Every finding on record at Health Care Inc

Based on observations, interview, review of the 2017 Food Code of the United States (U.S.) Public Health Service and the U.S. Food and Drug Administration (FDA), a review of facility policies titled, Hand Washing, Bare Hand Contact with Food and Use of Plastic Gloves and Cleaning Dishes/Dish Machine, the facility failed to ensure Employee Identifier (EI) #2 washed their hands and changed their gloves after handling dirty dishes and before handling clean dishes. This had the potential to affect 46 of residents receiving meals from the kitchen. Findings Include: The 2017 Food Code of the U.S. Public Health Service and the FDA included the following: . 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms . immediately before engaging in FOOD preparation including working with . clean EQUIPMENT and UTENSILS, . and: . (E) After handling soiled EQUIPMENT or UTENSILS; . 3-304.15 Gloves, Use Limitation. (A) If used, SINGLE-USE gloves shall be used for only one task . used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. The facility's policy for Hand Washing, last approved on 08/12/2021, included the following: Policy: Staff will wash hands frequently as needed throughout the day following proper hand washing procedure . Procedure: . 1. When to Wash Hands: . After handling soiled equipment or utensils . Before donning gloves . The facility's policy for Bare Hand Contact with Food and Use of Plastic Gloves, last approved on 08/12/2021, included the following: Policy: Plastic gloves will be worn . to ensure that bacteria are not transferred from the food handlers' hands . Procedure: . 2. Staff appropriately use utensils such as gloves . to prevent food borne illness. 3. Gloved hands are considered a food contact surface that can get contaminated or soiled. If used, single use gloves shall be used for only one task . used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. 4. Hands are to be washed . before putting on the plastic gloves. 6. Remember gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed. After handling soiled trays or dishes After handling anything soiled . Any time you touch any contaminated surface During food preparations, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks . 7. Wash hands after removing gloves. The facility's policy for Cleaning Dishes/Dish Machine, last approved on 08/12/2021, included the following: . Procedure: . 6. The person loading dirty dishes should not handle the clean dishes unless they change their apron and wash their hands thoroughly before moving from dirty to clean dishes. On 08/23/2022 at 01:04 PM, the surveyor observed EI #2 washing a rack of trays, which had been loaded in the single tank dishwashing machine. EI #2 was wearing a hair net, apron, and face mask. No gloves were worn at this time. The chemical, low-temperature, single tank dishwashing machine went through the following three cycles: wash, rinse, and chemical sanitizing. The dishwasher reached a temperature of 120 degrees Fahrenheit (F) during the wash cycle. Upon completion of the dishwashing cycle, EI #2 slid the rack of trays out of the dishwasher and allowed them to air dry in the rack. EI #2 then loaded pre-scraped plates into a rack and pre-rinsed them with a hand sprayer. EI #2 lowered the hood of the dishwashing machine using the handle-bar on the right-hand side of the machine, the clean side of the machine, with soiled hands. While the plates were washing, EI #2 put on blue disposable gloves. EI #2 did not wash his/her hands before putting on the gloves. EI #2 was observed with his/her left gloved hand resting on the dirty left side of the dish table. EI #2 did not change his/her gloves or wash his/her hands before raising the machine hood and pulling out the clean rack of dishes. After allowing the dishes to briefly air dry, EI #2 removed the dishes from the rack and placed them on a dish cart, again without having washed his/her hands and applying clean gloves. On 08/23/2022 at 1:16 PM, the Dietary Manager (DM), EI #1, was interviewed. EI #1 was asked what was the importance of separating dirty tasks from clean tasks. EI #1 responded, Because you could transfer infection and bacteria and make people sick. If you don't keep your hands clean, it could possibly get the clean dishes dirty.

Based on observation, interviews, record review and review of a facility policy titled, Comprehensive Care Plans Health Care Inc, the facility failed to ensure a care plan was developed/implemented for: 1) Resident Identifier (RI) #131's use of a Foley Catheter; and 2) RI #7's hearing aide usage. These deficient practices affected RI #'s 7 and 131, two of 14 residents whose care plans were reviewed. Findings Include: Review of a facility policy titled,Comprehensive Care Plans Health Care Inc., with a revised/reviewed date of 01/2022, revealed the following: . Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with . measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs . 1) RI #131 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #131's August 2022 Physicians's Orders documented: . Foley cath (catheter) Care QS (every shift) to 16 French May change Q (every)Month 15th or prn (as needed) . On 08/22/2022, at 11:12 AM, RI #131 was observed sitting in his/her WC (wheelchair). RI #131's Foley Catheter was in a GU ([CONDITION(S)]) bag attached to the right lower WC frame. A review of RI #131's medical records revealed there was no care plan for the use of the Foley Catheter. On 08/24/2022, at 4:18 PM, an interview was conducted with Employee Identifier (EI) #4, the LPN (Licensed Practical Nurse)/MDS (Minimum Data Set)/Care Plan Coordinator. The surveyor asked EI #4 how long has RI #131 had a Foley catheter. EI #4 said since August 1, 2022. EI #4 said she did not see a care plan for the use of the Foley Catheter but should have one. The surveyor asked EI #4 why would there be a need to have a care plan implemented for a resident with a Foley Catheter. EI #4 said it would let the staff know the resident has a Foley Catheter, and it would let each shift know they had to provide care for the Foley Catheter. 2) RI #7 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #7's Annual MDS assessment dated [DATE], documented, Hearing with minimal difficulty and coded to have hearing aids. RI #7's Care Area Triggers (CAT) Worksheet documented, Problem Area 4 - Communication - Use of Communication Devices - Hearing Aid. Care Plan Considerations. It was revealed RI #7 had a care plan for the hearing aid in place, and it would be Updated and Reviewed as needed. On 08/24/2022, at 11:01 AM, EI #4 was interviewed. EI #4 was asked was RI #7 coded for hearing aids on the MDS assessment. EI #4 responded, Yes. When asked if RI #7's care plan reflected RI #7 use of a hearing aid, EI #4 responded, No. It does not. EI #4 stated the use of the hearing aide should have been care planned for and she did not know why she did not implement a care plan for the hearing aid.

Based on interviews, record review and review of a facility policy titled Documentation of Wound Treatments Health Care Inc., the facility failed to ensure licensed staff consistently documented treatment was provided to the surgical incision on Resident Identifier (RI) #181's nose. This deficient practice affected RI #181, one of one residents sampled for documentation of treatment being provided to a resident's surgical incision. Findings Include: Review of an undated facility policy titled, Documentation of Wound Treatments Health Care Inc. revealed the following: Policy: The facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition, and changes in treatment. 2. a. Type of wound (pressure injury, surgical, etc.) . 3. Wound treatments are documented at the time of each treatment. RI #181 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #181's Surgery Site Wound Care undated orders, revealed the following: . After each vinegar water soak, apply ointment to incision and cover with non-stick bandage. Avoid placing adhesive or tape directly to incision . Perform wound care twice a day after surgery until wound is healed . A review of RI #181's August 2022 Treatment Record revealed treatment was to be provided to the surgical incision site on RI #181's nose on the 1st and 2nd shifts. Further review of the Treatment Record revealed there was no documented evidence of RI #181 having treatment provided to the surgical incision on 08/19/2022 on the 2nd shift, on 08/20/2022 on the 1st and 2nd shift, on 08/21/2022 on the first and 2nd shift, and on 08/22/2022 and 08/23/2022 on the 1st shift. On 08/23/2022 at 5:59 PM, an interview was conducted with Employee Identifier (EI) #3, the LPN (Licensed Practical Nurse) assigned to provide care to RI #181 on the 2nd shift on August 20th and 21st. EI #3 said he treated the resident's surgical incision, but when he got back to the nurse's desk he forgot to document it in the treatment book. On 08/24/2022 at 10:41 AM, an interview was conducted with EI #4, the LPN assigned to care for RI #181 on the the first shift on August 22nd and August 23. EI #4 stated she did not know why she did not document where she provided treatment to RI #181's surgical incision site. On 08/24/2022 at 1:55 PM, an unsuccessful attempt was made to contact EI #5, the RN (Registered Nurse) assigned to care or RI #181 on August 19 on the 2nd shift, on August 20th and August 21st on the 1st shift, who also failed to document treatments had been provided to RI #181's surgical incision site.

Based on interviews and review of the facility's Director of Nursing and Administrator job descriptions, the Administrator and Director of Nursing failed to operate the facility in a manner to allow the facility staff to vocalize allegations of abuse without fear of retaliation. This deficient practice placed RI #1, one of four sampled residents reviewed for abuse in immediate jeopardy, as this situation was likely to cause serious injury, harm, impairment or death. This deficient practice had the potential to affect all 47 residents currently residing in the facility. On 11/14/2020 at 6:30 PM, the Administrator was given a copy of the Immediate Jeopardy (IJ) template and notified of the finding of immediate jeopardy in the area of Administration, F835. Findings include: On 11/3/2020, Employee Identifier (EI) #1, the Director of Nursing (DON) was witnessed to verbally, physically and mentally abuse Resident Identifier (RI) #1 at approximately 8:00 AM and again at approximately 3:30 PM. Multiple staff members acknowledged witnessing these incidents on 11/3/2020 but stated they had not reported it to the Abuse Coordinator, who is the Administrator, because she was present and should have known already known what occurred. The facility's Abuse Coordinator (Administrator) did not identify these incidents as abuse and allowed the DON to continue working with residents until 11/9/2020, at which time the Administrator confined the DON to her office, submitted an initial report to the State Survey Agency and began an investigation into the allegations, after receiving a written report from the hospital that documented the alleged abuse. Refer to F600 and F607 The DIRECTOR OF NURSING SERVICES JOB DESCRIPTION signed by EI #1, the Director of Nursing (DON) on 1/30/2017, documented . General Purpose: To plan, organize, develop and direct the overall operation of the Nursing Services Department in accordance with current federal, state and local standards governing the facility, and as may be directed by the Administrator, to ensure that the highest degree of quality care is maintained at all times . The JOB DESCRIPTION signed by EI #2, the Administrator on 6/19/1989, documented . The administrator is responsible for the interpretation, implementation, and proper application of policies and progress established by the governing authority, and is delegated responsibility for the establishment of safe and effective administrative management, control, and operation of the services provided . On 11/9/2020 at 4:45 PM, an interview was conducted with EI #3, a Certified Nursing Assistant (CNA) who worked the 2:00 PM to 10:00 PM shift on 11/3/2020. When asked if she reported the incident to anyone at the facility, EI #3 stated no, because the Administrator and DON, whom you should report to, was there and knew about the incident. On 11/10/2020 at 10:48 AM, a telephone interview was conducted with EI #4, a CNA who worked the 2:00 PM to 10:00 PM shift on 11/3/2020. EI #4 stated she didn't report the incident to the DON because the DON was the one doing the yelling and screaming. EI #4 stated she didn't report it to the Administrator because she came in the resident's room and was aware of what was going on. During a telephone interview on 11/10/2020 at 11:40 AM, the local Emergency Medical Service (EMS) Director stated he had received a call from the Administator, and during the call the Administrator threated to call all the facilities whom EMS provide transport for and tell them to stop using the local EMS because they reported the facility to the State. According to the EMS Director he informed the Administrator that he did not report the facility to the State; he stated his staff only reported to the receiving facility what the nursing home staff had reported to the EMS staff. On 11/10/2020 at 3:34 PM, an interview was conducted with EI #5, a Licensed Practical Nurse (LPN) who worked the 6:00 AM to 2:00 PM shift on 11/3/2020. When asked why she didn't report the allegation of abuse, EI #5 stated the Administrator (EI #2) was there and didn't say anything. On 11/10/2020 at 4:20 PM, an interview was conducted with the contracted mental health therapist who was in the facility on 11/3/2020. When asked if she reported the incident, the mental health therapist replied no because she was trying to figure out what to do. The mental health therapist stated there was a lot of people around and saw and heard what happened. On 11/12/2020 at 10:40 AM, an interview was conducted with EI #8, a Registered Nurse (RN) who worked the 6:00 AM to 2:00 PM shift on 11/3/2020. When asked why she did not report the allegation of abuse, EI #8 stated the Abuse Coordinator is the Administrator and she came to the resident's room and heard the DON (EI #1) yelling and screaming at RI #1. On 11/12/2020 at 11:30 AM, an interview was conducted with EI #10, a LPN who worked the 6:00 AM to 2:00 PM shift on 11/3/2020. EI #10 stated she didn't report the allegation of abuse because she thought it was handled when the Administrator (EI #2) came into the resident's room. When asked if the Administrator witnessed the incident, EI #10 said yes she did. According to EI #10, the DON (EI #1) was so loud, she was heard by the Administrator when the Administrator was in the resident's room and when the DON was in the hall. In a follow up interview on 11/12/2020 at 2:30 PM, EI #5, an LPN who worked the 6:00 AM to 2:00 PM shift on 11/3/2020 stated she witnessed the DON verbally and mentally abuse RI #1 on 11/3/2020. When asked if she reported the allegation of abuse to the Abuse Coordinator, EI #5 said she did not. EI #5 stated she felt as though the Administrator covers for the DON because she was present on 11/3/2020 and heard the DON verbally and mentally abusing RI #1 and did nothing. In an interview on 11/12/2020 at 3:45 PM, EI #24, a CNA stated all the staff are scared, terrified and intimidated by the Administrator. EI #24 stated she knows she would lose her job if they talk with the State Surveyors. Contained within the facility's investigation file was the Five Day Report which read (RI #1) November 3, 2020 Incident . Issue with Respect to Retaliation for Reporting: While we were not specifically asked to make a determination regarding concerns about staff possibly fearing retaliation for reporting abuse, neglect, mistreatment, and misappropriation, we have, in order to understand how best to help the facility attain and maintain substantial compliance with reporting, determined the following: Staff who had failed to report an incident prior to November 3, 2020 incidents with (RI #1) stated that they were afraid of (EI #1). Another licensed nurse acknowledged that (EI #1) was harsh with the nurses and didn't hesitate to yell at them. Due to the termination of (EI #1), staff members reported that they felt more comfortable with a new DON . ************************* On 11/19/2020 at 2:00PM, the facility submitted an accepted Removal Plan which documented: F835 The Administrator and DON failed to operate the facility in a manner to allow facility staff to vocalize allegations of resident abuse without fear of retaliation. Effective November 15, 2020, Assistant Administrator (LNHA and RN) assumed responsibility of abuse coordinator upon discharge of former DON. Assistant Administrator will be in-serviced on all components of abuse policy by an outside consultant on Sunday, November 15, 2020. Task completed on November 15th, 2020. On Sunday, November 15, 2020, Assistant Administrator will in-service Administrator and Interim DON on all components of abuse policy and the facility's strict policy against retaliation against any staff member reporting any allegation of abuse, neglect, mistreatment, or misappropriation. These in-services will be completed on Sunday, November 15, 2020. Task completed on November 15th, 2020. Permanent DON will receive in-service by the Assistant Administrator on Tuesday, November 17,, 2020. Beginning Sunday, November 15, 2020, the Assistant Administrator/Designee will in-service facility staff on the above personnel changes and on resident rights related to freedom from abuse. These in-services will include all components of abuse policy, and the facility's strict policy against retaliation against any staff member reporting any allegation of abuse, neglect, mistreatment, or misappropriation. These in-services will be completed on Monday, November 16, 2020. Any staff member who has not completed the above in-services by this date will be removed from the schedule and not allowed to return to work until the in-service is completed. Of 54 total staff, 44 have completed this task as of Monday, November 16, 2020, 6:00PM. Four contract employees are utilized by the facility. Their training will be completed Tuesday, November 17, 2020. As of 4:00PM Tuesday, November 17, 2020, all facility employees and contract employees have completed this training. The Assistant Administrator will oversee implementation of the removal plan and investigations until the facility achieves substantial compliance. (Name) and (Name) of the law firm (Name), will provide guidance and oversight to ensure policies are implemented and any further allegations are thoroughly investigated until substantial compliance is obtained by the facility. Immediacy will be removed Thursday, November 19, 2020 ************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F 835 was lowered to a F level on 11/19/2020, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as the result of the investigation of complaint/report number AL 470.

Based on interviews and review the facility's policy titled PREVENTION OF ABUSE, NEGLECT, AND EXPLORTATION (EXPLOITATION) OF ANY RESIDENT, the facility failed to ensure five of seven components of the abuse policy were implemented. On 11/3/2020, Employee Identifier (EI #1), the Director of Nursing (DON) was witnessed to verbally, physically, and/or mentally abuse RI #1 at approximately 8:00 AM and again at approximately 3:30 PM. The facility's Administrator, who is also the Abuse Coordinator did not identify these incidents as abuse and allowed the DON to continue working with residents until 11/9/2020, at which time the Administrator confined the DON to her office, submitted an initial report to the State Agency and began an investigation into the allegations, after receiving a written report from the hospital that documented the alleged abuse. This deficient practice placed RI #1, one of four sampled residents reviewed for abuse in immediate jeopardy, as this situation was likely to cause serious injury, harm, impairment or death. On 11/14/2020 at 6:30 PM, the Administrator was given a copy of the Immediate Jeopardy (IJ) template and notified of the finding of substandard quality of care at immediate jeopardy in the area of Freedom from Abuse, Neglect, and Exploitation, F607. Findings include: The facility's undated policy titled PREVENTION OF ABUSE, NEGLECT, AND EXPLORTATION (EXPLOITATION) OF ANY RESIDENT documented THE PURPOSE OF THIS POLICY IS TO ENSURE THAT THIS FACILITY IS DOING ALL THAT IS WITHIN OUT CONTROL TO PREVENT OCCRANCE OF ANY TYPE OF ABUSE TOWARD OUR RESIDENTS . THIS FACILITY HAS DEVELOPED AND IMPLEMENTED POLICIES AND PROCEDURES THAT INCLUDE 7 COMPONENTS TO PREVENT OCCURANCE . STEP 3: PREVENTION: . STEP 4: IDENTIFICATION: . THE DIRECTOR OF NURSING HAS A TRACKING FORM THAT SHE UTILIIZES TO HELP IDENTIFY OCCURANCE, PATTERNS, TRENDS THAT MAY CONSTITUTE ABUSE . STEP 5: INVESTIGATION: ANY REPORT CONCERNING SUSPICION OF ABUSE, . AN IMMEDIATE INVESTIGATION WILL BEGIN . STEP 6: PROTECTION: RESIDENTS WILL BE PROTECTED FROM HARM DURING AN INVESTIGATION BY: PERSON/EMPLOYEE IDENTIFIED WILL BE IMMEDIATELY TOLD TO LEAVE THE FACILITY UNTIL INVESTIGATION AND DETERMINATION IS COMPLETED . STEP 7: REPORTING/RESPONSE: FACILITY WILL REPORT PER POLICY AND PROCEDURE ALL ALLEGED VIOLATIONS AND ALL SUBSTANTIATED INCIDENTS IMMEDIATELY TO THE STATE AGENCY, BUT NOT LATER THAN 2 HOURS AFTER THE ALLEGATION IS MADE, IF THE EVENTS THAT CAUSED THE ALLEGATION INVOLVE ABUSE OR RESULT IN SERIOUS BODILY INJURY, . THIS REPORT WILL BE MADE ONLINE . On 11/3/2020, Employee Identifier (EI) #1, the Director of Nursing (DON) was witnessed to verbally, physically and mentally abuse Resident Identifier (RI) #1 at approximately 8:00 AM and again at approximately 3:30 PM. Multiple staff members acknowledged witnessing these incidents on 11/3/2020 but stated they had not reported it to the Abuse Coordinator, who is the Administrator, because she was present and should have known already known what occurred. The facility's Abuse Coordinator (Administrator) did not identify these incidents as abuse and allowed the DON to continue working with residents until 11/9/2020, at which time the Administrator confined the DON to her office, submitted an initial report to the State Survey Agency and began an investigation into the allegations, after receiving a written report from the hospital that documented the alleged abuse. Refer to F600 In an interview on 11/10/2020 at 1:15 PM, EI #2, the Administrator and Abuse Coordinator stated she didn't witness any physical or verbal abuse between RI #1 and EI #1 on 11/3/2020. EI #2 further explained that no resident or staff reported an allegation of abuse to her. EI #2 stated the allegation of abuse was reported to the State Survey Agency on 11/9/2020 because she reviewed RI #1's hospital record and the alleged abuse was documented. When asked if the DON (EI #1) was in the facility on today, EI #2 said yes. EI #2 stated the DON was in her office, not working with residents until the investigation is completed. On 11/12/2020 at 4:45 PM, EI #2, the Administrator and Abuse Coordinator stated during the morning of 11/3/2020, in regard to the incident between RI #1 and EI #1, the Director of Nursing (DON), she didn't hear any abusive tones coming from EI #1, the DON. According to EI #2, during the afternoon, she did not hear EI #1 screaming at RI #1. EI #2 stated RI #1 was screaming so EI #1 was having to talk over the resident. In a follow up interview on 11/13/2020 at 12:30 PM, EI #2 stated she didn't consider what she witnessed on 11/3/2020 between RI #1 and EI #1 as abuse. According to EI #2, the facility's policy stated the staff should immediately be told to leave the facility until the investigation is completed. When asked if the facility's policy was followed when the DON (EI #1) was allowed to remain at the facility, EI #2 said no. EI #2 stated the DON was not sent home on 11/3/2020 because in her presence there was no abuse. During an interview on 11/14/2020 at 4:20 PM, EI #2 was asked if any other employee was accused of abuse, would they be allowed to stay on the premises in the business office. EI #2 answered no, they would have to leave the facility. ************************* On 11/19/2020 at 2:00 PM, the facility submitted an acceptable Removal Plan which documented: F607 The facility failed to ensure 5 of 7 components of the abuse policy were implemented. RI#1 has been discharged from the facility. Case worker with (Name) Regional Medical Center informed facility resident would go to another LTC facility in Cullman (name of facility is unknown). Health Care Inc. has not refused to readmit resident, and would welcome the resident back if she chose to do so. All residents have the potential to be affected. Assistant Administrator will be in-serviced on all components of abuse policy by an outside consultant on Sunday, November 15, 2020. Task completed on November 15th, 2020. On Sunday, November 15th, 2020, Assistant administrator accepted responsibility for the completion facility investigation alleging verbal abuse of resident by former DON. 5-day report will be uploaded to the State portal Tuesday, November 17th, 2020. Beginning on November 19, 2020, the assistant administrator will re-open the investigation into the allegations of verbal, physical, and mental abuse related to RI #1. The investigation will be completed with a full five-day report to ADPH on or before November 23, 2020 in accordance with the attached investigation plan. Beginning on November 19, 2020, (Name) and (Name) of the law firm (Name) will provide guidance and direction of the Investigation Plan including implementation of the plan by the facility, review of interviews with facility staff, guidance and direction with any re-interviews and content for re-interview, and review and guidance regarding investigation results and findings including review of the five-day report. On Sunday, November 15, 2020, the Assistant Administrator in-serviced the Administrator and the interim DON on all components of abuse policy. Task completed on November 15th, 2020. Social Worker will be in-serviced on all components of abuse policy by an outside consultant on Sunday, November 15, 2020. Task completed on November 15th, 2020. Beginning on November 15, 2020, the Social worker/Designee will interview all staff to ensure there are no unreported allegations of abuse, neglect, mistreatment or misappropriation. Staff interviews will be completed by Monday, November 16th, 2020. The Social Worker/Designee shall immediately report any allegation to the Assistant Administrator who shall institute a full investigation and make reports to ADPH as required. Of 54 total staff, 44 have completed this task as of Monday, November 16, 2020, 6:00PM. Four contract employees are utilized by the facility. Their training will be completed Tuesday, November 17, 2020. As of 4:00PM Tuesday, November 17, 2020, all facility employees and contract employees have completed this training. Beginning on November 15, 2020, the Social worker/Designee will interview all residents who are able to answer interview questions, to ensure there are no unreported allegations of abuse, neglect, mistreatment or misappropriation. Residents that are not able to comprehend the interview will be assessed for signs or symptoms of abuse through body audits and contact with family or resident representatives. Residents that are not able to answer the interview questions will be assessed for signs or symptoms of abuse through body audits and contact with family or resident representatives. Resident interviews will be completed by Monday, November 16th, 2020. The Social worker/Designee shall immediately report any allegation to the Assistant Administrator who shall institute a full investigation and make reports to ADPH as required. Of 47 residents, 42 were in-serviced, three were unable to comprehend and assessed by body audits and contact with family or resident representatives, and two refused. Beginning Sunday, November 15, 2020, the Assistant Administrator/Designee will in-service facility staff on the above personnel changes and on resident rights related to freedom from abuse. These in-services will include all components of abuse policy, and the facility's strict policy against retaliation against any staff member reporting any allegation of abuse, neglect, mistreatment, or misappropriation. These in-services will be completed on Monday, November 16th, 2020. Any staff member who has not completed the above in-services by this date will be removed from the schedule and not allowed to return to work until the in-service is completed. Of 54 total staff, 44 have completed this task as of Monday, November 16, 2020, 6:00PM. Four contract employees are utilized by the facility. Their training will be completed Tuesday, November 17, 2020. As of 4:00PM Tuesday, November 17, 2020, all facility employees and contract employees have completed this training. (Name) and (Name) of the law firm (Name), will provide guidance and oversight to ensure policies are implemented and any further allegations are thoroughly investigated until substantial compliance is obtained by the facility. Immediacy will be removed Thursday, November 19th, 2020 ************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F 607 was lowered to a D level on 11/19/2020, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as the result of the investigation of complaint/report number AL 470.

Based on interviews, review of the facility's POLICY AND PROCEDURE OF ABUSE AND SUSPECTED ABUSE, the facility's investigation file, a complaint received by the State Survey Agency, and Resident Identifier (RI) #1's medical and hospital records, the facility failed to ensure RI #1 was not verbally, physically, and mentally abused by Employee Identifier (EI) #1, the Director of Nursing (DON) twice on 11/3/2020. On 11/3/2020 at approximately 8:00 AM, witnesses reported the DON began hollering and screaming at RI #1 to get back into the room. The DON was observed to forcefully place RI #1 back on the bed. Then at approximately 3:30 PM, the DON was again observed hollering at RI #1, who was wanting to leave and making statements about wanting to harm/kill his/herself. Witnesses reported the DON yelled and told RI #1 to go ahead and kill him/herself, that the resident sounded stupid. RI #1 was subsequently transferred to a local hospital for [MEDICAL CONDITION]. This deficient practice placed RI #1, one of four sampled residents reviewed for abuse in immediate jeopardy, as this situation was likely to cause serious injury, harm, impairment or death. On 11/14/2020 at 6:30 PM, the Administrator was given a copy of the Immediate Jeopardy (IJ) template and notified of the finding of substandard quality of care at immediate jeopardy in the area of Freedom from Abuse, Neglect, and Exploitation, F600. Findings include: The facility's undated POLICY AND PROCEDURE OF ABUSE AND SUSPECTED ABUSE documented IT IS HCI'S GOALS TO ENSURE THE RESIDENTS HAVE THE RIGHTS TO BE FREE FROM ABUSE, . AS DEFINED IN THIS POLICY . DEFINITIONS: 1. ABUSE - IT IS THE WILLFUL INFLICTION OF INJURY, UNREASONABLE CONFINEMENT, INTIMIDATION, OR PUNISHMENT WITH RESULTING PHYSICAL HARM, PAIN OR MENTAL ANGUISH . INSTANCES OF ABUSE OF ALL RESIDENTS, IRRESPECTIVE OF ANY MENTAL OR PHYSICAL CONDITION, CAUSE PHYSICAL HARM, PAIN OR MENTAL ANGUISH. IT INCLUDES VERBAL ABUSE, . PHYSICAL ABUSE, AND MENTAL ABUSE . WILLFUL, AS USED IN THIS DEFINITION OF ABUSE, MEANS THE INDIVIDUAL MUST HAVE ACTED DELIBERATELY, NOT THAT THE INDIVIDUAL MUST HAVE INTENDED TO INFLICT INJURY OR HARM . 6. VERBAL ABUSE - IS THE USE OF ORAL WRITTEN OR GESTURED LANGUAGE THAT WILLFULLY INCLUDES DISPARAGING AND DEROGATORY TERMS TO RESIDENTS . 8. PHYSICAL ABUSE - INCLUDES HITTING, SLAPPING, PINCHING AND KICKING. IT ALSO INCLUDES CONTROLLING BEHAVIOR BY CORPORAL PUNISHMENT. 9. MENTAL ABUSE - INCLUDES, BUT IS NOT LIMITED TO HUMILIATION, HARRASSMENT, AND THREATS OF PUNISHMENTS OF DEPRIVATION . On 11/6/2020, the State Survey Agency received a complaint which alleged the Director of Nursing screamed, yelled, shoved, pushed, cursed and spit at RI #1 on 11/3/2020. RI #1 was admitted to the facility 10/10/2017 with a medical history to include: Heart Failure, Diabetes Mellitus, Anxiety Disorder, [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. RI #1's Annual Minimum Data Set with an assessment reference date of 9/25/2020 indicated RI #1 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14. In a telephone interview on 11/10/2020 at 9:20 AM, RI #1 stated he/she went to the DON on 11/3/2020 because he/she wanted to leave the facility. According to RI #1, the DON told him/her to go back to his/her room. RI #1 stated the DON hit him/her in the back as she (DON) walked with RI #1 to the resident's room. RI #1 stated the DON was screaming at him/her saying I was acting like a two-year-old. When asked how this made him/her feel, RI #1 stated bad. On 11/10/2020 at 3:34 PM, an interview was conducted with EI #5, a Licensed Practical Nurse (LPN) who worked the 6:00 AM to 2:00 PM shift on 11/3/2020. EI #5 stated during the shift, RI #1 was anxious, wanted to leave, was not happy and was exit seeking. EI #5 said she observed the DON (EI #1) to raise her voice at RI #1, RI #1 then got upset and overturned a bedside table and chair. EI #5 said the DON then got in front of RI #1 and told the resident that he/she needed to calm down, that no one would take him/her. EI #5 said that when the DON said this, RI #1 hit the window with his/her right hand, the DON then took RI #1 by his/her shirt and forced the resident down on the bed. According to EI #5, the Administrator (EI #2) walked in and heard the DON talking loudly to the resident and did nothing. When asked what time this occurred, EI #5 stated around 8:00 AM. When asked if there was any other witnesses to this incident, EI #5 stated EI #8, a Registered Nurse (RN) was also there. According to EI #5, when the Administrator arrived, she asked everyone to leave the room; EI #5 stated she left but EI #8 stayed in the room with the Administrator. On 11/10/2020 at 4:31 PM, an interview was conducted with EI #8, a RN who worked the 6:00 AM to 2:00 PM shift on 11/3/2020. EI #8 stated she was in the office when she heard screaming. EI #8 stated she came out of the office and witnessed the DON (EI #1) scream at RI #1, who was at the nurses' desk, to get back into his/her room. According to EI #8, the DON told RI #1 to go back into his/her room because he/she was on isolation. RI #1 went into his/her room and the DON followed the resident. EI #8 observed the DON to push RI #1 onto the bed and yell at the resident. EI #8 stated the DON then asked her to go and get the [MEDICATION NAME] injection. EI #8 stated she brought the [MEDICATION NAME] injection back to the DON. EI #8 stated she administered the [MEDICATION NAME] injection to RI #1, who was kicking, while the DON held RI #1's hands and arms. According to EI #8, the Administrator (EI #2) came and saw what was going on. When asked what time this occurred, EI #8 stated around 8:00 AM. EI #8 stated what she witnessed was considered abuse. On 11/10/2020 at 5:00 PM, an interview was conducted with EI #10, a LPN who worked the 6:00 AM to 2:00 PM shift on 11/3/2020. EI #10 stated RI #1 was agitated and kept coming out of his/her room saying he/she wanted to leave. EI #10 stated when the DON (EI #1) came out of her office, she informed her that she was having a hard time trying to redirect RI #1. The DON then walked into RI #1's room and EI #10 stated she heard a chair being thrown and RI #1 yelling. When asked who was present in RI #1's room, EI #10 stated she was, the DON (EI #1) and EI #8, a RN. EI #10 stated the DON was yelling so loudly at the resident. The resident was administered [MEDICATION NAME] because RI #1 kept saying that he/she wanted to leave. According to EI #10, when the Administrator, EI #2, came into RI #1's room, she left. EI #10 stated after RI #1 was administered [MEDICATION NAME], the resident was calm the rest of the shift. In a follow-up interview on 11/12/2020 at 11:30 AM, EI #10 was asked what time the incident occurred. EI #10 stated she wasn't sure, but it was probably mid-morning, before lunch. EI #10 stated the DON (EI #1) was screaming very loud at the resident saying, you've got to stop acting like this, nobody will take you. According to EI #10, when the DON told the resident that he/she was about to get a ([MEDICATION NAME]) shot, the resident said no but the DON stated that she could RI #1 a shot when he/she was acting like this. EI #10 stated the DON was yelling very loudly at the resident. EI #10 stated when the Administrator (EI #2) came into RI #1's room, she left. When asked if EI #2 witnessed the DON yell at the resident, EI #10 said yes because the DON was screaming so loud that the Administrator had to hear it before she got into the room and she definitely heard it when she (EI #2) was in the resident's room. On 11/9/2020 at 4:45 PM, an interview was conducted with EI #3, a Certified Nursing Assistant (CNA) who worked the 2:00 PM to 10:00 PM shift on 11/3/2020. EI #3 stated she was at the nurses' desk and witnessed the DON (EI #1) go into RI #1's room. According to EI #3, EI #22, a CNA was also present in RI #1's room. EI #3 stated when she heard the DON (EI #1) screaming at the resident, she went into the resident's room. The resident, RI #1, was seated on the side of the bed and the DON was kneeling so that she was face to face with the resident. EI #3 stated the DON was screaming so much that she saw spit landing on the resident's face. EI #3 stated the resident was crying, begging the DON to stop yelling and saying, why are you doing this to me. According to EI #3, EI #22, told her that she didn't need to be in the resident's room. EI #3 stated the DON pointed her finger towards the resident's chest and screamed saying cut your crap out, you are spreading germs throughout the facility, I don't have time for this. EI #3 stated the DON touched the resident's chest with her finger and it caused the resident to go back on the bed. EI #3 stated the DON was screaming so loud that she was losing her voice. According to EI #3, the Administrator (EI #2) came and pulled the DON out of the resident's room. The DON then left the facility. A staff member then called the ambulance to come and pick the resident up. When the ambulance arrived at the facility, EI #3 stated a nurse (EI #7) informed the ambulance crew that RI #1 was suicidal. According to EI #3, after the incident the resident informed her that he/she wanted to die, and he/she didn't want to be at the facility if he/she was treated like that. On 11/9/2020 at 4:45 PM, an interview was conducted with EI #4, a CNA who worked the 2:00 PM to 10:00 PM shift on 11/3/2020. EI #4 stated around 3:00 PM, she witnessed the DON (EI #1) yell and scream at RI #1 to get back in his/her room when the resident came out of his/her room. Afterwards, EI #4 stated the Administrator (EI #2) told the DON to leave. EI #4 stated she considered this incident to be verbal abuse. During an interview on 11/9/2020 at 5:15 PM, EI #7, a LPN stated she worked in the facility on 11/3/2020 during the 2:00 PM to 10:00 PM shift. EI #7 stated she was administering medications when she heard raised voices and yelling coming from RI #1's room. EI #7 stated she couldn't tell who was yelling but within minutes she saw the DON (EI #1) come out of RI #1's room. According to EI #7, when the DON came out of RI #1's room, she informed EI #7 to send RI #1 out because the resident was suicidal. RI #1's physician's telephone order written by EI #7 dated 11/3/2020, documented Send to (name of hospital) ER (emergency room ) for Psych eval. On 11/10/2020 at 9:52 AM, an interview was conducted with an Emergency Medical Service (EMS) staff who transported RI #1 from the facility to the local hospital on [DATE]. According to the EMS staff, the facility staff informed him RI #1 was being sent to the hospital because of a suicidal attempt; the resident had refused medication, care and treatment. According to the EMS staff when he arrived in the facility, RI #1 was disconnected, not talking and not suicidal. The resident didn't answer any questions until he/she was in the ambulance. A CNA came outside as the resident was being loaded and informed the EMS staff the DON had yelled, screamed and pushed the resident. The EMS staff stated RI #1 was polite during transport and informed the staff that he/she didn't feel safe at the facility anymore. According to the EMS staff, RI #1 informed him the DON had come into the resident's room, pushed the resident down on the bed and yelled at him/her. RI #1 informed the EMS staff that he/she didn't want to go back to the facility and that he/she wanted to kill him/herself if he/she had to continue to stay at the facility. On 11/10/2020 at 10:25 AM, an interview was conducted with EI #19, a CNA who worked the 2:00 PM to 10:00 PM shift on 11/3/2020. EI #19 stated she was in the shower room when she heard what she thought was two residents screaming. EI #19 stated she came down the hall to see and ask what was going on, when EI #3, a CNA, informed her that the DON (EI #1) was yelling at a resident. According to EI #19, EI #3 informed her that she had witnessed the DON (EI #1) hit RI #1. EI #19 stated as she got closer to the resident's room, she heard the DON (EI #1) say I am not going to lose my job over you. In a follow up interview on 11/12/2020 at 10:15 AM, EI #19 stated this incident took place after 2:00 PM but that she couldn't recall the exact time. On 11/10/2020 at 10:40 AM, an interview was conducted with a RN from the hospital RI #1 was transferred to on 11/3/2020. The RN stated the resident was fearful and stated he/she didn't want to go back to the nursing facility because the nurse (EI #1, the DON) had hit him/her. According to the RN, RI #1 was tearful, didn't feel safe at the facility and asked the RN to promise that he would not send the resident back to the facility. The local hospital medical record for RI #1 dated 11/3/2020, documented . Patient sent from Health Care, Inc . Patient reports abuse from nurse. History of Present Illness The patient presents to the emergency department and reports being assaulted . The patient (his/herself) tells me that the head nurse pushed (him/her) down hard on the bed and (he/she) has mid back pain . On 11/10/2020 at 4:20 PM, an interview was conducted with the contracted mental health therapist who was in the facility on 11/3/2020. The mental health therapist stated she was in the conference room typing a note when she heard screaming. The mental health therapist stated she ran in the direction of the screaming and when she got to RI #1's room, she noticed it was the DON (EI #1) screaming at RI #1. According to the mental health therapist, RI #1 was agitated, wanted to leave the facility and said that he/she was going to kill him/herself. In response to what the resident was saying, the mental health therapist stated the DON said, go ahead you sound stupid, do you know how stupid that sounds. The DON then came out of the resident's room, threw her mask down and said that she quit. The mental health therapist stated she and the Administrator (EI #2) then went into RI #1's room, where the Administrator calmed the resident down by telling him/her that he/she would be able to leave the facility. The mental health therapist stated the screaming done by the DON towards RI #1 was verbal abuse. RI #1's . BEHAVIORAL HEALTHCARE Progress Note written by the contracted mental health therapist and dated 11/3/2020, documented . Crisis intervention and resolution at Health Care Inc. as requested by the nursing staff . (RI #1) had been severely agitated and acting out. Therapist went to see (RI #1) . (RI #1) was red eyed and still crying as therapist sat down with (him/her) . (RI #1) stated that (he/she) does not want to be here anymore . (RI #1) stated that some people here are not nice to (him/her) . Later in the afternoon therapist could hear screaming and yelling coming from the direction of (RI #1's) room. Therapist went there to find the director of nursing arguing with (RI #1) . (RI #1) was laying on (his/her) back on (his/her) bed crying , (his/her) face was red and (he/she) appeared extremely distraught. (RI #1) could not talk for a few minutes and then (he/she) expressed that (he/she) had gone to the nurse's door to ask about when (he/she) is supposed to be leaving and was escorted back to (his/her) room with stern reminders . In an interview on 11/10/2020 at 12:50 PM, EI #1, the DON denied being verbally, physically and mentally abusive to RI #1 on 11/3/2020. EI #1 did state she may have raised her voice, but she was not abusive to the resident. Contained within the facility's investigation file was the Five Day Report which read (RI #1) November 3, 2020 Incident . Reported allegation: According to the initial 24 hour report submitted by Health Care Incorporated (HCI) and our interviews with (EI #2), Administrator, and (EI #23), Assistant Administrator, the facility became aware of a November 3, 2020 allegation of abuse regarding resident (RI #1) on November 9, 2020 during a complaint survey at the facility. The facility initially conducted an investigation into the allegation, however, our firm was retained to oversee a complete reinvestigation of the November 3, 2020 incident on November 19, 2020 . Investigation Report: Detailed interviews were conducted with facility staff who were reported to have knowledge of the situation involving (RI #1) on November 3, 2020. Through our initial interviews and preliminary reviews, it became apparent that there were potentially several separate instances of abuse. During the morning of November 3, 2020, there was a potential incident of verbal abuse by (EI #1), the former DON, a potential incident of mental abuse by (EI #1), and a potential incident of physical abuse by (EI #1). During the afternoon of November 3, 2020, there was a potential incident of verbal abuse by (EI #1) the former DON, a potential incident of mental abuse by (EI #1), and a potential incident of physical abuse by (EI #1) . Results of Investigation: Based on the investigation conducted in this matter, we substantiate the following: Verbal, mental, and physical abuse by DON (EI #1) against Resident (RI #1) on the morning of November 3, 2020. Verbal, mental, and physical abuse by DON (EI #1) against Resident (RI #1) on the afternoon of November 3, 2020 . ************************* On 11/19/2020 at 2:00 PM, the facility submitted an acceptable Removal Plan which documented: F600 The facility failed to insure RI #1 was not verbally, physically, and/or mentally abused by the Director of Nursing two separate times on 11/3/2020. RI#1 has been discharged from the facility. Case worker with (Name) Regional Medical Center informed facility resident would go to another LTC facility in Cullman (name of facility is unknown). Health Care Inc. has not refused to readmit resident, and would welcome the resident back if (he/she) chose to do so. All Residents have the potential to be affected. Director of Nursing (DON) was discharged from employment with the facility after submitting her immediate resignation on Friday, November 13th, 2020. Interim DON commenced duties immediately following discharge of former DON. Permanent DON to begin employment on Tuesday, November 17th, 2020. Assistant Administrator has assumed responsibility as abuse coordinator effective Sunday, November 15, 2020. Assistant Administrator will be in-serviced on all components of abuse policy by an outside consultant on Sunday, November 15, 2020. Task completed on November 15th, 2020. On Sunday, November 15, 2020, the Assistant Administrator in-serviced the Administrator and the interim DON on all components of abuse policy. Task completed on November 15th, 2020. Beginning Sunday, November 15, 2020, the Assistant Administrator/Designee will in-service facility staff on the above personnel changes and on resident rights related to freedom from abuse. These in-services will include all components of abuse policy, and the facility's strict policy against retaliation against any staff member reporting any allegation of abuse, neglect, mistreatment, or misappropriation. These in-services will be completed on Monday, November 16th, 2020. Any staff member who has not completed the above in-services by this date will be removed from the schedule and not allowed to return to work until the in-service is completed. Of 54 total staff, 44 have completed this task as of Monday, November 16, 2020, 6:00PM. Four contract employees are utilized by the facility. Their training will be completed Tuesday, November 17, 2020. As of 4:00PM Tuesday, November 17, 2020, all facility employees and contract employees have completed this training. Beginning Sunday, November 15, 2020, Assistant Administrator/Designee will provide in-services to each resident regarding the above personnel changes, all components of abuse policy, and the facility's strict policy against retaliation against any resident reporting any allegation of abuse, neglect, mistreatment, or misappropriation. Resident in-services will be completed by Monday, November 16th, 2020. Of 47 residents, 42 were in-serviced, three were unable to comprehend, and two refused. Social Worker will be in-serviced on all components of abuse policy by an outside consultant on Sunday, November 15, 2020. Task completed on November 15th, 2020. Beginning on November 15, 2020, the Social worker/Designee will interview all residents who are able to answer interview questions, to ensure there are no unreported allegations of abuse, neglect, mistreatment or misappropriation, and the facility's strict policy against retaliation against any resident reporting any allegation of abuse, neglect, mistreatment, or misappropriation. Residents that are not able to answer the interview questions will be assessed for signs or symptoms of abuse through body audits and contact with family or resident representatives. Resident interviews will be completed by Monday, November 16th, 2020. Of 47 residents, 42 were in-serviced, three were unable to comprehend and assessed by body audits and contact with family or resident representatives, and two refused. Beginning on November 15, 2020, the Social worker/Designee will interview all staff to ensure there are no unreported allegations of abuse, neglect, mistreatment or misappropriation. Staff interviews will be completed by Monday, November 16th, 2020. The Social Worker/Designee shall immediately report any allegation to the Assistant Administrator who shall institute a full investigation and make reports to ADPH as required. Of 54 total staff, 44 have completed this task as of Monday, November 16, 2020, 6:00PM. Four contract employees are utilized by the facility. Their training will be completed Tuesday, November 17, 2020. As of 4:00PM Tuesday, November 17, 2020, all facility employees and contract employees have completed this training. Beginning on November 19, 2020, the assistant administrator will re-open the investigation into the allegations of verbal, physical, and mental abuse related to RI #1. The investigation will be completed with a full five-day report to ADPH on or before November 23, 2020 in accordance with the attached investigation plan. Beginning on November 19, 2020, (Name) and (Name) of the law firm (Name) will provide guidance and direction of the Investigation Plan including implementation of the plan by the facility, review of interviews with facility staff, guidance and direction with any re-interviews and content for re-interview, and review and guidance regarding investigation results and findings including review of the five-day report. (Name) and (Name) of the law firm (Name), will provide guidance and oversight to ensure policies are implemented and any further allegations are thoroughly investigated until substantial compliance is obtained by the facility Immediacy will be removed Thursday, November 19th, 2020 ************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F600 was lowered to a D level on 11/19/2020, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as the result of the investigation of complaint/report number AL 470.

Based on observations, interviews, and review of facility policies titled, Food Safety and Sanitation and Employee Sanitary Practices, the facility failed to ensure: 1) open food items were covered and labeled with a use by date prior to storage in the reach-in refrigerator, and 2) a dietary manager and dietary aide wore a hair net to completely cover all hair on their head while serving residents' food for the supper meal on the tray line in the kitchen area. This had a potential to affect 44 of 45 residents in the facility receiving meals from the kitchen. Findings Include: 1) A review of a facility policy titled, Food Safety and Sanitation, with no date, revealed . 4. All leftovers are labeled, covered, and dated when stored . On 08/05/19 at 03:04 p.m., during the tour of the kitchen, the surveyor observed the following food items in the reach-in refrigerator with no use by dates and no covering over the food items: 1. one container of stewed tomatoes, 2. one container of mixed salad with diced tomatoes, and 3. 40 small clear cups of watermelon. On 08/05/19 at 03:13 p.m., the surveyor conducted an interview with Employee Identifier (EI) #4, the Dishwasher Aide. The surveyor asked EI #4 if the stewed tomatoes, mixed salad with diced tomatoes and 40 small clear cups of watermelon in the reach-in refrigerator had a use by date or covering over these food item. EI #4 stated no. EI #4 further stated that she had to answer a phone call and had put the food items in the reach-in refrigerator without covering the food items and did not put a use by date on them. The surveyor asked EI #4 what was the potential concern of food items not having a use by date or covering food in a reach-in refrigerator. EI #4 stated the residents could get food poisoning if the food was left in refrigerator too long of a time. 2) A review of a facility policy titled, Employee Sanitary Practices, with no date, revealed . 1. Wear hair restraints .to prevent hair from contacting exposed food . On 08/05/19 at 04:09 p.m., during the tour of the kitchen, the surveyor observed EI #5, Dietary Manager, scooping ice out of an ice cooler and putting ice in a cup while standing by the tray line for the residents supper meal. EI #5 was observed with her hair net on the center of her head; all of her hair was not covered by the hair net, and the back of her hair was lying on her neck. The surveyor observed EI #6, a dietary aide, while serving residents' food on the tray line in the kitchen area for the supper meal. EI #6 had her hair net on the center of her head; all of her hair was not covered by the hair net, and the back of her hair was lying on her neck. EI #6 continued pouring water in the resident cups for the supper meal with her hair not all covered with the hair net. On 08/05/19 at 04:31 p.m., the surveyor conducted an interview with EI #5. EI #5 was asked if EI #6's hair was contained in her hair net while pouring water in the residents' cups for the supper meal. EI #5 stated that all of EI #6's hair was not contained in the hair net. EI #5 further stated that a few strands of EI #6's hair was lying on the back of her neck. EI #5 was asked what would be the potential harm with EI #6's hair not being contained and completely covered in the hair net while pouring water in the residents cups for the supper meal. EI #5 replied that EI #6's hair could get in the residents' food and make somebody sick. The surveyor asked EI #5 why should all of EI #6's hair be restrained in the hair net. EI #5 replied that the hair should be contained in a hair net for food safety concerns. On 08/05/19 at 04:39 p.m., the surveyor conducted an interview with EI #5. EI #5 was asked when she was scooping ice out of the ice cooler and putting ice in the cup was the back of her hair lying on her neck and not completely covered with a hair net. EI #5 stated she did not know. EI #5 was then asked what would be the potential harm with her hair not being contained and completely covered in the hair net while in the kitchen. EI #5 stated that the hair could get in the food and make somebody sick. On 08/07/19 at 03:02 p.m., the surveyor conducted an interview with EI #6. EI #6 was asked, on 08/05/19 at 04:09 p.m. while she was pouring water in the residents' cups on the food tray line, was her hair completely covered by the hairnet. EI #6 replied, no. The surveyor asked EI #6 why her hair was not covered up. EI #6 replied that she thought that her hair was all covered up, but it was not. EI #6 was then asked what would be the potential harm with hair not being contained and completely covered in the hair net while in the kitchen. EI #6 stated you should cover your hair with a hair net to keep hair from getting in the residents' food, which might cause the resident to choke. EI #6 further stated that the hair in a resident's food may deter the resident from eating their food.

Based on observation, interviews, and review of a facility policy titled, Policy and Procedure For Hand-Washing, the facility failed to ensure Employee Identifier (EI) #1, a Licensed Practical Nurse, washed her hands during a medication pass for Resident Identifier (RI) #26: EI #1 did not wash hands after she cleaned the top of the medication cart with her ungloved hands, and prior to putting on her gloves to pick up RI #26's cup of oral medications. Further, EI #1 touched the top of RI #26's right and left foot with both of her gloved hands, then gave oral medications without first washing her hands. After administering the oral medications, EI #1 changed gloves without washing hands to administer RI #26's eye drops, and again changed gloves without washing hands to administer inhalation medication. After administering all of RI #26's medications, EI #1 removed gloves and returned to the medication cart to document without washing her hands. This affected one of two licensed nurses observed during medication administration pass, and one of three residents observed during medication administration pass. Findings Include: RI #26 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. A review of a facility policy titled, Policy and Procedure For Hand-Washing, with a revised date of 7/23/2014, revealed .WHEN TO WASH HANDS, BUT NOT LIMITED TOO: (WHEN IN DOUBT WASH THEM HANDS) .4. Before preparing or handling medications; 5. After having prolonged contact with a Resident; 6. After handling .contaminated .etc .9. After removing gloves .12. Whenever in doubt . On 8/07/19 at 07:50 a.m., the surveyor observed EI #1, a Licensed Practical Nurse (LPN), during a medication administration pass for RI #26. The surveyor observed the following during EI #1's medication pass for RI #26: 1. EI #1 cleaned the top of the medication cart with her ungloved hands, did not wash her hands, put on her gloves, and picked up RI #26's cup of oral medication with her gloved hands. 2. EI #1 touched the top of the RI #26's right and left foot with both of her gloved hands, did not remove her gloves to wash her hands, and gave RI #26's cup of oral medications with the right gloved hand. 3. After RI #26 swallowed the oral medication solution, EI #1 removed her pair of gloves, and put on another pair of gloves, without washing her hands, and put RI #26's eye medication in both eyes. 4. EI #1 removed her gloves after giving RI #26's eye medication, did not wash her hands, and put RI #26's inhalation medication in the reservoir of the face mask, 5. EI #1 removed her gloves after giving RI #26's inhalation medication, did not wash her hands, put on a pair of gloves to clean RI #26's reservoir and face mask of the breathing machine; and 6. EI #1 removed her gloves, did not wash her hands, left RI #26's room to go to the medication cart and document in the binder the medications given to RI #26. On 8/07/19 at 12:45 p.m., the surveyor conducted an interview with EI #1, a Licensed Practical Nurse. EI #1 was asked did you wash your hands during the medication pass with RI #26 during the following observations: 1. after you cleaned the top of the medication cart with your ungloved hands, and prior to putting on your gloves to pick up RI #26's cup of oral medication, 2. after you touched the top of the RI #26's right and left foot with both of your gloved hands, and prior to giving RI #26's cup of oral medications with the right right gloved hand, 3. after RI #26 swallowed the oral medication solution, removed a pair of gloves, and prior to putting on another pair of gloves to give RI #26's eye medication to both eyes, 4. after giving RI #26's eye medication, removing your gloves, and prior to putting RI #26's inhalation medication in the reservoir of the face mask, 5. after giving RI #26's inhalation medication, removing your gloves, and prior to putting on gloves to clean RI #26's reservoir and face mask of the breathing machine. and 6. after removing your gloves, prior to leaving RI #26's room and ,left RI #26's room to go to the medication cart, and document in the binder the medications given to RI #26. EI #1 stated no, she did not wash her hands. EI #1 was asked why she had not washed her hands during RI #26's medication pass. EI #1 stated that she was nervous. EI #1 was asked what was the facility policy regarding hand hygiene prior to and after giving a resident medications, after removing your gloves, after patient care, and after touching contaminated objects. EI #1 stated the policy states that you should wash your hands. EI #1 was asked what would be the concern with a licensed nurse not washing her hands prior to and after giving a resident medications, after removing her gloves, after patient care, and after touching contaminated objects. EI # 1 stated it could spread infection and cross contamination. On 8/07/19 at 1:02 p.m., the surveyor conducted an interviews with EI #2, Infection Control Preventionist/Licensed Practical Nurse. EI #2 was asked what was the facility policy regarding hand hygiene prior to and after giving a resident their medications, after removing your gloves, after patient care, and after touching contaminated objects. EI #2 stated you should wash your hands. EI #2 was asked what would be the concern with a licensed nurse not washing her hands prior to and after giving a resident medications, after removing her gloves, after patient care, and after touching contaminated objects. EI #2 stated you should wash your hands to prevent the transmission of infections

Based on record review, interview, and a review of a facility document titled Resident Assessment Instrument User Manual, the facility failed to ensure Resident Identifier (RI) #1's Minimum Data Set (MDS) assessments were accurately coded for the use of an anticoagulant. This affected one of two sampled residents for whom MDS assessments were reviewed for coding of an anticoagulant. Findings Include: RI #1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. A review of a facility document titled Resident Assessment Instrument User Manual, Version 3.0, revised October/November 2012, revealed .Steps for Assessment 1. Review the resident's medical record for documentation that any of these medications were received by the resident during the 7-day look-back period . ND410E Anticoagulant . Record the number of days an anticoagulant medication was received by the resident at any time during the 7-day look-back period . A review of RI #1's Physician orders [REDACTED].Eliquis 2.5 mg tablet Give 1 tablet by mouth 2 times a day ([MEDICAL CONDITION]) . A review of the following MDS assessments for RI #1 with Assessment Reference Dates (ARDs) of 7/07/2018, 10/05/2018, 1/03/2019, 4/01/2019, and 6/29/2019 revealed . NO410E: Medication received: Days anticoagulant 0 . Review of RI #1's Medication Administration Record [REDACTED]. On 8/07/19 at 4:45 p.m., an interview was conducted with EI #3, MDS Coordinator/Licensed Practical Nurse. EI #3 was asked who was responsible for ensuring RI #1's Quarterly and Yearly Minimum Data Set (MDS) assessments with Assessment Reference Dates of : 7/07/2018, 10/05/2018, 1/03/2019, 4/01/2019, and 6/29/2019 were coded accurately. EI #3 stated that she was. EI #3 was asked if RI #1's Quarterly and Yearly MDS with ARDs of 7/07/2018, 10/05/2018, 1/03/2019, 4/01/2019, and 6/29/2019 were coded accurately for there use of an anticoagulant. EI #3 stated no. EI #3 was asked what should have been coded for the area of anticoagulant. EI #3 stated it should have been coded yes for each of the assessments. EI #3 further stated that EI #1 was on an anticoagulant during these 7 day look back dates. EI #1 was asked why should RI #1's Quarterly and Yearly MDS assessments have been coded accurately for an anticoagulant. EI #1 stated that the MDS Assessments gives you the whole picture of the resident and how to take care of that resident.

Based on observations, interview and review of the Food Code by the Food and Drug Administration (FDA) (YEAR), the facility failed to ensure condiments were labeled with an use by date. This had the potential to affect 44 of 47 residents who received meals from the facility's kitchen. Findings Include: The Food Code by the Food and Drug Administration (FDA) of the United States (U.S.) Department of Heath and Human Services (HHS) included the following: . ,[DATE].17 . Date Marking (B) . Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and package by a FOOD PR[NAME]ESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on PREMISES, sold or discarded . (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1 . On [DATE] at 8:09 AM, a brief tour of the kitchen was conducted. The surveyor observed red food coloring, 32 oz (ounce), with an open date of [DATE], and no use by date. On [DATE] at 8:30 AM, an interview was conducted with EI (Employee Identifier) #3, the Dietary Manager. The surveyor asked EI #3 who was responsible for labeling items with an use by date. EI #3 said she was responsible as well as the cooks. EI #3 was asked why was it important to have a use by date labeled on the food items. EI #3 said so the staff would know when to use it and when it expired. On [DATE] at 8:56 AM, the surveyor observed the reach in cooler. Thousand Island salad dressing and mayonnaise were observed with no use by date. On [DATE] at 9:10 AM, the surveyor conducted an interview with EI #3. The surveyor asked EI #3, why should mayonnaise and salad dressing have a use by date. EI #3 said because the mayonnaise has milk and eggs in it. EI #3 said the salad dressing was kept in the refrigerator and should have a use by date.

Based on observation, interview, and record review, the facility failed to ensure RI #17's wheelchair (w/c) bilateral armrests were free of torn, tattered, jagged, and sharp edges. This affected RI #17, one of 22 sampled residents. Findings Include: RI #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #17's Significant Change Minimum Data Set, dated dated [DATE], revealed RI #17's Brief Interview for Mental Status score of 9, indicating moderate impairment in cognition. The MDS also revealed RI #17 used a wheelchair (w/c) for mobility. A review of RI #17's care plan dated 03/7/17, for At Risk for Excessive Bleeding/Bruising RT (related to) (on blood thinner-A-Fib) revealed the following: .APPROACH PLAN . Observe for red splotches on skin . A review of RI #17's (MONTH) (YEAR)'s physician's orders [REDACTED]. MEDICATIONS . [MEDICATION NAME] 75 MG (MILLIGRAM) TAB (TABLET) GIVE 1 TABLET BY MOUTH ONCE DAILY. (A-FIB) . On 06/26/18 at 8:55 AM, RI #17 was alert, awake and oriented, up to the w/c in his/her room. Bruising was noted on both upper extremities. RI #17 said he/she wished he/she could have a new w/c. The surveyor aked why. RI #17 replied look at his/her arms, he/she got all of these bruises and skin tears because of the arms on the wheelchair. The surveyor observed both armrests of RI #17's w/c to have torn and tattered areas. The left armrest (inner aspect) had torn and tattered areas and the right armrest (outer aspect) also had torn and tattered areas. RI #17 stated he/she had spoken with the Administrator and was told they did not have anymore chairs. RI #17 also said he/she talked with EI (Employee Identifier) #5, Maintenance about the w/c, and EI #5 said he did not see anything wrong with the chair's armrest. RI #17 said he/she talked with them a few weeks prior, but nothing had been done. On 06/27/18 at 4:35 PM, an observation of RI #17's wheelchair and an interview with EI #5 was conducted. The surveyor asked what did EI #5 see regarding the resident's w/c armrests. EI #5 stated, Nothing. The surveyor asked EI #5 to look again and touch the resident's w/c. EI #5 stated, the left inner aspect was rough and cracked, the right outer aspects had a scrub spot and a crack in the armrest. The surveyor informed EI #5 that RI #17 complained of bruising and skin tears. The surveyor pointed to RI #17's bilateral upper extremities, and informed EI #5 that RI #17 stated he/she had talked with him about the wheelchair and was asked if that was correct. EI #5 stated, Yes, I told (RI #17) we could get another chair. The surveyor asked EI #5 why had he not gotten RI #17 another wheelchair. EI #5 stated, I offered. RI #17 replied to EI #5 not to tell that lady that lie. The surveyor asked how often he checked w/c's. EI #5 stated, Daily. The surveyor informed EI #5 that during tour on yesterday, Tuesday 06/26/18, at 8:55 AM, the chair had those areas. EI #5 stated he checked RI #17's w/c on yesterday about 8:30 AM, but had not checked the chair today. On 6/28/18 at 12:45 PM, during an interview with EI #6, Licensed Practical Nurse/LPN/ Care Plan Coordinator, the surveyor and EI #6 reviewed RI #17's care plan. The surveyor asked what care plans did RI #17 have with concerns r/t to skin. EI #6 stated, At risk for excessive bleeding and bruising r/t on blood thinner for A-Fib, (RI #17) on [MEDICATION NAME]. The surveyor asked what was the approach. EI #6 stated, Be cautious with skin during care, observe for splotches on (his/her) skin and any bleeding. The surveyor informed EI #6 on Tuesday and Wednesday, RI #17's bilateral upper extremities were observed with some bruising and splotchy areas and RI #17's w/c had some torn and tattered areas. The surveyor asked what could those areas cause. EI #6 stated, Could tear (his/her) skin. The surveyor asked according to the care plan was it followed. EI #6 stated, No, because the nurses was supposed to observe and report it to me, so that I could call the doctor.

Based on observation, interview, record review and a review of the facility's policy titled, MEDICATION ADMINISTRATION-GENERAL GUIDELINES, the facility failed to ensure licensed staff did not leave the medication cart unlocked, unattended and out of staff's sight during medication administration. This affected one of two medication carts, and one of three nurses observed during medication pass. Findings Include: A review of a facility policy titled, MEDICATION ADMINISTRATION-GENERAL GUIDELINES with an effective date of 07/01/09, revealed: .B. Administration .13) During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse . Resident Identifier (RI) #7 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #7's Admission Minimum (MDS) data set [DATE], revealed RI #7's Brief Interview for Mental Status score of 15, indicating cognition was intact. On 06/26/18 at 4:05 PM, Employee Identifier (EI) #7, Licensed Practical Nurse/LPN, was observed during medication administration. EI #7 entered RI #7's room and left the medication cart unlocked. EI #7 closed RI #7's door. The medication cart was out of sight and unattended by EI #7. On 6/26/18 at 4:20 PM, during an interview with EI #7, the surveyor asked what was left unlocked. EI #7 stated, Medication Cart. The surveyor asked was the medication cart in her view at all times, EI #7 stated, No, because I closed the resident's door, and I could not see it. The surveyor asked what was the potential harm for leaving the medication cart unattended, unlocked and out of view. EI #7 stated, Residents and staff could open medication cart and take medications out of the medication cart.

Based on observations, interview, record review and a review of the facility's policy titled, POLICY AND PR[NAME]EDURE FOR HAND-WASHING, the facility failed to ensure staff washed their hands after removing contaminated gloves and before touching other items, and before applying clean gloves. This affected three of three nurses and three of three residents observed during medication pass. Findings Include: A review of the facility's policy titled, POLICY AND PR[NAME]EDURE FOR HAND-WASHING with a revised date of 7/23/14, revealed the following: . POLICY: TO PROVIDE [MEDICATION NAME] (GUIDELINES) TO EMPLOYEES FOR PROPER AND APPROPRIATE HAND WASHING TECHNIQUES THAT WILL AID IN THE PREVENTION OF THE TRANSMISSION OF INFECTIONS, AND TO PREVENT THE SPREAD OF INFECTIOUS DISEASES.WHEN TO WASH HANDS, BUT NOT LIMITED TOO: (WHEN IN DOUBT WASH THEM HANDS): . 9. After removing gloves; . HANDSANTIZER (HANDSANITIZER) WHEN PROVIDING CARE IN A ROOM WITH NO BATHROOM. 2. USE HANDSANTIZER (HANDSANITIZER) BEFORE OPENING CURTAIN OR DOOR KNOB OR TOUCHING ANYTHING IN THE ROOM. 1. RI (Resident Identifier) #25 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #25's Annual MDS, dated [DATE], revealed RI #25's BIMS score of 10, indicating moderate impairment in cognition. On 06/26/18 at 3:27 PM, Employee Identifier (EI) #1, Licensed Practical Nurse/LPN was observed during medication pass administration. EI #1 applied clean gloves and obtained a finger stick blood sugar. EI #1 removed her gloves and applied clean gloves without washing her hands or using hand sanitizer. EI #1 administered artificial tears to RI #25, one drop to both eyes. EI #1 removed her gloves and reviewed RI #25's MARs (Medication Administration Record). EI #1 removed insulin from the drawer of the medication cart, obtained an alcohol prep and wiped the top of the insulin bottle. EI #1 removed a syringe from the medication cart, drew up six units of insulin in the syringe and obtained clean gloves. EI #1 locked the medication cart, reviewed RI #25's MARs again and entered RI #25's room. EI #1 applied gloves without washing her hands before applying clean gloves. EI #1 administered RI #25's insulin, removed her gloves and cleaned the accu check monitor. EI #1 did not wash her hands or use hand sanitizer after she removed her gloves. 2. RI #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #7's Admission Minimum (MDS) data set [DATE], revealed RI #7's Brief Interview for Mental Status score of 15, indicating cognition was intact. On 06/26/18 at 4:05 PM, EI #7, LPN was observed during medication pass. EI #7 applied gloves, obtained a basket for medications, cleaned the basket with a sani-wipe and removed her gloves. EI #7 opened the medication cart, dispensed medications and reviewed the MARs. EI #7 entered RI #7's room and administered the medications. EI #7 did not wash her hands or use hand sanitizer after removing her gloves and before touching other items. On 6/26/18 at 4:20 PM, during an interview with EI #7, the surveyor asked what should be done after gloves were removed. EI #7 stated, Wash hands. The surveyor asked was that what she did everytime she removed her gloves. EI #7 stated, I truly believe I did. The surveyor reminded EI #7 after she cleaned the basket and prepared the medications, she removed her gloves and did not wash her hands. The surveyor asked when was the next time she washed her hands. EI #7 stated, right before she gave the eye drops. The surveyor asked what was the potential harm when gloves were removed and hands were not washed. EI #7 stated, Infections, anytime remove gloves, always wash hands. The surveyor asked was that what she had done. EI #7 stated, No. 3. RI #40 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #40's Significant Change MDS dated [DATE], revealed RI #40 had short and long term memory problems and was severely impaired for cognitive skills for daily decision making. On 06/27/18 at 8:05 AM, EI #2 was observed during medication pass administration. EI #2, LPN washed her hands and medications were dispensed. Medications were crushed individually and gloves were applied. The capsule contents were poured in the medication cup. EI #2 removed her gloves and did not wash her hands or use hand sanitizer. EI #2 placed each medication/medication cup in the basket and reviewed RI #40's MARs. EI #2 obtained a pen and wrote the name of each medication on the medication cups. On 06/27/18 at 8:59 AM, during an interview with EI #2, LPN, the surveyor asked what should be done when gloves were removed, EI #2 stated, Wash hands. The surveyor asked was that what she had done everytime. EI #2 stated, To the best I can remember, all but one time. The surveyor asked what was the potential for harm when hands were not washed after gloves were removed. EI # stated, Bacteria and contamination.

Based on observation, interview and review of a facility policy titled, Employee Sanitary Practices, the facility failed to ensure the hair of Employee Identifier (EI) #3, the Dietary Manager, was completely contained in the hair net. This was observed on two of three days of the survey and had the potential to affect all 44 residents receiving meals from the kitchen at the time of the survey. Findings Include: A review of a facility policy titled Employee Sanitary Practices, no date, revealed . Procedure: All employees shall 1. Wear hair restraints . to prevent hair from contacting exposed food . On 04/18/17 at 2:35 p.m., on the initial tour of the facility, EI #3 was observed in the food preparation area with her hair not completely contained in the hair net. On 04/19/17 at 8:15 a.m., EI #3 was again observed in the food preparation area with her hair not completely contained in the hair net. On 04/19/17 at 3:55 p.m., an interview was conducted with EI #3. EI #3 was asked how should hair be covered with the hair net. EI #3 replied it should be totally covered. EI #3 was asked when should the hair be hanging loose from under the hair net. EI #3 replied, never if in the kitchen. EI #3 was asked what was the policy on hair nets in the kitchen. EI#3 replied the hair should be completely covered. EI #3 was asked how could loose hair hanging from a hairnet be a potential harm to the residents. EI #3 replied hair could get in to the food and cause cross contamination.

Based on interview, record review and review of a facility policy titled, [MEDICAL CONDITION] MEDICATIONS the facility failed to ensure AIMS (Abnormal Involuntary Movement Scale) assessments were completed routinely for residents receiving antipsychotic medications. This deficient practice affected Resident Identifier (RI) #2, RI #3, RI #6, RI #7 and RI #8, five of six residents whose medication regimens were reviewed for antipsychotic usage, and had the potential to affect 23 other residents identified by the facility as receiving antipsychotic medications. Finding Include: A facility policy titled [MEDICAL CONDITION] MEDICATIONS, no date, documented: . STANDARDS: 1. THE FACILITY WILL MAKE EVERY EFFORT TO COMPLY WITH STATE AND FEDERAL REGULATIONS RELATED TO THE USE OF PSYCHOPHARMACOLOGICAL MEDICATIONS IN THE LONG TERM CARE FACILITY TO INCLUDE REGULAR REVIEW FOR CONTINUED NEED, APPROPRIATE DOSAGE, SIDE EFFECTS, RISK/OR BENEFITS . NURSING: 4. AIMS WILL BE PERFORMED ON ANY RESIDENT ON AND (an) ANTIPSYCHOTIC ON A QUARTERLY BASIS . 1. RI #2 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #2's AIMS assessment form dated 09/26/16, revealed the last time an AIMS assessment had been completed for RI #2 was 12/05/16. A Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 01/30/17, assessed RI #2 as scoring an 11 on the Brief Interview for Mental Status (BIMS) indicating moderately impaired cognition. RI #2 was also assessed as having received an antipsychotic medication during this assessment period. RI #2's April 2017 physician's orders [REDACTED].> . [MEDICATION NAME] 25 mg (milligrams) TAB (tablet) . Give 1 TABLET PO (by mouth) 2 times A DAY. (PSYCHOTIC D/O (disorder)) . [MEDICATION NAME] 25 MG TAB . GIVE 1/2 TAB (12.5MG) @ (at) NOON. (PSYCHOTIC D/O) . On 04/20/17 at 11:26 p.m., an interview was conducted with Employee Identifier (EI) #2, the Director of Nursing. The surveyor asked EI #2, when should RI #2's next AIMS assessment, after the 12/05/16 assessment, have been completed. EI #2 said the AIMS assessment should have been completed last month (February 2017). 2. RI #3 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #3's April physician's orders [REDACTED].> . [MEDICATION NAME] 50 MG . GIVE 1 & 1/2 TABLETS (75 MG) BY MOUTH 2 TIMES A DAY . A review of RI #3's Quarterly MDS with an ARD of 02/8/17, assessed RI #3 as having received an antipsychotic medication during this assessment period. A review of RI #3's AIMS assessment form dated 09/12/16, revealed the last time the assessment was completed was 12/08/16. On 04/20/17 at 11:26 p.m., an interview was conducted with EI #2. The surveyor asked EI #2 when should RI #3's next AIMS assessment, after the 12/08/16 assessment, have been completed. EI #2 said the AIMS assessment should have been completed last month (February 2017). 3. RI #6 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. RI #6's April physician's orders [REDACTED].> . [MEDICATION NAME] 20 MG .TABLET GIVE 1 TABLET BY MOUTH ONCE DAILY . A review of RI #6's Admission MDS with an ARD of 05/15/16, assessed RI #6 as having received an antipsychotic medication during this assessment period. A review of RI #6's AIMS assessment form dated 9/22/16, revealed the last time the assessment was completed was 12/09/16. On 04/20/17 at 11:26 p.m., an interview was conducted with EI #2. The surveyor asked EI #2 when should RI #6's next AIMS assessment, after the 12/09/16 assessment, have been completed. EI #2 said the AIMS assessment should have been completed last month (February 2017). 4. RI #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #7's AIMS assessment form dated 10/05/16, revealed the last time an AIMS assessment had been completed for RI #7 was 12/08/16. A Quarterly MDS assessment with an ARD of 03/02/17, assessed RI #7 as scoring a 15 on the BIMS. RI #7 was also assessed as having received an antipsychotic medication during this assessment period. RI #7's April 2017 physician's orders [REDACTED].> . [MEDICATION NAME] 50 MG . Give 1 TABLET BY MOUTH 2 TIMES A DAY . On 04/20/17 at 11:26 a.m., an interview was conducted with EI #2. The surveyor asked EI #2, when should RI #7's next AIMS assessment, after the 12/08/16 assessment, have been completed. EI #2 said the AIMS assessment should have been completed last month (February 2017). 5. RI #8 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of a facility form titled Abnormal Involuntary Movement Scale (AIMS) for RI #8 dated 09/12/16, revealed the last assessment was completed 12/08/16. A review of RI #8's Physicians Orders for April 2017 revealed: . [MEDICATION NAME] 5 MG GIVE 1 TABLET BY MOUTH EVERY MORNING . A review of RI #8's Annual MDS with an ARD of 12/21/16, assessed RI #8 as having received an antipsychotic medication during this assessment period. On 04/20/17 at 10:30 a.m., an interview was conducted with EI #2. EI #2 was asked to locate the AIMS in the resident's chart. EI #2 located the AIMS and replied it was last done 12/08/16 for RI #8. EI #2 was asked when should the AIMS be done again. EI #2 replied it should have been done in March 2017. EI #2 was asked how often should an AIMS be done. EI #2 replied quarterly and she added she was a little behind. EI #2 was asked what the harm was in not doing the AIMS quarterly. EI #2 replied the resident could have more extrapyramidal symptoms (continuous spasms and muscle contractions, tremors and uncontrolled movement of the tongue). On 04/20/17 at 11:26 p.m., an interview was conducted with EI #2. The surveyor asked EI #2 what was the purpose of completing the AIMS assessment. EI #2 said the purpose was to monitor for the side effects of the antipsychotic medication. The surveyor asked EI #2, what could be some of the results or complications that could result in not monitoring the residents who were receiving antipsychotic medications. EI#2 said some new extrapyramidal symptoms like involuntary movement of the face and trunk, tardive dyskinesia (irregular jerky movements) and ataxia (lack of voluntary coordination of muscle movements) could be missed.

Based on observations and interview, the facility failed to ensure the survey results were in an area easily accessible to all residents for three of three days of the survey. This had the potential to affect 50 of 50 residents that resided in the facility. Findings Include: On 04/18/17 at 5:20 p.m., the surveyor observed 4 years of survey results posted high on the information bulletin board at the entrance door. The survey results were not accessible to residents in wheelchairs. On 04/19/17 at 7:50 a.m., the surveyor observed the survey results remained not accessible to residents in wheelchairs. On 04/20/17 at 12:30 p.m., the surveyor observed the survey results remained, out of reach, and not accessible to residents in wheelchairs. On 04/20/17 at 12:15 p.m., an interview was conducted with Employee Identifier (EI) #1, the Administrator. The surveyor asked EI #1 who was responsible for ensuring survey results were posted. EI #1 responded, herself. EI #1 was then asked, where were the survey results posted. EI #1 responded, at the front door on the information bulletin board. EI #1 was asked should the survey results be accessible to ambulatory as well as wheelchair bound residents. EI #1 responded, yes ma'am. EI #1 accompanied the surveyor to the bulletin board and the surveyor asked if the survey results were accessible to residents in wheelchairs. EI #1 responded, no they were not.

Based on record review, observation and interview, the facility failed to ensure a licensed staff member administered the prescribed medication to RI (Resident Identifier) #12 as ordered by the Physician. During the Medication Administation observation onf on 04/06/2016, the Registered Nurse (Employee Identifier #2), did not administer the [MEDICATION NAME] medication to RI #12, as ordered by the physician. This affected one of six residents observed during Medication Administration on 04/06/2016. Findings Include: A review of a facility policy titled, .MEDICATION ADMINISTRATION-GENERAL GUIDELINES with an effective date of July 1, 2009 revealed: .Policy: Medications are administered as prescribed .Procedures: .B. Administration .2) Medications are administered in accordance with written orders of the attending physician. RI #12 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #12's significant change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 03/21/2016 revealed the resident had a BIMS (Brief Interview for Mental Status) of 10, which indicated the resident was moderately impaired for daily decision making. The MDS also revealed the resident was frequently incontinent of bowel and bladder. A review of RI #12's Physician orders [REDACTED].[MEDICATION NAME] 100 MG (Milligram) GIVE 1 CAPSULE BY MOUTH 2 TIMES A DAY. On 04/06/2016 at 4:25 PM, EI (Employee Identifier) #2 RN (Registered Nurse) was observed during Medication Administration. EI #2 was observed to not administer the [MEDICATION NAME] 100 mg by mouth as prescribed by the Physician, to RI #12. On 04/07/2016 at 3:45 PM, an interview was conducted with EI #1 RN DON (Director of Nursing). EI #1 was asked what was the policy and procedure on following Physician orders. EI #1 said follow all Physician orders. EI #1 was asked was it an acceptable practice of this facility to not give a medication that was ordered by the Physician. EI #1 said no. EI #1 was asked what was the potential harm in not giving a prescribed medication. EI #1 said it depends on the medication and not following the Physician orders. On 04/07/2016 at 4:10 PM, an interview was conducted with EI #2 RN. EI #2 was asked did RI #12 have an order for [REDACTED].#2 was asked why she did not administer the [MEDICATION NAME]. EI #2 said, I might have overlooked it. EI #2 was asked what was the potential harm for not giving [MEDICATION NAME] as prescribed. EI #2 said it softens the stool so he could become constipated. You should not miss any medications. That was an oversight on my part. I may have just been nervous.

Based on observation, record review and interviews, the facility failed to ensure a licensed staff member did not dry her hands with the same paper towel that was used for turning the faucet off. This had the potential to affect one of three nurses observed during Medication Administration. Findings Include: A review of a facility policy titled, POLICY AND PROCEDURE FOR HAND-WASHING with a revised date of 07/23/14 revealed: .POLICY: TO PROVIDE [MEDICATION NAME] (GUIDELINES) TO EMPLOYEES FOR PROPER AND APPROPRIATE HAND WASHING TECHNIQUES THAT WILL AID IN THE PREVENTION OF THE TRANSMISSION OF INFECTIONS, AND TO PREVENT THE SPREAD OF INFECTIOUS DISEASES.PROCEDURE GUIDELINES: .3. Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel. RI (Resident Identifier) #12 was readmitted to the facility 12/18/2015 with [DIAGNOSES REDACTED]. RI #12's Significant Change MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 03/21/2016 revealed a BIMS (Brief Interview for Mental Status) score of 10 which indicated moderately impaired for daily decision making. On 04/06/2016 at 4:25 PM, EI (Employee Identifier) #2 RN (Registered Nurse), was observed during Medication Administration with RI #12. EI #2 administered RI #12's pills then went to the bathroom to wash her hands and when she was finished washing her hands she used a paper towel to turn the faucet off then immediately dried her hands with the same paper towel. EI #2 was observed two more times during Medication Administration with RI #12 repeating the same technique with handwashing. On 04/07/2016 at 4:10 PM, an interview was conducted with EI #2 RN. EI #2 was asked did she use the same paper towel that she turned the faucet off with to dry her hands. EI #2 said she felt her hands were still damp. EI #2 was asked why she should not have dried her hands on the same paper towel that she used to turn the faucet off with. EI #2 said the paper towel would be dirty. EI #2 was asked what was the potential harm in using the same paper towel used to turn the faucet off with to dry her hands. EI #2 said it could spread bacteria. On 04/07/2016 at 3:45 PM, an interview was conducted with EI #1 RN DON (Director of Nursing) Infection Control. EI #1 was asked what measures the facility had in place to monitor and investigate causes of infection and the manner in which it spreads. EI #1 said they looked at trends. EI #1 was asked what infections was the facility currently monitoring. EI #1 said none at this time. EI #1 was asked what was the facility's policy on handwashing. EI #1 said dry hands thoroughly with a paper towel and turn the faucet off with a clean paper towel. EI #1 was asked what was the potential harm if a staff member turned the faucet off with a paper towel after washing her hands then used that same paper towel to dry her hands. EI #1 said recontamination.

Based on observations, interviews, and review of facility policies and the Food and Drug Administration (FDA) Food Code 2013, the facility failed to ensure: 1) the dishmachine had a data plate that was affixed to the machine and easily readable, specifying proper usage of the machine; 2) the dish machine thermometer was in working order on 03/23/2015 to ensure proper sanitization of dishes; 3) staff utilizing the dish machine did not touch clean dishes after handling soiled dishes without first washing hands and changing gloves in an attempt to prevent the potential for cross-contamination; 4) dishes and cups were not stored for use while wet; and 5) commercial health shakes were not labeled with a use-by-date exceeding manufacturer specifications after thawed. These failures had the potential to affect all 41 of 41 residents receiving meals from the Dietary Department. Findings Include: 1) Review of the FDA Food Code 2013, Chapter 4 Equipment, Utensils, and Linens revealed the following: "... 4-204.113 Warewashing Machine, Data Plate Operating Specifications. A WAREWASHING machine shall be provided with an easily accessible and readable data plate affixed to the machine by the manufacturer that indicates the machine's design and operation specifications including the: (A) Temperatures required for washing, rinsing, and SANITIZING..." While observing operation of the dish machine on 03/24/2015 at 8:39 AM, the surveyor asked Employee Identifier (EI) #1, the Dietary Manager, if the machine had a data plate that listed the specifics for usage. EI #1 stated they had never had one. On 03/24/2015 at 4:03 PM, the surveyor noted the data plate for the dish machine was located on the side of the machine and had peeled off and curled up, making it difficult to read the specifications for use. EI #1, the Dietary Manager, was interviewed on 03/25/2015 at 1:03 PM. During the interview EI #1 stated the dish machine data plate was located on the side and was peeling off, making it hard to see. When asked why it was important for the data plate to be on the machine for employees to see, EI #1 said it was important for staff to accurately read it to ensure the machine was working properly and to ensure safety of the dishes. 2) Review of the FDA Food Code 2013, Chapter 4 Equipment, Utensils, and Linens revealed the following: "...4-204.115 Warewashing Machines, Temperature Measuring Devices. A WAREWASHING machine shall be equipped with a TEMPERATURE MEASURING DEVICE that indicates the temperature of the water..." Review of the facility's policy titled "Resource: Sanitation of Dishes/Dish Machine" revealed the following: "... Low temperature Diswasher (Dishwasher) Spray Type Dish Machines Using Chemical to Sanitize... Wash Temperature 120 (degrees)..." Another undated facility policy titled "CLEANING DISHES DISH MACHINE" revealed the following: "POLICY: Dishes and cookware will be washed and sanitized after each meal... Note: Check the dish machine gauges throughout the cycle to assure proper temperatures." During the initial tour of the kitchen on 03/23/2015 beginning at 2:00 PM, the surveyor observed EI #3, dietary staff, utilizing the dish machine. EI #3 stated that if the three dials go around you know the machine is working. EI #3 stated she did not know what was wrong with the thermometer because it had not moved for the wash cycle. The surveyor noted the thermometer stayed on 100 degrees Fahrenheit (F), the lowest possible reading on the thermometer. EI #3 was observed to run three cycles through the machine without the thermometer functioning. The thermometer remained on the lowest possible reading for all cycles. EI #3 continued to use the machine and put the dishes away for future use. EI #1, the Dietary Manager, was interviewed on 03/25/2015 at 1:03 PM. EI #1 was asked why it was important for the thermometer on the dish machine to be in working order. EI #1 explained it was important to ensure the water was at the correct temperature for washing and killing germs. 3) Review of an undated facility policy titled "CLEANING DISHES DISH MACHINE" revealed the following: "POLICY: Dishes and cookware will be washed and sanitized after each meal... PROCEDURE: ...5... Persons loading dirty dishes should not handle clean dishes unless apron and gloves are changed and hands are washed thoroughly before moving from dirty to clean dishes..." During the initial tour of the kitchen on 03/23/2015 beginning at 2:00 PM, the surveyor observed EI #3, dietary staff, utilizing the dish machine. EI #3 was observed to put away clean cups and pitchers wearing the same dirty gloves she had used to load dirty utensils into the dish machine. EI #3 then removed her gloves and donned a new pair without washing her hands. EI #3 was observed rinsing dirty cups and mugs. After rinsing the dirty dishes, EI #3 removed her gloves and, without washing her hands, donned new gloves, to pull a rack of clean utensils from the machine. With the same gloves, EI #3 flipped the utensils over and placed them back into the machine. EI #3 then rinsed dirty trays and dishes and, with the same dirty gloves, reached over to pull the clean utensils out of the dish machine. On 3/24/2015 at 8:39 AM, the surveyor again observed dietary staff utilizing the dish machine. The staff member was observed to handle dirty dishes while wearing gloves and use the same gloves to pull a clean rack from the dish machine and put the items away. The staff member then changed gloves without washing hands, and placed a dirty rack of dishes into the machine. After loading the dirty rack, the staff member removed gloves but did not wash hands and was rearranging racks of clean dishes to get to some empty racks. After obtaining the racks, the staff member donned new gloves but did not wash her hands to remove a rack of clean dishes from the dish machine. The Dietary Manager was present during this observation. EI #1, the Dietary Manager, was interviewed on 03/25/2015 at 1:03 PM. EI #1 was asked when employees should wash their hands and change gloves when using the dish machine. EI #1 stated dietary staff did not have to wash hands while washing dishes if going from dirty to clean because they did not have time to do that every time, but should change gloves. EI #1 stated that if dishes were put away using dirty gloves there was a potential for cross-contamination. 4) Review of the FDA Food Code 2013, Chapter 4 Equipment, Utensils, and Linens revealed the following: "... 4-9 PROTECTION OF CLEAN ITEMS... Drying 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried..." Review of an undated facility policy titled "CLEANING DISHES DISH MACHINE" revealed the following: "POLICY: Dishes and cookware will be washed and sanitized after each meal... PROCEDURE: ...7. Allow dishes to dry on racks... 8. Remove dishes, inspect for cleanliness and dryness and put away..." During the initial tour of the kitchen on 03/23/2015 beginning at 2:00 PM, the surveyor observed two racks containing inverted cups and bowls holding moisture. The bowls were in 3 stacks of five and two stacks of six and were wet-nested (stacked wet). EI #3, a dietary staff member, stated the items were stored there for use. EI #3 removed several of the bowls from the stacks and agreed they were wet. Also during the initial tour, the surveyor noted a tray containing 9 inverted cups with moisture on the bottom shelf of a stainless steel work surface in the main area of the kitchen. EI #1, the Dietary Manager, was interviewed on 03/25/2015 at 1:03 PM. EI #3 stated the trays used to place the cups and bowls on could hold moisture and could allow bacterial growth. 5) Review of the manufacturer information for the facility's commercial shakes revealed the shakes had a use-by-date of 14 days once thawed. During the initial tour of the kitchen on 03/23/2015 beginning at 2:00 PM, the surveyor noted thawed commercial shakes in a stainless steel upright cooler. The shakes were labeled with the following dates: 4/2, 4/5, and 4/11. EI #1, the Dietary Manager, stated they labeled the shakes with a 21 day use-by-date once pulled from the freezer. EI #1, the Dietary Manager, was interviewed on 03/25/2015 at 1:03 PM. When asked why she was labeling the shakes with a 21 day use-by-date, EI #1 stated she did not know where the 21 day use-by-date had come from. When asked what potential harm could occur if the shakes were not labeled with the correct use-by-date, EI #1 stated they could go bad.

Based on interviews and record reviews, the facility failed to manage Resident Trust funds in a manner to ensure that residents were able to access funds after business hours and on weekends. Furthermore, residents did not receive receipts of transactions. This affected four of four residents in attendance for the Resident Group Meeting held on 03/24/2015 and Resident Identifier (RI) #s 6 and 10, and had the potential to affect 33 of 33 residents with a Resident Trust fund account. Findings include: The facility's policy labeled "POLICY & PROCEDURE ON RESIDENT'S PETTY CASH" not dated, stipulates: "PURPOSE: The purpose of this policy is to insure the security of the resident's money ... The account maximum is $50.00, withdrawal is weekly by resident request and will be provided by the Business Office Staff. PROCEDURE: Scheduled as follows. 1. Each Thursday the residents are asked if they need money. 2. The petty cash is distributed by business office staff, to the residents on Friday in sealed envelopes labeled with their name. 3. Account balances are updated and posted so residents can be made aware of balance upon request at any given time. ..." On 3/24/15 at 9:00 AM, a Resident Group meeting was held with four residents in attendance. In this meeting, the residents were asked about their resident trust account (funds managed by the facility). Three of the four said they were smokers and that someone from the business office takes their money and goes and purchases their cigarettes for them, and they never see a receipt or sign a voucher. The other person in the meeting explained the money must be requested before the checks come in and make the money last the entire month. The resident went on to say, the residents request the money by sending a CNA (Certified Nursing Assistant) to ask for it; then the next day or two days later, the bookkeeper will bring the money. The surveyor asked the residents if a receipt was provided when cash was requested. All the residents in the group stated they never receive a receipt. When the group was asked if they were able to access petty cash on the weekends or at night, all agreed they could not access any funds at those times. 1) RI #6 was admitted to the facility on [DATE]. RI #6 was identified with a BIMS (Brief Interview for Mental Status) score of 15 out of 15 on the Quarterly Minimum Data Set ((MDS) dated [DATE]. This cognitive score meant RI #6 was cognitively intact for decision making. On 3/24/15 at 3:15 PM, a Resident Interview was conducted with RI #6. RI #6 was asked how does a resident access the petty cash fund. RI #6 said residents tell the nurse, who then tells the business office staff, and the money is delivered in a day or two. RI #6 further stated the money requested is sometimes never received. The surveyor asked what is done if the money is not received and RI #6 said you have to ask again the next week. 2) RI #10 was admitted to the facility on [DATE]. RI #10's MDS dated [DATE] identified the resident with a BIMS score of 15, indicating the resident was cognitively intact. On 3/25/15 at 1:35 PM in a resident interview with RI #10, the resident was asked how to access the trust fund for cash. RI #10 residents let facility staff know how much they want and then it takes about a day or two to get the money. RI #10 further stated if residents want something from the store they write it down and give it to staff and usually get it in about a week. The surveyor inquired as to why it took a week to get the money. RI #10 said it takes the facility that long to make a list of what residents want and then go to the store. RI #10 was asked if receipts were provided and RI #10 said, "No." A review of the Resident Trust Fund Account was done on 3/25/15 at 9:30 AM with Employee Identifier (EI) #2, Bookkeeper. When asked if the facility maintained a petty cash fund, EI #2 said they kept $30.00 on a nurses' cart for petty cash. There was no other petty cash fund. When asked when did residents have access to this $30.00 petty cash account, EI #2 said on weekends and at night. The surveyor asked if there had been any activity in the $30.00 petty cash fund. EI #2 said there had been no activity since she had started working at the facility, which was August 2014. The surveyor asked EI #2 if the residents knew about this available petty cash. EI #2 said she did not know. EI #2 was asked how the residents can access their resident account for more than petty cash. EI #2 said the resident goes to the Social Services Representative and then the representative calls EI #2 and EI #2 goes and cashes a check. EI #2 then takes the money to the resident, usually within 24 hours. EI #2 was asked if she gave a receipt of the transactions to the residents. EI #2 said she does not provide receipts.