Every finding on record at Hatley Health Care Inc

Based on record reviews, interviews, review of the State Agency's Online Incident Reporting System Report, and a facility policy Medication Administration, the facility failed to ensure licensed staff clarified medication orders for Paxlovid for Resident Identifier (RI) #182. The resident received an order for Paxlovid on [DATE], the Medication Administration Record (MAR) did not match the medication pharmacy label instructions as to give two tablets twice a day; three nurses administered the medication at the incorrect dose for two days before it was determined to be incorrect dose. This affected one of one resident reviewed for receiving Paxlovid. This deficient practice was cited as a result of investigation for complaint/number AL00042087. Findings Include: On [DATE] the facility submitted an incident through the Alabama Department of Public Health (ADPH) Online Incident Reporting System. The report of the incident documented . Name of staff member alleged to be involved: (Names of Employee Identifier's (EI) #10, EI #9 and EI #11) . Date and time of occurrence: [DATE] . Narrative summary of the incident: Resident tested positive for COVID-19 on [DATE]. On [DATE] an order for Paxlovid was written. When medication arrived from the pharmacy, the directions on the box were different from the Medication Administration Record (MAR). The above nurses failed to clarify order with pharmacy/MD. I was notified on [DATE] around 10am that resident had received incorrect doses of Paxlovid (under-dosed) from Friday-Monday. Resident on Paxlovid for COVID-19. Nurse Practitioner (NP) was made aware and saw resident at 11:33AM. Resident was sent to emergency room (ER) on [DATE] at 1pm due to decline in status. Facility received phone call on [DATE] around 2am stating that resident had expired around 12:52am. A review of the facility policy Medication Administration, dated [DATE], revealed . 11. Compare medication source (bubble pack, vial, .) with the MAR to verify resident name, medication name, form, dose, route, and time. 20. report any discrepancies to nurse manager immediately. A review of the medication order on [DATE] read Paxlovid ,d+[DATE] Milligram (mg) by mouth BID (Two times a day) x (times) 5 days (reduced dose due to CKD (chronic kidney disease)) GFR 44. This was verbal order by EI #13, the NP written by EI #8. RN. A review of the MAR revealed, Paxlovid (,d+[DATE]) Tablet Therapy Pack 10 x 150 MG & 10 x 100MG (Nimatrelvir & Ritonavir ,d+[DATE]) Give 1 tablet by mouth two times a day for COVID 19 . A review of the pharmacy label of the medication revealed, Paxlovid ,d+[DATE]MG . GIVE 2 TABLETS BY MOUTH 2 TIMES A DAY X 5 DAYS. RI #182 admitted [DATE] DX congestive heart failure, Malignant neoplasm of kidney, acquired absence of Kidney, and Pacemaker. On [DATE] at 9:03 AM an interview was conducted with EI #8, Registered Nurse (RN) who said she wrote the order but could not recall much about the resident other than what unit the resident was on and that the resident had tested positive for COVID. EI #8 said EI #13, the NP, gave the order, she wrote it as he said which was a reduced dose due to CKD. EI #8 said she did not know anything about the medication nor what a usual dose was. On [DATE] at 9:58 AM and 11:31 AM the surveyor was unable to reach EI #10, Licensed Practical Nurse (LPN), she no longer worked at the facility. EI #10 was the nurse to administer the first dose of paxlovid. On [DATE] at 10:00 AM during an interview with EI #9, LPN said she recalled RI #182's medication label on the medication was different than the MAR but was not and still not familiar with that medication. EI #9 said she gave it as the MAR directed which was one tablet two times a day. EI #9 said it was started the evening before by EI #10. EI #9 said the medication label from the Pharmacy had Paxlovid ,d+[DATE] mg give 2 tablets two times a day for 5 days. When EI #9 was asked how did she verify the medication, she said by the MAR, and she did see it said different on the medication pack but she thought since EI #10 had started it the night before she may had forgotten to place a change in directions label on the medication. EI #9 said she should have called the doctor or the pharmacy to clarify the order when it did not match. EI #9 said she did not do that because she thought EI #10 had already done that and forgot to place a label change on the package. EI #9 said she had never given paxlovid before and was not familiar with how to give it, so she gave it how it read on the MAR. EI #9 was asked what the outcome could be if the medication was not given correctly and she stated symptoms may not improve or could worsen. When EI #9 was asked what was the policy related to medication administration. EI #9 said pull up the MAR, get medication from the cart, match medication from cart to the MAR if they do not match, you should clarify any discrepancies and report it to the DON, which she did not do because she thought EI #10 forgot to change the label. On [DATE] at10:56 AM an interview was conducted with EI #15, Pharmacist. During the interview EI #15, said the order for RI #182 was paxlovid ,d+[DATE] mg twice a day for five days a reduced dose due to CKD. EI #15 said the usual dose was 300mg and 100 mg which was two tablets twice day. EI #15 said the reduced dose was ,d+[DATE] mg also two tablets twice a day for five days. On [DATE] at 11:30 AM during an interview with EI #11, LPN, she recalled RI #182 had paxlovid ordered, and the MAR had one tablet and the package had two tablets. EI #11 said in report EI #10 said it was the reduced dose to give one tablet. EI #11 said she later found out two tablets should have been given and that was the reduced dose. EI #11 said the incorrect dose was given for two days. EI #11 was asked what should she have done to make sure the correct dose was given. EI #11 said when the MAR said one tablet and package said two she should have either called the doctor or the pharmacy for clarification. EI #11 said they should follow the rules of giving medication, which were right resident, right dose, right medication. EI #11 said the concern with RI #182 not receiving the correct dose of medication was RI #182 may not have received the full dose. On [DATE] at 9:49 AM EI #12, LPN was interviewed. she said the order for paxlovid was ,d+[DATE] mg twice a day. EI #12 said she was not sure how many tablets were to be given; she recalled the package, and the MAR did not match so she notified the Director of Nursing (DON) and got clarification of the order. EI #12 said she discovered the medication had not been given as ordered when the package said give two tablets and the MAR said give one. EI #12 said this was an error because the wrong dose was given. EI #12 said the first nurse that gave the medication should have clarified the order, she was unsure who that nurse was. EI #12 was asked what was not done that may have prevented giving the incorrect dose. EI #12 said clarifying the order. On [DATE] at 2:08 PM during an interview EI #2, DON, who recalled the Paxlovid order for RI #182 was ,d+[DATE]mg by mouth twice a day for five days. She did not know the usual dose and said the order was determined by the NP and doctor. EI #2 said EI #10 noticed it Saturday morning and did not do anything to clarify the order. EI #2 said the MAR said one tablet and the package said two, the medication was supposed to be two tablets twice a day for five days. EI #2 said the concern with the Paxlovid not given as medication package directed was that the correct dose was not given for two days. EI #2 said the outcome of the investigation was the medication was ordered, two tablets should have been given, only one was given and nurses did not realize two tablets were the correct dose. The nurse entered in quantity one tablet not realizing it was to be two tablets verses one. The pharmacy did not call facility to verify two tablets verse one. It was the fault of the nurse for not clarifying when she saw one tablet on MAR and two tablets on the Pharmacy package. EI #2 said the nurse EI #10 should have clarified the order, and nurses after her that noticed it should have verified it when they noticed it too. EI #2 was asked what was the policy for staff medication administration. EI #2 said compare MAR to resident with their name, medication name, drug strength to medication package or card. EI #2 said to validate nurses should be sure right resident, right medication, and right dose. EI #2 said three nurses gave the medication without clarifying and they noticed one tablet on MAR and two tablets on medication package label. EI #2 said the medication should be validated before giving medication to a resident, and anytime they noticed a discrepancy they should verify the order. EI #2 said if the MAR and the medication label did not match the nurse should verify or clarify the order which could be done by looking in the resident chart at the orders or call the NP or doctor to get clarification. EI #2 said a concern of the nurses giving medication with the MAR and the medication package not matching would be the accurate dose could not be given.

Based on observations, interviews, review of the medical record and review of the facility policy titled, CATHETER CARE the facility failed to ensure that Resident Identifier (RI) #36's urinary catheter drainage bag was not hanging above the level of the bladder. This affected RI #36 one of two residents sampled for Catheter care. Findings include: A facility policy titled, CATHETER CARE with a revision date of 04/14/2020, revealed: . Policy: To prevent the spread of infection. To promote quality resident personal care. Policy Explanation and Compliance Guidelines: . 10. Catheter tubing should lay across the resident's leg and the bad (bag) should hang below the level of the bladder. On 06/13/2023 at 11:13 AM RI #36's urinary drainage bag was observed hooked and hanging on a cup-holder in the arm of their recliner. The drainage tubing was above the level of the bladder. On 06/13/2023 at 05:30 PM RI #36's urinary drainage bag was still hanging on the cup holder on the arm of the recliner. The tubing at the top of the drainage bag was approximately 4 inches above where the resident's bladder was as he/she was seated in the recliner seat. On 06/15/2023 at 10:56 AM an interview was conducted Employee Identifier (EI) #14, a Certified Nursing Assistant (CNA). EI #14 was asked who got RI #36 up Tuesday to the recliner. EI #14 said she did. EI #14 was asked where she hung the urinary drainage bag. She said she had threaded the tubing through his/her pants and had nowhere to hang it. EI #14 added it was supposed to be below the level of the bladder. EI #14 was asked where the urinary drainage bag should have been. She answered on the wheelchair. EI #14 was asked if the wheelchair was not there, where was the drainage bag hanging. She said on the recliner. EI #14 was asked where on the recliner. She said in the cup holder on the arm of the recliner. EI #14 was asked why she hung it in the cup holder if she knew it should be below the level of the bladder. She responded, I don't know. EI #14 was asked when the drainage bag was hanging in the cup holder, was the tubing above the level of the bladder. She said yes. EI #14 said she had hung it there before. EI #14 was asked what was the concern of the tubing to the urinary drainage bag hanging above the level of the bag. She said it may not drain or it might back up. EI #14 was asked what was the concern of the urine not draining or maybe backing up. She said an infection can happen. On 06/15/2023 at 12:08 PM an interview was conducted with EI #9, the Licensed Practical Nurse (LPN) for RI #36 on Tuesday 6/13/2023. EI #9 was asked on Tuesday when she observed RI #36 in his/her recliner, where was the urinary drainage bag hanging. EI #9 said the cupholder on the arm of his/her recliner. EI #9 was asked who identified the drainage bag was hanging in the cupholder on the arm of RI #36's recliner. EI #9 said she went in to help rehab (rehabilitation) staff that was helping the resident that day. She said that she took it off of the cup-holder on the arm of the recliner and lowered it to the side of the wheelchair. EI #9 was asked why she lowered it. She said she saw that it was high up above the bladder and knew it needed to go down. EI #9 was asked why it needed to be lowered. She said so it would drain and empty the bladder. EI #9 was asked what was the concern of the urinary drainage bag tubing being above the level of RI #36's bladder for over 6 hours. She said no drainage, the risk of holding the urine in that bladder and risk for a Urinary Tract Infection. On 06/15/23 at 2:01 PM an interview was conducted with EI #2, the Director of Nursing. EI #2 was asked what was the concern of the urinary drainage bag tubing being above the level of the bladder. She answered it could cause back-flow of urine back into the bladder and potentially cause a Urinary Tract Infection.

Based on observations, interviews, the Nursing Home Residents' Rights from the facility's admission packet, and the facility's policies for SERVING OF MEALS POLICY and RESIDENT DINING POLICY; the facility failed to ensure resident dignity by regularly serving meals on disposable dinnerware with disposable cutlery. This affected Resident Identifier (RI) #39 and RI #64 and had the potential to affect 81 of 81 residents receiving meals in the facility. Findings include: Nursing Home Residents' Rights, undated, from the facility's admission packet included the following: Residents of nursing homes have rights that are guaranteed to them under Federal and State laws. The laws require nursing homes to treat each resident with dignity and respect and care for each resident in an environment that promotes and protects their rights. Right to a Dignified Existence * Be treated with consideration, respect and dignity, recognizing each resident's individuality, wishes and preferences . * Quality of life is maintained or improved . * A home-like environment . * Equal access to quality care . The facility's SERVING OF MEALS POLICY, dated May 2003, included the following: Purpose: . To enhance the resident's quality of life. The facility's RESIDENT DINING POLICY, dated 3/30/2016, included the following: Purpose: To provide an environment that promotes a pleasant dining experience, . I. Environment . 9. Plastic silverware will be used for residents of Memory Lane (A-Wing/Dementia Unit) for safety. Interdisciplinary team will discuss and review appropriate use of plastic silverware for any resident outside of Memory Lane. Dining observations for lunch on 06/13/2023 included the following: At 11:13 AM, unit staff were observed passing trays to residents. The lunch meals were served in Styrofoam dinnerware. General interviews revealed Styrofoam dinnerware had been used for a while. At 11:39 AM, observed all residents on A-Wing were served on Styrofoam dinnerware. An observation of the resident tray line for supper on 06/13/2023 beginning at 4:50 PM revealed the following: Puree Banana Pudding, Puree Bread, and Regular Banana Pudding were all portioned in Styrofoam cups with plastic lids. At 5:01 PM, Foodservice staff were on the tray line preparing meals to be served in Styrofoam clam shells with plastic silverware wrapped in a paper napkin. Three people were serving on the tray line: two on hot line and one on cold line. The first person on the hot line was the starter: getting the Styrofoam containers and serving alternate meal items and puree trays. The second person served all remaining hot food items. The third person placed desserts, puree bread, water, and tea on the trays and then placed trays in the insulated cart for delivery to the floor (Wing/Unit/Hall). Observed an Alternative Meal prepared for service in Styrofoam Clam Shell with a Styrofoam cup with plastic lid. Observed a Chopped Mechanical Meal prepared for service in Styrofoam Clam Shell with a Styrofoam cup with plastic lid. Observed a Regular Meal prepared for service in Styrofoam Clam Shell with a Styrafoam cup with a plastic lid. Observed a Puree Meal prepared for service in Styrofoam Clam Shell with a Styrofoam cup with a plastic lid. Dining observations for lunch on 06/14/2023 included the following: At 11:05 AM, Dietary staff observed on tray line assembling trays with Styrofoam clam shell containers. At 11:09 AM, RI #19 was observed in his/her room eating lunch from a Styrofoam container. At 11:28 AM, residents on A-Wing were all observed to be served lunch on Styrofoam dinnerware. RI #39 was readmitted to the facility on [DATE] with a diagnosis of Depression. On 06/13/2023 at 11:38 AM, RI #39 was observed eating lunch, while in bed with the head of bed up. The meal was served in a hinged Styrofoam container. On 06/14/2023 at 8:10 AM, RI #39 was observed in bed with the breakfast tray on top of the over bed table in front of the resident. The meal was served in a hinged Styrofoam container. RI #39 said he/she had been eating off of Styrofoam ever since he/she had been at facility. When asked how did that make him/her feel, RI #39 stated he/she did not like it. RI #39 said his/her preference was eating food off of a regular plate. RI #39 said no one had ever asked him/her the type of plate he/she would like to eat off of. RI #64 was admitted to the facility on [DATE] with a diagnosis of depression. On 06/13/2023 at 5:22 PM, the resident was asked how long meals had been served on Styrofoam plates and cups with disposable silverware. RI #64 said it had been a while, since he/she has been here. RI #64 said he/she had been served food on plates with silverware a couple of times. When asked which would he/she prefer to be served on, Styrofoam plates or real plates (China), RI #64 said it would be nice to have real silverware and plates. Upon being asked if he/she had told anyone about his/her preference, RI #64 said they know about it. On 06/14/2023 at 11:38 AM, RI #64's lunch meal was served on Styrofoam dinnerware with disposable silverware. On 06/14/2023 at 9:46 AM, it was noted that C-wing had no residents. On 06/15/2023 at 11:18 AM, the Director of Nursing, Employee Identifier (EI) #2, was interviewed. EI #2 was asked why were disposable silverware/flatware (plastic knives, forks, and spoons) and dinnerware (Styrofoam clam shells, cups, and bowls) being used for all resident meals. EI #2 said it went back to COVID, short staffing, and staff leaving. EI #2 said we probably started around March or April 2020. Upon being asked when COVID started to decline in the facility and restrictions were lifted, EI #2 said we stopped screening visitors and employees in April 2023 and the last COVID case was at least a few months ago. EI #2 said the concerns with using Styrofoam were that the food may get cold or soggy. EI #2 said disposable dinnerware and flatware did not create a homelike environment for the residents. n 06/15/23 at 11:34 AM, the Administrator, EI #1, was interviewed. EI #1 was asked how long disposable dinnerware and flatware had been continuously used for resident meals. EI #1 said since COVID. EI #1 said we used normal plates until August 2020 and at the first COVID case we started using disposable. Upon being asked what the concerns would be for residents repeatedly receiving meals served with disposable flatware and dinnerware; EI #1 said it could be a home-like environment issue and someone could say a dignity issue.

Based on observation, interview, NURSING HOME RESIDENTS' RIGHTS from the facility's admission packet, and the facility's policies for RESIDENT DINING and SERVING OF MEALS; the facility failed to ensure a homelike environment by not regularly providing a communal dining experience for residents. This had the potential to affect 81 of 81 residents receiving meals in the facility. Findings include: NURSING HOME RESIDENTS' RIGHTS, undated, from the facility's admission packet included the following: Residents of nursing homes have rights that are guaranteed to them under Federal and State laws. The laws require nursing homes to treat each resident with dignity and respect and care for each resident in an environment that promotes and protects their rights. Right to a Dignified Existence * Be treated with consideration, respect and dignity, recognizing each resident's individuality, wishes and preferences . * Quality of life is maintained or improved . * A home-like environment . * Equal access to quality care . The facility's SERVING OF MEALS POLICY, dated May 2003, included the following: Purpose: To ensure that each resident is served each meal in a timely manner. To enhance the resident's quality of life. 1. Residents scheduled to eat in the dining room will be served first . 2. Residents not scheduled to eat in the dining room must wait for their tray until all scheduled residents are served. The facility's RESIDENT DINING POLICY, dated 3/30/2016, included the following: Purpose: To provide an environment that promotes a pleasant dining experience, to promote an enhanced nutritional status for all residents, to provide quality care to enhance the resident's quality of care. I. Environment . 5. Residents should be seated at tables with friends, residents with similar mental status, . During the initial kitchen tour on 06/13/2023 at 11:25 AM, Employee Identifier (EI) #4, the Registered Dietitian (RD), was asked about residents' dining times. EI #4 stated they were not serving dining room meals, just meals in the room. Dining observations for lunch on 06/13/2023 included the following: At 11:13 AM, staff was observed passing trays. No residents took meals in the dining rooms. At 11:39 AM, no residents were observed to be served lunch in the A-Wing dining room. At 5:15 PM, supper service was observed. No residents ate the supper meal in the dining rooms. On 06/14/2023 at 9:46 AM, it was noted that C-wing had no residents. A Resident Council Meeting was held on 06/14/2023 at 10:00 AM with seven members present. All the residents said they eat meals in their rooms and none of them could ever remember eating a meal in the dining room. Dining observations for lunch on 06/14/2023 included the following: At 11:02 AM, the main dining room on B-wing was observed. No residents were present in the dining room. The dining room contained 14 square tables with 21 chairs. At 11:08 AM, D-Wing (600,700, and 800 room numbers) was observed. At 11:09 AM on D-Wing, Resident Identifier (RI) #19 was seen in his/her room eating lunch on side of the bed. RI #19 was eating independently and alone in a quiet room. At 11:11 AM on D-Wing, RI #8 was observed in a wheelchair in his/her room eating independently and alone. At 11:12 AM on D-Wing, RI #70 was observed in a chair in his/her room eating independently and alone in a quiet room. At 11:14 AM, the D-Wing dining room was observed to be empty of residents and the lights were turned off. The dining room contained six square tables, ten chairs, a piano, a television, and four large windows. At 11:17 AM on D-Wing, RI #50 was observed in a chair in his/her room eating lunch alone with the television on. At 11:24 AM, the dining room on A-Wing (Memory Care) was observed. The dining room was empty of residents and the lights were turned off. The dining room included four square tables and three windows. At 11:28 AM on A-Wing, a staff member was heard to say to RI #45, (Name of RI #45) it is time for lunch. RI #45 asked the staff member, Where are we eating at? The staff member responded, In your room. The staff member assisted RI #45 to his/her room. Dining observations for supper on 06/14/2023 included the following: At 4:47 PM, no residents were present in the main dining room on B-wing for dinner. At 4:50 PM, the D-Wing was observed with two staff members passing out dinner trays from a food cart in the hallway and a third staff member pushing the food cart. RI #36 was observed in his/her room eating independently after set-up. At 4:55 PM, the D-Wing dining room was observed. The dining room was empty of residents with the door open and the lights off. Three male residents were in hallway socializing with one another by the dining room. Observed staff serving meals to resident rooms. At 5:03 PM, the A-Wing dining room was observed with the door closed. On 06/15/2023 at 11:18 AM, the Director of Nursing, EI #2, was interviewed. EI #2 said we had residents eat in their rooms when COVID came along; then we had some staffing issues for a while. EI #2 said we plan to start getting them back in the dining room now that COVID is over. EI #2 did not have any documentation of meetings or plans to resume resident dining room meals. EI #2 said they were getting staff levels back up and that staffing was not an issue for resident dining room meals. EI #2 said psychosocial issues were a concern when residents are limited to eating meals in their room. EI #2 said the advantage to residents eating in the dining rooms was more socialization. EI #2 further said she would not expect the residents to always eat in their rooms. Upon being asked when COVID start to decline in the facility and restrictions were lifted, EI #2 said we stopped screening visitors and employees in April 2023 and the last COVID case was at least a few months ago. On 06/15/23 at 11:34 AM, the Administrator, EI #1, was interviewed. EI #1 said isolation, depression, and lack of social interaction would be the concerns for residents limited to eating meals in their rooms. EI #1 further said social activity and social interaction would be the advantages to residents eating in the dining rooms. On 06/15/23 at 2:22 PM, the Dietary Manager, EI #3, was interviewed. When asked how he was notified of residents who were scheduled to eat in the dining room, EI #3 said he was not. EI #3 said I really do not know where they are eating; we just send the carts down to the hall. EI #3 further said we have five carts; three go to D-Wing and two go to A-Wing. EI #3 said the trays are organized by room numbers for service on halls.

Based on interviews and review of facility policy titled, [NAME] HEALTH CARE NARCOTIC POLICY, the facility failed to ensure Employee Identifier (EI) #3 gave Resident Identifier (RI) #1's [MEDICATION(S)] and [MEDICATION(S)] as ordered by the physician. This had the potential to affect one of six residents sampled. Findings Include: A review of facility policy titled, [NAME] HEALTH CARE NARCOTIC POLICY, dated 1/02/2014 that revealed the following: PURPOSE: To provide an accurate count of the narcotic, . 6. The charge nurse must sign the book at the time the narcotic is removed from the locked box . The surveyor conducted an interview on 9/08/2021 at 4:09 p.m., with (EI) #2, Director of Nursing (DON). During the interview EI #2 stated EI #4, Licensed Practical Nurse (LPN) reported to the facility on [DATE] that on 8/02/2021 when she was counting narcotics with EI #3, LPN there was one less count showing on the medication narcotic sheet then in the bubble pack. EI #2 stated EI #4 said this was RI #1's [MEDICATION(S)] and [MEDICATION(S)]. EI #2 stated EI #4 said EI #3 realized this and just popped the medications out of the bubble pack and put them into the sharp's container. EI #2 stated this happened on 8/02/2021 between 6:30 - 6:45 p.m. but was not reported until 8/03/2021 at 7:30 a.m. EI #2 was asked what was the potential harm and she stated that RI #1 had a breakthrough [CONDITION(S)] that night. EI #2 stated RI #1 was sent out on 8/02/2021 at approximately 10:00 p.m. and returned on 8/03/2021 (the next morning) approximately 5:30 a.m. The surveyor conducted an interview with EI #3 on 9/08/2021 at 5:08 p.m. At this time, EI #3 stated after signing off the narcotic sheet she did not pull the medications ([MEDICATION(S)] and [MEDICATION(S)]), she got sidetracked. EI #3 stated she never gave the medications. She stated she saw the medications still in the bubble pack at the end of the shift, so she popped them out and discarded them into the sharp's container. EI #3 stated the facility's policy on discarding narcotics was to discard with two nurses and each nurse had to sign the back of the narcotic sheet. EI #3 stated the concerns when a resident's medications are discarded into a sharps container instead of giving it to the resident, if it was a narcotic someone could get it out of the sharp's container and if it was a [CONDITION(S)] medication the resident could have a [CONDITION(S)]. The surveyor conducted an interview with EI #4 on 9/09/2021 at 8:30 a.m. EI #4 stated she witnessed EI #3 discard RI #1's [MEDICATION(S)] and [MEDICATION(S)] into the sharp's container. EI #4 stated when EI #3 found the medication error she did not say anything to her, EI #3 just popped the medication out of the card, put the pills into the sharps container and continued to count the cards. EI #4 stated it appears that RI #1 did miss a dose of his/her [MEDICATION(S)] and [MEDICATION(S)] because of this incident.

Based on interviews and a review of the facility policy titled, [NAME] HEALTH CARE NARCOTIC POLICY, the facility failed to ensure Resident Identifier (RI) #1's medical doctor and sponsor were notified when the resident's 8:00 a.m. dosage of [MEDICATION(S)] and [MEDICATION(S)] were not given on 8/02/2021. This deficient practice had the potential to affect one out of six residents sampled. Findings Include: A review of a policy titled, [NAME] HEALTH CARE NARCOTIC POLICY, dated 1/02/2014, revealed the following: . ***Any discrepancy in the narcotic count must be immediately reported to the Supervisor. The Supervisor will report the discrepancy to the DON and ADON . RI #1 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The surveyor conducted an interview with EI #2, Director of Nursing (DON) on 9/08/2021 at 4:09 p.m. EI #2 stated the incident happened on 8/02/2021 between 6:30 and 6:45 p.m. EI #2 stated EI #4 had delayed reporting the incident. EI #2 stated EI #4 should have called the doctor and received whatever instructions were needed to monitor the resident. The surveyor conducted an interview with Employee Identifier (EI) #3 on 9/08/2021 at 5:08 p.m. EI #3, Licensed Practical Nurse (LPN) was asked why she did not give RI #1's [MEDICATION(S)] and [MEDICATION(S)]. EI #3 stated she did not know, she got sidetracked. EI #3 was asked who she reported the incident to, and she stated she should have called the doctor. EI #3 stated she did not know why she did not notify the doctor. EI #3 was asked if she notified the sponsor and she stated no, she did not notify RI #1's sponsor either. EI #3 stated she was aware of RI #1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The surveyor conducted an interview with EI #4, LPN on 9/09/2021 at 8:30 a.m. EI #4 stated she should have notified the doctor whenever the error was found. EI #4 stated the doctor could have told her what could have been done and maybe a breakthrough [CONDITION(S)] could have been prevented. The surveyor conducted an interview on 9/09/2021 at 11:41 a.m. with EI #5, Certified Registered Nurse Practitioner (CRNP). EI #5 stated he was notified that RI #1 was sent out on 8/02/2021 around 10 p.m. for having [CONDITION(S)] like activity but was not told until the next morning that RI #1 had missed a dose of the medications ([MEDICATION(S)] and [MEDICATION(S)]). The EI #5 stated he should have been notified when the nurse realized RI #1 missed their medications. EI #5 stated when he found out about the missing medications the resident had already been sent out to the hospital. The surveyor conducted an interview with RI #1's Sponsor on 9/09/2021 at 12:02 p.m. The Sponsor stated the facility did not notify him/her until the afternoon of 8/3/21 that RI #1's [MEDICATION(S)] and [MEDICATION(S)] had been missed. The surveyor conducted an interview on 9/09/2021 at 5:03 p.m. with EI #1, Medical Director. RI #1 stated he should have been notified at the point when the error happened. RI #1 stated he could have gone from there to give instructions on what to do. RI #1 stated if he had been notified, he would have given instructions according to the medication missed, the resident's condition, labs results of liver and kidney functions, and blood levels of [CONDITION(S)] medication.

Based on observation, interviews and a review of a facility policy titled, Infection Prevention and Control Program, the facility failed to ensure EI (Employee Identifier) #4 folding laundry, did not allow the laundry to touch the floor or her clothing. This affected 1 of 1 laundry staff observed folding clean laundry. Findings include: A facility policy titled, Infection Prevention and Control Program, date implemented, 11/28/17, revealed, Policy: It is a policy of this facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Policy Explanation and Compliance Guidelines: .10. Linens: a. Laundry and direct care staff shall handle, store, process and transport linens so as to prevent spread of infection. d. Never place linen on floor . An observation was made on 05/09/19 at 10:11 a.m. of the laundry area. EI #4 was observed folding sheets, gowns, and under pads. Two sheets were observed touching the floor while being folded. Multiple sheets, gowns and under pads were observed touching EI #4 's clothing as he/she folded. On 05/09/19 at 10:38 AM, an interview was conducted with EI #4 , laundry staff. EI #4 was asked, should laundry touch your clothing while folding. EI #4 replied, she did not think so. EI #4 was asked, should the laundry touch the floor while folding. EI #4 replied, no. EI #4 was asked, did the laundry touch her clothing, or the floor, when she was folding clothes. EI #4 replied, if so, it was by accident, the fans were blowing everywhere. EI #4 was asked, where was that load of laundry going, that she was folding. EI #4 replied, each wing, it was divided up. EI #4 was asked, what was the potential concern of the laundry touching she clothing or touching the floor. EI #4 replied, it would be considered dirty. On 05/09/19 at 10:48 AM, an interview was conducted with EI #3 Assistant Director Of Nursing (ADON)/ Infection Control. EI #3 was asked, should laundry touch the floor while being folded. EI #3 replied, no. EI #3 was asked, should laundry touch an employee's clothing while being folded. EI #3 replied, no. EI #3 was asked, what was the potential concern of the laundry touching the floor or the employee's clothing. EI #3 replied, infection control.

Based on a review of a facility policies titled, STORAGE OF MEDICATIONS AND BIOLOGICALS and CONTROLLED MEDICATION STORAGE, observations and interviews, the facility failed to ensure: 1. the A Wing medication storage room / cabinet did not contain expired medications, including five unopened bags of normal saline intravenous fluids, along with eight other medication including creams, ointments, gel, liquid and tablets and 2. the Medication Cart for the 600 hall did not include a medication (narcotic) labeled with an unreadable expiration (discard) date. This affected one of two medication rooms observed and one of four medication carts observed. Findings include 1. A review of the facility's policy titled, 3.1: STORAGE OF MEDICATIONS AND BIOLOGICALS, with a date of 3/11, revealed: . Procedure . 11. Outdated, contaminated, or deteriorated medications and . are removed from stock, disposed of according to procedures for medication disposal, . The Surveyor reviewed another facility policy titled, 4.3: Disposal of Medication Non-Controlled Medication Destruction, with a date of 3/11, . Policy . expired medications, .are destroyed or disposed of per federal/state regulations. On 05/08/19 at 04:29 pm, the Surveyor observed, with Employee Identifier (EI) # 5, the A Wing Medication Storage Room. Observations were made of the following items: One of the lower cabinets contained a paper bag with expired intravenous fluids (see the expiration dates below). The Surveyor observed with EI# 5, a total of five unopened bags of normal saline 0.9 Sodium Chloride injection, labeled for a resident,t one bag with an expiration of [DATE] (YEAR), one bag with an expiration date of (MONTH) (YEAR) and three bags with an expiration date of (MONTH) (YEAR). The Surveyor also observed, with EI# 5, an upper cabinet containing the following: 1. one opened bottle of Icy Hot Arthritis pain relief lotion 5.5 ounces with a handwritten first name on it, expired 6/14; 2. one opened tube of Preparation H ointment 2 ounces with Resident Identifier # 32 hand written name on it, expired 6/2017; 3. one opened tube of Capzasin HP Arthritis Pain relief topical [MEDICATION NAME] cream 1.5 ounces, expired 7/17; 4. one opened tube of Risamine Ointment with a label for a resident, expired 3/18; 5. one opened [MEDICATION NAME] 1 percent Iodoquinol 1 percent cream with label for a resident, expired 7/17; 6. one opened bottle of Allergy Tablets [MEDICATION NAME] 4 mg tablets 1000 tablets with a resident's name hand written on it expires 3/18; 7. one opened bottle of Pepto Bismol Max [MEDICATION NAME] 4 ounce bottle, expired 2/16 and 8. one tube of [MEDICATION NAME] maximum tooth ache get unopened instant pain relief .42 ounces, expired (YEAR), with a resident's name handwritten on the box. On 05/08/19 at 05:37 pm, the Surveyor interviewed EI #5. EI #5 was asked if she observed expired intravenous fluids with the surveyor in the Medication Storage Room cabinet. EI # 5 replied, yes ma'am. She was asked, how many bags of expired fluids were in the cabinet. EI# 5 replied, to be honest it was four or five. EI #5 was asked, did she observe eight medications including, tubes of ointments,creams, lotion, liquid medication and tablets that had expired, with the surveyor in the medication storage room cabinet. EI#5 replied, yes ma'am. She was asked, what was the facility policy regarding expired medication in the medication storage room/cabinet. EI# 5 replied, expired medications are supposed to be turned in to the Director Of Nursing (DON) to be destroyed. EI #5 was asked, according to the policy what was the correct time frame expired medication should be turned in to the DON. EI# 5 replied, she could not tell the exact time frame, but in a timely manner. EI #5 was asked, what was the potential harm for having expired medications including, intravenous fluids, creams, liquids and tablets in the medication storage room cabinets. EI# 5 replied, the potential harm was it could be used on another resident. 2. A review for the facility policy titled, 3.2 CONTROLLED MEDICATION STORAGE revealed: . 10. Controlled medication expiration dates and storage dates are periodically monitored by the consultant staff. On 05/08/19 at 08:38 am, the Surveyor observed with EI# 6, the Medication Cart for the 600 hall and found: 1. Label -Resident # 92 [MEDICATION NAME] 0.5 mg total 27 verified, 3/8/19 date on top right corner of the label. Part of the label was cut off bottom of card, was unreadable. The Surveyor and EI #6 were unable to read the Discard after date. The Surveyor asked EI #6 how did she know what the expiration date was for that medication. EI# 6 replied, you don't positively know. On 05/09/19 at 08:10 am, the Surveyor interviewed EI# 6. EI #6 was asked, on (MONTH) 8th 2019 did she observe an [MEDICATION NAME] card of medication that had an unreadable discard date, on the medication cart in the locked narcotic box. EI# 6 replied, yes she did and she did correct that. EI #6 was asked was medication signed out off on the card that had an unreadable expiration date. EI# 6 replied, yes there were three or four of them. EI #6 was asked what was the potential harm with a medication on the cart with an unreadable expiration date. EI# 6 replied, it could have been expired, the medication strength may not have been as potent. And EI# 6 continued, they should not be giving out dated medications.

Based on interviews, medical record reviews, review of facility policies titled, ABUSE, NEGLECT AND EXPLOITATION and REPORTING ALLEGATIONS OF ABUSE, NEGLECT AND EXPLOITATION and review of a document titled, Alabama Department of Public Health Online Incident Reporting System, the facility failed to timely report 13 allegations of abuse to the State Agency after the incidents occurred. This affected 14 of 71 facility reported incidents that were reviewed and affected Resident Identifier's (RI) #434, #74, #79, #47, #8, #69, #115, #22, #21, #104, #46, #38, #109, #70 and two unsampled, discharged residents. Findings Include: A review of the facility policy titled ABUSE, NEGLECT AND EXPLOITATION, with no date, revealed the following: .The facility must: .13. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: a. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, . A review of the facility's policy titled, REPORTING ALLEGATIONS OF ABUSE, NEGLECT AND EXPLOITATION, with no date, documented: Policy: It is the policy of this facility to report all allegations of abuse/neglect/exploitation to appropriate agencies in accordance with current state and federal regulations. Review of the Alabama Department of Public Health Online Incident Reporting System, revealed the following: 1) An incident of mistreatment was reported by a Certified Nursing Assistant (CNA), regarding another CNA being abnormally rough with Resident Identifier (RI) #434 on 04/25/2019 at 10:30 AM. This incident was not reported to the State Agency until 04/25/2019 at 3:29 PM. 2) An incident of verbal abuse was reported occurring on 01/12/2019 at 6:57 PM where RI #79 was fussing at other residents and staff and RI #74 threatened to kill RI #79. This incident was not reported to the State Agency until 01/14/2019 at 8:04 AM. 3) An incident of physical abuse was reported occurring on 01/08/2019 at 10:00 AM where RI #47 reported that a CNA, was rough and jerked RI #47 in the bathroom. This incident was not reported to the State Agency until 01/09/19 at 1:37 PM. 4) An incident of physical abuse was reported occurring when RI #8 reported that a CNA, was rough when giving a shower on 11/22/2018 at 5:00 p.m. This incident was not reported to the State Agency until 11/23/2018 at 10:02 AM. 5) An incident of physical abuse was reported occurring on 10/31/18 at 5:54 PM where RI #115 hit RI #69 on the shoulder and RI #69 pushed RI #115 onto the bed. This incident was not reported to the State Agency until 11/01/18 at 7:22 AM. 6) An incident of neglect was reported occurring on 10/31/18 at 6:00 PM where a CNA, refused to change RI #22 and talked hateful to RI #22. This incident was not reported to the State Agency until 11/01/18 at 9:02 AM. 7) An incident of physical abuse was reported occurring on 10/30/18 at 8:30 PM where RI #104 stated that RI #21 grabbed and bent his/her hand back. This incident was not reported to the State Agency until 10/31/18 at 7:36 AM. 8) An incident of physical abuse was reported occurring on 10/30/18 at 8:30 PM where RI #115 went up to RI #79 and started slapping RI #79's hands. This incident was not reported to the State Agency until 10/31/18 at 7:47 AM. 9) An incident of physical abuse was reported occurring on 10/27/18 at 5:00 PM where RI #115 walked into RI #46's room and hit RI #46 on the left shoulder. This incident was not reported to the State Agency until 10/29/18 at 7:08 AM. 10) An incident of physical abuse was reported occurring on 10/23/18 at 12:00 AM where RI #38 went into RI #46's room and RI #46 twisted RI #38's arm. This incident was not reported to the State Agency until 10/25/18 at 4:27 PM. 11) An incident of physical abuse was reported occurring on 09/16/18 at 8:45 AM where RI #79 came around the corner of the nurse's station where RI #109 was sitting in a wheelchair and RI #109 kicked RI #79's wheelchair and RI #79 grabbed RI #109's lower leg and squeezed it. This incident was not reported to the State Agency until 09/16/18 at 2:31 PM. 12) an incident of physical abuse on 09/10/18 at 1:15 PM where a unsampled, discharged resident came in to the activity room and tapped RI #70 on the arm and told RI #70 to move because it was his/her spot. This incident was not reported until 09/12/18 at 1:43 PM, 13) An incident of injuries of unknown source was identified on 08/28/18 at 9:30 PM when RI #88 was noted to be guarding his/her right arm per EI #12, Licensed Practical Nurse (LPN), and xrays revealed a [MEDICAL CONDITION] distal humerus and elbow joint. The incident was not reported to the State Agency until 08/29/18 at 12:26 PM. 14) An incident of physical abuse was reported occurring on 07/14/18 at 10:00 PM where another unsampled, discharged resident complained that RI #69 (spouse) was hitting him/her in the chest. This incident was not reported to the State Agency until 07/15/18 at 6:16 AM. On 05/09/19 at 2:45 p.m., an interview was conducted with EI #2, Registered Nurse (RN)/Assistant Director of Nursing (ADON)Abuse Coordinator. EI #2 was asked, when should an allegation of abuse be reported to the State Agency. EI #2 said within two hours. EI #2 was then asked to individually review the 14 incidents listed and asked whether they were reported to the State Agency within the designated two hour time frame. EI #2 answered no, to all 14 incidents and explained that some of the incidents had been slid underneath her office door and she found them on her return to work. She further stated that she had found one of the incidents written on a 24 hour report form. On 05/09/19 at 4:08 p.m., an interview was conducted with EI #1, Administrator. EI #1 was asked if he had been made aware of the facility not reporting incidents timely to the State Agency. EI #1 said yes. EI #1 was asked what was the reason identified for the reports being submitted late. EI #1 stated they had been doing education with the employees identified for not reporting timely and that all employees receive abuse training twice a year. This citation resulted from the investigation of complaint/report # AL 246.

Based on observation, interview and a review of the (YEAR) Food Code U.S. (United States) Public Health Service FDA (Food and Drug Administration), the facility failed to ensure the dumpster lid was closed. This was observed on 05/10/18. This has the potential to affect all 132 residents residing in the facility. Findings Include: A review of the (YEAR) Food Code, revealed: . 5-501.15 Outside Receptacles. (A) Receptacles and waste handling units for REFUSE, recyclables, and returnables 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. On 05/08/18 at 5:09 p.m., the surveyor along with (Employee Identifier) EI #23, a dietary aide, toured the outside area of the kitchen. The first dumpster had the lid completely open. The second one had an one inch gap between the lids. On 05/10/18 at 1:03 p.m., an interview was conducted with EI #23. EI #23 was asked what did she observe when going out to the dumpster. EI #23 replied, the first dumpster lid was open. EI #23 was asked what did she observe about the second dumpster. EI #23 replied, it had a space between the lids. EI #23 was asked who was responsible for keeping the dumpster lids closed. EI #23 replied, the first dumpster, the kitchen. EI #23 was asked what did the facility's policy say regarding the dumpster. EI #23 replied, they were suppose to be closed after each use. EI #23 was asked what was the potential harm when the dumpster lid was not closed. EI #23 replied, a racoon or something could get in the dumpster.

Based on observations, interviews and review of facility policies titled, Equipment, Food Storage: Dry Goods, Service Line Checklist, Food: Preparation, and Staff Attire and review of the (YEAR) Food Code U.S. (United States) Public Health Service FDA (Food and Drug Administration), the facility failed to ensure: 1) a stored blender was free of debris; 2) food items in the dry storage area was sealed; 3) temperatures of all food items on the trayline were taken; and 4) dietary workers hair was completely enclosed in their hairnets and strains of loose hair was not on the back of a dietary worker's shirt. This had the potential to affect 131 of 132 residents who received meals from the kitchen. Findings Include: 1) A review of a facility policy titled, Equipment, with a revised date of 09/17, revealed: Policy Statement All food service equipment will be clean, sanitary . Procedures . 3. All food contact equipment will be cleaned and sanitized after every use. A review of the (YEAR) Food Code, revealed: . 4-701.10 Food Contact Surfaces . Equipment Food-Contact Surfaces . shall be SANITIZED. 4-702.11 Before use After Cleaning. FOOD-CONTACT SURFACES of EQUIPMENT shall be SANITIZED Before Use after cleaning. On 05/08/18 at 4:57 p.m., the surveyor observed powdered sugar and icing located on the bowl holder and on the back plate of the mixer. The mixer was stored away under a plastic covering to be used again. There was chocolate icing on the bag that covered the mixer. On 5/10/18 at 1:13 p.m., an interview was conducted with (Employee Identifier) EI #23, a Dietary Aide. EI #23 was asked what did she see on the mixer on 05/08/18. EI #23 replied, powdered sugar. EI #23 was asked was it put away for next use. EI #23 replied, yes ma'am. EI #23 was asked, who was responsible for making sure equipment was clean before covering it up. EI #23 replied, the last person who used it. EI #23 was asked why was it important that equipment was clean when putting it away. EI #23 replied, everything was suppose to be sanitized. EI #23 was asked, what was the facility's policy on cleaning equipment. EI #23 replied, clean the work area when finished. 2) A review of a facility policy titled, Food Storage: Dry Goods, with a revised date of 09/17 revealed: . Procedures . 5. All packaged . food items will be kept clean, dry and properly sealed. 6. Storage area will be . arranged for easy identification, and date marked as appropriate. On 05/08/18 at 4:24 p.m., the surveyor toured the storage area along with EI #23. Pure cane sugar was in a large zip lock bag and the zip lock bag was not sealed. The open date was 04/19/18, but no use by date was observed. There was a large zip lock bag with cake mix in it. The open date was 05/03/18 but no use by date was observed and the the zip lock bag was not sealed. There was a large bag of Rottini noodles opened on 03/21/18. The noodles were tied, but there was a large hole at the opening of the bag exposing the noodles and there was no use by date. On 05/10/18 at 1:18 p.m., an interview was conducted with EI #23. EI #23 was asked while touring the dry storage area what did she notice about the cake mix, bag of sugar and Rottini noodles. EI #23 replied, they were all opened. EI #23 was asked how should opened food be properly stored. EI #23 replied, in a sealed bag. EI #23 was asked what was the problem with leaving opened food items exposed or unsealed. EI #23 replied, it could cause bugs and was unsanitary. EI #23 was asked who was responsible for making sure food was stored properly. EI #23 replied, the person that used it last. 3) A review of a facility document titled, Service Line Checklist, with a date of 05/09/18, revealed during the lunch meal, no temperature of the main meat, (chicken) was taken and recorded. A review of a document titled, Food: Preparation, with a revised date of 9/17, revealed: . Procedures . 13. All foods will be held at appropriate temperatures, greater than 135 F (Fahrenheit) .14. Temperature for TCS (Time Temperature Control for Safety) foods will be recorded at time of service . On 05/09/18 at 10:25 a.m., during the lunch meal trayline, the surveyor observed EI #18, the Dietary Aide, taking temperatures on the trayline. All temperatures of the food were taken and written down except the temperature of the fried chicken. On 05/10/18 at 1:27 p.m., the surveyor conducted an interview with EI #18. EI #18 was asked, who was responsible for taking temperatures on the tray line. EI #18 replied, the head cook. EI #18 was asked what did the facility policy say about taking food temperatures on the tray line. EI #18 replied, take the temperature of food once it was put on the tray line. EI #18 was asked why should food temperatures be taken on the tray line. EI #18 replied, to make sure it was above the temperature danger zone. EI #18 was asked when should food temperature be taken on the tray line. EI #18 replied, once the food was set up, and right before you start serving. EI #18 was asked what was the potential harm when food items were not taken on the tray line. EI #18 replied, she had to make sure it was above the danger zone because if it was below it could grow bacteria. EI #18 was asked did she take the temperature of the chicken on 05/09/18. EI #18 replied, no ma'am. EI #18 said she over looked that one. EI #18 was asked where was it documented that she took the temperature of the chicken on the tray line. EI #18 said that it was not on there (menu log) On 05/10/18 at 1:40 p.m., an interview was conducted with EI #17, the Kitchen Manager. EI #17 was asked who was responsible for taking the temperatures on the trayline. EI #17 replied, the head cook. EI #17 was asked what did the facility's policy say about taking temperatures of food items on the tray line. EI #17 replied, TCS foods would be recorded at time of service. EI #17 was asked where was it documented. EI #17 replied, it was not. EI #17 said the square was empty, referring to the lunch menu log. 4) A review of a facility policy titled, Staff Attire, with a revised date of 9/17, revealed: . Procedures 1. All staff members will have their hair off the shoulder, confined in a hair net or cap . On 05/09/18 at 11:07 a.m., the surveyor observed three Dietary Aides, EI #16, 21 and 22, at the tray line with hair coming out of their nets. EI #16's hair was touching the top of her clothing. Some of her hair had broken off and was on the back of her top. EI #17, hair was hanging out at the back of her hair net. On 05/10/18 at 1:33 p.m., the surveyor conducted an interview with EI #17. EI #17 was asked who should wear hairnets. EI #17 replied, every body in the kitchen. EI #17 was asked, when should a hairnet be worn. EI #17 replied, anytime in the kitchen, and around the food production area. EI #17 was asked how should a hairnet be properly worn. EI #17 replied, pulled down with the hair pulled in. EI #17 was asked what was the problem with hair hanging out of the net. EI #17 replied, it had the potential for hair to fall into the food. EI #17 was asked was there hair on the back of a worker's clothing. EI #17 replied, yes. EI #17 was asked which dietary workers hair was not completely enclosed within their hairnet. EI #17 replied, EI #16, 21 and 22.

Based on observation, interview, record review and review of a facility policy titled, Incontinent & (and) Catheter Care, the facility failed to ensure a Certified Nursing Assistant (CNA) washed her hands during glove changes while performing incontinent care for Resident Identifier (RI) #123. This was observed on 05/09/18, and affected RI #123, one of one residents observed for incontinence care. Findings Include: A review of a facility policy titled, INCONTINENT & CATHETER CARE, with a revised date of 04/06/10 revealed: . IV. COMPLETION 1. Wash hands and change gloves as deemed necessary during the procedure to prevent the spread of infection. RI #123 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 05/09/18 at 9:05 a.m., Employee Identifier (EI) #5, a CNA was observed performing incontinent care for RI #123. EI #5 gathered the supplies washed her hands and put on gloves. EI #5 positioned RI #123, loosened the brief and wiped the perineal area of RI #123. EI #5 removed her gloves, picked up a clean brief and put on clean gloves. EI #5 rolled RI #123 to the right side and cleaned the buttock area. EI #5 placed the clean brief under RI #123, and applied moisture barrier cream. EI #5 removed her gloves and put on clean gloves. EI #5 placed a clean pad under RI #123. EI #5 did not wash her hands between glove changes. On 05/10/18 at 8:35 a.m., an interview was conducted with EI #5. EI #5 was asked what was the policy on washing hands during incontinent care. EI #5 replied, wash hands before and after resident care and between glove changes. EI #5 was asked, what should be done when gloves are removed. EI #5 replied, wash hands or use sanitizer. EI #5 was asked if she washed her hands between glove changes. EI #5 replied, no. EI #5 was asked what was the risk when removing gloves during incontinent care and not washing hands. EI #5 replied, cross contamination. On 05/10/18 at 1:20 p.m., an interview was conducted with EI #3, the Registered Nurse (RN)/Infection Control Nurse. EI #3 was asked what was the policy on hand washing hands during glove changes. EI #3 replied, any time going from dirty to clean and any time gloves were visibly soiled. EI #3 was asked if staff should wash their hands with each glove change. EI #3 replied, yes staff should wash their hands or use an alcohol based hand rub. EI #3 was asked what was the harm in the staff not washing their hands between glove changes. EI #3 replied, it spreads infection and it was cross contamination.

Based on observations, interview and record review, the facility failed to ensure: (1) Resident Identifier (RI) #53, a resident at risk for developing pressure ulcers, intervention to have his/her feet elevated off the mattress, and to wear heel protectors while in bed was implemented. This was observed on two of three days of the survey; and (2) RI #15 and RI #93, residents at risk of developing pressure ulcers, had cushion on the oxygen tubing behind their ears. This was observed on two of three days of the survey. These deficient practices affected RI #53, one of three residents sampled for pressure ulcers, and RI #15 and RI #93, two of three sampled residents using oxygen: Findings Include: (1) RI #53 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. RI #53's Pressure Ulcer care plan, with a Problem Onset date of 06/14/17, documented: . Approaches . * Apply heel protects to feet while in bed and float heels . A Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 02/21/18, identified RI #53 as being at risk for pressures ulcers. On 05/09/18 at 10:32 a.m., the surveyor observed the Treatment Nurse, Employee Identifier (EI) #11, prepare to provide wound care to the top of a toe on RI #53's right foot. RI #53's feet were on the mattress and no heel protectors were worn at this time. On 05/10/18 at 8:01 a.m., the surveyor observed RI #53's bare feet on the mattress, with no heel protectors on. On 05/10/18 at 2:30 p.m., the surveyor conducted an interview with EI #12, RI #53's assigned Certified Nursing Assistant (CNA). The surveyor asked EI #12 how should RI #53's feet be when he/she was in bed. EI #12 said they should be elevated on pillows so RI #53's heels would not rub on the bed and get a pressure sore on them. The surveyor asked EI #12, according to RI #53's plan of care, what should be on RI #53's feet. EI #12 said heel protectors. When asked what was the rationale for RI #53 having on heel protectors, EI #12 replied, so RI #53's feet would be off the bed and it would release pressure from his/her heels. EI #12 and the surveyor went to RI #53's room to see if there were heel protectors in the room. EI #12 looked in RI #53's dresser drawers and stated there were no heel proctors in RI #53's room. (2) RI #15 was admitted to the facility on [DATE], and readmitted on [DATE], with a [DIAGNOSES REDACTED]. A Significant Change MDS assessment, with an ARD of 01/19/18, identified RI #15 as being at risk for pressures ulcers. RI #15's Oxygen Therapy care plan, with a Problem Onset date of 02/09/18, documented: . Approaches * Check cushion behind my ears q (every) shift and PRN (as needed) to assure in place appropriately . RI #15's (MONTH) (YEAR) Physician order [REDACTED].> . OXYGEN @ (at) 3LPM (liters per minute) VIA (by way of) NC (nasal cannula) DAILY PRN SHORTNESS OF BREATH . On 05/09/18 at 8:35 a.m., the surveyor observed RI #15's oxygen infusing at 3 liters per minute. There was no cushion on the tubing behind RI #15's ears. On 05/10/18 at 8:48 a.m, the surveyor again observed RI #15 wearing oxygen. There remained no cushion on the tubing behind RI #15's ears. On 05/10/18 at 2:53 p.m., the surveyor conducted an interview with EI #13, the nurse assigned to care for RI #15. The surveyor asked EI #13, according to the care plans of residents who are receiving oxygen, what should they have on the tubing behind their ears. EI #13 said cushion. The surveyor asked EI #13 if there was no cushion on the tubing behind the ears, were the care plans being followed. EI #13 said no. The surveyor asked EI #13 to look behind RI #15's ears and asked did RI #15 have cushion on the tubing behind his/her ears. EI #13 said no. RI #93 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #93's Oxygen Therapy care plan, with a Problem Onset date of 04/13/17, documented: . Approaches * Check cushion behind ears q shift and prn to assure in place appropriately . An Annual MDS assessment, with an ARD of 03/13/18, identified RI #93 as being at risk for pressures ulcers. RI #93's (MONTH) (YEAR) Physician order [REDACTED].> . OXYGEN AT 2 LITERS VIA NASAL CANNULA . On 05/08/18 at 5:29 p.m., the surveyor observed RI #93's oxygen infusing at 2 liters per minute. There was no cushion on the tubing behind RI #93's ears. On 05/10/18 at 7:56 a.m, the surveyor again observed RI #93 wearing oxygen. There remained no cushion on the tubing behind RI #93's ears. On 05/10/18 at 2:53 p.m., the surveyor conducted an interview with EI #13. The surveyor asked EI #13 to look behind RI #93's ears and asked did RI #93 have cushion on the tubing behind his/her ears. EI #13 said no. The surveyor asked EI #13 what was the rational for ensuring cushion was on the tubing behind the residents ears. EI #13 replied, to prevent breakdown.

Based on observation, interview and record review, the facility failed to ensure Resident Identifier (RI) #89's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 03/27/18, was coded correctly under urinary continence for RI #89's use of a Foley catheter. Findings Include: RI #89 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a Quarterly MDS dated [DATE], revealed RI #89 was coded as always continent. On 05/08/18 at 5:00 p.m., RI #89 was observed in bed. A Foley catheter was observed hanging to the left side of the bed contained in a privacy bag. On 05/10/18 at 1:50 p.m., an interview was conducted with Employee Identifier (EI) #4, a Registered Nurse (RN)/MDS Coordinator. EI #4 was asked if RI #89 had a Foley catheter. EI #4 replied, yes. EI #4 was asked, when was RI #89's Foley catheter ordered. EI #4 replied she was not sure, RI #89 had it a long time. EI #4 was asked how should the urinary continence section on the 03/27/18, MDS be coded. EI #4 replied, Foley catheter and not rated which was a 9. EI #4 was asked in the under urinary continence section, it was coded as 0 always continent, would that assessment be accurate. EI #4 replied, no. EI #4 was asked what was the risk of the MDS not being coded accurately. EI #4 replied, some one may not realize the resident had a Foley catheter.

Based on observations, interview and review of a facility policy titled, Resident Rights Policy, the facility failed to ensure RL (Room Locator) 1-4 were free of scrapes, gashes, cracks, and missing paint on the walls. The facility further failed to ensure Resident Identifier (RI) #'s 15, 31 and 93's rooms did not have deep scrapes, dents, and missing paint on the walls, and RI #31's arm rests on his/her wheel chair were not torn. This affected three of 111 rooms in the facility, and affected one of 10 wheelchairs observed during the survey. Findings Include: (1) A review of a facility policy titled, Resident Rights Policy, with a revised date of 12/19/16, revealed the following: . Safe environment. The resident has a right to a . comfortable and Homelike environment . On 05/08/18 at 4:57 p.m., the surveyor observed in RL #1, on the A and B side of the room, walls with deep punctures in the sheetrock, and a brown stain in the ceiling on the B side of the room. On 05/08/18 at 5:12 p.m., the surveyor observed in RL #2, on the A and B side of the room, walls with gashes and holes in sheetrock. On 05/08/18 at 5:30 p.m., the surveyor observed in RL #3, the ceiling had cracked plaster and brown stain on the left side. On 05/09/18 at 8:36 a.m., the surveyor observed in RL #4, chipped paint on the walls on both the A and B sides of the room. Behind the head board on the A side of the room there was a hole in the wall. In the bath room, in the middle of the wall, was chipped paint and there was a hole in the wall in the corner behind the dresser on the B side of the room. On 05/10/18 at 5:45 p.m., the surveyor toured rooms in the facility with Employee Identifier (EI) #19, the Maintenance Director and observed the same issues previously documented. On 05/10/18 at 6:10 p.m., the surveyor conducted an interview with EI #19. EI #19 was asked when touring with the surveyor, did he observe in RL #'s 1-4 scrapes, holes, gashes, cracks and missing paint on the walls. EI #19 replied, yes ma'am. EI #19 was asked why were there holes, gashes, cracks, scrapes and missing paint on the walls. EI #19 replied, from the beds hitting the walls and bedside tables hitting the wall. EI #19 was asked when was a walk through conduced last. EI #19 replied, he walked through every day. EI #19 stated he had also done a walk through of residents' rooms in (MONTH) of (YEAR). EI #19 further stated maintenance goes in the rooms quarterly. EI #19 was asked when looking at the holes, scrapes, gashes and missing paint on the walls, was that a homelike experience for the residents. EI #19 replied no ma'am. EI #19 was asked who was responsible for repairing holes, scrapes, gashes and missing paint on the residents walls. EI #19 replied, the Maintenance Director. EI #19 was asked how did he think it made the residents feel with holes, scrapes, gashes, and missing paint on the walls. EI #19 replied, not very happy. (2) RI #15 was admitted to the facility on [DATE], and readmitted on [DATE]. On 05/09/18 at 8:53 a.m., the surveyor observed a wall in RI #15's room with pieces of missing paint on the lower wall. EI #15 said it had been that way for a while. On 05/10/18 at 8:02 a.m., the surveyor observed the wall to remain the same. RI #93 was admitted to the facility on [DATE]. On 05/08/18 at 5:30 p.m., the surveyor observed missing pieces of paint and sheetrock on the wall on the left side of RI #93's bed. On 05/09/18 at 8:14 a.m., the wall in RI #93's room remained the same. On 05/10/18 at 7:54 a.m., the surveyor observed the wall to remain in the same condition. RI #31 was admitted to the facility on [DATE]. A Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 02/05/18, revealed RI #31 used a wheelchair. On 05/09/18 at 9:47 a.m., the surveyor observed missing paint on the wall near the left side of RI #31's bed. On 05/09/18 at 11:40 a.m., the surveyor observed the left and right arm rest on RI #31's wheelchair to be torn. On 05/10/18 at 8:06 a.m., the wall in RI #31's room remained in the same condition. On 05/10/18 at 8:16 a.m., the surveyor observed the arm rests on RI #31's wheelchair remained the same. On 05/10/18 at 5:45 p.m., the surveyor conducted an interview with EI #19. EI #19 was asked who was responsible for repairing the residents wheelchair. EI #19 replied, EI #20, the Maintenance worker. EI #19 was asked why was RI #31's wheel chair arm rest not repaired. EI #19 replied he wrote it up to be repaired that morning, referring to a work order. EI #19 was asked had it been repaired yet. EI #19 replied, no ma'am. EI #19 was asked what kind of harm could a cracked wheel chair arm rest cause the resident. EI #19 replied, skin tear and bacteria. EI #19 was asked why was it important to keep residents wheel chair arm rests repaired. EI #19 replied, so the resident would not get injured or an infection. EI #19 was asked to describe RI #31's wheelchair armrest. EI #19 replied, it looked like the top layer had come off, it looked used, and the vinyl had separated from the mesh. EI #19 was asked how did he think the resident felt having damaged arm rest on his/her wheelchair. EI #19 replied, he/she may have felt it was dangerous or it was not perfect.

Based on observations, interview, and review of the facility's policies titled Receiving and Food and Supply Storage Procedures, the facility failed to ensure: 1) food items were properly labeled with the item name and use by date and were discarded once the use by date was exceeded; and 2) chicken was thawed in the walk-in cooler in a manner to prevent cross contamination. These failures had the potential to affect all residents receiving meals from the kitchen. The facility's Resident Census and Condition of Residents form, dated 03/14/2017, indicated 144 residents resided in the facility. Findings include: 1) Review of the facility policy titled Receiving, dated 05/2014, revealed the following: . Action Steps . 6. All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation. 7. All food items will be stored in a manner that insures appropriate and timely utilization based on the principles of first in - first out . During the initial tour of the kitchen on 03/14/2017 at 2:00 p.m., the following items were observed in the walk-in cooler: - two plastic containers of soup not labeled with an item name - chopped ham (identified by the Dietary Manager) not labeled with an item name - Bologna labeled with a use by date of 03/07/2017 - another container of Bologna with a use by date of 03/11/2017 - Vegetable soup labeled with a use by date of 03/12/2017 - Turkey labeled with a use by date of 03/11/2017 - Sausage for mechanical soft and puree diets with no use by date On 03/15/2017 at 11:28 a.m. three pans of jello were observed in the cooler with a use by date of 03/14/2017. Employee Identifier (EI) #4, the Dietary Manager, was interviewed on 03/16/2017 at 2:45 p.m EI #4 said food should be labeled upon placement into the cooler with the date received, open date, use by date, and what the item is. EI #4 said if items were not labeled with the use by date you would not know when it should be discarded. EI #4 also explained items past their use by dates should be discarded every morning. EI #4 said if items were stored past their use by dates they could grow bacteria and make people sick. 2) Review of the facility's policy titled Food and Supply Storage, undated, revealed the following: . REFRIGERATED STORAGE . Store fresh chicken in leak-proof containers. Thaw meat in the cooler. Raw meat must be stored below cooked products . During the initial tour of the kitchen on 03/14/2017 at 2:00 p.m., a metal pan containing thawing chicken was noted to contain bloody juices. The pan extended out past the shelf and was positioned right beside a box of tomatoes. Employee Identifier (EI) #4, the Dietary Manager, was interviewed on 03/16/2017 at 2:45 p.m EI #4 said when thawing chicken, cooked foods should be stored on top, then raw vegetables, and on bottom, the raw meats and poultry. After discussing the observation of the pan with bloody juices beside the tomatoes, EI #4 agreed the storage could cause disease.

Based on observation, interview, and review of a document titled Hand Hygiene Table, the facility failed to ensure staff wore gloves when changing dirty bed linens. Further, staff did not wash hands or change gloves prior to handling the clean linens. This deficient practice was observed during one of one observation of staff changing dirty linens. Findings include: Review of the facility's undated document titled Hand Hygiene Table revealed staff should either use antimicrobial soap and water or an alcohol based hand rub before and after handling clean or soiled linens. On 03/15/2017 at 8:50 a.m., Employee Identifier (EI) #11, a Certified Nursing Assistant (CNA), was observed changing bed linens in Resident Identifier (RI) #14's room. EI #11 did not wear any gloves to remove the soiled linens from the bed and was observed holding the linens against her clothing. EI #11 then replaced the soiled linens with clean linens without washing her hands or applying gloves. EI #11, the CNA, was interviewed on 03/15/2017 at 2:45 p.m EI #11 said they strip resident beds on Mondays, Wednesdays, and Fridays. EI #11 agreed she did not wear gloves when changing the linens, but said she had never been told she had to. EI #11 was then asked when she should wash hands when changing bed linens. She stated she used hand sanitizer after she made the bed with clean linens, but said she had not cleaned her hands after she took the dirty linens off or put the clean ones on. EI #11 said she should wash her hands to avoid transferring anything to the clean linens. EI #2, the Infection Control Nurse, was interviewed on 03/16/2017 at 3:00 p.m EI #2 explained staff should wear gloves when changing bed linens to prevent the spread of infection. She also stated staff should wash hands before and after handling the linens. She said it was important for staff to wash hands after handling dirty linens, before touching the clean ones, to prevent transferring germs from the dirty to the clean.

Based on observations, interviews, medical record review and review of the facility's policy titled, Therapeutic Diets, the facility failed to ensure Resident Identifier (RI) #3 received a regular mechanical soft diet for breakfast and lunch on 3/15/2017. This affected RI #3, one of 14 sampled residents observed for meals. The facility's Resident Census and Conditions of Residents form, dated 3/14/2017, indicated 40 residents in the facility received mechanically altered diets. Findings Include: The facility's policy dated May 2014 titled, Therapeutic Diets, documented Policy Statement It is the center policy to provide therapeutic diets in accordance with physician orders [REDACTED]. RI #3 was admitted to the facility on [DATE]. A review of RI #3's Annual Minimum Data Set with an Assessment Reference Date (ARD) of 9/13/2016, identified RI #3 as being cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. RI #3 was assessed as being independent with eating after set-up. RI #3's care plan titled Resident is at nutritional risk . with a problem onset date of 9/13/2016 last reviewed 3/7/2017 had an approach of . Diet as ordered . RI #3's March 2017 Physician order [REDACTED].#3 was ordered a regular with mechanical soft diet. On 3/15/2017 at 8:20 a.m., during the breakfast meal observation, RI #3's plate contained two whole sausage patties. RI #3 consumed all of the oatmeal and half of the biscuit provided on the tray, but did not eat the sausage patties. On 3/15/2017 at 12:21 p.m., during the lunch meal observation, RI #3's plate contained two pieces of fried chicken, a whole thigh and leg. RI #3 consumed half of the chicken noodle soup, half of the roll provided, but did not eat the fried chicken. RI #3 explained to the surveyor that he/she had his/her top teeth pulled in January 2017, and it hurt his/her gums to eat hard foods, so he/she did not eat the fried chicken. An interview was conducted with Employee Identifier (EI) #4, the Dietary Manager, on 3/16/2017 at 9:18 a.m. EI #4 was asked if whole sausage patties and a fried chicken leg and thigh were considered part of a mechanical soft diet. EI #4 replied, no ma'am. During an interview on 3/16/2017 at 9:45 a.m., EI #3, the Registered Nurse (RN) Manager of the hall where RI #3 resides, was asked what type of diet should RI #3 be receiving. EI #3 responded, regular diet with mechanical soft. When asked if whole sausage patties and a fried chicken leg and thigh were considered part of a mechanical soft diet, EI #3 responded, no. EI #3 further explained the potential harm in not following an order for [REDACTED].

Based on observations, interview, medical record reviews and a review of a facility document titled, Hand Hygiene Table, the facility failed to ensure Employee Identifier (EI) #1, a Registered Nurse (RN) washed her hands and changed gloves after cleaning the wound of Resident Identifier (RI) #3 and before continuing with RI #3's wound care. EI #1 further failed to ensure she washed her hands and changed gloves when she performed wound care on RI #10's multiple wounds. This deficient practice affected RI #3 and RI #10, two of three residents observed for wound care. Findings Include: A review of an undated facility document titled, Hand Hygiene Table, revealed hand hygiene should be performed using .Either Antimicrobial Soap and Water or Alcohol Based Hand Rub . After handling items potentially contaminated with blood, body fluids, secretions, or excretions . When during resident care, moving from a contaminated body site to a clean site . 1) RI #3 was admitted to the facility on [DATE]. RI #3's physician orders [REDACTED]. On 3/15/2017 at 11:46 a.m., EI #1, the RN/Wound Care Nurse, was observed performing wound care on the Stage 2 pressure ulcer on RI #3's sacrum. EI #1 washed her hands and applied gloves then removed the dirty dressing from RI #3's sacrum. EI #1 then ungloved and washed her hands and applied clean gloves. EI #1 then cleansed the wound with saline soaked gauze. EI #1 did not change gloves and wash hands after cleaning the wound. EI #1 then proceeded to cut the [MEDICATION NAME] gauze with sterile scissors and transferred it to the wound using sterile tweezers and secured it in place using gloved fingers; then covered the wound with the [MEDICATION NAME] Border dressing. On 3/16/2017 at 2:33 p.m. and interview was conducted with EI #1, the RN who performed the wound care on RI #3. EI #1 was asked when should gloves be changed and hands washed during wound care. EI #1 responded, prior to touching the old dressing, prior to cleaning the wound, and then prior to changing the dressing (before applying the new dressing). When EI #1 was asked if she washed her hands and changed her gloves after cleaning the wound of RI #3 and prior to applying the clean dressing, EI #1 replied, she thought she did, but was nervous. EI #1 further explained the potential harm in not washing the hands and changing gloves after cleaning the wound and before continuing with wound treatment could result in contamination of the wound, because you are going from a dirty to a clean area. On 3/16/2017 at 3:02 p.m. an interview was conducted with EI #2, the Infection Control Nurse. EI #2 was asked when during wound care should gloves be changed and hand hygiene performed. EI #2 explained, before starting wound care and anytime during wound care when going from dirty to clean. When asked if it was an acceptable practice to clean a dirty wound with hand held gauze and then, without changing gloves and washing hands, continue to apply the clean dressing, EI #2 responded, no. EI #2 further explained the harm in doing so could result in the spreading of bacteria. 2) RI #10 was admitted to the facility on [DATE]. RI #10's physician orders [REDACTED]. The RN/Wound Care Nurse, EI #1, was observed providing wound treatment to RI #10 on 3/15/2017 at 2:30 PM. EI #1 washed her hands and applied gloves before cleaning and measuring the area to RI #10's right buttock. Without removing her gloves and washing her hands, EI #1 then cleaned and measured the area to RI #10's left buttock. EI #1 was interviewed on 3/16/2017 at 2:42 PM. EI #1 was asked what should be done after cleaning one open wound before cleaning the second open wound. EI #1 stated to remove gloves and wash hands to avoid cross contamination. When asked why she had not removed her gloves and washed her hands between wound treatments, she stated she forgot.

Based on observation, record review and interviews, the facility failed to follow the Consistent Carbohydrate Diet (CCD) as planned on 02/23/16. This had the potential to affect 46 of 46 residents for whom a CCD diet was ordered. The facility also failed to follow the printed tray slips as planned for Resident Identifier (RI) #s: 3, 8, 18, 20, 25, 28 and 29. This involved 7 of 18 sampled residents for whom meals were observed. Findings Included: A) CCD DIET The facility's Healthcare Services Group Diet Manual (2016 edition) related to Diabetes Management (pages 24 & 25) directs staff as follows: . Evidence exists that both the quantity and the type of carbohydrate in food influence blood glucose levels. However, the primary predictor of glycemic response is the total amount of carbohydrate consumed. Although substituting sucrose containing foods for [MEDICATION NAME] amount of other carbohydrates may have a similar effect on glucose levels, consumption should be minimized to avoid displacing nutrient dense food choices. The use of non-nutritive sweeteners can reduce overall calorie and carbohydrate intake and be appropriately incorporated into meal planning as a substitute for caloric sweeteners . Menu Planning Guidelines: . Meal planning should incorporate a consistent carbohydrate load at each meal for each day . All food can fit into the diet for individuals with Diabetes. The portion size may be used to adjust the amount of carbohydrate . Foods not allowed: . Products with sugar-based Frosting, syrup, and/or excessive Amounts of added sugar and/or High fructose corn syrup. On 02/23/16 at 9:52 a.m., a dietary staff member, Employee Identifer (EI) #20 portioned individual servings of Apple Crisp into 8 oz thermal-insulated bowls. The Chef, EI #19 affirmed at this time, that she had made only one type of Apple Crisp (with sugar) for both regular and diabetic residents. The surveyor observed only one size portion for all servings: 4 oz or 1/2 cup. On 02/23/16 at 10:04 a.m., the dietary staff member portioned pureed Apple Crisp with the same size scoop, into the same size bowls for use on the lunch trayline. The facility's pre-planned menu for Tuesday, 02/23/16 included 1/2 cup Apple Crisp for the Regular diets, and 1/2 cup Sugar Free (SF) Apple Crisp for residents on the CCD diet. No Sugar Free Apple Crisp was prepared and served on the 02/23/16 lunch trayline. The recipe for the regular Apple Crisp included both white granulated and light brown granulated sugars, providing a total of 49 grams carbohydrate per 1/2 cup serving. The recipe for the sugar free apple crisp included no sugar, using instead a sugar substitute. Each serving would have provided 23 grams of carbohydrate per 1/2 cup serving according to the nutritional analysis provided by facility staff. The Diet Census List (printed 02/22/16) included a total of 103 residents on diets other than CCD (Regular, No Added Salt, Mechanical Soft and Pureed); and a total of 46 residents on a CCD diet. The 02/23/16 Production Counts indicated the need of 128 (1/2-cup) servings of Apple Crisp; one (1-cup) serving, one (6-oz) serving, and 12 (3-oz) servings. No sugar free Apple Crisp was listed. During the 02/23/16 lunch meal, the trayline staff provided the same size portion and type of Apple Crisp to all residents (including pureed), whether regular or sugar-restricted diets. On 02/23/16 at 11:35 AM, the Dietary Account Manager, EI #4 was asked why the sugar free Apple Crisp had not been prepared and served to the residents on carbohydrate controlled diets. EI #4 stated they followed the tray cards, and their production sheets had not specified the need of sugar free Apple Crisp. The surveyor noted numerous hand-written changes (in entree and side dishes) had been made to the day's menu; all had been prepared and included, except for the sugar free Apple Crisp. On 02/24/16 at 1:00 p.m., the surveyor asked the Registered Dietitian (RD), EI #3, how she communicated menu changes to the production staff. EI #3 stated she gave the Manager/EI #4 a copy of the changes. EI #3 explained the diabetics were not happy with 1/2 size portions of regular desserts, so they were going back to sugar free. When asked what potential hazard could result from providing the same dessert (and portion size) to the residents on sugar-restricted diets, EI #3 stated, slight blood sugar elevation. B) TRAY SLIPS The facility policy related to Food Preferences HCSG (Healthcare Services Group ) Policy 005, dated May 2014 states the following: It is the center policy that individual food preferences are identified for all residents . Action Steps: . 2. The Food Services Director or designee will complete a Food Preference Interview within 72 hours of admission for the purpose of identifying individual food and beverage preferences. 3. Food allergies [REDACTED]. 4. The individual tray assembly ticket will identify all food items appropriate for the resident . based on diet order, allergies [REDACTED]. 1) RI #3 had current (02/01/16 through 02/29/16) diet orders of Mechanical Soft, CCD, Chopped Meat. A Nursing-Dietary Communication Form for RI #3 dated 12/30/15 included orders for an additional Snack cake with Lunch and Dinner. On 02/22/16 the resident's lunch tray slip designated Oatmeal Creme Pie/Snack Cake. No snack cake was sent with the meal. On 02/24/16 at 8:30 a.m., RI #3 received plain gravy with the breakfast meal. The tray slip specified Sausage Gravy. 2) RI #8 was ordered a Regular, NAS (No Added Salt), No Dairy Products or Caffeine (Physician Orders: 02/01/16 through 02/29/16). Additional physician's orders [REDACTED]. A Nursing-Dietary Communication Form for RI #8 dated 02/22/16 and signed by the Registered Dietitian (RD), specified the same orders: D/C (stop) No dairy products. Resident may have dairy. On 02/24/16 at 8:00 a.m., RI #8's breakfast tray included Sausage Gravy and Biscuit, in addition to a carton of Milk and other designated items. The tray slip specified NAS, No Dairy Products as well as Lactos(e) Free Milk/Biscuit and PLAIN GRAVY. The resident was upset at the receipt of the sausage gravy due to her strong distaste for the item. On 02/24/16 at 12:40 p.m., the RD (EI #3) confirmed with the survey staff, that she was responsible for obtaining residents' food preferences, as well as other dietary and nursing staff on admission, quarterly or as needed. EI #3 explained she documented the preferences and sent them to the kitchen on a dietary communication sheet. EI #4, Dietary Account Manager, would then enter the preferences into the kitchen computer. On 02/25/16 at 8:30 a.m., the surveyors asked the Healthcare Services Group District Manager (EI #5) how the facility communicated dietary information to the kitchen. EI #5 explained the RD obtained residents' food preferences and physician orders [REDACTED]. EI #5 stated the computer also printed the preferences and diet changes on each resident's tray slip. When asked why RI #8's lactose restriction had not been removed from the computer system, EI #5 promised to investigate, stating it had not been entered as a dislike. 3) RI #18 received a breakfast tray on 02/24/16 which included Sausage Gravy, Biscuit and two Sausage Patties (in addition to other specified items on the tray slip). The resident was upset, stating he/she preferred Crisp Bacon. RI #18 did not like Sausage Gravy, preferring instead Plain Gravy. The tray slip specified: Sausage Gravy - 2 Oz and PLAIN GRAVY ONLY PLAIN GRAVY AT BREAKFAST 4) RI #20 received a breakfast tray on 02/24/16 which included Sausage Gravy, Biscuit and other specified items. A family member was in the room, upset with the meal stating RI #20 would not eat Sausage Gravy, preferring Plain White Gravy. RI #20 ate none of the gravy. The resident's tray slip specified: Gravy Biscuit - 1 Avg (average), Biscuit - 1 slice . plain gravy NO SAUSAGE GRAVY. 5) On 02/24/16 (Wed) a plate waste study was conducted following the breakfast meal to determine the accuracy and intake of foods sent on the breakfast trays. A tray slip was picked up from the untouched tray of RI #25. The food sent on this CCD tray was accurate, with the exception of Gravy. Plain Gravy was sent with the meal. The tray slip specified Sausage Gravy. This resident had been discharged from the facility on 02/19/16, five days prior. 6) On 02/24/16 at 7:45 a.m., RI #28 failed to receive a portion of Sausage Gravy with his/her breakfast meal as specified on the tray slip. 7) On 02/24/16 at 7:45 a.m., the breakfast tray served to RI #29 did not include Sausage Gravy as specified on the tray slip. On 02/24/16 at 3:35 p.m., the surveyor asked the Dietary Account Manager (EI #4) how food preferences were captured on each resident's tray slip. EI #4 explained the Nursing-Dietary Communication Form provided this information, and was completed by nursing staff or the RD. EI #4 stated she then entered this information into their computer system. When asked how often the residents' meals/trays were checked for accuracy, EI #4 responded every day at Lunch and Dinner, at least one or two food carts.