Every finding on record at Hartford Health Care

Based on observations, interviews, resident record review, and review of a facility policy Oxygen Administration, the facility failed to ensure respiratory care, specifically the provision of oxygen therapy, was not provided without a physician order for Resident Identifier (RI) #39. This had the potential to affect RI #39, one resident reviewed for respiratory care. Findings included: Review of a facility policy titled Oxygen Administration, effective August 2019, revealed the following: Policy Oxygen will be administered per physician's order. RI #39 was readmitted to the facility on on 1/20/2022 and had diagnoses that included Anxiety, Dyspnea, Obstructive Sleep Apnea, and Chronic Respiratory Failure with Hypoxia. On 12/12/2023 at 04:37 PM RI #39 was receiving oxygen at two liters per minute (2 l/m) by nasal cannula and Registered Nurse (RN) #1 verified that Resident #39 was receiving oxygen by nasal cannula at 2 l/m. During an interview on 12/13/2023 at 03:15 PM with the Assistant Director of Nursing (ADON), she revealed RI #39 did not have an order to administer oxygen. The ADON said she was not sure why RI #39 did not have an order for the oxygen, RI #39 previously had an order but it had been discontinued. The ADON stated she was going to call the doctor and get an order; the risks for using oxygen without an order could include confusion, elevated C02 (carbon dioxide), & dryness of nasal membranes. The ADON stated that an order was needed to administer oxygen.

Based on observation, interview, and review of a facility policy titled Labeling and Dating, the facility failed to label and date a bag of ground chicken observed in the refrigerator on 12/12/2023 during the initial tour of the kitchen. This had the potential to affect 18 of 76 residents who received Dysphagia Mechanical Soft (Dys Mech) and Dysphagia Advanced (Dys Adv) diet texture meals from the kitchen. Findings include: An undated facility policy titled Labeling and Dating, documented: . Importance of Labeling and Dating Proper labeling and dating ensures that all foods are stored, rotated, and utilized in a First In First Out (FIFO) manner. This will minimize waste and ensure that items that are passed their due date are discarded. Guidelines for Labeling and Dating All food should be dated upon receipt before being stored. Food labels must include: The food item name . Leftovers must be labeled and dated with the date they are prepared and the use by date. On 12/12/2023 at 1:17 PM, during the initial tour of the kitchen, the surveyor observed a bag of ground chicken with no date or label in the refrigerator. A Diet Guide Sheet provided by the facility documented: . Monday (Day 23) . Dinner . BBQ Chicken Thigh . Dys Adv (Dysphagia Advanced) Ground . Dys Mech (Dysphagia Mechanical) Ground . On 12/14/2023 at 11:05 AM an interview was conducted with the Dietary Manager (DM). The DM said, the undated and unlabeled chopped chicken observed on 12/12/2023 during the initial tour of the kitchen was served during dinner on 12/11/2023 to resident's who received Dysphagia advanced and Dysphagia mechanical diets. The DM said, items should be dated and labeled when placed in the refrigerator to make sure it can be pulled properly to ensure freshness of the food. She said, the bag of chicken was not labeled and dated due to staff forgetting to do so on 12/11/2023. The DM said, the possible negative outcome of not dating or labeling food placed in the refrigerator was the chance residents could receive outdated food.

Based on observations, interviews, and review of a facility policy titled, Infection Control Guide and a facility document titled, Standard Precautions, the facility failed to ensure: a staff member implemented Airborne Isolation Precautions in a manner to prevent the spread of infection. Airborne Isolation Precautions were clearly identified for Resident Identifier (RI) #278 the use of Personal Protection Equipment upon entering the room of , a resident for whom Airborne Isolation Precautions were clearly identified, This deficient practice affected RI #278, 1 of 3 residents reviewed for transmission based precautions. Findings Include: A review of a facility policy titled, Infection Control Guide, with no date, revealed: .use .personal protective equipment (PPE) .gloves, gowns and eye protection in situations where exposure . RI #278 was admitted to the facility on [DATE]. On 12/13/2023 at 4:59 PM, a review of the physician orders dated 12/07/2023 revealed resident to be placed on airborne isolation precautions. A review of RI #278's base line care plan, dated 12/07/2023, revealed: Resident COVID positive .Airborne Isolation Precautions to be observed . On 12/12/2023 at 2:15 PM, a Director of Care Coordination, was observed entering RI #278's room without applying a gown. A sign posted on the resident's door read Airborne Isolation Bed: Stop You will need the following PPE for this isolation: . FACE SHIELD . Gown . Gloves . Mask . On 12/12/2023 at 2:36 PM, after 21 minutes inside the room, the Director of Care Coordinator, opened the door of RI #278's room and asked Medication Assistant, Certified (MAC) #1 to hand her a yellow isolation gown from the isolation box outside of room. MAC #1 handed the Director of Care Coordinator a yellow isolation gown from outside of RI #278's room. On 12/12/2023 at 12:47 PM, an interview was conducted with MAC #1. MAC #1 was asked, what kind of isolation was RI #278 placed on. MAC #1 stated, airborne isolation due to COVID diagnosis. MAC #1 was asked when a resident was on airborne isolation precautions, what kind of Personal Protected Equipment should a staff member put on before entering a resident room. MAC #1 stated face mask, gloves, and a gown. MAC #1 was asked when Director of Care Coordination opened RI #278 room door was she wearing a gown. MAC #1 stated, no. MAC #1 was asked what does company policy say to do when a resident is placed on Airborne isolation. MAC #1 stated Personal Protective Equipment is required. On 12/12/2023 at 03:18 PM, an interview was conducted with Director of Care Coordinator, she was asked, what kind of isolation was RI #278 placed on. Director of Care Coordination stated, airborne isolation due to COVID. Director of Care Coordination, was asked, when a resident was on airborne isolation precautions, what kind of Personal Protected Equipment should a staff member put on before entering a resident room. Director of Care Coordination stated gloves, face shield, mask, but she did not have a gown. She was asked what was the concern of not donning proper PPE. Director of Care Coordination stated, infection control. She was asked what does facility policy say to do when a resident is placed on Airborne isolation. She stated to donn proper PPE. The Director of Care Coordination was asked did she follow company policy and she stated, no. On 12/14/2023 at 04:31 PM, an interview was conducted with the Infection Control Preventionist. Infection Control Preventionist was asked what kind of isolation was RI #278 on. Infection Control Preventionist stated, airborne isolation due to COVID diagnosis. He was asked, according to the facility's policy, what kind of precautions should a staff member take when entering a resident's room with airborne isolation precautions. He stated, put on N95, gloves, gown and face shield. Infection Control Preventionist was asked why should staff dress appropriately with Protected Personal Equipment when entering a resident room with contact isolation precautions. He replied to prevent the spread from resident to resident and to protect themselves and their families. He was asked what the concern was of a person not wearing the proper PPE when entering a COVID positive room. He replied, contracting the virus or spreading it.

Based on observations, interviews, and review of a facility document titled Alabama Your Resident Rights and Protection Under State and Federal Law, and review of a facility policy titled Dining and Meal Service, the facility failed to ensure residents were offered the opportunity to eat meals in the dining room. Residents were only eating the lunch meals in the dining room Monday through Friday. A review of the mealtimes did not specify service for the dining room. This was observed on two days of the survey and had the potential to affect 78 of the 80 residents receiving meals from the kitchen. Findings include: Review of an undated facility document titled Alabama Your Resident Rights and Protection Under State and Federal Law revealed . Dignity and Respect. You have the right to be treated with consideration and respect in full recognition of your dignity and individuality. A facility policy titled Dining and Meal Service with an effective date of 1/1/2017, documented POLICY The dining experience will be person-centered with the purpose of enhancing each individual resident's/patient's quality of life . The facility's undated, untitled, documentation of meal times for each hall, did not specify any meal times for dining rooms. On 12/12/2023 at 5:15 PM, residents were observed eating supper in their rooms, no residents were served in the dining room. Certified Nursing Assistant (CNA) #3 said, she did not know why residents were not eating in the dining room. On 12/13/2023 at 8:52 AM there were not any residents observed eating breakfast in the dining room. CNA #1 said, in the year that he had worked at the facility residents only ate the lunch meal in the dining room, other meals were served in their rooms. On 12/13/2023 at 9:04 AM, CNA #2 was observed returning a dirty tray cart to the kitchen area. CNA #2 said, she had worked at the facility for little over a year and she was not sure why residents were not eating meals, other than lunch, in the dining room. When asked about meals on the weekends, CNA #2 said, they eat all meals in their rooms on the weekends. On 12/13/2023 at 5:24 PM, there were not any residents observed eating the supper meal in the dining room, meals were served on the halls in resident rooms. On 12/13/2023 at 10:00 AM nine residents present at a group meeting expressed they enjoyed eating meals in the dining room. The residents expressed they used to eat three meals a day in the dining room but not anymore. When asked if they ate meals in the dining room on the weekends, they replied, on Saturday and Sunday they were not given a choice, they had to eat meals in their rooms. On 12/14/2023 at 9:58 AM, the Administrator was asked about residents not being served meals in the dining room. The Administrator said, residents were not offered the opportunity to eat meals in the dining room except at lunch Monday through Friday. The Administrator said, they would be working on it and it was a resident right to be offered the opportunity to eat meals in the dining room. On 12/14/2023 at 10:51 AM, during an interview with the Dietary Manager, she said, they serve one meal a day, at lunch Monday through Friday in the dining room. She said, meals had been served only at lunch in the dining room on Monday through Friday for a while. She said no meals were served in the dining room on Saturday or Sunday; meals were served in the residents' rooms only.

Based on record review, interview, and Payroll Based Journal (PBJ) Report, the facility failed to report accurate staffing data from July 01, 2023 - September 30, 2023, to Centers for Medicare & Medicaid Services (CMS). This affected one quarter of data reviewed during the survey. Findings include: The PBJ report generated for the quarter of 07/01/2023 through 09/30/2023 documented: . This Staffing Data Report identifies areas of concern that will be triggered . Metric . Excessively Low Weekend Staffing . Triggered = Submitted Weekend Staffing data is excessively low . On 12/14/2023 at 2:06 PM, an interview was conducted with the Human Resources (HR) Payroll Manager. The Payroll Manger stated she was responsible for turning in PBJ data to the corporate office, who then submitted the data to CMS. When questioned about the low weekend staffing data from July 2023 - September 2023, she explained that the hours reported did not accurately reflect direct patient care due to some staff working additional shifts. She admitted that the data for that period was coded incorrectly, leading to the appearance of low weekend staffing. She emphasized the importance of providing accurate information to CMS to ensure proper care for the residents. On 12/14/2023 at 2:30 PM, an interview was conducted with the Administrator. The Administrator said the PBJ data was submitted by the Coperate office upon receiving it from the facility's Payroll Manager. When asked about the low weekend staffing on the PBJ report for the fourth quarter of 2023, the Administrator clarified the facility did not actually have low weekend staffing during that period. The trigger for this discrepancy was attributed to some administrative staff incorrectly coding their hours while providing direct patient care. The Administrator said the data should be correct in order to provide an accurate representation of the care provided to residents.

Based on observation, record review and interviews, the facility failed to ensure a Registered Nurse (RN) did not leave a cup of medications in Resident Identifier (RI) #4's room to self-administer at a later time, without first assessing the resident for the ability to safely self administer medications. This had the potential to affect one of one resident observed self-administering medications. Findings Include: RI #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/29/2018 at 8:01 a.m., while outside of RI #4's room, the surveyor observed the nurse leave the room and go down the hall to the next room. RI #4 was observed with four or more pills in a cup, taking them (without the nurse present). RI #4 also had one large pill on the rollator. The nurse did not return to the room while RI #4 took the pills. However, review of RI #4's comprehensive care plans and medical record, revealed there was no care plan addressing self administration of medications; nor was there an assessment related to the RI #4's ability to safely self-administer medications. On 11/29/2018 at 8:39 a.m., an interview was conducted with Employee Identifier (EI) #5, RN. RI #5 said she had not stayed in the room while RI #4 was taking the medications because RI #4 said he/she would get them later. When asked why it was important for Medication Nurses to stay with the residents until they finish their medications, EI #5 replied, they should stay in the event if something were to happen. On 11/29/2018 at 9:11 a.m., an interview was conducted with EI #2, Director of Nursing. EI #2 stated that they did not have a policy addressing self-administration of medications; however, she said an assessment form would be completed if the resident was able to self medicate. EI #2 said when administering medications, the nurse should visualize the patient taking the medication. When asked why that was important, EI #2 replied, to ensure the resident took their medications properly, did not put them in the trash or give them to another resident. EI #2 explained it was for the residents' safety. EI #2 said EI #5 should have stayed in the room until RI #4 took all of the medications.

Based on observation, interviews, record review, and review of the facility policy titled, Handwashing/Hand Hygiene, the facility failed to ensure licensed staff washed their hands during the administration of eye drops to Resident Identifier (RI) #19. This affected one of six residents and one of four nurses observed during medication pass observations. Finding include: A review of the facility policy, dated (MONTH) 1, (YEAR), Handwashing/Hand Hygiene revealed the following: Policy statement This center considers hand hygiene the primary means to prevent the spread of infection. POLICY INTERPRETATION AND IMPLEMENTATION . K. after removing gloves RI #19 was admitted to the facility on [DATE]. On 11/27/18 at 5:59 PM, Employee Identifier (EI) #3, License Practical Nurse (LPN), was observed administering RI #19's evening eye drops. EI #3 washed her hands, put on gloves, and administered one drop in RI #19's right and left eye. EI #3 then removed gloves, waited for about four minutes, and then put on another pair of gloves to administer a second drop into RI #19's right and left eye. EI #3 did not wash hands before applying a new pair of gloves. On 11/28/18 at 2:44 PM an interview conducted with EI #3. EI #3 said hands should be washed before and after putting on gloves. EI#3 was asked if she washed her hands before she put on the second pair of gloves when administering RI #19's eye drops. EI #3 said no. EI#3 was asked what the potential harm was in not washing hands before putting on gloves to instill eye drops. EI#3 said it could cause contamination. On 11/28/18 at 3:10 PM an interview was conducted with EI #4, Register Nurse (RN)/Infection Control. EI #4 said hands should be washed before and after putting on gloves. EI#4 was asked what the facility's policy was on hands washing when instilling eye drops. EI #4 stated before putting on gloves, between gloves changes, and after resident care. EI #4 was asked what the potential harm was in not washing hands before putting on gloves to instill eye drops. EI#4 replied, possible spread of bacteria or virus and an increase in the chance of infection.

Based on observation, interviews and review of a facility policy titled 6.0 General Dose Preparation and Medication Administration, the facility failed to ensure a licensed nurse, Employee Identifier (EI) #3, did not leave a cup of [MEDICATION NAME] at Resident Identifier (RI) #11's bedside during the morning Medication Administration Observation on 12/14/16. This deficient practice affected RI #11, one of four residents observed during the Medication Administration Observation. Findings Included: A facility policy titled 6.0 General Dose Preparation and Medication Administration dated 01/01/13, documented the following: . Procedure: 1. Facility staff should comply with Facility policy, Applicable Law and the State Operations Manual when administering medications . 3.9 Facility staff should not leave medications or chemicals unattended . RI #11 was originally admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #11's Physician order [REDACTED]. . [MEDICATION NAME] POWDER - 17 grams by mouth daily, mix in at least 8 ounces of fluids for bowel irregularity . On 12/14/16 at 8:52 a.m., during the morning Medication Administration Observation the surveyor observed EI #3, the medication nurse administer RI #11's morning medications, which included [MEDICATION NAME] powder - 17 grams in 8 ounces of fluids, to RI #11 who was observed sitting in a wheelchair in the room. After RI #11 had taken the pills orally and drank a portion of the [MEDICATION NAME], EI #3 left the room at 8:55 a.m., and return to the medication cart. EI #3 said she would go back to make sure the resident drank the [MEDICATION NAME]. The surveyor observed EI #3 administer medication to two other residents before returning to RI #11's room at 9:05 a.m. At this time (9:05 a.m.), RI #11 was observed to have a portion of the [MEDICATION NAME] remaining in the plastic cup. EI #3 instructed RI #11 to drink the remaining portion of the [MEDICATION NAME]. On 12/14/16 at 1:55 p.m., the surveyor conducted an interview with EI #3, the medication nurse. The surveyor asked EI #3 should she leave medications unattended at the resident's bedside. EI #3 stated No. The surveyor asked EI #3, when she gave RI #11 the medications, what medication was left at the bedside. EI #3 stated, [MEDICATION NAME]. The surveyor asked EI #3 what could happen as a result of leaving medication at the bedside. EI #3 stated, Someone else could get it. The surveyor asked EI #3 if RI #11 had been assessed to self administer medications. EI #3 stated, No. On 12/14/16 at 3:15 p.m., the surveyor conducted an interview with EI #4, the Minimum Data Set Coordinator. The surveyor asked EI #4 who was responsible for determining if a resident was able to self administer their medications. EI #4 stated, The IDT (Interdisciplinary Team) and the patient has to be evaluated by a nurse, most likely that would be me. The surveyor asked EI #4 if RI #11 had been evaluated or assessed by the IDT to self administer medications. EI #4 said no sir. The surveyor asked EI #4, should medications be left at the residents bedside unattended. EI #4 stated, No, we do not do that. On 12/14/16 at 3:35 p.m., the surveyor conducted an interview with EI #1, the Director Of Nursing. The surveyor asked EI #1 who was responsible for determining if a resident was able to self administer their medications. EI #1 stated, The IDT and we discuss that. Also, we would assess for accuracy to see if (the resident) was able to self administer. The surveyor asked EI #1 if RI #11 had been evaluated or assessed by the IDT to self administer medications. EI #1 stated, No sir, (RI #11) has not been evaluated to self administer medications. The surveyor asked EI #4 should medications be left at the residents bedside unattended. EI #1 stated, No sir medications should not be left at the bedside unattended.

Based on observations, interviews and record review, the facility failed to ensure Resident Identifier (RI) #13's catheter bag was covered in a privacy bag, and was not visible from the hallway on 12/13/16 and 12/14/16, two of three days of the survey. This affected RI #13, one of two sampled residents who had catheters. Findings Include: RI #13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. . CHANGE BED SIDE DRAINAGE BAG AS NEEDED . CHANGE 16 FRENCH FOLEY CATHETER WITH FIVE TO TEN CCS (centimeters) BULB BALLOON AS NEEDED . On 12/13/16 at 11:40 a.m., during the initial tour, RI #13's catheter bag was not in a privacy bag and was visible from the hallway. On 12/13/16 at 5:15 p.m., the surveyor observed RI #13's door to the hallway to be open, and the catheter bag was not in a privacy bag. On 12/13/16 at 5:32 p.m., the surveyor observed RI #13's door open. The catheter bag was hanging on the right side of the bed and was visible from the hallway. There was no privacy cover on the catheter bag. On 12/14/16 at 8:34 a.m., RI #13 was observed lying in bed. The door was open and the catheter bag was visible from the hallway. There was no privacy cover on the catheter bag. On 12/15/16 at 12:00 p.m., an interview was conducted with Employee Identifier (EI) #2, the Registered Nurse (RN)/Unit Charge nurse for the 200 Hall. EI #2 was asked if a catheter bag should be placed in a privacy bag. EI #2 stated, yes it should. EI #2 was asked who was responsible for ensuring the catheter bag be placed in a privacy bag. EI #2 stated, the charge nurse and other members of the Administration team who round on the hall. EI #2 was asked when was RI #13 admitted to the facility. EI #2 stated RI #13 was admitted to the facility on [DATE]. When asked if RI #13's catheter bag should have been placed in a privacy bag, EI #2 stated, absolutely. On 12/15/16 at 3:00 p.m., an interview, was conducted with EI #1, the Director of Nursing. EI #1 was asked who was responsible for ensuring that a resident's catheter bag is in a privacy bag. EI #1 stated the charge nurse who admitted the resident. When asked why RI #13's catheter bag was not in a privacy bag for two of three days of the survey, EI #1 stated, probably because therapy or the Certified Nursing Assistant did not know and removed it. EI #1 was asked if RI #13's catheter bag should have been placed in a privacy bag, and not visible from the hallway. EI #1 replied, yes Ma'am it should. EI #1 was asked what type of issue is it for a catheter bag, which is visible from the hallway, and not in a privacy bag be. EI #1 replied, a dignity issue.

Based on observations, record review and interview: 1. The facility failed to assure utensils and food equipment were effectively sanitized and air dried to prevent potential food borne contamination. A) Flatware (spoons) were observed nested with water droplets and were not effectively sanitized and air dried prior to use/storage. B) The facility failed to assure food preparation equipment (blender) was air dried prior to storage. Pooled water was observed on the bottom of the container. 2. The facility failed to assure stored frozen food (Ice Cream) was maintained frozen (hard). Ice Cream was observed soft to touch and left finger indentations on the cup. 3. The facility failed to assure effective cleaning and sanitizing equipment food-contact surfaces as evidenced by: A)Tea Urn faucet/spigot when disassembled was observed with a heavy brown build-up evident that the urn was not cleaned every 24 hours per standard of practice. B) Juice machine dispensing nozzle was disassembled and observed coated with a build-up which indicated cleaning frequency failed to prevent accumulation of soil. The above practices posed the potential for food contamination and compromised food safety. This had the potential to affect all 78 residents who received meal trays from dining services. Findings include: 1. The 2013 Food Code by the United States Public Health (USPHS) and the Food and Drug Administration (FDA) included the following: 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried . (A) On 10/20/2015 at 11:15 AM, flatware was observed stored on the trayline to be placed on individual food trays. Five spoons were observed nested. The Dietary Manager (DM), Employee Identifier (EI) #8 was asked to remove the nested spoons for examination. Three of the five spoons were observed to have water droplets and were not air dried. EI #8 was asked if the spoons were air dried and he replied No. EI #8 was asked, what was the potential risk to residents if spoons are not air dried and he replied there was a potential for bacterial growth. B) On 10/20/2015 at 11:20 AM, the blender was observed stored on its stand with the container cover. When uncovered and turned on the side, water rolled and pooled on the bottom of the container. The DM acknowledged the lack of air drying and said there was a potential for bacterial growth. 2. The facility failed to assure stored frozen food (Ice Cream) was maintained frozen (hard). The 2013 Food Code by the United States Public Health (USPHS) and the Food and Drug Administration (FDA) included the following: Temperature and Time Control 3-501.11 Frozen Food. Stored frozen FOODS shall be maintained frozen . On 10/19/2015 at 4:43 PM, stored Ice Cream was observed soft to touch when pressure was applied and left finger indentations on the cup. The internal temperature of the ice cream was measured at +8 degrees Fahrenheit. This monitoring was observed by the facility evening cook, EI #10. On 10/22/2015 at 12:10 PM, EI #10 verified the ice cream was soft. EI #10 further stated that the ice cream should be hard and that she wouldn't (would not) want to serve my residents no soft Ice Cream. 3. A) The 2013 Food Code by the United States Public Health (USPHS) and the Food and Drug Administration (FDA) included the following: Frequency 4-602.11 Equipment Food-Contact Surfaces and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and utensils shall be cleaned . (E) .surfaces of UTENSILS and EQUIPMENT contacting FOOD that is not TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cleaned: .(2) At least every 24 hours for iced tea dispensers . On 10/21/2015 at 3:15 PM, one of 3 tea urns spigots was disassembled at the faucet. The internal plunger was observed to be heavily coated with a solid brown substance. The DM, EI #8 was asked if the spigot had been cleaned daily and he responded No. EI #8 was asked what would be a potential problem if not cleaned daily and he responded, cross-contamination and altered taste. B) The 2013 Food Code by the United States Public Health (USPHS) and the Food and Drug Administration (FDA) included the following: 4-602.11 (E)(4)- Beverage dispensing nozzles .(b) absent manufacture specifications, at a frequency necessary to preclude accumulation of soil or mold The Juice Machine dispensing nozzle was disassembled on 10/21/2015 at 2:35 PM and observed to be coated with build-up which indicated cleaning frequency failed to prevent an accumulation of soil. EI #8 was asked, how often the nozzle should be cleaned and responded that it should be soaked every night. He was asked, looking at the nozzle, has it been soaked every night and EI #8 responded No. EI #8 was asked about potential problems if not frequently cleaned and responded that there was a potential to set up mold and contamination. On 10/22/2015 at 10:30 AM, a request was made for the policy/cleaning for the nozzle and he stated he did not have one.

Based on observation, record review and interviews, the facility failed to assure written planned menus were prepared in advance for all prescribed diets (NFF - No Fried Food) and meals served followed the established guidelines in the approved diet manual. This deficient practice had the potential to affect 26 of 78 residents who received meals from dining services and NFF was in the diet order. Findings include: On 10/19/2015 during the Entrance Conference the team leader requested a copy of all menus (including therapeutic) for that day and the duration of the survey. Included in the request was for a list which included resident's name, room number, diet order and location of meal delivery. The facility provided a Week at a Glance menus plus three Diet Spreadsheets (menu plans - 3 sheets per day, for Week 5 days 30,31 and 32) 10/20/15, 10/21/15 and 10/22/15. A review of the facility Diet Spreadsheet revealed extended menu plans for 14 varied diets and combinations. The MASTER RESIDENT by NAME list which included resident's name, room number, diet order and location of delivery dated 10/19/2015 was compared with the Diet Spreadsheets. There were no written planned menus nor explanation (foot notes) to describe the NFF letters used. On 10/20/15 the Master Resident by Name listing of diet orders revealed 26 names with varied combinations of NFF, i.e. LCS (Low Concentrated Sweets)/NFF, NAS (No Added Salt)/NFF, LCS/NAS/NFF, and LCS/NAS/NFF/RENAL. The facility's preplanned/approved menu plans were observed. There was no written plan or documented information related to a NFF diet. The Dietary Manager (DM), Employee Identifier (EI) #8 explained NFF was No Fried Foods. At 10:47 AM on 10/20/2015, the Dietary Manager (DM), EI #8 was asked, where is the written planned menu for NFF diets. EI #8 said On the menus. After looking at the Spreadsheets, EI #8 said, it is not there. The observed facility diet manual utilized was the Diet & Nutrition Care 2014 (edition) Becky Dorner & Associates. The manual content was reviewed. There was no evidence or reference to a NFF diet. The DM, EI #8 was asked if the manual addressed the NFF diet and he said that it did not.

Based on observation, interview and record review the facility failed to ensure two Certified Nursing Assistants (CNAs) did not enter the bathroom to wash their hands while Resident Identifier (RI) #18 was toileting. This affected 1 of 15 sampled current residents. A facility document titled: Resident's Rights revealed: YOU HAVE THE RIGHT TO BE TREATED WITH DIGNITY, PRIVACY, . YOU HAVE THE RIGHT TO PRIVACY INCLUDING . PERSONAL CARE . RI # 18 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/26/2015 revealed RI #18 was currently on a toileting program and required extensive assistance with one person physical assist. The MDS further revealed RI #18 was moderately impaired in cognition with a Brief Interview for Mental Status (BIMS) of 8. On 10/20/15 at 4:00 PM prior to performing incontinent and pericare for another resident, Employee Identifier's (EI) #5 and EI #6 entered the bathroom to wash their hands while RI #18 was toileting. On 10/21/15 at 2:00 PM, an interview was conducted with EI #7, Director of Nursing. EI #7 was asked was it an acceptable practice of the facility for CNAs to enter a bathroom to wash their hands when a resident is toileting. EI #7 said no. EI #7 was asked why was it not an acceptable practice to interrupt a resident using the bathroom. EI #7 said privacy. EI #7 was asked what was the potential harm to a resident for an employee to continually interrupt a resident, while toileting, to wash their hands. EI #7 said privacy issue. On 10/21/15 at 2:05 PM, an interview was conducted with EI #6, CNA. EI #6 was asked what did you do before applying your gloves. EI #6 said washed hands in the bathroom. EI #6 was asked what was RI #18 doing. EI #6 said using the restroom. EI #6 was asked why did she go into the the bathroom to wash her hands when RI #18 was in there. EI #6 said she was nervous. EI #6 was asked should she have interrupted RI #18 to wash her hands while the resident was toileting. EI #6 said no, because that's his/her privacy time. EI #6 was asked what was the potential harm to RI #18 for interrupting the resident while in the bathroom. EI #6 said privacy and dignity. EI #6 was asked when should residents be provided privacy. EI #6 said at all times. EI #6 was asked if RI #18 was provided privacy when she entered to wash her hands. EI #6 said no. On 10/21/15 at 3:30 PM, an interview was conducted with EI #5, another CNA. EI #5 was asked, prior to performing incontinent care on RI #1, what did you do. EI #5 said washed hands. EI #5 was asked where did she wash her hands. EI #5 said in RI #1 and 18's bathroom. EI #5 was asked where was RI #18 when she washed her hands. EI #5 said RI #18 was in the restroom on the Sabina lift on the toilet. EI #5 was asked why she entered the bathroom to wash her hands while RI #18 was in the bathroom. EI #5 said the only other place to wash their hands was the soiled linen room. EI #5 was asked if she should have interrupted RI #18 while in the bathroom to wash her hands. EI #5 said she shouldn't have interrupted. EI #5 was asked what was the potential harm to RI #18 for interrupting the resident's time in the bathroom. EI #5 said privacy and dignity.

Based on observations, interviews and record review, the facility failed to ensure: 1) skin protectant cream was applied to RI (Resident Identifier) #1's perineum in a manner to prevent possible contamination during the 10/20/2015 incontinent care observation. 2) EI (Employee Identifier) #2, a CNA (Certified Nurses Aide) washed her hands prior to donning gloves, after removing her gloves, before handling clean supplies and prior to leaving RI #5's room during the 10/21/2015 incontinent care observation. The facility further failed to ensure EI #2 used separate wipes when cleansing RI #5's labia and perineum during the incontinent care observation on 10/21/2015. 3) EI #3, an LPN (Licensed Practical Nurse) washed her hands after removing her gloves and before applying new gloves during RI #5's incontinent care on 10/21/2015. This affected RI #1 and RI #5, two of two residents observed during incontinent care. Findings include: 1) A review of Potter and Perry, Fundamentals of Nursing, Eighth Edition, Chapter 39, page 801 indicated .perineal hygiene . (2) (c) .wipe in direction from perineum to rectum . RI #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 8/31/2015 revealed RI #1 was totally dependent with one person physical assist for personal hygiene needs, had an indwelling urinary catheter and was always incontinent of bowel. A review of RI #1's Care Plan with a problem onset date of 12/31/2013 and a revision date of 9/9/15 revealed: 1. .ALTERATION IN SKIN INTEGRITY RELATED TO . INCONTINENCE. Care plan approaches included: . APPLY MOISTURE BARRIER AFTER PERICARE . 2. . has a history of Urinary Tract Infections r/t urinary incontinence Urinary Retention Obstructive uropathy .Foley Catheter . A review of RI #1's Physician order [REDACTED]. APPLY [MEDICATION NAME] POWDER TO SKIN BETWEEN LEGS-INNER THIGHS EVERY SHIFT . APPLY ZINC OXIDE TO BUTTOCKS EVERY SHIFT FOR PREVENTATIVE MEASURES . On 10/20/15 at 4:00 PM, incontinent care was observed on RI #1. Upon completion of the incontinent care, EI #5 was observed applying a skin protectant from the resident's perineum up to the pubis. EI #5 applied more skin protectant to her gloves. EI #5 did not change gloves. EI #5 again applied the skin protectant from back to front, from the perineum upward towards the pubis and labia. On 10/21/15 at 3:45 PM, an interview was conducted with EI #5. EI #5 was asked how would you apply skin barrier. EI #5 said away from the vagina. EI #5 was asked why was that important. EI #5 said to prevent infections. EI #5 was asked what was the potential harm in not applying a skin barrier correctly. EI #5 said infections. On 10/21/15 at 4:30 PM, an interview was conducted with EI #4, Risk Manager. EI #4 was asked how should perineum and rectal areas be cleaned. EI #4 said on ladies, front to back, always wiping away from the urethra. EI #4 was asked why was it important to wipe away from the perineum. EI #4 said to decrease the risk for UTIs. EI #4 was asked when should gloves be removed and hands sanitized. EI #4 said after touching dirty. EI #4 was asked is it an acceptable practice of the facility for gloves not to be changed and hands to be sanitized prior to applying more skin barrier to the inner thighs and perineal areas. EI #4 said they should be changed in between. 2) Review of Potter and Perry's Fundamentals of Nursing, copyright 2013, Chapter 39, page 797-805 revealed: Skill 39-1 BATHING AND PERINEAL CARE .IMPLEMENTATION .b. Perform hand hygiene .o. Provide perineal hygiene . (2) Female patient (a) Apply clean pair of gloves . (c) Wash labia majora . gently retract labia from thigh: wash carefully in skin folds. Wipe in direction from perineum to rectum. Repeat on opposite side using separate section of washcloth. (d) Gently separate labia .to expose urethral meatus and vaginal orifice. , wash downward from pubic area toward rectum . Wash middle and both sides of the perineum. Use separate section of cloth for each stroke . p. Remove soiled gloves . q.(1) Perform hand hygiene and apply clean pair of gloves . RI #5 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #5's Significant Change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 07/08/2015 documented RI #5 was frequently incontinent of bowel and bladder and required extensive assist of two persons for toileting. On 10/21/2015 at 4:33 PM, the surveyor observed EI #2, the CNA and EI #3, the LPN performing incontinent care on RI #5. EI #2 was observed to enter the room, get a brief and wipes from the closet. EI #2 put on her gloves without washing her hands. EI #2 then placed the draw sheet under RI #5 and assisted EI #3 in lifting RI #5 up in the bed. EI #2 then unfastened RI #5's brief and began cleaning RI #5's perineum. EI #2 used the same wipe for the right side and left side of the perineum. EI #2 used another wipe to clean RI #5 from the top to the bottom and then from the bottom to the top of the labia. EI #3, the LPN, then completed the care to the buttocks. EI #2 assisted with placing the clean brief on RI #5, pulling the bed covers over RI #5. EI #2 then removed her gloves and put the box of wipes in the cabinet/closet. EI #2 then left RI #5's room. EI #2 performed all the above on RI #5 without washing her hands or changing her gloves. On 10/21/2015 at 4:42 PM, EI #3, the LPN was interviewed about RI #5's incontinent care. EI #3 was asked how did the CNA, EI #2, clean RI #5's labia. EI #3 stated she went front to back then back to front with the same wipe. When asked what the potential for harm was in cleaning the labia in that manner, EI #3 stated infection. On 10/21/2015 at 4:53 PM, EI #2 was interviewed about RI #5's incontinent care observation. EI #2 was asked what should be done upon entering a resident's room. She stated wash your hands and that she had not. EI #2 was asked when should hands be washed during incontinent care. She stated before, after and during care if necessary. When had she washed her hands, EI #2 stated she had not washed her hands. EI #2 was asked how the labia should be washed. EI #2 stated open the labia, wash front to back with a clean wipe. When asked how she had washed RI #5's labia, EI #2 stated she had washed from top to bottom then bottom to top and did not use a clean wipe for the second wipe. EI #2 was asked if she had washed her hands after removing her gloves. She stated she had not. When asked what the potential for harm was in not washing her hands or changing her gloves during incontinent care, EI #2 stated contamination. When asked what the potential for harm was in not changing wipes and not cleaning the labia correctly, EI #2 stated possible yeast or other infections. 3) Review of Potter and Perry's Fundamentals of Nursing, copyright 2013, Chapter 39, page 797-805 revealed: Skill 39-1 BATHING AND PERINEAL CARE .IMPLEMENTATION .b. Perform hand hygiene .o. Provide perineal hygiene . q. Wash back . (1) Perform hand hygiene and apply clean pair of gloves . (4) If fecal material is present, enclose in a fold of underpad or toilet tissue and remove with disposable wipes. (5) Clean buttocks and anus, washing front to back . Remove contaminated gloves . perform hand hygiene . During an incontinent care observation on 10/21/2015 at 4:33 PM, the surveyor observed EI #3, an LPN performing care on RI #5. EI #3 entered RI #5's room, washed her hands and put on her gloves. EI #3 assisted EI #2, a CNA perform incontinent care to RI #5. EI #3 cleaned BM from RI #5's buttocks. EI #3 removed her gloves and put on new gloves without washing her hands. EI #3 completed care, removed her gloves and then washed her hands. On 10/21/2015 at 4:42 PM, the surveyor interviewed EI #3 about RI #5's incontinent care observation. EI #3 was asked when should hands be washed during incontinent care. She replied before, after changing soiled brief, and after providing care. When asked what should be done after removing her gloves, EI #3 stated sanitize or wash your hands. EI #3 was asked how many times did she change her gloves. She stated once. When asked if she had washed or sanitized her hands after changing her gloves, EI #3 stated no. EI #3 was asked what the potential for harm was in not washing her hands after changing her gloves. EI #3 stated it could cause an infection. EI #3 further stated that the incontinent care for RI #5 had not been done correctly. On 10/22/2015 at 11:02 AM, the surveyor interviewed EI #4, Risk Manager. EI #4 was asked when should hands be washed during incontinent care. She replied before donning gloves, from dirty to clean, during the changing of gloves. When asked when gloves should be changed during incontinent care, EI #4 stated when going from dirty to clean. EI #4 was asked what staff should do after removing gloves. She stated to sanitize or wash hands. EI #4 was asked how the labia should be washed. She replied the labia should be washed in downward manner, side/ side and then the middle. When asked if staff should use the same wipe, EI #4 stated no. EI #4 was asked what the potential for harm was in not washing hands before care, during care, after removal of gloves and upon completion of care. She stated there is an increase for urinary tract infections. When asked what the potential for harm was in not cleansing the labia with separate wipes and from front to back, EI #4 stated there was a risk for urinary tract infections.

Based on observation, interview and record review, the facility failed to ensure the staff posting forms contained the actual hours worked for all nursing staff listed. This was observed on 10/19/2015, 10/20/2015 and 10/21/2015. The actual hours worked by nursing staff was not listed on staff posting forms which were reviewed from 12/1/2014 to 10/22/2015. This had the potential to affect all 83 residents residing in the facility. Findings include: During the initial tour on 10/19/2015 at 5:30 PM, the surveyor observed the staff posting form at the first nurse's station at the front of the building. The staff posting form did not include the actual hours worked for the nursing staff listed on the form. On 10/20/2015 at 4:00 PM, the surveyor reviewed the staff posting forms which the facility had provided from 12/01/2014 to 10/21/2015. The surveyor observed that the total actual hours worked by nursing staff were not listed on these forms. On 10/20/2015 at 4:30 PM, the surveyor observed the staff posting form at the front nurse's station which did not include the actual hours worked. On 10/21/2015 at 5:08 PM, the surveyor interviewed EI (Employee Identifier) #1, Staffing Coordinator. EI #1 stated she was responsible for filling out the staff posting forms. EI #1 was asked which components should the staff posting sheet contain. She stated the components were the facility name, the date, the census, the shift, staff and the total actual hours worked. When asked if the staffing sheets contained these components prior to 10/21/2015 she stated no. EI #1 stated that according to the watermelon book, (State Operation Manual), it should.

Based on record review and interview, the facility failed to ensure a Basic Metabolic Profile (BMP) was obtained for Resident Identifier (RI) #3 in September 2014 as ordered by the physician. This affected 1 of 10 sampled residents for whom lab results were reviewed. Findings Include: RI #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of RI #3's "Physician Orders" for the month of September 2014 revealed a lab order for a monthly BMP dated 03/10/2014. On 11/5/2014 at 3:28 PM, the surveyor asked Employee Identifier (EI) #1, Registered Nurse (RN) Supervisor, if she could help locate the lab work in RI #3's chart. EI #1 looked through the chart and was unable to locate BMP results from September. EI #1 stated she may have to pull them up in the computer. At 3:55 PM, EI #1 provided a copy of a cumulative lab report for RI #3 which revealed a Complete Blood Count (CBC) had been performed on 09/23/2014, but no BMP. The surveyor contacted the laboratory on 11/6/2014 at 7:00 AM. When asked to locate BMP results on RI #3, the lab staff stated a BMP had been done 08/26/2014, but she did not show any BMP results for the month of September. The lab then provided a copy of RI #3's "Account Inquiry" via fax which indicated a BMP had been run on 08/26/2014, but the next BMP had not been done until 10/27/2014. EI #2, the Director of Nursing, was interviewed on 11/06/2014 at 12:06 PM. He stated he had contacted the lab and been unable to locate a BMP for the month of September. When asked what RI #3's lab orders were at that time, EI #2 stated the BMP was ordered monthly and should have been done. When asked if there was anywhere else the lab work could have been run, EI #2 stated he had already called their back-up lab and they did not have the BMP either. The surveyor then asked EI #2 why it was important to run labs as ordered by the physician. EI #2 stated "to follow physician orders."

Based on observation, interview and record review, the facility failed to ensure CNAs (Certified Nursing Assistants) transferred RI (Resident Identifier) #11 in a manner to prevent potential injury. This affected one of one resident observed during a transfer. Findings include: RI #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission MDS (Minimum Data Set), dated 01/24/2012, assessed RI #11 as having long and short-term memory problems and requiring extensive assistance with bed mobility and transfers. The facility's policy (dated 11/01/11) titled, "Transfer Technique (Bed to Chair)" revealed: "...9. Assist the resident to "push up" from the bed while you firmly guide with gait belt." During tour on 10/30/2012 at 4:15 PM, RI #11's family member stated the CNAs were lifting him using his clothing and they had torn two pair of pajama bottoms. The family member showed the surveyor two pair of pajama bottoms that were torn approximately four inches from the top on both sides. RI #11's fall care plan, dated 01/15/2012, revealed: "Ambulates x (times) 2 staff with gait belt and walker." The Physician orders [REDACTED]. "... Fall precautions ..." RI #11's "CNA Care Card" documented: "...Walker/rolling ... gait belt." On 10/31/2012 at 4:15 PM, two CNAs were observed transferring RI #11 from the bed to the wheelchair for supper. The CNAs washed their hands, put on gloves, removed the covers, and lowered the head of the bed. After checking to see if RI #11 was soiled, the CNAs assisted RI #11 to a sitting position on the side of the bed. Placing their arms underneath RI #11's arms, the CNAs held onto the waistband of RI #11's pants, lifted him and transferred him to the wheelchair. On 11/01/2012 at 9:00 AM, a CNA, EI (Employee Identifier) #8, who regularly provides care for RI #11 was interviewed. EI #8 was asked what would be the harm in pulling a resident from a sitting to a standing position using the waistband of the resident's pants. The CNA replied it could tear the clothing and cause pain to the resident. On 11/01/2012 at 9:30 AM, the Staff Development RN (Registered Nurse), EI #4, was interviewed. EI #4 was given a copy of the CNA Care Card and asked how the CNA would know how to transfer the resident from instructions on the card. EI #4 stated, "It really doesn't say. I'm not seeing it." EI #4 was asked if it was ok to hold onto the top of a resident's pants to assist with transferring them. EI #4 stated that was not right and was not what she had taught them to do. EI #4 was asked why this would not be a good idea. She stated that it was not safe, the clothing could tear, it would be uncomfortable for the resident, it could cause pain, and the resident could fall. On 11/01/2012 at 10:00 AM, the LPTA (Licensed Physical Therapy Assistant), EI #5, was asked how RI #11 should be transferred from bed to chair. EI #5 stated a gait belt should be used. EI #5 was asked when she would advise using a gait belt. She responded it should be used to transfer from bed to wheelchair.

Based on observations, record review, and interviews the facility failed to prevent the potential for cross-contamination by using moistened four by four gauzes to cleanse Resident Identifier (RI) #4's heel wound from the same container of moistened four by four gauzes that were used to clean the supra pubic catheter for RI #4. This affected one of two residents observed for wound care. Finding include: The facility's Policy and Procedure for "Dressing - Aseptic" dated 08/01/12, identified: "Aseptic dressing technique will be utilized in the dressing changes of all decubitus ulcers, surgical wounds requiring a treatment. ... Purpose Aseptic dressing will protect open wounds from contamination and absorb drainage." RI # 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set, with an assessment reference date of 10/08/12, revealed RI #4's mental interview score was a three, indicating the resident was unable to complete the interview. RI #4 also required assistance with all activities of daily living, including bathing, dressing, eating and toileting. On 10/31/12 at 9:40 AM, the Treatment Nurse, Employee Identifier (EI) #1, with the assistance of the Assistant Director of Nursing (EI #2) were observed to provide catheter care to RI #4's supra-pubic catheter and wound care to the resident's left heel. EI #1 was observed to set up the over bed table, placing a clean barrier to the table and placing clean supplies for the care on the barrier. EI #1 opened four containers of four by fours, making two rows with one container behind the other. EI#1 placed normal saline in one of the front two containers of 4x4s and the 4x4s beside it was left dry. EI #1 then placed normal saline in the container of 4x4s directly behind the first one, also leaving the other container of 4x4s dry. EI #1 was observed to reach into the first container of moistened 4x4s and used the 4x4s to clean the supra-pubic catheter site and tubing. EI #1 was observed to reach into the same container of moistened 4x4s three times, each time squeezing the extra saline back into the 4x4 container. After EI #1 completed the treatment to the catheter site she removed her gloves, washed her hands and donned clean gloves. EI #1 then moved the over bed table to the left side of the resident's bed to provide wound care to the left heel. EI #1 was observed to reach into the same container of moistened 4x4s that had been used to clean the catheter and obtained 4x4s, then cleaned RI #4's heel. At the end of the wound care the second package of moistened 4x4 had not been used. EI #1 was interviewed on 11/1/12 at 12:45 PM. EI #1 was asked why she set up four containers of 4x4s. EI #1 replied because she had two areas to clean. EI #1 was asked if there would be a potential for harm cleaning two different areas from the same package of moistened 4x4. EI #1 replied, "Yes, that is a possibility." EI #1 was asked what was the possibility. EI #1 said the possibility was cross-contamination.

Based on observation, interviews and record review, the facility failed to: 1) discard expired commercially prepared salad in a timely manner; and 2) serve food on the 10/05/11 lunch trayline at recommended safe temperatures (greater than 135 degrees or less than 41 degrees Fahrenheit/F). This had the potential to affect all 75 residents for whom meals were prepared and served at the time of this survey. Findings include: 1) During the initial kitchen inspection on 10/04/11 at 11:20 AM, one 5-pound container of commercially prepared cucumber and onion salad was stored in the walk-in refrigerator. The "use by" date was marked as 09/21/11, nearly 2 weeks earlier. The salad was labeled as opened by the facility on 09/14/11. 2) The facility's policy and procedure (A:5.14) related to "Minimum Temperature at Point of Service," dated 02/07/11 specifies the following procedure: "...2. The minimum temperature of food while holding on the tray-line should be: Hot Food (greater than or equal to) 135 F Cold Food (less than or equal to) 41 F." On 10/05/11 at 11:05 AM, lunch trayline temperatures were measured by Dietary staff as follows: Pasta Salad: 45 degrees F Tomato/Cucumber/Onion Salad: 45 degrees F Egg Salad: 45 degrees F Pureed Egg Salad Sandwiches: 60 degrees F Pureed Beets: 130 degrees F Despite the findings of food temperatures within the danger zone (above 41 degrees F, and below 135 degrees F), tray line staff served all of the above foods to the residents. At 11:22 AM, Dietary staff again measured the temperature of the pureed egg salad. The internal temperature was 51 degrees F. A larger pan of ice was obtained and the pureed egg salad was placed in it. The temperature of the pureed egg salad was rechecked at 11:35 AM and found to be 58 degrees F. Trayline staff continued to serve the pureed egg salad. The regular egg salad was rechecked by Dietary staff at 11:40 AM, and found to be 43 degrees F. Trayline staff continued to serve the regular egg salad, as well as the other foods, above. On 10/05/11 at 11:27 AM, the surveyor asked the Dietary Manager, EI #3, to confirm the appropriate temperature at which cold foods should be served from the tray line. EI #3 responded, 45 degrees F.

Based on observation, interviews and record review, the facility failed to serve the type of bread that was planned, and the appropriate size portion of entree to residents at two of two meals observed. This affected 15 residents on pureed and 19 residents on mechanically altered diets, or 34 of 75 total residents for whom meals were prepared and served at the time of this survey. Findings include: 1) The 10/04/11 supper menu included the following planned items for residents on the Pureed and Mechanical Soft Diets, respectively: Pureed Garlic Bread (#16 scoop) and Bread/margarine (1 slice) Instead of the above, tray line staff served regular pureed bread mix (with water) to the Pureed Diets, and regular garlic bread to residents on the Mechanical Soft Diet. The Assistant Dietary Manager, EI (Employee Identifier) #4 confirmed the above during an interview on 10/04/11 at 5:15 PM. The Dietary Manager, EI #3, stated on 10/04/11 at 5:20 PM, the residents on Mechanical Soft diets were supposed to receive a slice of regular white bread with margarine. She said the toasted, buttered garlic bread appeared to be too crusty. EI #3 explained the residents with Pureed diet orders should have received pureed garlic bread, however staff had already prepared the pureed bread mix prior to the start of the tray line. The Diversicare Management 2009 Food Service Diet Manual specifies: "A Mechanical Soft or Dental Soft Diet is used for individuals who have difficulty chewing regular textured foods.... Grains (include) soft, non-chewy, not hard and crusty." 2) The 10/05/11 lunch menu specified two #8 (4 ounce) scoops of pureed Egg Salad Sandwich for residents on the Pureed Diet. Throughout this tray line, the cook (EI #5) served one #8 scoop of the pureed egg salad sandwich entree to residents on the Pureed Diet. At 12:05 PM, the cook confirmed to the surveyor only one scoop was given to each resident. The surveyor asked EI #5 how much bread she had added to the egg salad before pureeing the mixture. EI #5 confirmed it was 30 slices of bread (2 slices per resident serving). When the surveyor asked why only one scoop of the sandwich had been given, EI #5 responded she did not know. Despite the interview, EI #5 continued to serve the remaining three residents, one scoop of the pureed egg salad sandwich (half of the recommended portion). The "TrayCard Preview Report" dated 10/04/11, confirmed 15 orders for the Pureed Diet, and 19 Mechanical Soft (ground) Diets. The Pureed Egg Salad Sandwich recipe (#969) confirmed the inclusion of 30 slices of white bread in the recipe for 15 servings, with 45 total eggs (three per person). The portion size was listed as two #8 scoops (8 oz total).

Based on observations, interviews, and record review, the facility failed to ensure RI (Resident Identifier) #10's hand splint was consistently applied as scheduled. The facility also failed to monitor the application and effectiveness of this splint. This affected one of two residents sampled with hand splints. Findings include: The facility document titled, "Rehabilitation/Restorative Nursing Care: Splint and Brace Assistance," dated March 2010, revealed: "Facility Requirement: ...A resident with a limited range of motion receives appropriate treatment and services to increase and/or prevent further decrease in range of motion. Splint and Brace Assistance - can be 2 types. ...2. Where staff have a scheduled program of applying and removing a splint or brace, assessing the resident's skin and circulation under the device, and reposition the limb in correct alignment. These sessions are planned, scheduled, and documented in the clinical record. Potential Candidates for splint/brace: Residents with deformity contractions Residents with no active ROM (Range of Motion) Residents with spastic paralysis Possible Goals For use of splint: Maintain proper alignment of limbs To reduce plasticity To obtain maximum potential ROM To prevent further contractures..." The "Position Description" for a Restorative Nursing Assistant, dated April 2010, revealed: "Accountability Objective: Responsible to work with residents needing restorative nursing measures to provide skill practice in such activities as walking, mobility, dressing and grooming, eating and swallowing, transferring, ambulation care, and communication in order to improve and maintain function in physical abilities and ADLs, and prevent further impairment. ...Key Responsibilities: 1. Administer restorative activities specific to resident needs based on the plan of care ...4. Ensure placement of restorative devices/equipment (e.g. splints, positioning devices) ...6. Document per treatment activity 7. Report changes in resident condition, evidence of pain or motivational level to licensed nurse. 8. Notify Restorative nurse, charge nurse or appropriate therapy discipline of problems, referrals, and reassessment needs ...10. Maintain consistent resident care schedule... ...12. Follow policy and procedure for restorative nursing programs." RI #10 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #10's Quarterly MDS (Minimum Data Set) assessment, dated 07/28/11, revealed she was cognitively intact and required extensive assistance with all ADLs (Activities of Daily Living) except for eating, which she required limited assistance. RI #10 was also identified as having range of motion impairment on one side that included both upper and lower extremities. She was also identified as wearing a splint or brace for all 7 days of the assessment period. RI #10's "Physician Orders" for October 2011 revealed: "Splint applied to left wrist and hand every shift by restorative CNA (Certified Nursing Assistant) per schedule as resident allows." RI #10's Care Plan for contractures, dated 08/09/05, revealed the approach: "...Soft resting hand splint to L) (left) hand; off prn (as needed) and as desired." The sign hanging on the inside of the closet door revealed: "Apply splint to left hand between 9-10 am and remove between 3-4 pm..." RI #10's "CNA Care Card" that the CNAs look at to know what to do for each resident, dated 08/10/11, was hanging inside the resident's closet door. It revealed under "special equipment," left hand splint. RI #10's "Functional Maintenance Plan," subtitled "Splint Application Sheet" for the months of August, September, and October 2011 revealed: "Frequency/Duration: Daily left hand." This documentation showed that RI #10 consistently wore the splint. The only day that it was documented she refused to wear the splint was October 5, 2011, the second day of the survey. RI #10's "Therapy Communication," dated 03/30/11 revealed the resident had decreased active range of motion in her left elbow, wrist and fingers. This communication showed that RI #10 was currently on a functional maintenance plan with restorative nursing providing passive ROM to the left upper extremities and is putting on and taking off a hand splint. On 10/04/11 at 11:39 AM, during the initial tour of the facility, RI #10 was in her room in a wheelchair. Her left hand was contracted, but there was nothing in her hand. RI #10 said she was supposed to have a splint on her left hand. On 10/04/11 at 5:23 PM, RI #10 was in her room in a wheelchair. Her left hand was in a fist and contracted. She had no splint or anything in her left hand. On 10/05/11 at 8:20 AM, RI #10 was feeding herself breakfast. She did not have a splint on her left hand. She said her left hand was hurting. On 10/05/11 at 11:30 AM, RI #10 was in her room in bed. She did not have her splint on her left hand. RI #10 said her left hand was hurting. On 10/05/11 at 12:47 PM, RI #10 was finishing up her lunch meal in her room. She did not have a splint on her left hand. On 10/05/11 at 12:56 PM, RI #10 was in her room. She did not have a splint on her left hand. On 10/05/11 at 5:00 PM, RI #10 was in her room sitting in her wheelchair. She had a hand splint on her left hand and wrist. The surveyor mentioned to the resident that she noticed she was wearing a hand splint. RI #10 responded, "Yeah. They put it on just a little bit ago. It feels better when I have the splint on." On 10/06/11 at 8:25 AM, RI #10 was in her room in her bed. Her left hand was contracted, with no splint on it. On 10/06/11 at 11:14 AM, the Administrator, EI (Employee Identifier) #1, was asked if there was a facility policy regarding splints. He said there was not, only the "Splint and Brace Assistance" document. EI #1 said each resident has their own individualized maintenance plan. On 10/06/11 at 7:53 AM, EI #6, the restorative CNA (Certified Nursing Assistant) for RI #10 was interviewed. She was asked if she was responsible for applying RI #10's splint for her left hand. She said she was, as well as the other CNAs. EI #6 was asked when RI #10 was supposed to wear the splint. She said she was not sure. EI #6 explained that RI #10 will sometimes take the splint off. EI #6 was asked how often she checks to make sure the splint is on. She said about every two hours. EI #6 was asked if she was aware of the sheet on the inside of the closet door in RI #10's room that shows when she wears it. She said she was not familiar with that. EI #6 was asked if she attempted to apply RI #10's splint yesterday (10/05/11). She said she did, about 9:30 AM, but the resident did not want to wear it. EI #6 explained that she reported that to the nurse and documented it, then went back to the resident later and applied it about 2:30 or 3:00 PM. EI #6 was asked if she tried to apply the splint between 9:30 and 3:00. She said she was not sure. EI #6 was informed that the surveyor's concern was that the hand splint had not been consistently applied during the survey. EI #6 said RI #10 usually wears it most of the time. On 10/06/11 at 9:28 AM, EI #7, the Restorative LPN (Licensed Practical Nurse) was interviewed. She was asked who was responsible for making sure splints are applied. She said the CNAs unless it is specifically something for Restorative CNAs to do. EI #7 was asked how she monitors to make sure the splints are applied. She said she looks at the residents as she is walking by the rooms, and if it is not on, she will put it on. EI #7 was asked if RI #10's splint is supposed to only be applied by Restorative CNAs. She said any CNA can apply her splint. EI #7 said RI #10 refused to wear the splint at times and that she can remove it. A review of RI #10's medical record revealed only one documented entry on the splint book for 10/05/11 where she refused to wear it. There was no documentation of the resident removing the splint herself. EI #7 was informed that the splint had not been applied consistently during the survey, and it only takes a short amount of time for the resident's ROM to decline. EI #7 responded, "You're right." On 10/06/11 at 8:40 AM, EI #8, the Therapy Director, was asked who was responsible for determining if a resident needs a splint. She said the Occupational Therapist decides. Therapy picks that individual up on caseload, they do an assessment, monitor about two weeks, then pass the responsibility to Restorative. EI #8 was asked when RI #10's hand splint was supposed to be worn. She said it was the same schedule as everyone else: applied about 9 or 10 AM and off about 3 or 4 PM (four to five hours). EI #8 was asked when the splint was first ordered. She said RI #10 has been wearing that splint for over four years. EI #8 was asked the reason for the splint. She explained that it was to try to stop her from getting more contracted, and to maintain good skin integrity of that hand. EI #8 was asked what the potential harm was if she did not wear it. EI #8 explained that one day of wearing it may not affect her, but if she did not wear it for three or four days, that hand could stay contracted to the point that they might not be able to open it and clean it. A review of RI #10's medical record revealed there was no documentation regarding assessing or monitoring her hand splint for the entire year of 2011. On 10/06/11 at 2:30 PM, the Director of Nursing, EI #2, was asked who was responsible for monitoring to make sure RI #10's splint is applied. He said EI #7 did that and she will write a therapy screen to see if it is still appropriate. EI #2 was asked how often EI #7 should do a screen. He said once the splint is put in place, it will stay there until a problem comes up. EI #2 was informed that RI #10's splint had not been applied consistently during the survey, and there was a lack of monitoring. He said he understood.