Every finding on record at Hanceville Nursing & Rehab Center, Inc

Based on observation, interviews, the facility's Week 4 menu, the facility's Disher (scoop) Sizes chart, the facility's Diet Type Report, and the facility's policies for Menu Planning and Menu Planning and Requirements, the facility failed to ensure residents receiving a Pureed Diet for Lunch on 12/10/2025 (Wednesday) received a full half cup (1/2 cup, 4-ounce) portion of Pureed Stewed Tomatoes and Pureed [NAME] Rice.This had the potential to affect five of 24 residents receiving Pureed Diets.Findings Include: Review of the facility's policy titled, Menu Planning, dated 11/03/2022, included the following: . 1. Menus are planned and approved by the Dietary Manager and the Registered Dietitian.2. Menus are planned for four-week cycles. 3. The menu format will include: .Diet Textures: .Pureed. Review of the facility's policy titled, Menu Planning and Requirements, dated 05/05/2025, included the following: . Guideline: Menus are planned to provide nourishing, palatable, attractive meals that meet the nutritional needs of residents served . in accordance with the Dietary Reference Intakes/Recommended Dietary Allowances as issued by the Food and Nutrition Board of the National Research Council, of the National Academy of Sciences . On 12/10/2025 at 10:50 AM observation of the residents' Lunch tray line revealed the blue-handled #16 dishers/scoops (1/4 cup, 2-ounce) were to be used when serving the pureed white rice and pureed stewed tomatoes. The AM [NAME] said the server was to use 2 scoops per serving for these items. Review of the facility's Week 4 Pureed Menu for Lunch on 12/10/2025 (Wednesday), also indicated a 1/2 cup serving for pureed white rice and a 1/2 cup serving for pureed stewed tomatoes was to be served On 12/10/2025 at 11:25 AM the Dietary Aide (DA) serving the residents plates from the steam table was asked why she was only using one scoop from a #16 disher to portion the pureed stewed tomatoes and pureed white rice onto the Pureed Diets. The DA said she was giving a heaping scoop. At this time the AM [NAME] informed the DA she should have been serving two scoops of pureed tomatoes and pureed rice. It was observed by the surveyors that five Pureed trays had received the incorrect portions sizes of pureed rice and stewed tomatoes. On 12/10/2025 at 12:54 PM the DA was interviewed. The DA said she normally used a 4-ounce (1/2 cup, #8 disher/scoop) when serving pureed rice, pureed meat, and pureed vegetables, but today she didn't use a 4-ounce. The DA said they did not have any 4-ounce scoops today. The DA said if she did not have the correct size scoop, she just uses the blue scoop (#16 disher/scoop, 1/4 cup, 2-ounce) and just heap the serving size. The DA said she now understands she must use 2 scoops when using the blue scoops. On 12/11/2025 at 9:44 AM the Certified Dietary Manager (CDM) was interviewed. When asked the problem with using the 2-ounce serving size scoop (blue handled #16 disher/scoop, 1/4 cup) for the pureed white rice and pureed stewed tomatoes on Wednesday, the CDM said it was supposed to be a 4-ounce (1/2 cup, #8 disher/scoop). The CDM said the residents' nutrition was not adequate if they don't get enough food. When asked if the menu was being followed, the CDM said for the first few pureed trays it wasn't being followed. The CDM said the staff used the 2-ounce scoop because they did not have the 4-ounce scoop. On 12/11/2025 at 10:38 AM the Registered Dietitian (RD) was interviewed via telephone. When asked the problem with using the 2-ounce serving size scoop (blue handled #16 disher/scoop, 1/4 cup) for the pureed white rice and pureed stewed tomatoes on Wednesday, the RD said there was no problem, as long as we used two scoops to follow the menu. When asked if the staff did that, the RD said no, they used a heaping scoop instead of double scoops. The RD said potentially the residents would not get what they need due to receiving less than a full portion. When asked if the menu was being followed, the RD said if they received a heaping scoop, no.

Based on observations, interviews, the United States (U.S.) Food and Drug Administration (FDA) 2022 Food Code, the dishwasher manufacturer's Operation, Cleaning, and Maintenance Manual, and the facility's policies for Food and Equipment Storage and Safety and Sanitation: Mechanical Dishwashing Procedure, the facility failed to ensure the potential for cross contamination did not exist when:1) storage shelves were less than six inches from the floor,2) a sink drainpipe did not extend into a floor drain; and3) the dishwasher final rinse did not exceed 195 degrees Fahrenheit (F). This had the potential to affect 185 of 185 residents receiving meals from the facility's kitchen.Findings Include:1) The U.S. FDA 2022 Food Code included the following: . 3-305.11 Food Storage. (A) . FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm [centimeters] (6 inches) above the floor.4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) . cleaned EQUIPMENT and UTENSILS . shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor.Review of the facility's policy titled, Food and Equipment Storage, dated 10/01/2023, included the following: . PROCEDURE . Note: Food and equipment should be stored at minimum of 6 inches above the ground. On 12/09/2025 at 8:17 AM, the surveyor observed a pot and pan shelving rack that looked too low to the floor.On 12/09/2025 at 8:50 AM the Walk-In Cooler was observed to have a shelf on the left side of the cooler that appeared too low to the floor. On 12/10/2025 at 9:18 AM the Maintenance Supervisor (MS) measured the shelf at two and three-fourth inches from the floor. The MS said with the shelf being too low, you could not see or clean under it. Next the MS measured the distance of the bottom of the pot and pan shelving rack to the floor. The bottom shelf of the pot and pan shelving rack was slanted. One end of the bottom shelf was 3 inches from the floor and the other end of the shelf was 4 inches from the floor. The MS said the shelf was not far enough away from the floor. He further said you could not see under it and rodents could hide there. On 12/11/2025 at 9:44 AM, the Certified Dietary Manager (CDM) was interviewed. The CDM said the concern with the pot and pan shelving rack being less than six inches off the floor had to do with cleaning and air flow. The CDM said it could be cleaned underneath the shelf better with it being higher off the ground. The CDM said the concern with the food storage shelf in the Walk-in Cooler being less than six inches off the floor was being able to clean under it and air to be able to flow freely under it.On 12/11/2025 10:38 AM, The Registered Dietitian (RD) was interviewed via (by way of) telephone. The RD said the pot and pan shelving rack being less than six inches off the floor meant there was not adequate room to clean under it. The RD said the food storage shelf in the Walk-in Cooler being less than six inches off the floor meant there was not adequate room to clean under it. 2) The U.S. FDA 2022 Food Code included the following:5-402.11 Backflow Prevention. (A) . a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed.During the initial kitchen observation on 12/09/2025 at 8:16 AM, one of the three drains from the Three-Compartment Sink was observed resting inside the floor drain. On 12/10/2025 at 9:28 AM the Three-Compartment Sink's floor drain was observed with the MS. The MS said the drainpipe extending into the floor drain came from the rinse sink. He said the drainpipe was in the floor drain. The MS said a strap had broken and that was why that drainpipe was low. The MS said the problem was that waste water could come back into the sink from the floor drain. On 12/11/2025 at 9:44 AM the CDM was interviewed. The CDM said the concern with the Three-Compartment Sink's drainpipe resting in the floor drain was the air gap. She said the drainpipe is supposed to be above the level of the floor so that sewage will not back up through the drainpipe. On 12/11/2025 10:38 AM the RD was interviewed via telephone. The RD said the concern with the Three-Compartment Sink drainpipe resting in the floor drain was the lack of an air gap, which could cause potential backflow in the drain by causing a potential cross connection. 3) The dishwasher manufacturer's Operation, Cleaning, and Maintenance Manual, dated 07/01/2019, included the following: . The final rinse temperature must be between 180-195 (degrees) F (Fahrenheit) .The U.S. FDA 2022 Food Code included the following:4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. (A) . in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90 C (194 F), or less than: . (2) For all other machines, 82 C [Centigrade/Celsius] (180 F).The facility's policy for Safety and Sanitation: Mechanical Dishwashing Procedure, dated 11/04/2022, included the following: . POLICY:Dishwashing is a very important part of infection control. On 12/09/2025 at 9:20 AM the surveyor observed dishwashing of resident breakfast dishes. DA #11 was unloading the dishwasher. The wash temperature was observed to be at 146 degrees F and the final rinse temperature was 198 degrees F. DA #11 said the normal final rinse temperature is between 180 degrees and 198 degrees.On 12/10/2025 at 9:28 AM the Dishwasher final rinse temperature went up to 198 degrees F while the MS was watching the indicator. The manufacturer operation guide posted on the front of the Dishwasher indicated the final rinse temperature should be between 180 to 195 degrees F. The MS said the temperature was something they could adjust. On 12/11/2025 at 9:44 AM, the Certified Dietary Manager was interviewed. The CDM said the final rinse temperature being too high could damage the machine. She was unable to answer how this could potentially affect the residents. On 12/11/2025 10:38 AM, The Registered Dietitian (RD) was interviewed via telephone. The RD said the problem with the Dishwasher final rinse temperature being too high was the potential flash evaporation of the final rinse water.

Based on observation, interviews, the United States (U.S.) Food and Drug Administration (FDA) 2022 Food Code, and a facility policy titled, Dumpsters, the facility failed to ensure a dumpster door was closed and food-related trash, which could attract vermin, was not on the ground in the dumpster area on 12/09/2025. This had the potential to affect 187 of 187 residents in the facility.Findings Include:The facility's policy titled, Dumpsters, dated 05/06/2021, included the following: . The facility will maintain dumpsters for the disposal of waste materials.Procedure:Dumpsters will be kept closed when not in use.The area surrounding dumpsters will be kept clean and free from debris. The U.S. FDA 2022 Food Code included the following: . 5-501.15 Outside Receptacles. (A) Receptacles and waste handling units for REFUSE, . used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers. (B) Receptacles and waste handling units for REFUSE and recyclables . shall be installed so that accumulation of debris and insect and rodent attraction and harborage are minimized and effective cleaning is facilitated around . the unit. 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, . shall be kept covered: . (B) With tight-fitting lids or doors if kept outside the FOOD ESTABLISHMENT.On 12/09/2025 at 9:13 AM, Maintenance Worker, Employee Identifier (EI) #10 was present during observation of the six dumpsters. One of the six dumpsters had a side door open. In addition, there was a plastic spoon, a straw, and fork on the ground by the dumpster. EI #10 said the door being open could attract animals that would try to get things out of there. He also said rats could be attracted. EI #10 said it could affect the residents and could cause infection and viruses. EI #10 said the dumpster was last picked up Monday morning (12/08/2025). On 12/11/2025 at 9:44 AM the Certified Dietary Manager (CDM) was interviewed. The CDM said the concern with the dumpster door being left open was rodents and all kinds of creatures, like bugs, can get into dumpster. The CDM further said you don't want trash everywhere; bugs and rodents are attracted to it. When asked how the residents could be affected, the CDM said bugs and rodents could be attracted into the building; you need to stop them before they come into the building.On 12/11/2025 at 10:38 AM the Registered Dietitian (RD) was interviewed by telephone. The RD said tight lids enclose the dumpster for pest control. When asked about the food related items (plastic spoon, plastic fork and a straw) being on the ground around the dumpster, the RD said the dumpster area is all about pest control.

Based on observations, interviews, record reviews, and review of the facility's policy titled Oxygen Safety the facility failed to ensure oxygen signage was posted outside the room doors of Resident Identifier (RI) #49 and RI #55, two of four residents' requiring oxygen on one of seven units at the facility. Findings Include: A review of the facility's policy titled, Oxygen Safety with a revised date of 09/06/2019, revealed the following: . a. Safety is the responsibility of all . Oxygen Storage: . 10. Precautionary signs readable from 5 feet shall be maintained on the door or gate where oxygen is used or stored.RI #49 was readmitted to the facility on [DATE] with diagnoses including: Chronic Diastolic Congestive Heart Failure and Chronic Obstructive Pulmonary Disease and Dependence on Supplemental Oxygen.RI #49's Quarterly MDS assessment with an ARD of 10/21/2025 documented a BIMS score of 15 of 15 which indicated intact cognition. RI #49 was also coded as using oxygen during this assessment period.RI #49's December 2025 Physician Orders contained an order dated 04/28/2025 for oxygen use.On 12/09/2025 at 10:32 AM, during the initial tour, RI #49 was observed wearing oxygen (O2) by nasal cannula with no oxygen signage on the door indicating oxygen was in use. RI #55 was admitted to the facility on [DATE] with diagnoses including: Chronic Obstructive Pulmonary Disease and Vascular Dementia.RI #55's Quarterly MDS assessment with an ARD of 12/01/2024 documented a BIMS score of 10 of 15 which indicated moderate cognitive impairment. RI #55 was also coded as using oxygen during this assessment period.RI #55's December 2025 Physician Orders documented an order dated 07/16/2025 for oxygen use.On 12/09/2025 at 10:08 AM, during the initial tour, RI #55's was observed wearing oxygen (O2) by nasal cannula with no oxygen signage on the door indicating 02 was in use.On 12/09/2025 at 4:03 PM an interview was conducted with Licensed Practical Nurse (LPN) #14, who said a sign is placed outside the door to let everyone know a resident is on oxygen and that the sign indicates oxygen was in use. On 12/09/2025 at 5:10 PM an interview with the Unit Manager (UM) #7, was conducted who said after the surveyors arrived, she realized the oxygen signs were not on doors and placed them on four doors, RI #49's and 55. When asked what prompted her to place the oxygen signs on the door, UM #7 said, she knew signs were to be on the doors if the resident was on oxygen. UM #7 was asked, what did the company policy say regarding residents on oxygen use. UM #7 said residents were to have a sign on the door that says the residents are on oxygen. When asked was company policy followed, UM #7 said no.

Based on observations, record review, interviews, review of facility policies titled Enteral Nutrition Protocol, Ice - Machine Cleaning, Safety and Sanitation: Cleaning and Sanitation of Ice Scoops, and review of the United States (U.S.) Food and Drug Administration (FDA) 2022 Food Code, the facility failed to ensure care, cleaning, and services in the facility were provided in a manner to prevent cross-contamination and the spread of infections.Specifically,1) On 12/09/2025, 12/10/2025, and 12/11/2025, RI #121'syringe used for administering water bolus flushes was observed without labels or dates to indicate when the syringe had been changed, or if it had been changed daily per facility protocol and RI #121's physician orders.2) On 12/09/2025 and 12/10/2025 ice machines on Room Locator (RL) #1 and RL #2 were observed with brown and pink substances and staff said, they were in need of cleaning.3) On 12/10/2025 observation of an ice chest on RL #1 revealed an improperly stored scoop left inside the chest that could lead to bacterial growth.4) On 12/10/2025 observation of a window air conditioner unit on RL #1 revealed a gap of open space to the outside of the building that could allow pests or rodents inside the nutrition room. These deficient practices affected RI #121, one of three residents sampled with feeding tubes; and RL #1 and RL #2, two of six units at the facility with ice machines. Findings include: 1) Review of a facility policy titled Enteral Nutrition Protocol, with a revised date of 12/29/2024, revealed the following: . PURPOSE: To provide a guide for enteral nutrition orders process and G (Gastrostomy)-tube care. II. G-Tube/PEG (Percutaneous Endoscopic Gastrostomy) Orders . E. Change administration set and bag every day and as needed . RI #121 was admitted to the facility on [DATE] with a diagnosis of Dysphagia. Review of RI #121's PEG TUBE care plan, with an initiated date of 02/28/2022 revealed an intervention to administer bolus water and flushes per tube and to change the administration set as ordered. RI #121's Annual Minimum Data Set (MDS)assessment with an Assessment Reference Date (ARD) of 10/23/2025 documented use of a feeding tube during the assessment period. Review of RI #121's Order Summary Report (Physicians Orders) for December 2025 revealed RI #121 was to receive 200 ml (milliliter) bolus of water per the feeding tube daily. RI #121 also had an order dated 03/27/2025 to change the administration set and bag at QHS (every bed time). On 12/09/2025 at 12:43 PM the surveyor observed a syringe in a plastic bag hanging on the feeding pump pole in RI #121's room. There was no resident name or date on the outside of bag, indicating when the syringe had been changed. On 12/10/2025 at 8:11 AM, a syringe was again observed by the surveyor in a plastic bag hanging on RI #121's feeding pump pole with no resident name or date the syringe had been changed. On 12/11/2025 at 8:24 AM the surveyor again observed a syringe in a plastic bag hanging on the feeding pole in RI #121's room without a resident name or date the syringe had been changed. On 12/11/2025 at 8:29 AM in an interview with Unit Manager (UM) #9, she said, feeding syringes were changed every day. UM #9 said the evidence that the syringes had been changed would be on the outside of bag. UM #9 said you would expect to see the resident's name, the date, time and who changed the feeding syringe on the outside of the bag. UM #9 said it would be important to ensure these things were on the syringe bag so you would know the syringe had been changed. UM #9 said, not changing the syringe could lead to infection. 2) The U.S. FDA 2022 Food Code included the following: . 1-201.10 Statement of Application and Listing of Terms. (A) The following definitions shall apply in the interpretation and application of this Code. (B) Terms Defined. As used in this Code, each of the terms listed . shall have the meaning stated below. Equipment. (1) Equipment means an article that is used in the operation of a FOOD ESTABLISHMENT such as . ice maker, . Food means . ice, . used or intended for use . for human consumption . 3-304.11 Food Contact with Equipment and Utensils. FOOD shall only contact surfaces of: (A) EQUIPMENT and UTENSILS that are cleaned . and SANITIZED . The facility's policy titled Ice Machine - Cleaning, dated 09/07/2022, included the following:. POLICY:The ice machine cleaning procedure is . carried out to meet State and Local health codes. NOTE: This procedure is to be done on a regular basis. On 12/09/2025 at 3:56 PM the Certified Dietary Manager (CDM) tried to wipe a brown substance off the ice machine, said she did not know what it was, and Maintenance was responsible for cleaning the ice machine. On 12/10/2025 at 9:18 AM the Maintenance Supervisor (MS) said the ice machine was deep-cleaned every quarter and the filter was changed every three months, or sooner if something happened with the water line. On 12/10/2025 at 4:42 PM Unit Manager (UM) #7 came to RL #1 where the ice machine was observed to have a pink substance inside the ice collection bin that could be wiped off with a paper towel. When asked the last time the ice machine was cleaned, UM #7 said she really did not know. On 12/10/2025 at 4:53 PM the MS came to RL #1, looked into the ice machine and said it did not look good. On 12/10/2025 at 5:00 PM the ice machine in RL #2 was opened and pink/brownish particles were observed on top of the plastic shield inside the ice machine, the particles could be removed with a paper towel and the filter on the wall of the ice machine was dirty. The MS said the filter was last changed on 09/08/2025 and filters were changed every three months or as needed. The MS said the ice machine was filthy. 3) The U.S. FDA 2022 Food Code included the following: . 1-201.10 Statement of Application and Listing of Terms. (A) The following definitions shall apply in the interpretation and application of this Code. (B) Terms Defined. As used in this Code, each of the terms listed . shall have the meaning stated below. Equipment. (1) Equipment means an article that is used in the operation of a FOOD ESTABLISHMENT such as a . ice maker, . Food means . ice, . used or intended for use . for human consumption . 3-304.11 Food Contact with Equipment and Utensils. FOOD shall only contact surfaces of: (A) EQUIPMENT and UTENSILS that are cleaned . and SANITIZED . 3-304.12 In-Use Utensils, Between-Use Storage. During pauses in FOOD preparation or dispensing, FOOD preparation and dispensing UTENSILS shall be stored: . (E) In a clean, protected location . such as ice scoops . The facility policy for Safety and Sanitation: Cleaning and Sanitation of Ice Scoops, dated 11/04/2022, included the following:. POLICY:Ice scoops will be cleaned in a manner to ensure equipment is cleaned and sanitized. On 12/10/2025 at 4:33 PM an observation was made of an insulated cooler in RL #1 with ice and a blue plastic scoop was left inside. LPN (Licensed Practical Nurse) #6 was asked if that was normally how they left the insulated cooler and the scoop after ice pass. LPN #6 said no, the insulated cooler should be emptied and wiped out. LPN #6 further said she would have rinsed the scoop and dried it off and put it in the scoop holder. On 12/10/2025 at 4:42 PM UM #7 came into RL #1 and said the insulated cooler was last used that day between 1:30 and 2:00 PM. UM #7 said, after passing ice out, they were supposed to dump out the ice. She further said the scoop should be placed in the scoop holder at the end of the shelf, not left inside the insulated cooler. UM #7 said if this was not done, the scoop could be growing bacteria. 4) The U.S. FDA 2022 Food Code included the following: . 6-202.15 Outer Openings, Protected. (A) . outer openings . shall be protected against the entry of insects and rodents by: (1) Filling or closing holes and other gaps along floors, walls, and ceilings; (2) Closed, tight-fitting windows; . On 12/10/2025 at 4:53 PM the MS came into RL #1. The MS looked at the air conditioner window unit and said the extension to seal off the air conditioning window unit was separated revealing a half inch wide opening directly to the outside. The MS said the opening should have been filled in or gapped so things like spiders, ants, and rats could not enter the building.

Based on observation, interviews, and review of the facility's policies titled, Dining Room Service and Promoting/Maintaining Resident Dignity During Mealtimes, the facility failed to ensure trays, insulated lids, and trash were not stacked and left on the dining room table in Room Locator (RL #3) on 12/09/2025, while residents were eating a meal at the table. Staff said this was not presenting a homelike environment for dining experience. This had the potential to affect five of 35 sampled residents. Findings Include: A facility policy titled Dining Room Service dated 09/05/2022, included the following: . Policy:Individuals will be encouraged to receive dining room service. A comfortable, attractive atmosphere will be maintained in the dining room area.A facility policy titled Promoting/Maintaining Residents Dignity During Mealtimes dated 12/02/2025, included the following: . Policy:It is the practice of the facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhances his or her quality of life, recognizing each resident's individuality and protecting the rights of each resident. On 12/09/2025 at 12:09 PM trays were served to five residents requiring feeding assist and seated at one large table in RL #3. During the observation, six facility employees were assisting residents; the employees took the meal plates off the trays and unwrapped utensils; the employees also opened drink containers and poured the beverages into cups or sippy cups; three stacks of lids filled with trash (empty beverage containers, crumbled up foil, and crumbled napkins) were observed sitting on trays on the table in front of the residents while they were eating; the stacked lids and trash were clearly in each resident's line of vision and were located near their plates. On 12/09/2025 at 12:48 PM Certified Nursing Assistant (CNA) #8 was asked why the meal plates were taken off the trays and placed directly on the table. CNA #8 said she did not know why. CNA #8 said she thought it was because it was more like a house or a home. CNA #8 said she should not have left trays with lids and trash on the table. On 12/09/2025 at 12:50 PM Unit Manager (UM) #9 was asked why the trays and the lids with trash were left on the table. UM #9 said it was not a good thing and they should have been removed. When asked why these things should be taken off the table, UM #9 said so it would be more homelike. On 12/11/2025 at 9:44 AM the Certified Dietary Manager (CDM) said they should have put the trash into the garbage and not in the lid cover. The CDM said this would be for sanitation and it was a dignity concern. On 12/11/2025 at 10:38 AM the Registered Dietitian (RD) was interviewed by telephone and said, the concern with staff stacking trays, lid covers, and trash (napkins, crumbled foil and opened beverage cartons) on the dining table and leaving them there while residents were eating was, it would not be an attractive environment and dining experience.

Based on observations, interviews, and record reviews, the facility failed to ensure:1) Resident Identifier (RI) #180's rescue inhaler was secured in the medication cart on 12/09/2025 instead of being found in RI #180's room on the bed side table, creating the risk of being overused by RI #180; and2) an unlabeled and undated, used vial of Lidocaine 1% was found in a drawer in a medication room on 12/11/2025, and staff said they would not know how long it had been there or when it was last used.This affected RI #180 and one of four medication rooms observed by the surveyor during the medication storage task.Findings Include: 1) RI #180 was admitted to the facility on [DATE] with diagnoses including: Chronic Obstructive Pulmonary Disease, Congestive Heart Failure and Acute and Chronic Respiratory Failure with Hypoxia. RI #180's Quarterly Minimum Data Set assessment with an Assessment Reference Date of 10/02/2024 documented a Brief Interview for Mental Status score was 15 of 15 which indicated intact cognition. A review of RI #180's December 2025 Physician's Orders revealed the following: . Start Date . 08/18/2025 . Albuterol Sulfate HFA (Hydrofluoroalkane) Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (microgram .) (Albuterol Sulfate) 2 inhalation inhale orally every 6 hours as needed for Shortness of Breath/wheezing . Provide oxygen at 2 Liters/Minute Nasal Cannula as needed (PRN) every shift for Shortness of Breath daily . On 12/09/2025 at 3:57 PM the surveyor observed one Albuterol HFA 90 mcg microgram inhaler dated 10/18/2025 with an expiration date of 4/27 (2027) on the corner of RI #180's brown bedside table in the resident's room. On 12/09/2025 at 4:28 PM an interview was conducted with Licensed Practical Nurse (LPN) #14. When asked what type of inhalers RI #180 was prescribed, LPN #14 said RI #180's Albuterol Sulfate HFA Inhalation Aerosol Solution 108 mcg/act was for every six hours as needed. LPN #14 said she administers this medication to RI #180 and RI #180 hands the medication back to her after RI #180 takes it. LPN #14 was asked if she could show the surveyor the Albuterol Inhaler in the medication cart. LPN #14 was not able to confirm the inhaler was in medication cart. On 12/09/2025 at 4:36 PM the surveyor observed with LPN #14 one Albuterol HFA 90 mcg inhaler dated 10/18/2025 with an expiration date of 4/27 on the corner of RI #180's brown bedside table in the resident's room. LPN #14 confirmed this was the rescue inhaler that should have been on the medication cart and that no medication should be left in RI #180's room. In the continued interview with LPN #14, when asked if RI #180 had an order to self-administer medications, she said no, and the company policy was not followed. LPN #14 said the concerns with leaving albuterol medication at the bedside would be it could cause heart palpitations which could lead to a heart attack which could result in death. On 12/09/2025 at 5:15 PM an interview was conducted with Unit Manager (UM) #7. When asked if RI #180 had an order to self-administer medications, she said no and she had not assessed RI #180 to self-administration medications because it was too dangerous, and RI #180 would administer more than he/she was supposed to. UM #7 was asked what the concern was of having medication left at the bedside. UM #7 said the Albuterol Sulfate could be overused and could cause dizziness leading to falls, increased heart rate which could lead to Atrial Fibrillation or Ventricular Tachycardia, Heart Attack or death. On 12/10/2025 at 5:08 PM an interview was conducted with RI #180. RI #180 was asked when the last time was he/she used the rescue inhaler. RI #180 said sometime last week, and a nurse let him/her keep the inhaler, but he/she did not remember who the nurse was. When asked where he/she kept the inhaler, RI #180 said on the corner of the bedside table. On 12/10/2025 at 5:39 PM an interview was conducted with Director of Nursing (DON). The DON said she was made aware of the inhaler left on the bedside table of RI #180. She further said inhalers were kept in the medication cart and RI #180 did not have a current physician order to keep at bedside. The DON was asked what the concern was of having medication left at the bedside. The DON said it depends on the resident's allergy, up to including death. 2) On 12/12/2025 at 11:20 AM the surveyor along with LPN #13 observed a used vial of Lidocaine 1 % with no resident name, date, time opened nor expiration date on the vial in a drawer in a medication room. On 12/12/2025 at 12:30 PM an interview was conducted with LPN #13. The LPN was asked what should be done after a multi dose drug is opened. LPN #13 said the medication should be labeled with the date opened and when it expires, which is 28 days after it is opened. LPN #13 said the medication should be stored on the medication cart. LPN #13 said the issue with this not being done would be you are not sure if the medication was out of date. On 12/12/2025 at 1:25 PM the surveyor conducted an interview with UM #19. The UM was asked what should be done after a multi dose drug is opened. UM #19 said the medication should be labeled with the date opened and when it expires, which is 28 days after it is opened, and it should be stored on the medication cart, otherwise you would not know how long it had been there.

Based on interview, review of the facility's Non-Controlled CERTIFICATE OF INVENTORY AND DESTRUCTION forms and review of a facility policy titled, Drug destruction, the facility failed to ensure the Non-Controlled CERTIFICATE OF INVENTORY AND DESTRUCTION forms contained the two required signatures. This deficient practice affected (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) 2019 and (MONTH) 2019, four of twelve months of Non-Controlled CERTIFICATE OF INVENTORY AND DESTRUCTION forms reviewed. Findings Include: A review of a facility policy titled, Drug destruction, dated 12/03/2018, revealed: . 5. A Non-Controlled Medication Destruction Record must be maintained for all non-controlled drugs destroyed . The following information shall be included on this record: . h. The signature of the consultant pharmacist destroying the medications; and i. The signature of the person(s) witnessing the destruction of the medications. Review of the CERTIFICATE OF INVENTORY AND DESTRUCTION forms for the Non-Controlled drugs, dated (MONTH) 8, (YEAR), revealed seven sheets with one signature; (MONTH) 9, (YEAR), revealed one sheet with one signature, (MONTH) 14, (YEAR), revealed one sheet with one signature, (MONTH) 1, 2019, revealed one sheet with one signature and (MONTH) 25, 2019, revealed one sheet with one signature. On 10/03/2019 at 12:04 p.m., the surveyor conducted an interview with Employee Identifier (EI) #1, the Registered Nurse (RN) Assistant Director of Nursing (ADON). EI #1 was asked, when reviewing the Non-Controlled CERTIFICATE OF INVENTORY AND DESTRUCTION forms for the dates of (MONTH) 1, 2019; (MONTH) 25, 2019; (MONTH) 8, (YEAR); (MONTH) 9, (YEAR) and (MONTH) 14, (YEAR), how many signatures were noted on the forms. EI #1 said one. EI #1 was asked how many signatures should be on the Non-Controlled CERTIFICATE OF INVENTORY AND DESTRUCTION forms. EI #1 said two. EI #1 was asked why was there only one signature on the CERTIFICATE OF INVENTORY AND DESTRUCTION forms. EI #1 said with the volume of papers, the sheets may not have been seen.

Based on observation, interview and review of the Food Code 2013, the facility failed to ensure the outside grease bin was free of grease build up on the outside of the bin and free of debris on the inside of the bin. This was observed on 7/11/17, and had the potential to affect all residents residing in the facility. Findings Include: The Food Code U.S. Public Health Service FDA 2013 states: .5-501.116 Cleaning Receptacles. (B) Soiled receptacles and waste handling units for REFUSE, recyclables, and returnables shall be cleaned at a frequency necessary to prevent them from developing a buildup of soil or becoming attractants for insects and rodents. On 7/11/17 at 2:28 p.m., the Surveyor along with Employee Identifier (EI) #1, Dietary Manager, observed the outside grease bin. The bin was dirty and had black grease build up on the outside of the bin and debris on the inside of the bin. On 7/12/17 at 3:30 p.m., an interview was conducted with EI #1. EI #1 was asked if the outside grease bin should be free of grease build up on the outside of the bin. EI #1 replied she was unsure because it had never been brought up before. EI #1 was asked if the inside of the grease bin should be free of debris. EI #1 replied she could see the purpose to allow for proper drainage. EI #1 was asked what was the potential harm of the grease bin having grease build up on the outside and debris on the inside. EI #1 responded it could attract pests.

Based on medication pass observation, staff interview, medical record review and a review of Potter and Perry's FUNDAMENTALS OF NURSING, the facility failed to ensure Employee Identifier (EI) #5 followed physician's orders [REDACTED].#31's order for [MEDICATION NAME]. This deficient practice affected RI #31, one of four residents and EI #5, one of three nurses observed during medication administration. Findings Include: Review of Potter and Perry's, FUNDAMENTALS OF NURSING, NINTH EDITION, UNIT V, CHAPTER 32, Foundations for Nursing Practice, Medication Administration, pages 626, 658 and 659, revealed: .Standards Standards are actions that ensure safe nursing practice . To prevent medication errors, follow the six rights of medication administration consistently every time you administer medications . 2. The right dose . SKILL 32-1 ADMINISTERING ORAL MEDICATIONS . STEP . i. Stay until patient completely takes all medications by their prescribed route . RATIONALE . You are responsible for ensuring that patient receives ordered dosage . RI #31 was originally admitted to the facility on [DATE] and was readmitted on [DATE], with a [DIAGNOSES REDACTED]. Review of RI #31's physician orders [REDACTED]. . POLYETHYLENE [MEDICATION NAME] 3350 POWD, Generic for: [MEDICATION NAME] POWDER MIX 1 SCOOP (17 GM) (grams) WITH 8 OZ (ounces) OF FLUIDS AND DRINK BY MOUTH ONCE DAILY. DX (diagnosis): BOWEL REGULARITY On 07/13/2017 at 10:00 a.m. during medication pass observation, the surveyor observed EI #5, LPN (Licensed Practical Nurse) administer medications to RI #31. EI #5 measured eight ounces of water in a clear plastic, graduated cup. The surveyor observed EI #5 measure 17 grams of [MEDICATION NAME] into the lid from the container of [MEDICATION NAME] and pour the medication into the cup containing eight ounces of water. EI #5 inserted a straw into the cup and stirred the mixture. EI #5 knocked on RI #31's door and entered the room with medications. EI #5 handed the plastic cup with the [MEDICATION NAME] mixture to RI #31 to drink. Approximately one-half of the [MEDICATION NAME] mixture was left in the cup. RI #31 handed the cup containing the remaining [MEDICATION NAME] mixture back to EI #5. EI #5 entered RI #31's bathroom and poured the mixture into the sink and then washed her hands. On 07/13/2017 at 10:48 a.m. in an interview with EI #5, the surveyor asked, what was in the cup she provided to RI #31. EI #5 replied, [MEDICATION NAME] was in the cup of 8 oz. of water, the [MEDICATION NAME] was 17 gms. The surveyor asked EI #5, did RI #31 consume all the substance/liquid in the cup. EI #5 said, No, half. The surveyor asked, did RI #31 receive the prescribed dosage of [MEDICATION NAME] if RI #31 consumed half of the water that it was dissolved in. EI #5 answered, No. EI #5 was asked, would that be considered a medication error. EI #5 said, It should be.

Based on observations, interviews, medical record review, a review of the facility's policy titled, Incontinent Resident - Care of and Potter and Perry's FUNDAMENTALS OF NURSING, the facility failed to ensure a Certified Nursing Assistant (CNA), Employee Identifier (EI) #2, washed her hands and changed her gloves after cleaning the front perineal area and before cleaning Resident Identifier (RI) #8's buttocks. Further, the facility failed to ensure a CNA, EI #3, washed her hands and changed her gloves before applying barrier cream to RI #8's buttocks. This affected one of two residents observed during incontinence care. Findings Include: A review of the facility's policy titled, Incontinent Resident - Care of with a revision date of 1/20/2016, revealed: . PROCEDURE: . 2. Clean downward from front to back with one stroke. Use a clean wipe for each stroke. 5. Wash hands and apply new gloves. 6. Clean the rectal area; . A review of Potter and Perry's FUNDAMENTALS OF NURSING NINTH EDITION,Unit V (5), page 458, revealed: . the WHO (World Health Organization)(2009) recommend the following hand hygiene guidelines: 1. When hands are visibly dirty, when hands are soiled with blood or other body fluids, . 3 .After contact with body fluids or excretions, . When moving from a contaminated to a clean body site during care . RI #8 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. During an incontinence care observation for RI #8 on 7/12/2017 at 11:44 a.m., a CNA, EI #2, did not wash her hands and change her gloves after cleaning the front perineal area and before cleaning the buttocks. Further, EI #3 did not wash her hands and change her gloves after cleaning RI #8's buttocks and prior to applying barrier cream. An interview was conducted on 7/12/2017 at 3:10 p.m., with EI #2 and EI #3. EI #2 was asked when should hands be washed and gloves changed during incontinence care. EI #2 stated, After touching anything dirty. EI #2 was asked what should be done after cleaning the front perineal area and before cleaning the buttocks. EI #2 stated, Wash your hands and change your gloves. EI #2 was asked what was the potential for harm in not washing hands and changing gloves. EI #2 replied, Spread of infection. EI #3 was asked what should be done after cleaning the buttocks and before applying barrier cream. EI #3 stated, Wash your hands and change gloves. EI #3 was asked if she did that. EI #3 said, I don't think so. EI #3 was asked what was the potential for harm in not washing hands and changing gloves before applying barrier cream during incontinence care. EI #3 replied, UTI (urinary tract infection). An interview was conducted on 7/13/2017 at 8:36 a.m., with EI #4, a Licensed Practical Nurse/ Infection Control Nurse. EI #4 was asked when should hands be washed and gloves changed during incontinence care. EI #4 stated, When going from one area to another, anytime you change your gloves, at the beginning of a skill and after a skill. EI #4 was asked what must be done after cleaning the front perineal area and before cleaning the buttocks. EI #4 stated, Wash your hands and apply new gloves. EI #4 was asked what should be done after cleaning the buttocks and before applying barrier cream. EI #4 stated, Wash your hands and apply new gloves. EI #4 was asked what was the potential for harm in not washing hands and changing gloves before applying barrier cream during incontinence care. EI #4 replied, Risk of contamination.

Based on interviews and record review, the facility failed to provide evidence the sponsor/responsible party of Resident Identifier (RI) #30 was notified when RI #30 developed multiple open areas to the buttocks. This affected RI #30, one of six residents sampled for pressure ulcers. Findings Include: RI #30 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #30's Body Audit Documentation form, dated 02/02/15, revealed RI #30 was admitted to the facility with redness to the buttocks. RI #30's Body Audit Documentation form, dated 02/04/15, revealed RI #30 now had red scaly dry flaky skin to the buttocks. RI #30's Body Audit Documentation form, dated 02/11/16, documented: Notes: Irritation noted [MEDICATION NAME] cream applied (c) (with) Incontinent episodes . RI #30's Body Audit Documentation form, dated 03/17/16, documented: Notes: Superficial areas (c) o (no) drainage noted - Irritation (c) change in moisture barrier product - Protective Skin Care: moisture barrier ointment (changed sign) to [MEDICATION NAME] . On 05/26/16 at 10:01 a.m., the surveyor conducted an interview with Employee Identifier (EI) #2, the Registered Nurse Unit Manager of the unit RI #30 resided on. The surveyor asked EI #2 was RI #30 admitted to the facility with any pressure ulcers. EI #2 said, Not that I can recall. The surveyor asked EI #2 did RI #30 have any skin concerns to the buttocks. EI #2 said the facility had been treating RI #30 with [MEDICATION NAME] because RI #30 had dry flaky skin to the buttocks. The surveyor asked EI #2 was the family notified about RI #30's buttocks and the [MEDICATION NAME]. EI #2 replied. No. The surveyor asked EI #2 was RI #30 using the [MEDICATION NAME] when RI #30 was admitted to the facility. EI #2 said no. EI #2 said when RI #30 was admitted to the facility RI #30 could actually transfer herself/himself to the toilet. The surveyor asked EI #2, even though the facility was using the [MEDICATION NAME] as a moisture barrier and skin protectant, was it a new form of treatment for [REDACTED]. EI #3 replied, Yes . The surveyor asked EI #2, on 03/17/16, what change was there concerning RI #30's buttocks. EI #2 replied the skin on RI #30's buttocks had been really flaky and irritated. The surveyor asked EI #2 was the family notified of the change in RI #30's skin. EI #2 replied, No. The surveyor asked EI #2 what the condition of RI #30's buttocks was on admission. EI #2 said RI #30 had redness to the buttocks. The surveyor asked EI #2 did RI #30 develop any open areas to the buttocks since being at the facility. EI #2 replied yes. EI #2 said RI #30 had dry flaky skin, then excoriation, then irritation. The surveyor asked EI #2 were these all changes in RI #30's skin. EI #2 replied, Yes. The surveyor asked EI #2 should the family be notified of any changes with the resident. EI #2 replied, Yes. On 05/26/16 at 2:26 p.m., the surveyor conducted an interview with EI #1, the Director of Nursing. The surveyor asked EI #1 should RI #30's family have been notified when RI #30 had the excoriation and opened areas to the buttocks. EI #1 replied, Yes Ma'am. On 05/26/16 at 2:35 p.m., a phone call was placed to RI #30's sponsor/responsible party. The sponsor/responsible party did not answer and no return call was received prior to the survey team exiting the facility on 05/26/16; however on 05/31/16 at 1:59 p.m., the surveyor received a call from the sponsor/responsible party. The surveyor asked the sponsor/responsible party, if the facility had notified her that RI #30 had developed some flaky skin, irritation and opened areas to the buttocks. The sponsor/responsible party replied no.

Based on interviews, record review, and review of a facility policy titled Abuse Prevention Policy, the facility failed to ensure two new employees, Employee Identifier (EI) #3 and EI #4, were checked on the nurse aide registry prior to employment. This affected EI #3 and EI #4, two of six employee files reviewed and had the potential to affect all 204 residents residing in the facility. Findings Include: A facility policy titled Abuse Prevention Policy with a revised date of 11-30-12, documented: Screening: . 4. This facility will confer with the State Nurse Aid Register and other licensing authorities to ensure that the prospective employee is not on their register . On 05/24/16 at 12:05 p.m., during the Entrance Conference, Employee Identifier (EI) #5, the Administrator, was identified as the Abuse Coordinator. On 05/25/16, a review of EI #3's, the Human Resource Coordinator's personnel file revealed EI #3 was hired by the facility on 04/15/16. There was no evidence found by the surveyor to indicate EI #3 was checked on the nurse aide registry prior to employment at the facility. On 05/25/16, a review of EI #4's, a housekeeper's, personnel file revealed EI #4 was hired by the facility on 03/21/16. There was no evidence found by the surveyor to indicate EI #4 was checked on the nurse aide registry prior to employment at the facility. On 05/25/16 at 5:25 p.m., the surveyor conducted an interview with EI #3. The surveyor asked EI #3 who was responsible for checking the nurse aide registry on potential hires. EI #3 said it starts here with her. EI #3 said then it goes through to the Director Of Nursing (DON), EI #1, for approval. The surveyor asked EI #3, which potential hires were checked against the registry. EI #3 said certain departments, like Certified Nursing Assistant (CNA's) and Nurses. The surveyor asked EI #3 where was the evidence for checking the nurse aide registry for herself (EI #3) and EI #4. There was no evidence provided to the surveyor that EI #3 and EI #4 had been check against the nurse aide registry by EI #3. On 05/25/16 at 5:42 p.m., the surveyor conducted an interview with EI #6, the Assistant Human Resource Coordinator. The surveyor asked EI #6 if EI #3 and EI #4 should have been checked on the nurse aide registry. EI #6 said she thought if staff were not certified they did not have to be checked. The surveyor asked EI #6 what was the potential harm if potential employees were not checked against the nurse aide registry. EI #6 said they could do harm to somebody. On 05/26/16 at 1:16 p.m., the surveyor conducted an interview with EI #5, the Administrator. The surveyor asked EI #5 what steps were taken to screen potential employee hires for history of reported abuse. EI #5 said background checks and checks against the registry. On 05/26/16 at 1:40 p.m., the surveyor conducted another interview with EI #5. The surveyor asked EI #5 who was responsible for checking the nurse aide registry on potential hires. EI #5 said EI #6. The surveyor asked EI #5 when are the potential hires checked against the Registry. EI #5 said he thought that change was implemented to check everyone whether CNA or not. EI #5 said everyone during the hiring process and 2 times a year were checked. The surveyor asked EI #5 what evidence should be kept on file to show that potential hires were checked prior to hire. EI #5 said print outs from the registry. The surveyor asked EI #5 why was there no evidence in EI #3's and EI #4's file that the employees had been checked against the nurse aide registry. EI #5 said because they were only checking nursing previously.

Based on observation, interviews, record review and review of a facility policy titled Incontinent Resident - Care of, the facility failed to ensure a Certified Nursing Assistant (CNA), Employee Identifier (EI) #7, changed her contaminated gloves prior to touching the clean incontinent pad/adult brief of Resident Identifier (RI) #17 on 05/25/16. This affected RI #17, one of one resident observed for incontinent care. Findings Include: An article from the Center for Disease Control (CDC) and Prevention titled Protocol for Hand Hygiene and Glove Use Observation with an updated date of May 9, 2013, documented: . Glove Use . 2. Examples of situations when gloves should be changed: . 3. After contacting a potentially contaminated site before moving to a clean site . A facility policy titled Incontinent Resident - Care of with a revised date of 01/20/16, documented: . INFECTION CONTROL: 1. Observe universal precautions 2. Wash your hands before and after all procedures. Wear gloves when appropriate . 4. Dispose of disposable equipment appropriately . RI #17 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A Significant Change Minimum Data Set assessment dated [DATE], assessed RI #17 as having short and long term memory problems and severely impaired cognitive skills for daily decision making. RI #17 was also assessed as needing extensive assistance with personal hygiene. On 05/25/16 beginning at 3:45 p.m., the surveyors observed EI #7 and EI #9 provide incontinent care to RI #17. After EI #9 provided incontinent care to RI #17's perineal area and left buttocks, EI #7 removed the dirty incontinent pad and soiled adult brief from beneath RI #17 and placed the items in a clear plastic bag. EI #7 cleaned RI #17's right buttocks with a disposable wipe, threw the disposable wipe in the plastic bag then proceeded to pull a clean incontinent pad and clean adult brief beneath RI #17 with contaminated gloves still on. EI #7 then removed her contaminated gloves and washed her hands. On 05/25/16 at 6:00 p.m., the surveyors conducted an interview with EI #7. The above observation was read back to EI #7. EI #7 was asked what she should have done before pulling the clean incontinent pad and clean adult brief beneath RI #17. EI #7 said she should have washed her hands. The surveyor asked EI #7 what was it considered when contaminated gloves are not removed before touching clean linen/briefs. EI #7 replied, Contaminating the area, spreading germs. On 05/26/16 at 2:03 p.m., the surveyors conducted an interview with the Infection Control Nurse, EI #8. The surveyor asked EI #8 what CNAs should do with their contaminated gloves before touching a clean adult brief/pad. EI #8 replied, Remove gloves and wash hands prior to donning new gloves. The surveyor asked EI #8 what it was called when this was not done. EI #8 replied, Possible contamination.

Based on record review, observation, and interviews, the facility failed to ensure a Certified Nursing Assistant (CNA) separated and cleaned the labia and cleaned the vaginal area of Resident Identifier (RI) #5 during incontinent care on 4/15/2015. This affected 1 of 2 sampled residents observed during incontinent care. Findings Include: A review of a facility policy titled, "SUBJECT Incontinent Resident - Care of" with a revised date of 2/24/12 revealed: "PROCEDURE: A. Female Residents 1. Separate the labia 2. Clean ... " RI #5 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of RI #5's most current Minimum Data Set (MDS) for Significant change in status with an Assessment Reference Date (ARD) of 2/26/2015 revealed RI #5's Brief Interview for Mental Status (BIMS) score of 3, indicating severe impairment in RI #5's cognition. The MDS revealed RI #5 required extensive assistance with all Activities of Living (ADLs). The MDS further revealed the resident was always incontinent of bladder and bowel. A review of RI# 5's revised care plan for bowel and bladder elimination on (4/2015) revealed: "RI #5 is incontinent of bladder and incontinent of bowel,... Individualized Approach * Provide good peri-care after each incontinent episode ... " On 4/15/2015, RI #5 was continuously observed by surveyor sitting in a geri chair in the dayroom from 3:00 PM until 3:45 PM. At 3:45 PM, the surveyor noted the dirty brief removed from RI #5 to have both stool and urine in brief. The surveyor asked CNA #2 what she observed in RI #5's brief and she stated stool and urine. When RI #5 completed toileting on the commode, the CNAs assisted RI #5 to stand and told RI #5 to hold on to the rail on the wall by the toilet. CNA #1 cleaned RI #5's rectal area wiping front to back. CNA #1 nor CNA #2 cleaned RI #5's vaginal area or separated the labia and cleaned. On 4/15/2015 at 4:25 PM, an interview was conducted with Employee Identifier (EI) #6, CNA. EI #6 was asked if RI #5 had urine and stool in the dirty brief she had removed on 4/15/2015 at 3:50 PM during incontinent care. EI #6 replied "yes". EI #6 was asked if incontinent care was done to RI #5's front side such as RI #5's creases and labia. EI #6 stated "no ma'am, it was not". EI #6 was asked what was the potential harm if incontinent care was not done to the resident's front side after urinating. EI #6 said the resident's skin could break down and be irritated and red. On 4/15/2015 at 4:35 PM, an interview was conducted with EI #7, CNA. EI #7 was asked what the facility's policy said about doing incontinent care if a resident has urine and stool in the brief. EI #7 said the policy said incontinent care should be done to the front side as well as the back side. EI #7 was asked if RI #5 had urine and stool in the dirty brief on 4/15/2015 at 3:50 PM and EI #7 replied "yes ma'am." Then EI #7 was asked if incontinent care was done to RI #5's front side such as RI #5's creases and labia. EI #7 stated "no ma'am." EI #7 was asked should the resident's vaginal area have been cleaned and should RI #5's labia have been separated and cleaned. EI #7 said "yes ma'am." Then EI #7 was asked why this was not done and she said "I was nervous." EI #7 was asked what was the potential harm if incontinent care was not done to the resident's front side after urinating. EI #7 said the resident's skin could break down and possibly have infection. On 4/16/2015 at 9:25 AM, an interview was conducted with EI #8, Registered Nurse (RN) Charge Nurse. EI #8 was asked what the facility's policy said about doing incontinent care if a resident's brief had urine and stool in it. EI #8 said the resident needed to be cleaned from front to back. EI #8 was asked if a female resident had urine and stool in the brief, should the resident's vaginal area be cleaned and should the resident's labia be separated and cleaned. EI#8 said "yes ma'am." EI #8 was asked if it was an acceptable practice of that facility for a CNA not to separate the labia and clean the vaginal area during incontinent care of a resident with urine and stool in the brief. EI #8 replied "no." EI #8 was asked what was the potential harm if a resident was not cleaned properly during incontinent care; such as, not cleaning the vaginal area and separating the labia to be cleaned when the resident's brief was soiled with stool and urine. EI #8 stated urinary tract infections (UTIs).

Based on record review, observation and interview, the facility failed to ensure RI (Resident Identifier) #31's O2 (Oxygen)filter did not have a moderate amount of a grey, dust-like substance present on the filter on 4/14/15 and 4/15/15, two of three days of the survey. This affected 1 of 4 sampled residents observed wearing O2. Findings Include: A review of a facility policy titled, "Oxygen Concentrators-Cleaning of " with an issue date of 1/11/10 revealed: "...PROCEDURE: 1. Oxygen concentrators should be cleaned with a disinfectant solution and filters should be checked monthly for cleanliness ... " RI #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #31's Admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/23/15 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15 which indicated the resident was cognitively intact. The MDS further revealed the resident was receiving oxygen therapy. A review of RI #31's physician's orders [REDACTED]. A review of a facility document revealed that RI #31's O2 concentrator had been checked on 11/15/14 and cleaned on 4/15/15. On 4/14/15 at 4:34 PM, during initial tour, the surveyor observed RI #31's O2 filter to have a moderate amount of a grey, dust-like substance present on it. The resident had O2 infusing at 4L/NC at that time. On 4/15/15 at 10:30 AM, the surveyor observed RI #31's O2 filter with a moderate amount of a grey dust-like substance present on the filter. The resident had O2 infusing at 4L/NC at that time. On 4/15/15 at 11:14 AM, an interview was conducted with EI (Employee Identifier) #1, RN (Registered Nurse) Unit Manager. EI #1 was asked to tell the surveyor what was present on RI #31's O2 filter. EI #1 said dust. EI #1 was asked to describe what was present on the O2 filter. EI #1 said, "Moderate amount of dust." EI #1 was asked if she could tell the surveyor by looking at the filter how long it had been since the O2 filter had been cleaned. EI #1 said she was not sure and that it had been cleaned before RI #31 was admitted . EI #1 was asked how often was the filter supposed to be cleaned. EI #1 said they changed the O2 water bottle and tubing every Sunday and when she was a medication cart nurse, she checked it then. EI #1 was asked who was responsible for cleaning the O2 filters. EI #1 said the nurses. EI #1 was asked if she could tell the surveyor why the filter was not cleaned. EI #1 said no ma'am. EI #1 was asked if it was an acceptable practice for the O2 filter to have an accumulation of a grey, dust-like substance on it. EI #1 said, "No ma'am." EI #1 was asked what was the potential harm if an O2 filter had an accumulation of a grey, dust-like substance and the resident had O2 infusing via NC. EI #1 said, "Machine could malfunction and not run to the best of it's ability."

Based on observations, record review and interviews, the facility failed to ensure that two CNAs (Certified nursing assistants), after providing incontinent care with feces present to RI #3 on 4/15/15, washed their hands after removing their gloves and before touching clean linen and a clean brief. This affected 1 of 2 residents observed during incontinent care. Findings include: A review of Potter & Perry, "FUNDAMENTALS OF NURSING" , EIGHTH EDITION, CHAPTER 28, INFECTION PREVENTION and CONTROL, PAGE 419 revealed" ...perform hand hygiene between tasks and procedures ...." A review of the CDC (Centers for Disease Control and Prevention) Hand Hygiene Basics, last updated:May 1, 2014 revealed: " ...Healthcare providers should practice hand hygiene at key points in time to disrupt the transmission of microorganisms to patients including: before patient contact; after contact with ... body fluids ...(even if gloves are worn); ... (wearing gloves is not enough to prevent the transmission of pathogens in healthcare settings). ..." RI (Resident Identifier) #3 was readmitted on [DATE] with [DIAGNOSES REDACTED]. RI #3's most recent Significant Change MDS (Minimum Data Set) with an ARD (assessment reference date) of 03/02/2015 revealed that RI #3 had a BIMS (Brief interview for mental status) score of 6 indicating severe cognitive impairment for daily decision making. The MDS also indicated RI #3 needed extensive assistance with personal hygiene, was impaired in upper and lower extremities on both sides and was always incontinent of bowel and bladder. A review of RI #3's care plan with a revised date of 03/15 revealed: #11 CONCERNS...Activities of daily living: ...a limited range of motion to spine and upper and lower extremities. ... INDIVIDUALIZED APPROACH ...Extensive help x (times) 1 with ...personal hygiene.... #11b CONCERNS Bowel and bladder elimination: ...occasionally incontinent of bladder ... INDIVIDUALIZED APPROACH Provide good peri-care after each incontinent episode ...." On 4/15/15 at 4:00 P.M., EI (Employee Identifier) #4 and EI #5 were observed performing incontinent care including BM (bowel movement) on RI #3. After BM was cleaned from RI #3 and EI #5 washed and dried her hands and donned gloves, RI #3's perineal area was cleaned. The surveyor observed EI #5 and EI #4 change gloves during the perineal incontinent care, however EI # 4 and #5 did not wash or sanitize their hands between glove changes and before touching and placing a clean sheet, pad and brief on RI #3. On 4/15/15 at 3:05 P.M., an interview was conducted with EI #5, CNA. EI #5 was asked what was the facility's policy on hand washing. EI #5 said hands have to be washed upon entering and exiting a resident's room and when gloves were visibly soiled. EI #5 was asked did she wash her hands after cleaning BM and performing perineal care on RI #3 and before touching and placing clean linen and brief under RI #3. EI #5 said no. EI #5 was asked why she did not wash her hands before changing her gloves and before touching the clean linen and brief and EI #5 said it was not policy. The surveyor asked EI #5 what was the potential harm to RI #3 when hands were not washed before changing gloves and touching clean linens and brief. EI #5 said UTI (urinary tract infection). On 4/15/15 at 5:40 P.M., an interview was conducted with EI #4, CNA. EI #4 was asked, at what time when performing incontinent care for RI #3 should hands be washed. EI #4 said when gloves were heavily soiled and after wiping 3 times. EI #4 was asked did she wash her hands after performing incontinent care and before she touched clean linen and a brief. EI #4 said she did not wash her hands because she did not come in contact with BM. EI #4 was asked why she did not wash her hands and EI #4 stated that it was not policy. EI #4 was asked what was the potential harm to RI #3 when hands were not washed before touching clean linen and brief and EI #4 said UTI or infection. On 4/16/15 at 9:40 A.M. ,an interview was conducted with EI #3, RN (registered nurse)-NM (nurse manager). EI # 3 was asked what was the facility's policy on hand washing. EI #2 said before and after gloves. EI #2 was asked when performing incontinent care, when should CNAs wash their hands. EI #2 said they just need to change gloves when they touch dirty. EI #2 was asked if it was an acceptable practice in the facility for a CNA to clean BM from a resident and not wash hands before they touched and placed clean linen and brief under a resident. EI # 2 said no, hands would need to be washed. EI #2 was asked what was the potential harm to a resident when CNA's hands were not washed after performing incontinent care and before clean linen and brief were touched and placed under a resident. EI #2 said infection control. On 4/16/15 at 9:58 A.M., an interview was conducted with EI #2, LPN (Licensed Practical Nurse)-Infection Control Coordinator. EI # 2 was asked how infections were prevented in the facility. EI #2 stated through education, compliance rounds, QA ( quality assurance) process, and surveillance infections were tracked and trended. EI #2 was asked how infections were controlled in the facility. EI #2 said issues were identified, trended, surveillanced, areas were cleaned and disinfected, issues were recognized promptly and appropriate antibiotics and isolation was put in place as needed. The surveyor asked how were in house and nosocomial infections investigated in the facility. EI #2 said signs and symptoms were reviewed, when and where the infection started and factors and co-morbidity. EI #2 said all findings were reported to the CRNP (certified registered nurse practitioner) who was available five days a week. EI #2 was asked how the facility decided what procedures, such as isolation, should be applied to a resident. EI #2 said the cultures would be reviewed, tracked and the appropriate precautions and antibiotics would be given. EI #2 was asked if direct care staff were washing their hands and changing gloves according to the facility's protocol. EI #2 said yes. EI #2 was asked how direct care staff were monitored to ensure hands were washed and gloves were changed according to facility protocol. EI # 2 stated compliance rounds and frequent in-services. EI #2 was asked what was the facility's policy on hand washing and EI #2 said hands were washed before and after care and when gloves were visibly soiled. The surveyor asked when incontinent care was performed, when should CNAs wash their hands. EI #2 said before care was started if gloves were visibly soiled, before tasks and on the conclusion of incontinent care. EI #2 was asked if it was an acceptable practice for a CNA to clean BM from a resident and not wash their hands before touching and placing clean linen and brief under a resident. EI #2 said if the gloves were visibly soiled only. EI #2 was asked what was the potential harm to a resident when a CNA did not wash their hands after performing incontinent care with BM and before touching and placing clean linen and brief under a resident. EI #2 said if the gloves were contaminated, the possibility of transference of microorganisms.

Based on observation, interviews and record review, the facility failed to ensure Resident Identifier (RI) #14 was thoroughly cleaned of fecal matter prior to completion of incontinence care. This involved one of two residents observed during incontinence care. Findings included: RI #14 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most current (quarterly) Minimum Data Set, with an assessment reference date of 04/09/14 documented a BIMS (Brief Interview for Mental status) score of 3 out of 15 which indicated RI # 14 was severely impaired for cognitive skills of daily decision making. RI #14 was an extensive to total dependence upon staff for all activities of daily living. RI #14 was determined to be always incontinent of both bowel and bladder and totally dependent on staff for toileting assistance, with impaired range of motion to her lower extremities. The facility's policy related to "Care of the Incontinent Resident" (revised 02/24/12) cited the purpose as: "To keep the resident clean and dry." "Procedure (female residents): 1. Separate the labia 2. Clean downward from front to back with one stroke. Use ... a clean wipe for each stroke. Use more than one if needed. 3. Dispose wet wipe... . 4. Repeat steps 2 and 3 until the area is clean. 5. Change gloves... . ...7. Clean the rectal area; clean from the vagina to the anus with one stroke. 8. Repeat step 7 until area is clean; use a clean part of the washcloth or a clean wipe for each stroke. 9. Change gloves." The facility policies: "Infection Control" (dated 09/20/10), "Infection Control - Hand Hygiene" (dated 11/18/09), and "Care of the Incontinent Resident" (dated 02/24/12), did not document when facility staff are to change gloves and wash hands when a resident is soiled with stool. On 05/21/14 at 2:55 PM, Employee Identifier (EI) #1, a Certified Nursing Assistant (CNA), EI #2 (CNA), and EI #3, a Licensed Practical Nurse (LPN/Infection Control nurse), entered RI #15's room to provide incontinence care. RI #15 was observed to be soiled with stool. EI #1 and EI #2 performed incontinent care. Both EI #1 and EI #2 said they were finished with the care, and began to apply the new, clean brief. The surveyor asked EI #1 to re-wipe the resident's inner labia. EI #1 changed gloves and wiped RI #15's inner labia, soiling her glove with stool. EI #1 then wiped the resident three more times with the soiled glove, removing stool with each wipe. EI #1 changed her gloves and wiped the inner labia five times, removing stool with each wipe. EI #1's glove was soiled with stool after the first wipe. EI #1 changed gloves and wiped the inner labia six times, removing stool with each wipe. EI #1's glove was soiled with stool after the first wipe. EI #1 wiped two more times with new wipes, while wearing the same soiled gloves. The wipes were finally clean after the last two wipes. During an interview on 05/21/14 at 3:15 PM, the surveyor asked EI #1, when a resident was soiled with stool, when should she change her gloves and wash her hands. EI #1 said, staff are to change their gloves when they are soiled, and wash their hands after completing peri-care. On 05/22/14 at 12:00 PM, during an interview with the Infection Control Nurse (EI #3), she was asked what the procedure was for changing gloves and washing hands after gloves were soiled with stool. EI #3 said the staff should change gloves when they are visibly soiled, continue peri-care and wash their hands after peri-care is completed.

Based on observation, record review and interview the facility failed to ensure RI (Resident Identifier) #20 was assessed for self administration of medications before allowing her to self administer the nebulizer treatment. This affected RI #20, one of one sampled residents observed to self administer a medication. Findings Include: RI # 20 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Cognitive Status care plan dated 09/10 documented that she is alert at times with short term memory problems, her mental function varies over the day, requiring cues and supervision with her daily decision making. The quarterly MDS (Minimum Data Set) dated 3/14/2013, asessed RI # 20 with a BIMS ( Brief Interview of Mental Status) as 8 out of 15. This revealed RI # 20's cognitive status was moderately impaired for daily decision making. A review of the facility's policy for self administration documented: "Self Administration of Drugs." Revised 12/09/05. "The policy for self administration of drugs is that an interdisciplinary team will assess each resident that expresses a desire to self administer drugs... At the end of the assessment, a recommendation will be made to the physician if the resident is deemed to be a candidate for self administration. If the physician agrees, then the resident will be allowed to self administer medications, and will be reassessed annually and at significant change." A review of the physician orders [REDACTED]. "[MEDICATION NAME] 0.083% Inhal Soln (Inhalation Solution) Administer one vial via nebulizer once daily for SOB (Shortness of Breath), dated 1/13/2013." On 03/26/2013, RI #20 was observed from 1:00 PM until 1:15 PM self administering her nebulizer treatment. When the surveyor observed RI #20, she was sitting in a chair in her room. The mouth piece of the nebulizer was against her cheek, instead of in her mouth, and the medication was observed in the inhalation cup. RI # 20 was sitting with her eyes closed and did not open them when the surveyor walked into the room. After the 15 minute observation, the surveyor asked the Registered Nurse, Employee Identifier (EI) # 2 to come to the room. When asked where the medication nurse was, EI #2 stated she had gone on her lunch break. When asked who was monitoring the treatment, she stated she didn't know. On 03/28/2013 at 2:35 PM, The LPN (Licensed Practical Nurse) EI # 3, medication nurse for RI #20 was interviewed. When asked if she had stayed with RI # 20 during the treatment, she stated she had not because RI # 20 doesn't always want to take it at the time it is ordered. She further stated that RI #20 had waited to eat her lunch before starting the treatment and that RI #20 had turned the machine on herself. EI # 3 was asked if she had gone to lunch before the treatment was finished. EI #3 stated that she had gone to lunch. When asked how she was sure the treatment was completed as ordered she stated she didn't know. When asked EI #3 replied that she would consider that as self administration and stated she did not think RI # 20 had been assessed for self administration.

Based on record review and interview the facility failed to ensure RI (Resident Identifier) #'s 19, 21, and 23 were allowed to continue to smoke after a new smoking policy went into effect in July 2012, after these three residents had already been admitted and allowed to smoke. This affected three of three sampled residents who smoke. Findings Include: A facility smoking policy titled "Smoking Regulations"dated and revised 09/17/07 documented "...3. Smoking by residents will be in a designated area only...5. It is not the intent of the facility to prohibit or restrict smoking privileges..." A facility letter dated 02/16/12 was presented to the employees of the facility. It documented "As of February 24, 2012 we will be implementing a new smoking policy for all employees...any employee who wishes to smoke will be required to use the gazebo area located behind Harmony Hill at the back of the parking lot..." A second facility smoking policy titled "Smoking Regulations - Electronic Cigarettes" revised 06/25/12 documented "...RESIDENTS: 1. It is the policy of Hanceville Nursing and Rehab Center that any resident of the facility will use the electronic cigarette (e-cigarette) or nicotine patch. No traditional cigarettes will be allowed on the facility campus...STAFF: 1. Staff may smoke only in the designated smoking area outside..." A second facility letter dated 06/26/12 was sent to the residents and/or resident sponsor. This letter documented "...Any resident that smokes will be asked to convert to the e-cigarette or nicotine patch while staying in our facility...In an effort to continue this campaign, we have moved our employee/visitor smoking grounds to the gazebo area located across the parking lot behind Harmony Hill..." On 06/26/12 a meeting was held with EI (Employee Identifier) #1, Nursing Home Administrator and the residents who were smokers. The minutes to this meeting were given to the surveyor. The minutes titled "RESIDENT SMOKERS MEETING" dated 06/26/12 documented "...II. Introduction of Meeting Intentions EI #1 announced that the ADPH (Alabama Department of Public Health) is changing regulations. He stated that our facility is going to be moving to electronic cigarettes (e-cigarettes) or nicotine patches for all resident smokers....IV. Resident Questions/Concerns EI #1 affirmed that all residents will still have the right to smoke...RI #23 stated it is not fair to take their rights away..." One resident who is no longer residing at the facility stated "This is our home. Her constitutional rights cannot be taken away...EI #1 said we are not taking away rights, but they will agree to disagree..." 1) RI #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #23's most recent quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 02/01/13 documented RI #23 had a BIMS (Brief Interview for Mental Status) of 15 which indicated RI #23 is cognitively intact. A review of RI #23's care plans with a date of 02/11 documented "CONCERN Activities of Daily Living: ...She goes outside to the designated smoking area to smoke...INDIVIDUALIZED APPROACHES...Assist as needed outside to smoke in designated smoking area..." A review of ACTIVITY PROGRESS NOTES documented on 09/14/11 "...socializing with (c with a line over it) fell ow smokers..." Another note dated 11/07/11 documented "...This last year she has done the majority of her exercising and socialization going back and forth to the smoking area..." Another note dated 03/01/12 documented "...She spends most of her day wheeling back and forth between her room, the dining areas and the smoking area..." A review of SOCIAL PROGRESS NOTES & EVALUATION documented on 02/14/11 "Psychosocial...She enjoys...smoking..." Another note dated 03/03/11 documented "...She spends leisure time in smoking area..." Another note dated 05/06/11 documented "...Spends much of her leisure times smoking with friends outside..." Another note dated 12/07/11 documented "...She enjoys socializing with others and smoking daily..." Another note dated 03/01/12 documented "...She spends leisure time smoking..." Another note dated 05/25/12 documented "...She spends a lot of time outside socializing with other residents and smoking..." A review of RI #23's "Safe Smoking Assessment" dated 02/08/11 indicated under section "IDT (Interdisciplinary Team) DETERMINATION...1. Safe Smoker (has a check mark by it)...2. The Care Plan Team determines the degree of supervision the resident needs while smoking...Independent (has a check mark by it)...3. The resident's Care Plan includes: Smoking Designation (has a check mark by it)...Protective Gear (has a check mark by it)...4. Smoking Policy given to resident or responsible party? Yes (has a check mark by it)..." On 03/26/13 at 10:00 AM, RI #23 stopped this surveyor in the hallway and began asking questions about residents being able to smoke. RI #23 complained of residents not being able to smoke anymore. RI #23 stated the employees are allowed to smoke but there was nowhere left for the residents to smoke. RI #23 stated it had been almost a year since this change went into effect. RI #23 stated the residents were told they would have to use an electronic cigarette or wear a patch. RI #23 stated she felt as though her rights were being taken away. On 03/26/13 at 3:00 PM RI #23 attended the Group Meeting and expressed the same concerns regarding residents not being allowed to smoke anymore. RI #23 stated they (the residents who smoke) just want to smoke outside and socialize with others. On 03/27/13 at 4:48 PM an interview was conducted with EI #1, Nursing Home Administrator. EI #1 was asked what did the facility's new smoking policy say about residents, visitors and employees availability to smoke. EI #1 stated "We migrated to electronic cigarettes and that is for the resident's health. Visitors and employees are allowed to smoke in a gazebo area in the back of the property." EI #1 was asked when this policy went into effect. EI #1 stated 07/26/12. EI #1 was asked when did the residents find out about the change in policy. EI #1 stated they had a couple of meetings with the residents and gave them a 30 days notice. EI #1 was asked why was there a change to the facility's smoking policy. EI #1 stated they were trying to create a cleaner environment. EI #1 was asked what was in the smoking policy prior to the change of 07/26/12. EI #1 stated that no resident would be allowed to keep smoking paraphernalia on them and lock boxes were provided for each resident on the outside smoking area. EI #1 was asked when were the residents told about the use of electronic cigarettes or use of a patch. EI #1 stated June 2012. On 03/28/13 at 10:00 AM RI #23 was interviewed. RI #23 stated she had been allowed to smoke when she was admitted to the facility and lockers had been provided for them to keep cigarettes and lighters outside at the smoking area. RI #23 stated she and other smokers and visitors would socialize outside at the smoking area. RI #23 stated the change in policy happened almost a year ago after they had a meeting with EI #1. RI #23 stated they were told "the state" was making the change and they were either going to have to use the e-cigarettes or a nicotine patch. RI #23 stated she always enjoyed being able to go outside to socialize with her family (who smoke) and the other residents. She stated now she can't go outside with her visitors or family because the residents can't smoke and her visitors or family would have to go to the gazebo at the back of the property. RI #23 stated that she just feels like her rights have been taken away and this (smoking) is something she enjoys. 2) RI (Resident Identifier) #21 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent quarterly (Minimum Data Set) MDS with an (Assessment Reference Date) ARD of 1/3/13 documented the resident to have a (Brief Interview for Mental Status) BIMs score of 12 indicating a moderately impaired cognitive status. Review of the document titled "Safe Smoking Assessment" dated 5/26/11 documented the resident has weakness in lower extremities but demonstrates safe smoking technique. Review of the document titled "Activity Progress Notes" dated 4/26/12 documented "...she conts (continues) to go outside to smoke & (and) socialize c (with) other residents..." Review of the document titled "Activity Progress Note" dated 7/17/12 documented "...D. SUMMARY...Since the last review, resident enjoyed these preferred activities....participating in games outdoors c (with) smokers..." Review of the document titled " INTERDISCIPLINARY CARE PLAN" documented "7/09... CONCERNS Activities: ...She goes outside to smoke and socializes with other residents..." On 03/26/13 at 3:00 PM RI #21 attended the Group Meeting and expressed the same concerns regarding residents not being allowed to smoke anymore. RI #21 stated they just want to smoke outside and socialize with others. An interview was conducted with RI #21 on 3/28/13 at 8:24 A.M. The surveyor asked RI #21 when was she notified she could no longer smoke cigarettes outside. RI# 21 replied that she was not sure of the exact date but it had been months or a year. The surveyor then asked why was she told she could not smoke cigarettes outside anymore. RI #21 explained that the Administrator EI (Employee Identifier) #1 called a meeting with all of the smokers and they were told that the Health Department told him to shut it down (smoking cigarettes outside) and that they could smoke electronic cigarettes or not smoke. The surveyor then asked RI #21 what did she choose to do. RI #21 replied that she smokes electronic cigarettes in her room. She further stated "It messed things up for us, we all use to smoke outside, visit with each other and socialize". 3) Resident Identifier (RI) #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #19s Annual MDS 01/08/13 revealed RI #19s BIMS score was 12, indicating moderately impairment for cognition. The MDS also documented RI #19 was independent with toileting and personal hygiene and required supervision with bed mobility, transfers, walking, locomotion and dressing. A review of the facility's form titled Safe Smoking Assessment for RI #19 revealed the following: "This assessment must be completed upon admission for All residents who wish to smoke. ...Date 2/7/12 ..." A review of this assessment revealed RI #19 was determined to be a safe smoker. A review of RI #19's care plan with a concern of Activity of Daily Living with an entry date of 01/10/12 revealed the following: "... She enjoys smoking...Individualized Approach...Assist her out to smoke as needed/desires...DC'd (discontinued) Date 7/20/12 ..." On 03/23/13 at 11:21 AM, during a conversation between the surveyor and another resident regarding smoking, RI #19 approached the surveyor and stated, "No ma'am, they don't let us smoke no more." The surveyor asked who had she talked to regarding smoking. RI #19 stated, "Boss man he just told us state told them not to smoke in the building. We used to smoke on patio." The surveyor asked how has the facility helped with the resident's smoking. RI #19 stated, "You could go to another facility if want to, nicotine patch or the electric cigarette. Electric cigarette cost too much and don't last. Every once in a while I smoke electric cigarette, but cost too much ."