Every finding on record at Glenwood Center

Based on observation, interview, the facility's Diet Type Report, the 2022 Food Code, the facility's Labeling and Dating Inservice, and the facility's policies for Food Storage: Cold Foods and Meal Distribution; the facility failed to ensure thawed nutritional shakes had Use By dates, two shelves in the Walk-in Freezer were at least six inches from the floor, cups being used for Dinner service on 02/25/2024 were not placed rim down directly atop a cart with spillage upon it, and two gallons of milk, with a manufacturer's date of 02/26/2024, were not labeled with a Use By date of 02/29/2024, This had the potential to affect 117 of 117 residents receiving meals from the facility kitchen. Findings include: The facility's Diet Type Report, dated 02/25/2024, listed 117 residents receiving meals. 1.) Nutritional Shakes The United States (U.S.) Food and Drug Administration (FDA) 2022 Food Code included the following: . 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . (B) . refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked . to indicate the date or day by which the FOOD shall be consumed on the PREMISES . or discarded . The facility's Labeling and Dating Inservice, undated, included the following: . Guidelines for Labeling and Dating . Items that are removed from a labeled case in the freezer and placed in the refrigerator for thawing should be labeled with the date of removal from the freezer and an appropriate 'use by' date . During the initial tour of the kitchen with the Dietary Manager (DM) on 02/25/24 at 3:26 PM, two 4-ounce Sysco Imperial Chocolate Shakes (nutritional shakes) were observed in the reach-in refrigerator. There was not a Use By date on either carton. The DM said he did not know why the cartons were not dated. The DM said the nutritional shakes had to be discarded within fourteen days of thawing. Two additional 4-ounce Sysco Imperial Chocolate Shakes without Use By dates were observed in Walk-in Cooler #2. Manufacturer instructions for thawing and dating were requested from the DM. On 02/26/2024 at 8:52 AM, the DM said the manufacturer instructions were on each carton of Sysco Imperial Chocolate Shake. The following was documented on the Sysco Imperial Chocolate Shake carton: HANDLING INSTRUCTIONS: Store frozen. Thaw under refrigeration (40 F or below). Use within 14 days after thawing. On 02/27/2024 at 5:20 PM, the Dietary Manager (DM) was interviewed. When asked the problem with undated Sysco Imperial Chocolate Shakes in the refrigerators on 02/25/2024, the DM said we do not know when it was thawed, and it must be used within fourteen days. The DM further said it could have gone bad and possibly have been sent out and it could make a resident sick. The DM also said 22 to 24 Sysco Imperial Shakes were served to residents each meal. 2.) Shelving The U.S. FDA 2022 Food Code included the following: . 3-305.11 Food Storage. (A) . FOOD shall be protected from contamination by storing the FOOD: . (3) At least 15 cm (6 inches) above the floor. The facility's policy for Food Storage: Cold Foods, dated February 2023, included the following: . Policy Statement All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code. Procedures 1. All food items will be stored 6 inches above the floor . During the initial tour of the kitchen on 02/25/24 at 3:44 PM, the Walk-in Freezer was observed with the Dietary Manager (DM) and the Contract Foodservice District Manager (District Mgr.). The freezer door was ajar. Inside the Walk-in Freezer, two bottom shelves were each broken from the frame at one corner. These shelves each had food stored on them and appeared to be less than 6 inches from the floor. One shelf had two boxes of potatoes on it and the other shelf had a small, wrapped packet of potatoes stored on it. On 02/26/2024 at 4:57 PM, the Maintenance Director measured the shortest distance from the floor to the top of each of the two, broken bottom shelves in the Walk-in Freezer. One shelf was five inches from the floor, this was the shelf holding two cases of frozen potatoes on 02/25/2024. The other shelf was four inches from the floor. On 02/27/2024 at 5:20 PM, the Dietary Manager (DM) was interviewed. The DM said problems with storing food less than six inches from the floor included chemicals splashing on the food during cleaning, low shelves are hard to properly clean under, and allows easier access to the food by rodents. 3.) Cups The U.S. FDA 2022 Food Code included the following: . 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. 4-602.11 Equipment Food-Contact Surfaces and Utensils. (A) Equipment food-contact surfaces and utensils shall be cleaned: . (5) At any time during the operation when contamination may have occurred. 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) . cleaned EQUIPMENT and UTENSILS, . shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; . The facility's policy for Meal Distribution, dated February 2023, included the following: . Policy Statement Meals are transported to the dining locations in a manner that . protects against contamination . Procedures . 6. Proper food handling techniques to prevent contamination . will be used for point-of-service. dining. On 02/25/2024 at 4:49 PM, Dinner service was observed on the 300 Hall. Licensed Practical Nurse (LPN) #9 was preparing beverages for the resident trays as needed. Clear plastic cups were observed to be separately placed on a tray, which was on the bottom shelf of the drink cart. While pouring beverages into the clear plastic cups, LPN #9 spilled orange drink and tea onto the top of the drink cart. LPN #9 removed four clear cups from the tray on the bottom shelf, stacked them upside down, and put them on the top of the drink cart. After filling two clear cups with tea, LPN #9 removed the last three clear cups from the tray and stacked them upside down. On 02/25/2024 at 5:04 PM, LPN #9 was interviewed. LPN #9 said his job was to pour drinks during the tray pass (delivery). When asked where he put the clear plastic cups after pulling them off the tray on the bottom of the drink cart, LPN #9 said he stacked them up and put them face down on the top of the drink cart. LPN #9 said he placed the stack of clear plastic cups face down on top of the drink cart; because they were already face down, so face down was the first thing that came to mind. LPN #9 said he did not clean the top of the drink cart before placing the clear plastic cups on top of it. 4.) Milk The U.S. FDA 2022 Food Code included the following: . 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . (B) . refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked . to indicate the date or day by which the FOOD shall be consumed on the PREMISES . or discarded . (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. The facility's Labeling and Dating Inservice, undated, included the following: . 'Use By' Dating Guidelines The manufacturer's expiration date, when available, is the 'use by' for unopened items. During an observation of the Residents' Nourishment Refrigerator in the Station A Pantry on 02/26/2024 at 3:32 PM, two partially filled gallon jugs of Whole Milk were observed; each with a manufacturer's Use By date of 02/26/2024 and a handwritten Use By date of 02/29/2024. On 02/26/2024 at 4:30 PM, the Dietary Manager (DM) was shown the jugs of Whole Milk with the handwritten, extended Use By dates in the Station A Pantry. The DM said they cannot date it past the manufacturer's Use By date, since it is a dairy product, and the milk could be bad by that date. The DM further said it could get served to a resident and they might get sick.

Based on observation, interview, the facility's Diet Type Report, the 2022 Food Code, and the facility's maintenance work orders; the facility failed to maintain the Walk-in Freezer door in working order. This had the potential to affect 117 of 117 residents receiving meals from the facility kitchen. Findings include: The United States (U.S.) Food and Drug Administration (FDA) 2022 Food Code included the following: . 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair . (B) EQUIPMENT components such as doors . shall be kept intact, tight, and adjusted . A facility maintenance service request for the Walk-in Freezer, dated 07/02/2023, resulted in the following service report from a visit on 07/12/2023: . Found door handle has be (been) broken off since last time here, not letting door latch and bottom of door is now warped. we cannot guarantee that it will freeze properly. A maintenance work order request (Work Order #10019) from the Dietary Manager for Walk-in Freezer repair, dated 02/20/2024, stated the freezer door will not shut properly. The facility's Diet Type Report, dated 02/25/2024, listed 117 residents receiving meals. During the initial tour of the kitchen on 02/25/24 at 3:44 PM, the Walk-in Freezer was observed with the Dietary Manager (DM) and the Contract Foodservice District Manager (District Mgr.). There was a sign on the freezer door with instructions to make sure to close the freezer door completely. The freezer door was ajar. Multiple ice droplets had formed on the ceiling of the Walk-in Freezer and there were knobs (small hills) of ice on the floor. The long edge of the door (by the lock/handle and away from the hinges) was badly bent. Three-fourths upward along this long edge, there was visible space between the metal veneer on the interior side of the door and the door core. In addition, the space between the metal veneer and the door core had sections of built-up ice, which was at least one inch thick. Near the bottom of this long edge, the metal veneer on the exterior side of the door was pulled away from the door core and the core itself was splintering. The freezer door was not closing properly. The District Mgr. was seen to forcibly push the freezer door several times before the door closed. The DM said he had put in a maintenance request to get the freezer door repaired but had not heard any response from Maintenance. The DM was able to provide a printed copy of the high priority maintenance request, Work Order #10019, dated 02/20/2024, which was assigned to the Director of Maintenance. On 02/25/24 at 5:06 PM, the Dietary Manager (DM) was asked how long the Walk-in Freezer door had been a problem. The DM said they had been trying different things with it for a while now. On 02/26/24 at 4:35 PM, the Maintenance Director was interviewed. The Maintenance Director said the Walk-in Freezer was building up ice all along the door and he had to sometimes go clean it off. The Maintenance Director further said heat strips had been put around the door, but they did not seem to be working to keep the ice from building up. When asked if the freezer door was in good repair, the Maintenance Director said the door probably needed to be replaced. The Maintenance Director further said the bottom of the door was starting to come apart and the ice building up in the space under the metal veneer was just tearing the door up more. When asked what was keeping him from replacing the freezer door, the Maintenance Director said nothing; that he probably just needed to find a new door. The Maintenance Director said the Walk-in Freezer door had been a problem since he started working at the facility about a year ago. On 02/27/24 at 5:20 PM, the Dietary Manager (DM) was interviewed. The DM was asked what problems the Dietary Department had encountered due to the condition of the Walk-in Freezer door. The DM said the Walk-in Freezer door has often been frozen shut and the staff cannot get into it. The DM further said the staff has called me early in the morning before breakfast saying they cannot get into the freezer. The DM also said we have had to pour hot water on it to just break the ice to get in. Additionally, the DM said normally, we must kick it (donkey-style kick) four or five times to break the ice to get into the freezer.

Based on observation, interview, the facility's Diet Type Report, the facility's Tuesday, Week 2 Menu, the facility's Portion Control Chart, and the facility's policy, Menus; the facility failed to ensure 4-ounce portions of Applesauce were prepared for service to the Dysphagia Advanced Diets and the Pureed Diets prior to Lunch on 02/27/2024. This had the potential to affect 35 of 117 residents receiving meals from the kitchen. Findings include: The facility's Menus policy, dated October 2022, included the following: . Policy Statement Menus will be planned in advance to meet the nutritional needs of the residents/patients in accordance with established national guidelines. Procedures . 6. Menus will be served as written . The facility's Tuesday, Week 2, Fall/Winter 2023-2024 Menu for Lunch listed the following for all Dysphagia Advanced diets and Puree diets: . Applesauce 1/2 Cup The facility's Portion Control Chart, undated, documented the capacity of a #8 size disher/scoop to be 4 ounces or 1/2 cup. The facility's Diet Type Report, dated 02/25/2024, listed 117 residents receiving meals; 35 of those were receiving either Dysphagia Advanced or Puree textured diets. During the Resident Council Meeting held on 02/27/2024 at 9:50 AM, residents said they had a food concern about portion size. Preparations for the lunch meal were observed on Tuesday, 02/27/2024. At 10:00 AM, the Diet Aide was observed to repeatedly fill a scoop half-full of applesauce and then empty each portion into a small bowl for individual service. When asked why she was not completely filling the scoop, the Diet Aide said it was because they only get a half a serving. When asked what size scoop she was using, the Diet Aide turned and asked the AM Cook, who was working nearby. The AM Cook said it was a #8 scoop, because the residents were to get a 4-ounce (1/2 cup) serving. The Dietary Manager (DM) was interviewed on 02/27/2024 at 5:20 PM. The DM said the #8 scoop not being filled when portioning the applesauce meant the residents would not get the proper nutritional value for the portion size they were supposed to receive.

Based on observations, interviews, and a facility document titled RESIDENT RIGHTS UNDER FEDERAL LAW the facility failed to provide necessary maintenance services to maintain Resident Identifier (RI) #26's bathroom and a chair in the sitting area of the 300 hall in good repair. This had the potential to affect RI #26 one of 24 sampled residents and residents residing on the 300 hall. Findings include: A review of the RESIDENT RIGHTS UNDER FEDERAL LAW, dated 11/28/2016 revealed . 9. Safe Environment. The resident has the right to a safe, clean, comfortable, and homelike environment, . 9.2 Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. RI #26 was admitted to the facility on [DATE] with diagnoses to include Age Related Physical Debility. On 02/25/2024 at 03:22 PM an observation was made of RI #26's bathroom floor tiles that were brown, white, and light brown in color with approximately 10 percent of the floor tiles cracked with pieces missing. On 02/28/2024 at 12:10 PM an observation was made with the MD and he was asked about the floor tiles. He stated there were cracked tiles on RI #26's bathroom floor. The MD stated that the tiles should not be cracked because they could be a tripping hazard and the appearance was not good. On 02/25/2024 at 04:48 PM an observation was made in the sitting area on the 300 hall of a tan leather chair that had worn areas on both arms, the seat cushion, and the back of the chair. The worn areas on the chair had a different appearing texture that was a blackish gray color. On 02/28/2024 at 12:21 PM interview was conducted with the Maintenance Director (MD). The MD stated that the brown leather chair in the sitting area of the 300 hall by the nurses station looked like the leather was coming off of the chair. The MD stated that the chair should not be that way because it did not look like a homelike environment.

Based on resident record review, interview, and review of a facility policy titled Person-Centered Care Plan, the facility failed to develop a care plan specific for Urinary Tract Infection (UTI), when Resident Identified (RI) #16 was admitted to the facility with a UTI and antibiotic treatment. This had the potential to affect RI #16, one of three residents sampled for UTI. Findings include: A facility policy titled Person-Centered Care Plan with a revision date of 10/24/2022 documented . POLICY . Care plan includes measurable objectives and timetables to meet a patient's medical, nursing, nutrition, mental and psychosocial needs that are identified in the comprehensive assessments. RI #16 was admitted to the facility 01/24/2024 with a diagnosis of Urinary Tract Infection. RI #16 had a physician order dated 01/24/2024 to receive Keflex Oral Capsule, one capsule, three times a day for UTI for seven days. RI #16 had a care plan with a created date of 01/24/2024 for Nutritional Risk related to a history of Malnutrition, Depression, UTI, Chronic Kidney Disease and Weakness, but it was not specific to address the UTI or RI #16 receiving antibiotics. RI #16's January 2024 Medication Administration Record documented RI #16 received Keflex from 01/24/2024 through 01/31/2024 for a UTI. On 02/27/2024 at 1:00 PM during an interview with Minimum Data Set (MDS) Coordinator/ Licensed Practical Nurse (LPN) #18, she said RI #16 received Keflex for a UTI for seven days when admitted on [DATE]. When asked where the care plan was, she said, she did not see one and it was possibly an oversight. When asked who was responsible for completing the care plans, she said, the MDS office. LPN #18 said the care plan for the UTI should have been done when the UTI occurred which was 01/24/2024.

Based on interviews and review of resident records, and a facility policy titled Skin Integrity and Wound Management, the facility failed to ensure Licensed Practical Nurse (LPN) #21 did not apply an Opti-foam dressing to Resident Identifier (RI) #13's sacral wound without a physician's order. On 02/27/2024 an Opti-foam dressing was observed being removed from RI #13's sacrum. The physician's order for wound care directed staff to apply moisture barrier cream to the wound. This had the potential to affect RI #13, one of two residents observed for wound care. Findings include: A facility policy titled Skin Integrity and Wound Management dated 02/01/2023 documented: . 6.13 Implement special wound care treatments/techniques, as indicated and ordered . RI #13 was admitted to the facility on [DATE] with diagnoses of Muscle Weakness and Dependence on Wheelchair. RI #13's Order Summary Report documented an order dated 02/23/2024 as follows . Cleanse unstageable to sacrum with wound cleanser and apply moisture barrier cream every day and night shift . On 02/27/2024 at 10:26 AM Registered Nurse (RN) #20 removed RI #13's brief revealing an Opti-foam dressing dated 02/27/2024 on the resident's sacrum. RN #20 removed the Opti-foam dressing from RI #13's sacrum. On 02/27/2024 at 10:53 AM an interview with RN #20 was conducted. RN #20 stated the order for RI #13 was to cleanse with wound cleanser and apply moisture barrier to the sacrum daily. RN #20 stated that there was an Opti-foam dressing with a date of 02/27 and initials on his/her sacrum when she removed his/her brief. RN #20 stated that the initials that were written on the Opti-foam dressing were LPN #21. RN #20 stated that there was not an order for the Opti-foam dressing for RI #13's sacrum. RN #20 stated that there was not a physician order for the Opti-foam dressing and nothing should be done without an order. On 02/27/2024 at 11:01 AM an interview with LPN #21 was conducted. LPN #21 stated that she had applied an Opti-foam dressing to RI #13's sacrum that morning. LPN #21 stated the order for RI #13's sacrum, was to clean the wound with cleanser and moisture barrier cream. LPN #21 stated that there was no order for the Opti-foam dressing, and she did not look at the order before applying the Opti-foam dressing. On 02/28/2024 at 12:37 PM an interview with the Director of Nursing (DON) was conducted. The DON stated there would need to be an order to apply an Opti-foam dressing. She stated that RI #13's current wound order was barrier cream and RI #13 did not have an order for an Opti-foam dressing. She stated that applying a wound dressing that was not ordered by the physician could cause the wound to worsen.

Based on observations, interviews, resident record review, and review of a facility policy titled Activities of Daily Living (ADLs), the facility failed to provide a shower and clean clothes for Resident Identifier (RI) #26, as observed during the survey. RI #26 was observed wearing the same clothing on 4 of 4 days of the survey, 02/25/2024 through 02/28/2024. This had the potential to affect one of ten residents sampled for activities of daily living. Findings include: Review of the policy titled Activities of Daily Living (ADLs) with a revision date of 05/01/2023 revealed .PURPOSE To ensure ADLs are provided in accordance with accepted standards of practice, the care plan, and the patient's choices and preferences. RI #26 was admitted to the facility on [DATE] with a diagnosis of Hemiplegia and Hemiparesis following Cerebrovascular Disease Affecting Left Non-Dominant Side and Age-Related Physical Debility. RI #26's care plan created on 09/23/2019 with a focus area of . requires assistance with ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to: Age related debility, self care deficit, impaired cognition and limited mobility . documented an intervention for staff to provide appropriate level of assistance as needed for ADL care, A review of RI #26's Quarterly Minimum Data Set (MDS) with a Assessment Reference Date of 12/17/2023 revealed RI #26 had a Brief Interview Mental Status (BIMS) score of 13. Additionally, RI #26 was coded as having upper and lower extremity impairment on one side and was coded as needing partial/moderate assistance with shower/bath and upper body dressing. RI #26's quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 12/17/2023 coded RI #26 with a Brief Interview for Mental Status (BIMS) score of 13, upper and lower extremity impairment on one side, and RI #26 was coded as requiring partial/moderate assistance with shower/bath and upper body dressing. A facility Shower/Bath Schedule documented RI #26 was to receive a Shower/Bath on Tuesday, Thursday, and Saturday. On 02/25/2024 at 3:22 PM an observation was made of RI #26 in a white flannel shirt with blue and brown stripes. RI #26 said, his/her shower days were Saturday, Tuesday, and Thursday. RI #26 said, he/she did not get a bath or shower on Saturday (yesterday) and had on the same clothing since yesterday. On 02/26/2024 at 03:08 PM an observation was made of RI #26 in blue jeans and a white flannel shirt with brown and blue stripes. On 02/27/2024 at 09:41 AM an observation was made of RI #26 in blue jeans and a white flannel shirt with brown and blue stripes. RI #26 said, he/she had not had a bath in six days. On 02/28/2024 at 08:49 AM an observation was made of RI #26 in blue jeans and the same white flannel shirt with blue and brown stripes. On 02/28/2024 at 09:33 AM RI #26 stated that he/she did not get a bath on 02/27/2024 (yesterday/Tuesday) or 02/28/2024 (today). RI #26 stated, he/she had been taking off his/her clothing at night and putting them back on in the morning and had not received assistance from staff. On 02/28/2024 at 09:07 AM Certified Nursing Assistance (CNA) #19 stated she did not assist with RI #26's clothing on 02/28/2024. CNA #19 stated, she did not give a bath to RI #26 on 02/27/2024. CNA #19 said, there was a risk of infection, sores, rashes, and breakdown if residents did not get a bath on their scheduled days. On 02/28/2024 at 12:37 PM an interview with Director of Nursing (DON) was conducted. The DON #2 stated bath/showers are given to residents three times a week. The DON stated, the last documented bath/shower for RI #26 was on 02/22/2024. She stated, that was five days RI #26 was without a bath. The DON stated, residents clothing was to be changed daily and as needed. The DON stated, wearing the same clothing would be bad hygiene and could cause skin breakdown.

Based on observations, interviews, resident record review, and review of Fundamentals of Nursing Tenth Edition and review of facility procedures titled CATHETER: INDWELLING URINARY-CARE OF and PERINEAL CARE, the facility failed to ensure Resident Identifier (RI) #73, a resident with a history of Urinary Tract Infection (UTI), had a urinary catheter and drainage bag maintained in a manner to prevent infection and received incontinent care in a manner to prevent infection. On 02/27/2024, RI #73's catheter tubing was observed twisted and touching the bottom of the overbed table and bed; and on 02/28/2024 Certified Nursing Assistant (CNA) #12 and CNA #13 left bowel movement on RI #73's perineum after care had been provided. This had the potential to affect RI #73, one of five residents sampled for catheter use. Findings include: A review of Fundamentals of Nursing Tenth Edition documented: . Chapter 46 Urinary Elimination .Maintain an unobstructed flow of urine through the catheter, drainage tubing and drainage bag . Prevent the urinary drainage bag from touching or dragging on the floor . A review of a facility policy titled CATHETER: INDWELLING URINARY- CARE OF with a revision date of 02/01/2023 documented .13. Secure catheter tubing to keep the drainage bag below the level of the patient's bladder and off the floor. Position catheter for straight drainage and keep catheter and tubing free from kinks . A review of a facility policy with a revised date of 06/01/2021 documented PERINEAL CARE . 15. Cleanse the rectal area with cleanser cleansing from front to back. Rinse and dry well. RI #73 was admitted to the facility 01/19/2024 and had diagnoses to include: Urinary Tract Infection and Neurogenic Bladder. RI #73's most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/04/2024 indicated RI #73 used an indwelling catheter and was always incontinent of bowel. A review of RI #73's February 2024 Physician's Orders documented: .Continue Indwelling catheter 16 French (FR) with 10cc balloon to bedside straight drainage for diagnosis of Neurogenic Bladder . On 02/27/2024 at 9:43 AM RI #73 was observed lying in bed with the urinary catheter bag, touching the bedside table leg and the leg of the bed, and the urinary catheter tubing was twisted in places. On 02/27/2024 at 4:30 PM an interview was conducted with the Director of Nursing (DON). The DON said, RI #73 had a catheter for Neurogenic Bladder diagnoses and had a history of UTI. The DON was asked about the observation on 02/27/2024, where RI #73's catheter bag was twisted and made contact with the overbed table and bed near the floor. The DON said, the catheter bag should always be secured and should not come into contact with the overbed table or bed, and the tubing should not be twisted. When asked about the concern, the DON stated, it was an infection control concern. To prevent the catheter bag from being twisted or touching the overbed table or bed, the DON said, staff should secure the bag whenever they are in the room, and this should be done at least every two hours. 33739 On 02/28/2024 at 9:07 AM, CNA #12 and CNA #13 were observed working together to perform incontinent care for RI #73 and used disposable wipes to clean bowel movement from RI #73's perineum. On 02/28/2024 at 9:25 AM, when CNA #12 and CNA #13 had completed perineal care for RI #73, the surveyor asked CNA #13 to open the brief and observe the perineal area. CNA #12 said, there was bowel movement on the inside of RI #73's right thigh. CNA #12 said, the policy for performing pericare was to wash her hands, put on gloves, wipe the front until clean, change gloves after washing hands, put on new gloves, turn the resident, clean the back until clean, and remove the brief. CNA #12 said, wash hands, put on new gloves, place the clean brief, secure it, and make sure the resident was clean of bowel movement before placing the clean brief. When CNA #12 was asked if RI #73 was clean of bowel movement before the brief was secured, she said, no. CNA #12 said, she should have looked closer to make sure RI #73 was clean with no visible bowel movement before placing and securing the clean brief. CNA #12 stated, the concern with bowel movement being left on a resident was skin break down and infections like a UTI. CNA #12 said, it could be avoided by making sure all bowel movement was removed before placing the clean brief. On 02/28/2024 at 12:10 PM during an interview with the Infection Prevention Nurse (IPN), she said, staff should clean the entire area to include in the creases and inner thighs. They should use a final wipe to ensure it comes clean with no visible sign of bowel movement (BM). The IPN said, staff should make sure the resident was clean and free of BM before placing and securing the clean brief. The IPN said, the concern when staff did not make sure a resident was clean of BM before placing and securing a clean brief was skin breakdown and infection such as a UTI. The IPN said, a resident's catheter bag should be placed toward the end of the bed with privacy bag facing out, not touching floor or the overbed table. The IPN said, a resident's catheter bag should never be resting on the over bed table legs or touching anything that increased the risk for contamination. The IPN said, the concern with RI #73's catheter bag touching the overbed table legs was contamination.

Based on observations, interviews, and record review, the facility failed to ensure Resident Identifier (RI) #90's nebulizer mouthpiece was stored in a covering on three of four days of the survey. This deficient practice had the potential to affect one of one resident sampled for nebulizer administration. Findings include: RI #90 was admitted to the facility on [DATE] and had diagnosis of Chronic Obstruction Pulmonary Disease (COPD). RI #90's Order Summary Report documented, . Ipratropium-Albuterol Solution 0.5-2.5 (3) Milligrams (MG)/3 Milliliters (ML) . inhale orally via nebulizer two times a day for COPD Order Date 01/02/2024 Start Date 01/02/2024 . On 02/25/2024 at 5:15 PM, RI #90's nebulizer was observed on the bedside table with the mouthpiece connected to it. The nebulizer was not in a bag or covered. On 02/26/2024 at 9:32 AM, RI #90's nebulizer was observed on the bedside table with the mouthpiece connected to it. The nebulizer was not in a bag or covered. On 02/27/2024 at 8:04 AM, RI #90's nebulizer was observed on the bedside table with the mouthpiece connected to it. The nebulizer was not in a bag or covered. An interview was conducted with Registered Nurse (RN) #17 on 02/28/2024 at 9:17 AM. RN #17 stated RI #90's nebulizer's mouthpiece should be stored in a bag that was labeled when it was not in use. She stated the concern of not being stored in a bag was infection control and not staying clean. An interview was conducted with the Director of Nursing (DON) on 02/28/2024 at 11:31 AM. The DON stated RI #90's nebulizer's mouthpiece should be stored in a bag when it was not in use. She stated the concern of the mouthpiece not being stored in a bag when not in use was it would be dirty and it needed to stay clean.

Based on observation, interviews and review of a facility policy titled Linen Handling, the facility failed to ensure a Certified Nursing Assistant (CNA) #11 did not place soiled linens on the floor while providing morning care and pericare. This was observed on 02/28/2024 and had the potential to affect Resident Identifier (RI) #44 one of 24 sampled residents. Findings include: A facility policy titled Linen Handling with a revision date of 05/01/2023 documented . PURPOSE To provide effective containment and reduce potential for cross-contamination from soiled linen. PROCESS . 7.4 Soiled linen should be bagged or directly placed in covered container at the location where removing linen . RI #44 was admitted to the facility 04/26/2017 with a diagnosis of Vascular Dementia. On 02/28/2024 at 10:40 AM, CNA #11 exited RI #44's room leaving a pile of soiled linens on the floor at the foot of the beds and a plastic trash bag with the trash in it on the floor beside the linens. On 02/28/2024 at 10:49 AM CNA #11 returned to RI #44's room and she was asked what was on the floor. She said, RI #44's soiled linens. CNA #11 said, she should have taken bags for linen and trash when she entered the room to provide care. CNA #11 said, she put them in the floor because she was in a hurry to change RI #44, she did not have a bag, so she put them on the floor. CNA #11 said, she had received training and was told she should bring bags with her in the room and place the soiled linen in the bag. CNA #11 said, the concern in placing soiled linens on the floor was contamination and she had contaminated the floor. On 02/28/2024 at 12:19 PM the Infection Prevention Nurse (IPN) was asked where should staff place linens when they are removed from a resident's bed. The IPN said, in a bag, not on the floor, bed or bedside table, they are to take bags in the rooms with them. The IPN said, staff should never place soiled linens on the floor, they were trained to take bags in with them for soiled linens and trash. The IPN said, the concern with the CNA putting soiled linens on the floor was contamination and tracking it from room to room.

Based on interview, the facility's Diet Type Report, the 02/27/2024 Resident Council Meeting, and the facility's Meal Times schedule; the facility failed to ensure the period of time between Dinner and Breakfast did not exceed 14 hours. This had the potential to affect 117 of 117 residents receiving meals from the facility's kitchen. Findings include: The facility's Meal Times schedule, undated, listed the following: Breakfast: 7:00 AM Dining Room 7:15 AM LTC (Long Term Care) Rooms 320 through 331-B 7:30 AM Rehab (Rehabilitation Unit/100 Hall) 7:45 AM LTC Rooms 300 through 308 8:00 AM TCU (Transitional Care Unit/200 Hall) 8:20 AM LTC Rooms 309 through 319 . Dinner (Supper): 4:15 PM LTC Rooms 320 through 331-B 4:30 PM Rehab (100 Hall) 4:45 PM Dining Room 5:00 PM LTC Rooms 300 through 308 5:15 PM TCU (200 Hall) 5:35 PM LTC Rooms 309 through 319. The facility's Diet Type Report, dated 02/25/2024, listed 117 residents receiving meals. On 02/27/2024 at 9:30 AM, the Resident Council Minutes for the last six months (August 2023 through January 2024) were reviewed. There was no record of a discussion for the Resident Council to approve a time span greater than 14 hours between Dinner and Breakfast. A Resident Council Meeting was held on 02/27/2024 at 9:50 AM with nine residents attending. The residents said they had never been asked to approve a period of over 14 hours between Supper (Dinner) and Breakfast. When asked if they got hungry between Supper (Dinner) and Breakfast, all nine residents said yes. The residents said snacks like Oatmeal Pies and Fudge Rounds were given to them. The residents also said they used to get sandwiches, but they did not get them anymore. The residents said they would like to have Pimento Cheese and Cottage Cheese. The residents further said one had to be in the Dining Room by 7 AM for Breakfast, 11 AM for Lunch, and 4 PM for Supper (Dinner). On 02/27/2024 at 10:30 AM, the available monthly Dining/Food Committee minutes (July 2023 through January 2024) were reviewed with the Dietary Manager (DM). There was no record of a discussion for the Dining/Food Committee to approve a time span of greater than 14 hours between Dinner and Breakfast. The DM said individually packaged Oatmeal Cream Pies, Fudge Rounds, and things like that were sent to the halls for snacks each evening. The DM also said the kitchen did not prepare labeled snacks for the residents. On 02/27/2024 at 5:20 PM, the Dietary Manager (DM) was interviewed further. When asked if the residents were served a substantial evening snack, the DM said they have Peanut Butter Crackers, Fudge Rounds, Oatmeal Cream Pies, Whole Milk, and Chocolate Milk available. The DM further said he wanted to start providing sandwiches for the residents to have available at night. The DM said he was not aware of a resident group approving a time span of over 14 hours between Dinner (Supper) and Breakfast. Using the information on the facility's Meal Times, the DM was asked to review the period of time between: the service of Dinner (Supper) for the LTC 300 Hall (320-331B) at 4:15 PM and the service of Breakfast at 7:15 AM would be 15 hours, the service of Dinner for the Rehab Hall at 4:30 PM and the service of Breakfast at 7:30 AM would be 15 hours, the service of Dinner for the Dining Room at 4:45 PM and the service of Breakfast at 7 AM would be 14 hours and 15 minutes, the service of Dinner for the LTC 300 Hall (300-308) at 5:00 PM and the service of Breakfast at 7:45 AM would be 14 hours and 45 minutes, the service of Dinner for the TCU 200 Hall at 5:15 PM and the service of Breakfast at 8 AM would be 14 hours and 45 minutes, and the service of Dinner for the LTC 300 Hall (309-319) at 5:35 PM and the service of Breakfast at 8:20 AM would be 14 hours and 45 minutes. The DM said the established service times for resident meals exceeded the regulatory 14-hour period allowed between the dinner (supper) meal and the next day breakfast meal. When asked how this could this affect residents, the DM said they are going to get hungry.

Based on observations, interviews, record reviews, and review of a facility policy titled, Controlled Substance: Management Of, it was determined the facility failed to ensure residents' narcotic medications were not misappropriated by facility staff for 8 (Resident Identifier [RI] #12, RI #14, RI #15, RI #16, RI #17, RI #18, RI #19, and RI #4) of 10 residents reviewed for misappropriation. This failure had the potential to affect any resident with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Finding include: The facility policy titled, Controlled Drugs, Management of, revised on 06/01/2021, revealed, All staff who administer medications will safeguard controlled drugs. This policy applies to all medications listed in Schedule II through IV of the Comprehensive Drug Abuse Control Act of 1970. The policy also indicated, Receipt: Controlled drugs are received in separate containers with separate invoices. Licensed nursing staff must accept delivery and take responsibility for receipt of controlled drugs. Review of an Online Incident Report, dated as submitted to the state agency on 03/01/2022, revealed a nurse reported to the Director of Nursing (DON) that there was a discrepancy in the narcotic book. The DON and Assistant Director of Nursing (ADON) reviewed the narcotic book and found 28 [MEDICATION(S)] (a narcotic pain medication) 7.5 milligrams (mg) tablets missing from RI #14's inventory. The facility's investigation indicated the DON and ADON found several other discrepancies in the narcotic book. The suspected employee was placed on suspension, and staff received training regarding correct usage of the narcotic book, shift counts, and continuing to count all narcotics even if a resident is hospitalized . The police were notified of the missing narcotics. Further review of the facility's investigation documentation, including copies of the narcotic book pages, revealed the following: - On 02/24/2022, RI #14 had 67 [MEDICATION(S)] (a narcotic pain medication) 7.5-325 mg tablets. On 02/25/2022, the narcotic count was transferred to a new page of the narcotic book and the count was documented as 39. The other 28 tablets (of the 57 remaining at the end of the previous page) were missing. The transcribed telephone interview the facility conducted with EI #7, the Licensed Practical Nurse (LPN) who initially discovered the discrepancy, indicated EI #7 went to obtain a pain pill for RI #14 and noticed the page of the narcotic book for the resident's [MEDICATION(S)] ([MEDICATION(S)] with Acetaminophen) looked like it had been, transferred from another page with my signature, but that was not my signature. EI #7's statement indicated she looked back at the previous page and noticed that the last time the medication was administered was by EI #7, but the page was not full when the count was transferred to a new page. EI #7 indicated there were pills missing. EI #7 called EI #17, the LPN who was on duty during the prior shift, to ask if she knew what was going on and was told by EI #17 that liquid protein had been spilled on the card, so the card was taken up to destroy. EI #7 indicated that EI #17 stated she would take care of it in the morning. After speaking with EI #17, EI #7 indicated she contacted the DON. - On 02/28/2022, RI #15 had 17 [MEDICATION(S)] 5/325 mg tablets remaining; on 03/01/2022, the card was missing. - On 02/23/2022, RI #19 had 79 [MEDICATION(S)] (a narcotic pain medication) 20 mg tablets, but on 02/24/2022, the count had been transferred to a new page of the narcotic book, and the count had been changed to 68, indicating 11 tablets were missing. - On 02/15/2022, RI #16 had 30 [MEDICATION(S)] 20 mg tablets, and another 118 tablets were delivered that day. On 02/24/2022, the count was transferred to a new page of the narcotic book and the count was changed to 118, indicating the original 30 tablets were missing. - On 02/16/2022, RI #18 had 38 [MEDICATION(S)] 10-325 mg tablets, and when the count was transferred to a new page, the count was changed to 30, indicating 8 tablets were missing. - On 01/18/2022, RI #17 had 15 [MEDICATION(S)] 5/325 mg tablets, and all 15 tablets were missing. - On 01/29/2022, RI #17 had 25 [MEDICATION(S)] 7.5/325 mg tablets that were supposed to be transferred to the Transitional Care Unit (TCU) when the resident was transferred; however, the medications were not signed into the TCU narcotic book. Twenty-five tablets were missing. - On 03/01/2022, RI #16 had 59 [MEDICATION(S)] 10 mg tablets, and when the count was transferred to a new page of the narcotic book, the count was changed to 58, indicating one tablet was missing. - On 12/17/2021, RI #12 had 41 [MEDICATION(S)] 7.5-325 mg tablets, but on the same date, the count was transferred to a new page of the narcotic book and was changed to 30 tablets, indicating 11 tablets were missing. - On 02/20/2022 and 03/01/2022, RI #4 had [MEDICATION(S)] 7.5-325 mg wasted by EI #17; however, the nurses whose signatures appeared with EI #17's denied signing with EI #17 or witnessing the medication being wasted. Review of transcribed interviews conducted by the facility with staff as a part of the investigation revealed EI #17 was questioned regarding the individual residents' missing narcotics. EI #17 replied she had no knowledge of where any of the medications were, other than RI #14's [MEDICATION(S)] tablets, which she stated had liquid protein spilled on them, requiring them to be wasted. Review of a police report revealed the facility reported the missing narcotics to local law enforcement on 03/01/2022 at 9:47 PM. The report indicated an officer was dispatched to the facility in reference to the theft of narcotics and that EI #3, the previous DON, reported to the officer that during an inventory, 28 [MEDICATION(S)] 7.5 mg tablets had been stolen. Per the report, EI #3 told the officer she believed the theft took place between 02/24/2022 and 02/25/2022. The report indicated EI #3 told the officer she was unsure of the value of the narcotics because the medication was billed through the Medicare system. Additionally, the report indicated EI #3 told the officer she believed an employee stole the medications, as they were the only ones who had access to the inventory data and narcotics. Further review of the facility's investigation documentation revealed a subpoena from the Office of the Attorney General, dated 04/28/2022, requesting documents including: - Copy of Master Narcotic Count Sheet (incoming/outgoing/transfer). - Copy of nurse's post-incident drug test results. - Copy of each resident victim's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . - Copy of the nurses' initials and signature sheets. - Copy of nurses' work schedule for 12/01/2021 - 03/02/2022. - Copy of facility policies regarding counting cards and wasting narcotic medications, prior to the incident. - Copy of any write-ups or disciplinary actions against EI #17 during her employment with the facility. - Copy of pharmacy manifests for each resident victim as related to the missing narcotics. Review of the Alabama State Board of Nursing website revealed EI #17's LPN license was revoked on 08/15/2022. Observation and review of the facility's Narcotic Logbook on 9/23/2022 revealed a large, leather-bound book with pages numbered 1-323. These pages had spaces designated for the nurses to write the resident's name, medication name, medication dose, directions for use, the physician's name, and the prescription number at the top of each page. Each page had 60 lines where nurses were to document the date and time of any doses administered (removed from inventory), the quantity on hand, the quantity remaining, the route of administration, and the nurse's initials. There was a section to be completed by the nurse when the pages became full and there were narcotics remaining. This section, Transfer from book number was to be completed when there were remaining tablets, but no remaining lines to track the count for that medication. For example, if a resident had a medication on page 30, with an original count of 100 tablets, and the resident was to receive one tablet per dose administered, the page would only allow for 60 doses to be tracked as they were removed. When the page was full, staff would then turn to the next open page in the book and complete the Transfer from book number section to indicate the count was transferred from page 30. The count of 40 remaining tablets would be carried over to the new page. If staff wanted to check when the last dose of the [MEDICATION(S)] was given prior to the count being transferred to the new page, they would have to turn back to page 30 and review the last entry. At the bottom of each page, there were two signature lines that were to be completed if a drug was discontinued or transferred to another hallway or unit. The signature lines were to be signed by the nurse who was discontinuing or transferring the medication and by the nurse receiving the medication. Each medication cart had one of these books. An interview was conducted on 09/22/2022 at 9:24 AM with Employee Identifier (EI) #9, Registered Nurse (RN). EI #9 stated the facility's new system was that the nurse going off shift had to count the narcotics with the oncoming nurse. They both counted how many medication cards were on hand, how many count sheets (one per card) there were, and how many actual tablets there were. EI #9 stated the nurses were to complete the narcotic count with the time they gave each medication and sign the entry. EI #9 stated if the narcotic count, sheet count, and card count did not match, she would contact the DON. EI #9 stated she would not be allowed to leave the facility until the discrepancy was resolved. Upon completion of the interview, the surveyor observed as three random narcotics were counted. The number of tablets, number of cards, and count sheets all matched. An interview was conducted on 09/22/2022 at 5:45 PM with EI #7, LPN, who stated she was working on night shift on 03/01/2022 and was preparing to give a resident an as needed (PRN) narcotic. EI #7 stated the narcotic count was on a new page, so she turned back to the last page in the blue narcotic log to see when the last dose was given. EI #7 stated she noticed the transferred amount was short by 30 tablets. EI #7 stated she called EI #17 at home, and EI #17 told EI #7 she spilled liquid protein on the top of the cart and the medication card became soiled and sticky from the spilled protein. EI #17 told EI #7 that she gave the contaminated narcotic card to the DON. EI #7 stated after speaking with EI #17, she notified the DON. The DON and Assistant DON (ADON) arrived at the facility to investigate. EI #7 stated they all searched every medication room and medication cart and did not find the missing card. EI #7 stated the facility no longer used the blue narcotic book, but now used a system where each card that came into the unit was counted, as well as the narcotic count sheets. EI #7 stated they counted cards, sheets, and pills with the oncoming nurse, and she did not accept the keys to the medication cart unless the narcotic count was correct. EI #7 stated she received training after the incident with the missing narcotics, on how to waste a medication and the proper way to transfer information to a new count sheet. EI #7 stated she was interviewed by the Attorney General and was subpoenaed to court but received a letter prior to the court date stating she was no longer needed. A telephone interview was conducted on 09/23/2022 at 8:58 AM with EI #3, the previous DON. EI #3 stated she received a call from EI #7, who said she had found the narcotic count was incorrect. EI #3 stated she and the ADON went to the facility and discovered a card of narcotic tablets was missing. EI #3 stated she thought the missing medication was [MEDICATION(S)]. EI #3 stated during the investigation, many forged signatures were found on the pages of the narcotic books, where the counts had been transferred to a new page of the books. EI #3 stated she reported the findings to the police and the State of Alabama, and the Attorney General's office became involved. The incident was also reported to the State Board of Nursing. EI #7 stated she sent the facility's investigation to the Attorney General's office but did not hear back from them. An interview was conducted on 09/22/2022 at 2:06 PM with EI #8, the current DON, who stated she was not the DON at the time of the incident but did help with the investigation. EI #8 stated the investigation had found forged signatures, including her own, in the blue narcotic logbook. RI #8 confirmed the forged signature was documented in the area for discontinued medications. EI #8 stated the facility now used a different system, which included the counting of all narcotic cards coming to the unit and adjusting the count when narcotics were discontinued, or cards were completed. EI #8 stated they counted the cards, pills, and count sheets, and both nurses were to sign that the count was completed and correct. EI #8 stated she felt the new system was better. She stated she thought the facility monitored for a while after the misappropriation incident happened. EI #8 stated residents could suffer increased pain if they did not receive their pain medications. An interview was conducted on 09/23/2022 at 8:44 AM with EI #1, the Administrator, who stated most of the investigation was completed by the DON and ADON because it was a clinical issue, and they had a clearer understanding of the issue. EI #1 stated EI #17 was suspended immediately, and the police were notified. EI #1 stated staff were reeducated on the proper ways to account for narcotics. EI #1 confirmed the facility notified the police and contacted the Alabama Board of Nursing. EI #1 stated, The Attorney General reached out to us in a subpoena, but we never went to court. EI #1 stated some of the staff received subpoenas. EI #1 stated she felt the systems the facility had in place now were appropriate. EI #1 stated residents could experience an increase in pain which could lead to hospitalization if they did not receive their pain medications. Review of an In-Service Sign In Sheet dated 03/02/2022 indicated the topics covered included correctly signing the narcotic count sheet with the off-going nurse and never accepting the keys to the medication cart until all narcotics were accounted for. The training also included that if a medication needed to be wasted, a second nurse must witness the waste and sign for the waste. The training included that when transferring a resident to another unit or hallway or transferring a count to a new page in the narcotic logbook, there must be another nurse to witness the transfer and sign the logbook. The training indicated narcotics must be counted, even if a resident was in the hospital, and the cards must be counted until they are removed from the cart by the DON or ADON. The facility did not provide documentation of any monitoring to ensure the corrective actions were consistently implemented and that staff education was effective. Record reviews and/or interviews with the residents whose medications were misappropriated revealed the following: 1. Review of an annual Minimum Data Set (MDS), dated [DATE], revealed RI #4 had a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident had severe cognitive impairment. The MDS indicated the resident received scheduled pain medication and as needed (PRN) pain medication. The MDS indicated RI #4 rated the intensity of his/her pain as four on a scale of zero to ten, with zero meaning no pain and ten meaning extremely severe pain. Review of RI #4's Order Summary Report revealed the resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the February 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Review of RI #12's quarterly MDS dated [DATE] revealed the resident had a BIMS score of 14, indicating the resident was cognitively intact. The MDS indicated the resident received scheduled and PRN pain medication and had occasional pain which the resident rated at an intensity of three on a scale of zero to ten. Review of an Order Summary Report for RI #12 revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the March 2022 MAR for RI #12 indicated the resident received the [MEDICATION(S)] on ten occasions and that the medication was effective. The resident's highest pain intensity was three on a scale of zero to ten. During an interview on 09/23/2022 at 9:55 AM, RI #12 stated he/she had no complaints and loved the facility. EI #12 stated he/she received medications for pain when he/she asked for them and that he/she always got his/her medications. EI #12 denied ever having asked for pain medicine and not receiving it. 3. Review of a quarterly MDS, dated [DATE], revealed RI #14 had a BIMS score of 15, indicating the resident was cognitively intact. The MDS indicated the resident received scheduled pain medication. According to the MDS, the resident had occasional pain and rated the intensity at two on a scale of zero to ten. Review of the February 2022 MAR for RI #14 revealed the resident was to receive [MEDICATION(S)] tablet 7.5-325 mg every 12 hours as needed for pain. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Review of RI #15's admission MDS dated [DATE] revealed the resident had a BIMS score of 8, indicating moderate cognitive impairment. The MDS indicated the resident received scheduled pain medication and PRN medication and rated the intensity of his/her pain at two on a scale of zero to ten. Review of the February 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 5. Review of RI #16's annual Minimum Data Set (MDS), dated [DATE], revealed the resident had a BIMS score of 12, indicating moderate cognitive impairment. The MDS indicated the resident received scheduled pain medication, reported occasional pain, and rated the intensity of the pain at two on a scale of zero to ten. Record Review of the February 2022 MAR for RI #16 revealed the resident was to receive [MEDICATION(S)] tablet 10-325 mg once every 6 hours for pain. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 6. Review of RI #17's admission Minimum Data Set (MDS), dated [DATE], revealed the resident was severely impaired in cognitive skills for daily decision making per a staff assessment of mental status. The MDS indicated the resident received scheduled pain medication and PRN medication and was unable to rate the intensity of his/her pain. Review of the February MAR for RI #17 revealed the resident was to receive [MEDICATION(S)] tablet 7.5-325 mg every 4 hours as needed for pain. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 7. Review of a significant change MDS, dated [DATE], revealed RI #18 had a BIMS score of 15, indicating the resident was cognitively intact. The MDS indicated the resident received scheduled pain medication and PRN medication, had occasional pain, and rated the intensity of the pain at two on a scale of zero to ten. Review of the February 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 8. Review of a quarterly MDS, dated [DATE], revealed RI #19 had a BIMS score of 13, indicating the resident was cognitively intact. The MDS indicated the resident received scheduled pain medication and PRN medication and rated the intensity of his/her pain as three on a scale of zero to ten. Review of the February 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review and interview of an additional resident who had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Review of an annual MDS dated [DATE] revealed RI #11 had a BIMS score of 15, indicating the resident was cognitively intact. - Review of an Order Summary Report revealed RI #11 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . - During an interview on 09/23/2022 at 9:55 AM, RI #11 stated his/her pain control had been good, and that he/she had not missed any doses of pain medication. EI #11 stated he/she did not remember ever having a missed dose of pain medication.

Based on record review, interviews, document review, and review of a facility policy titled, Controlled Drugs, Management of, the facility failed to ensure an effective system was established to verify accurate receipt of all controlled drugs for 2 (Resident Identifier [RI] #11 and RI #13) of 10 residents reviewed for misappropriation of medications. The failed practice had the potential to affect any resident with physician's orders for narcotic medications. Findings included: Review of a facility policy titled, Controlled Drugs, Management of, revised on 06/01/2021, revealed, All staff who administer medications will safeguard controlled drugs. This policy applies to all medications listed in Schedule II through IV of the Comprehensive Drug Abuse Control Act of 1970. The policy also indicated, Receipt: Controlled drugs are received in separate containers with separate invoices. Licensed nursing staff must accept delivery and take responsibility for receipt of controlled drugs. 1. Review of an Online Incident Report, dated as reported to the Alabama Department of Public Health on 02/14/2022, revealed the facility was unable to locate 60 tablets of [MEDICATION(S)] (a narcotic pain medication) and 30 tablets of [MEDICATION(S)] (a medication used to control seizures or treat nerve pain) tablets. A review of the facility's investigation, dated 02/14/2022, revealed upon discovery of the missing medications, the facility conducted a search of all medication carts and medication storage rooms but did not locate the missing medications. The investigation report indicated the facility provided staff education and the medications were replaced at the expense of the facility and an employee was placed on administrative leave. The suspected offender was identified as Employee Identifier (EI) #2, a Licensed Practical Nurse (LPN). Review of a statement dated 02/16/2022 from EI #2 revealed the nurse was on duty on 02/09/2022, the night the missing medications were delivered to the facility. The statement indicated EI #2 remembered receiving one green bag, three purple bags, and one red box from the pharmacy delivery staff. EI #2's statement indicated he did not deliver any medications to the other nurse on duty that night. 1.a) Based on further review of the Online Incident Report, dated as reported to the Alabama Department of Public Health on 02/14/2022, Resident Identifier (RI) #11 was the resident who was discovered to have had 30 tablets of [MEDICATION(S)] missing. Review of an annual Minimum Data Set (MDS), dated [DATE], revealed RI #11 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS indicated the resident received scheduled and as needed (PRN) pain medication for pain which the resident rated as an intensity of two on a scale of zero to ten, with zero meaning no pain and ten meaning extremely severe pain. Review of a Care Plan, dated as revised on 09/14/2022, revealed the resident was at risk for alteration in comfort related to Diabetes, Left Above the Knee (AKA) Amputation, and chronic pain. Interventions included monitoring and observing for problems sleeping, utilizing a pain scale (to assess the intensity of the resident's pain), medicating the resident as ordered for pain, and monitoring for the medication's effectiveness and for any side effects. Review of an Order Summary Report revealed RI #11 had a physician's order (most recently ordered 08/16/2022) for [MEDICATION(S)] 300 milligrams (mg) by mouth at bedtime for pain. Review of the February 2022 Medication Administration Record (MAR) revealed RI #11 received all scheduled doses of [MEDICATION(S)] as ordered. During an interview on 09/23/2022 at 9:55 AM, RI #11 stated his/her pain control had been good, and that he/she had not missed any doses of pain medication. EI #11 stated he/she did not remember ever having a missed dose of pain medication. 1.b) Based on further review of the Online Incident Report, dated as reported to the Alabama Department of Public Health on 02/14/2022, RI #13 was the resident who was discovered to have had 60 tablets of [MEDICATION(S)] (a narcotic pain medication) missing. Review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed RI #13 had a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. The MDS indicated the resident received as needed (PRN) pain medication but was unable to rate the intensity of the pain. Review of a Care Plan, dated as revised on 04/20/2022, revealed RI #13 was at risk for alteration in comfort related to chronic pain. Interventions included monitoring for nonverbal signs of pain, such as an increase in agitation, grimacing, or resistance to care and completing pain assessments per protocol. Review of the February 2022 MAR for RI #13 revealed the resident was to receive [MEDICATION(S)] ([MEDICATION(S)]/acetaminophen) 5-325 mg tablets, one tablet twice a day for pain. The MAR indicated the resident received all scheduled doses except for the 8:00 PM doses on 02/11/2022, 02/12/2022 and 02/18/2022. According to the pain levels noted on the MAR, RI #13 rated the intensity of his/her pain as between zero and 4 on the day shift (8:00 AM dose) and rated the pain between zero and three on evening shift (8:00 PM dose). A telephone interview was conducted on 09/23/2022 at 8:00 AM with EI #2, who stated after COVID-19 broke out, the facility received pharmacy deliveries in the front lobby of the facility. EI #2 stated he received a purple bag and red box the evening of 02/09/2022. EI #2 stated the purple bags contained all medications that were not narcotics, and the red box contained medications for replacement in the Omnicell machine. EI #2 stated narcotics were delivered in a yellow/gold bag, and he did not receive any yellow/gold bags that evening. EI #2 stated he did not know any medications were missing until he was preparing to give [MEDICATION(S)] to RI #11. EI #2 stated there was no [MEDICATION(S)] in the cart, so he notified pharmacy to receive a code for the Omnicell machine. EI #2 stated if the staff needed to remove a controlled medication from the Omnicell machine, they were required to call the pharmacy, and the pharmacy would provide the staff with a code for tracking purposes. EI #2 stated the staff then would log into the Omnicell using the code, and a second nurse would sign as a witness. EI #2 stated when he called the pharmacy, the pharmacy explained that a new card of medication had been delivered on 02/09/2022 and was signed for by staff. EI #2 asked who had signed for the medication and was told it was himself. EI #2 stated he notified the Director of Nursing (DON) immediately. EI #2 stated he did not take the medications and believed the medications were never delivered to the facility. EI #2 stated he received education after the incident and was instructed to open all bags of medication and compare what was received with the manifest before signing the receipt. A telephone interview was conducted on 09/23/2022 at 8:58 AM with EI #3, the previous DON. EI #3 stated she received a call from EI #2, who stated when he contacted the pharmacy for a code for the [MEDICATION(S)], he was told the medication had already been delivered and he had signed for it. EI #3 stated the facility used to receive all deliveries of medications on each unit until the COVID pandemic started. After that, the facility received all medications in the front lobby. EI #3 stated she and the Assistant Director of Nursing (ADON) searched the building and medication carts and did not find the medications. EI #3 stated they notified pharmacy, and the pharmacy made the decision to utilize pharmacy staff for deliveries of medications instead of the contracted courier service they had been using. EI #3 stated she provided education to staff immediately and instructed them to open all medication bags and inspect the contents and compare the medications received to the manifests before signing the receipts. EI #3 stated she performed random monitoring after this system was put in place, by checking the manifest and verifying the medications were in the building. She stated she did not use a formal monitoring tool or document the monitoring. EI #3 stated all new nurses, including contract nurses, were trained with a staff nurse for several days and were instructed on the proper procedure for accepting medications. Observation on 09/22/2022 at 3:30 PM revealed a pharmacy driver delivered medications to EI #4, LPN. EI #4 received a purple bag and a yellow/gold bag from the driver. EI #4 opened both bags of medications and verified the contents, then signed the paper manifest as well as the electronic manifest on the driver's phone. An interview was conducted on 09/22/2022 at 2:00 PM with EI #10, Pharmacist, who stated she was not aware of the issues concerning the deliveries to the building in the past but knew the pharmacy used their own drivers for deliveries now. An interview was conducted on 09/22/2022 at 3:30 PM with EI #5, pharmacy driver, who stated he delivered to the facility five days a week if there were any medications to be delivered. EI #5 stated he attempted to deliver all medications during the dayshift hours because of the previous incident at the facility, but sometimes came during the evening hours. EI #5 stated he delivered the medications to each unit and waited for the staff to sign the manifest on paper and the electronic form on his cell phone. Staff interviews were conducted to determine if the facility's licensed nurses were knowledgeable regarding the facility's system for receipt of narcotic medications, as follows: - An interview was conducted on 09/22/2022 at 9:24 AM with EI #9, Registered Nurse (RN), who stated she was usually not working when pharmacy delivered medications to the facility but was trained to open all packages delivered from pharmacy and verify that what was in the package matched the manifest. EI #9 stated if the manifest and medications did not match, she was to notify the pharmacy and the DON. - An interview was conducted on 09/22/2022 at 3:38 with EI #4, who stated she was a contract nurse and had worked at the facility for two weeks. EI #4 stated she received training regarding the proper steps when accepting medications into the facility. EI #4 stated she opened the packages and checked them against the manifest before signing anything. EI #4 stated the narcotics were delivered in yellow/gold bags, and all other medications were delivered in the purple bags. - An interview was conducted on 09/22/2022 at 4:00 PM with EI #6, LPN, who stated she was a contract nurse and was trained by facility staff on the correct way to accept delivered medications from the pharmacy. EI #6 stated she did not sign the manifest until all medications were correctly accounted for. EI #6 stated she had a second nurse sign the manifest to verify the receipt of narcotics. - An interview was conducted on 09/22/2022 at 5:45 PM with EI #7, LPN, who stated the pharmacy drivers used to deliver all medications to each nursing unit until the COVID outbreak and had now started doing this again. EI #7 stated she was educated on the process for accepting medications from pharmacy, which included opening the packages and counting the medication cards and verifying that everything was correct before signing the manifest. EI #7 stated she was instructed to contact the pharmacy and DON if the manifest and medications did not match. An interview was conducted on 09/22/2022 at 2:06 PM with EI #8, the current Director of Nursing (DON). EI #8 stated she received training after this incident, as she was a charge nurse at that time. EI #8 stated the training included for staff to open all pharmacy packages and compare the contents against the manifest, and to sign the manifest only after staff verified it for accuracy. If the manifest and medications were not accurate, staff were to notify the pharmacy and the DON. An interview was conducted on 09/23/2022 at 8:44 AM with EI #1, Administrator, who stated medications were dropped off at the front lobby after the COVID outbreak started in 2020. EI #1 stated the drivers now came into the building and delivered the medications directly to the nurses on the units. EI #2 confirmed the staff were reeducated on the process for receiving medications from pharmacy and now opened all packages and inspected them to ensure the medications and manifests were accurate. EI #1 stated if residents did not receive narcotic medications as ordered, they could have increased pain and possibly require hospitalization .

Based on observation, interview, review of Resident Identifier (RI) #2's medical record and the facility's policy titled Medication Administration: Inhaled (MDIs) (Metered Dose Inhalers), the facility failed to ensure Employee Identifier (EI) #2, a Registered Nurse (RN) administered RI #2's inhaler medication in accordance with the facility's policy and procedure. This deficient practice affected RI #2, one of four residents observed for medication administration. Findings include: The facility's policy titled, Medication Administration: Inhaled (MDIs), with a revised date of 11/1/2019, documented . 3. Administer medication . 3.4 Evaluate patient's heart rate, respiratory rate, and breath sounds . 3.8 Instruct patient to slowly exhale through pursed lips. 3.9 Place spacer in patient's mouth. If not using spaces, hold MDI 1 1/2 inches away from patient's open mouth. 3.10 Instruct patient to begin inhaling slowly, while actuating the MDI. 3.11 Instruct patient to continue inhaling slowly and deeply, hold breath for 5 to 10 seconds, then exhale. 3.12 Wait for one minute between puffs of the same medication and five minutes between puffs of different medications . 8. Evaluate patient's heart rate, respiratory rate and breath sounds after administration . During medication pass observation on 8/26/2020 beginning at 7:55 AM, EI #2, a RN handed RI #2 an [MEDICATION NAME] inhaler for administration without any instructions on what to do or assessment of the resident. One minute later, EI #2 handed RI #2 the [MEDICATION NAME] inhaler. EI #2 again did not provide any instructions to the resident on what to do. EI #2 did not assess RI #2's heart rate, respiratory rate or breath sounds after administration of the inhaler medications. In an interview on 8/26/2020 at 10:35 AM, EI #2, a RN was asked if she assessed RI #2 prior to and after administration of the inhaler medications. EI #2 said no. When asked should she have, EI #2 replied yes. When asked why she didn't, EI #2 said she was nervous. EI #2 was asked if she instructed RI #2 on how to use the inhaler medication when it was handed to the resident. EI # answered, she did not. When asked if she waited five minutes in between the administration of the [MEDICATION NAME] and [MEDICATION NAME] inhalers, EI #2 replied, she did not. EI #2 stated she should have waited but she was nervous. EI #2 stated the concern with no waiting five minutes between each inhaler was that the resident might not get the full benefit of the medication.

Based on observations, interviews, review of FUNDAMENTALS OF NURSING NINTH EDITION and the facility's policy titled IC203 Hand Hygiene, the facility failed to ensure Employee Identifier (EI) #1, a Licensed Practical Nurse (LPN) did not place Resident Identifier (RI) #1's [MEDICATION NAME] Insulin pen on top of the medication cart without a barrier. The facility further failed to ensure EI #2, a Registered Nurse (RN) changed her gloves after touching a potentially contaminated item before she administered medications to RI #2. These deficient practices affected RI #1 and RI #2, two of four residents observed for medication administration. Findings include: 1) Page 445 of Chapter 29 titled Infection Prevention and Control of FUNDAMENTALS OF NURSING NINTH EDITION documented . Modes of Transmission . The major route of transmission of pathogens identified in the health care setting is the unwashed hands of the health care worker. Equipment used within the environment often becomes a source for the transmission of pathogens . During medication pass observation on 8/25/2020 at 3:31 PM, EI #1, an LPN placed RI #1's [MEDICATION NAME] Insulin pen on top of some papers and book on top of the medication cart prior to administering the medication to the resident. In an interview on 8/26/2020 at 10:54 AM, EI #1, an LPN was asked should she place items to be used in a medication pass on potentially contaminated surfaces. EI #1 said no. When asked where she placed RI #1's Insulin pen prior to administration, EI #1 replied on top of the book on the cart. EI #1 was asked what the book and papers should be considered. EI #1 stated potentially contaminated because she did not know what might be on them. EI #1 was asked what the concern was with placing an insulin pen on a potentially contaminated surface prior to administration. EI #1 answered cross contamination and infection control. In an interview on 8/26/2020 at 11:11 AM, EI #3, the Infection Control Preventionist was asked should items used in medication pass be placed on potentially contaminated surfaces. EI #3 replied, no, they must have a barrier. When asked what the concern was with placing an Insulin pen on a potentially contaminated surface, EI #3 answered the transmission of bacteria and infection control. 2) The facility's policy titled IC203 Hand Hygiene with a revision date of 11/28/2017, documented POLICY Adherence to hand hygiene practices is maintained by all Center personnel . PURPOSE To improve hand hygiene practices and reduce the transmission of pathogenic microorganisms . PROCESS 1. Perform hand hygiene: . 1.5 After contact with the patient's environment . During medication pass observation on 8/26/2020 at 7:55 AM, EI #2, a RN wore gloves while she adjusted RI #2's bed with the bed remote. EI #2 then wore those same gloves when she administered two inhaler medications, a nasal spray and by mouth medications to RI #2. In an interview on 8/26/2020 at 10:35 AM, EI #2, a RN was asked did she change her gloves and sanitize her hands after she used RI #2's remote to adjust the resident's bed prior to medication administration. EI #2 replied, no. EI #2 was asked what the concern was with not changing gloves after touching a potentially contaminated item or surface. EI #2 answered, the spread of infection by spreading bacteria on whatever touched to the resident. In an interview on 8/26/2020 at 11:11 AM, EI #3, the Infection Control Preventionist was asked should a nurse adjust a bed with the remote control while wearing gloves and then administer medications wearing those same gloves, EI #3 answered no. EI #3 explained the nurse should have set the medications down on a barrier on the bedside table, adjust the bed, sanitize her hands, reapply gloves, administer the medications then wash her hands. When asked what the concern was with not changing gloves after touching a potentially contaminated item then administering medication wearing the same gloves, EI #3 answered the transmission of bacteria and infection control.

Based on observations, interview, review of facility documents titled, Use By Dating Guideline and Cleaning Procedure Mixer, the facility failed to ensure: 1. outdated thickened apple juice was not stored in the emergency food supply and 2. the food mixer was clean and free from food particles between uses. These failures had the potential to affect 108 of 108 residents who received meals from the kitchen. Findings Include: 1)The facility policy titled, Use By Dating Guidelines, dated 05/01/11, . The manufacturer's expiration date, when available, is the use by for unopened items . On 01/21/20 at 02:19 p.m., the surveyor and Employee Identifier (EI) #1, Dietary Account Manager, observed the following food items in the emergency food supply five honey like consistency thickened apple juice 46 ounce boxes with a use by date of 12/25/19. On 01/21/20 at 02:19 a.m., an interview was conducted with EI #1. EI #1 was asked what was the use by date date on the five honey like consistency thickened apple juice 46 ounce boxes. EI #1 stated 12/25/19. EI #1 was then asked should the out dated food items be in the emergency food supply. EI #1 stated no. EI #1 was then asked what was the potential harm in having outdated food items in the emergency food supply. EI #4 stated it could make the resident sick. 2) A review of the facility document titled Cleaning Procedure, documented: Cleaning Procedure Mixer When: After each use . 4. Scrub all stationary parts of mixer . Give special attention to : underside of head, corners, cord, handles, underneath rolled rims, and walls around area . On 01/21/20 at 02:33 p.m., the surveyor and EI #1 observed the mixer. The surveyor asked EI #1 did covering the mixer mean it was clean. EI #1 stated yes, that meant it was clean. The surveyor asked EI #1 to take the cover off the mixer. The surveyor observed the top of the mixer to have a white thick substance (food particles). EI #1 was asked what was that on the top of the mixer. EI #1 stated food. EI #1 was then asked what was the potential harm in the food particles being left on the mixer. EI #1 stated bacteria could grow on it.

Based on interview, medical record review and review of a facility policy titled, Person-Centered Care Plan, the facility failed to ensure Resident Identifier (RI) #61 and RI #65's care plans regarding code status were revised to reflect RI #61 and RI #65's DNR (Do Not Resuscitate) decision. This affected RI #61 and RI #65, two of 32 residents whose care plans were reviewed for code status. Findings Include: A review of a facility policy titled, Person-Centered Care Plan, with a Revision Date 03/01/18, documented: .7. Care plans will be: .7.2 Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals; . 1.) RI #61 was readmitted to the facility on [DATE]. On 11/07/18 at 3:22 p.m., a review of RI #61's medical record revealed a DNR order was written on readmission on 10/30/18 and was noted on RI #61's facesheet. Further review revealed a Full Code Care Plan initiated on 11/02/18 did not reflect RI #61's decision for DNR and no advanced directive form was found on RI #61's chart as per facility policy. On 11/07/18 at 4:15 p.m., an interview was conducted with Employee Identifier (EI) #3, Registered Nurse (RN)/Minimum Data Set (MDS) Coordinator. EI #3 was asked how should RI #61's care plan reflect the current code status. EI #3 said RI #61's care plan should reflect his/her most current code status which was a DNR. EI #3 was asked if a resident returned from the hospital with a new DNR order, when should the care plan reflect the new updated code status. EI #3 stated upon readmission to the facility. EI #3 was asked to review RI #61's medical record and was then asked if a signed advanced directive was in RI #61's chart. EI #3 stated, no. EI #3 was asked should there be a signed advanced directive on the chart. EI #3 answered, yes. 2.) RI #65 was readmitted to the facility on [DATE]. On 11/07/18 at 6:38 p.m., a review of RI #65's medical record revealed a Full Code order was written on 01/13/18 (readmission) and was noted on RI #65's facesheet. Further review revealed a DNR Care Plan (initiated 6/03/2016 and revised 6/30/2017) was not revised to reflect RI #65's decision on 01/13/18 for Full Code and no advanced directive form was found on RI #65's chart as per facility policy. On 11/07/18 at 6:50 p.m., an interview was conducted with EI #3, RN/MDS Coordinator. EI #3 was asked what code status care plan should RI #65 have. EI #3 said he/she should have a full code care plan, per the orders. EI #3 was asked when gathering information for the MDS, where did she get the information for the MDS and care plans. EI #3 stated she was only responsible for what triggered on the MDS. EI #3 was asked where did she get the information for advanced directives. EI #3 said from the orders.

Based on observation, interview, medical record review and review of Potter and Perry, Fundamentals of Nursing, the facility failed to ensure Resident Identifier (RI) #27's physician's orders [REDACTED]. This affected RI #27, one of 32 residents whose orders were reviewed. Findings Include: A review of Potter and Perry, Fundamentals of Nursing, Ninth Edition, Chapter 23, Legal Implications in Nursing Practice, page 311, revealed: .Health Care Providers' Orders .Nurses follow health care providers' orders unless they believe that the orders are in error . RI #27 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #27's physician's orders [REDACTED]. On 11/05/18 at 5:48 p.m., the surveyor observed RI #27's oxygen tubing dated 10/27/18. On 11/06/18 at 11:07 a.m. the surveyor observed RI #27's oxygen tubing was still dated 10/27/18. On 11/08/18 at 8:02 a.m., an interview was conducted with Employee Identifier (EI) #2, Licensed Practical Nurse (LPN). EI #2 was asked who was responsible for changing the tubing on the oxygen concentrators. EI #2 said it was changed every Sunday night on night shift and it was on the Medication Administration Record [REDACTED]. EI #2 replied, bacterial growth in the tubing and also the tubing will go soft, bend and crack.

Based on observation, interview and review of a facility policy titled, Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, the facility failed to ensure expired medications and medical supplies were not stored in a medication room on the long term care unit. This deficient practice affected one of three medication storage rooms in the facility. Findings Include: A review of a facility policy titled, Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, with a Revision Date 10/31/16, revealed: .4. Facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by the manufacturer or supplier guidelines; .are stored separate from other medications until destroyed or returned to the pharmacy or supplier. On 11/06/18 at 10:19 a.m., the surveyor observed the medication storage room on the long term care unit with Employee Identifier (EI) #2, Licensed Practical Nurse (LPN). The following expired medication and medical supplies were observed: 1. one 30 ML (milliliter) vial filled with Sodium Chloride 0.9% with an expiration date of 07/2016, 2. three syringes with expiration date of 01/2018, five [MEDICATION NAME] syringes with expiration date of 06/2018, 3. one 25 G (gauge) [MEDICATION NAME] needle with an expiration date 07/2018, and 4. 13 red top blood specimen lab tubes with an expiration date 09/30/18. EI #2, LPN, verified with surveyor that all above medication/supplies observed were expired and should not have been present in medication room. On 11/08/18 at 11:41 a.m., an interview was conducted with Employee Identifier (EI) #1, Registered Nurse (RN)/Director of Nursing (DON). EI #1 was asked who was responsible for ensuring all medications and supplies in the medication rooms were within date and not expired. EI #1 said, usually the central supply clerk stocked the supplies in the medication rooms, the RN is responsible for ordering the over the counter medications and then the medication nurses were responsible for checking the dates on the medications before use. EI #1 was asked should expired supplies have been in the medication room. EI #1 replied, no. EI #1 was asked why were expired supplies in the medication room. EI #1 stated they were left in there when a nurse cleaned up the medication room a few weeks ago. EI #1 was asked what was the concern with expired medication/supplies being stored in the medication room. EI #1 answered, they could potentially be used.

Based on observations, interviews and a review of the facility policies titled Personal Hygiene, Productions Tools, Hand Washing, Dry Storage as well as the 2013 Food Code, the facility failed to ensure: 1) wet utensils were not wrapped in napkins and domes and trays were not stacked wet, 2) staff hair was completely enclosed inside of their hair net on 1/24/18, 3) staff did not touch the trash can lid and wash their hands before starting a new task, 4) Mushrooms in the cooler were not spoiled and a use by date was on the container, 5) Ceiling tiles and vents were free of dust and grease like substance. This had the potential to affect 110 of 114 residents who received meals from the kitchen. Findings Include: 1) A review of the Food Code dated 2013 revealed under 4-903.11 (B) Clean Equipment and UTENSILS shall be stored . (1) in a self-draining position that allows air dying; . On 01/24/18 at 11:11 a.m., the surveyor observed four domes stacked wet with water in them. (Employee Identifier) EI #5, dish aide, put two domes over the resident's plates. The surveyor observed EI #5 wipe water from residents trays with a napkin. The surveyor observed EI #5 unwrap ready to go napkins. Water was observed on the spoons, forks, and knives. On 1/25/18 at 2:49 a.m., the surveyor conducted an interview with EI #5. EI #5 was asked what was on the trays, domes, forks, spoons and knives on 1/24/2018. EI #5 replied, water drops. EI #5 was asked did she unwrap utensils with water on them. EI #5 replied, yes ma'am. EI #5 was asked why should trays, domes, forks, spoons and knives be dry before giving them to the residents. EI #5 replied, to prevent cross contamination. EI #5 was asked did she wipe water from trays with a napkin. EI #5 replied, yes ma'am. EI #5 was asked what was the facility policy on how utensils and dishes should be allowed to dry. EI #5 replied, they should be allowed to air dry. 2) A review of a facility policy titled, Personal Hygiene with a revision date of 12/01/2015 revealed: Policy Food and Nutrition Service employees present a neat, clean, professional appearance .PR(NAME)ESS .7. Hair restraints such as hats, hair covering, or nets are worn to effectively keep hair from contacting exposed food. On 01/24/18 at 10:31 a.m., the surveyor observed EI #6, cook, hair was not completely under her hairnet. The back of her hair and side of her hair was hanging out of her hairnet. EI #6 was taking food to the steam table. On 01/25/18 at 2:57 p.m., the surveyor conducted an interview with EI #6. EI #6 was asked was her hair completed under her hair net. EI #6 replied, no ma'am. EI #6 was asked what did the facility policy say regarding worker's hair being completely within the hairnet. EI #6 replied, all of their hair had to be restrained while in the kitchen. EI #6 was asked when was she in-serviced on the use of hairnets. EI #6 replied, two months ago. EI #6 was asked what was the potential harm when worker's hair was not completely enclosed inside their hairnet. EI #6 replied, cross contamination. On 1/25/2018 at 3:38 PM, an interview was conducted with EI #1, Dietary Manger in training. EI #1 was asked what worker's hair was not completely enclosed inside their hairnet. EI #1 replied, EI #6. EI #1 was asked what did the facility policy say regarding worker's hair being completely enclosed within the hairnet. EI #1 replied, it had to be completely covered. EI #1 was asked when was staff in-serviced last on hairnet. EI #1 replied, last month. EI #1 was asked what was the potential harm when workers hair was not completely enclosed inside of their hairnets. EI #1 replied, cross continuation. 3) A review of a facility policy titled, Hand Washing with a Revision Date of 03/16/15 revealed: Policy Hand Washing is performed frequently and using correct hand washing technique .PR(NAME)ESS 1. Hand washing is performed after: . 1.7 When moving from one task to another. On 01/24/18 at 11:11 a.m., EI #6 wiped the preparation table off. EI #6 put food debris from the preparation table in the garbage can. EI #6 touch the trash can lid and continued wiping the preparation table off. EI #6 did not wash her hands after touching the trash can lid. On 01/25/2018 at 3:05 p.m., the surveyor conducted an interview with EI #6. EI #6 was asked what she touched near the three compartment sink then continued to clean on 01/24/2018 at the lunch meal. EI #6 replied, she touched the garbage lid. EI #6 was asked did she wash her hands after touching the garbage lid. EI #6 replied, she did not realize she needed to wash her hands. EI #6 was asked what did the facility policy say regarding when staff should wash their hands in the kitchen. EI #6 replied, every time we change our task, whenever our gloves were soiled, and when we entered the kitchen. EI #6 was asked when was she in-serviced on hand washing. EI #6 replied, a week ago. EI #6 was asked what was the potential harm to the residents when staff did not wash their hands in the kitchen after performing a dirty task and handling food. EI #6 replied, cross contamination. 4) A review of a facility policy titled, Dry Storage with a Revision Date of 12/01/15 revealed: .PURPOSE to prevent damage, spoilage, contamination . 2. Food Storage: .2.6 Open packages are stored in closed containers, tightly secured with ties or in food quality storage bags and includes use by date. On 01/23/2018 at 2:18 p.m., the surveyor toured the kitchen with EI #1. The surveyor observed mushroom in a ten pound box with no use by date. The mushrooms were spoiled. The box contained 50 or more mushrooms. On 01/25/2018 at 3:32 p.m., an interview was conducted with EI #1. EI #1 was asked what food item in the cooler had no use by date. EI #1 replied, mushrooms. EI #1 was asked why was the mushrooms opened in the cooler with no use by date. EI #1 replied, someone put them up without putting a date on them. EI #1 was asked what did the mushroom looked like. EI #1 replied, old, they were spoiled. EI #1 was asked what was the facility policy regarding spoiled food items and food items with no use by date in the cooler. EI #1 replied, they must be discarded. EI #1 was asked who was responsible for removing food items out of the cooler when they are spoiled or out of date. EI #1 replied, there was no one assigned person. EI #1 was asked what was the potential harm to the residents when food items were in the cooler without a use by date. EI #1 replied, could cause sickness. EI #1 was asked how often was the cooler observed for spoiled food and foods with no use by date. EI #1 replied, at least once a day. 5) A review of the 2013 Food Code revealed: 6-201.17 Walls and Ceilings, Attachments .vents covers .and other attachments shall be EASILY CLEANABLE. On 01/24/2018 at 11:11 a.m., the surveyor observed the ceiling. The ceiling was observed to have a grease and dust like substance on it. The food preparation table was located under the greasy ceiling. There were two ceiling vents full of dust and grease. The dish rack was located under the vents. On 01/25/2018 at 3:21 pm., the surveyor conducted an interview with EI #1. EI #1 was asked what was in the ceiling vents in the kitchen. EI #1 replied, it look like a grease build up and dust. EI #1 was asked what was on the tile in the ceiling. EI #1 replied, grease, dust and spilled food. EI #1 was asked when were the vents and the tile clean last. EI #1 replied, that was a question for maintenance. EI #1 was asked who was responsible for making sure the vents and the tile in the ceiling were cleaned. EI #1 replied she was not sure. EI #1 was asked what kitchen equipment was located under the ceiling tile. EI #1 replied, the food preparation table. EI #1 was asked what equipment was located under the vents. EI #1 replied, storage shelf. EI #1 was asked what was the potential harm when dust and grease was in the ceiling and the preparation table was located under it. EI #10 replied, cross contamination. On 01/25/2018 at 4:46 p.m., the surveyor conducted an interview with EI #4, the Maintenance Supervisor. EI #4 was asked who was responsible for making sure the vents and tile in the ceiling was cleaned. EI #4 replied, maintenance. EI #4 was asked what did the facility policy say regarding the cleanliness of the vents and the tile in the ceiling. EI #4 replied, clean the vents once a month. On 1/25/2018 at 5:01 p.m., an interview was conducted with EI #7, the Assistant Maintenance Director. EI #7 was asked what was in the ceiling. EI #7 replied, grease in the vents. EI #7 was asked what was on the tile in the ceiling. EI #7 replied, food stains. EI #7 was asked who was responsible for making sure the vents were cleaned. EI #7 replied, he was.