Every finding on record at Greene County Nursing Home

Based on observation, interview and a facility policy titled Proper Drying and Storage of Tableware the facility failed to ensure pots, pans, and serving utensils were air dried after being washed in the three compartment sink on 2/23/22 during observation of the kitchen. This had the potential to affect all residents receiving meals from the kitchen. Findings Include: A policy titled Proper Drying and Storage of Tableware, dated November 2018 documented: . All dishes, trays, utensils, . will be air dried. After proper machine and/or pot & (and) pan washing, rinsing, and sanitizing, all dishes, trays . will be air dried. On 2/23/22 at 4:52 PM, an observation was made of pots placed on top of serving utensils in the drain rack, stacked together to dry, by the three compartment sink. On 2/24/22 at 3:59 PM an interview was conducted with Employee Identifier (EI) #3, Dietary Manager. EI #3 was asked how pots and serving utensils were to be dried. EI #3 stated, air dried on a rack, after being washed in the three compartment sink. EI 3 was asked if pots should be stored on top of serving utensils to dry after being washed in the three compartment sink. EI #3 stated no, they should not be dried, stacked together. EI #3 was asked why pans should not be placed on top of serving utensils to dry. EI #3 stated, contamination, because water would drip on the serving utensils and could cause contamination. EI #3 was asked what was the potential negative outcome of placing items to dry on top of each other. EI #3 stated contamination.

Based on interviews, resident group meeting, the facility's document titled RESIDENT'S RIGHTS and CMS (Center for Medicare & (and) Medicaid Services) Memorandum (Memo) QSO-20-39-NH, the facility failed to implement visitation for residents of the facility since 11/12/21. This deficient practice had the potential to affect all 36 residents residing in the facility. Findings Include: An undated facility document titled RESIDENT'S RIGHTS documented: . Right to convenient visits and communications with others. A CMS Memorandum QSO-20-29-NH with a revised date of 11/12/21 documented: .Visitation Guidance: CMS is issuing new guidance for visitation in nursing homes during the COVID-19 PHE (Public Health Emergency), . Visitation is now allowed for all residents at all times . Indoor- Visitation Facilities must allow indoor visitation at all times for all residents as permitted under the regulations. facilities can no longer limit the frequency and length of visits for residents, the number of of visitors , or require advance scheduling of visits. A resident council group meeting was held on 02/24/22 at 10:00 AM with eleven residents present. All residents confirmed they have not had any family/sponsor visits in two or three months or more. On 02/24/22 at 10:27 AM an interview was conducted with EI (Employee Identifier) #1 Administrator. EI #1 was asked when families/sponsors were last able to visit. EI #1 said August 5, 2021. EI #1 was asked if the facility had started family/sponsors visitation back. EI #1 said no, the families/sponsors had not been notified of visitation. EI #1 was asked why had the facility not had family visitation since August 5, 2021. EI #1 said he, the MD (medical doctor), and Quality Assurance agreed to suspend visiting due to COVID. EI #1 had not read and was not aware of any new guidance regarding visitation. On 02/25/22 at 10:21 AM an interview was conducted with EI #4, Social Worker per phone. EI #4 was asked if families/sponsors were visiting residents. EI # 4 said no, they had not had in house visits. EI #4 was asked why had visitation not been allowed. EI #4 said because of COVID and the decision to not have visitation was not up to her, she was following the directive of the administrator. On 02/25/22 at 10:30 AM a follow up interview was conducted with EI #1. EI #1 said he had printed out a CMS Memo but had not read it. EI #1 was asked if the facility had implemented visitation for residents. EI #1 said no. EI #1 was asked why the facility had not implemented the procedure to allow visitation for all residents. EI #1 said he was not aware of the CMS Memo. EI #1 was asked if the residents had the right to have visits. EI #1 said, yes they do.

Based on interviews, resident record review, review of the MDS (Minimum Data Set) Coordinator - Job Description, and review of the updated CMS (Centers for Medicare & Medicaid Services) QSO (Quality, Safety & [and] Oversight Group) -21-17-NH (Nursing Home) Memo, the facility failed to ensure Comprehensive MDS assessments were completed in a timely manner after CMS ended the Emergency Blanket MDS waiver on 02/10/2021. This deficient practice affected Resident Identifier #'s 53, 54, 55, 56, 153, 155, 101, 102 and 103, nine of 13 residents whose MDS assessments were reviewed. Findings Include: A review of the updated CMS QSO-21-17-NH Memo, with an update of 02/10/2021, revealed the following: . SUBJECT: Updates to Long-Term Care (LTC) Emergency Regulatory Waivers issued in response to COVID-19 . Ending of Select Emergency Blanket Waivers During the COVID-19 PHE (Public Health Emergency) . Emergency Blanket Waiver of Minimum Data Set (MDS) Timeframe Requirements (42 CFR 483.20) CMS waived the MDS timeframe requirement at 42 CRF 483.20 for assessments to allow providers flexibility in completing and transmitting assessments. This action was intended to allow facilities to prioritize infection control effects in response to the PHE. However, the majority of facilities have been completing and transmitting assessments timely, therefore we believe all providers should be able to complete and transmit MDS assessments as required at 42 CRF 483.20. Also, CMS believes nursing homes should have developed practices for completing these assessments timely, which are critical for resident care planning. As a result, CMS is ending the emergency blanket waiver for 42 CRF 483.20 . Review of the MDS Coordinator - Job Description, with an effective date of 01/01/2022, revealed the following: . 11. Monitors all of the facility's resident assessments and care plans to ensure that they: a. Are completed in a timely manner . 1) RI #53 was admitted to the facility on [DATE], and readmitted on [DATE]. A review of RI #53's Comprehensive MDS assessments revealed RI #53's last Comprehensive MDS assessment was transmitted to CMS on 09/24/2019. On 02/24/2022 at 5:17 PM, an interview was conducted with Employee Identifier (EI) #2, the Interim Director of Nursing (DON). When asked what her job responsibilities were when it came to the residents MDS assessments, EI #2 said she was initially attempting to get the MDS assessments caught up. The surveyor asked EI #2 was she aware that according to an updated CMS QSO Memo dated 05/10/2021, facilities were to resume completing MDS assessments as they normally would. EI #2 said she was not aware of that until today (02/24/2022). The surveyor asked EI #2, on reviewing RI #53's MDS assessments, when was a Comprehensive MDS assessment last completed for RI #53. EI #2 said in August of 2019. When asked when CMS ended the MDS Wavier on 05/10/2021, when should a Comprehensive MDS assessment have been completed for RI #53, EI #2 said an Annual (which is a Comprehensive assessment) MDS assessment should have been completed in August of 2021. The surveyor asked EI #2 where was there evidence a Comprehensive MDS assessment had been completed for RI #53 after the MDS waiver ended on 05/10/2021. EI #2 said there was no evidence any MDS assessment was completed for RI #53, after 05/10/2021, until 02/22/2022. 2) RI #54 was admitted to the facility on [DATE]. A review of RI #54's Comprehensive MDS assessments revealed RI #54's last Comprehensive MDS assessment was transmitted to CMS on 04/13/2020. On 02/24/22 at 5:17 PM in a continued interview with EI #2, EI #2 said when CMS ended the MDS Wavier on 05/10/2021, RI #54 should have had a Comprehensive MDS assessment completed in December of 2021. When asked where was there evidence a Comprehensive MDS assessment was completed for RI #54 after 05/10/2021, EI #2 said there was no evidence one was completed. 3) RI #55 was admitted to the facility on [DATE]. A review of RI #55's MDS assessments revealed only one MDS assessment, a Comprehensive MDS assessment dated [DATE], had been transmitted to CMS since RI #55's admission to the facility. On 02/24/22 at 5:17 PM in a continued interview with EI #2, the surveyor asked EI #2 when was RI #55 admitted to the facility. EI #2 said RI #55 was admitted to the facility on [DATE]. EI #2 said the only assessment that has been completed for RI #55 was an Admission MDS assessment which was completed on 2/20/2022. 4) RI #56 was admitted to the facility on [DATE], and readmitted on [DATE]. A review of RI #56's MDS assessments revealed the last Comprehensive MDS assessment transmitted to CMS was dated 04/17/2019. On 02/24/22 at 5:17 PM a continued interview was conducted with EI #2. The surveyor asked EI #2 what type MDS assessment was first completed for RI #56 after 05/10/2021. EI #2 said there was a Quarterly MDS assessment completed for RI #56 on 08/05/2021. When asked what type MDS assessment should have been completed for RI #56 after the Quarterly MDS assessment, EI #2 said RI #56 should have had an Annual MDS assessment completed in October of 2021. EI #2 said there was no evidence the Comprehensive MDS assessment had been completed. 5) RI #155 was admitted to the facility on [DATE]. A review of RI #155's comprehensive MDS Assessment revealed RI #155's last comprehensive MDS Assessment was transmitted to CMS on 03/09/20. On 02/24/22 at 5:33 PM an interview was conducted with EI #2. EI #2 was asked when was RI #155's last comprehensive assessment completed and what was it. EI #2 said 03/09/20 and it was a quarterly. EI #2 was asked when the MDS wavier ended on 5/10/21 what MDS assessments should have been done. EI #2 said RI #155 should have had an annual in June 2021. EI #2 was asked was there evidence this assessment was completed. EI #2 said there was no evidence this assessment was completed. EI #2 was asked should this MDS assessment have been done. EI #2 said yes, it should have been done. 6) RI #153 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. A review of RI #153's Comprehensive MDS Assessments revealed RI #153's last Comprehensive MDS Assessment was transmitted to CMS on 05/20/20. On 02/24/22 at 5:33 PM an interview was conducted with EI #2. EI #2 was asked when was RI #153's last comprehensive assessment completed. EI #2 said 05/20/20 and it was a Readmission. EI #2 was asked when the MDS wavier ended on 05/10/21, what MDS assessments should have been completed. EI #2 said an Annual MDS in 11/2021. EI #2 was asked where was the evidence that the Annual MDS in November 2021 was done. EI #2 said there was no evidence the assessment was done. 7) RI #101 was readmitted to the facility on [DATE]. A record review on 02/24/2022 at 8:45 AM revealed a missed Annual Minimum Data assessment due in December of 2021. An interview was conducted with EI #2 on 2/24/22 at 5:50 PM. EI #2 was asked when was the last MDS completed for RI #101. EI #2 stated a readmission MDS in August of 2021. EI #2 was asked what Annual MDS was missing since May of 2021. EI #2 stated an Annual in September 2021. EI #2 was asked if there was any evidence that the MDS had been completed. EI #2 stated no evidence that the MDS was completed. 8) RI #102 was readmitted to the facility on [DATE]. A record review for RI #102 revealed a missing annual MDS for June 2021. In the continued interview with EI #2 on 2/24/22 at 5:50 PM, EI #2 was asked when was the last MDS completed for RI #102. EI #2 stated a quarterly MDS in February of 2022. EI #2 was asked what annual MDS was missing since May of 2021. EI #2 stated an annual in June 2021. EI #2 was asked if there was any evidence the missing MDS had been completed. EI #2 stated there was no evidence the MDS had been completed. 9) RI #103 was readmitted to the facility on [DATE]. A record review for RI #103 revealed a missing annual MDS for November 2021. In the continued interview with EI #2, on 2/24/22 at 5:50 PM, EI #2 was asked when was the last MDS completed for RI #103. EI #2 stated a quarterly MDS in February of 2022. EI #2 was asked what annual MDS was missing since May of 2021. EI #2 stated an annual in November 2021. EI #2 was asked if there was any evidence the missing MDS had been completed. EI #2 stated there was no evidence the MDS had been completed. EI #2 was asked what was the importance of completing MDS Assessments. EI #2 stated quality indicators for the facility, shows a mechanism for identifying change and helps support claims and payments. EI #2 was asked why the resident MDS were missing. EI #2 stated she did not know, due to only working at the facility for two weeks.

Based on interviews, resident record review, review of the MDS (Minimum Data Set) Coordinator - Job Description, and review of the updated CMS (Centers for Medicare & Medicaid Services) QSO (Quality, Safety & [and] Oversight Group) -21-17-NH (Nursing Home) Memo, the facility failed to ensure Quarterly MDS assessments were completed in a timely manner after CMS ended the Emergency Blanket MDS waiver on 02/10/2021. This deficient practice for Resident Identifier #'s 53, 54, 55, 153, 155, 101, 102, 103, 104 and 105, 10 of 13 residents whose MDS assessments were reviewed. Findings Include: A review of the updated CMS QSO-21-17-NH Memo, with an update of 02/10/2021, revealed the following: . SUBJECT: Updates to Long-Term Care (LTC) Emergency Regulatory Waivers issued in response to COVID-19 . Ending of Select Emergency Blanket Waivers During the COVID-19 PHE (Public Health Emergency) . Emergency Blanket Waiver of Minimum Data Set (MDS) Timeframe Requirements (42 CFR 483.20) CMS waived the MDS timeframe requirement at 42 CRF 483.20 for assessments to allow providers flexibility in completing and transmitting assessments. This action was intended to allow facilities to prioritize infection control effects in response to the PHE. However, the majority of facilities have been completing and transmitting assessments timely, therefore we believe all providers should be able to complete and transmit MDS assessments as required at 42 CRF 483.20. Also, CMS believes nursing homes should have developed practices for completing these assessments timely, which are critical for resident care planning. As a result, CMS is ending the emergency blanket waiver for 42 CRF 483.20 . Review of the MDS Coordinator - Job Description, with an effective date of 01/01/2022, revealed the following: . 11. Monitors all of the facility's resident assessments and care plans to ensure that they: a. Are completed in a timely manner . 1) RI #53 was admitted to the facility on [DATE], and readmitted on [DATE]. A review of RI #53's Comprehensive MDS assessments revealed RI #53's last Quarterly MDS assessment transmitted to CMS before 03/08/2022 was on on 03/12/2019. On 02/24/2022 at 5:17 PM, an interview was conducted with Employee Identifier (EI) #2, the Interim Director of Nursing (DON). EI #2 said the last MDS assessment completed for RI #53 was on 02/22/2022, and it was a Quarterly MDS assessment. EI #2 said in May of 2021 and in November of 2021, RI #53 should have had Quarterly MDS assessments completed. The surveyor asked EI #2 where was there evidence the Quarterly MDS assessments were completed for RI #53. EI #2 said there was no evidence they had been completed. 2) RI #54 was admitted to the facility on [DATE]. A review of RI #54's Quarterly MDS assessments revealed RI #54's last Quarterly MDS assessment was transmitted to CMS on 09/06/2021. On 02/24/22 at 5:17 PM in a continued interview with EI #2. When asked when should a Quarterly MDS assessment have been completed next, EI #2 said in December of 2021, but there was no evidence one had been completed. 3) RI #55 was admitted to the facility on [DATE]. A review of RI #55's MDS assessments revealed only one MDS assessment, a Comprehensive MDS assessment dated [DATE], had been transmitted to CMS since RI #55's admission to the facility. On 02/24/22 at 5:17 PM in a continued interview with EI #2, the surveyor asked EI #2 when was RI #55 admitted to the facility. EI #2 said RI #55 was admitted to the facility on [DATE]. The surveyor asked EI #2 how many Quarterly MDS assessments should have been completed after the MDS waiver ended on 05/10/2021, EI #2 said two. When asked where was there evidence RI #55 had Quarterly assessments completed as required, EI #2 said there was no evidence RI #55 had any Quarterly MDS assessments completed. 4) RI #153 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. A review of RI #153's Comprehensive MDS Assessments revealed RI #153 had two Quarterly MDS Assessments not completed. On 02/24/22 at 5:33 PM an interview was conducted with EI #2. EI #2 was asked when was RI #153's last comprehensive assessment completed. EI #2 said on 05/20/20 and it was a readmission. EI #2 was asked when the MDS wavier ended on 05/10/2021, what MDS assessments should have been completed. EI #2 said a quarterly in May and August of 2021. EI #2 was asked where was the evidence that the Quarterly MDS's in May and August of 2021 was done. EI #2 said there was no evidence the assessments were done. 5) RI #155 was admitted to the facility on [DATE]. A review of RI #155's MDS Assessments revealed RI #155 had two Quarterly MDS assessments not completed. On 02/24/22 at 5:33 PM an interview was conducted with EI #2. EI #2 was asked when was RI #155's last comprehensive assessment completed and what was it. EI #2 said 03/09/20 and it was a quarterly. EI #2 was asked when the MDS wavier ended on 5/10/21 what MDS assessments should have been done. EI #2 said RI #155 should have had two quarterly MDS assessments one in September and December 2021. EI #2 was asked was there evidence these assessment were completed. EI #2 said there was no evidence these assessments were completed. EI #2 was asked should these MDS assessment have been done. EI #2 said yes, it should have been done. 6) RI #153 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. A review of RI #153's Comprehensive MDS Assessments revealed RI #153's last Comprehensive MDS Assessment was transmitted to CMS on 05/20/20. On 02/24/22 at 5:33 PM an interview was conducted with EI #2. EI #2 was asked when was RI #153's last comprehensive assessment completed. EI #2 said on 05/20/20 and it was a readmission. EI #2 was asked when the MDS wavier ended on 05/10/2021, what MDS assessments should have been completed. EI #2 said a quarterly in May and August of 2021. EI #2 was asked where was the evidence that the Quarterly MDS's in May and August of 2021 was done. EI #2 said there was no evidence the assessments were done. 6) RI #101 was readmitted to the facility on [DATE]. A record review on 2/24/22 at 8:45 AM revealed a missed Quarterly Minimum Data due in December of 2021. An interview was conducted with EI #2, on 2/24/22 at 5:50 PM. EI #2 was asked when was the last MDS completed for RI #101. EI #2 stated a readmission MDS in August of 2021. EI #2 was asked what quarterly MDS was missing since May of 2021. EI #2 stated a Quarterly in December 2021. EI #2 was asked if there was any evidence the MDS had been completed. EI #2 stated there was no evidence the MDS had been completed. 7) RI #102 was readmitted to the facility on [DATE]. A record review for RI #102 revealed a missing quarterly MDS for September 2021 and December 2021. An interview was conducted with EI #2 on 2/24/22 at 5:50 PM. EI #2 was asked when was the last MDS completed for RI #102. EI #2 stated a quarterly MDS in February of 2022. EI #2 was asked what quarterly MDS was missing since May of 2021. EI #2 stated a Quarterly in September 2021 and December 2021. EI #2 was asked if there was any evidence the missing MDS had been completed. EI #2 stated there was no evidence the MDS had been completed. 8) RI #103 was readmitted to the facility on [DATE]. A record review for RI #103 revealed a missing quarterly MDS for May 2021 and August 2021. An interview was conducted with EI #2 on 2/24/22 at 5:50 PM. EI #2 was asked when was the last MDS completed for RI #103. EI #2 stated a quarterly MDS in February of 2022. EI #2 was asked what quarterly MDS was missing since May of 2021. EI #2 stated a Quarterly in May 2021 and August 2021. EI #2 was asked if there was any evidence the missing MDS had been completed. EI #2 stated there was no evidence the MDS had been completed 9) RI #104 was readmitted to the facility on [DATE]. A record review for RI #104 revealed a missing quarterly MDS for May 2021 and November 2021. An interview was conducted with EI #2 on 2/24/22 at 5:50 PM. EI 2 was asked when was the last MDS completed for RI #104. EI #2 stated an annual MDS in February of 2022. EI #2 was asked what quarterly MDS was missing since May of 2021. EI #2 stated a Quarterly in May 2021 and November 2021. EI #2 was asked if there was any evidence the missing MDS had been completed. EI #2 stated there was no evidence the MDS had been completed 10) RI #105 was readmitted to the facility on [DATE]. A record review for RI #105 revealed a missing quarterly MDS for May 2021 and November 2021. An interview was conducted with EI #2 on 2/24/22 at 5:50 PM. EI #2 was asked when was the last MDS completed for RI #104. EI #2 stated an annual MDS in February of 2022. EI #2 was asked what quarterly MDS was missing since May of 2021. EI #2 stated a Quarterly in May 2021, August 2021, and November 2021. EI #2 was asked if there was any evidence the missing MDS had been completed. EI #2 stated there was no evidence the MDS had been completed. EI #2 was asked what was the importance of completing MDS Assessments. EI #2 stated quality indicators for the facility, shows a mechanism for identifying change and helps support claims and payments. EI #2 was asked why the resident MDS were missing. EI #2 stated she did not know, due to only working at the facility for two weeks.

Based on resident record review, interviews, and a facility policy titled Comprehensive Care Plans the facility failed to to develop a care plan for RI #105 for the use of anticoagulant (AC) medication since 3/6/21. This affected one of 13 sampled residents for whom care plans were reviewed. Findings Include: A review of a policy titled Comprehensive Care Plan with a revision date of 1/30/18 documented: .Purpose: To provide individualized care for each resident. Goal: To attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . RI #105 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #105's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #105's care plans did not reveal a care plan for the use of AC medication or [MEDICATION(S)]. On 2/24/22 at 4:27 PM an interview was conducted with Employee Identifier (EI) # 2. EI #2 was asked if RI #105 was receiving AC medication. EI #2 responded yes [MEDICATION(S)] 75 mg started on 3/6/21. EI #2 further stated the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . EI # 2 was asked if RI #105 had a current care plan for AC medication. EI #2 responded no. EI #2 was asked why a resident should be care planned for the use of AC medication. EI #2 stated, to monitor for bleeding and the risk of bleeding. EI #2 was asked why RI #105 was not care planned for AC medication. EI #2 stated she was not sure but it appeared to be missed.

Based on interview, review of the RECORD OF MEDICATION DESTRUCTION Control Drug Destructions forms, and review of a facility policy titled Disposal of Medications, the facility failed to ensure the required signatures were on the Controlled Drug Destruction forms. This affected two of five months, February and October of 2021, reviewed for destruction of controlled medications. Findings Include: Review of the facility policy titled Disposal of Medications, dated 12/2012, revealed the following: . PROCEDURES . 2. b. For the State of Alabama, these controlled substances shall be disposed of by the nursing care center in the presence of appropriately titled professionals . · x Two licensed nurses employed by the nursing care center · x Administrator and licensed nurse employed by the nursing care center · x Others as listed: Pharmacist . On 02/25/2022 at 8:19 AM, the surveyor observed the Controlled Medication Destruction forms for February 2022 (three signatures noted), October 2021 (two signatures noted), September 2021 (three signatures noted), July 2021 (three signatures noted), and February 2021 (two signatures noted). Two of the five months were without the required signatures. On 02/25/2022 at 11:42 AM, the surveyor conducted an interview with Employee Identifier (EI) #1, the Administrator. The surveyor asked EI #1 who was responsible for destroying narcotic (controlled) medications. EI #1 said two registered nurses and the pharmacist came every month. When asked how many signatures should be on the Controlled Drug Destruction form, EI #1 said two. The surveyor showed EI #1 a copy of a Record of Medication Destruction form for controlled medications, and EI #1 stated he saw where it needed to be two witnesses as well as the pharmacists signature.

Based on observations, interviews, review of a facility policy titled, FOOD STORAGE LABELING and review of the (YEAR) Food and Drug Administration (FDA) Food Code, the facility failed to ensure: 1) Items in a standing refrigerator unit in the kitchen were labeled and dated; and 2) Two frozen turkeys were not thawing in a pan on the floor of the walk in cooler/refrigerator. This had the potential to affect all 41 residents receiving meals from the kitchen. Findings Include: 1) A review of a facility policy with a revised date of 6/2019, titled, FOOD STORAGE LABELING, revealed: POLICY: The facility will ensure the safety and quality of food by following good storage and labeling procedures. PR[NAME]EDURE: 1. All food items must be labeled with the date they are received. 2. All food items that are not in their original containers must be labeled with the common food name of the food and the date they are received. 2. Suggested labeling includes: a. Common Name b. Date of preparation or Use By Date c. Example: Food prepared on 2/1 must be used or discarded by 2/7 . On 8/05/19 at 4:10 PM, during the initial tour of the kitchen, the surveyor observed a container of red onions with no label or dating on the plastic container in the stand up refrigerator. On 08/07/19 at 3:07 PM, an interview was conducted with EI (Employee Identifier) #1, a dietary aide. EI #1 was asked who was responsible for labeling and dating food in the stand up refrigerator. EI #1 stated, Mostly the cooks or dietary staff. EI #1 was asked why was it important to label and date food in the refrigerator. EI #1 replied, Because you don't know how long its been in the refrigerator and you don't want anyone to get sick. EI #1 was asked what is the concern of not labeling and dating items in the refrigerator. EI#1 stated, Cross contamination and airborne sickness. On 08/07/19 at 3:27 PM, an interview was conducted with EI #2, the Dietary Manager. EI #2 was asked who was responsible for labeling and dating food in the stand up refrigerator. EI #2 stated, Any dietary worker in the kitchen. If you prep and prepare it then you are responsible for labeling and dating and left overs as well. EI #2 was asked why was it important to label and date food in the refrigerator. EI #2 replied, Cross contamination and certain patients may have allergies and we don't want to spread food borne illness. EI #2 was asked what is the concern of not labeling and dating items in the refrigerator. EI #2 said, it might make someone sick or cross contamination. 2) Review of the FDA Food Code (YEAR) revealed the following: . Preventing Contamination from the Premises 3-305.11 Food Storage. . (3) At least 15 cm (6 inches) above the floor. On 8/05/19 at 4:13 PM, during the initial tour in the walk in cooler/refrigerator, the surveyor observed two frozen turkey's on the floor of the cooler/refrigerator inside a pan thawing, according to the dietary manager. On 8/07/19 at 3:12 PM, an interview was conducted with EI #1, dietary aide. EI #1 was asked how should meats be thawed. EI #1 stated, The day before cooking, in the cooler, in the bus pan like we had it and up off the floor. EI #1 was asked if meats should be in a pan flat on the floor in the cooler being thawed. EI #1 responded, No. EI #1 was asked the concern of thawing foods in a pan flat on the floor. EI #1 stated, Something could fall off into it. On 8/07/19 at 3:41 PM, an interview was conducted with EI #2. Dietary Manager. EI #2 was asked how should meats be thawed. EI #2 stated, In refrigerator of walk in 6 inches off the floor. EI #2 was asked if meats should be in a pan flat on the floor in the cooler being thawed. EI #2 responded, No ma'am. EI # 2 was asked who placed the turkeys in the cooler on the floor and why. EI #2 said, I don't know. EI #2 was asked the concern of thawing foods in a pan flat on the floor. EI #2 stated, If on the floor a chemical on the floor could seep through the container.

Based on record review, interview and a review of a facility policy titled, Change in Condition-Notification, the facility failed to ensure RI (Resident Identifier) #44's sponsor was notified of the resident's admission (transfer) to the hospital on [DATE] and readmission to the facility on [DATE]. This deficient practice affected RI #44, one of three sampled residents who were reviewed for hospitalization . Findings include: A review of a facility policy titled, Change in Condition-Notification, with a reviewed dated of 06/2011 revealed: . The Nursing Home must promptly inform the resident and/or responsible party when there is a change in condition. Change in condition is defined as: . A decision to transfer or discharge the resident from the facility . Nursing Service Department is responsible for notification of . responsible party . Document as appropriate . RI #44 was admitted to the facility on [DATE], discharge(transferred) to the hospital on [DATE] and readmitted to the facility on [DATE]. RI #44's Nurses Notes documented: .6/15/2019 . Resident sent to the ER (emergency room ) for bleeding . 6/28/2019 .Resident returned to facility . There was no documentation of notification of RI #44's sponsor/responsible party. On 8/8/19 at 11:35 a.m. an interview was conducted with EI ( Employee Identifier) #3, LPN (Licensed Practical Nurse). EI #3 was asked was RI #44 transferred to the hospital and readmitted to the facility. EI #3 said, RI #44 returned to the facility on [DATE]. EI #3 was asked if she documented RI #44's admission and readmission in the nurses noted on 6/28/19. EI #3 said yes. EI #3 was asked if RI #44's sponsor/NOK (Next of kin) was notified of the resident's readmission on 6/28/19. EI #3 said, I did not document it, so if I did not document it, it did not get done. EI #3 was asked if there was documentation of RI #44's sponsor/NOK being notified of his/her transfer to the hospital on [DATE]. EI #3 said, I don't see any documentation that family was notified.EI #3 was asked if RI #44's sponsor/NOK should have been notified of his/her transfer to the hospital and readmission to the facility on [DATE]. EI #3 said they should have. EI #3 was asked what was the facility's policy regarding a resident's change in condition. EI #3 said anytime there is a change in a resident's condition, the sponsor should be notified.

Based on record review, interview and review of the CMS (Center for Medicare and Medicaid Services) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure RI (Resident Identifier ) #1's Admission MDS (Minimum Data Set) assessment was completed within 14 days of admission. This deficient practice affected one of 14 sampled residents whose MDS assessments were reviewed. Findings Include: A review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Chapter 2: Assessment for the RAI (Resident Assessment Instrument) documented: .01. Admission Assessment The Admission Assessment is a comprehensive Assesment for a new resident and, .must be completed by the end of day 14, counting the date of admission to the nursing home as day 1 . RI #1 was admitted to the facility on [DATE]. RI #1's admission MDS with an ARD (Assessment Reference Date) of 2/20/19 was listed as open. On 8/8/19 at 9:12 a.m., an interview was conducted with EI (Employee Indentifer) #4, MDS Coordinator. EI #4 was asked when was RI #1 admitted to the facility. EI #4 said on 2/20/19. EI #4 was asked why was RI #1's Admission MDS still opened. EI #4 said it was opened and that it had not been done. EI #4 was asked should RI #1's Admission MDS have been done. EI #4 said yes it should have been done. EI #4 was asked who was responsible for ensuring MDSs were done. EI #4 said the MDS Coordinator.

Based on observations, interview and the facility policies titled, STORAGE OF REFRIGERATED FOOD AND FOOD STORAGE LABELING , the facility failed to ensure: 1. a container of Vanilla Icing had a used by date 2. a box of cabbages and a carton of liquid eggs had an open and use-by-date, 3. a tray of sausage and bacon was labeled and 4. 2 gallons of buttermilk was discarded on [DATE]. This deficient practice had the potential to affected 45 of 45 residents receiving meals from the kitchen. Finding Include: A review of a facility policy titled, STORAGE OF REFRIGERATED FOOD, with revision dates (MONTH) (YEAR)- (MONTH) (YEAR) revealed: .PR[NAME]EDURE: .5. All opened foods are labeled with common name of food,date stored and use-by-date. 6 .foods .may be stored for 7 days . A review of a facility policy titled, FOOD STORAGE LABELING, with no effective date, revealed: .POLICY The facility will ensure the safety and quality of food by following good storage and labeling procedures. PR[NAME]EDURE: .2 All food items that are not in their original containers must be labled with the common name of the food, and the date they are received .5 iv .discard foods that have passed its .use-by date or expiration date On [DATE] at 5:40 p.m., during the initial tour of the kitchen, the surveyor observed the following in the the walk in cooler: 1 container of Vanilla Icing dated with no used by date, a box of cabbages and a carton of liquid eggs with no open of used by date and a tray of sausage and bacon with plastic wrap with no label and 2 half of gallon of buttermilk date [DATE]. On [DATE] at 9:30 an interview was conducted with Employee Identifier (EI) #4, Dietary Manager. EI # 4 was asked during the initial tour on [DATE], what food items in the walk in cooler did not have an open and used by date. EI #4 said a pan of breakfast meat, a carton of liquid eggs and a contain of Vanilla Icing had an open date but no use-by-date, and a box of cabbages with no label, no open or use by date. EI #4 was asked what food items in the walk in cooler had expired. EI #4 said 2 half of gallons of buttermilk with an expired date of [DATE]. EI #4 was asked when should food items be tabled. EI #4 said any food that is open and and used required and open and used by date. EI #4 was asked what is the potential harm with food items not having an open and use- by date and expired date. EI #4 said it could caused an outbreak with one resident getting sick. in the walk in cooler did not have an open and used by date. A. The pan of breakfast meat did not have an open or used by date, a carton of liquid eggs. The Vanilla Icing container had an open date, but no use by date. The case/box cabbage did have a label, no open or used by date. Q. What food items in the walk in cooler had an expired date. A. 2 half a gallons Buttermilk and it expired on [DATE]. Q. When should food items be labeled. A. Anything that is open and not used up fully, it is required to have an open and used by date. Q. What is the potential harm to residents when food items are not labeled, no open or used by date. A. It could cause a potential outbreak with one patient/resident being sick. EI#4 agreed with above statement.

Based on observation, interview and a facility policy titled, Mental Grievance Policy,the facility failed to ensure residents in the group meeting held on 07/7/17 at 10:00 a. m. were aware of the grievance process. This affected all 10 residents attending the group meeting. Finding Include: A review of a facility policy titled, Mental Grievance Policy, with a revision date of 01/31/18 documented: RESIDENT GRIEVANCE PR[NAME]EDURE GOAL To ensure that the voiced grievances of a resident are made without discrimination or reprisal in a timely manner . On 7/17/18 at 10:00 a.m., a resident council meeting was held. A total of 10 residents attended the meeting. The residents were asked if they knew how to file a grievance. All 10 residents at the meeting stated they did not know how to file a grievance. On 7/17/18 at 3:36 p.m. an interview was conducted with EI (Employee Indentifer) #2, Social Service Designee. EI #2 was asked how are residents made of aware of the how to file a written grievance. EI #2 said when she is at work she completes the form, when she is not at work residents tell the nurse and she follows up. EI #2 was asked if residents knew where to get the form to file a written grievance. EI #2 said they probably don't because she usually completes the forms. EI #2 was asked if residents were aware of the grievance process. EI #2 said, No they are not. EI #2 was asked were there notices throughout the facility about the grievance process. EI #2 said, No

Based on interview, record review and a document review titled, CEU's (Continuing Education Units) for CNA's (Certified Nursing Assistant), the facility failed to ensure CNA's, Employee Identifiers (EI) #'s 5, 6, 7, 8 and 9 received 12 hours of mandatory annual training. This deficient practice affected 5 out 12 CNA's whose training records were reviewed. A review of a document titled, CEU's for CNA's, documented EI #s 5, 6, 7, 8, and 9 did not have the 12 hours of mandatory annual training for the calendar year. On 7/19/2018 at 2:19 p.m., an interview was conducted with EI #1, RN (Registered Nurse), Acting DON( Director of Nurses). EI #1 was asked how many CEUs are required for the CNA's per calendar year. EI #1 said 12 CEU's. EI #1 was asked did EI #'s 5, 6, 7, 8 7, 8, and 9 have their 12 CEU's for the calendar year. EI #1 said, No. EI #1 was asked what was the importance of CNA's having CEU's. EI #1 said to learn new things to do their job adequately.

Based on observation, interview and medical record review, the facility failed to adequately code RI (Resident Identifiers) #12's and # 37's Yearly MDS (Minimum Data Set) Assessments to reflect tobacco users. This affected 2 out of 5 residents who were identified as smokers in the facility. Finding Include: RI #13 was readmitted to the facility on [DATE]. A review of RI #13's Resident Smoking assessment dated [DATE] documented resident as a smoker. A review of RI #13's Yearly MDS with an ARD (Assessment Reference Date ) of 08/17/2017 revealed Section J 1300 was not coded for tobacco use. RI #37 was admitted to the facility on [DATE]. A review of RI #37's Resident Smoking assessment dated [DATE] documented resident as a smoker. RI #37's Yearly MDS with and ARD of 06/08/2016 revealed Section J1300 was not coded for tobacco use. On 7/17/18 at 6:35 p.m., the Surveyor observed RI #13 and RI #37 smoking in designated smoking area supervised by staff. On 7/19/18 an interview was conducted with EI (Employee Identifier)#3, RN (Registered Nurse), MDS Coordinator. EI #3 was asked if RI #13 and RI #37 were smokers. EI #3 said yes. EI #3 was asked if RI #13 and RI #37 were coded on his/her yearly MDS Assessment for tobacco use. EI # 3 said, No they were not.

Based on observations, interviews, and review of the facility policy titled Menus and the preplanned menu for 05/23/2017, the facility failed to ensure the preplanned menu for the supper meal on 05/23/2017 was followed. Staff combined beef stirfry with rice prior to serving, which resulted in residents receiving a smaller portion, half (1/2) cup less than specified on the menu. This had the potential to affect all residents with orders for regular or mechanical soft diets. The facility's diet orders list indicated 43 of 49 residents in the facility had orders for regular or mechanical soft diets. Findings include: Review of the facility's policy titled Menus, dated 02/2010, revealed the following: POLICY: Menus are planned to to meet the nutritional needs of the residents in accordance with the Recommended Dietary Allowances . PROCEDURE: 1. Menus for regular and therapeutic diets are preplanned and developed to meet the nutritional needs of the majority of the residents . 3. Foods will be served as planned . The facility's preplanned menu for the 05/23/2017 supper meal indicated residents were planned to receive six ounces of stir fry with vegetables and 1/2 (one half) cup of brown rice. During trayline observations on 05/23/2017 at 5:10 p.m., it was noted staff had combined the stirfry and rice into one item. Employee Identifier (EI) #7, a cook, was observed serving trays. For residents receiving regular and mechanically altered diets, EI #7 was serving six ounces of the stir fry and rice combined; therefore, residents were shorted 1/2 cup of food. On 05/23/2017 at 5:40 p.m. EI #7 said she knew which portion sizes to use because it was listed on the dining sheet. However, once she pulled that sheet, she said it was not listed. EI #8, the Certified Dietary Manager (who was also present), explained it was important to serve the correct portion sizes to provide residents with the correct amount of protein and calories. During a follow-up interview with EI #8, the Dietary Manager, on 05/24/2017 at 1:10 p.m., EI #8 confirmed staff had only served six ounces of the stirfry and rice combined and agreed residents had been shorted 1/2 cup.

Based on interview and review of a facility policy titled MEDICATION REGIMEN REVIEW AND REPORTING and Monthly Consultant Pharmacist Reports, the facility failed to ensure monthly pharmacy recommendations to the physician and nursing department were acted upon. This affected recommendations for December 2016, January 2017, February 2017 and March 2017, four of 12 months reviewed. Findings included: A review of the facility policy titled MEDICATION REGIMEN REVIEW AND REPORTING, dated 11/2016, revealed the following: POLICY Medication Regimen Review (MRR) is defined as the systematic evaluation of medication therapy . The consultant pharmacist reviews the medication regimen of each resident at least monthly. Findings and recommendations are communicated to those with . responsibility to implement the recommendations, and responded to in an appropriate and timely fashion. PROCEDURES . 8. The consultant pharmacist and the nursing care center follows up on the recommendations to verify that appropriate action has been taken. Recommendations shall be acted upon within 30 calendar days. c. For recommendations that do not require physician intervention, the director of nursing or licensed designee will address the recommendations. The facility's monthly Consultant Pharmacist Communication reports were reviewed during the survey and revealed reports for the months of December 2016, January 2017, February 2017, and March 2017 that had not been responded to or acted upon as follows: December 2016: Two of two Communication to Physician. January 2017: Seven of 15 notes to the Physician and six of 11 recommendations to nursing. February 2017: 14 of 23 notes to the Physician and 12 of 23 recommendations to nursing. The February report also contained four pages with 10 items the pharmacist had identified as pending action or response from previous months. March 2017: Nine of 15 notes to the Physician and 5 of 13 recommendations to nursing. The March report also contained 12 pages with 37 items the pharmacist had identified as pending action or response from previous months. On 5/24/2017 at 4:00 p.m. EI (Employee Identifier) #1, DON (Director of Nursing), was asked why the pharmacy reports for December 2016, January, February, and March 2017, had not been completed with action and response. EI #1 replied, December was not done and January, February, and March were spotty because in December she transitioned from the position of Administrator to DON. When asked why it was important to follow up on communication to the Physician, EI #1 said, if adjustments in medications were not made it could result in overdose or interactions. When asked why it was important to follow up on recommendations to nursing, EI #1 said, there could be gaps or things wrong on the MAR (Medication Administration Record), incorrect dosage, and laboratory reports may need to be reviewed.

Based on observation, interviews, and review of the facility's policy titled Menus, the preplanned menu for 05/23/2017, and the facility's recipes for pureed stirfry and rice, the facility failed to ensure staff served the planned portion sizes for the pureed supper meal on 05/23/2017, to ensure adequate nutritive content was provided to residents. This affected Resident Identifier (RI) #s 11 and 12, and had the potential to affect all residents with orders for a pureed diet. The facility's diet order list indicated six residents had orders for pureed diets. Findings include: Review of the facility's policy titled Menus, dated 02/2010, revealed the following: POLICY: Menus are planned to to meet the nutritional needs of the residents in accordance with the Recommended Dietary Allowances . PROCEDURE: 1. Menus for . therapeutic diets are preplanned and developed to meet the nutritional needs of the .residents . 3. Foods will be served as planned . The facility's preplanned menu for the 05/23/2017 supper meal indicated residents with orders for a pureed diet were planned to receive two #10 scoops of pureed stir fry (equivalent to 4/5 of a cup) and a #8 scoop (equivalent to 1/2 cup) of pureed rice. Review of the facility's recipe for pureed stirfry with vegetables, dated 11/03/2016, revealed the following: . Portion Size: 2 #10 scoops . Review of the facility's recipe for pureed brown rice, dated 11/03/2016, revealed the following: . Portion Size: #8 scoop . During trayline observations on 05/23/2017 at 5:10 p.m., it was noted staff had pureed the stirfry and rice together. Employee Identifier (EI) #7, a cook, was observed serving trays. For residents receiving pureed diets, EI #7 was serving one #12 scoop of the pureed stirfry and rice combined. RI #s 11 and 12 were among the residents observed to receive inadequate pureed portion sizes. On 05/23/2017 at 5:40 p.m. EI #7 said she knew which portion sizes to use because it was listed on the dining sheet. However, once she pulled that sheet, she said it was not listed. EI #8, the Certified Dietary Manager (who was also present), explained it was important to serve the correct portion sizes to provide residents with the correct amount of protein and calories. EI #8 agreed the portions served to residents with pureed diet orders were too little.

Based on interviews, review of the facility's policy titled . ABUSE, and review of employee files, the facility failed to ensure the screening component of the facility's abuse policy was implemented by not checking references or the Abuse Registry prior to hire. This affected Employee Identifier (EI) #9, housekeeping staff, one of five newly hired employees reviewed for screening procedures. Findings include: Review of the facility's policy titled . ABUSE, revised 02/02/2016 and 05/23/2017, revealed the following: . II. Screening: all potential staff are to have background checks, reference checks including attempts to gain information from current or previous employers, abuse registry checks . EI #9's employee file was reviewed on 05/23/5017 at 3:30 p.m There was no documentation of any reference checks or an abuse registry check prior to hire. Employee Identifier (EI) #10, the Human Resources Coordinator, was interviewed on 05/24/2017 at 8:03 a.m EI #10 stated she was unable to locate EI #9's abuse registry check or reference checks. EI #10 explained the purpose of the abuse registry check was to make sure potential hires had not done something in the past to harm a resident. She said the purpose of reference checks was to see the type of work done in the past and whether they were honest about where they had worked. During an interview on 05/24/2017 at 9:50 a.m., EI #1, the Director of Nursing/Abuse Coordinator, said screening of potential hires should include background checks, reference checks, and abuse registry checks. EI #1 said the purpose of checking the abuse registry was to make sure the potential hire was not a known abuser. She said the purpose of reference checks was to determine if they were rehirable, because if not, it could indicate a problem. EI #1 said the facility's abuse policy for screening of potential hires had not been followed.

Based on observations, record review, and interviews, the facility failed to ensure Resident Identifier (RI) #5's plan of care regarding the use of two siderails to aide in positioning was implemented. On tow days of the survey, RI #5 was observed with four side rails in the up position, instead of two, as care planned. This deficient practice affected one of 12 residents for whom care plans were reviewed. Findings include: RI #5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #5's most recent Minimum Data Set Assessment, an annual assessment, with an Assessment Reference Date of 04/07/2017, indicated RI #5 had moderately impaired cognition and required extensive assistance of two plus people for bed mobility. RI #5's undated RESIDENT STATUS SHEET (Kardex) indicated RI #5 required siderails constantly and documented they should be up times two to aid in the positioning of RI #5's wedge. RI #5's May 2017 Physician order [REDACTED]. During the initial tour of the facility on 05/23/2017 beginning at 11:03 a.m., RI #5 was observed in bed with 1/2 (half) siderails up times four, two at the top and two at the bottom. On 05/23/2017 at 2:48 p.m. and 3:00 p.m., RI #5 was again observed in bed with 1/2 siderails up times four. On 05/24/2017 at 8:00 a.m., RI #5 was observed in bed with 1/2 siderails up times four. Employee Identifier (EI) #4, RI #5's Certified Nursing Assistant (CNA), was interviewed on 05/24/2017 at 10:12 a.m EI #4 indicated she took care of RI #5 on a regular basis. She explained CNAs used a Kardex book to know what care residents required. During the interview, EI #4 entered RI #5's room and two 1/2 side rails were up on the residents's left side, and the top 1/2 rail on the resident's right side was also up. When asked what RI #5's Kardex specified regarding siderails, EI #4 stated it indicated RI #5 was to use siderails constantly, and should be up times two to aid in positioning of RI #5's wedge. EI #5, Charge Nurse/Licensed Practical Nurse, was interviewed on 05/24/2017 at 10:20 a.m EI #5 said per RI #5's orders, two side rails should be up times two to aid in the positioning of the wedge. EI #5 explained this meant the top two siderails should be up and the bottom two down. During an interview with EI #6, Registered Nurse, on 05/24/2017 at 10:35 a.m., EI #6 said RI #5's top two side rails should be up and the bottom two down, according to orders. EI #6 said it was important to use the siderails as specified because the resident was assessed, and it was what they determined best for the resident.

Based on record reviews, interviews and review of an untitled facility policy addressing Certified Nursing Assistant (CNA) training, the facility failed to ensure Employee Identifier (EI) #2, a CNA, received 12 hours of education, including courses on Abuse Prevention and Dementia Care. This affected one of five CNA training files reviewed. Finding include : Review of an untitled and undated facility policy addressing CNA training revealed the following : . It is the policy of Greene County Nursing Home that each employee maintain the required 12 continuing education hours in order to remain a CNA employee . A review of EI#2's training record revealed EI #2's hire date was 05/13/2014. The log of inservice education only documented seven hours of continuing education hours, and did not include documentation of Abuse or Dementia training. On 5/24/2017 at 8:06 a.m., an interview was conducted with EI#3, Administrative Assistant. EI #3 stated she was responsible for maintaining records of CNA training. EI #3 said EI#2 did not have 12 hours of education because she did not attend inservices in January, February, March, or April of 2017. During a follow-up interview with EI #3 on 05/24/2017 at 9:07 a.m., EI #3 stated she was unable to locate any documentation of Abuse or Dementia training for EI #2. EI #1, the Director of Nursing, was interviewed on 05/24/2017 at 9:50 a.m EI #1 stated CNAs were required to get 12 hours of education per year, including the topics of Abuse Prevention and Dementia Care. EI #1 said CNA training was important to ensure residents received quality care.

Based on record review, interview, and review of the facility's LAB POLICY, the facility failed to ensure Resident Identifier (RI) #3's Comprehensive Metabolic Profile lab orders were transcribed into the computer properly. Instead, they were ordered as Basic Metabolic Profiles. This affected one of eight residents for whom lab orders and results were reviewed. Findings include: Review of the facility's LAB POLICY, dated 05/2014, revealed the following: . PROCEDURE: * Doctors' orders received for specific lab. * Lab ordered in computer . RI #3 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #3's May 2017 physician's orders [REDACTED]. A physician's Progress Note, dated 04/17/2017, documented a lab order for an additional Comprehensive Metabolic Profile. However, review of RI #3's lab reports dated 06/14/2016, 01/03/2017, and 04/18/2017 indicated Basic Metabolic Profiles had been ordered instead. On 05/23/2017 at 4:40 p.m., Employee Identifier (EI) #6, Registered Nurse, was asked if she could provide the lab orders and results for RI #3's labwork. At 5:15 p.m., EI #6 returned and stated the bottom line was RI #3's lab order had been entered as a Metabolic Panel, which is equivalent to a Basic Metabolic Panel instead of a Comprehensive Metabolic Panel. EI #6 said the physician ordered a Comprehensive Metabolic Panel but due to a transcription error, they completed a Basic Metabolic Panel instead. EI #7 explained the Comprehensive Metabolic Profile tested for additional items that were not included in a Basic Metabolic Profile. When asked why it was important to ensure lab orders were transcribed properly, EI #6 said it could affect the resident if they do not get the correct labwork.