled residents receiving respiratory treatments. Findings Include: 1) A review of the facility policy tilted, NURSING MEDICATIONS/ADMINISTRATING with no effective date revealed: .Procedure 1. Maintain a clean technique throughout the procedure. A review of a facility policy titled, Standard Precautions with no effective date revealed: .Standard Precautions will be used in the care of all residents regardless of their [DIAGNOSES REDACTED]. 2. Gloves a. Wear gloves (clean, non-sterile) when you anticipate direct contact . e. Change gloves, as necessary, during the care of a resident to prevent cross-contamination . RI #17 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/18/17 at 8:15 a.m., the surveyor observed Employee Identifier (EI) #3, Licensed Practical Nurse (LPN) during medication administration. EI #3 placed an ungloved finger inside the pill crush packet. EI #3 then removed clean gloves from the top of the medication cart and placed the gloves into her uniform pocket. EI #3 removed the gloves from her pocket, applied the gloves, and cleaned Resident Identifier (RI) #17's eyes with the [MEDICATION NAME] eyelid cleanser using the gloves she removed from her uniform pocket. An interview was conducted on 10/18/17 at 3:38 p.m., with EI #3. The surveyor asked EI #3, during morning medication pass did she put her ungloved finger inside the plastic pill crush pack. EI #3 replied yes. EI #3 was asked what did she do with the gloves she removed from the medication cart before entering RI #17's room. EI #3 stated she put them in her pocket and used them to clean RI #17's eyes with the eyelid cleanser. EI #3 was asked what was the harm when she put her finger into the plastic pill pack and used gloves out of her uniform pocket. EI #3 replied contamination and it could introduce an infection. An interview was conducted on 10/19/17 at 11:05 a.m., with EI #4, a Registered Nurse (RN)/Infection Control Nurse. EI #4 was asked, what was it considered when the nurse put her ungloved finger inside a medication pill pack. EI #4 stated, contamination. EI #4 said it was an infection control issue because you cannot put your hand inside the pill pack or inside the cup. 2) A review of an untitled facility policy with an effective date of 3/05 revealed the following: . SUBJECT: USE OF A NEBULIZER STANDARDS: MD orders will be followed for the use of nebulizers .CLEANING THE NEBULIZER: .4. Make sure the nebulizer is completely dry before storing the nebulizer . RI #14 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 10/17/17 at 4:00 p.m., the surveyor observed RI #14's nebulizer mask lying on a table in his/her room uncovered and not stored. On 10/19/17 at 8:25 a.m., the surveyor observed RI #14's nebulizer mask uncovered inside the resident's second drawer. On 10/19/17 at 8:45 a.m. an interviewed was conducted with EI #5, RN. EI #5 was asked if RI #14 received nebulizer treatments. EI #5 said, Yes. EI #5 accompanied the surveyor to RI #14's room. EI #5 was asked where was RI #14's nebulizer mask. EI #5 said the nebulizer mask was in his/her drawer. EI #5 was asked where should RI #14's nebulizer mask be stored when not in use. EI #5 said, In a ziplock bag and zipped up. EI #5 was asked what was the potential harm in not storing a nebulizer mask when not in use. EI #5 said the risk for infection, any type of bacterial or lung infection. On 10/19/17 at 11:05 a.m., an interview was conducted with EI #4. EI #4 was asked where should a nebulizer mask be stored when not in use. EI #4 stated it should be stored in a plastic bag. EI #4 was asked what was the potential harm for a nebulizer mask not being stored in a plastic bag. EI #4 replied you could get any kind of respiratory infection, contamination and it could get into your lungs as well.

Based on record review and interviews, the facility failed to ensure Resident Identifier (RI) #1, a non-verbal, totally dependent resident, was not left alone after his/her son was observed with his ungloved finger in the resident's rectum on 10/28/2016. An interview with RI #1's son revealed he was allegedly attempting to remove feces from RI #1's rectum. According to two Licensed Practical Nurses, Employee Identifier (EI) #'s 15 and #16, on 10/28/2016, while observing residents on their nursing rounds, RI #1's son was observed removing his ungloved finger from RI #1's rectum. Even though the son stated he was removing feces from RI #1's rectum, both staff members denied observing any feces on RI #1's son fingers or hand, as well as on the resident or his/her bed linens. The Registered Nurse (RN) Unit Manager, EI #14, was notified and stated she immediately had a conversation with the resident's son after being notified of this incident. EI #14 stated she encouraged RI #1's son to call a staff member instead of providing care when RI #1 needed any assistance. Further, EI #14 stated during this conversation with RI #1's son, he was informed of the possible injury(ies) he could cause if he continued to perform any medical procedures that he is not trained to perform, such as digitally removing feces. After this conversation, RI #1's son was allowed to re-enter the resident's room without staff supervision or monitoring of the son's interactions with RI #1. Later after this incident, according to the facility's investigation, a Certified Nursing Assistant observed the door to RI #1's room was closed. EI #15 and #16 went to the resident's room. Upon entering the room, the resident's light was off and RI #1's son was observed with his hand in the resident's perineal area. EI #15 and #16 said RI #1's son informed them he was checking RI #1 to see if RI #1 was wet. While one staff member remained in the room with RI #1, the other staff member notified the RN Supervisor, EI #14 and RI #1's son was instructed to leave the facility. RI #1 was examined for signs of trauma and no signs and symptoms were observed. The Medical Director was notified and orders were received to send RI #1 to the local emergency room (ER) for further examination for possible sexual assault. According to ER documents, no injuries were detected upon an examination. Further, the facility notified the local law enforcement agency and an Incident/Offense Report was completed. Leaving RI #1, alone in a room without supervision and monitoring of RI #1's son interactions, placed RI #1 in a potentially abusive and harmful situation. On 11/10/2016, at 8:24 a.m., the Assistant Administrator was notified of the findings of Immediate Jeopardy in the area of Resident Behavior and Facility Practices, F 223. The immediate jeopardy began on 10/28/2016. On 10/28/2016 to 10/31/2016, the facility immediately implemented corrective actions to prevent recurrence of the identified deficient practices; thus Immediate Jeopardy Past Non-compliance was cited in the area of Resident Behavior and Facility Practices. This deficient practice, affected RI #1, one of four residents sampled for abuse. Findings Include: A review of Potter and Perry, Fundamentals of Nursing, Eighth Edition, with a copyright date of 2013, Chapter 46: Bowel Elimination, page 1107, documented: . Digital removal is a last resort in the management of severe constipation and practiced when all other methods have failed. The procedure is very uncomfortable for the patient. Excess rectal manipulation causes irritation to the mucosa; bleeding; and stimulation of the vagus nerve, which results in a reflex slowing of the heart rate. Because of the potential complications of the procedure, a health care provider's order is necessary to remove a fecal impaction . RI #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An Admission Minimum Data Set, assessment dated [DATE], assessed RI #1 as scoring a 0 on the Brief Interview for Mental Status indicating RI #1 was cognitively impaired. RI #1 was assessed as being totally dependent on staff for toilet use and personal hygiene and had impairment on one side of the lower and upper extremities. The assessment also indicated RI #1 was frequently incontinent of urine and always incontinent of bowel. RI #1's progress note dated 10/28/2016 at 17:45 (5:47 p.m.) documented: . Note Text: Notified this afternoon that pt's (patient's) son had been noted in (RI #1's) room attempting to perform an inappropriate medical procedure. RN supervisor (EI #14) went to speak with son. RN came back to notify SW (Social Worker) of conversation with son. While having this conversation, charge nurses came into SW office to notify RN that they had entered pt's room and noted pt's son was observed with the covers back and had his hands between pt's legs . RI #1's Physician order [REDACTED]. . Send to ER (emergency room ) for evaluation . A review of a police report titled: Alabama Uniform Incident/Offense Report completed for RI #1 on 10/28/2016, at 15:40 (3:40 p.m.), documented: . The victim is a resident at Gadsden Health Care. The suspect is the victim's son. The witnesses are employees of Gadsden Health Care. On October 28, 2016 the suspect was visiting the victim. The witnesses stated at approximately 2:31 pm they walked into the victim's room. The witnesses said when they entered the room they noticed the suspect had his finger inside the victim's rectum. The witnesses asked the suspect what he was doing. The witnesses said the suspect told them that his (family member) was stopped up and he was digging stool out. The witnesses said they did not see any stool on the bed or the suspect's finger. One of the witnesses stayed with the suspect and victim while the other witness went and got the RN Unit Manager (EI #14). (EI #14) had the suspect to go into the hallway. (EI #14) asked the suspect what he was doing. Again the suspect said he was trying to relieve his (family member's) constipation. (EI #14) told the suspect in the future if he thinks his (family member) needs attention for him to find an employee. The witnesses said at approximately 2:55 pm they noticed that the victim's door was closed. The witnesses said they went to the victim's room and opened the door. The witnesses said the lights to the victim's room was off. The witnesses said the suspect had the victim's sheet pulled down and the victim's gown puled (pulled) up. The witnesses said the suspect had his hands between the victim's legs and he had a finger in the victim's (genital area). The witnesses asked the suspect what he was doing. The witnesses said the suspect told them he was checking to see if his (family member) was wet. Again (EI #14) was called. (EI #14) asked the suspect to leave the property. Investigator (name of investigator) was notified. (Name of investigator) advised to list the offense as sexual misconduct. A review of RI #1's ER documentation documented the following: . Basic Information Time seen: Date & (and) time 10/28/2016 19:18:00 (7:18 p.m.) . History of Present Illness The patient presents with PT IS AN (age of RI #1) YO (year old) NONVERBAL (sex of RI #1) WITH A PMH (past medical history) [MEDICAL CONDITION] FROM (HIS/HER) NURSING HOME TO BE EVALUATED FOR POSSIBLE SEXUAL ASSAULT. PER NURSING HOME PT'S SON CAME TO VISIT TODAY, AND WAS WITNESSED WITH HIS INDEX FINGER INSERTED INTO HIS (FAMILY MEMBER'S) RECTUM. WHEN THE NURSE CONFRONTED HIM HE STATED THAT HE WANTED TO MAKE SURE THERE ISN'T FECAL IMPACTION. LATER HE WAS WITNESSED WITH HIS HANDS ON (FAMILY MEMBER) DIAPER OVER THE (GENITAL) AREA, HE STATED THAT HE WANTED TO MAKE SURE IT WASN'T WET . Physical Examination . Gastrointestinal: Soft, Nontender, Normal Bowel sounds, MIDLINE SCAR, rectal exam: Normal tone, NO INJURY, No tenderness . On 10/29/2016 at 11:18 a.m., the Alabama Department of Public Health Online Incident Reporting System received the following incident report: . 7) Name (s) of resident (s) involved: (Name of RI #1) 8) Date and time of injury discovered: 10/28/2016 9) Time: 02:00 PM 10) Description of injury: during walking rounds at shift change the nurses entered room (RI #1's room number) and observed son of (RI #1) with his ungloved finger inserted into his (family member)'s rectum. He immediately removed his finger and stated he/she is impacted and in pain I am trying to help (RI #1) the nurse explained that was their job. A review of the facility investigative file dated 10/28/2016, at 2:15 p.m., revealed the following statement written by EI #14, the RN supervisor: (EI #16), LPN entered admission's office asking this nurse to please come to (RI #1's room) . (EI #16) stated (name of RI #1's son) had his finger in (RI #1's) rectum, he says (RI #1's) constipated. I then went to (RI #1's room number) accompanied by (EI #18), LPN (Wound Care nurse) . I asked (name of RI #1's son) can I please talk c (with) you outside of this room? (name of RI #1's son) followed me unto the hallway. I said (name of RI #1's son) it was brought to my attention, that you had your finger in (RI #1's) rectum . (name of RI #1's son) stated, When I came in (RI #1) had (his/her) hand at (his/her) butt digging (him/herself) out. I was helping by cleaning off (his/her) hand and getting the stool out . This nurse stated (name of RI #1's son) putting your finger in the patient's rectum is a nurse's job. Did you ask or tell the nurse that (RI #1) is constipated? (name of RI #1's son) replied No . and I can do it myself . This nurse replied, (Sir/Madam), if at any time you feel that (RI #1) is constipated, you are to call the nurse and she will call the doctor to get orders on what to do next . By putting your finger in (RI #1's) rectum you could have caused injury to (RI #1's) colon. Can you promise me that you will not attempt to remove stool from (RI #1's) rectum? (name of RI #1's son) stated, I will call for assistant from now on but if it takes as long as 15 to 30 minutes I will do it myself. Then (name of RI #1's son) gave me two thumbs up and re-entered the room . On 11/8/2016 at 5:02 p.m., the surveyor conducted an interview with EI #14, the RN/Unit Manager of Rehabilitation Station 3. EI #14 explained her written statement was for the investigation of RI #1. EI #14 said, on 10/28/16, EI #16, the nurse coming on and EI #15, the nurse leaving were doing their rounds when they walked in RI #1's room. EI #14 said RI #1's son had his finger in RI #1's rectum. EI #14 said that was when she asked RI #1's son to step out of the room because she did not want to talk in front of RI #1. EI #14 said after she finished talking to RI #1's son, the son went back in RI #1's room. The surveyor asked EI #14 did EI #15 and #16 contact her again that evening about RI #1's family member. EI #14 replied, Yes. EI #14 said EI #16 approached her and said they asked RI #1's son to leave because he closed the door and when she (EI #16) went back to check on RI #1 the son said he was checking RI #1 to see if the resident was wet. EI #14 said EI #16 observed the son's hand on RI #1's perineal area. The surveyor asked EI #14 if RI #1 had on an adult brief. EI #14 said, no. EI #14 said the residents who are incontinent use pads when they are in bed. The surveyor asked EI #14 did the facility suspect RI #1's son had sexually assaulted RI #1. EI #14 said, because RI #1's son did a nursing act, something that could possibly injure RI #1 internally, the facility sent RI #1 out because the son took it upon himself to check RI #1's rectum. EI #14 said the facility treated it as sexual abuse because of what RI #1's son did. EI #14 said, she was not sure why RI #1's son would be checking the resident. EI #14 said, RI #1's son had always been overprotective of RI #1. EI #14 explained what she meant by overprotective was when care was being provided for RI #1, sometimes the resident's son would not leave the room and sometimes he would. A review of EI #15's statement dated 10/28/2016 at 2:31 p.m., revealed EI #15 was the LPN assigned to care for RI #1 on the 6 a.m. - 2 p.m. shift on 10/28/16. The statement revealed: . Upon entering rm (number of RI #1's room) to give report to on coming nurse (EI #16), pt. son was noticed digging pt. out with his finger in (RI #1's) rectum leaning over the bed. (EI #16) & (and) I explained to pt's son that he was not to do that & it is the staff's job. (RI #16) left room to get supervisor (EI #14) as I stayed with the pt . (EI #14) entered the room and asked (RI #1's) son to step outside the rm. to talk and (EI #16) & I continued to give report. At 3:05 pm (p.m.) a CNA (Certified Nursing Assistant) was walking down (number of hall RI #1 resided on) and (EI #16) & I asked if (RI #1's room number) door was closed and the CNA checked and stated that it was closed. (EI #16) & I went down hallway to (RI #1's room) and as we entered the room the lights were off and the pt. was lying on (his/her) back and the pt's son was leaning over (RI #1) and was checking to see if (he/she) was wet as he stated with his hands in (RI #1's) peri area . On 11/9/2016 at 7:55 a.m., the surveyor conducted an interview with EI #15. EI #15 explained that she had to write a statement because of what she saw regarding RI #1. The surveyor asked EI #15 what did she see when she entered RI #1's room. EI #15 stated, When we entered (RI #1's) room the son was leaning over (RI #1's) bed and he had his ungloved finger in (RI #1's) rectum digging (RI #1) out. When asked what else was observed, EI #15 said the son had some paper towel from the bathroom laying on the bed. EI #15 said she asked the son if he called for assistance and the son said, no because he could do it himself. EI #15 said by this time EI #16 had gone to get EI #14. EI #15 said she asked a CNA had RI #1's son asked for assistance for RI #1 to use the bathroom and the CNA said, no. EI #15 said, when EI #14 came to the room, she (EI #14) asked the son to step out of the room so she could talk to him. EI #15 said the son stepped out of the room and she and EI #16 went over to RI #1 to make sure the resident was clean. EI #15 said they did not observe any stool on RI #1. EI #15 said they pulled the covers up on RI #1 and got the resident situated in bed. The surveyor asked EI #15 what happened the second time they entered RI #1's room. EI #15 replied, Once we finished doing our walking rounds, (EI #16) and I went to the nurses' station to write our statements. EI #15 said once they were writing their statements, a CNA was walking up the hall and EI #16 asked the CNA if RI #1's door was open or closed. EI #15 said the CNA said the door was closed. The surveyor asked EI #15 what she did at that time. EI #15 said, she and EI #16 went down to check on RI #1. EI #15 said, when they opened the door to RI #1's room the lights were off and RI #1 was laying on (his/her) back. The son was standing over RI #1 on the left side of the resident's bed. EI #15 said once they opened the door to RI #1's room, the son's hand was in RI #1's perineal area. EI #15 said when the door was opened the son turned toward them and said he was checking to see if RI #1 was wet. EI #15 said, EI #16 immediately went to get EI #14 who explained to the son that the facility had staff to check the resident. EI #15 said RI #1's son should have been monitored because she did not know if he understood what he was doing was inappropriate. The surveyor asked EI #15 what the facility has done to ensure an incident like this one will not reoccur. EI #15 said, facility staff had been inserviced on suspected abuse and told to notify the Abuse Coordinator, stay with the patient and there were pictures of RI #1's son posted at the nurses station and time clock with numbers to call if RI #1's son was seen. A review of the EI #16's statement dated 10/28/2016 at 2:35 p.m., revealed the following statement written by EI #16, the LPN assigned to care for RI #1 on the 2 p.m. - 10 p.m. shift on 10/28/16: During report c (with) (EI #15), we opened the door to (RI #1's room). Upon entering the room patient was laying on (his/her) right side and the sheets were at patients feet. Patient was exposed from waist down and (RI #1's) son was bent over and digging patient out with finger in (his/her) rectum. He stopped upon seeing (EI #15) and myself approach the bed. He stated, (RI #1) is impacted. I noticed no stool/BM (bowel movement) on the son's fingers ((he) was not wearing gloves) or on the bed or on the patient's bottom. I immediately left the room and got supervisor (EI #14). (EI #15) stayed c the patient until (EI #14) and I arrived back to the room . (EI #14) ask the son to please step outside the room so that she could talk to him. (EI #15) and I at that time attended to the patient. Patient had (no) s/s (signs and symptoms) of distress. we placed the patient on (his/her) back, the pad & sheets were clean and dry. We covered the patient c sheet and blanket. (EI #15) and I continued to finish our walking rounds & report. 305 pm (3:05 p.m.) - while at the desk writing statements (EI #15) and I looked down the hall, not seeing anyone I ask a CNA to check (RI #1's room number) door to make sure it was open. CNA stated No it's closed. (EI #15) and I then went back to the room. Upon entering the room found that the son was in the room again, the patient was exposed from waist down, lying on (his/her) back and the son was removing his hand from patients Peri-Area. The son immediately states, I was checking to see if (RI #1) was wet - I immediately left the room as (EI #15) stayed c the patient, and made (EI #14) aware of what we just saw . I went back to the room and told the son the (that) he must leave now . On 11/9/2016 at 9:00 a.m., the surveyor conducted a phone interview with EI #16. The surveyor asked EI #16 when she became aware of the first incident involving RI #1's son having his ungloved finger in RI #1's rectum. EI #16 said, she and EI #15 walked in on it. EI #16 said she and EI #15 were doing walking rounds when they walked in RI #1's room and she noticed RI #1 was laying on his/her right side. EI #16 said RI #1 was totally exposed from the buttocks to the waist down and RI #1's son was bent down with his finger in RI #1's rectum. EI #16 said, the first thing the son said was he was digging RI #1's impaction. EI #16 said, she did not see any stool on the son's hands, sheets or the bed. EI #16 stated RI #1's son did not have on any gloves. EI #16 said she immediately rushed from the room to go and get help. EI #16 stated she found EI #14, the RN Unit Manager, in another room and informed EI #14 she needed to see her because it was an emergency. EI #16 said EI #14 went to RI #1's room and asked RI #1's son to come outside the room to talk with her. EI #16 said RI #1's son exited the room while she and EI #15 checked RI #1's bottom. EI #16 said RI #1 did not have any stools on (him/her) and was dry. EI #16 said she and RI #15 pulled the sheet up over RI #1, made sure the resident was comfortable, placed him/her on their back and left the room. EI #16 said EI #14, the son and EI #18, a Wound Care nurse, were on the outside of the room when she and EI #15 left the room. The surveyor asked EI #16 if RI #1's son re-entered RI #1's room. EI #16 said, yes. EI #16 added, when she opened the door to RI #1's room again, RI #1's son was in the room. The surveyor asked EI #16 what RI #1's son was doing. EI #16 replied, (RI #1) was on (his/her) back. (RI #1) was fully exposed again from the waist down and the son had pulled up (RI #1's) gown. When I saw the son, his hand was moving from (RI #1's) peri area. He said I am checking to see if (RI #1) is wet. The surveyor asked EI #16 was the call light on or had RI #1's son asked for assistance. EI #16 said, no. EI #16 said, she and EI #15 went in RI #1's room because the door was closed. EI #16 said, she ran out of the room again and went to find EI #14. The surveyor asked EI #16 what she thought should have been done after the first incident occurred. EI #16 replied, He should have been monitored. He could have harmed (RI #1). The surveyor asked EI #16 what the facility had done to ensure an incident like this one would not reoccur. EI #16 said, there were flyers put out with RI #1's son's picture on them, they were told to call 911 if the son entered the building, and they were given contact numbers to call if the son was seen in the building. EI #16 said inservices were done immediately and staff were told to never leave a patient alone and to make sure they got help and reported the incident. EI #16 said, they were also told if the situation seemed like it was abusive to be sure the resident was safe. EI #16 said, even though RI #1's son said he was digging RI #1 out, there was no stool observed on the son's finger or on RI #1. EI #16 said, trying to remove an impaction is a nursing procedure and should only be done by nurses or someone with nursing experience. A review of EI #18's, the LPN / Wound Care Nurses, statement dated 10/28/2016 (no time), documented: Accompanied (EI #14) to resident's room to speak with son in hallway. (EI #14) asked RI #1's son if he had put his finger in (RI #1's) rectum. The son replied, yes because (he/she) was trying to dig (him/herself) out when I entered the room. (EI #14) Explained that was a nursing procedure and also has to be ordered by a M.D. (Medical Doctor). She also explained that it could cause injury to the patient. She (EI #14) asked the son to promise her that he would not provide any care to (his/her) (RI #1) that he would call the nurse for any needs but the son said ok but if staff took longer than 15-20 minutes that he would do if (it) himself . He gave us two thumbs up & (and) walked by (back) into (RI #1's) room. On 11/9/2016 at 10:06 a.m., the surveyor conducted an interview with EI #18. EI #18 said EI #14 asked her to go with her when she spoke to RI #1's son. EI #18 said EI #14 asked RI #1's son to step outside the door to speak with her. EI #18 said EI #14 asked the son if he was trying to remove feces from (RI #1) and the son said he was. EI #18 said the son said he was doing it so RI #1 would not have to. EI #18 said, EI #14 asked the son what made him think (RI #1) needed help using the bathroom. EI #18 said, the son said he could tell RI #1 was in pain. EI #18 said EI #14 told the son if he thought that at any time RI #1 was in pain, he needed to call nursing staff. EI #18 said EI #14 told RI #1's son that what he did was a medical procedure and he could hurt RI #1 by sticking his finger in RI #1's rectum. The surveyor asked EI #18, after EI #14 finished talking with RI #1's son, what did the son do. EI #18 replied, He went back in the room. She (EI #14) said he had to promise her he was not going to try to perform any personal care at all. The son said he wasn't going to make any promises if it took more than 15 or 20 minutes. On 11/9/2016 at 1:19 p.m., the surveyor conducted a phone interview with RI #1's son. The surveyor asked the son what he was attempting to do when staff found him with his finger in RI #1's rectum. The son said he was getting bowel movement out of RI #1. The son said he did not want to see feces on RI #1's hand so he was getting it out of RI #1's tail. The son said he spread RI #1's butt cheeks and got the feces out of RI #1's tail. The surveyor asked the son if he asked staff to come in the room and change RI #1. The son said he did not because he was not going to let RI #1 have feces in her tail. The son said he did not want to see feces on RI #1's hand. On 11/9/2016 at 2:12 p.m., the surveyor conducted a second interview with EI #15. During EI #15's first interview, she stated, she and EI #16 had not observed any stool on RI #1. The surveyor asked EI #15, when she left RI #1's room the first time, were the lights on or off. EI #15 replied, We did not turn the lights off. So they had to be on. The surveyor asked EI #15 when she re-entered RI #1's room the second time, how were the lights. EI #15 said, the lights were off. EI #15 said, she did not know who turned the lights off, but when she re-entered the room she was pretty sure she turned them on. The surveyor asked EI #15, since RI #1's son was not a nurse or in the nursing profession, could the son's attempt to remove feces from RI #1's rectum have caused harm to the resident. EI #15 replied, Yes. On 11/9/2016 at 4:37 p.m., the surveyor conducted a second interview with EI #14, the RN Unit Manager. The surveyor asked EI #14, could RI #1's family member have harmed RI #1 in his attempt to remove feces from the rectum. EI #14 replied, Yes. On 11/10/2016 at 8:24 a.m., the surveyor conducted an interview with EI #21, the Assistant Administrator. The surveyor asked EI #21, after EI #14 talked to RI #1's son, what did EI #14 say transpired. EI #21 said RI #1's son told EI #14 if he could not get RI #1 taken care of within 15-20 minutes, then he would have to take care of it himself. EI #21 said, EI #14 immediately went to get the Director of Nursing (DON) who was also the Abuse Coordinator. The surveyor asked EI #21 if RI #1's son re-enter RI #1's room. EI #21 replied, As it was told to me he did. The surveyor asked EI #21 after the son reentered RI #1's room, what happened. EI #21 said as he was informed by the nurses, EI #15 and EI #16, when they re-entered the room a few minutes later, RI #1's son had the covers pulled down and had his hand in RI #1's perineal area. On 11/10/2016 at 12:49 p.m., the surveyor conducted a phone interview with EI #20, the former DON. The surveyor asked EI #20 could RI #1's son have injured or harmed RI #1 in any way with his attempt to remove feces from RI #1's rectum. EI #20 replied, Yes he could have. The surveyor asked EI #20 how the son could have harmed RI #1. EI #20 replied, With him not being in the medical profession, he could have ruptured her rectum. The surveyor asked EI #20 what EI #14 should have done after the first incident was brought to her attention. EI #20 said EI #14 probably should have had RI #1's son leave or have staff in the room with him while he visited. ***************************************************** The facility immediately implemented corrective action to prevent recurrence of the identified deficient practice on 10/28/2016. These corrective actions included: (1) Nurses are examining the patient now for outward signs of trauma. After this examination was completed, the patient was sent to the hospital to be examined by a physician for internal trauma. Prior to the patient leaving the Facility, the staff made the emergency room staff aware of the situation so that they could be able to prevent the son from making contact with RI #1 at the emergency room . (2) The Facility's entire staff was in-serviced on staff remaining with residents during situations in which there is any reason to believe a resident's safety is in question. The Director of Nursing is currently in-servicing all staff in the Facility now. The Facility's nursing supervisors was in-servicing staff on every shift over the weekend.(3) The Director of Nursing, personally called every nurse and CNA scheduled to work on the patient's hall to make sure they know that the son is not allowed in the building and that he is allowed no contact with RI #1. The DON will also discuss with each of the staff members their responsibilities to stay with a resident if they ever feel that the resident's safety has been called into question.(4) The Facility made flyers that were placed in the staff break rooms and nursing stations reiterating that the patient's son is not allowed in the building or contact with RI #1. The flyer included a picture of the son taken from one of the Facility's surveillance cameras.(5) The staff involved with the situation met with police officers fully cooperated with the police department's investigation of the incident.(6) The Facility's social worker called Department of Human Resources and made them aware of the incident.(7) The Facility notified the patient's power-of-attorney. The power-of-attorney called the patient's family members to solicit their help and cooperation with keeping the son from making contact with RI #1. The facility's form titled, Quality Assurance Committee Meeting Minutes dated 10/31/2016 at 9:30 a.m., was revealed. The following was documented: . TOPIC/DISCUSSION . Resident safety In situations where abuse is suspected or the resident's safety is questioned, staff will: (1) remain with the resident (2) ensure the resident's safety . After review of the facility's investigation file, in-service/education records, staff interviews, and QA plan, the facility implemented corrective actions from 10/28/2016 to 10/31/2016. The facility will continue to monitor and/or revise their corrective action plan to prevent recurrence and maintain compliance. This deficiencies were written as a result of complaint/report #AL 774.

Based on interviews, record review and review of a facility policy titled Abuse Prevention Unusual Occurrence, the facility failed to ensure Employee Identifier (EI) #14, the Registered Nurse (RN) supervisor implemented the facility's abuse policy on protection. According to EI #15 and #16, two Licensed Practical Nurses (LPNs) making walking rounds, Resident Identifier (RI) #1's son was observed with an ungloved finger in RI #1's rectum on 10/28/2016. EI #16 informed EI #14 of the incident. In an interview with EI #14, she stated when she went to RI #1's room, she asked RI #1's son to come out of the room so she could speak with him. According to EI #14 she informed the son that the facility had staff to assist the resident with his/her needs. EI #14 stated after she spoke with the son, the son re-entered RI #1's room alone, and she (EI #14) went to report the incident to the Director of Nursing (DON), EI #20. Interviews with EI #15 and #16 revealed after this incident, RI #1's son was later observed in the resident's room with the lights off with his hands in the resident's perineal area. RI #1 was not protected from further potential abuse. On 11/10/2016, at 8:24 a.m., the Assistant Administrator, EI #21, was notified of the findings of Immediate Jeopardy in the area of Resident Behavior and Facility Practices, F 226. The immediate jeopardy began on 10/28/2016. On 10/28/2016 to 10/31/2016, the facility immediately implemented corrective actions to prevent recurrence of the identified deficient practices; thus Immediate Jeopardy Past Non-compliance was cited in the area of Resident Behavior and Facility Practices. This affected RI #1, one of four residents sampled for abuse. Findings Include: A facility policy titled Abuse Prevention Unusual Occurrence signed by EI #14, dated 09/12/2013, documented: . All alleged violations will be thoroughly investigated and the resident will be protected to prevent further potential abuse while the investigation is in progress . In the event the alleged abuse is involving a resident family member, a determination will be made by administration as the ability of the family member to make additional visits . RI #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a facility form titled Quality Assurance Committee Meeting Minutes dated 10/31/2016, documented: . TOPIC/DISCUSSION . Resident safety In situations where abuse is suspected or the resident's safety is questioned, staff will: (1) remain with the resident (2) ensure the resident's safety . (4) Remain with the resident and await further instruction . On 11/8/2016 at 5:02 p.m., the surveyor conducted an interview with EI #14, the RN Unit Manager. The surveyor asked EI #14 when she went to RI #1's room to speak with the son, where were EI #15 and EI #16. EI #14 said EI #15 and EI #16 continued their report in RI #1's room, then moved on the the next room. EI #14 said that was when she asked the son to step out of RI #1's room. EI #14 said after she finished talking to RI #1's son, he walked back into RI #1's room and she went to page the DON (Director of Nursing). The surveyor asked EI #14 who was in the room when RI #1's son went back in the room. EI #14 replied, No one. EI #14 said after she finished talking with the DON, EI #16 approached her and said they asked RI #1's son to leave because RI #1's son closed the door to RI #1's room and when she (EI #16) went back in to check on RI #1, the son was observed with his hand on RI #1's perineal area. The surveyor asked EI #14 what she thought staff should have done when RI #1's son was first observed with his finger in RI #1's rectum. EI #14 replied, Made sure the patient was secure. The surveyor asked EI #14 how that could have been done. EI #14 replied, To stay with (RI #1) and counsel the son and educated him more. On 11/9/2016 at 7:55 a.m., the surveyor conducted an interview with EI #15, the LPN assigned to care for RI #1 on the 6:00 a.m. - 2:00 p.m. shift on 10/28/16. The surveyor asked EI #15 what she saw when she entered RI #1's room. EI #15 replied, When we entered (his/her) room, the son was leaning over (RI #1's) bed and the son had his ungloved finger in (RI #1's) rectum digging (him/her) out. When asked if she observed any stool on RI #1, EI #15 said, no. EI #15 said, she asked the son if he called for assistance, and the son said no because he could do it by himself. EI #15 said, after she and EI #16 got RI #1's covers pulled up over the resident, she and EI #16 continued to do their rounds. EI #15 said at that time, EI #14, the RN Unit Manager, and the son were on the outside of the room talking. The surveyor asked EI #15 what happened the second time she entered RI #1's room. EI #15 said, once they opened RI #1's door the lights were off. EI #15 said the son was standing over RI #1 with his hands in RI #1's perineal area. EI #15 said the son stated he was checking RI #1 to see if the resident was wet. The surveyor asked EI #15 should the son have been allowed back in RI #1's room after the first incident. EI #15 replied, I don't think he should have. The surveyor asked EI #15 what should have been done. EI #15 replied, I think he should have been monitored because I don't know if he understood if what he was doing was inappropriate. The surveyor asked EI #15 when something like this happens, how the facility protects the resident. EI #15 said RI #1 should have been monitored or the perpetrator should have been removed from the facility. On 11/9/2016 at 9:00 a.m., the surveyor conducted a phone interview with EI #16, the LPN assigned to care for RI #1 on the 2:00 p.m. - 10:00 p.m. shift on 10/28/16. The surveyor asked EI #16 what the facility's policy said about protecting the resident when an incident occurs. EI #16 answered, Never leave the resident alone . The surveyor asked EI #16 why was RI #1's son allowed to go back in RI #1's room alone after he was observed with his finger in RI #1's rectum. EI #16 did not know. EI #16 said, she did not know what was discussed between RI #1's son and EI #14. The surveyor asked EI #16 what she thought should have been done after the first incident occurred. EI #16 said, RI #1's son should have been monitored. On 11/9/2016 at 9:39 a.m., the surveyor conducted an interview with EI #17, the facility's Social Worker. The surveyor asked EI #17, according to the facility's policy, what should staff do when an incident occurs and the resident may need protection. EI #17 replied, They are supposed to stay with the patient or resident. The surveyor asked EI #17 did that occur with the situation with RI #1. EI #17 said, not from what she understood. On 11/9/2016 at 10:06 a.m., the surveyor conducted an interview with EI #18, a LPN Wound Care Nurse. EI #18 said EI #14 asked her to go with her when she spoke to RI #1's son. The surveyor asked EI #18 where was the son when she and EI #14 went to RI #1's room. EI #18 replied, In the room. EI #18 said, EI #14 asked the son to step out of the room so she could speak to him. The surveyor asked EI #18 after EI #14 finished talking with RI #1's son, what did he do. EI #18 replied, The son went back in the room. She (EI #14) said the son had to promise her, he was not going to try to perform any personal care at all. The son said he wasn't going to make any promises if it took more than 15-20 minutes. The surveyor asked EI #18 if she or EI #14 enter the room with RI #1's son. EI #18 replied, No Ma'am. We went back to the nurses' station. The nurses were still doing walking rounds. The surveyor asked EI #18 what the facility's policy said about protecting the resident when an incident had occurred. EI #18 said, Don't leave the resident . On 11/9/2016 at 12:30 p.m., the surveyor conducted an interview with EI #19, the DON. EI #19 explained that according to EI #14, when EI #16 and EI #15 were doing walking rounds at shift change, they entered RI #1's room and saw RI #1's son bent over the resident with his ungloved index finger in RI #1's rectum. EI #19 said as she and EI #21, the Assistant Administrator, EI #20, the former DON and EI #14, the RN Supervisor were going to the unit RI #1 resided on, EI #16 came to them and let them know she asked RI #1's son to leave because she and EI #15 re-entered RI #1's room, and saw his hand coming from RI #1's perineal area. EI #19 said the son was saying, he was checking RI #1 to see if the resident was wet. The surveyor asked EI #19, after the first incident where RI #1's son was observed with his finger in RI #1's rectum, was the son allowed back in RI #1's room. EI #19 replied, Yes. The surveyor asked EI #19 was RI #1's son in the room alone with RI #1. EI #19 said, Yes. The surveyor asked EI #19 how does the facility's policy say staff should protect the resident after an incident has occurred. EI #19 said the threat should be removed. On 11/10/2016 at 8:24 a.m., the surveyor conducted an interview with EI #21, the Assistant Administrator. The surveyor asked EI #21 what the facility's policy said about protecting the resident when an alleged or factual incident has occurred with a resident. EI #21 replied, The staff should stay with the resident, notify a supervisor or DON. On 11/10/2016 at 12:49 p.m., the surveyor conducted an interview with EI #20, the former Director of Nursing (DON). EI #20 said EI #14, the RN Unit Manager, informed her the nurses were making walking rounds when they went in RI #1's room and observed RI #1 turned on his/her side and RI #1's son had his finger in the resident's rectum trying to dig the resident out. The surveyor asked EI #20 what EI #14 did after this was brought to her attention. EI #20 replied, She (EI #14) took the son in the hallway and asked him not to do this and get medical staff and he gave the thumbs up. The surveyor asked EI #20 after EI #14 told RI #1's son this, what did he do. EI #20 replied, The son went back in the room. The surveyor asked EI #20 did any staff go in the room with RI #1's son when he went back into RI #1's room. EI #20 said, No. The two nurses did their walking rounds while the RN was talking to the son. After she finished talking with the son she came and told me what had happened. The surveyor asked EI #20 what the facility's policy said about protecting the resident when any incident happens that may have put the resident's safety or health in harm. EI #20 replied, They are to protect the patient. The surveyor asked EI #20 how staff protects the resident. EI #20 said, Remove the source. The surveyor asked EI #20, in this incident, who was the source. EI #20 said RI #1's son. The surveyor asked EI #20 was RI #1 protected after the first incident. EI #20 replied, Other than staff being in the hallway that was it. ******************************************************** The facility immediately implemented corrective action to prevent recurrence of the identified deficient practice on 10/28/2016. These corrective actions included: (1) Nurses are examining the patient now for outward signs of trauma. After this examination was completed, the patient was sent to the hospital to be examined by a physician for internal trauma. Prior to the patient leaving the Facility, the staff made the emergency room staff aware of the situation so that they could be able to prevent the son from making contact with RI #1 at the emergency room . (2) The Facility's entire staff was in-serviced on staff remaining with residents during situations in which there is any reason to believe a resident's safety is in question. The Director of Nursing is currently in-servicing all staff in the Facility now. The Facility's nursing supervisors was in-servicing staff on every shift over the weekend.(3) The Director of Nursing, personally called every nurse and CNA scheduled to work on the patient's hall to make sure they know that the son is not allowed in the building and that he is allowed no contact with RI #1. The DON will also discuss with each of the staff members their responsibilities to stay with a resident if they ever feel that the resident's safety has been called into question.(4) The Facility made flyers that were placed in the staff break rooms and nursing stations reiterating that the patient's son is not allowed in the building or contact with RI #1. The flyer included a picture of the son taken from one of the Facility's surveillance cameras.(5) The staff involved with the situation met with police officers fully cooperated with the police department's investigation of the incident.(6) The Facility's social worker called Department of Human Resources and made them aware of the incident.(7) The Facility notified the patient's power-of-attorney. The power-of-attorney called the patient's family members to solicit their help and cooperation with keeping the son from making contact with RI #1. The facility's form titled, Quality Assurance Committee Meeting Minutes dated 10/31/2016 at 9:30 a.m., was revealed. The following was documented: . TOPIC/DISCUSSION . Resident safety In situations where abuse is suspected or the resident ' s safety is questioned, staff will: (1) remain with the resident (2) ensure the resident's safety . After review of the facility's investigation file, in-service/education records, staff interviews, and QA plan, the facility implemented corrective actions from 10/28/2016 to 10/31/2016. The facility will continue to monitor and/or revise their corrective action plan to prevent recurrence and maintain compliance. This deficiencies were written as a result of complaint/report #AL 774.

Based on interviews, record reviews, review of a facility policy titled Abuse Prevention Unusual Occurrence and review of the Registered Nurse Supervisor, Employee Identifier (EI) #14's Job Description, EI #14 failed to ensure Resident Identifier (RI) #1's son did not re-enter RI #1's room alone after the son was observed with his ungloved index finger in the resident's rectum on 10/28/2016. According to EI #14, she had a conversation with RI #1's son about his actions, then allowed the son to re-entered RI #1's room alone. EI #15 and EI #16, the Licensed Practical Nurses (LPNs) observed the resident's son with his ungloved finger in RI #1's rectum, and later observed the son in RI #1's room with his hand in RI #1's perineal area. RI #1's son, being left alone with RI #1 placed RI #1 in a potentially unsafe environment. Leaving RI #1, alone in a room without supervision and monitoring of RI #1's son's interactions, placed RI #1 in a potentially abusive and harmful situation. On 11/10/2016, at 8:24 a.m., the Assistant Administrator was notified of the findings of Immediate Jeopardy in the area of Administration, F 490. The immediate jeopardy began on 10/28/2016. On 10/28/2016 to 10/31/2016, the facility immediately implemented corrective actions to prevent recurrence of the identified deficient practices; thus Immediate Jeopardy Past Non-compliance was cited in the area of Administration. This affected RI #1, one of four residents sampled for abuse. Findings Include: Cross reference F 223 and F 226. A facility policy titled Abuse Prevention Unusual Occurrence signed 9/12/2013, documented: . All alleged violations will be thoroughly investigated and the resident will be protected to prevent further potential abuse while the investigation is in progress . In the event the alleged abuse is involving a resident family member, a determination will be made by administration as the ability of the family member to make additional visits . A review of RI #14's Job Description - RN Supervisor, signed by EI #14 on 09/12/13, documented: . ESSENTIAL FUNCTIONS . 15. Maintains safe environment and practices for staff, residents or visitors . 22. Performs all assigned tasks/assignments/projects in accordance with established policies and procedures . 23. Responsible for assessing issues and problems. Must be able to implement problem resolutions skills to address issues within scope of established policies and procedures . Should be able to recognize problematic areas but supply possible solutions and idea for referred issues . RI #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #1's progress note dated 10/28/2016 at 17:45 (5:47 p.m.) documented: . Note Text: Notified this afternoon that pt's (patient's) son had been noted in (RI #1's) room attempting to perform an inappropriate medical procedure. RN supervisor (EI #14) went to speak with son. RN came back to notify SW (Social Worker) of conversation with son. While having this conversation, charge nurses came into SW office to notify RN that they had entered pt's room and noted pt's son was observed with the covers back and had his hands between pt's legs . On 11/08/2016 at 5:02 p.m., the surveyor conducted an interview with EI #14. The surveyor asked EI #14 when she finished speaking with RI #1's son where did the son go. EI #14 replied, He went back in the room. That's when I went to page the DON (Director of Nursing). The surveyor asked EI #14 who was in the room when the son went back in the room with RI #1. EI #14 said, No one. The surveyor asked EI #14 what she thought staff should have done when RI #1's son was first observed with his finger in RI #1's rectum. EI #14 said, make sure the patient was secure. The surveyor asked EI #14 how that could have been done. EI #14 replied, To stay with (him/her) . On 11/09/2016 at 7:55 a.m., the surveyor conducted an interview with EI #15, the LPN assigned to care for RI #1 on the 6:00 a.m. - 2:00 p.m. shift on 10/28/16. The surveyor asked EI #15 should RI #1's son have been allowed back in RI #1's room after the first incident. EI #15 replied, I don't think he should have. The surveyor asked EI #15 what should have been done. EI #15 replied, I think he should have been monitored because I don't know if he understood what he was doing was inappropriate. On 11/09/2016 at 9:00 a.m. the surveyor asked EI #16 what did she think should have been done after the first incident occurred? EI #16 replied, He should have been monitored . On 11/10/2016 at 12:49 p.m., the surveyor conducted a phone interview with EI #20, the former DON. The surveyor asked EI #20 what EI #14 should have done after the first incident was brought to her attention. EI #20 said, EI #14 probably should have had RI #1's son leave or have staff in the room with him while he visited. A review of a facility form titled In-Service / Re-Education, dated 10/28/2016, documented: Resident safety - staff to remain with Residents during situations in which there is any reason to believe a resident's safety is in question . ******************************************************* The facility immediately implemented corrective action to prevent recurrence of the identified deficient practice on 10/28/2016. These corrective actions included: (1) Nurses are examining the patient now for outward signs of trauma. After this examination was completed, the patient was sent to the hospital to be examined by a physician for internal trauma. Prior to the patient leaving the Facility, the staff made the emergency room staff aware of the situation so that they could be able to prevent the son from making contact with RI #1 at the emergency room . (2) The Facility's entire staff was in-serviced on staff remaining with residents during situations in which there is any reason to believe a resident's safety is in question. The Director of Nursing is currently in-servicing all staff in the Facility now. The Facility's nursing supervisors was in-servicing staff on every shift over the weekend.(3) The Director of Nursing, personally called every nurse and CNA scheduled to work on the patient's hall to make sure they know that the son is not allowed in the building and that he is allowed no contact with RI #1. The DON will also discuss with each of the staff members their responsibilities to stay with a resident if they ever feel that the resident's safety has been called into question.(4) The Facility made flyers that were placed in the staff break rooms and nursing stations reiterating that the patient's son is not allowed in the building or contact with RI #1. The flyer included a picture of the son taken from one of the Facility's surveillance cameras.(5) The staff involved with the situation met with police officers fully cooperated with the police department's investigation of the incident.(6) The Facility's social worker called Department of Human Resources and made them aware of the incident.(7) The Facility notified the patient's power-of-attorney. The power-of-attorney called the patient's family members to solicit their help and cooperation with keeping the son from making contact with RI #1. The facility's form titled, Quality Assurance Committee Meeting Minutes dated 10/31/2016 at 9:30 a.m., was revealed. The following was documented: . TOPIC/DISCUSSION . Resident safety In situations where abuse is suspected or the resident ' s safety is questioned, staff will: (1) remain with the resident (2) ensure the resident's safety . After review of the facility's investigation file, in-service/education records, staff interviews, and QA plan, the facility implemented corrective actions from 10/28/2016 to 10/31/2016. The facility will continue to monitor and/or revise their corrective action plan to prevent recurrence and maintain compliance. This deficiencies were written as a result of complaint/report #AL 774.

Based on observation, record review and interviews, the facility failed to ensure the wash water of the dishmachine was maintained at a recommended temperature of 120 degrees Fahrenheit (F) or above, and the concentration of chlorine sanitizer was 50 parts per million (ppm) on two of three days of the survey. This had the potential to affect all 143 residents to whom meals were served at the time of this survey. Findings Included: The facility policy related to Sanitation of Dishes/Dish Machine (dated 2013) mandates a low temperature dishwasher using chemicals to sanitize, must have a wash temperature of 120 degrees F and 50 ppm (parts per million) hypochlorite. The State Operation Manual, Appendix PP Guidance to Surveyors for Long Term Care Facilities (Revision 118, 06/12/14) provides specifications according to the U.S. Department of Health and Human Services, Public Health Services, Food and Drug Administration Food Code for Low Temperature Dishwasher (chemical sanitization). These regulations specify the final rinse water to be 50 ppm (parts per million) hypochlorite (chlorine) on dish surface in final rinse. During the initial kitchen tour on 11/08/2016 at 12:55 p.m., dietary staff were in the process of processing lunch dishes through the low temperature/chemical sanitizing dishmachine. The surveyor observed the temperature of the wash water to be 110 degrees F. The concentration of the chlorine sanitizer was checked by a staff member, registering (barely) 50 ppm in the exterior water reservoir of the machine. The concentration of chlorine on the surface of a plate was checked via a test strip; it was significantly less than 50 ppm (approximately 10 ppm). The function of the dishmachine was again observed on 11/09/2016 at 9:00 a.m. Racks (two at a time) of silverware, bowls, glasses, Dinex lids and other assorted dishes were processed consistently at wash temperatures below the recommended 120 degrees F, at: 112, 115, 112, and 112 degrees F, respectively. A staff member, Employee Identifier (EI) #1 confirmed the chlorine concentration of a droplet of rinse water on the surface of a newly washed glass and subsequently, a bowl, were both less than 50 ppm. Additional dishwashing staff were interviewed on 11/09/2016 at 9:07 a.m. EI #2 confirmed the goal temperature of the wash water was 120 to 140 degrees F, and 50 ppm for the chemical concentration. EI #2 explained she would run two cycles of the dishmachine to get the temperature up to 120 degrees F, then would check the chemical concentration of chlorine in the reservoir (never on the surface of the plate). With the completion of another cycle of dishes, EI #2 affirmed the wash water temperature was 110 degrees F and less than 50 ppm in the reservoir. After a few seconds, the color on the test strip changed slightly to register 50 ppm at the tip of the strip; the test strip did not register a definite 50 ppm throughout the strip from the rinse water contact. On 11/09/2016 at 9:16 a.m., EI #1, a dietary aide and the Assistant Dietary Manager (EI #3) affirmed the wash water was 110 degrees, then 112 degrees F. The chlorine concentration on the surface of a plate registered less than 10 ppm. On 11/09/2016 at 9:30 a.m., EI #3, the Assistant Dietary Manager and EI #4, the Dietary Manager both affirmed the wash water temperature should be warmer (at least 120 degrees F) to sanitize and prevent bacterial growth.

Based on observations, interviews, record review and review of a facility policy titled Dignity and Respect, the facility failed to ensure privacy was maintained for Resident Identifier (RI) #9 when Employee Identifier (EI) #27, a Certified Nursing Assistant (CNA) failed to pull the privacy curtain during incontinent care on 11/09/16. RI #9's buttocks and genitalia were exposed to the room mate and anyone passing by in the hallway. This deficient practices affected RI #9, one of four residents observed for incontinent care. Findings Include: RI #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A facility policy titled Dignity and Respect dated 2/2006, documented the following: . It is the policy of this facility that all residents will be treated with dignity, respect, consideration, and individuality by all staff members. This will be evidenced by, but not limited to, the following: . Cubicle curtains will be pulled around the patient's in order to provide privacy for the resident . On 11/9/2016 at 8:50 a.m., EI #27 a CNA, was observed by the surveyor performing incontinent care on RI #9. RI #9 was observed lying in bed positioned on his/her right side with his/her buttocks exposed to the room mate. The privacy curtains in RI #9's room were not fully closed around the bed nor between RI #9 and the roommate. When the surveyor entered RI #9's room, the resident was visible from the hallway. RI #9's roommate was observed sitting in a chair between the the beds while EI #27 was providing incontinent care. RI #9's exposed buttocks and genitalia were visible to anyone passing by RI #9's room. On 11/9/2016 at 8:55 a.m., during an interview with RI #9, the surveyor asked RI #9 how did it feel having his/her buttocks exposed during incontinent care, and the curtains not being pulled between the roommates. RI #9 said he/she hoped no one saw him/her in bed naked. On 11/9/2016 at 11:40 a.m., the surveyor conducted an interview with EI #27. The surveyor asked EI #27 what she should do when providing incontinent care to a resident. EI #27 said, pull the curtains for privacy if there is another resident in the room. EI #27 said this provided privacy and dignity for both residents. Mainly the resident who is being provided incontinent care. The surveyor asked EI #27 if she pulled the privacy curtains to provide privacy for RI #9 on 1109/16, during the incontinent care. EI #27 said no, she did not; not in the beginning. EI #27 said she knew better, but did not do better at that time. The surveyor asked EI #27 why was it important to pull the privacy curtains during incontinent care. EI #27 said, so you will not embarrass the resident or expose them. EI #27 said this was a dignity issue and privacy issue. The surveyor asked EI #27 what body parts of RI #9 were exposed at the time. EI #27 said the resident's buttocks and from the waist down. The surveyor asked EI #27 if anyone else witnessed RI #9 being exposed. EI #27 said the wound care nurse, EI #22, and the other resident (the roommate). On 11/9/2016 at 11:50 a.m., the surveyor conducted an interview with EI #23, the Unit Manager. The surveyor asked EI #23 what should the staff do when they provide incontinent care for a resident. EI #23 said, provide privacy. The surveyor asked EI #23 why was it important to provide privacy for a resident during incontinent care. EI #23 said to maintain their dignity and privacy. EI #23 said close the blinds, pull the privacy curtains and have the door closed. On 11/9/2016 at 12:15 p.m., the surveyor conducted an interview with EI #22, a Licensed Practical Nurse/Wound Care Nurse. The surveyor asked EI #22 what should staff do to provide privacy during incontinent care. EI #22 said always pull the privacy curtains, shut the blinds and keep the peri area covered. The surveyor asked EI #22 what she observed on 11/09/16, during the incontinent care with RI #9. EI #22 said, the CNA (EI #27) was in the resident's room and she did not pull the privacy curtains between the two residents. EI #22 said RI #9's buttocks was exposed. EI #22 said everything was exposed. The surveyor asked EI #22 if she was able to see RI #9 from the hallway. EI #22 said yes, the sheet was off RI #9 and the privacy curtains were not pulled. The surveyor asked EI #22 when was the privacy curtains pulled to maintain RI #9's privacy. EI #22 said when she saw it, she told EI #27 to pull the privacy curtain right then. EI #22 said she had to instruct EI #27 to pull the privacy curtain.

Based on interviews and record reviews, the facility failed to report and investigate an allegation of alleged verbal abuse on Resident Identifier (RI) #16, which was reported to the Social Worker by the resident on 09/06/2016. This affected RI #16, one of four residents sampled for abuse. Findings Include: A facility policy with an effective date of 9/7/2000, titled . SUBJECT: ABUSE PREVENTION UNUSUAL OCCURRENCE ., documented: . STANDARD: . Any complaints and/or allegations of abuse, neglect, or misappropriation of residents property should be reported to the Abuse Coordinator . DEFINITIONS ABUSE Verbal: The use of oral, . or gestured language that willfully includes disparaging and derogatory terms to resident or their families . Investigation: Each allegation will be thoroughly investigated to hopefully determine the person responsible for the allegation/violation . All alleged violations will be thoroughly investigated and the resident will be protected to prevent further potential abuse while the investigation is in progress . A summary of the investigation, including the allegation/violation actual statements . will be documented . RI #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/19/2016, assessed RI #16 under Section C- Cognitive Patterns as being cognitively intact with a score of 15. On 11/09/2016 at 1:30 p.m. during the group interview, Resident Identifier (RI) #16 reported to the surveyor that a Certified Nursing Assistant (CNA) had yelled at her and told her to shut-up, and he/she does not want the CNA to be his/her aide anymore. The surveyor asked RI #16 when did this incident occur, RI #16 replied, a couple of months ago. RI #16 was asked if he/she had reported the incident to the facility. RI #16 stated, Yes that it was reported, but the aide is still working with him/her and he/she does not like it. The surveyor asked RI #16 who did he/she report the incident to. RI #16 replied, the social worker. On 11/10/2016 at 11:30 a.m. an interview was conducted with Employee Identifier (EI) #26, Social Worker. The surveyor asked EI #26 if she remembered RI #16 reporting an incident about a CNA yelling shut-up to the resident. EI #26 stated, Yes, I do, I told the former Director of Nursing (DON), EI #20, because she was the Abuse Coordinator, I emailed her on 9/6/16. The surveyor asked EI #26 if the DON filed a grievance. EI #26 replied, no she did not and I didn't fill one out. The surveyor asked EI #26 if the former DON followed up on the incident with the State. EI #26 replied, no, she did not know. EI #26 said the DON never reported anything back to her. On 11/10/2016 at 12:45 p.m., a telephone interview was conducted with EI #20, the former DON. The surveyor asked EI #20 if she remembered the incident with RI #16 reporting to the social worker that a CNA had told the resident to shut-up. EI #20 replied, she did not. The surveyor asked EI #20 if the incident was investigated because EI #26 had emailed details about the incident to her on 9/6/2016. EI #20 replied, yes, and that EI #26 had the documentation. The surveyor informed EI #20 that the surveyor had already spoken to EI #26 and reviewed the grievance logs, the incident and accidents reports to the State and there was no evidence documenting that it had been investigated. The surveyor asked EI #20 where is the evidence that it was done, EI #20 replied, she did not know.

Based on observations, interviews and record reviews, the facility failed to ensure staff knocked on Resident Identifier (RI) #10's and RI #3's door, and room locator (RL) # 8, 9 and 10's door prior to entering the resident rooms. This was observed on two of three days of the survey, and affected 2 of 9 halls of the facility. Findings Include: A facility policy titled Subject: Dignity and Respect with an effective date of 6/2002, and a review date of 2/2006, revealed the following: . All staff members will knock on the resident's room before entering . On 11/08/2016 at 2:05 p.m., the surveyor observed Employee Identifier (EI) #24 walk into RL #9 and RL #8 without knocking. EI #24 then walked out of the room and walked across the hall into RL #10 without knocking. On 11/08/2016 at 2:20 p.m., the surveyor observed EI #24 walk into RL #10 to answer the call light and entered the room without knocking. On 11/09/2016 at 09:30 a.m., the surveyor observed EI #25 walk into RI #10's room without knocking. On 11/09/2016 at 09:35 a.m., the surveyor observed EI #25 walk into RI #3's room without knocking. On 11/09/2016 at 5:10 p.m.,. an interview was conducted with EI #24. EI #24 was asked how he was trained to enter into a residents room. EI #24 replied, to knock on the door, announce myself, introduce myself, ask for permission to come in. The surveyor informed EI #24 that he was observed walking into resident's room without knocking. EI #24 was asked why did he do that. EI #24 replied; I just forgot, felt like I was at home, just comfortable working on that hall. EI #24 was asked what type of issue is it to enter into a residents rooms without knocking. EI #24 replied, It's a privacy issue. On 11/10/2016 at 12:00 noon, an interview was conducted with EI #25. The surveyor asked EI #25 how was she trained as a Certified Nursing Assistant (CNA) to enter a residents room. EI #25 replied, to knock, to announce your name and proceed if they give permission. When asked what type of issue was it to enter a resident's room without knocking, EI #25 replied, It's a privacy, invasion issue. On 11/10/2016 at 12:35 p.m., an interview was conducted with EI #19 the Director of Nursing (DON). EI #19 was asked how are the CNA's trained to enter into a residents room. EI #19 replied, they are trained to knock and wait for a response before entering. EI #19 was asked, what type of issue was it to enter into a residents room without knocking. EI #19 replied, it's an invasion of privacy.

Based on observations and interview, the facility failed to maintain the walls and furnishings of each resident's room in an orderly and/or sanitary condition. Walls were marred with black scuffs, paint was peeling on the front of an air-conditioning unit, and the metal air deflectors of heating/air-conditioning units contained an accumulation of rust and debris. This included Room Locator #s: 1 through 7, affecting 7 of 139 resident rooms. Findings Included: During the initial facility tour on 11/08/2016 at 1:45 p.m., and throughout the survey (11/09/2016 and 11/10/2016) the following was observed: 1) RL #1: the front of the heater/air-conditioning unit had a significant amount of flaking paint. 2) RL #2: the dresser drawer handle on the first of four drawers was missing one screw, causing the handle to dangle. The front of the air-conditioning unit was significantly marred. 3) RL #3: the metal air deflectors atop the heating/air-conditioning unit was rusty, with an accumulation of dirt and debris. 4) RL #4: the metal air deflectors atop the air-conditioning/heating unit contained an accumulation of dried debris. Flaking sheet rock was observed on the wall beside the air-conditioning unit, and a black scuff (5 foot long, 1 to 2 inches wide) ran along the wall adjacent to the A bed, 6 inches above the baseboard. The wall behind the B bed had a long, black scuff mark. 4) RL #5: the wall at the closet was significantly scuffed: 15 long by 3 wide. 5) RL #6: the wall behind the A bed was significantly scuffed. 6) RL #7: the headboard of the B bed was loose/wobbly. On 11/10/2016 at 8:05 a.m., the Maintenance Director (Employee Identifier/EI #8) accompanied the surveyor to view the above concerns. When asked how often the air deflectors were cleaned, EI #8 stated it was the Housekeeping Department's responsibility. EI #8 stated it was his responsibility to periodically paint and touch up. When a policy was requested, EI #8 explained there was no policy related to painting.

Based on observation, record review and interviews, the facility failed to revise the care plans of Resident Identifier (RI) #12 and #19 to reflect the change in each resident's care as ordered. This affected RI #12 and RI #19, two of 21 sampled residents. Findings Included: The facility policy related to Care Planning--Interdisciplinary Team (dated 1/2011) specifies: .the Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. 1) RI #12 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The most current (10/31/16) Physicians' orders were to Restrict H2O (water) to 1500cc (cubic centimeters)/24 hrs (hours). A care plan related to [MEDICAL CONDITION] (revised 02/17/15) included interventions for Dietary to send 1560 cc per day, with meals; sugar free supplemental shakes 120 ml (milliliters) twice daily; Nursing/Activities to offer at least 440 cc/day of fluids between meals, and the inclusion of a bedtime snack each evening with additional fluid (ice cream or milk). This care plan promoted a provision of over 2200 cc fluid per day. On 11/10/2016 at 8:40 a.m., the Licensed Practical Nurse, Employee Identifier (EI) #5 (responsible for the care of RI #12) confirmed this resident was on a 1500 cc daily fluid restriction due to heart failure and a history of low sodium levels. On 11/10/2016 at 12:15 p.m., the Care Plan Coordinator (EI #6) explained the care plans were developed by following the physician's orders [REDACTED].#12's records, EI #6 stated they should have divided the (1500 cc) fluid restriction between meals, medications and snacks. When asked why the restriction had not been implemented, EI #6 was not sure. The Unit Manager (EI #7) affirmed RI #12's current 1500 cc fluid restriction on 11/10/2016 at 1:37 p.m., explaining it was due to problems with fluid overload. When asked what problem might result from the lack of this being reflected in the current care plan, EI #7 stated the care plan conflicted with the physician's orders [REDACTED]. When asked when the care plans were revised, EI #7 stated they were revised as needed, but were discussed quarterly; the care plan should have been changed. 2) RI #19 has resided in the facility since 07/10/2015 with [DIAGNOSES REDACTED]. Current Physicians' orders (dated 10/31/2016) included diet orders for Low Concentrated Sweets, Regular texture. In contrast, the resident's nutritional care plan (revised 09/23/2016) specified a focus of potential weight loss due in part to a mechanically altered diet. On 11/10/2016 at 12:20 p.m., the Care Plan Coordinator (EI #6) affirmed RI #19's order for a regular consistency diet and stated the care plan should have been changed.

Based on observation, interview and record review the facility failed to ensure a Certified Nursing Assistant (CNA) performed incontinent care in a manner to prevent infection for Resident Identifier (RI) #2. This was observed on 11/09/2016 and affected RI #2, one of four residents observed for incontinent care. Findings Included: A review of a facility policy with a revised date of September 2005 titled Perineal Care revealed . Steps in the Procedure . 9. b. Wash perineal area, wiping front to back. (1) Separate (genital) and wash area downward from front to back. RI #2 was admitted to the facility 10/06/2008 with a [DIAGNOSES REDACTED]. A review of RI #2's most recent quarterly Minimum Data Set with an Assessment Reference Date of 10/24/2016 revealed RI #2 was totally dependant for toilet use. On 11/9/2016 at 10:00 a.m., Employee Identifier (EI) #11, a Certified Nursing Assistant was observed providing incontinent care for RI #2. EI #11 cleaned RI #2's front area down each side of the groin. EI #11 then cleaned down the catheter without separating the (genital) and cleaning. On 11/9/2016 at 1:00 p.m., an interview was conducted with EI #11. EI #11 was asked how was she trained to perform incontinent care. EI #11 replied wipe each side, then separate the (genital) and wipe down each side then down the middle, then do the back side. EI #11 was asked what was the potential for harm in not wiping a resident correctly. EI #11 replied they may not get clean and it could cause an infection, especially a urinary tract infection. On 11/10/2016 at 8:00 a.m., an interview was conducted with EI #10, the Infection Control Nurse. EI #10 was asked what was the procedure for providing incontinent care. EI #10 replied the staff was to part the (genital) clean down each side then down the middle. EI #10 said if the resident had a catheter, then wipe down the catheter. EI #10 was asked what the potential for harm would be in staff not separating the (genital) and cleaning during incontinent care. EI #10 replied bacteria harbors and can go back into the urethra and could cause a urinary tract infection.