Every finding on record at Greenbriar at the Altamont Skilled Nursing Facilit

Based on observation, interviews, the facility's policy for Cleaning of Miscellaneous Equipment and Utensils, and the 2017 Food Code, the facility failed to ensure the kitchen floor was smooth and easily cleanable to reduce the potential for foodborne illness. This deficient practice had the potential to affect 78 of 78 residents receiving meals from the kitchen. Findings include: A review of the 2017 Food Code of the United States Public Health Service and the FDA (United States Food and Drug Administration) included the following: . 1-201.10 Statement of Application and Listing of Terms. Easily Cleanable. (1) 'Easily cleanable' means a characteristic of a surface that: (a) Allows effective removal of soil by normal cleaning methods; (b) Is dependent on the material, design, construction, and installation of the surface; and (c) Varies with the likelihood of the surface's role in introducing pathogenic or toxigenic agents or other contaminants into FOOD based on the surface's APPROVED placement, purpose, and use. 'Easily Movable' means: (1) Portable; mounted on casters, gliders, or rollers; or provided with a mechanical means to safely tilt a unit of EQUIPMENT for cleaning; . 'Smooth' means: . (3) A floor, wall, or ceiling having an even or level surface with no roughness or projections that render it difficult to clean. Preventing Contamination from the Premises 3-305.11 Food Storage. (A) . FOOD shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; . 3-305.14 Food Preparation. During preparation, UNPACKAGED FOOD shall be protected from environmental sources of contamination. Preventing Contamination from Other Sources 3-307.11 Miscellaneous Sources of Contamination. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306. Indoor Areas 6-101.11 Surface Characteristics. (A) . materials for indoor floor . surfaces under conditions of normal use shall be: (1) SMOOTH, durable, and EASILY CLEANABLE for areas where FOOD ESTABLISHMENT operations are conducted; . Cleanability 6-201.11 Floors, Walls, and Ceilings. . except for antislip floor coverings or applications that may be used for safety reasons, floors, floor coverings, . shall be designed, constructed, and installed so they are SMOOTH and EASILY CLEANABLE. A review of the 2017 Food Code of the United States Public Health Service and the FDA in the Annex 3 Public Health Reasons/Administrative Guidelines the following was included: . Preventing Contamination from the Premises 3-305.11 Food Storage. 3-305.12 Food Storage, Prohibited Areas. Pathogens can contaminate and/or grow in food that is not stored properly. Drips of condensate and drafts of unfiltered air can be sources of microbial contamination for stored food. Shoes carry contamination onto the floors of food preparation and storage areas. Even trace amounts of refuse or wastes . can become sources of food contamination. Moist conditions . promote microbial growth. 3-305.14 Food Preparation. Food preparation activities may expose food to an environment that may lead to the food's contamination. Just as food must be protected during storage, it must also be protected during preparation. Sources of environmental contamination . may be encountered when preparing food in a building that is not constructed according to Food Code requirements. Indoor Areas 6-101.11 Surface Characteristics. Floors, walls, and ceilings that are constructed of smooth and durable surface materials are more easily cleaned. Floor surfaces that are graded to drain and consist of effectively treated materials will prevent contamination of foods from dust and organisms from pooled moisture. The facility's policy Cleaning of Miscellaneous Equipment and Utensils, with an effective date of 11/2019, included the following: . Purpose: To prevent the spread of bacteria that may cause food borne illnesses. Standard: Equipment and utensils should be cleaned according to an established cleaning schedule. Process: . Basic procedures are as follows: . 14. Floors * Sweep floor at least daily and as needed. * Mop floor using disinfecting detergent solution, as needed, and at least once daily . * Move wheeled carts and other movable objects; clean under stationary equipment as much as possible . On 4/06/21 at 1:50 PM, Employee Identifier (EI) #2, the Registered Dietitian (RD) and Director of Food Service, said the kitchen was serving 78 residents on the Skilled Care floor of the facility. During the kitchen tour on 4/06/21 at 2:00 PM, five milk crates were observed to be holding up the lowest shelf in the chemical storage area. Due to the milk crates, the floor could not be easily swept or mopped under this shelf. There was more than one day's accumulation of dirt and trash (bottle lids) on the floor under the shelf. At 2:03 PM, EI #2 was asked what was the problem with the floor under the chemical shelving in the closet. EI #2 said, It is dirty and remains dirty. Pests. During the kitchen tour with EI #2 on 4/06/21 at 2:05 PM, the kitchen floor was observed to have patches of black and grey on red. During an inspection of the kitchen on 4/07/21 at 9:20 AM, the black strip on the floor between the Three Compartment Pot and Pan Washing Sink and the Cook's Food Preparation Area appeared very dirty and to have small, irregular-shaped particles attached to it. The particles appeared to be bits of plastic, paper, and foil. The black floor surface felt rough to the touch of the surveyor's fingers, while the red floor area felt smooth. On 4/07/21 at 10:00 AM, EI #1, the Maintenance Director, was interviewed in the Kitchen in the area between the Three Compartment Pot and Pan Washing Sink and the Cook's Food Preparation Area. When asked what was the material used for the floor where there was a rough black strip, he said it was concrete that had attracted the dirt and rubber from shoes and wheels. The surveyor touched the black surface of the floor and asked why does this feel rough compared to the rest of the floor. EI #1 said it was concrete and the rest of the floor had epoxy paint. He further said the area was due to a plumbing repair from around 2015. When asked if there were pieces of paper and plastic attached to the black section of floor, EI #1 said he thought that was paint. A piece of foil was peeled off of the black floor section by the surveyor. When asked why there was a distinct cut off from black to grey in the same high traffic area if the black was due to rubber-soled shoes and equipment wheels, EI #1 said maybe they do not stand in front of those shelves as much. Upon being asked if the black floor area was easily cleanable, EI #1 said he would pressure wash it. On 4/07/21 at 10:40 AM, the surveyor peeled off pieces of paper and foil from the black area on the floor located between the Three Compartment Pot and Pan Washing Sink and the Cook's Food Preparation Area. On 4/07/21 at 11:08 AM, EI #3, the Utility Aide scheduled from 7:00 AM to 3:00 PM was interviewed. EI #3 said he had worked at the facility for eleven years and his duties included sweeping, mopping, taking out garbage, dishwashing, and putting up stock. When asked how often he swept and mopped the kitchen, EI #3 said at 8:00 AM, 11:00 AM, and 2:00 PM. EI #3 said he swept and mopped the floor at least three times a day and at each time he mopped the high traffic area from the Dishwashing area to the Food Service Office, which passed between the Three Compartment Pot and Pan Washing Sink and the Cook's Food Preparation Area. The surveyor commented that the majority of the Kitchen floor was red, but there were long strips of black also. When asked if there was any problem in cleaning the black areas, EI #3 said the red part was smooth and easy to mop, but when they pulled up the pipes, they did something. EI #3 said the black was like tar and it would tear your mop up. EI #3 said he had to scrub it with a floor brush. EI #3 said the floor had been like that since the pipes were pulled up in that area years ago. He further said the floor was supposed to be sloped towards the drains, but these were not. When the surveyor said it looks hard to clean, EI #3 said, Right. EI #3 said he had to use a brush to loosen up whatever was on there and then mop. He further said that some of the black came up with the mop. He also said paper, like salt/pepper packets, stuck to the black section. When asked if he thought the black was a material and not dirt, EI #3 said the black strip was filled with something where they cut into the floor. He said it was not regular cement, it was something else. EI #3 further said the red floor was easy to clean, but the black and grey sections were not smooth and were not easy to clean. On 4/07/21 at 12:36 PM, EI #2, the RD and Director of Food Service, used a metal tape measure to measure the width and length of the black and grey areas. Near the Food Service Office and the elevator, there was a 14 inch wide and 52.5 inch length of mottled black over grey. This 14 inch wide strip then angled, became black, and went straight for 23 feet between the Three Compartment Pot and Pan Sink and the Cook's Preparation Area. The strip then angled again at the(NAME)area for 1.5 feet to the shelving area and then straight again for one foot and one inch. The strip then became grey for 5 feet to the dishwashing area entrance. The grey strip, still 14 inches wide, then made a 90 degree right angle toward a table, which was next to the steamtable used for Skilled Care breakfast. Close to the table the grey was mottled with black. There was also a 19 inch by 13 inch rough grey area in front of the ice machine. In addition, at the hall just entering the Kitchen by the elevator, the red floor was pitted in several large spots down to the underfloor so that the surface was uneven. On 4/08/21 at 11:01 AM, EI #2, the RD and Director of Food Service was interviewed. EI #2 said she had been working in the facility for about one year. EI #2 was asked if the kitchen floor was clean on 4/7/21 at 9:20 AM, 10:00 AM, or 12:36 PM. EI #2 said it had been mopped, but she was sure there were areas that were not. When asked if the black area that ran parallel to the Three Compartment Pot and Pan Sink was clean at those times, EI #2 said, No. EI #2 was asked why it was important to have clean floors in the kitchen. EI #2 said to prevent pest issues and accidents. Upon being asked when, how, and who cleaned the kitchen floor, EI #2 said the Utility Dietary Aides use a chemical pod in the mop water and typically mop after each meal, if not more often. In addition, EI #2 said yesterday the floors flooded due to a leak from the dishmachine so that was cleaned up in addition to the regular schedule and they had to use a wet vacuum due to the accumulation of water. When asked what challenges there were in maintaining a clean floor in this kitchen, EI #2 said the surface was uneven. Upon being asked if the floor surface was smooth and easily cleanable, EI #2 said in places it was smooth. When asked about other places of the floor, EI #2 said a few areas were rough. EI #2 was asked why a kitchen floor would be graded/sloped and she replied to drain. When asked what was the potential harm of having a floor that was difficult to clean, EI #2 said potential for pests and accidents. When asked what was the potential harm of having a dirty floor in the kitchen, EI #2 said potential for pests and accidents. Upon being asked how a dirty kitchen floor could potentially affect the residents, EI #2 said potential physical contaminants.

Based on observations, interviews, and a facility policy titled Food Receipt and Storage, the facility failed to ensure a bag of six ham pieces and five crab cakes wrapped in plastic were labeled and dated prior to storage in the walk-in freezer. This had the potenital to affect 82 of 82 residents receiving meals from the kitchen. Findings Include: A facility policy titled Food Receipt and Storage with an effective date on 6/2018 revealed . PR[NAME]ESS: 2. Storage: . n. frozen items removed from original packaging should be labeled . and dated. On 2/04/20 at 8:07 AM, an observation was made in the walk-in freezer of a food item wrapped in clear plastic. An immediate interview was conducted with Employee Identifier (EI) #6, Dining Services Manager. EI #6 was asked, what was in the the clear plastic wrap. EI #6 replied, it was five crab cakes. EI #6 was asked, where was the label. EI #6 replied, the crab cakes did not have a label. A second item was observed unlabeled by the surveyor. EI #6 was asked, what was in the the clear plastic wrap. EI #6 replied, it was six pieces of ham. EI #6 was asked, where was the label. EI #6 replied, it was not labeled. On 2/06/20 at 9:07 AM, a second interview was conducted with EI #6. EI #6 was asked, on the morning of 2/4/20, what was found in the walk-in freezer with the surveyor. EI #6 replied, crab cakes and ham pieces. EI #6 was asked, were the ham or the crab cakes labeled with use by date or identification of contents. EI #6 replied, no. EI #6 was asked, where should unlabeled frozen food items be stored. EI #6 replied, they should not be stored anywhere, all opened items in the freezer should be labeled with the delivery date, use by date, and contents labeled. EI #6 was asked, why was the ham in the freezer. EI #6 replied, the ham was used to season vegetables. EI #6 was asked, who was responsible for labeling items to be placed in the freezer. EI #6 replied, any and every individual in the dietary department should label items before placing them in the freezer. EI #6 was asked, how were items labeled for storage in the freezer. EI #6 replied, items were placed in the correct packaging and then labeled with use by date per policy and content label. EI #6 was asked, how many servings of vegetables would have been seasoned with the quantity of ham that was in the freezer unlabeled. EI #6 replied, it would have been used to season one dish for one meal, so around 200 servings of vegetables. EI #6 was asked, what was the potential harm to residents when food items were placed in the freezer without a use by date or content label. EI #6 replied, not knowing the date or the contents could lead to bacteria growth. On 2/06/20 at 12:16 PM, an interview was conducted with EI #5, Dietitian. EI #5 was asked, who was responsible for labeling items to be placed in the freezer. EI #5 replied, whoever placed the food in the freezer. EI #5 was asked, what was found unlabeled in the freezer on 2/4/20. EI #5 replied, some ham and some crab cakes. EI #5 was asked, where should unlabeled frozen food items be stored. EI #5 replied, there should not be any unlabeled frozen food. EI #5 was asked, when were food items labeled that were stored in the freezer. EI #5 replied, before placing into the freezer. EI #5 was asked, why were the crab cakes not labeled. EI #5 replied, because the cook put them in the freezer without labeling them. EI #5 was asked, why was the ham not labeled. EI #5 replied, because the cook put them in the freezer without labeling them. EI #5 was asked, how often was ham used to prepare food. EI #5 replied, a couple times per week. EI #5 was asked, how were items labeled for storage in the freezer. EI #5 replied, with the opened date, contents, and use by date.

Based on record review and interviews the facility failed to ensure all alleged allegations of abuse were reported to the State Agency no later than two hours after the allegation was made. This affected Resident Identifier (RI) # 44, 24, and 68, three of three residents sampled for abuse allegation reporting. Findings Include: 1.) Resident Identifier (RI) #44 was re-admitted to the facility on [DATE]. The facility submitted an allegation of Physical Abuse involving RI #44 via Online Incident Reporting System on 9/2/2019 at 11:25 AM. The report identified the incident occurred on 9/2/2019 at 4:00 AM. On 2/05/2020 at 5:10 PM, an interview was conducted with Employee Identifier (EI) #3, Registered Nurse (RN) Unit Manager. EI #3 was asked, if she had knowledge of the incident involving RI #44. EI #3 replied, yes she did. EI #3 was asked, when she was made aware of the incident. EI #3 replied, sometime between midnight and 5:00 AM on 9/2/2019. EI #3 was asked, what time did she notify the Director of Nursing (DON). EI #3 replied, when she got off the phone with EI #4. EI #3 was asked, who was responsible for reporting to the State Agency. EI #3 replied, EI #1, Executive Director or EI #2, Director of Nursing. On 2/05/2020 at 5:43 PM an interview was conducted with EI #2. EI #2 was asked, when was she notified of the incident involving RI #44. EI #2 replied, sometime early the morning it occurred. EI #2 was asked if the incident met the definition of abuse. EI #2 replied, yes. EI #2 was asked, who she reported the incident to. EI #2 replied, EI #1. EI #2 was asked when did she report the incident to EI #1, Executive Director, Abuse Coordinator. EI #2 replied, sometime early that morning. EI #2 was asked what were the reporting requirements for suspected physical abuse. EI #2 replied, if there was bodily injury it should be reported within two hours. If there was no bodily injury then reporting should be within twenty-four hours. EI #2 was asked, when was the incident involving RI #44 reported to the State Agency. EI #2 replied, 11:25 AM on 9/2/2019. EI #2 was asked, if the incident involved abuse. EI #2 replied, a suspected allegation of abuse. EI #2 was asked if the incident involved alleged physical abuse why was it not reported within two hours. EI #2 replied, because there was no bodily injury. 2.) RI #24 was admitted to the facility on [DATE]. The facility submitted an allegation of Physical Abuse involving RI #24 via Online Incident Reporting System on 2/22/2019 10:09 AM. The report identified the incident occurred on 2/21/2019 7:45 PM. A review of Departmental Notes for RI #24 with a date and time of 2/21/2019 9:46 PM revealed, . at around 7:45 PM RI #24's roommate was noted standing outside their room and when asked why he/she was not in bed he/she stated that someone had hit him/her in the nose . On 2/06/2020 at 12:30 PM, an interview was conducted with EI #2. EI #2 was asked, when was she notified of the alleged abuse involving RI #24. EI #2 replied, on 2/21/2019. EI #2 was asked, what time was she made aware of the alleged abuse. EI #2 replied, immediately, about the time of the incident. EI #2 was asked, who notified her of the incident. EI #2 was asked, did she reported the incident to EI #1. EI #2 replied, yes. EI #2 was asked, at what time did she notify EI #1. EI #2 replied, almost immediately. EI #2 was asked, what was the response of EI #1. EI #2 replied, that the incident needed to be reported to the State Agency. EI #2 was asked why did the incident need to be reported to the State Agency. EI #2 replied, it was an allegation of abuse, resident on resident. EI #2 was asked when was the State Agency notified. EI #2 replied, 2/22/2019 at 10:00 AM. EI #2 was asked, if the reporting requirements were met. EI #2 replied, yes, there was no physical injury. EI #2 read the regulation. EI #2 was asked, after reading the regulation, were the reporting requirements met. EI #2 replied, no. EI #2 was asked, why were the reporting requirements not met. EI #2 replied, because it was an allegation of abuse. EI #2 was asked, who was responsible for reporting an allegation of abuse to the State Agency. EI #2 replied, social services, myself and EI #1. EI #2 was asked, did the facility ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, were reported immediately. EI #2 replied, no. On 2/06/2020 at 1:19 PM, an interview was conducted with EI #1. EI #1 was asked, when she was notified of the alleged abuse of RI #24. EI #1 replied, on the 21st of February. EI #1 was asked, what time was she notified. EI #1 replied, she did not remember. EI #1 was asked, when was the State Agency notified. EI #1 replied, on 2/22/19 and was not sure of the time. EI #1 was asked, was this incident an allegation of abuse. EI #1 replied, yes, an allegation of resident to resident. EI #1 was asked, what were the reporting requirements for allegation of abuse. EI #1 replied, per our policy if no serious body injury to report in 24 hours. EI #1 was asked, if this was still the facility policy. EI #1 replied, yes. EI #1 read the regulation. EI #1 was asked after reading the regulation, did the facility's policy comply with the regulation. EI #1 replied, there was some discrepancy. EI #1 was asked, should the incident have been reported within two hours. EI #1 replied, yes, based on the regulation. EI #1 was asked, why was the incident not reported within two hours to the Sate Agency. EI #1 replied, it was reported within twenty-four hours based on the facility policy. EI #1 was asked, who was responsible for reporting an allegation of abuse to the State Agency. EI #1 replied, the Abuse Coordinator. EI #1 was asked who was the Abuse Coordinator. EI #1 replied, herself. EI #1 was asked, did the facility ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, were reported immediately, but not later than two hours after the allegation was made. EI #1 replied, no 3.) RI #68 was admitted to the facility on [DATE] and re-admitted on [DATE]. The facility submitted an allegation of Mental Abuse involving RI #68 via Online Incident Reporting System on 6/4/2019 5:26 PM . The report identified the incident occurred on 6/3/2019 2:00 PM. On 2/06/2020 at 12:49 PM, an interview was conducted with EI #2, DON. EI #2 was asked, when was she notified of the allegation of mental abuse involving RI #68. EI #2 replied, on 6/3/19 around 3:00 PM. EI #2 was asked, who did she report the alleged abuse to. EI #2 replied, EI #1 was out on leave. EI #2 was asked, was she responsible for reporting abuse allegations in EI #1's absence. EI #2 replied herself or the social service director. EI #2 was asked who was responsible for reporting an allegation of abuse to the State Agency. She replied the social service director, herself or EI #1. EI #2 was asked, when was the State Agency notified. EI #2 replied, on 6/4/19 5:26 PM. EI #2 was asked, why was it important to report allegations of abuse. EI #2 replied, to ensure they were protecting their residents. EI #2 was asked, did the facility ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, were reported immediately, but not later than two hours after the allegation was made. EI #2 replied, no, it was greater than two hours. On 2/06/2020 at 1:40 PM, an interview was conducted with EI #1, Executive Director. EI #1 was asked, according to the investigative report, when was the alleged abuse reported for RI #68. EI #1 replied, per the online incident reporting, 6/4/2019. EI #1 was asked, according to the online incident reporting system narrative summary of the incident, when was the alleged abuse reported to the facility. EI #1 replied, on 6/03/19. EI #1 was asked, why was alleged abuse without serious bodily injury not reported within two hours to the State Agency. EI #1 replied, they reported based off their policy. This deficient practice was cited as a result of the investigation of complaint/report # AL 071.

Based on record review, interview, and review of a facility policy titled, Disposal of Medications Non-Controlled Medication Destruction, the facility failed to ensure the required signatures were on two of 11 Non-Controlled Record of Medication Destruction Sheets for the month of April, (YEAR). This affected one of 10 months of Non-Controlled Medication Destruction Records reviewed. Findings Include: Review of a facility policy titled, Disposal of Medications Non-Controlled Medication Destruction, dated 3/2011, revealed: . 3. The registered nurse and/or pharmacist witnessing the destruction .ensures that the following information is entered on the Record of Medication Destruction form . J. Signature of witnesses, two witnesses required for non-controlled substances . in the designated areas on the destruction form . On 12/12/2018 at 1:55 p.m., the surveyor reviewed the facility's Non-Controlled Medication Destruction Book. A review of the (MONTH) (YEAR), Non-Controlled Medication Destruction Sheets, revealed two of 11 signature sheets, dated 04/27/2018, did not contain the required two signatures. On 12/12/18 at 05:15 p.m., the surveyor conducted an interview with Employee Identifier (EI) #2, the Director of Nursing. The surveyor asked EI#2, what information should be on the Non-Controlled Medication Destruction Sheet. EI#2 replied, the resident name, the medication, quantity of medication, date destroyed, and signatures of two nurses and/or pharmacy, should be listed. The surveyor asked EI#2, who was responsible for ensuring the Non-Controlled Medication Destruction Sheets were filled out completely. EI#2 said she was responsible for ensuring the sheets are filled out. The surveyor asked EI#2, on her review of the (MONTH) (YEAR) Non-Controlled Medication Destruction Sheets, how many signatures did she observe. EI#2 said there was only one signature on two of the Non-Controlled Medication Destruction Sheets for (MONTH) (YEAR). The surveyor asked EI#2, how many signatures should be on the Non-Controlled Medication Destruction Sheets. EI#2 replied, there should be two signatures on the Non-Controlled Medication Destruction Sheets.

Based on observation, interviews, and review of a facility policy titled, Medication Administration-General Guidelines, the facility failed to ensure a Licensed Practical Nurse (LPN) washed her hands prior to and after administering a topical medication ointment to Resident Identifier (RI) #74. This deficient practice affected one of five residents observed during medication administration with one of four nurses. Findings Include: A review of a facility policy titled, Medication Administration-General Guidelines, dated 03/2011, revealed: . Procedures . 6. Cleanse hands with soap and water before handling medication and before and after direct contact with resident. (Other examples where this would be necessary are when administering topical .medications.) . RI #74 was admitted to the facility on [DATE]. On 12/11/2018 at 08:12 a.m., the surveyor observed Employee Identifier (EI) #1, a Licensed Practical Nurse (LPN), during a medication administration pass for RI #74. The surveyor observed EI #1 put RI #74's pill medication cup in the garbage can after RI #74 took the oral medications, put gloves on both hands (did not wash hands prior to putting on the gloves), put a topical medication ointment on RI #74's lower back area, remove her gloves (did not wash her hands), and took the garbage bag out of the room. EI #1 did not wash her hands prior to and after administering the topical medication ointment to RI #74. On 12/11/2018 at 10:40 a.m., an interview was conducted with EI #1, LPN. EI #1 was asked did you wash your hands prior to putting on gloves before administering the topical medication ointment to RI #74's lower back during the medication administration pass. EI #1 stated no. EI #1 was asked if she washed her hands after she removed her gloves from administering the topical medication ointment to RI #74. EI #1 stated no. EI #1 was asked why she did not wash her hands prior to and after administering the topical medication ointment to RI #74. EI #1 stated that she forgot to wash her hands. EI #1 was asked what is the facility policy regarding hand hygiene during administration of a topical medication ointment to a resident. EI #1 stated you should cleanse your hands with soap and water before and after direct contact with the resident. EI #1 was asked if the facility policy was followed on RI #74 during administration of the topical medication ointment. EI #1 stated no. EI #1 was asked what would be the concern with a Licensed Practical Nurse not washing their hands prior to and after administering a topical medication ointment to a resident. EI #1 stated that it could cause pathogens to transport from host to host or recipient to recipient to a resident. EI #1 further stated that this could cause an illness to a resident. On 12/11/2018 at 10:49 a.m., an interview was conducted with EI #2, Director of Nursing (DON) and Infection Control Preventionist. EI #2 was asked what is the facility policy regarding hand hygiene during administration of a topical medication ointment. EI #2 stated you should clean your hands with soap and water or hand gel prior to and after giving a topical medication ointment. EI #2 was asked what would be the concern with a Licensed Practical Nurse not washing their hands prior to and after administering a topical medication ointment to a resident. EI #2 stated it could spread germs and cause infection to a resident. _______________________________________________

Based on observation, resident group interview and staff interviews, the facility failed to ensure the results of the facility's most recent survey was readily accessible to residents, visitors and other individuals. This had a potential to affect all the residents, visitors and other individuals in the facility. Findings Include: On 12/10/18 1:28 at p.m., during the initial tour of the facility, the surveyor observed a letter written in small font, typed print, to notify visitors, families and residents on the location of survey results. This letter was posted outside the elevator on the third floor not easily visible to read by residents sitting in wheelchairs. Approximately eight residents were noted around this area sitting in wheelchairs. To read the posting, the surveyor was eye level, at approximately five feet tall, and approximately one foot distance from the posting. On 12/11/18 3:18 at p.m., the surveyor and Employee Identifier (EI) #2, Director of Nursing, toured the facility to observe the notification of survey results letter posted outside of the elevator on the third floor. When the surveyor asked EI #2 if the letter could be easily read by residents in wheelchairs, EI #2 stated, no, probably not. The Surveyor asked EI #2 how far the sign was from the floor. EI #2 responded probably about 4 1/2 or 5 feet from the floor. On 12/11/18 at 10:06 a.m., during the resident council meeting, the surveyor asked the 12 residents in attendance if they were aware of the location of the results from the last State Inspection. None of the 12 residents in attendance were aware of the Survey Inspection Results, nor the location of the results. An interview with EI #3, Executive Director (ED), was conducted on 12/12/18 at 11:07 a.m. EI #3 was asked where the survey results binders were located in the facility, EI #3 responded that one binder was located behind the south nurse's station and one binder was in the therapy gym. When asked how the residents or visitors could access the results at these locations, EI #3 responded that if anyone asked to see the results of the survey, they would have to ask staff. On 12/12/18 at 05:10 p.m., the surveyor observed the survey results binder on the wall beside the door on the inside of the therapy gym. The surveyor asked EI #5, Physical Therapy Assistant, who was inside the therapy gym at the time, if the therapy gym was opened twenty-four hours for anyone to enter the room. EI #5 stated the therapy gym door is closed and locked between the hours of 5:30 p.m. and 7:30 a.m. On 12/12/18 at 05:23 at p.m., the surveyor observed the survey results binder located behind the nurse's station on the facility's South locked unit. EI #6, a registered nurse on duty at the South's nurse's station, was asked it the unit doors were locked at all times and require a code to enter the south unit. EI #6 stated yes. EI #6 was asked if the residents or visitors are allowed behind the nurse's station. EI #6 stated no.

Based on observation, interview and review of Potter and Perry's Fundamentals of Nursing, the facility failed to ensure Certified Nursing Assistants (CNA) washed their hands between glove changes. On 1/31/18, Employee Identifier (EI) #2, a CNA failed to wash her hands after providing care to Resident Identifier Identifier (RI) #69 before touching clean items. On 1/31/18, EI #3, a CNA failed to washed her hands before exiting the room after completing incontinent care on Resident Identifier (RI) #80. This affected RI#69, one resident observed for incontinent care and RI #80, one resident observed for catheter care. Findings Include: A review of POTTER AND PERRY's FUNDAMENTALS OF NURSING, NINTH EDITION, UNIT V, page 458, revealed: . the WHO (World Health Organization) (2009) recommended the following hand hygiene guidelines: . 3. After contact with body fluids or excretions, . (even if gloves are worn) When moving from a contaminated to a clean body site during care . After removing gloves . 1. RI #80 was readmitted to the facility 5/22/17 with a [DIAGNOSES REDACTED]. On 1/31/18 at 9:43 a.m., Employee Identifier (EI) #3, CNA was observed performing catheter care for RI #80. EI #3 began cleaning the front area, after cleaning she removed her gloves and washed her hands, then as she turned the resident and removed the soiled brief she removed her gloves and put on clean gloves without washing her hands. EI #3 cleaned the buttocks area then removed her gloves and put on clean gloves again without washing her hands. On 1/31/18 at 10:00 a.m., an interview was conducted with EI #3, CNA. EI #3 was asked what was the policy on washing hands when changing gloves. EI #3 replied, when taking gloves off you should wash hands before putting on clean gloves. EI #3 was asked when should she have washed her hands. EI #3 replied, when she took her gloves off. EI #3 was asked if she washed her hands with the last two glove changes; she replied, no. EI# 3 was asked what was the harm in not washing her hands between glove changes. EI #3 replied, infection control. 2. RI #69 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 1/31/18 at 9:43 a.m. EI #2 was observed removing soiled gloves multiple times and applying clean gloves , touching clean items (brief, draw sheet, bed remote), and exiting the room without washing her hands while performing incontinence care. An interview was conducted on 1/31/18 at 10:15 a.m. EI #2 was asked what was supposed to be done after removing soiled gloves. EI #2 replied, Discard them and wash my hands. EI #2 was asked what was supposed to be done before putting on clean gloves. EI #2 replied, Wash my hands. EI #2 was asked if she had washed her hands every time after removing soiled gloves and before putting on clean gloves. EI #2 said, No. EI #2 was asked what was the potential for harm in not washing hands after removing soiled gloves and before putting clean gloves on. EI #2 replied, Cross contamination. EI #2 was asked what should be done after finishing incontinence care before leaving the room. EI #2 replied, Wash your hands. EI #2 was asked what should be done after cleaning stool from the buttocks and before touching clean items. EI #2 replied Wash your hands. On 2/1/18 at 1:18 p.m., an interview was conducted with EI #1, Director of Nursing, she was asked when should staff wash hands during glove changes. EI #1 replied, before and after putting gloves. EI #1 was asked when should staff touch clean items. EI #1 replied, after removing gloves and washing hands. EI #1 was asked what was the harm in staff not washing hands when touching clean items. EI #1 replied, the spread of germs. EI #1 was asked if it would be appropriate for staff to exit the room without washing their hands. EI #1 replied, no. EI #1 was asked what was the harm in staff exiting a resident's room without washing their hands. EI #1 replied, the spread of germs. EI #1 was asked what was the harm in staff not washing their hands between glove changes. EI #1 replied, the possibility of spreading germs.

Based on observations, interviews, and record reviews the facility failed to maintain a clean and sanitary kitchen and distribute food in a sanitary manner as evidence by: 1) Three male employees not wearing hair restraints; 2) Kitchen stove, ovens and equipment not being cleaned; 3) Kitchen floors including walk-in cooler and freezers not being swept clean and debris removed; 4) Walk-in cooler and freezers shelves not clean and free of debris, grime, and rust. 5) Two runoff drains were full of food and debris and a grey like substance which had a foul odor; 6) Nine items of food opened, partially used and not dated or labeled and three of the nine not securely sealed. 7) Ice cream freezer box having a buildup of ice, which was over 1 inch on all four sides. 8) Ice machines and refrigerators in kitchen and on the resident's floor (3 South) not cleaned and maintained. 9) Did not have hand washing soap in the kitchen for two of three days during the survey. This had the potential to affect 84 of 85 residents in the facility that receive foods from the dietary department. Findings include: The 2013's U.S. Public Health Food Code Hair Restraints 2-402.11 Effectiveness. (A) FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, .to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; . The 2013's U.S. Public Health Food Code Management and Personnel 2-1 SUPERVISION . 2-102.11 Demonstration. Based on the RISKS inherent to the FOOD operation, during inspections and upon request the PERSON IN CHARGE shall demonstrate to the REGULATORY AUTHORITY knowledge of food borne disease prevention, . and the requirements of this code. The PERSON IN CHARGE shall demonstrate this knowledge by: . (B) Being a certified FOOD protection manager who has shown proficiency . (8) Describing the relationship between the prevention of foodborne illness and the management and control of the following: (a) Cross contamination, .(c) Handwashing, and (d) Maintaining the FOOD ESTABLISHMENT in a clean condition and in good repair; . (10) Explaining the relationship between FOOD safety and providing EQUIPMENT that is: .(b) Properly designed, constructed, located, installed, operated, maintained, and cleaned; . (11) Explaining correct procedures for cleaning and SANITIZING UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT . The 2013's U.S. Public Health Food Code Labeled and Dated: 3-501.17 Ready-to-eat, time/Temperature Control for Safety Food, Date Marking . prepared and held in a Food Establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the PREMISES, sold, or discarded when held at a temperature of (41 degrees) F (Fahrenheit) or less for a maximum of 7 days. (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by-date . The 2013's U.S. Public Health Food Code Operation and maintenance 5-402.13 Conveying Sewage. SEWAGE shall be conveyed to the point of disposal through an APPROVED sanitary SEWAGE system or other system .operated according to LAW The 2013's U.S. Public Health Food Code Handwashing Sinks 6-301.11 Handwashing Cleanser, Availability. Each HANDWASHING SINK or group of 2 adjacent HANDWASHING SINKS shall be provide with a supply of hand cleaning liquid, powered, or bar soap The facility's policy dated 7/2014, titled Cleaning Schedules identified the PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses. PROCESS: Dietary Management should establish the frequency of equipment cleaning.5. The Dietary Management should supervise adherence to the cleaning schedule, and assure duties are completed as assigned with date and signatures. 6. A thorough inspection of kitchen sanitation should be completed weekly. On 10/31/16 on the initial tour of the kitchen, a male cook with a full beard was cooking by the stove with no beard cover on. When the surveyor attempted to wash her hands, there was no soap in the soap dispenser. The three compartment sinks had one sink stopped up, there was food (biscuit pieces) under the sink. There was different participles of food under cabinets and work area tables. The stove and ovens had cooked on grease and grime on the eyes of the stove, inside the ovens and on the front and sides of the stoves. The oven steamer had food particles on the front and inside. The grease drawer on the stove had more than a few days cooked in grease and burned on food. The work tables were not cleaned and wiped down. On this initial tour of the kitchen on 10/31/16 at 11:30 a.m., there were items not dated and labeled: 1) A quart carton of Breakfast liquid eggs opened, 1/2 used but not dated and labeled. 2) A bag of chicken nuggets, opened, partially used not securely sealed, not labeled and dated. 3) A plastic bag of pre-made cookie, opened and partially used, not securely closed and not dated. 4) A bag of chicken filets opened, partially used, not securely sealed, not dated and labeled. Surveyor showed these to the cook, he took the bag and dropped the chicken filets into the fryer to cook. 5) In the freezer an open box full of waffle strips was opened and the waffle strips had come out of the box and then frozen. They were were not securely sealed in the plastic bag in the box. Not dated when opened. 6) In the walk-in cooler there were two trays of chocolate cake slices. They were not securely wrapped with plastic and were not labeled or dated. 7) In the dry good area, there was a bag of rolls with other bags of rolls which were partially used bags of rolls inside and not labeled with dates. 8) In a refrigerator there was a quart size 1/2 used thickened ice tea, with no opened date. Surveyor observed this on 11/1/16. 9) In the walk-in cooler, there were orange and cranberry juice poured up in glasses with tops on them, with no date. On 11/1/16 at 11:30 a.m., when the surveyor entered the kitchen there was two male employees both with beards and no beard covers. A closer examination revealed one of the two male staff did not have a hair restraint over his hair. When the surveyor attempted to wash her hands (11/1/16 at 11:30 a.m.), there was no soap in the soap dispenser again. One of the Dietary Managers, Employee Identifier (EI) #7 said someone had been told to replace the soap bag, and she thought it had been replaced. After further examination, it had been replaced but the top had not been removed from the bag. The surveyor asked the Dietary Manager EI #7, how had everyone been cleaning their hands. No reply. At this time the two large sinks in the kitchen (one the 3 compartment sink and one the two sink vegetable sinks) were noted to have runoff pipes going down into two open drains on each side of the kitchen. Both run-off valves/pipes had large food particles in the open area and a grey like substance on them. There was an odor omitting from these areas. Over the two sink area, there was a large thick plastic wrap stuck in between the wall and the sink. The plastic appeared to have been there a while for it had food particles on it. A cook explained that they (maintenance) had worked on the sink and after repairs were done, they returned the sink to the wall, but it did not fit correctly, so they put the plastic between the wall and sink. On 11/1/16 at 11:30 a.m. the surveyor observed the large can opener with grease and blackish substance (grime) around the base and the metal parts. The DM, EI #7 took the removal part and placed it in the 3 compartment wash sink. The walk-in cooler had debris on the floor and shelves, and some of the metal shelves had black and grey substance on them. There appeared to be a build-up of the substance and some were dark red with a rust like substance. The walk in freezer had broken shelves, slanting the boxes of food. The ice machines were inspected and a dark grimy substance was on the lip where ice was dispensed. On the SNF dining room area, there was another ice machine where the liquids are set up for each meal for all residents that eat in dining room and in their rooms. The surveyor looked in the ice machine and the same dark grimy substance was found. The surveyor asked the cook and the Dietary Manager who was responsible for cleaning the ice machines. The cook said she thought the maintenance people did that. On 11/02/16 at 9:09 a.m., a dishwashing observation revealed the kitchen floor still had the same crumb-like debris on the floor that was there on 10/31/16. The floor did not appear to have been swept or mopped in three days. The floors in the cooler and walk-in freezer appeared as though they had not been swept out since the first observation (10/31), for the debris on the floor appeared to be the same. An interview with the Dietary Managers, EI #6 and EI # 7 and with the Corporate Registered Nutritionist EI # 8 on 11/3/16 at 8:45 a.m., they were asked what is the purpose of keeping kitchen clean. EI #7 said, to make sure no one gets sick and for food safety. They were asked why should the cooler shelves be clean and the floor swept clean. EI # 6 and #7 said, 'for food safety and sanitation.' They were asked who was responsible for cleaning the ice machines. EI # 6 said the maintenance runs the chemicals and flushes them out and we clean the machines. EI #6 said, dietary does the water filter. EI #6 and #7 was asked about the runoff pipes for sewage from the sinks in the kitchen. They said the maintenance people take care of these. EI #6 and #7 were asked what was the reason to wear hair restraints. EI #6 said to keep food free of hair and the food protected. EI #7 was asked why was it important to label and date food when opened or partially used. She stated so that the staff know when they can use the food by and so food does not grow bacteria or anyone gets really sick. Cleaning schedules were asked for and obtained. Several of the major jobs like cleaning drip pans under stove and stove eyes, wipe down work station, sweeping and mopping, and make sure prep sink is free of food before and after shift; were assigned to All Cooks. It was also noted several major jobs like cleaning out the sink run offs, cleaning out stoves, steamers, and sinks were not on the cleaning schedules. EI # 6 and EI #7 were asked why certain staff were not assigned these tasks. They said, That it is everybody job. They were asked what is the purpose of cleaning. EI #6 and EI #7 said, So that you have no cross-contamination, so that people do not get sick.

Based on observation, group interview, and staff interview the facility failed to ensure residents in the group meeting held on 11/01/16 didn't know they had a right to see the survey results and they didn't know where it was located. The facility further failed to ensure there were notices in the facility indicating the location of the survey results. This was observed on three of four days of the survey and had the potential to affect all residents in the facility. Findings include: A review of the RESIDENT HANDBOOK dated November 2006, page 11 revealed the following: .Survey Results You have the right to examine the results of the most recent standard survey of . conducted by federal or state surveyors, and any plan of correction in effect with respect to On 10/31/16 at 12:45 p.m., during the inital tour of the facility the surveyor was unable to locate the survey results on all halls and lobbies. Also there was no notice found indicating where the survey results were located. On 11/1/16 at 10:30 a.m, a group meeting was held. A total of 12 residents attended the meeting. The residents were asked if they were aware of their right to see a copy of the the lastest survey results and where it was located. All 12 resdients stated they were not aware of their right to see a copy of the latest survey results nor did they know where the results were located in the facility. On 11/1/16 at 3:20 p.m., the surveyor was unable to locate survey results in the facility, and there were no signs throughout the facility indicating where they were located. On 11/2/16 at 11:30 a.m. the surveyor was unable to locate survey results in the facility, and there were no signs throughout the facility indicating where they were located. On 11/2/16 at 2:30 p.m., the surveyor observed a black binder with ADPH (Alabama Department of Public Health) located at the nurses desk on the South Unit under a white piece of copy paper. On 11/2/16 at 3:15 p.m., the surveyor conducted an interview with EI(Employee Identifier) #5 Director of Social Services. EI #5 was asked how did residents know where the survey results book is located. EI #5 said residents are told it is in a binder in the therapy office. EI #5 was asked are there any notices indicating where the survey results are located. Surveyor toured the facility with EI #5 and there was one sign posted on a bulletin board in the left hand corner on the Rehab Unit in a back hall by the Director of Nurses office not readily accessible. EI #5 acknowledged there were no other notices posted in the facility indicating where the survey results were located. EI #5 was asked was why was it important for resdients to know what the results of the survey were and where they were located. EI #5 replied it is their right they live here.

Based on record review and interview, the facility failed to ensure there were individualized approaches in the care plan that instructed staff when to check and change Resident Identifier (RI) #4, an incontinent resident. This affected RI #4, one of 14 residents whose care plans were reviewed. Findings include: RI #4 was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. RI #4 's Significant Change Minimum Data Set (MDS) Assessment with an assessment reference date of 9/8/16 indicated RI #4 was moderately impaired in cognitive skills for daily decision making, with a Brief Interview for Mental Status (BIMS) of 10. RI #4 was assessed as always being incontinent of bowel and bladder. RI #4 ' s care plan with a problem titled . incontinence related to inability to sense the need to void . with a problem onset date of 11/24/10, had a documented approach of . Pericare after each incontinent episode . This care plan did not include an individualized intervention specifying when the resident should be checked or changed for incontinent episodes. On 11/3/16 at 7:58 a.m., Employee Identifier (EI) #2, the MDS Coordinator was asked if RI #4 had a care plan addressing urinary and bowel incontinence. EI #2 replied yes, but when asked if that care plan had interventions specifying when to check and change the resident, EI #2 stated no, nothing specifying when to check and change.

Based on observation, record review and interviews, the facility failed to ensure that two Certified Nursing Assistants (CNAs), Employee Identifier (EI) #3 and EI #4 performed catheter care for Resident Identifier (RI) #3, a resident with a history of Urinary Tract Infection (UTI) in a manner to prevent infection. This was evidenced by: EI #3 and EI #4 each wore two pair of gloves (doubled gloved) to provide care. EI #4 failed to change gloves and wash/sanitize hands at appropriate times during the provision of care. This affected one of two residents observed for catheter/pericare. Findings include: A review of a facility policy with an effective date of 5/2016, titled, .Catheter Care . revealed: .Purpose: .Urinary catheter care helps prevent complications of infections . A review of Potter and Perry, Fundamentals of Nursing , eighth edition, copyright 2013 Chapter 39, Hygiene , page 801-802 revealed: o. Provide perineal hygiene .2. Female patient .(a) Apply pair of clean gloves .(c)Wash labia majora .(d) .Clean thoroughly around labia minora, clitoris and vaginal orifice .(e) Provide catheter care .p. Remove soiled gloves and discard .q.(1) Perform hand hygiene and apply clean pair of gloves .(5) Clean buttocks and anus .Remove contaminated gloves .and perform hand hygiene . RI #3 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. RI #3 's Quarterly Minimum Data Set (MDS) with an assessment reference date of 10/04/2016 documented the use of an indwelling catheter under the section for bowel and bladder. A review of RI #3 ' s November 2016 physician orders [REDACTED]. On 11/02/2016 at 10:15 a.m. an observation was made during the performance of catheter care/incontinent care for RI #3 with two CNA ' s, EI #3 and EI # 4. After assembling supplies, EI #3 and EI #4 washed hands and both CNA's put on two pair of gloves each. EI #3 assisted in positioning RI #3 as EI #4 performed the actual care. While wearing two pair of gloves, EI #4 performed pericare and catheter care on RI #3, then rolled RI #3 onto his/her left side and without removing or changing gloves EI #4 cleaned RI #3 's buttocks, removing stool. After buttocks was cleaned of stool EI #4 removed outer pair of gloves and with the remaining pair of gloves still on, positioned a clean brief under RI #3 and applied barrier cream to the buttocks. EI #4 then removed the last pair of gloves and without washing hands or sanitizing put on a new pair of gloves and applied barrier cream to RI #3' s perineal area prior to fastening brief with EI #3' s assistance. On 11/02/2016 at 1:58 p.m., an interview was conducted with EI #4, the CNA that performed the catheter care for RI #3. The surveyor asked EI #4 how many pair of gloves did she put on to do catheter care. EI #4 explained she put on two pair of gloves to start with and after cleaning RI #3 's front and backside she removed the outer layer of gloves and applied barrier cream to backside. EI #4 said she put on new gloves then, but did not wash hands prior to gloving. EI #4 stated she only washed her hands before care began and then after it ended. When asked when hands should be washed or sanitized during catheter care, EI #4 replied before care begins, each time gloves are changed and at the end. When asked if wearing double gloves was an acceptable practice, EI #4 responded no. EI #4 further explained the potential harm in not washing hands or changing gloves appropriately could result in a possible infection. On 11/02/2016 at 3:45 p.m., an interview was conducted with EI #1, the Director of Nursing concerning the catheter care observation. EI #1 explained that double gloving is not an acceptable practice and it is not acceptable to change gloves without performing hand hygiene. She further explained that hands should be washed or sanitized before starting care, before donning and removing gloves and when going from one side of the body to the other. She also stated the potential harm in not performing hand hygiene or changing gloves appropriately during catheter care could result in cross contamination. On 11/03/2016 at 7:37 a.m., an interview was conducted with EI #3, the CNA that assisted with the catheter care for RI #3. EI #3 stated that she did put on two pairs of gloves prior to care and that this was not an accepted practice. She further stated that gloves should be changed between cleaning front and back, when gloves become soiled and when finished with care. When asked what would be the potential harm in not changing gloves or performing hand hygiene appropriately during catheter care, EI #3 replied cross contamination and infections.

Based on observations and staff interview, the facility failed to post Nurse Staff information in a prominent place readily accessible for visitors and residents for three of four days of the survey. Findings include: Review of the facility's policy titled, Nurse Staffing Informinton -(SNF) with an effective date of 6/2014 revealed the following: PURPOSE: To provide public access to nurse staff information. STANDARD: The facility shall make nurse staffing infomation avaiable to the public and post in a prominent place readily accessible to residents and visitiors On 10/31/16 at 12:40 p.m., the surveyor observed the Nurse Staffing Information posted on a bulletin board by the Director of Nurses Office in a back hall on the Rehab Unit. It was not in a prominent place readily accessible for residents and vistiors, nor at a height for residents in wheelchair. On 11/01/16 at 8:30 a.m., the surveyor observed the Nurse Staffing Information posted on a bulletin board by the Director of Nurses Office in a back hall on the Rehab Unit. It was not in a prominent place readily accessible for residents and visitors, nor at a height for residents in a wheelchair. On 11/02/16 at 8:40 a.m., the surveyor observed the Nurse Staffing Information posted on a bulletin board by the Director of Nurses Office in a back hall on the Rehab Unit. It was not in a prominent place readily accessible for residents and visitors, nor at a height for residents in a wheelchair. An interview was conducted the EI (Employee Identifier) #9 Staffing Coordinator on 11/2/16 at 4:15 p.m. EI #9 was asked where was the daily nursing staffing data posted in the facility. EI #9 replied across from the time clock in a glass case by the Director of Nurses Office. EI #9 was asked if the daily nurse staffing data was posted anywhere else in the facility. EI #9 said, No. EI #9 was asked was the daily nurse staffing posted in a promient place where residents and visitors can see it. EI #9 replied it is visible, but would have to ask nursing staff where it is located.

Based on observation, interviews and record review, the facility failed to ensure dietary staff re-heated chicken tenders and french fries that did not reach a temperature of 135 degrees Fahrenheit (F) or above prior to serving residents on 12/09/15 during the lunch meal. This had the potential to affect 54 residents receiving meals on the South Unit. Finding Include: The facility policy titled: Food, leftover-Storage and Use with an Effective Date: 7/2015 documented .PURPOSE: To assure that food borne illnesses are avoided PROCESS: 6. Reheat leftover foods to 165 degrees for at least 15 seconds within two (2)hours. The 2013 Food and Drug Administration FOOD CODE specifies under regulation, 3-401.13 Plant Food Cooking for Hot Holding that Fruits and vegetables that are cooked for hot holding shall be cooked to a temperature of 135 degrees F. The 2013 Food and Drug Administration FOOD CODE, mandates under regulation 3-501.16(A) Potentially Hazardous Food . Hot .Holding .shall be maintained (1) At 135 degrees F or above. On 12/09/15 at 11:40 Employee Identifier (EI) #3 a Dietary staff member and EI #4 the Dining Services Manager were observed checking the temperatures of the chicken tenders and french fries for residents who eat their meal on the South Unit of the facility. The chicken tenders temperature was 133.7 degrees F and the french fries were 126.6 degrees F. EI #3 failed to reheat the items to 165 degrees F before placing them on the tray line to be served to the residents. On 12/09/15 at 1:05 PM an interview was conducted with EI #4 she was asked what the facility's policy was regarding temperatures of warming food items. EI #4 replied, reheat to 165 degrees F. She was then asked if EI #3 had done this. EI #4 replied no. EI #4 was asked if the rewarmed items temperatures were recorded after they were rewarmed. EI #4 replied yes they should be. EI #4 was asked if the temperatures were taken after arriving to each unit from the kitchen and recorded. EI #4 replied yes and recorded. EI #4 was asked what was the potential for harm if the food temperature does not meet federal regulations. EI #4 stated, Sickness, Food Poisoning. A second interview was conducted with EI #4 on 12/09/15 at 3:40 PM she was asked to review the recorded temperatures for the South Unit for the chicken tenders and french fries that were taken prior to placing on the tray line to be served at 11:40 AM. EI #4 was then asked if that was the appropriate temperature for serving to the residents. She stated, No. EI #4 was asked what should have been done with the chicken tenders and french fries. She replied either bring down to the kitchen to reheat or call for another pan. EI #4 was asked if the chicken tenders or the french fries were reheated before they were placed on the steam table for serving. She stated, They were not. EI #4 was asked what temperature should the chicken tenders and french fries have been re-heated to. EI #4 replied 165 degrees F. EI #4 was asked what the potential for harm would be if these items were not re-heated to 165 degrees F. EI #4 stated, Palpability and Safety.

Based on observation and interview the facility failed to ensure licensed staff did not touch the inside of the medicine and drinking cups for Resident Identifier (RI) # 13 and 14. This was observed on 12/9/15 during medication administration and affected two of six residents observed. Findings Include: RI #13 was admitted to the facility on [DATE]. A review of RI #13's Physicians Orders for December 2015 revealed medications for 9:00 AM: Aspirin 81 milligrams (mg) once daily, [MEDICATION NAME] 20 mg once daily, Zesteril 5 mg once daily, Multi vitamin once daily, [MEDICATION NAME] 17 grams once daily, [MEDICATION NAME] 3.125 mg twice daily, [MEDICATION NAME] 7.5-325 mg twice a day and [MEDICATION NAME] 250 mg twice daily. RI #14 was admitted to the facility 10/7/14. A review of RI #14's Physician order [REDACTED]. On 12/9/15 at 8:00 AM the surveyor observed Employee Identifier (EI) #2, Registered Nurse during medication administration. EI #2 was observed picking up the medication cups for RI #13 touching the inside of the medication cup and the drinking cup. Once she completed RI #13 she began with RI #14 also touching the inside of the medication cup and the drinking cup. On 12/9/15 at 8:15 AM an interview was conducted with EI #2, she was asked how did she pick up the medication cup. EI #2 replied she placed her fingers inside the cup. EI #2 was asked how did she pick up the drinking cup, she replied the same way. EI #2 was asked how should she have picked up the cups. EI #2 replied from the bottom. EI #2 was asked if she should have touched the inside of the medication and drinking cups. EI #2 replied no. EI #2 was asked what was the potential for harm in touching the inside of the medication cups and the drinking cups. EI #2 replied infection control. On 12/10/15 at 7:55 AM an interview was conducted with EI #1, Director of Nursing. EI #1 was asked was it acceptable for a nurse to touch the inside of a medication and drinking cup prior to giving the resident the medications. EI #1 replied no. EI #1 was asked how should staff pick up clean medication and drinking cups. EI #1 replied they should always only handle the outside of the cup. EI #1 was asked what was the potential for harm in a nurse touching the inside of the medication cup and the drinking cup prior to giving the resident the medication. EI #1 replied contamination.

Based on observation, interview and record review the facility failed to ensure pots, pans and other cook wear was not wet nested. This was observed on 10/23/14 and had the potential to affect all 92 residents receiving meals from dietary. Findings Include: A review of a policy titled "Sink Sanitization, Three Compartment" dated 9/20/14 documented the following: "...Purpose: To prevent the spread of bacteria that may cause food borne illnesses...Process...Step Three...Allow/pots/utensils to air dry; store pots upside down or covered. Do not stack wet..." On 10/23/14 at 3:10pm the surveyor observed the following cook wear stacked together wet to dry on the drying rack: 6 large muffin pans, 14 large trays, 4 colanders, 2 long pans and 11 regular size pots and pans. The pans placed on the drying rack were wet upon removal. An interview was conducted with EI (employee identifier) # 2, Dining Manger on 10/23/14 at 3:15PM. EI # 2 explained the rack the cook wear was on was a drying rack. EI # 2 was asked if pots, pans, colanders, trays and muffin pans supposed to be stacked together and she stated no due to nesting. EI # 2 was asked what will nesting do to the drying process and she stated it would prevent pans from drying correctly. EI # 2 explained that staff are trained not to stack together to prevent nesting. EI # 2 was asked what is the potential harm to residents if dishes are left to dry stacked together. EI # 2 stated possible mold and it could make the residents sick.

Based on observation and interview the facility failed to ensure RI (Resident Identifier) # 20 and RI # 21 were not served cold eggs for the breakfast meal on 10/22/14. This had the potential to affect all residents receiving trays from dietary on the South Hall. Findings Include: 1. RI # 20 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI # 20's most recent Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/10/14 documented a Brief Interview of Mental Status score of 15 out of 15 which indicated RI # 20 was cognitively intact. On 10/21/14 at 11:00AM during the initial tour of the facility RI # 20 stated she did not eat breakfast because it was cold on 6 out of 7 days of the week. On 10/22/14 at 8:03AM RI # 20 reported to the surveyor that the eggs on the tray were cold. RI # 20 placed the eggs in the surveyor's hands and they were cold to touch. On 10/22/14 at 10:15AM RI # 20 complained of cold eggs during the resident council meeting. RI # 21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 2. A review of RI # 21's most recent Quarterly MDS with an ARD of 8/2/14 documented a BIMS score of 13 out of 15 indicating RI # 21 was cognitively intact. On 10/21/14 at 11:20AM during the initial tour of the facility RI # 21 reported the breakfast was cold every morning. RI # 21 reported to the surveyor on 10/22/14 at 8:35AM that her oatmeal was barely warm and she couldn't eat the eggs. During the resident council meeting on 10/22/14 at 10:15AM, two additional residents complained of cold breakfast to include eggs and oatmeal. On 10/22/14 at 7:10AM the Surveyor entered the kitchen to observe the breakfast tray line. A total of three carts were plated and taken to the south hall of the facility. The first cart left the kitchen at 7:30AM and the second cart left the kitchen at 7:45AM. The 3rd cart left the kitchen at 7:55AM with a test tray and arrived on the hall at 7:58AM. At 8:30AM the third cart had been delivered but 6 trays remained on the second cart to be delivered. The trays were all delivered by 8:35AM On 10/22/14 at 8:35AM the surveyor completed a breakfast test tray for the south hall the following temperatures were documented: Grits 119.5 degrees and eggs 86 degrees. The bacon and toast were not tempted during the test tray. EI # 2 reported the eggs were cold to taste. The surveyor tasted the eggs and they were cold to taste. An interview was completed with EI # 2, Dining manager on 10/22/14 at 8:45AM. EI # 2 explained that the eggs were cold and not palatable. EI # 2 was asked the reason why the eggs were cold and she stated it would be hard to determine. EI # 2 further stated to increase the palatability of the eggs they could be served in a bowl which may retain the heat. EI # 2 was asked if there was a set temperature for food being served to residents and she stated just from the tray line but it should be palatable.

Based on record review and interview the facility failed to ensure a Significant Change Minimum Data Set (MDS) was completed when RI (Resident Identifier) # 3 was admitted to hospice on 6-10-14. This affected 1 of 5 sampled residents for Hospice. Findings Include: A review of "The Centers for Medicare and Medicaid Services, Long-Term Care Facility Resident Assessment Instrument User's Manual" (MDS 3.0), April 2012 specifies (pg. 2-21): "A SCSA (Significant Change in Status Assessment) is required to be performed when a terminally ill resident enrolls in a hospice program... and remains a resident at the nursing home. The ARD (Assessment Reference Date) must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). A SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place." RI # 3 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a physician's orders [REDACTED]. A review of RI # 3's most recent physician's orders [REDACTED]. A review of RI # 3's medical record on 10/23/14 at 10:00 AM revealed no Significant Change Minimum Data Set when RI # 3 was admitted to Hospice on 6/10/14. An interview was conducted with EI (employee identifier) # 1, RN (Registered Nurse) on 10/23/14 at 10:45 AM. EI # 1 stated that RI # 3 was admitted to Hospice on 6/10/14. EI # 3 was asked if a Significant Change MDS was completed upon RI # 3's admission to Hospice and she stated no. EI # 3 was asked should a Significant Change MDS have been completed upon RI # 3's admission to Hospice and she stated yes. EI # 3 further stated that it should be completed to identify any other changes and it should be done to identify the resident is on Hospice.

Based on observation, interview, and record review, the facility failed to ensure a CNA (Certified Nursing Assistant) and licensed staff washed their hands and changed gloves in a manner to prevent cross-contamination during perineal care. This affected RI (Resident Identifier) #5, one of two residents observed for incontinent care. Findings included: Potter and Perry, "FUNDAMENTALS OF NURSING", Eighth Edition, copyright 2013, Chapter 28, Infection Prevention and Control, page 411, documents: "The CDC...recommends the following:...1...wash hands with water and either a nonantimicrobial or antimicrobial soap...3a. Before, after, and between direct patient contact...b. After contact with body fluids or excretions,...c. When moving from a contaminated to a clean body site during patient care...g. After removing gloves...". A review of a facility "In-service Attendance Record" dated 1/14/2013 was titled "Standard Precautions". The content source "Centers for Disease Control and Prevention" with "Page last updated: July 12, 2011" revealed "...Guide to Infection Prevention...Key situations where hand hygiene should be performed...5. If hands will be moving from a contaminated-body site to a clean-body site...6. After glove removal...Key recommendations for use of PPE (Personal Protective Equipment)...4. Wear gloves for potential contact with blood, body fluids...3. Perform hand hygiene immediately after removing gloves..." RI #5 was readmitted to the facility on [DATE]. A review of RI #5's most recent quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/6/2014 revealed a BIMS (Brief Interview for Mental Status) score of 3, which indicated severely impaired skills for daily decision making. The MDS also revealed RI #5 was always incontinent of bowel and bladder and was totally dependent on staff for toileting and hygiene. On 10/22/2014 at 10:50 AM, an observation was made of EI #3, CNA and EI #4, LPN (Licensed Practical Nurse) providing incontinent care for RI #5. RI #5 had a loose BM (bowel movement) that came through the resident's brief and pants. RI #3 used multiple wipes to clean the resident's perineum in front, on the thighs, and in back. EI #3 then changed gloves and applied a clean brief next to the resident, applied moisture barrier cream to the resident, and then changed gloves. The resident was rolled on the other side and EI #4 cleaned BM, changed gloves, applied moisture barrier cream and a clean brief. EI #3 removed her gloves and went to the closet to look through the resident's cloths for pants. EI #4 looked through the resident's drawers in the bed side table. EI #3 and #4 then covered the resident with a sheet until pants could be found, all before using alcohol hand gel or washing their hands. On 10/22/2014 at 11:20 AM, an interview was conducted with EI #3. EI #3 was asked what was the facility policy about when to wash hands. EI #3 stated to wash before and after care. EI #3 was asked why she cleaned BM and changed gloves during incontinent care without washing her hands. EI #3 stated that she flipped her glove to remove it and she wasn't finished with care. EI #3 was asked what could be the harm in not washing hands when changing gloves during incontinent care. She stated there would be none because you could use hand sanitizer. EI #3 was asked why then, did she not use hand sanitizer between glove changes and she said that she did not want to keep the resident exposed. EI #4 was interviewed on 10/22/2014 at 11:30 AM, and she was asked what was the facility policy about when to wash hands. EI #4 said before and after care. EI #4 was asked when to wash hands during incontinent care while cleaning BM. EI #4 stated that if gloves are soiled to take them off and wash hands and reglove. EI #4 was asked why did she clean BM and change gloves during incontinent care without washing hands. EI #4 stated, "I saw it on the glove and changed gloves. I don't know why I didn't wash my hands." EI #4 was asked what would be the harm in not washing hands when changing gloves during incontinent care. EI #4 stated infection control because you do not want to pass on anything to residents or pick up anything from them. On 10/23/2014 at 10:50 AM, an interview was conducted with EI #5, DON (Director of Nursing). EI #5 was asked how the facility prevented infection. EI #5 stated that they teach, starting with good universal precautions and good handwashing. EI #5 was asked what were staff trained about when to wash their hands. EI #5 stated that the staff can use hand gel but the best practice was to wash before and after each resident. EI #5 was asked why did staff not wash their hands when cleaning BM and changing gloves during incontinent care. EI #5 stated, "I think it is something that slipped their minds, maybe their nerves from being nervous." EI #5 was asked what would be the harm in not washing hands when changing gloves during incontinent care and cleaning BM. EI #5 replied there was potential to spread infection.

Based on observations, record review and interview, the facility failed to ensure that incontinent care was provided in a timely manner for RI (Resident Identifier) #1, #8 and #13. This affected 3 of 7 residents sampled for incontinent care. Findings include: A review of the facility's policy titled: "Perineal Care (Incontinence Care) with an effective date of 6/2013 documented, "...PURPOSE: Good perineal care helps prevent infection, irritation and skin breakdown...STANDARD: Residents who are incontinent of urine or feces should receive perineal care as needed..." A review of the facility's Certified Nursing Assistants (CNA) Job Description dated April 1, 2009 documented: " ...Summary of Duties: Responsible for providing residents with routine daily nursing care and services in accordance with the resident's assessment and plan of care and as directed. Essential Job Functions: 6. Check resident routinely to ensure that his/her personal care needs are being met..." 1.) Resident Identifier (RI) #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1's most recent Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD), of 10/15/13 revealed RI #1 had both short and long term memory problem and was severely impaired in cognitively skills for daily decision making. The MDS also documented RI #1 had a pressure ulcer. A review of RI #1's Care Plan with a "Problem Onset" date of 04/14/09 documented, "...(Name of resident/RI #8) has Potential for skin breakdown r/t (related to) B&B (Bowel and Bladder) incontinence...assist/encourage to turn and reposition q (every) 2 hrs (hours) and prn (as needed)..." On 11/5/13 at 4:45 PM, RI #1 was observed being pushed into the South Dining Room by staff while in her Geri Chair. RI #1's feet were elevated and a blanket was observed lying on top of the resident. A continuous observation was made of RI #1 by the surveyor beginning at 4:45 PM until 7:05 PM. During this time, RI #1 was not repositioned by staff or herself. RI #1 remained in the South Dining Room until 7:00 PM at which time EI #5 (CNA) pushed the resident to her room. On 11/05/2013 at 7:05 PM, the surveyor observed EI (Employee Identifier)#5 Certified Nursing Assistant (CNA) transfer RI #1 from her geri chair to the bed and perform incontinence care. When EI #5 removed the brief, the surveyor observed the brief to be saturated with urine. The surveyor also observed a Stage II pressure ulcer to RI #1's coccyx/buttock area which was open to air with no dressing. On 11/05/2013 at 7:25 PM, the surveyor conducted an interview with EI #5 CNA. The surveyor asked EI #5 how often RI #1 was supposed to be checked and changed. EI #5 stated that it was to be done every two hours. The surveyor asked EI #5 when was the last time EI #5 had checked and changed RI #1. EI #5 state "At 3 PM." The surveyor asked EI#5 what the potential for harm was when RI #1 was not checked and changed for long periods of time. EI #5 stated RI #1's "bottom could break down". On 11/5/13 at 7:35 PM, EI #6 Director of Nursing (DON) was asked how often were staff supposed to check and change residents. EI #6 replied, "Minimum of every 2 hours-at least check them." EI #6 was asked how often should RI #1 be checked. EI #6 said RI #1 should be checked every 2 hours at a minimum. EI #6 was asked what was the facility's policy on checking and changing of incontinent residents. EI #6 said it was the same and stated, "Minimum of every 2 hours." The surveyor explained RI #1 had been tracked from 4:45 PM to 7:05 PM and asked would that be a reasonable time to not check a resident. EI #6 said that would be pushing it. EI #6 was asked would it be their policy to wait that long. EI #6 said, "No." 2.) RI #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #8's most recent Quarterly MDS with an ARD of 8/25/13 revealed RI #8 scored a 3 out of possible 15 on the BIMS (Brief Interview for Mental Status) indicating RI #8 was severely impaired for cognitive skills for daily decision making. The MDS also revealed RI #8 was at risk of developing pressure sores. RI #8's Care Plan with a "Problem/Onset" date of 5/28/13 documented: "...(Resident name/RI #8) has incontinence related to: dementia...Assist with toileting as needed and or pericare...Toilet before meals..." On 11/5/13 at 2:15 PM, RI #8 was observed in the South Dining room with other residents getting ready for Bingo. RI #8 was sitting in a high back wheelchair at a table with other residents. The surveyor made a continuous observation of RI #8 from 2:15 PM until 7:15 PM. At 7:10 PM, RI #8 asked the surveyor if she could help her go to bed. EI #7 (RN) then walked up to where RI #8 was sitting and transported RI #8 to her room. EI #7 told RI #8 she would have to see who the aide assigned to her was and she would return. RI #8 remained sitting in her wheelchair and at 7:13 PM, EI #7 returned to RI #8's room and told her she was waiting for help. At 7:15 PM, EI #7 returned to the resident's room and told RI #8 she was going to get her ready for bed. At 7:30 PM, EI #7 and the surveyor entered the residents room and closed the door. During the continuous observation of RI #8, no one was observed to reposition the resident, nor did the resident reposition herself. On 11/05/2013 at 7:30 PM, the surveyor observed EI #7 perform incontinence care on RI #8. When EI #7 began to remove RI #8's brief, RI #8 asked that EI #7 stop the care. RI #8 stated that she needed to urinate. RI #8 urinated in the brief. EI #7 performed incontinence care on RI #8. On 11/05/2013 at 7:40 PM, the surveyor interviewed EI #7 about RI #8's incontinence care. The surveyor asked EI #7 how often was RI #8 supposed to be checked and changed. EI #7 stated every two hours and as needed. The surveyor asked EI #7 when was the last time RI #8 was checked and changed. EI #7 stated that she did not know. The surveyor asked EI #7 how often does the care plan state that RI #8 was to be checked and changed. EI #7 stated "The standard is every two hours and as needed." The surveyor asked EI #7 what the potential for harm would be in not checking and changing RI #8. EI #7 stated it could cause a UTI (Urinary Tract Infection) or skin breakdown. On 11/5/13 at 7:35 PM, EI #6 Director of Nursing (DON) was asked how often were staff supposed to check and change residents. EI #6 replied, "Minimum of every 2 hours, at least check them." EI #6 was asked how often should RI #8 be checked and changed. EI #6 said, "I would say offer her to toilet at least every 2 hours; make sure she is not wet." EI #6 was asked what was the facility's policy on checking and changing of incontinent residents. EI #6 said. "That is the minimum-every 2 hours." The surveyor explained RI #8 had been tracked from 2:15 PM to 7:15 PM, and asked would that be a reasonable time to not check a resident. EI #6 replied, "No." EI #6 was asked would it be their policy to wait that long. EI #6 said, "No." 3. Resident Identifier (RI) # 13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Section H Bladder and Bowel revealed RI #13 was occasionally incontinent of bladder and bowel. A review of RI #13's Care Plans revealed "... Problem onset: 09/24/2013 (Resident Name RI #13) has incontinence related to [MEDICAL CONDITION] Assist with toileting as needed..." On 11/05/2013 at 5:15 PM, Resident Identifier (RI) #13 was observed sitting in a Rock and Go chair in the South Dining Room waiting for the evening meal. The surveyor made a continuous observation of RI #13 from 5:15 until 7:45 PM without RI #13 being repositioned by staff or herself. At 7:50 PM, Employee Identifier #8, Certified Nursing Assistant (CNA) took RI #13 from the Dinning Room. EI #8 informed the surveyor RI #13 was going to be given a bath. RI #13 was taken into the Shower/Bath room at 7:50 PM. On 11/05/2013 at 7:50 PM, the surveyor observed RI #13 in the shower room with EI #8. EI #8 removed RI #13's pants and pulled down her brief. The surveyor noted that RI #13's brief was soaked with urine. On 11/05/2013 at 7:55 PM, the surveyor interviewed EI #8 about RI #13's observation. The surveyor asked EI #8 how often RI # 13 was supposed to be checked and changed. EI #8 stated every two hours. The surveyor asked EI #8 when was the last time she had checked RI #13. EI #8 stated before supper at about 4:30 PM. The surveyor asked EI #8 what was the potential for harm when RI #13 was not checked and changed in a timely matter. EI #8 stated the resident was at risk for skin breakdown and infection. On 11/6/13 at 9:25 AM, EI #9 (Medical Director) was asked what would be the potential harm for an incontinent resident with a sacral decubitus being left in a brief with saturated urine for an extended period of time. EI #9 said, "We like to keep them dry, being wet would not help it." EI #9 further stated, "It's hard to get them checked every two hours, but within five hours they should have been checked."

Based on the Resident Group Meeting held on 11/06/2013, observation, record review and interviews, the facility failed to resolve a grievance voiced during the facility's Resident Council Meeting and the Resident Group Meeting on October 4, 2013 regarding residents waiting extended times for meals. This affected 1 of 4 grievances reviewed during the survey. Findings include: The facility's policy titled "Resident Grievances" with an effective date of 2/2013 revealed "PURPOSE The resident has a right to voice grievances without discrimination or reprisal. ... PROCESS From time to time, resident or family members may voice grievances in the following forums: ...Verbal complaint during resident or family council meetings... 1) The grievance form should be forwarded to the Executive Director, or designee 2) The staff nurse or department manager should take steps to resolve the grievance 3) The Executive Director or designee should follow-up with the resident/legal representative to discuss actions taken to resolve the grievance. ..." A review of the "Resident Council Meeting Minutes (Minutes)" dated 10/4/2013 documented (on page 3), a resident had concerns regarding the delivery of the meals. The Minutes documented a member stated they have to sit for a long time before the meals are served. No information was documented regarding which meal or if all meals were late. Attached to the Minutes was a copy of an email sent by Employee Identifier (EI) #1, Social Service Director to EI #2, Registered Dietitian regarding the resident statement in the Resident Council Meeting. The following was documented to EI #2: " 'We sit a long time before it's (meal) is served, but they serve it right away when it comes' (They may be making themselves sit too long by going into the dining room too early, but I couldn't get a good understanding)." A review of Resident Council Meeting Minutes dated 11/1/2013 documented (on page 2), all problems from the previous resident council meeting had not been resolved. A Resident Council Meeting was held on 11/6/13 at 10:00 AM with 8 members in attendance. The surveyor asked the resident's about meal delivery. One resident in the meeting spoke up and said they have to sit, wait and watch people eat in the dining room. A review of the Meal Service Delivery Schedule for South Dinning Room revealed Breakfast should be delivered by 8:30 AM, Lunch started at 11:10 AM/finished at 1:10 PM and Dinner started at 5:10 PM/finished at 7:10 PM. On 11/6/13 at 4:50 PM, an interview was conducted with RI #1's sponsor. RI #1's sponsor was asked about meals at the facility. RI #1's sponsor said she doesn't think it is fair that residents have to sit around the sides of the walls in the dining room and watch other residents eat. RI #1's sponsor said a lot of the residents that are watching other residents eat are alert and oriented and are forced to sit and watch the first feeding group eat. She further said her mother had to be fed by staff and was fed before the alert, oriented residents sitting around the wall watching. 1.) Resident Identifier (RI) # 13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#13 had severe cognitive impairment. The MDS also revealed RI #13 required assistance when moving from her room to the Dining Room. On 11/05/2013 at 5:15 PM, RI #13 was observed in the South Dining Room. RI #13 was observed sitting in a Rock and Go against the Dining Room wall while other residents were served their evening meal. At 6:25 PM after the first group of residents had completed their meals, RI #13 was pushed her to a table for her evening meal. The staff started serving the second seating at 6:25 PM. RI #13 was observed eating her meal at 6:30 PM. On 11/06/2013 the surveyor made a continuous observation of RI #13 sitting in a Rock and Go in the area of South Dining Room from 11:05 AM until she was served her meal at 1:30 PM. 2.) RI #12 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #12's most recent Annual MDS with an ARD date of 7/21/13 revealed RI #12 scored a 14 out of possible 15 on the BIMS indication the resident was Cognitively Intact for daily decision making. The MDS also documented RI #12 was Independent with eating and required setup only. On 11/6/13 at 11:30 AM, RI #12 was observed sitting in her wheelchair on the left side of the Nurse's station against the wall with other residents. The surveyor asked RI #12 if she was waiting to eat. RI #12 replied, "Yeah, it will be after 1:00 PM because we have to wait on the other residents to finish eating." At 12:35 PM, RI #12 was observed still sitting in her wheelchair against the wall in the dining room with her head leaning downward sleeping. At 1:00 PM, staff told RI #12 she could move up to the table with other residents to eat. 3.) RI #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #8's most recent Quarterly MDS with an ARD of 8/25/13 revealed RI #8 scored a 3 out of possible 15 on the BIMS indicating RI #8 was severely impaired for cognitive skills for daily decision making. On 11/5/13 at 4:00 PM, RI #8 was transported in her wheelchair to the South Dining Room. RI #8 was placed at a table with other residents so that she could watch TV and talk with other residents. At 4:47 PM, RI #8 was pushed away from the table and placed against the back wall of the room beside another resident. At 4:55 PM, RI #8 was still sitting against the back wall in the South Dining Room talking with another resident. A total of 8 tables was observed with resident's sitting at them in the South Dining Room. Three tables observed had three residents at them, three tables had two residents at them and two tables only had one resident sitting at them. There were two residents sitting against the wall to the left and right side of the nurses station watching the residents at the tables. The surveyor heard RI #8 tell the resident sitting next to her that someone was sitting at the table where she normally sat. The surveyor asked RI #8 if she was ready to eat. RI #8 said she didn't eat until the other ones at the table had finished eating. At 5:10 PM, RI #8 was observed still sitting in her wheelchair against the back wall of the South Dining Room with other residents. The surveyor asked her what time she normally ate. RI #8 said, "Normally around 6:00 PM." At 5:20 PM, three staff were observed passing out pears to residents sitting at the tables in the dining room. At 5:25 PM, the first plate arrived to the first table near the kitchen door and a nurse (RN/Registered Nurse) sat down and began to feed the resident at the table. AT 5:27 PM, the second table was served, at 5:29 PM the third table was served, at 5:30 PM, the middle row of tables was served and the last row of tables to the left of the room was served at 5:32 PM. RI #8 along with other residents sitting across the back wall to the right and left of the room watched the residents at the tables eat their meal. At 6:00 PM, residents that had finished eating at the tables were taken out of the South Dining Room and the tables were cleaned. At 6:07 PM, RI #8 was pushed to the front table in the middle of the dining room. At 6:15 PM, RI #8 held up her hand and asked for a cup of coffee and staff obtained it for her. At 6:20 PM, a clothes protector was placed on the resident by staff. At 6:24 PM, tea and water was provided to the resident and at 6:27 PM, RI #8's tray arrived to the table. RI #8 began to eat at 6:30 PM. 4.) On 11/06/2013 at 11:05 AM, the surveyor observed food items brought to the South Dining Room for meal services. Hot food items were placed in a heating device and cold food items put on ice. Plates, bowls, and other serving items were brought to the Dining Room at 11:12 AM. Staff started bring residents to the tables at 11:15 AM. The kitchen staff completed taking the temperature of the food to be served at 11:28 AM and started plating for the South Dining Room. The staff stopped because some of the residents had not been given beverages and salt and pepper had not been passed out to the residents. Plating was started back at 11:54 AM, stopped at 11:58 AM and started back at 12:00 noon. The last resident for the first seating was served at 12:27 PM. The first plate for the second seating was served at 1:14 PM and the last plate was served at 1:35 PM. On 11/7/2013 at 1:25 PM and 3:30 PM, the surveyor interviewed EI #1, Social Services Director regarding the 10/04/2013 Resident Council Meeting Minutes. The surveyor asked EI #1 what was the residents problem regarding their meals. EI #1 stated "A resident said they have to sit a long time before it is served but they serve it right a way when it comes". The surveyor asked EI #1 what steps had been taken to resolve that problem. EI #1 stated she emailed EI # 2, RD, EI #6, Director of Nursing and EI #3 Executive Director. She further explained she had put on the email that the residents may be making themselves sit too long by going into the dining room too soon and she was not able to get a good understanding. The surveyor asked EI #1 how can a problem be solved if she did not have a good understanding of the problem. After looking at the list of residents who attended the 10/2013 meeting, EI #1 stated that most of those residents had memory problems; if it was the residents going too early, Nursing or Activity would address it and if it was because the plates were late, Dietary would address it. When the surveyor asked EI #1 if the facility had any documentation of any department addressing this problem, EI #1 stated, "It did not". On 11/7/2013 at 4:00 PM, the surveyor interviewed EI #2 RD, regarding the 10/04/2013 Resident Council Meeting Minutes. The surveyor asked EI #2 if she had received an email from EI #1 regarding Resident Council Meeting. EI #2 stated she had received an email with the issues that was on the Resident Council Meeting form. The Surveyor asked EI #2 what steps had been taken to resolved the problem. EI #2 stated she would have to go to her office to check her emails and other documentation. EI #2 returned with EI #3, Executive Director and EI #1. They were not able to provide the surveyor with anything that had been done to address the problem voiced in the Resident Council Meeting. The surveyor asked EI #2 if she had followed up with the residents in the 10/04/2013 Meeting. EI #2 stated she had not talked to them. The surveyor asked EI #2 what was the potential for harm when steps are not taken to resolve the problems from Resident Council Meeting. EI #2 stated the residents would not be happy if they have to continue to wait.