Every finding on record at Galleria Woods Skilled Nursing Facility

Based on observations, interviews, and review of a facility policy titled, Crisis Use of Facemasks (COVID-19 Outbreak), the facility failed to ensure staff were correctly wearing their face masks while in the facility. This deficient practice had the potential to affect all 28 of 28 residents residing in the facility and interacting with facility staff. Findings Include: A review of a facility policy titled, Personal Protective Equipment-Contingency and Crisis Use of Facemasks (COVID-19 Outbreak), dated April 2020, revealed, . Objective To prevent transmission of infectious agents through the inhalation of droplets. General Procedure for Donning and Doffing Masks 1. To put on mask: . b. Be sure that the face mask covers the nose and mouth while wearing. e. Do not remove the mask while performing treatment or services for a resident. On 12/14/21 at 4:28 PM the surveyor observed a sign posted under the staff time clock that instructed staff on the following: ATTENTION ALL STAFF!!!! IT IS REQUIRED THAT ALL STAFF WEAR FACE MASKS WHEN ON THE SKILLED UNIT AND IN COMMON AREAS!! YOU WILL NOT BE ALLOWED IN THE BUILDING WITHOUT A FACE MASK!! IF YOU HAVE ANY QUESTIONS PLEASE ASK!! An observation was made on 12/14/21 at 8:17 AM of EI #6, a Certified Nursing Assistant (CNA), in RI #19's room with her mask down below her mouth assisting the resident. On 12/14/21 at 9:10 AM another observation was made of EI #6, CNA, leaving RI #1's room with her mask under her nose. On 12/14/21 at 11:26 AM EI #6 was observed delivering RI #26's meal tray. After EI #6 set the tray on the bedside table, she pulled her mask down off of her face and was observed talking to the resident and visitors. On 12/14/21 at 11:28 AM EI #6 was interviewed. EI #6 was asked, what was the policy on wearing masks. EI #6 replied, she was supposed to wear it when coming into the building over her nose at all times. EI #6 was asked, how she was wearing the masks. EI #6 said she wears them over her nose but when she talks it goes below her nose. EI #6 was asked if she pulled the mask off of her face when talking to the resident. EI #6 said she did not remember what she did. EI #6 was asked, what was the risk of not wearing the mask correctly. EI #6 replied, you could possibly spread the coronavirus or whatever you have going on with yourself. EI #6 was asked if she should have pulled her mask away from her face. EI #6 replied, no. On 12/14/21 at 8:18 AM, EI #3, Licensed Practical Nurse (LPN), was observed in the hallway assisting an unidentified resident with her surgical mask down below the nose. Another observation was made on 12/14/21 at 8:59 AM of EI #3. EI #3 came out of a resident room with her surgical mask under her nose. EI #3's nose was not covered as she walked down the hallway. On 12/16/21 at 7:59 AM EI #3, LPN, was observed walking down B Hall with her mask below her nose. On 12/16/21 at 7:59 AM an interview was conducted with EI #3, LPN. EI #3 was asked how she wears her mask. EI #3 replied, she was supposed to wear it above her nose, but it kept falling down. EI #3 was asked, what was the correct way to wear the mask. EI #3 replied, over the bridge of the nose and around the cheek and under the chin. EI #3 was asked, what was the risk of not wearing the mask correctly. EI #3 replied, you could contract something or bring something in to somebody. EI #3 further stated the mask should not be worn below the nose. On 12/15/21 at 2:39 PM an observation was made of several CNAs in hallway A, gathered for shift change. EI #11, a CNA, had her mask pulled all the way down under her chin, with nothing covering her mouth or nose while talking to the other CNAs gathered in the group. On 12/15/21 at 2:40 PM an interview with EI #11, CNA, was conducted. EI #11 was asked why she had her mask off in the hallway. EI #11 replied, she did not know, she was talking to another staff member and she took it off so she could hear her. EI #11 was asked if she should have removed her mask. EI #11 replied, no. EI #11 was asked, what was the risk of removing the mask. EI #11 replied, COVID. On 12/16/21 at 9:26 AM an interview was conducted with EI #2, Infection Preventionist/Registered Nurse (RN)/Assistant Director of Nursing. EI #2 was asked, how often education on donning and doffing PPE (Personal Protective Equipment) was performed. EI #2 replied, on hire, annually and if there was an outbreak it would be done more often. EI #2 was asked, how often were staff educated on the proper way to wear a mask. EI #2 replied, we go over it a lot more, on hire, annually, when an outbreak occurs and monthly doing spot checks. An interview was conducted with EI #1, the Director of Clinical Services, on 12/16/21 at 9:59 AM. EI #1 was asked, what the procedure/policy was on how to properly wear a mask. EI #1 replied, staff have to wear a mask at all times. EI #1 was asked, how should staff be wearing a mask. EI #1 replied, it should cover their nose and mouth. EI #1 was asked, what was the risk of not wearing a mask correctly. EI #1 replied, exposure.

Based on observations, interviews, and review of the facility policy titled, Labeling and Dating for Safe Storage of Food, the facility failed to ensure food items in the dry storage area were sealed and labeled with an open date and used-by date. This deficient practice had the potential to affect 28 out of 28 residents receiving meals from the kitchen. Findings Include: A review of a facility policy titled, Labeling and Dating for Safe Storage of Food, with a revised date of 3/6/20, revealed, OBJECTIVE: . labeling and dating are critical in order to promote food safety. All products should be dated when opened. Use-By dates on all food once opened . On 12/14/21 at 8:15 AM, the surveyor toured the kitchen. While in the dry storage area the surveyor observed an unsealed bag of fish breading with no open date, green split peas that were opened at the corner and not sealed, German chocolate cake opened on the shelf, lentils with no open date and not covered, dried pinto bean opened with no open date and not covered, tempura batter mix opened with no open date, butter cream vanilla icing with the lid opened and on the shelf without an open date, and chocolate butter cream frosting with the lid partially opened and no open date. On 12/15/21 at 4:31 PM an interview was conducted with EI #8, the Dietician. EI #8 was asked what food items were opened without an open date and not covered properly. EI #8 said fish breading, icing, dried pinto beans, green split peas, and tempura batter. EI #8 was asked, who was responsible for making sure the dry good storage items had an open date and open foods were covered properly. EI #8 said technically, it was everybody's responsibility, they knew everything had to be wrapped, labeled and dated. EI #8 was asked what was the harm in having food on the shelf that was open without a date. EI #8 replied, we don't know how long it has been there. The food could dry out and not taste as well, and it could also expose the facility to rodents.

Based on observation, interview, and the Food and Drug Administration (FDA) 2017 Food Code, the facility failed to ensure the grease/oil receptacle was free from leaking oil. This was observed during the initial tour of the kitchen on 12/14/21, one of three days of the survey. This affected one of one grease/oil receptacle observed. Findings Include: A review of the FDA, 2017 Food Code, revealed: . 5-501.15 Outside Receptacles. (B) Receptacles and waste handling units for REFUSE . shall be installed so that accumulation of debris and insect and rodent attraction and harborage are minimized and effective cleaning is facilitated . On 12/14/2021 at 2:28 PM, the surveyor observed the dumpster area. The oil receptacle had oil draining from an open area in the bottom of the container. The oil leaves a trail about ten feet out from the oil container. On 12/15/2021 at 4:31 PM an interview was conducted with EI (Employee Identifier) #8, the Dietician. EI #8 was asked what was the problem with the oil refuse area. EI #8 said, the oil was leaking from the receptacle. EI #8 was asked who was responsible for cleaning up that area. EI #8 said they did not have anyone responsible for the cleaning of that area. EI #8 was asked, what was the harm with oil spillage in an open area and not cleaned up. EI #8 said, it could be a hazard, someone could slip on it and it could cause a fire.

Based on observations, interviews, medical record review and review of a facility policy titled, Care Plans-Comprehensive, the facility failed to ensure RI (Resident Identifier) #24's intervention for a fall mat at bedside was implemented on 12/15/21. This deficient practice affected RI #24, one of 13 residents whose care plans were reviewed. Findings Include: A review of a facility policy titled, Care Plans-Comprehensive, reviewed/revised May 2018, 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 .3. Each resident's comprehensive care plan is designed to: . e. Reflect treatment goals, .6. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident . RI #24 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. RI #24's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] RI #24's Care Plan documented .(Resident's name) is at risk for fall r/t (related to) past hx (history), [CONDITION(S)], [CONDITION(S)] and weakness . Interventions/Tasks . Mats on the floor at bedside Date initiated: 06/23/21 . On 12/15/21 at 11:23 AM, the surveyor did not observe a fall mat at the bedside for RI #24. On 12/15/21 at 11:45 AM, the surveyor observed RI #24 sitting up in bed eating lunch and there was no fall mat observed at the bedside. The surveyor observed the fall mat folded up between the bed and recliner. On 12/15/21 at 11:23 AM, an interview was conducted with EI (Employee Identifier) #10, LPN (Licensed Practical Nurse). EI #10 was asked if RI #24 was care planned for a fall mat at bedside. EI #10 said, yes. EI #10 was asked, when should RI #24 have the fall mat at his/her bedside. EI #10 said, when RI #24 was in bed. EI #10 was asked if there was a fall mat by his/her bedside at that time. EI #10 said, no. EI #10 was asked where was the fall mat. EI #10 said, behind the door. EI #10 was asked what was the potential harm of RI #24 not having a fall mat by the bedside as care planned. EI #10 said, RI #24 could get up out of his/her bed and have an injury. EI #10 was asked if he/she was care planned for a fall mat by his/her bedside, was the care plan being followed. EI #10 said, no. On 12/15/21 at 11:35 AM, an interview was conducted with EI #1, Registered Nurse/Director of Clinical Services. EI #1 was asked if RI #24 was care planned for a fall mat by the bedside. EI #1 said, yes. EI #1 was asked how would staff know when to put the fall mat by RI #24's bedside. EI #1 said it was a general procedure to put the fall mat by the bedside when the resident was in bed. EI #1 was asked, what was the potential harm for RI #24 who was care planned for a fall mat by the beside to not have a fall mat by the beside when in bed. EI #1 said, potential for injury.

Based on observations, interviews, and review of policies titled, POTS AND PANS- SANITIZING SOLUTION, CRITERIA FOR COMPLETION OF . QUARTERLY REPORT SANITATION FOR LONG TERM CARE and DISHWASHING PR[NAME]EDURE the facility failed to ensure: 1) wet pans were not stacked on top of each other; 2) staff did not use gloved hands to touch the broom, dust pan and then continue to wash dishes with the same gloves hands and 3) dietary staff had on a hair net while in the kitchen. This had the potential to affect 29 of 29 resident who received meals from the kitchen. Findings Include: 1) A review of a policy titled, POTS AND PANS-SANITIZING SOLUTION with a revised dated of 08/31/2018, revealed: .7. Sanitize pots and pans in third tank .8. Remove items. 9. Invert items on counter. Allow all items to air dry. On 4/10/2019 at 4:47 p.m. an observation was made of dishwashing of pans. The worker washing the items was observed stacking trays and serving pans on top of each other after washing. A small and medium pan was observed with water on and in the pan. A dietary staff then came into the area and got a wet pan stacked on top of other wet pans and put egg rolls in the pan. On 4/10/2019 at 5:19 p.m., an interview was conducted with Employee Identifier (EI) #4, utility worker. EI #4 was asked what was stacked on top of each other. EI #4 replied, pots. EI #4 was asked why were the pots stacked on top of each other. EI #4 replied, they were not put up properly. EI #4 was asked what did the facility policy say regarding stacking pans on top of each other. EI #4 replied, do not stack that was wet nesting. EI #4 was asked how many pans were stack on top of each other. EI #4 replied, three. EI #4 was asked how should pans be placed on the rack after sanitizing. EI #4 replied, in a line in a row. EI #4 was asked why was it important not to stack pans on top of each other. EI #4 replied, they will leave the pan wet and rust will form. EI #4 was asked who was responsible for washing dishes this evening. EI #4 replied, he was and another person. On 4/10/2019 at 5:24 p.m., an interview was conducted with EI #5, Sous Chief. EI #5 was asked where did he get a pan that he put egg rolls in. EI #5 replied, from the dishroom. EI #5 was asked what was in and on the pan. EI #5 replied, he did not see anything in the pan. EI #5 was asked what did he put in the pan. EI #5 replied, spring rolls. When the surveyor pointed to the pan and asked EI #5 what was in it, he replied, little drops of water. 2) A review of a policy titled, CRITERIA FOR COMPLETION OF . QUARTERLY REPORT SANITATION FOR LONG TERM CARE, with a revised date of 01/04/2019, revealed: 71-76 b. Plastic gloves worn when needed: iv.Hands washed as needed . when going from any dirty job to a clean job . On 4/10/2019 at 5:47 p.m., the surveyor observed EI #4 sweeping the floor. EI #4 placed the dust pan in his hand, with gloves on, to empty trash into the trash can. He did not change gloves after the task and then went back to washing dishes. On 4/10/2019 at 6:18 p.m., an interview was conducted with EI #4. He was asked when should he change gloves. EI #4 replied, every 30 minutes if he was dealing with dirty dishes he was suppose to get brand new gloves. EI #4 was asked what was in and on the dust pan. EI #4 replied, noodle/pasta. EI #4 was asked what did he do after sweeping the floor. EI #4 replied, he touched a pot. EI #4 was asked when going from dirty to clean should he wash his hands. EI #4 replied, yes ma'am. EI #4 was asked did he wash his hands after sweeping the floor and dumping the trash. EI #4 replied, no ma'am. EI #4 was asked what did the facility policy say about washing hands. EI #4 replied, after washing the dishes he was supposed to wash his hands. EI #4 was asked why was it important to wash his hands when going from a dirty task to a clean task. EI #4 replied, because he did not want dirty to be on clean. On 4/11/2019 at 10:20 a.m., an interview was conducted with the DON (Director of Nursing). EI #1 was asked when should staff wash their hands or changed gloves in the kitchen. EI #1 replied, any time they went from clean to dirt and try to go back to clean, they should wash their hand and put on clean gloves. EI #1 was asked why was it important that staff wash their hands between dirty and clean task. EI #1 replied, for the prevention of infection. EI #1 was asked should staff change gloves after sweeping the floor, touching a dust pan and returning back to washing dishes. EI #1 replied, yes ma'am. 3. A review of a policy titled, CRITERIA FOR COMPLETION OF . QUARTERLY REPORT SANITATION FOR LONG TERM CARE Personnel 65-70 Hygiene . Hair restraints properly in place for hair, . e. All staff preparing food in the food and Nutrition Services department must wear hair restraints. Staff coming into the Food and Nutrition Services department , i.e maintenance, should also wear hair restraints. 4/10/2019 at 11:02 a.m., the surveyor observed a dietary staff in the kitchen with no hair net on. On 4/11/2019 at 7:55 a.m., the surveyor conducted an interview with EI # 3, Dining Director Service. EI #3 was asked what staff did not have a hair net on his head on 4/10/2019. EI #3 replied, EI #6. EI #3 was asked why did he not have on a hair net. EI #3 replied, there was no reason he should not have had on a hair net. EI #3 was asked what was the facility policy on having hair nets on in the kitchen. EI #3 replied, everyone should have on a hair net. EI #3 stated they have hair nets on the outside of the kitchen. EI #3 said every person that walked in the kitchen should have a hair net on. On 4/11/2019 at 8:46 a.m., an interview was conducted with EI #6. He was asked when in the kitchen on 4/10/19, what did he have on his head. EI #6 replied, nothing. EI #6 was asked why did he not have on a hair net. EI #6 replied, he just forgot. EI #6 was asked what was the facility policy on having on a hair net in the kitchen. EI #6 replied, he should have had on a hair net. EI #6 was asked should he have had on a hair net. EI #6 replied, yes, absolutely he should have had one on. EI #6 was asked why was it important that he have on a hair net on in the kitchen. EI #6 replied, you did not want hair to end up in the food.

Based on observation, interview, record review and review of a facility policy titled, Storage and Expiration of Medications, Biologicals, Syringes and Needles, the facility failed to ensure 2 vials of [MEDICATION NAME] ([MEDICATION NAME]) and a 30 milliliter bottle of [MEDICATION NAME] were in a secured locked box. This was observed on 4/10/19 and affected one of one medication rooms. Findings Include: A review of a facility policy titled, Storage and Expiration of Medications, Biologicals, Syringes and Needles with an effective date of 12/1/07 revealed: . Procedure: . 3. General Storage Procedures: 3.1 Facility should store Schedule II controlled substances . to be at risk for abuse or diversion in a separate compartment within the locked . 12 Controlled Substances Storage: 12.1 Facility should ensure that Schedule II - V controlled substances are only accessible to licensing nursing, Pharmacy, and medical personnel designated by the Facility. 12.2 After receiving controlled substances and adding to inventory, Facility should ensure that Schedule II - V controlled substances are immediately placed into a secure storage area On 4/10/19 at 3:45 PM, a medication room observation was conducted with Employee Identifier (EI) #2, Licensed Practical Nurse (LPN). The surveyor and EI #2 observed in the locked medication refrigerator in the medication room, a locked secured box was a bottle of 30 milliliter oral [MEDICATION NAME]. Further observation revealed in the same medication refrigerator on the top shelf, not in the locked secured box, was a clear zippered narcotic fridge bag labeled as narcotic fridge box. Inside the bag were 2 vials of [MEDICATION NAME] injectable and 1 bottle of oral [MEDICATION NAME]. On 4/10/19 at 3:50 PM an interview was conducted with EI #2. EI #2 was asked what was in the fridge bag. EI #2 replied,one bottle of oral [MEDICATION NAME] and two vials of injectable [MEDICATION NAME]. EI #2 was asked what was in the secured box in the medication refrigerator. EI #2 replied, oral [MEDICATION NAME] for a resident. EI #2 was asked should the [MEDICATION NAME] in the refrigerated bag be in the secured locked box. EI #2 replied, yes. EI #2 was asked why was the [MEDICATION NAME] in the refrigerated bag not in the secured locked storage box. EI #2 replied, she did not know. EI #2 was asked what was the harm in the medication in the refrigerated bag not being in the secured locked box. EI #2 replied it was not under proper lock regulation and could easily be taken. On 4/11/19 at 11:01 AM, an interview was conducted with EI #1, Director Of Nursing. EI #1 was asked what was the policy for storage for refrigerated controlled medications. EI #1 read from the policy, 12 Controlled Substances Storage 12.1 Facility should ensure that Schedule II - V controlled substances are only accessible to licensing nursing, Pharmacy, and medical personnel designated by the facility. 12.2 After receiving controlled substances and adding to inventory, Facility should ensure that Schedule II - V controlled substances are immediately placed into a secure storage area ( . in all cases accordance with Applicable Law.) EI #1 was asked if the controlled medication in the zip bag was stored in the secured box in the medication refrigerator. EI #1 replied, it was stored outside the box. EI #1 was asked why was it not stored in the secured box. EI #1 replied, the bagged medicine would not fit in the box. EI #1 was asked what was the harm in the medication not stored in the secured locked box. EI #1 stated , It was stored under two locks and we followed our policy; however, someone could take the medication.

Based on observation, interview, record review and review of a facility policy titled, Prevention of Catheter Associated Urinary Tract Infection, the facility failed to ensure Resident Identifier (RI) #19, a resident admitted to the facility with a Foley catheter, had a qualifying [DIAGNOSES REDACTED]. This affected one of two residents sampled for Foley catheters. Findings Include: A review of a facility policy titled Prevention of Catheter Associated Urinary Tract Infection with an effective date of 1/2009 revealed: .Policy Detail A. Appropriate Urinary Catheter Use *Utilize urinary catheters when residents clinical condition demonstrates a need (see below for examples/guidance), and left in place only as long as needed. *Resident has chronic [MEDICAL CONDITION] or bladder outlet obstruction *To assist in healing of open Stage III or IV sacral pressure ulcers in incontinent residents *To improve comfort for end of life care if needed. RI #19 was admitted to the facility 3/8/19 with [DIAGNOSES REDACTED]. A review of a facility form titled Nursing Admission Data Collection with an effective date of 3/8/19 revealed: . page 20 . 5. Review for Residents with Indwelling Catheters 3. [DIAGNOSES REDACTED]. healing .Unspecified Fall . Vitamin D Deficiency Hypo-Osmolality and [MEDICAL CONDITION] . Elevated White Blood Cell Count . [MEDICAL CONDITION] .Rhabdomyolysis .[MEDICAL CONDITION] . [MEDICAL CONDITION] . A review of RI #19's admit Physician order [REDACTED]. Catheter Care for Indwelling catheter . Change Foley Bag and Tubing . Order Date 3/8/19 . On 4/9/19 at 12:00 PM, RI #19 was observed with a foley catheter to bedside drain bag. At lunch RI #19 was observed up in the wheelchair. On 4/10/19 a record review of a nurse note revealed RI #19 was admitted to the facility with a Foley catheter on 3/8/19 and non weight bearing left lower extremity. It was also documented that RI #19 was admitted wearing an adult brief and kept dry per staff. On 4/10/19 at 2:22 PM, an interview was conducted Employee Identifier (EI) #1, Director of Nursing. EI #1 was asked when was RI #19's Foley catheter ordered. EI #1 replied, on admission RI #19 came from the hospital with it. EI #1 was asked what was the [DIAGNOSES REDACTED]. EI #1 stated We were told on the report from the hospital to leave the Foley because the resident had difficulty moving and wanted it left in until the resident was getting up. EI #1 was asked who was giving the report. EI #1 replied it was nurse to nurse. EI #1 was asked if the Medical Doctor for RI #19 was the same as for the nursing facility. EI #1 replied, no. EI #1 was asked if receiving in a phone report just telling to leave a Foley catheter in was a [DIAGNOSES REDACTED].#1 replied, no. EI #1 was asked what was the facility protocol for discontinuing a foley. EI #1 replied, generally they get them out within a week. EI #1 was asked where was the assessment for the Foley catheter. EI #1 gave a copy of the assessment and surveyor and EI #1 reviewed it. Then EI #1 was asked if the [DIAGNOSES REDACTED].#1 replied, no. EI #1 was asked what was the harm in RI #19's Foley catheter not assessed for removal. EI #1 replied, the potential for infection. EI #1 was asked if RI #19 was admitted on [DATE] when should the resident have been assessed for the removal of the catheter. EI #1 replied, within the first week. EI #1 was asked if the reason given during the phone report was an acceptable [DIAGNOSES REDACTED]. EI #1 replied, no

Based on observations, interviews, a facility policy titled, PERSONAL HYGIENE, and a facility policy titled, Hair Restraints, the facility failed to ensure three kitchen staff restrained their hair during kitchen observations in the main kitchen and on the skilled unit while serving and/or preparing food. This was observed on two of three days of the survey and had the potential to affect all 26 residents receiving meals from the kitchen. Findings include: A review of a facility policy titled, PERSONAL HYGIENE with a revised date of 4/20/16 revealed: POLICY Guidelines for personal hygiene to promote a safe and sanitary department must be followed. PR[NAME]EDURE . 3. Head Covering Worn a. Wear . hair restraint. Hair must be appropriately restrained or completely covered. A review of a facility policy titled, Hair Restraints with a revised date of 5/10 revealed: Policy Overview All associates involved in food preparation must wear hair restraints. Policy Detail . 2. Hair that cannot be effectively restrained . must wear a hairnet. 3. hair that cannot be covered with a single hairnet will wear two (one for the front and one for the back). All hair must be covered. On 5/15/18 at 5:33 PM, Employee Indentifier (EI) #3, Dietary Aid on the Long Term Care unit, was observed with her bangs not secured in a hairnet while serving food for residents. On 5/15/18 at 6:15 PM, an interview was conducted with EI #3. EI #3 was asked what did the facility policy indicate about wearing a hairnet while serving food. EI #3 said, she had to wear a hairnet. EI #3 was asked, was all of her hair contained in the hairnet. EI #3 said, no ma'am. EI #3 was asked what hair was exposed. EI #3 said, bangs. EI #3 was asked should all hair be contained inside a hairnet. EI #3 said, yes. EI #3 was asked why did she not contain all her hair in the hairnet. EI #3 said, no reason, that was just how she wore it. EI #3 was asked what was the potential concern when hair was not contained in a hairnet. EI #3 said, hair could fall in food and drinks. On 5/16/18 at 10:40 AM, an observation of the kitchen and staff was made. EI #4, Dietary Aide, was observed wearing a crochet type head covering not covering all of her hair. Hair was exposed around her head. EI #4 was preparing trays of fish filets on a table in the kitchen area. On 5/16/18 at 10:52 AM, EI #5, Dietary Aide entered the kitchen, walked into the dry storage area and went to the food warmer next to the food preparation area. Her hairnet covered hair from the forehead to the top half of her hair in back. Her hair hung down to the top of her shirt and was not secured in the hairnet. On 5/16/18 at 5:00 PM, an interview was conducted with EI #6, Registered Dietician. EI #6 was asked what did the facility policy indicate regarding when hair restraints/nets should be worn. EI #6 said, hair nets needed to be worn when in the kitchen and preparation area. EI #6 was asked why should all hair be completely restrained when preparing and plating food for residents. EI #6 said, to prevent cross-contamination. EI #6 was asked what was considered an appropriate use of a hair restraint/net. EI #6 said, all hair within the hair net. On 5/16/18 at 5:29 PM, an interview was conducted with EI #7, Director of Dining Services. EI #7 was asked what did the facility policy indicate regarding when hair restraints/nets should be worn. EI #7 said, hair restraints should be worn at all times in food service area. EI #7 was asked why should hair be completely restrained when preparing and plating food for residents. EI #7 said, to prevent any physical contaminant. EI #7 was asked what was considered an appropriate use of a hair restraint/net. EI #7 said, all hair should be covered.

Based on record reviews, interviews and a facility policy titled, Discarding and Destroying Medication, the facility failed to ensure the method of destruction was documented on two of 12 months of medication destruction records. On 1/24/18 and 2/16/18 records did not reveal a method of destruction. This affected two of 12 months of medication disposal records reviewed. Findings include: A review of a facility policy titled, Discarding and Destroying Medications with a revised date of (MONTH) 2013 revealed: . Policy Statement Medications will be disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances. Policy Interpretation and Implementation . 7. The medication disposition record will contain the following information: . f. Method of disposition . On 5/17/18 at 11:24 AM, Narcotic and Non-narcotic medication destruction records were reviewed for April, (YEAR) through April, (YEAR). There was no method of destruction documented for the months of January, (YEAR) and February, (YEAR). On 5/17/18 at 3:00 PM, an interview was conducted with Employee Identifier (EI) #1, Director of Nursing (DON). EI #1 was asked how should Narcotic and Non-Narcotic destruction method be documented. EI #1 said, it should be documented and the type of destruction should be marked by the pharmacist. EI #1 was asked what was the importance of documenting the method of destruction. EI #1 said, it was a requirement. EI #1 was asked what was the method of destruction of the narcotic and non-narcotics. EI #1 said, RX (prescription) Destroyer and Sharps medication boxes were used. On 5/17/18 at 4:29 PM, a telephone interview was conducted with EI #2, Pharmacist. EI #2 was asked who was responsible for documenting the method of destruction of narcotic and non-narcotic medications. EI #2 said, the pharmacist. EI #2 was asked what was the importance of documenting the method of destruction for narcotic and non-narcotics. EI #2 said, to make sure where the medication was destroyed and where it was put after it was removed from packages. EI #2 was asked why was the method not documented for (MONTH) (YEAR) and (MONTH) (YEAR). EI #2 said, he must have missed it when he signed the forms.

Based on observation, interview, resident record review, a Facility Policy titled Wound Observation and Pressure Injury/Ulcer Staging Policy and the National Pressure Ulcer Advisory Panel (NPUAP) Pressure Injury Stages, the facility failed to ensure RI (Resident Identifier) #10's right heel wound that contained slough was accurately staged on 4/23/18 and 4/30/18, when the wound was staged as a II (two); and accurately staged on 5/8/18 after the wound bed no longer contained slough and continued to be staged as a II. This affected one of two residents reviewed for pressure ulcers. Findings include: A review of a facility policy titled, Wound Observation and Pressure Injury/Ulcer Staging Policy, with a revised date of 9/2017, revealed: Policy Overview All licensed nurses should follow established guidelines and protocols to observe, describe tissue, evaluate, measure wounds and stage of pressure injuries/ulcers. Policy Detail . B. Staging Protocol 1. Clinical standards do not support reverse staging or back staging pressure injuries/ulcers as a way to document healing . 2. Pressure injuries/ulcers will be staged according to the National Pressure Ulcer Advisory Panel (NPUAP) guidelines. A review of an undated NPUAP for NPUAP Pressure Injury Stages revealed: . Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough is removed, a Stage 3 (three) or Stage 4 (four) pressure injury will be revealed. RI #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #10's Quarterly Minimum Data Set Assessment, with an Assessment Reference Date of 04/10/2018, documented RI #10 had one unstageable pressure ulcer due to coverage of the wound bed by slough and/or eschar. The WOUND EVALUATION FLOW SHEET(s) for RI #10's right heel wound, dated 4/23/18 and 4/30/18, were reviewed. RI #10's pressure injury/ulcer was documented as a Stage II with 90 percent granulation tissue and 10 percent slough for both dates. Further, RI #10's wound flow sheet for the entry dated 5/8/18 documented the wound as a Stage II after there was no longer slough in the wound bed. On 5/17/18 at 9:52 AM, EI (Employee Identifier) #1 DON (Director of Nursing) observed RI #10's wound with the surveyor and described the wound as a pink, granulating Stage II that previously had slough. On 5/17/18 at 10:57 AM, EI #1 was asked why RI #10's pressure ulcer was a Stage II when the wound evaluation flow sheet documented there was 10 percent slough on 4/23/18 and 4/30/18. EI #1 said, she should have left it unstageable since there was still some slough. On 5/17/18 at 2:06 PM, an interview was conducted with EI #1. EI #1 was asked what it meant when slough was present in a wound and to describe slough. EI #1 said it was not a healthy tissue and you could not tell the depth when there was slough. EI #1 was asked what the facility policy was for how a pressure ulcer would be staged. EI #1 said, we use the National Pressure Ulcer Advisory Panel (NPUAP) guidelines. EI #1 was asked how did the NPUAP staging system describe unstageable wounds once slough or eschar was removed. EI #1 said, a stage three or four was revealed. EI #1 was asked why RI #10's right heel wound was staged a II after slough was gone on 5/8/18. EI #1 said, she just miss-staged it. EI #1 was asked what should RI #10's wound have been staged. EI #1 said, by these guidelines (NPUAP) it should have been a stage 3 (III).

Based on review of the facility's Abuse, Neglect & Exploitation Policy, a complaint received by the Alabama State Survey Agency, Resident Identifier (RI) #1's medical record and interviews, the facility failed to suspend Employee Identifier (EI) #5, a Certified Nursing Assistant upon learning of alleged abuse until after the matter had been investigated and a determination made as to the underlying allegation. On 1/18/2018 at 10:00 AM, RI #1 reported an allegation of abuse to EI #3, the Assistant Director of Clinical Services. Instead of suspending the staff (EI #5), EI #3 told EI #5 to not go back in RI #1's room. EI #5 was allowed to work during the 11:00 PM to 7:00 AM shift on 1/18/2018 and 1/21/2018. These deficient practices affected RI #1, one of three sampled residents reviewed for abuse, and placed RI #1 in immediate jeopardy of serious injury, harm or death. On 2/1/2018 at 4:03 PM, the Administrator was notified of the findings of substandard quality of care at the immediate jeopardy level in the area of Freedom from Abuse, Neglect, and Exploitation, F 610. Findings include: The facility's Abuse, Neglect & Exploitation Policy with a revision date of July 2017, documented Policy Overview . is committed to maintaining a safe environment for each resident, visitor and associate. Instances or allegations of abuse, neglect, mistreatment or exploitation should be treated seriously . Policy Detail . E. Protection 1. Protection of Resident. Upon learning of alleged abuse, neglect, mistreatment or exploitation, the Administrator or supervisor on duty should attempt to take necessary steps to ensure that residents are protected from subsequent episodes of abuse, neglect, mistreatment, or exploitation. If an allegation of abuse, neglect, mistreatment, or exploitation is made against an associate or associates, the accused individuals should be suspended until the matter has been investigated and a determination made as to the underlying allegation . On 01/19/2018 at 9:55 AM, the State Agency received a complaint which stated RI #1 reported a staff member grabbed him/her and pulled him/her across the bed as he/she yelled out, according to the complainant. RI #1 was admitted to the facility on [DATE] with a primary admitting [DIAGNOSES REDACTED].#1 has a medical history to include: Low Back Pain, and Muscle Weakness. RI #1's Admission Minimum Data Set (MDS) with an assessment reference date of 1/15/2018, revealed RI #1 was moderately impaired in cognitive skills, with a Brief Interview for Mental Status (BIMS) score of 11. The MDS indicated RI #1 required extensive assistance of one person with transfers and personal hygiene, and was totally dependent of one person assistance for bathing. According to this MDS, RI #1 used PRN (as needed) pain medications for occasional pain that had limited day to day activities. During the initial tour of the facility on 1/30/2018 at 8:10 AM, RI #1 stated she had a problem with the shower one time. RI #1 explained he/she wasn't willing to get up because of the pain. RI #1 stated around 4:00 AM/5:00 AM, a female staff member grabbed him/her and pulled him/her across the bed. In a telephone interview on 1/31/2018 at 10:10 AM, a family member of RI #1 was asked when the concern (allegation of abuse) was reported to the facility. RI #1's family member stated it was done by the resident the day of the incident. According to RI #1's family member, RI #1 reported it to a staff member and then to his/her family. During an interview on 1/31/2018 beginning at 2:55 PM, EI #3, the Assistant Director of Clinical Services (ADCS) was asked if any concerns been reported to her about RI #1. EI #3 stated she was informed the morning of 1/18/2018 that RI #1 wanted to talk with her. EI #3 stated around 10:00 AM, she went and spoke with the resident. Then RI #1 explained to her that a little girl had come around the side of the bed and told the resident that he/she was going to get a shower and that he/she was not going to stay in bed all day. EI #3 stated RI #1 could not remember the name of the staff but she later found out the staff was EI #5, a CNA. EI #3 stated she asked EI #5 (CNA) and EI #6 (LPN) what happened. According to EI #3, after she spoke with the staff she went back and spoke with RI #1 and told the resident that EI #5 would not come back into his/her room. Contained within the facility's investigation file was a typed interview statement from RI #1 conducted by EI #3 dated 1/19/2018 (1/18/2018) at 10:00 AM, which documented . Q (question): (RI #1) did you receive a shower last night? (A) (answer): Yes I did and I didn't care for it. Q: Can you tell me why? A: The little girl who came in here early in the morning and came around to my bed and told me I wasn't going to stay in bed all day and yanked me up and plopped me down on that big chair and took me to the shower . During an interview on 1/30/2018 beginning at 8:15 PM, EI #5, a CNA acknowledged that she cared for RI #1 during the 11:00 PM to 7:00 AM shift on 1/17/2018. EI #5 stated she went into RI #1's room around 5:00 AM (on 1/18/2018) to give the resident a bath. EI #5 stated she was made aware by the Assistant Director of Clinical Services, EI #3, of the allegations made by the resident on 1/18/2018. When asked if she was told that she would be suspended, EI #5 said no and explained that she was only told to read about the safety of a resident during care. EI #5 stated she reported to work on 1/18/2018. EI #5 stated when she returned to work on 1/18/2018, she ws told to switch assignments with another CNA because RI #1 did not want to be cared for by her anymore. EI #5 stated she had not cared for RI #1 since this incident. A review of EI #5's TIMECARD revealed EI #5 clocked in on Thursday, 1/18/2018 at 10:49 PM, and clocked out at 6:40 AM. Then EI #5 clocked in on Sunday, 1/21/2018 at 10:48 PM, and clocked out at 6:42 AM. In an interview on 2/1/2018 at 11:00 AM, EI #2, the Director of Clinical Services (DCS) was asked what the facility's policy said about protection of a resident when abuse was suspected by a staff member. EI #2 replied, they will be suspended until the investigation was completed. When asked if the CNA, EI #5, was suspended, EI #2 said no. When asked if EI #5 should have been suspended, EI #2 replied, she (EI #5) should have been suspended until the investigation was completed. ************************* On 2/1/2018 at 10:53 PM, the facility submitted an Allegation of Credible Compliance which documented: F610 Investigate/Prevent/Correct Alleged Violation Corrective Action for affected resident: * The resident was assessed by the physician on 1/22/2018 with unremarkable findings. * Resident of review is no longer in the facility. * The facility reported the allegation of abuse to the State on 1/22/18. * Findings of the 5 day investigation did not substantiate the allegations of abuse by (EI #5). * The Director of Clinical Services/designee initiated re-educate with associates on the Abuse Neglect & Exploitation Policy to include the definitions Abuse, Neglect, Adverse Event, Exploitation, Injury of Unknown Source, Involuntary Seclusion, Licensed Health Professional, Mental Abuse, Misappropriation of Resident Property, Mistreatment, Neglect, Nurse Aide Person-Centered Care, Resident Representative, Serious Bodily Injury, and Sexual Abuse. * The Director of Clinical Services/Designee will provide re-education with associates on the Incident/Accident Reporting Policy. * Associate training to include and focus on identifying abuse, reporting abuse and protection of the resident. * Re-education will be provided to the associates and will begin 2/1/18 at 4:30 pm by (EI #2), DCS will re-educate (EI #3), ADCS. (EI #3) will re-educate the evening shift CNA's and (name), LPN. (Name), LPN will re-educate night shift CNA's and (name), LPN. (Name), LPN will educate day shift CNA's and day shift LPN then upon each shift prior to starting the shift by the Director of Clinical Services and/or designee. * Interviews were conducted of other residents in which care was provided by the CNA. No further allegations of abuse or reportable incidents were found or reported since 1/18/2018. * Alleged perpetrators will be suspended immediately when abuse is suspected or reported pending investigation. System changes so problem doesn't recur * The Director of Clinical Services/designee initiated re-educate with associates on the Abuse Neglect & Exploitation Policy to include the definitions Abuse, Neglect, Adverse Event, Exploitation, Injury of Unknown Source, Involuntary Seclusions, Licensed Health Professional, Mental Abuse, Misappropriation of Resident Property, Mistreatment, Neglect, Nurse Aide Person-Centered Care, Resident Representative, Serious Bodily Injury, and Sexual Abuse. * The re-education include the process of Screening, Training Identification of Abuse, Neglect, Mistreatment and Exploitation and Training of Associates, Prevention, Protection, Investigation of Potential Abuse, Neglect and Exploitation, and External Reporting and Internal Reporting. * Re-educate associates on the Incident/Accident Reporting Process Policy. * Re-education will be performed immediately prior to each shift by DCS and/or designee ************************* After reviewing the facility's information provided in their Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F 610 was lowered to a D level on 2/2/2018, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 537.

Based on staff interviews and review of Employee Identifier (EI) #1, the Administrator and EI #2, the Director of Clinical Services' job description, EI #1, responsible for the day-to-day functions of the facility and EI #2, responsible for the overall function of the Clinical Service Department, failed to ensure the facility staff implemented the facility's abuse policy and procedure. The facility failed to timely report an allegation of abuse to the State Survey Agency and failed to provide protection to the resident when the staff member was allowed to continue to work after an allegation of abuse had been reported. These deficient practices affected RI #1, one of three sampled residents reviewed for abuse, and placed RI #1 in immediate jeopardy of serious injury, harm or death. On 2/1/2018 at 10:25 PM, the Administrator, Director of Clinical Services and Assistant Director of Clinical Services were informed of the findings of immediate jeopardy in the area of Administration, F 835. Findings include: Refer to F 609 and F 610 EI #2's Director, Clinical Services job description dated February 2015, documented . Job Summary Plans, organizes, develops, and directs the overall operations of the Clinical Services Department in accordance with federal, state and local standards. Responsible and accountable for maintaining the highest degree of quality care at all times . In an interview on 1/31/2018 at 4:15 PM, EI #2, the Director of Clinical Services (DCS) stated she was informed on Friday, 1/19/2018 by EI #3, the Assistant Director of Clinical Services (ADCS) that RI #1 did not want EI #5 back in his/her room because the staff member was rude. When asked if she talked with the resident, EI #2 said she did not talk with the resident until 1/22/2018. EI #2 was asked what her responsibility was regarding the safety and concerns expressed by the resident. EI #2 replied, she was to ensure the residents were safe. EI #2 was asked what was the facility's policy and procedure on reporting abuse. EI #2 said abuse should be reported immediately or no later than two hours. When asked if there was a delay in reporting the allegation of abuse, EI #2 said yes. In a follow-up interview on 2/1/2018 at 11:00 AM, EI #2, the DCS was asked what the facility's policy said about protection of a resident when abuse was suspected by a staff member. EI #2 replied, they will be suspended until the investigation was completed. When asked if the Certified Nursing Assistant (CNA), EI #5, was suspended, EI #2 said no. When asked if EI #5 should have been suspended, EI #2 replied, she (EI #5) should have been suspended until the investigation was completed. EI #1's Health Care Administrator job description dated August 2010, documented . Job Summary Under minimal supervision, directs the day-to-day health care functions of the community in accordance with current federal, state, and local standards, guidelines, and regulations that govern long-term care facilities to ensure the highest degree of quality care is provided to our residents at all times . During an interview on 2/1/2018 at 3:05 PM, EI #1 was asked when she was made aware of the incident with RI #1. EI #1 replied, EI #3 informed her after the stand-up meeting on 1/19/2018. EI #1 denied being told that RI #1 stated the staff had yanked and plopped him/her in a chair and taken to the shower. EI #1 stated it was portrayed to her that it was just a communication problem. EI #1 explained had she been told what the resident said, she would have started an investigation then. EI #1 stated an investigation should have been started on 1/18/2018. When asked why there was a delay in reporting the allegation to the State Agency, EI #1 explained EI #3, the ADCS got the information on 1/18/2018 but it was not reported to the State Agency until 1/22/2018. When asked if any other staff besides the CNA had been provided re-education since the incident, EI #1 said no but they will. EI #1 was asked how she ensured the staff followed the policy and procedure. EI #1 replied, ultimately it was her responsibility to ensure the staff followed the policy. ************************* On 2/1/2018 at 10:53 PM, the facility submitted an Allegation of Credible Compliance which documented: F835 Corrective Action for affected resident: * The resident was assessed by the physician on 1/22/2018 with unremarkable findings. * Resident of review is no longer in the facility. * The facility reported the allegation of abuse to the State on 1/22/18. * Findings of the 5 day investigation did not substantiate the allegations of abuse by (EI #5). * The Director of Clinical Services/designee initiated re-educate with associates on the Abuse Neglect & Exploitation Policy to include the definitions Abuse, Neglect, Adverse Event, Exploitation, Injury of Unknown Source, Involuntary Seclusion, Licensed Health Professional, Mental Abuse, Misappropriation of Resident Property, Mistreatment, Neglect, Nurse Aide Person-Centered Care, Resident Representative, Serious Bodily Injury, and Sexual Abuse. * The Director of Clinical Services/Designee will provide re-education with associates on the Incident/Accident Reporting Policy. * Associate training to include and focus on identifying abuse, reporting abuse and protection of the resident. * Re-education will be provided to the associates and will begin 2/1/18 at 4:30 pm by (EI #2), DCS will re-educate (EI #3), ADCS. (EI #3) will re-educate the evening shift CNA's and (name), LPN. (Name), LPN will re-educate night shift CNA's and (name), LPN. (Name), LPN will educate day shift CNA's and day shift LPN then upon each shift prior to starting the shift by the Director of Clinical Services and/or designee. * Interviews were conducted of other residents in which care was provided by the CNA. No further allegations of abuse or reportable incidents were found or reported since 1/18/2018. * Alleged perpetrators will be suspended immediately when abuse is suspected or reported pending investigation. System changes so problem doesn't recur * The Director of Clinical Services/designee initiated re-educate with associates on the Abuse Neglect & Exploitation Policy to include the definitions Abuse, Neglect, Adverse Event, Exploitation, Injury of Unknown Source, Involuntary Seclusions, Licensed Health Professional, Mental Abuse, Misappropriation of Resident Property, Mistreatment, Neglect, Nurse Aide Person-Centered Care, Resident Representative, Serious Bodily Injury, and Sexual Abuse. * The re-education include the process of Screening, Training Identification of Abuse, Neglect, Mistreatment and Exploitation and Training of Associates, Prevention, Protection, Investigation of Potential Abuse, Neglect and Exploitation, and External Reporting and Internal Reporting. * Re-educate associates on the Incident/Accident Reporting Process Policy. * Re-education will be performed immediately prior to each shift by DCS and/or designee * The Director of Clinical Services/Designee will provide re-educate with associates on the Incident/Accident Reporting Process Policy. * The alleged perpetrator will be suspended immediately when abuse is suspected or reported pending investigation * (Name), Regional Director of Clinical Services provided education to (EI #1), NHA (Nursing Home Administrator) and (EI #2), DCS regarding Abuse, Neglect & Exploitation Policy and Incident/Accident Reporting Process on Feb. 1, 2018 at 2:30p.m. ************************* After reviewing the facility's information provided in their Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F 835 was lowered to a D level on 2/2/2018, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 537.

Based on review of the facility's Abuse, Neglect & Exploitation Policy, Resident Identifier (RI) #1's medical record, the Alabama Department of Public Health Online Incident Reporting System, the facility's investigation file and interviews, the facility failed to timely report an allegation of abuse to the Alabama State Survey Agency. On 1/18/2018 at 10:00 AM, the facility received an allegation of abuse involving RI #1 and Employee Identifier (EI) #5, a Certified Nursing Assistant (CNA). This allegation of abuse was not reported to the Alabama State Survey Agency until 1/22/2018 at 7:44 PM. This deficient practice affected RI #1, one of three sampled residents reviewed for abuse. Findings include: The facility's Abuse, Neglect & Exploitation Policy, with a revision date of July 2017, documented . Policy Detail . G. External Reporting 1. All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property shall be reported: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, c. Such alleged violation shall be reported to: i. The State Survey Agency; . On 1/19/2018, the Alabama State Survey Agency received a complaint which alleged on 1/18/2018 around 4:00 AM, RI #1 was abused by a nurse aide when the nurse aide forced RI #1 by pulling the resident across the bed into a sitting position into a chair to be taken to the shower against her will. RI #1 was admitted to the facility on [DATE] with a primary admitting [DIAGNOSES REDACTED].#1 has a medical history to include: Low Back Pain, and Muscle Weakness. RI #1's Admission Minimum Data Set (MDS) with an assessment reference date of 1/15/2018, revealed RI #1 was moderately impaired in cognitive skills, with a Brief Interview for Mental Status (BIMS) score of 11. The MDS indicated RI #1 required extensive assistance of one person with transfers and personal hygiene, and was totally dependent of one person assistance for bathing. According to this MDS, RI #1 used PRN (as needed) pain medications for occasional pain that had limited day to day activities. During the initial tour of the facility on 1/30/2018 at 8:10 AM, RI #1 stated she had a problem with the shower one time. RI #1 explained he/she wasn't willing to get up because of the pain. RI #1 stated around 4:00 AM/5:00 AM, a female staff member grabbed him/her and pulled him/her across the bed. In a telephone interview on 1/31/2018 at 10:10 AM, a family member of RI #1 was asked when the allegation of abuse was reported to the facility. RI #1's family member stated it was done by the resident the day of the incident. According to RI #1's family member, RI #1 reported it to a staff member and then to his/her family. In an interview on 1/31/2018 at 12:15 PM, EI #4, a CNA was asked if RI #1 reported any concerns/problems to her. EI #4 replied, yes the resident (RI #1) was crying and he/she wanted to see the supervisor. EI #4 stated she went and got EI #6, a LPN. EI #4 acknowledged that RI #1 informed her that EI #5, a CNA had been rough with him/her. When asked if she thought RI #1 had been abused, EI #4 said she couldn't answer that because she was not there to witness it. EI #4 explained when the resident was upset and crying, she reported it to the nurse. During an interview on 1/31/2018 at 1:00 PM, EI #6, a LPN acknowledged that EI #4 informed her that RI #1 was upset about EI #5 (CNA) giving the resident a shower. According to EI #6, she was told by RI #1 that RI #1 did not want EI #5 (CNA) back in his/her room, that RI #1 didn't like the tone of voice in which EI #5 had spoken to him/her (RI #1) and then the resident began to cry. When asked if she had reported the resident's concerns to anyone, EI #6 said after she went home she called back to the facility and spoke with EI #3, the Assistant Director of Clinical Services (ADCS). During an interview on 1/31/2018 beginning at 2:55 PM, EI #3, the ADCS was asked if any concerns been reported to her about RI #1. EI #3 stated she was informed the morning of 1/18/2018 that RI #1 wanted to talk with her. EI #3 stated around 10:00 AM, she went and spoke with the resident. Then RI #1 explained to her that a little girl had come around the side of the bed and told the resident that he/she was going to get a shower and that he/she was not going to stay in bed all day. EI #3 stated RI #1 could not remember the name of the staff but she later found out the staff was EI #5, a CNA. EI #3 stated she asked EI #5 (CNA) and EI #6 (LPN) what happened. According to EI #3, after she spoke with the staff she went back and spoke with RI #1 and told the resident that EI #5 would not come back into his/her room. Contained within the facility's investigation file was a typed interview statement from RI #1 conducted by EI #3 dated 1/19/2018 (1/18/2018) at 10:00 AM, which documented . Q (question): (RI #1) did you receive a shower last night? (A) (answer): Yes I did and I didn't care for it. Q: Can you tell me why? A: The little girl who came in here early in the morning and came around to my bed and told me I wasn't going to stay in bed all day and yanked me up and plopped me down on that big chair and took me to the shower . In an interview on 1/31/2018 at 4:15 PM, EI #2, the Director of Clinical Services was asked what was the facility's policy and procedure on reporting abuse. EI #2 said abuse should be reported immediately or no later than two hours. When asked if there was a delay in reporting the allegation of abuse, EI #2 said yes. In a follow-up interview on 2/1/2018 at 11:00 AM, EI #2, the Director of Clinical Services acknowledged that on Friday, 1/19/2018 after the facility's stand-up meeting, EI #3 reported to her the concerns expressed by RI #1. When asked if EI #3 had reported to her that EI #5 yanked the resident and plopped her down in a chair, EI #2 said yes. A review of the Alabama Department of Public Health Online Incident Reporting System revealed on 1/22/2018 at 7:44 PM, the facility reported an allegation of abuse involving RI #1 and EI #5 to the State Survey Agency. This deficiency was cited as a result of the investigation of complaint/report number AL 537.

Based on observation, interview and a review of the 2013 U.S. PUBLIC HEALTH FOOD CODE, the facility failed to ensure a male employee with facial hair wore a beard restraint in the kitchen on 04/04/17 during the preparation of the dinner meal. This had the potential to affect 28 out of 28 residents in the facility that received meals from the dietary department. Findings Include: The 2013 U. S. Public Health Food Code revealed: .Hair Restraints 2-402.11 Effectiveness. (A) .FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, . to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, . On 04/04/17 at 4:30 p.m., the surveyor observed a male employee with a full beard in the kitchen without a beard cover on. On 04/04/17 at 5:15 p.m., an interview was conducted with EI (Employee Identifier) #3, Director of Dining Operations. EI #3 was asked if he was wearing a beard restraint while in the kitchen. EI #3 said, No. EI #3 was asked what was the facility's policy regarding wearing a beard restraint. EI #3 said if staff were in the food preparation area or engaged in the food process, staff were required to wear a beard restraint. EI #3 was asked what was the potential harm in not wearing a beard restraint while in the kitchen area. EI #3 said, Physical contamination to the food, if hair was to fall in the food.

Based on observation, group interview, staff interviews and a review of the facility's document titled RESIDENT RIGHTS, the facility failed to ensure residents in the group meeting held on 04/5/17, knew they had a right to see the survey results and where they were located. The facility further failed to ensure there were notices in the facility indicating the location of the survey results. This was observed on two of three days of the survey, affected nine residents who attended the group meeting and had the potential to affect all 28 residents in the facility. Findings Include: A review of a facility document titled, RESIDENT RIGHTS with a revised date of August 2000, revealed the following: .18. All state inspection reports .shall be posted in a prominent location . On 04/04/17 at 9:00 a.m., during the initial tour of the facility, the surveyor was unable to locate survey results in the facility, and there were no signs throughout the facility indicating where the survey results were located. On 04/05/17 at 8:30 a.m., the surveyor was unable to locate the survey results in the facility. On 04/05/17 at 9:30 a.m., a group meeting was held. A total of nine residents attended the meeting. The residents were asked if they were aware of their right to see a copy of the latest survey results and where it was located. All nine residents stated they were not aware of their right to see a copy of the latest survey results nor did they know where the results were located in the facility. On 04/05/17 at 4:00 p.m., the surveyor observed the survey results posted in a clear pocket on the wall on the 300 hallway. On 04/05/17 at 5:00 p.m., an interview was conducted with Employee Identifier (EI) #1, Activities Director. EI #1 was asked where were the survey results located in the facility. EI #1 said, I don't know, I am not sure. EI #1 was asked who was responsible for ensuring that residents were aware of the survey results and where they were located. EI #1 said, I don't know who is responsible. EI #1 was asked if she had talked with the residents about the survey results and where they were located in the facility. EI #1 said she had not talked to residents about the survey results. EI #1 was asked why it was important for the residents to know about the survey results and where they were located in the facility. EI #1 said it was their right to know. EI #1 was asked if there were any signs in the facility indicating where the survey results were located. EI #1 said, No I have not seen any signs lately . On 04/05/17 at 5:40 p.m., an interview was conducted with EI #2, Director of Nurses (DON). EI #2 was asked who was responsible for ensuring the residents were aware of the survey results and where they were located. EI #2 said the new Activities Director who had been hired but had not started yet. EI #2 said EI #1 was currently filling in. EI #2 was asked if there were signs in the facility indicating where the survey results were located. EI #2 said, No. EI #2 was asked if the survey results were easily accessible to residents where it was located now. EI #2 said, the results were probably accessible the majority of the day but not 24 hours a day. EI #2 was asked why it was important for residents to know about the survey results and where they were located in the facility. EI #2 said it was the resident's right to know about the survey results and where they were located.

Based on observation, interviews and record review, the facility failed to ensure: 1) residents' dishes and utensils were consistently sanitized when processed through the dishmachine; 2) ceiling tiles above the dish machine were free of peeling chips; and 3) the hair of male staff was consistently covered during the process of dish washing and food preparation. This had the potential to affect all 30 residents for whom meals were provided at the time of this survey. Findings included: The facility procedure regarding the Recording of Dishmachine Temperatures (pages 8-14; updated 11/2010) includes the following guidelines: 6. The concentration of the sanitary solution during the rinse cycle is 50 - 100 ppm (parts per million) with Chlorine sanitizer. This is used on low temperature dishmachines. During the initial kitchen tour on 04/12/16 at 2:10 PM, Employee Identifier (EI) #2 processed first a rack of separated flatware, then a rack of assorted items (drinking glass, thermal coffee mug and several 3-compartment plates) through the dish machine. The chemical concentration, when tested by facility staff, registered less than the recommended 50 ppm. The assorted items of the second rack were not observed to be re-washed and sanitized at 50 ppm. EI #2 processed dishes through the dishmachine without the use of a facial hair restraint over his beard. The facility policy and procedure, Personal Hygiene (page 2-22, updated 02/2014) specifies the following: .3. Head Covering Worn a. Wear a clean hat or other hair restraint. Hair must be appropriately restrained or completely covered. .c. Beards or any body hair that may be exposed (i.e., arms) must be covered. On 04/13/16 at 9:00 AM, two male cooks unwrapped frozen fish filets and prepared them for cooking. EI #3, with an uncovered facial goatee and EI #4 (with a small moustache) prepared first the fish, then continued with other food preparation tasks. EI #2 processed dishes through the dishmachine with no beard cover or restraint to cover his waist-length dread locks (held back in a pony tail). On 04/13/16 at 9:20 AM, as EI #2 processed dishes through the dishmachine, white flakes from the ceiling tiles above the dishmachine fell down onto the counter adjacent to the dishmachine. The ceiling tiles above the dishmachine had large areas of a white flaking substance. On 04/13/16 at 9:45 AM, the surveyor asked the Dietary Director (EI #1) what his policy was regarding beard covers. EI #1 explained they normally had hair nets for both hair on the head and on the face, which were worn all the time. At 9:50 AM, the surveyor questioned EI #1 about the dishroom ceiling. EI #1 explained the ceiling tiles had not been painted, and a request had been submitted to the Maintenance Department for replacement. On 04/14/16 at 7:50 AM, the surveyor asked EI #1 what potential harm might result from male staff not covering facial hair or dread locks. EI #1 stated it was possible that hair might fall on plates or into the food. When asked why staff had not been covering their hair, EI #1 could not explain, stating constant supervision was needed. EI #1 explained the dishwasher (EI #2) normally placed his hair inside his shirt. When asked how he could ensure the dishmachine consistently dispensed adequate chlorine to sanitize, EI #1 stated they would get the Dishmachine Technician in that day to repair the machine and continue to test the machine chlorine and adjust the water temperatures. On 04/14/16 at 10:15 AM, the Maintenance Director (EI #5) explained the Dishmachine Technician would change the dishmachine jets and convert the machine to hot water sanitation. EI #5 explained the combination of hard water and chlorine created a blockage.

Based on observation, interviews, and facility's policy, the facility failed to discard six (6) Thick and Easy Apple Juices after the manufacture's expiration date of March 7, 2015. This had the potential to affect 28 residents who received meals from the kitchen. The facility's "RESIDENT CENSUS AND CONDITION OF RESIDENTS (Form CMS-672), dated 4/16/15 indicated 29 residents resided in the facility, of which one resident was fed by way of a tube feeding. Findings include: The facility's undated "FOOD STORAGE" policy documented " ... Any expired or outdated food products should be discarded ... ." During the initial tour of the kitchen on 4/14/15 beginning at 8:10 AM, with Employee Identifier (EI) #1, the Executive Chef, six containers of Thick and Easy Apple Juice with a manufacture's expiration date of March 7, 2015 was observed in the dry storage room. When EI #1 was asked to confirm the date, he stated those should have been discarded. EI #2, the Assistant Director of Dining Services was interviewed on 4/15/15 at 3:40 PM. When asked what was the facility's policy for inspecting foods for expired dates, EI #2 said they check daily for expired dates all over the kitchen. When asked what harm could come to a resident if they drank a Thick and Easy Juice which was past the use by date. EI #2 replied, she couldn't say what kind of illness but harm could be caused.

Based on observation, interview and record review, the facility failed to ensure a resident with a history of Urinary Tract Infection [MEDICAL CONDITION] was provided catheter care in a manner to prevent cross-contamination. Employee Identifier (EI) #1, a Certified Nursing Assistant (CNA) failed to change the position of the wipe while cleansing Resident Identifier (RI) #1's labia. This affected RI #1, one of one sampled residents identified by the facility with a catheter. Findings include: Chapter 45 titled, "Urinary Elimination", page 1080 of "Potter and Perry's Fundamentals of Nursing 8th Edition" with copyright date of 2013, documented: "...Cleaning from pubis toward anus, clean labia minora. Use clean side of cloth for each wipe. ..." The facility's policy and procedure for "Perineal Care" with a revision date of October 2010 revealed the following: "... The purposes of this procedure... to prevent infections and skin irritation, ... Steps in the procedure... 9. For a female resident: .... (2) Continue ... Do not reuse the same washcloth ... to clean the urethra or labia. ..." RI #1 was admitted to the facility 02/27/2014 with [DIAGNOSES REDACTED]. RI#1's Admission Minimum Data Set (MDS) with an Assessment Reference Date of 03/06/2014, revealed RI #1 was totally dependent on staff for toilet use. The MDS documented RI#1 was always incontinent of bowel and had an indwelling catheter. EI #1 and EI #2, both CNAs, were observed performing catheter care to RI #1 on 05/30/2014 at 10:15 AM. While wiping RI #1's labia from front to back, EI #1 used the same wipe without changing the position of the wipe. In an interview on 05/30/2014 at 11:30 AM, EI #1 stated that cleansing the labia she should use a fresh wipe with each side of the labia and discard the used wipe in the trash. The surveyor asked EI #1 how many motions do you use while wiping the perineum and EI #1 stated, "You use one wipe and go down and then throw away the wipe."

Based on observation, interviews and record review, the facility failed to ensure Resident Identifier (RI) #1 was provided catheter care in a manner to prevent potential cross-contamination. Employee Identifier (EI) #1, a Certified Nursing Assistant (CNA) cleansed the resident's labia without changing position of the wipe and cleansed the catheter tubing in a back and forth motion toward the insertion site. This affected RI #1, one of four residents observed for incontinence care. Findings include: The facility's policy titled "Catheter Care, Urinary" revised October 2010 documented " ... The purpose of this procedure is to prevent catheter-associated urinary tract infections ... Steps in the Procedure ... 15. For the female: ... Use one area of the washcloth for each downward, cleansing stroke. Change the position of the washcloth with each downward stroke ... 16. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward ... ." RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Significant Change in Status Minimum Data Set with an assessment reference date of 6/10/14, indicated RI #1 had an indwelling catheter and required extensive assistance with toileting. During the provision of incontinence/catheter care on 7/22/14 at 1:30 PM, Employee Identifier (EI) #1, a Certified Nursing Assistant (CNA) wiped down the right side and then the left side of the resident's labia without changing the position of the wipe. EI #1 then took a new wipe and cleansed the catheter tubing in a back and forth motion toward the insertion site. In an interview on 7/22/14 at 3:00 PM, EI #1 was asked what is the potential harm in not changing the position of the wipe during catheter care, and she stated, infection. When asked what was the potential harm in cleansing the catheter tube towards the vagina, EI #1 said infections and bacteria. During an interview on 7/23/14 at 12:30 PM, EI #2, the Director of Nursing/Infection Control Nurse stated the correct technique for wiping during catheter care is to wipe down the right side and then down the left side and then down the center, while changing position of the wipe with each wipe. EI #2 stated that the correct technique for cleaning Foley tubing is to clean around the edge of the tubing and then down four to six inches away from the resident going towards the bag. When asked what was the potential harm in not changing the position of the wipe during catheter care or cleaning the catheter tubing correctly, EI #2 said infection.

Based on observation, interviews and record reviews, the facility failed to ensure Employee Identifier (EI) #1, a Certified Nursing Assistant (CNA) changed her gloves after performing catheter care and before placing a clean brief on Resident Identifier (RI) #1. The facility further failed to ensure EI #2, a CNA, did not turn off the water faucet with her bare hands, after washing and drying her hands. This affected RI #1, one of one sampled residents identified by the facility with a catheter. Findings include: The facility's policy titled, "Handwashing/Hand Hygiene" with a revision date of June 2010, revealed the following: "... Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. ... Policy Interpretation and Implementation ... 2. All personnel shall follow the handwashing/hand hygiene ... to help prevent the spread of infections ... 5. Employees must wash their hands ... c. Before and after direct resident contact ... n. Before and after assisting a resident with toileting ... r. After handling soiled or used linens ... catheters ... Procedure Washing Hands ... 4. Dry hands...with paper towels and then turn off faucets with a clean, dry paper towel ... ." RI #1 was admitted to the facility 02/27/14 with [DIAGNOSES REDACTED]. RI#1's Admission Minimum Data Set (MDS) with an Assessment Reference Date of 03/06/2014, revealed RI #1 was totally dependent on staff for toilet use and was always incontinent of bowel. The MDS also indicated that RI #1 had an indwelling catheter. During the provision of care on 05/30/2014 at 10:15 AM, EI #1 placed a clean incontinent brief under RI #1, while wearing soiled gloves. After completion of catheter care, EI #2 turned off the water faucet with her bare hands. In an interview with EI#1 on 05/30/2014 at 11:30 AM, she stated she should have changed her gloves after she cleansed RI#1's vagina and behind (buttocks). When asked what was the potential harm in not changing soiled gloves before touching clean surfaces and EI #1 stated, "Cross-Contamination." In an interview with EI #2 on 05/30/2014 at 11:45 AM, EI#2 stated she did not use a paper towel to turn off the water when she was observed washing her hands. When asked what was the potential harm in touching a soiled surface with clean hands, EI #2 stated, "Contamination, If I touched it with my hands without gloves on." In an interview on 05/30/2014 at 12:45 PM, EI #3, the Registered Nurse/Director of Nursing, stated that during catheter care the CNA should change gloves and wash their hands if the resident was soiled. The surveyor asked EI #3 what was the potential harm in moving from a soiled surface to a clean surface, EI #3 stated, "Infection". EI #3 further stated, after handwashing is complete the water faucet should be turned off using a paper towel. The surveyor asked what potential harm could be caused by touching soiled surfaces with clean hands and EI#3 stated, "Spread of Infection."