Every finding on record at Henry County Health and Rehabilitation Facility

Based on observations, interviews, resident record review, and the facility's Proper Use of Side Rails policy, the facility failed to perform ongoing assessments for the use of side rails for Resident Identifier (RI) #7 to ensure the side rails used met RI #7's needs. This deficient practice affected RI #7, one of one resident reviewed for side rail use. Findings included: The facility admitted Resident Identifier (RI) #7 on 03/17/2014. A review of RI #7's annual Minimum Data Set (MDS), dated [DATE], revealed severe cognitive impairment. Per the MDS, RI #7 required one-person extensive physical assistance with bed mobility and full staff performance of transfers. The MDS indicated the resident did not walk during the assessment period and did not use a bed rail. A review of RI #7's care plan revealed a problem of self-care deficit related to a history of [CONDITION(S)] ([CONDITION(S)]) with residual effects, with a problem onset date of 03/17/2014. Approaches included a bed with two 3/4 side rails with pads. A review of RI #7's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 02/02/2022 at 9:30 AM RI #7 was observed in bed with full padded side rails in place on both sides of RI #7's bed. A review of RI #7's medical record revealed there was no consent or ongoing assessments completed for the continued use of side rails. During an interview on 02/03/2022 at 12:04 PM, Employee Identifier (EI) #1, a Certified Nurse Aide (CNA), stated RI #7 had side rails up when in bed because the resident moved around a lot. Per EI #1, the side rails were padded for protection and to prevent the resident from putting their legs through the side rails. During an interview on 02/03/2022 at 12:09 PM, EI #2, a Licensed Practical Nurse (LPN), stated RI #7 had padded side rails when in bed to prevent falls, and the pads were to protect RI #7's legs. Per EI #2, the side rails were put in place in 2014 and RI #7 did not have a history of falls. EI #2 did not know why the side rails were in place since RI #7 had no history of falls. EI #2 could not find documentation in RI #7's medical record as to why the side rails were started and stated EI #5, the LPN Restorative Supervisor, conducted side rail assessments. During an interview on 02/03/2022 at 12:36 PM., EI #3, a CNA, stated RI #7 had padded side rails in the up position when in bed. EI #3 thought RI #7 used to get out of bed, so the side rails were added. Per EI #3, it had been years since RI #7 tried to get out of bed; however, staff still put the padded side rails up when RI #7 was in bed because there was a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 02/03/2022 at 1:27 PM, EI #4, a Restorative CNA, stated RI #7 did not try to get out of bed. EI #4 thought the family requested the padded side rails be in the up position when RI #7 was in bed. Per EI #4, the side rails were padded to keep RI #7 from bumping the rails. During an interview on 02/03/2022 at 1:31 PM, EI #5, the LPN Restorative Supervisor, stated RI #7 did not try to get out of bed, and it had been many years since RI #7 had a fall. EI #5 then stated EI #6, the LPN Restorative Nurse, did RI #7's side rail assessment. During an interview on 02/03/2022 at 1:41 PM, EI #6, the LPN Restorative Nurse, stated RI #7 did not try to get out of bed anymore, and the padded side rails were in place for safety due to family request. EI #6 did not do RI #7's side rail assessment and stated, if there was one, it would have been part of the initial resident paperwork, noting they did not conduct quarterly or annual assessments or obtain consents for side rails. EI #6 then stated side rails were not considered a restraint because they were in place for safety. Per EI #6, RI #7 did not try to get out of bed. On 02/03/2022 at 2:50 PM RI #7 was observed in bed with full padded side rails in place on both sides of RI #7's bed. During an interview on 02/03/2022 at 2:55 PM, EI #12, the Director of Nursing (DON)/Registered Nurse (RN), stated there were no restraints in the facility and side rails were not a restraint. EI #12 then stated a restraint was anything that stopped a resident from moving or touching their body, and EI #12 did not consider side rails a restraint. EI #12 stated RI #7 had not fallen in two or three years, and if the side rails were not there, RI #7 could roll out of bed. Per EI #12, the pads were in place to keep RI #7's legs or arms from going through the rails. EI #12 identified that assessments were done for side rails before initial use, an order was written, and the care plan was updated. EI #12 then stated EI #7, Maintenance Supervisor, was responsible for doing side rail assessments and that consents for side rail use were not obtained. During an interview on 02/03/2022 at 3:02 PM, EI #7, Maintenance Supervisor, stated EI #5 did side rail assessments and determined if a resident was at risk to fall out of bed. If an order was written, EI #7 stated he put the side rails on the bed. During an interview on 02/04/2022 at 8:55 AM, EI #11, the Administrator, stated a restraint was something that kept a resident from moving, and the facility had no restraints. EI #11 expected the proper staff to conduct assessments and what they provided to residents to be appropriate. Per EI #11, it was important to conduct ongoing evaluations of side rails because resident conditions were constantly changing, and they expected the proper paperwork to be completed as to why side rails were in place. A review of the facility's Proper Use of Side Rails policy, dated 09/09, revealed, The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms.2. Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents. 3. An assessment will be made to determine the resident's symptoms or reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: a. Bed mobility; and b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet. 4. The use of side rails as an assistive device will be addressed in the resident care plan.9. Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks. 10. The resident will be checked periodically for safety relative to side rail use.

Based on resident record review, interviews, and review of the facility's Antipsychotic Medication Use policy, the facility's Behavior Assessment and Monitoring policy, and the facility's Depression - Clinical Protocol policy, the facility failed to ensure Resident Identifier (RI) #31, was monitored for behaviors for which antipsychotic medication was administered and the facility further failed to ensure RI #31 and RI #47 were monitored for side effects of [CONDITION(S)] medications to include: antipsychotic and antidepressant medications. This affected two of 4 sampled residents reviewed for unnecessary medications who received antipsychotic and antidepressant medication. Findings included: A review of the facility's Antipsychotic Medication Use policy and procedure, dated 09/2009, revealed, . 4. Nursing staff will document in detail an individual's target symptom(s). 14. Nursing Staff will monitor and report any of the following side effects to the Attending Physician: a. Sedation; b. Orthostatic hypotension; c. Lightheadedness; d. Dry mouth; e. Blurred vision; f. Constipation; g. [CONDITION(S)], h. Increased psychotic symptoms . i. Extrapyramidal effects; j. Akathisia; k. Dystonia; l. Tremor; m. Rigidity; n. Akinesia; or tardive dyskinesia. A review of the facility's Behavior Assessment and Monitoring policy and procedure, dated 09/2009 revealed, Policy Statement 1. Problematic behavior will be identified and managed appropriately.3. The facility will comply with regulatory requirements related to the use of medications to manage problematic behavior. Monitoring 1. If the resident is being treated for problematic behavior or mood, the staff and physician will obtain and document ongoing assessments of changes (positive or negative) in the individual's behavior, mood, and function. A review of the facility's Depression - Clinical Protocol policy and procedure, dated 09/09, revealed, . The staff and physician will monitor the resident carefully for side effects specific to each class of medication as well as interactions between antidepressants and other classes of medications. RI #31 was readmitted to the facility on [DATE] and had diagnoses which included [CONDITION(S)] without Behavioral Disturbance, Adjustment Disorder with Depressed Mood, Major Depressive Disorder, Mood Disorder, Anxiety Disorder, Psychotic Disorder with Hallucinations, Delusional Disorders, and [CONDITION(S)]. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/26/2021, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment and had exhibited no behaviors during the seven days prior to the ARD. The MDS indicated RI #31 had received antipsychotic and antidepressant medication on seven of seven days prior to the ARD and received antipsychotic medication on a routine basis only. RI #31's care plan with problems that included Dementia, Depression, Adjustment Disorder, Episodic Mood Disorder, [CONDITION(S)] Disorder and Anxiety Disorder, history of making suicidal statements, hallucinations and episodes of paranoia, with a problem onset date of 01/15/2015, included other behaviors listed under approaches that included: yelling out, yelling at others, making accusations against staff and others. The care plan indicated the resident received antidepressant and antipsychotic medication which were ordered upon admission. Approaches to the problem included to report extrapyramidal related symptoms/adverse reaction and to document behaviors, interventions, and outcomes. The care plan also indicated the resident had a problem related to receiving multiple medications that was last reviewed 11/30/2021. An approach to the problem included to report possible unwanted drug-related side effects or interactions. A review of RI #31's February 2022 physician's orders revealed the resident was to receive [MEDICATION(S)] 200 milligrams (mg) by mouth every night for [CONDITION(S)] and [MEDICATION(S)] 20 mg by mouth daily for Major Depressive Disorder. The original date of the [MEDICATION(S)] order was 08/31/2018. The original date of the [MEDICATION(S)] order was 01/12/2015. A review of RI #31's electronic health record (EHR) and hard chart revealed no behavior monitoring and/or side effect monitoring for the medications. On 02/04/2022 at 11:16 AM, Employee Identifier (EI) #9, a Licensed Practical Nurse, was interviewed. She stated the behavior for which the resident was administered [MEDICATION(S)] was hitting at staff during care. She reviewed the resident's EHR and hard chart and was unable to find documentation of monitoring for target behaviors and/or side effects of the [MEDICATION(S)] and [MEDICATION(S)]. RI #47 was readmitted to the facility on [DATE] and had diagnoses to include: Psychotic Disorder with Delusions, Alzheimer's Disease, Depressive Episodes, Dementia with Behavior, Anxiety and [CONDITION(S)]. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date of 12/24/2021, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 5 which indicated severe cognitive impairment. The MDS indicated the resident had hallucinations and delusions as potential indicators of [CONDITION(S)] and had exhibited no behaviors during the seven days prior to the ARD. The MDS indicated the resident had received antipsychotic, antianxiety, and antidepressant medication on seven of seven days prior to the ARD. It indicated the resident was administered antipsychotic medication on a routine basis only. Review of RI #47's care plan with a problem onset date of 01/25/2019, most recently reviewed/revised 12/28/2021, indicated the resident's problems included the use of [CONDITION(S)] meds for diagnoses of Dementia with Delusions, Depression, and Anxiety. An approach for the problem was to observe for any side effects of the medication. RI #47's care plan with a revised date of 12/28/2021 had a problem related to receiving medications with potential risk for adverse drug reactions/unwanted effects/interactions. An approach was to document unwanted side effects or interactions to medications. A review of the physician's orders, dated 02/2022, indicated the resident was to receive the following medications: [MEDICATION(S)] 50 milligrams (mg) for Depressive Episodes (original order was 10/12/2020); [MEDICATION(S)] 50 mg at bedtime for [CONDITION(S)] (original order date was 07/19/2021); [MEDICATION(S)] 10 mg twice daily for Anxiety (original order date was 10/12/2020); and [MEDICATION(S)] 50 mg at bedtime for Delusions (original order date was 08/10/2021). A review of the resident's electronic health record (EHR) and hard chart revealed no documentation of side effects monitoring for the use of [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]. On 02/04/2022 at 11:33 AM, Employee Identifier (EI) #9, a Licensed Practical Nurse (LPN), was interviewed. After reviewing the resident's EHR and hard chart, she stated side effects for the use of the medications had not been monitored. She stated the nurse who wrote the physician's order for the medications was responsible to ensure side effect monitoring was done. On 02/04/2022 at 12:19 PM, EI #12, the Director of Nursing (DON), was interviewed. She stated a resident who received an antipsychotic medication was supposed to be monitored for the target behaviors for which the medication was being administered. She stated the registered nurse who worked on the hall where the resident resided was responsible to ensure behavior monitoring was done for residents who received antipsychotic medication. The DON stated a resident who received an antipsychotic and/or an antidepressant medication was supposed to be monitored for side effects of the medication. She stated the nurse who administered the medication was responsible to ensure the resident was monitored for side effects of the medication. On 02/04/2022 at 1:08 PM, EI #12, in a follow up interview, stated she could not find documentation of behavior monitoring for the use of [MEDICATION(S)] and/or side effect monitoring for the use of [MEDICATION(S)] and [MEDICATION(S)] for RI #31. She stated she could not find documentation of side effect monitoring for the use of [MEDICATION(S)], Trazadone, [MEDICATION(S)], and [MEDICATION(S)] for RI #47. On 02/04/2022 at 1:14 PM, EI #11, the Administrator, was interviewed. He stated residents who received antipsychotic medications should be monitored for the behaviors for which they were administered the medication. The administrator stated residents who received antipsychotic and/or antidepressant medication should be monitored for side effects of the medication. On 02/04/2022 at 2:02 PM, RI #31's and RI #47's psychiatrist, EI #10, was interviewed by phone. He stated he expected the facility to monitor residents who received antipsychotic medication for behaviors for which the medication was administered. He stated he expected the facility to monitor for side effects of antipsychotic and antidepressant medications.

Based on observation, resident record review, interviews, and review of the facility's Administering Medication policy, the facility's Administration of Metered-Dose Inhaler policy, and manufacturer's instructions for use, the facility failed to ensure a medication error rate of less than 5%. The facility had a medication error rate of 9.38%, which resulted from three errors in 32 opportunities and affected Resident Identifier (RI) #52 one of five residents observed receiving medications during the medication administration observation on 02/03/2022. Sixty-nine residents resided in the facility.Findings included: The facility's Administering Medications policy and procedure, dated 02/2014, indicated, . Medications will be administered by a licensed nurse in a safe and timely manner, and as prescribed. The facility's Administration of Metered-Dose Inhaler policy and procedure, not dated, indicated, . It is the policy of this facility to ensure medications are administered as prescribed, . 11. Instruct resident to exhale fully. 12. Press down on inhaler to release medication as the resident starts to breathe in slowly. 13. Instruct resident to hold breath and slowly count to ten, if possible, to allow medication time to deposit in airways. 14. Instruct resident to exhale slowly through pursed lips. 15. Repeat puffs as directed, waiting at least 1 (one) minute between puffs, or per the manufacturer's specifications. 16. If using a corticosteroid, allow resident to gargle with water if desired, to remove medication from mouth and back of throat. 17. If resident is using a corticosteroid and a bronchodilator, administer the bronchodilator first then wait 5 minutes before administering the corticosteroid. The [MEDICATION(S)] Instructions for Use information leaflet documented . Breathe out slowly and fully. While taking a slow, deep breath through your mouth, Press the dose-release button and continue to breathe in. Hold your breath for 10 seconds or for as long as comfortable. The [MEDICATION(S)] Inhaler Instructions for Use, safety information sheet documented: . After using your [MEDICATION(S)] inhaler: .Rinse your mouth with water and spit it out . Don't swallow the water . RI #52 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The number of inhalations the resident was to be administered was not included in the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 02/03/2022 at 8:28 AM, Employee Identifier (EI) #8, a Licensed Practical Nurse (LPN), was observed as she administered medications to RI #52 under the training supervision of EI #9, an LPN. Upon entry into the resident's room, EI #8 set the tray of medications on the overbed table in front of the resident. The resident immediately proceeded to self-administer two puffs of the [MEDICATION(S)] inhaler within 2-3 seconds, set it back on the medication tray, and self-administer one puff of the [MEDICATION(S)] inhaler. EI #8 did not instruct the resident to use the [MEDICATION(S)] inhaler first. For either inhaler, EI #8 did not instruct the resident to exhale fully, breathe in the medication slowly, hold their breath and slowly count to 10, and exhale slowly. EI #8 did not instruct the resident to inhale one puff of the [MEDICATION(S)] per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . After self-administering the [MEDICATION(S)] inhaler, the resident rinsed their mouth with water and swallowed the water. EI #8 did not instruct the resident to spit the water back into the cup after rinsing their mouth. EI #8 had set a bottle of Saline Nasal Spray on the tray instead of Afrin Nasal Spray. The resident picked up the bottle of Saline Nasal Spray and self-administered one spray into each nostril, although the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 02/04/2022 at 8:18 AM., EI #8 and EI #9 were interviewed regarding the observation of the administration of the inhalers and nasal spray on 02/03/2022. Both LPNs stated they had not read the patient use instructions and/or the package insert for [MEDICATION(S)] or [MEDICATION(S)] inhalers. EI #8 stated she had not instructed the resident to inhale the inhalers slowing and hold for 10 seconds if possible. EI #8 acknowledged the resident had self-administered two inhalations of [MEDICATION(S)] and the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #8 stated she had not instructed the resident to use the [MEDICATION(S)] inhaler first, nor to wait five minutes to administer the [MEDICATION(S)], per the facility's policy. EI #8 reviewed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she had not instructed the resident to rinse their mouth with water and to spit back into a cup. EI #8 and EI #9 both stated they had not been in-serviced on the proper administration of respiratory inhalers and/or on the facility's Administration of Metered-Dose Inhaler policy and procedure. EI #8 stated she had provided Saline Nasal Spray for self-administration by the resident. She reviewed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the resident had self-administered one spray of Saline Nasal Spray in each nostril. EI #8 acknowledged the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 02/04/2022 at 8:28 AM, Employee Identifier (EI) #12, the Director of Nursing (DON), was interviewed. She stated licensed staff received training on the administration of inhalers and on the facility's policy and procedure for administration of inhalers during their orientation. She stated that no QA (Quality Assurance) had been initiated to ensure inhalers were being administered correctly. The DON reviewed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated a licensed nurse, or the consultant pharmacist should have identified the problem and corrected it before then. The DON reviewed the order for Afrin Nasal Spray, dated 03/27/2020, and when informed Saline Nasal Spray was used instead of Afrin, stated nurses should have read the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON was informed of the medication error rate of 9.38% resulting from the administration of the wrong doses, administration errors, and/or administration of the wrong medications involving the [MEDICATION(S)] inhaler, [MEDICATION(S)] inhaler, and Afrin Nasal Spray. She stated she understood the errors and had no questions. On 02/04/2022 at 9:22 AM, EI #11, the Administrator, was interviewed. The above observations of the medication pass for RI #52 were reviewed with the Administrator. He stated his expectation was for licensed nurses to be trained to properly administer respiratory inhalers and to be in-serviced regarding the facility's respiratory inhaler policy and procedure. When informed of the medication error rate of 9.38%, he stated he had no further questions.

Based observation, interview and review of a facility policy titled, Food Storage in Freezer, the facility failed to ensure that tater tots, okra and sweet potato patties where sealed properly while in the freezer. This was observed on 5/13/2019 and had the potential to effect 101 residents receiving meals from the kitchen. Finding include: A review of a facility policy titled, Food Storage in Freezer with a review date of 5/15/19 revealed: . Procedure Frozen Foods: . 3. All foods should be covered , labeled , and dated with delivery date. On 5/13/2019 at 03:19 PM, the surveyor observed a half bag of tarter tots, a half bag of okra in a box and a half bag of sweet potatoes patties inside of a box. The bags were not completely sealed. On 05/15/19 at 10:39 AM, an interview was conducted with Employee Identifier (EI) #4, Dietary Director. EI#4 was asked how should food be sealed while in the original container. EI#4 replied, the bag needs to be closed as good as it can. EI #4 was asked, how were the tarter tots, sweet potatoes patties and okra sealed. EI#4 replied, the bags were not fully closed on the tarter tots, on the sweet potatoes patties and okra the box was pushed down, but the bag was not closed. EI#4 was asked, why was it important that food be sealed. EI#4 replied, when foods are in the freezer, to keep from getting freezer burn and to ensure quality. EI#4 was asked, what was the facility policy on sealing food. EI#4 replied, if it is taken out of the original container it should be put in zip lock storage bag with a use by date, and if left in the the original container, needed to tie the bag closed in the box. EI#4 was asked, who was responsible for the food to be sealed. EI#4 replied, the cook or staff member that used it

Based on record review, interviews, and review of a facility policy titled, Acute Condition Changes- Clinical Protocol 3.12 the facility failed to ensure licensed staff notified the physician of blood glucose greater than 450. This affected Resident Identifier (RI) #88, one of one residence whose blood glucose levels were reviewed. Findings include: A review of the facility policy titled, Acute Condition Changes - Clinical Protocol 3.12, with a reviewed date of 01/18 revealed Assessment and Recognition . 1. As part of the initial assessment, the Physician will help identify individuals with a significant risk for having acute changes of condition during their stay . In addition, the Nurse shall assess and document/report the following . b. Neurological assessment . g. Recent labs . 5. The nursing staff will contact the Physician based on the urgency of of the situation. For emergencies, they will call or page the Physician and request a prompt response (within approximately one-half hour or less . Monitoring and Follow-up 1. The staff will monitor and document the resident's progress and responses to treatment, and the Physician will adjust treatment accordingly. RI#88 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On (MONTH) 13, 2019 at 05:15 PM, during an initial tour of the facility, the surveyor knocked on Resident Identifier (RI) #88 's room door and received permission to enter the room. Employee Identifier (EI) #9 was present in the room and reported to the surveyor that she just finished obtaining a blood sugar. EI #9 revealed the reading was 400. A review of RI #88's (MONTH) 2019 electronic Medication Administration Record [REDACTED]= 206 / 4 units administered ; 1100 =356 / 10 units ; 1700 = 459 / 12 units administered, by Employee Identifier (EI) #8, 5/12/19 0700= 324 /8 units administered ; 1100 487 / 12 units administered by EI#8; 1700 = 374 /10 units . A review of Resident Identifier (RI) #88's (MONTH) 2019 Physician Orders revealed 8/20/18 . Check blood sugar three times daily before meals cover SS (sliding scale) with [MEDICATION NAME] 0-199 = 0 units , 200-250 = 4 units , 251-300 = 6 units , 301-350 = 8 units , 351-400=10 units, 401-450 = 12 units , >(greater than) 450 = notify Physician . A review of RI #88 Departmental Notes revealed no nursing note entry for (MONTH) 11, 2019 and no nursing note entry for (MONTH) 12, 2019. On 5/14/19 at 5:40 PM, an interview was conducted with EI #7, Registered Nurse (RN) Supervisor. EI#7 was asked, should the Physician be notified per the sliding scale order for a capillary blood glucose (CBG) or blood glucose reading over 450. EI #7 replied, yes. EI #7 was asked, was the Physician notified after the results on 5-11-19 at 1600 results or after the 5-12-19 1100 results. EI #7 replied, not that she was aware of. EI#7 was asked, what would the potential harm be of not notifying the physician of CBG over 450. EI #7 replied, the resident could go into a diabetic coma or have other issues from sugar. EI#7 was asked, where should the Physician notification be documented. EI #7 replied, under the notes tab on Echart. EI#7 was asked, when should the nurse document notification of Physican. EI #7 replied, immediately after notification. On 5/15/19 at 11:13 AM, an interview was conducted with EI #8, Licensed Practical Nurse (LPN). EI#8 was asked, did RI#88 have a sliding scale ordered. EI#8 replied, she/he did. EI#8 was asked, what was the results for RI#88 capillary blood glucose (CBG) check on Saturday, (MONTH) 11, 2019 at 1700. EI#8 replied, 459. EI#8 was asked, what treatment did the resident receive. EI#8 replied, 12 units, and EI #6, the Physician was there and he ordered the 12 units and to be rechecked in a few hours, it was down to 200 something then. EI#8 was asked, should she document when the Physician was notified. EI#8 replied, yes . EI#8 was asked, did she document that she notified the Physician. EI#8 replied, no. EI#8 was asked, what was the results for RI #88 blood glucose check on (MONTH) 12, 2019 at 1100. EI#8 replied, 487. EI#8 was asked, what treatment did the resident receive. EI#8 replied, 12 units of insulin because it was greater than 450 and she did not notify the Physician but did recheck it a few hours later and it was below 199. EI#8 was asked, what treatment did the ordered sliding scale prescribe for blood glucose greater than 450. EI#8 replied, notify Physician. EI#8 was asked, should she have notified the Physician. EI#8 replied, yes. EI#8 was asked, did she notify the Physician. EI#8 replied, no. EI#8 was asked, what was the policy or procedure for notifying Physicians. EI#8 replied, notify RN and she will notify the Physician. On 5/15/19 at 11:53 AM, a phone interview was conducted with EI #6 , Physician. EI#6 was asked, was he familiar with RI#88. EI #6 replied, yes. EI #6 was asked, did he have a standard sliding scale for insulin. EI #6 replied, yes. EI #6 was asked, if the order was written for staff to notify Physician for blood glucose greater than 450, when should staff notify the Physician. EI #6 replied, when they check it. EI#6 was asked, should staff notify him each time blood glucose is greater than 450. EI # 6 replied, yes, they should. EI#6 was asked, what should a nurse do for blood glucose reading of 459 or 487. EI # 6 replied, text me or call me. EI#6 was asked, did he recall if he was present at the facility on 5-11-19, Saturday. EI # 6 replied, he was there on Sunday, not Saturday. On 5/15/19 at 12:28 PM a second interview was conducted with EI#8, LPN. EI#8 was asked, what was the harm in not notifying the Physician for a resident with Stage 3 [MEDICAL CONDITION] (CKD) with blood glucose greater than 450. EI #8 replied,they could go into kidney failure, blood sugar could send her/him into a diabetic coma, several things. EI#8 was asked, was she sure she talked with EI#6, Physician on Saturday 5-11-19. EI #8 replied, it was Sunday, she did not notify the Physician on Saturday, 5-11-19. EI#8 was asked, should she have notified th Physician on Saturday. EI #8 replied, yes. EI#8 was asked, why did she not notify the Physician on Saturday. EI #8 replied, sometimes it took the Physician awhile to respond , so she used her judgement and gave the max ordered dose of 12 units and re-assessed. EI#8 was asked, should she notify the Physician every time it is greater than 450. EI #8 replied, yes. EI#8 was reminder that earlier they spoke and she said RI#6, Physician, was there on Saturday and gave her orders, now she was saying it was Sunday. EI #8 was asked did she notify the Physician on Saturday or Sunday. EI #8 replied, Sunday. On 5/15/19 at 03:29 PM an interview was conducted with EI#8, LPN. EI #8 was asked, when should you notify family of significant change. EI #8 replied, as soon as possible. EI #8 was asked, did you notify family. EI #8 replied, no. On 5/15/19 at 04:29 PM, an interview was conducted with EI #1, RN, Director Of Nursing. EI #1 was asked, regarding EI#6, Physician's sliding scale order, what required Physician notification. EI #1 replied, anything greater than 450. EI #1 was asked, who was responsible for notification of Physician. EI #1 replied, LPN charge nurse or Registered Nurse (RN). EI #1 was asked, why should staff notify the Physician when readings were outside ordered ranges. EI #1 replied, it was dangerous not to keep control of diabetes, (residents could experience complications) like [MEDICAL CONDITION] and Ketoacidosis. EI #1 was asked, when should staff not notify a Physician of blood glucose greater than 450, with an order to notify Physician greater than 450. EI #1 replied, should always, unless there was an order not to. EI #1 was asked, who was responsible for documenting notification of a Physician. EI #1 replied, the nurse that notified the Physician. EI #1 was asked, where should notification of Physician be documented. EI #1 replied, in the medical record in nurses notes. EI #1 was asked, why should notification of the Physician be documented. EI #1 replied, if it was not documented they did not do it, and it kept record of blood glucose and number of notifications. EI #1 was asked, when should staff not document notification of Physician. EI #1 replied, never. EI #1 was asked, who was responsible for documenting blood glucose values. EI #1 replied, the nurse that checked the blood glucose. EI #1 was asked, where were blood glucose values documented. EI #1 replied, eMAR. EI #1 was asked, when should staff not document blood glucose values. EI #1 replied, never. EI #1 was asked, when should staff not follow Physician Orders. EI #1 replied, they should until otherwise directed by the Physician or if it would put a resident at risk or danger. EI #1 was asked, when blood glucose was greater than 450 should staff always notify the Physician, when ordered. EI #1 replied, yes. EI #1 was asked, what was the potential harm for not notifying the Physician. EI #1 replied, he could not give orders to help residents blood glucose come down. EI #1 was asked, what was the potential for harm for not documenting notification of Physician. EI #1 replied, if it was not documented then they did not do it. The can say they checked it, but if it was not documented, it was not there.

Based on observation, record review and interview, the facility failed to ensure the treatment nurse removed her gloves and sanitized her hands after cleaning the wounds for Resident Identifier (RI) #77 and RI #4, and before placing the clean treatment and outer coverings. This affected two of two residents observed for wound care. Findings Include: RI #77 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of RI #77's (MONTH) 2019 Physician order [REDACTED].Clean Stage II to coccyx with Vashe cleanser, apply [MEDICATION NAME] powder and cover with border dressing QD (everyday) . On 5/14/19 at 10:18 AM, the surveyor observed wound care for RI #77 performed by Employee Identifier (EI) #2 , Licensed Practical Nurse, Treatment nurse. EI #2 prepared the needed supplies and entered the resident's room. EI #2, washed her hands and put on gloves. The nurse assisting removed the soiled dressing. EI #2 cleaned the wound, then measured the wound. EI #2 used another 4x4 and cleaned the wound again. EI #2, with a clean 4 x 4 patted the wound dry. EI #2 applied the [MEDICATION NAME] powder and outer covering with same soiled gloves she had on to clean the wound with. RI #4 was admitted to the facility 11/29/16 with a [DIAGNOSES REDACTED]. A review of RI #4's (MONTH) 2019 Physician order [REDACTED]. Clean Stage II wound to coccyx with Vashe cleanser, apply [MEDICATION NAME] powder and cover with [MEDICATION NAME] Q 3 days (every 3 days) . On 5/14/19 at 10:43 AM, EI #2 was observed performing wound care for RI #4. EI #2 prepared the needed supplies: 4 x 4's wet with Vashe cleanser, dry 4 x 4 for drying, [MEDICATION NAME] powder, and a [MEDICATION NAME] dressing dated prior to entering the resident room. The assisting nurse removed the resident's pants and loosened the brief and held the resident over for EI #2. EI #2 rolled the brief down and away from the wound with her gloved hand. EI #2 said the brief was wet. EI #2 used her left hand and held the brief down then cleaned the wound using her right hand. EI #2 measured the wound. EI #2 used the pre wet 4x4s and cleansed the wound again, then with the dry 4 x 4 patted the area dry. EI #2 placed the skin prep, the [MEDICATION NAME] powder and the [MEDICATION NAME] with the same soiled gloves she cleansed the wound with and touched the wet brief. On 5/14/19 at 11:00 AM, an interview was conducted with EI #2 regarding the wound care for both RI #77 and RI #4. The surveyor recapped the wound care for RI #77 and RI #4 with EI #2. EI #2 recalled she did not remove her gloves after cleaning the wound for each resident. EI #2 was asked when should she wash her hands and change gloves during wound care. EI #2 replied, before starting, if gloves get soiled or dirty to change, after cleaning a wound before placing the clean treatment and when finished. EI #2 was asked if her gloves were considered clean or dirty after cleaning a wound. EI #2 replied, dirty. EI #2 was asked when should a nurse clean a wound then with the same gloves apply the clean treatment and outer covering. EI #2 replied, they should not do that. EI #2 was asked if she changed her gloves and washed her hands after cleaning the wounds on both residents before placing the clean treatment and outer coverings. EI #2 replied, no, their policy did not specify to do that way. EI #2 was asked what was the risk for harm in using the same gloves to clean a wound then place the clean treatment and outer coverings. EI #2 replied,spread infection. On 5/15/19 at 3:00 PM, an interview was conducted with EI #5, RN, Infection Control Nurse. EI #5 was asked what was the recommended procedure for glove changes and washing hands during the performance of wound care. EI #5 replied, wash hands, put on gloves, remove the old dressing, remove gloves wash hands, put on new gloves, clean the wound remove gloves wash hands new gloves and place treatment and outer covering. EI #5 was asked when should a treatment nurse clean a resident's wound then with the same gloves place the clean treatment and outer covering. EI #5 replied, they should not. EI #5 was asked what would the risks be in a nurse cleaning a wound then with the same gloves place the clean treatment. EI #5 replied, it could spread infection. EI #5 was asked when should a nurse remove IV equipment from a resident's room. EI #5 replied, after the last dose was given. EI #5 was asked when should IV pump, pole and equipment remain in a resident room [ROOM NUMBER] days after the medication was discontinued. EI #5 replied, it should not, the nurse discontinuing the medication should have removed the pump, pole and equipment. EI #5 was asked what would the risks be in an IV pump, pole and equipment not being removed from a resident room for 23 days after the medication was discontinued. EI #5 replied, it could be a safety issue and infection control issue; it should have been removed the day the medication was discontinued and cleaned.

Based on observations, interviews and a review of facility policies Dry Storage Areas, Record of Food Temperatures, and Temperature Sheet, the facility failed to ensure: 1) peanut butter was not on the lid of the peanut butter container; 2) an opened and used by date was on a container of gravy mix and; 3) the temperature of the pork chops was taken on the tray line before serving to the residents. This had the potential to affect 100 of 107 residents receiving meals from the kitchen. Findings Include: 1) A review of a facility policy titled, Dry Storage Areas (undated) revealed: Policy: Dry storage areas will be kept in a condition which protects stored food from infestation. .Care of Storeroom .Food storage containers are cleaned after each use. On 06/12/18 at 9:16 a.m., the surveyor along with (Employee Identifier) EI #4 Dietary Director, toured dry storage. The surveyor observed a container of creamy peanut butter with peanut butter on top of the lid. On 6/14/18 at 9:24, an interview was conducted with EI #4, Dietary Director. EI #4 was asked what was on top of a lid of a peanut butter jar. EI #4 replied, peanut butter. EI #4 was asked who was responsible for making sure food containers were cleaned when putting them back into dry storage. EI #4 replied, whoever was using it is supposed to wipe it down if anything was on the jar. EI #4 was asked what did the facility policy say regarding dirty lids on food containers in dry storage. EI #4 replied, food containers should be cleaned before placing back into dry storage. EI #4 was asked what was wrong with food on top of a closed food container in dry storage. EI #4 replied, it could attract pests. 2) On 06/12/18 at 9:16 a.m., the surveyor along with (Employee Identifier) EI #4 the Dietary Director observed a 24 ounce bag of old fashion gravy mix in a medium zip lock bag with no open or used by date. 06/14/18 at 9:39 a.m., an interview was conductd with EI #4. EI #4 was asked what was the use by date on the gravy. EI #4, replied, it was not wrtitten on it. EI #4 was asked what did the facility policy say regarding using an open and use by date on food products. EI #4 replied, dry food storage must have an open date on it and use by date. EI #4 was asked who was responsible for putting use by dates on food items once opened. EI #4 replied, once opened, use the use by date that is printed. EI #4 was asked why was it important to put use by dates on food products. EI #4 replied to esure the quality of the food. 3) A review of a policy titled, Record of Food Temperatures (undated) revealed: Policy: It is the policy of this facility to record food temperatures daily to ensure food is at the proper serving temperature(s) before trays are assembled. .Procedure: . 1. Food temperature will be checked on all items prepared in the dietary department. 6. Measure and record the temperatures for each food product. Record temperature on temperature log. A review of the facility's Temperature Sheet dated 6/12/18 did not show the recording for the second batch of pork chops. 6/12/18 at 12:00 p.m., the surveyor observed a second batch of pork chops in a fryer basket. EI #5, dietary aide, took the basket of pork chop and put them in a pan that was on the trayline. EI #5 did not take the temperature of the pork chosp before placing them in the pan with other pork chops. The serveyor observed mashed potoatoes on the stove. Prior to serving the mashed potatoes to the residents, the temperature was not checked. On 6/14/18 at 9:32 a.m., an interview was conducted with EI #4. EI #4 was asked who took the temperatue of the second batch of pork chops. EI #4 replied, she did not see anyone take it. EI #4 was asked where was the second batch of pork chops temperature recorded on the menu log. EI #4 replied, it was not . EI #4 was asked who was responsible for taking food temperatures. EI #4 replied, the cook. EI #4 was asked why was it important to take food temperatures on the tray line. EI #4 replied it was the only way to ensure the food was cooked properly. On 6/14/18 at 10:53 a.m., an interview was conducted with EI #6, the head cook, supervisor. EI #6 was asked what was the temperature of the second batch of pork chops. EI #6 replied, she was not 100 percent sure. EI #6 was asked who was responsible for food temperatures. EI #6 replied, the cooks. EI #6 was asked why it is important to take food temperatures. EI #6 replied, to make sure it was at the temperature before it goes out on the hall. EI #6 was asked if she served pork chops and no temperature was taken. EI#6 replied, the first batch EI #5 pulled off was not taken. EI #6 was asked if she took the temperature of the second batch of pork chops. EI #6 replied, she did not.

Based on record review, interview and review of a facility policy Resident Assessment Instrument , the facility failed to ensure the Minimum Data Set ((MDS) dated [DATE] and 12/9/17 was coded for hospice care. This affected Resident Identifier (RI) #9, one of three residents sampled for hospice care. Findings Include: A review of a facility policy Resident Assessment Instrument (MDS) with a revised date of 1/18 revealed: .Policy Interpretation and Implementation . 4. The purpose of the assessment is to describe the resident's capability to perform .5. Information derived from the comprehensive assessment enables the staff to plan care . RI #9 was admitted to the facility 9/0/17 with a [DIAGNOSES REDACTED]. A review of RI #9's Physician order [REDACTED].Admit patient to .Hospice with terminal [DIAGNOSES REDACTED]. On 6/13/18 at 9:49 AM a review of RI #9's Significant Change (SC) MDS dated [DATE] and an SC MDS dated [DATE] revealed hospice was not coded under section O - Special Treatments, Procedures and Programs. On 6/13/18 at 12:27 PM an interview was conducted with Employee Identifier (EI) #2, Licensed Practical Nurse. EI #2 was asked if RI #9 was receiving hospice services. EI #2 replied, yes. EI #2 was asked when was hospice ordered. EI #2 replied 9/18/17. EI #2 was asked if a SC MDS was completed. EI #2 replied, yes. EI #2 was asked if hospice was coded. EI #2 replied, it was not coded in section O. EI #2 was asked if hospice should have been coded. EI #2 replied, yes. EI #2 was asked what were the risks of hospice not being coded on the MDS. EI #2 replied, the assessment would not be accurate.

Based on observations, interviews and a review of a facility policy titled, Posting Direct Care Daily Staffing Numbers, the facility failed to ensure staffing report was posted for 6/12/18 and the evening shift was posted on 6/13/18. This had the potential to affect all residents and their family members. Findings Include: A review of a facility policy titled, Posting Direct Care Daily Staffing Numbers (undated) revealed: .Policy: It is the policy of this facility to make staffing information readily available in a readable format to residents and visitors at any given time. Policy Explanation and Compliance Guidelines: .2. The facility will post the nurse staffing at the beginning of each shift On 6/12/18 at 5:50 PM, an observation of the posted(NAME)County Health and Rehabilitation Facility Direct Care Staff Daily Report revealed the report posted was dated 6/11/18. On 6/13/18 at 4:13 PM, the surveyor observed staffing posted for the morning shift, however the evening shift was not posted. Again at 5:25 PM, the surveyor observed that staffing for the second shift was not posted. On 6/14/18 at 2:07 p.m., an interview was conducted with with EI (Employee Identifier) #7, RN (Registered Nurse). EI #7 was asked who was responsible for posting the staffing report daily. EI #7 replied, in the morning the RN that gets the shift started. EI #7 stated she (EI #7)tally's up the actual hours from the previous shift. EI #7 was asked why was there no staffing report completed for 6/12/18. EI #7 replied, she was on the cart and she did not think she completed a sheet for the morning. EI #7 was asked when was a staffing form completed for 6/12/18. EI #7 replied she could not remember, it may have been done on the 13th. EI #7 was asked why was it important that staffing was posted and accurate. EI #7 replied, for visitors and others to know how many staff they have on hand. EI #7 was asked why was the second shift daily report not posted on 6/13/18 by 5:25 PM. EI #7 replied, she could not answer that, she did not complete the second shift posting. EI #7 was asked was the staffing on 6/13/18 accurate and current. EI #7 replied, no ma'am. On 6/14/18 at 2:42 p.m., an interview was conducted with EI #8, RN. EI #8 was asked who was responsible for posting staffing each day. EI #8 replied, the RN supervisor will do it when she gets here but if she was working on the cart, she (EI #8) normally did it. EI #8 was asked why was it important that staffing was posted correctly. EI #8 replied it shows how many staff are working in the building and how many hours they work. EI #8 was asked why was the second shift daily report not posted on 6/13/18 by 5:25 PM. EI #8 replied, yesterday was a busy day and she forgot to complete it. EI #8 was asked was the staffing form on 6/13/18 at 5:25 PM accurate and current. EI #8 replied, no ma'am.

Based on observation and interview, this facility failed to ensure that infection control practices were utilized in the preparation of medications for medication delivery for one of 9 residents (Resident Identifier (RI)) #30 observed during medication pass. This deficient practice involved one of five nurses during the medication pass observed to stir crushed medication with her index finger. Findings Include: RI #30 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of RI #30's (MONTH) (YEAR) Physician order [REDACTED].Two Tums tablets crushed and give .[MEDICATION NAME] liquid .[MEDICATION NAME] D 600 Milligram TABLET . On 6/12/18 at 11:02 AM Employee Identifier (EI) #3, Licensed Practical Nurse, was observed giving RI #30's medication by way of gastrostomy tube. EI #3 prepared each of the medications in separate medication cups. EI #3 crushed medication separately then melted each with water. EI #3 used a plastic spoon to stir the medication and water. EI #3 gathered her supplies and the medication and went into RI #30's room. EI #3 washed her hands and put on gloves. EI #3 checked the placement of the tube then proceded administering the medication. EI #3 poured the melted [MEDICATION NAME] in the barrel of the syringe. EI #3 poured additional water in the medication cup and stirred the contents with her left first finger and poured it in the barrel of the syringe. EI #3 poured the melted tums in the barrel of the syringe. EI #3 added additional water to the medication cup and stirred the contents with her first left finger then poured the contents in the barrel of the syringe. EI #3 followed the medication with water completing the task. On 6/12/18 at 11:30 AM an interview was conducted with EI #3. EI #3 was asked what was the policy on stirring crushed medications. EI #3 replied, stir with a spoon. EI #3 was asked if she stirred the medications with a spoon after she took the medications in RI#30's room. EI #replied, no she used her gloved finger. EI #3 was asked if she should use her finger to stir medications. EI #3 said no. EI#3 was asked what was the risks in using her finger to stir medication. EI #3 replied, spread germs. On 6/13/18 at 2:44 PM an interview was conducted with EI #1, Director of Nursing, Infection Control Nurse. EI #1 was asked what was the policy on stirring crushed medications. EI #1 replied, use a spoon or a stir stick. EI #1 was asked when would a nurse use her finger to stir medications. EI #1 replied, never. EI #1 was asked why would nurse not use her finger to stir medications. EI #1 replied, infection control issue and she could contaminate the medications.

Based on observation, interview and a review of a facility policy titled, Disposal of Garbage and Refuse Policy the facility failed to ensure: the dumpsters door lid and door was closed. This had the potential to affect all residents residing at the facility. Findings Include: A reviewer of a facility titled, Disposal of Garbage and Refuse Policy (undated) revealed: Policy: The facility shall properly dispose of kitchen garbage and refuse. Procedures: 7. Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, door, or covers. Containers and dumpsters shall be kept covered when not being loaded. On 6/12/18 at 9:42 a.m., the surveyor along with EI #4 ( Employee Identifier), Dietary Director, observed four dumpsites located outside behind the kitchen. Dumpster number one's door was opened at the side. Dumpster number two's lid was opened at the top of the dumpster. On 6/14/18 at 9:49, an interview was conducted with EI #4 . EI #4 was asked what did she see when looking at dumpster number one on 6/12/18. EI #4 replied, the door on the right side of the dumpster was opened. EI #4 was asked what did she see when looking at dumpster number two. EI #4 replied, there was a gap between the two lids. EI #4 replied, the gap was about six inches. EI #4 was asked who was responsible for keeping the dumpster door and lids closed. EI #4 replied, everyone in the facility uses the dumpster and everyone who uses it should close it back. EI #4 was asked why was it important to keep the dumpster doors and lids closed. EI #4 replied so it want attract rodents, pest and try to contain the smell.

Based on an interview and record reviews, the facility failed to ensure there was documentation to indicate 12 hours of inservice training for the CNAs (Certified Nursing Assistants) within the past 12 months. This was found on 10 of 10 CNAs training records reviewed. Findings include: A review of the facility's Policy and Procedure titled, EMPLOYEE INSERVICE POLICY, with a revision date of 6/02/2015, revealed, All personnel are required to attend regularly scheduled in-service training classes. Initial In-services: In-services will be scheduled at varying times, but typically in-services will be scheduled on Tuesday and Wednesday of the second pay period of each month and will last at least one hour. A review of the facility's inservice sign-in logs for the CNAs revealed no time for the inservices were documented to indicate the length for each program. A review was conducted on EI # 3, #4, #5, #6, #7, #8, #9, #10, #11, and #12. EI #3's hire date was 04/04/16 EI #4's hire date was 01/20/16 EI #5's hire date was 09/16/15 EI #6's hire date was 03/19/01 EI #7's hire date was 11/01/00 EI #8's hire date was 09/23/13 EI #9's hire date was 12/03/14 EI #10's hire date was 02/21/11 EI #11's hire date 09/27/12 EI #12's hire date 07/10/13. On 5/3/17 at 11:49 a.m., an interview was conducted with EI (Employee Identifier) #2, a RN (Registered Nurse)/Staff Development Coordinator. EI #2 was asked where the documentation was to indicate the time of the CNA training programs. EI #2 stated, There is no time on the sign in sheets. It is our policy that they last 1 hour at least monthly. EI #2 was asked how she could prove the CNAs had 12 hours of training. EI #2 stated, They signed the sign in sheet for the Inservice that last 1 hour. EI #2 was asked where the documentation was to support the 12 hours of training for the past 12 months. EI #2 stated, There is no specific times on the sign in sheets, it is the facility's Policy that the Inservices last for 1 hour. They actually receive more than 12 hours annually.

Based on observations, interview, and facility document titled, MAINTENANCE SUPERINTENDENT Job Description, the facility failed to ensure the bolts located on the toilet base were not protruding 1/2 (inch) to 2 long, rusted, and uncapped. This was observed in 26 resident bathrooms, 3 resident showers, and 1 public resident bathroom, on 4 of 4 halls. Findings include: A review of an undated facility document titled, MAINTENANCE SUPERINTENDENT Job Description, revealed, PURPOSE OF YOUR JOB POSITION The primary purpose of your job position is to maintain the grounds, facility, equipment in a safe and efficient manner in accordance with current applicable federal, state, and local standards, guidelines and regulations, our established policies and procedures, and as may be directed by the Administrator, to assure that a successful maintenance program is maintained at all times. On 5/04/17, starting at 10:23 a.m., observations were made of resident bathrooms, showers, and public resident bathrooms. The following were observed for ALs (Area Locator): AL #1- 1/2 rusted, uncapped bolts on toilet base AL #2-1 1/2 to 2 bolts on base of toilet protruding, rusted, and uncapped AL #3-1 1/2 to 2 bolts on base of toilet protruding, rusted, and uncapped AL #4- 1/2 to 1 uncapped bolts on toilet base AL #5- 1 1/2 to 2 bolts on toilet base, rusted, and uncapped AL #6- 1/2 to 1 bolt on base of toilet protruding, rusted and uncapped AL #7- 1/2 to 1 uncapped, rusted bolts on toilet base AL #8- 1/2 to 1 bolt on base of toilet, uncapped and rusted AL #9- 1/2 to 1 uncapped bolts on toilet base AL #10- 1 1/2 to 2 uncapped, rusted bolts on toilet base AL #11- 1/2 to 1 uncapped bolt at toilet base, rusted AL #12- 1/2 to 1 bolt at toilet base rusted, and uncovered AL #13- 1 1/2 to 2 uncapped, rusted bolts on toilet base AL #14-1 1/2 to 2 bolt on toilet base uncapped, and rusted Shower room of 200 Hall- 2 uncapped bolts on toilet base AL #15- 1/2 uncapped, rusted and corroded bolts on toilet base AL #16- 1 1/2-2 uncovered bolt, uncapped, rusted at the toilet base AL #17- 2 rusted, uncapped bolts on toilet base AL #18- 1/2 uncapped, rusted bolts on toilet base AL #19-1 1/2-2 uncovered bolt, uncapped, and rusted at toilet base Shower #1 of 300 Hall- 2 uncapped, rusted bolts on toilet base Shower #2 of 300 Hall- 2 uncapped, rusted bolts on toilet base AL #20-1 1/2-2 uncovered bolt at toilet base rusted, uncapped bolt AL #21- 1/2 rusted bolt with only one bolt capped on toilet base AL #22- 1/2 uncovered bolt to the left side of the toilet base, rusted and uncapped AL #23- 1/2 rusted bolt with only one bolt capped on toilet base AL #24- 1/2 uncovered bolt to the left side of toilet base, rusted and uncapped AL #25- 1/2 uncovered bolt to the right side of toilet base a rusted and uncapped AL #26- 1/2 rusted bolt with only one bolt capped on toilet base On 5/4/17 at 11:03 a.m., a tour with the surveyor was conducted with EI (Employee Identifier) #1, the Maintenance Director. EI #1 was shown rooms on each hall of the facility with uncapped and protruding bolts at the base of the toilets. On 5/4/17 at 11:16 a.m., an interview was conducted with EI #1, the Maintenance Director. EI #1 was asked who checked/monitored resident bathrooms for maintenance. EI #1 stated We have a monthly checklist, work order system, the CNA's, etcetera. fill out work orders and we check work orders and correct the problem. EI #1 was asked how often were bathrooms checked. EI #1 stated, We did daily walk-throughs and look visually doing an inspection. EI #1 was asked, during the tour with the surveyor what did he observe regarding the toilets. EI #1 stated, The stem of the toilet bolt sticking up from the floor. EI # 1 was asked what could be the concern with toilet bolts that were 1/2 to 2 in length, rusted, and uncapped. EI #1 stated, I don't know how to answer that. That's our standard protocol to snap a cap on but the one's uncovered were there when built.

Based on observations, record review and interview, the facility failed to: 1. prevent dietary staff from chewing gum while preparing houseshakes for residents. 2. ensure sectional plates were clean to sight and touch and were air dried. The above practices posed the potential for food contamination and compromised food safety. This had the potential to affect all 104 residents receiving meal trays from dining services. Findings include: 1. The 2013 Food Code by the United States Public Health (USP) and the Food and Drug Administration (FDA) included the following: Food Contamination Prevention 2-401.11 Eating, Drinking, or Using Tobacco. (A) Except as specified in ¶ (B) of this section, an EMPLOYEE shall eat, drink, or use any form of tobacco only in designated areas where the contamination of exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES; or other items needing protection can not result . Though the regulatory language does not specify gum chewing as a risk factor, the following undated facility policy addresses gum chewing specifically. Preventing Foodborne Illnesses-Food Handling , .Policy Interpretation and Implementation .3. c No .meal consumption is allow (allowed) in food service area (to include chewing gum . On 3/30/2016 at 11:50 AM, Employee Indentifer (EI) #8, a Dietary Aide, was observed preparing a special strawberry houseshake. EI #8 was observed to be chewing gum. The Registered Dietitian (RD), EI #7, was asked if the Dietary Aide, EI #8 was chewing gum? EI #7's response was yes. Then EI #7 went to EI #8 and asked the employee if she was chewing gum. The employee (EI #8) said she was sorry, disposed of the gum, washed her hands and re-gloved. On 3/30/2016 at 3:15 PM, the Dietary Aide, EI #8 was asked if she was chewing gum when preparing the houseshakes, what training she had received, and why she chewed gum on duty. EI #8 indicated that she had been trained to not chew gum, but had forgotten and was unsure of the reasons why not to. At this time, EI #7,the RD, was asked about the potential harm for chewing gum in dietary services and she responded that there was a potential to pass germs on to others and the potential of cross-contamination. 2. 1. The 2013 Food Code by the United States Public Health (USP) and the Food and Drug Administration (FDA) included the following: 1) 4-601.11 Equipment, Food , Food-Contact Surfaces, Nonfood-Contact surfaces, and utensils (A) Equipment Food-Contact Surfaces and utensils shall be clean to sight and touch . 2) 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and sanitizing, equipment and utensils: (A) Shall be air-dried or used after adequate draining . On 3/30/16 at 11:45 AM, divided (sectional) plates were observed on the trayline. Two of the three plates were observed with rolling water and one of the two contained food debris. The RD, EI #7, was asked about the debris which was removed by the surveyor's thumb nail. On 3/30/2016 at 3:25 PM, the RD, EI #7 was interviewed and stated the plates should not have been stored wet, that the Dietary Aide on the clean side of the dishmachine was responsible for assuring dinnerware was clean and air-dried. EI #7 indicated that potential bacterial growth was a risk factor and that inverting the plates during storage would be beneficial.

Based on observation, interview and record review the facility failed to ensure a Certified Nursing Assistant, Employee Identifier (EI) #2 covered Resident Identifer (RI) #6, when leaving the resident during foley catheter care. This allowed the resident's perneal area and buttocks to be exposed. This affected one of one sampled residents observed during foley catheter care. Findings Include: RI #20 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #20's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 4/5/2016, revealed a BIMS (Brief Interview for Mental Status) score of 15 indicating RI # 20 is cognitively intact. It further indicated RI #20 had an indwelling foley catheter. A review of the Fundamentals of Nursing, Eighth Edition, Potter and Perry revealed . Implementation . 4. Drape bath blanket on patient so only perineal area is covered . A review of the facility policy and procedured revealed Catheter Care, Urinary . Procedure . 12. Provide privacy. Cover the resident with a sheet, exposing only the perineal area. On 6/8/2016 at 10:45 AM, EI #2 and EI #3 were observed performing catheter care on RI #20. EI #2 was observed leaving the room in the middle of catheter care to obtain wash clothes, leaving RI #20's buttocks and perineal area exposed. On 6/8/2016 at 4:00 PM, an interview was conducted with EI #2. EI #2 was asked if she provided catheter care on RI #20 in the AM of 6/8/2016. She responded yes. EI # 2 was asked if she knew she left RI #20 uncovered while she left the room, she replied yes. EI #2 was asked what was the potential harm to RI #20 resulting from leaving RI #20 uncovered when leaving the room, she said dignity.

Based on observation, record review, and interview, the facility failed to ensure Employee Identifier (EI) #1, a Licensed Practical Nurse (LPN)/Treatment Nurse assessed Resident Identifier (RI) #7 for pain prior to performing wound care on 3/31/2016. RI #7 was observed to moan and groan throughout the treatment. This affected one of two residents observed during wound care. Findings Included: A review of a facility policy dated 09/09 titled, Administering Pain Medications, documented: .General Guidelines . 2. The resident's experience of pain is highly individual and subjective. Pain is whatever the resident says it is. 3. Intense pain can result from even minor procedures . 5. Be familiar with the physiologic and behavioral signs of pain Procedure . 4. Obtain objective information through assessment: a. Behavioral responses to (acute) pain; (1) facial wrinkling/grimacing . (3) crying or moaning . 6. Administer pain medications as ordered . A review of a facility policy dated 09/09 titled, Pain Assessment, documented: Purpose The purpose of this procedure is to assess the resident's pain level and provide optimal comfort through a pain control plan . General Guidelines . 4. Pain will be assessed and documented at each shift and as necessary . Procedure . 2. Ask the resident if he/she is experiencing any pain . 3. Assess pain . 4. Determine appropriate type of pain medication . 6. Medicate the resident as the physician ordered . RI #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #7's initial MDS (Minimal Data Set) with an ARD (Assessment Reference Date) of 02/23/2016 revealed RI #7 was severly impaired in cognition and was on routine as well as PRN (As Needed) pain medications. A review of RI #7's Physician order [REDACTED].#7 received [MEDICATION NAME] 7.5/325 mg (milligrams) twice a day at 6 am and 4 pm. RI #7 also received [MEDICATION NAME] 7.5/325 mg every four to six hours as needed for pain. On 03/31/2016 at 08:40 AM, the surveyor observed EI #1, the Treatment Nurse perform wound care to RI #7's right buttock with EI #2, a Certified Nursing Assistant (CNA) assisting her. EI #1 entered the room and instructed the resident on the wound care. After washing their hands and putting gloves on, EI #1 and EI #2 began positioning RI #7 for wound care. RI #7 began to moan and stated, Oh, me. Oh, me. EI #1 stated, I'm sorry. and continued to remove RI #7's dressing. EI #1 continued with wound care, measured the wound, cleansed with normal saline and applied [MEDICATION NAME] powder. RI #7 continued moaning/groaning throughout. EI #2, the CNA asked RI #7 if the resident was hurting. RI #7 stated, My hip is hurting. EI #1 continued with wound care, placing the [MEDICATION NAME] with border onto the wound. Upon completion, EI #2 asked RI #7, Is that better? RI #7 did not respond. After repositioning RI #7 in bed, EI #1 stated. We will get you something for pain. On 03/31/2016 at 09:05 AM, the surveyor interviewed EI #1, the Treatment Nurse. When asked what RI #7's demeanor was during wound care, EI #1 stated moaning. EI #1 was asked when should a resident be assessed for pain. She stated at the beginning of the shift and every two hours. When asked what should be done prior to wound care, EI #1 stated, Ask (the resident) if he/she was in pain. and further stated she had not asked RI #7. EI #1 was asked if RI #7 should have been assessed for pain prior to wound care. She stated yes. When asked if RI #7 was in pain during wound care, EI #1 stated she did not think it was the wound care that caused pain but the movement of the resident that was the cause of pain. EI #1 was asked if RI #7 had medications for pain. She stated that RI #7 receives pain meds twice a day routinely and has pain medications as needed (PRN). EI #7 was asked if she premedicated residents prior to wound care. She responded, I do when I know they need it and (RI #7) does need it. (RI #7) probably needs to be (pre-medicated). EI #1 did not know when the last time RI #7 had received pain medication. EI #1 was asked why it was important to treat pain. She stated to get rid of pain and to keep the resident as comfortable as possible. EI #1 further stated RI #7 was not comfortable. On 03/31/2016 at 1:05 PM, the surveyor interviewed EI #3, an LPN who was routinely assigned to RI #7. EI #3 was asked what medications does RI #7 have for pain. She replied [MEDICATION NAME] twice a day and as needed for a [DIAGNOSES REDACTED].#3 further stated that RI #7 could not describe the pain but she could tell by the resident's grimaces and facial expressions. The surveyor explained the wound care observation of 03/31/2016 where the resident moaned throughout the care. EI #3 was asked what measures could be taken to relieve pain. EI #3 stated to ask the resident if he/she was in pain before the treatment and to give pain medications prior to the treatment. A review of RI #7's Medication Administration Record [REDACTED].

Based on observation, record review and interviews, the facility failed to ensure Employee Identifier (EI) #5, a Certified Nursing Assistant (CNA), performed catheter care for Resident Identifier (RI) #3, a resident with a history of Urinary Tract Infection [MEDICAL CONDITION] in a manner to prevent infection. This was evidenced by: EI #5 used the same area of a washcloth multiple times during the provision of RI #3's catheter care and EI #5 used a backward and forward motion to clean RI #3's urinary catheter tubing. This affected RI #3, one of two residents observed during the provision of catheter/incontinence care. Findings Included: A review of an undated facility document titled, Catheter Care, Urinary, revealed: .The purpose of this procedure is to prevent infection of the resident's urinary tract . Procedure .7. Wash the resident's genitalia and perineum thoroughly with soap and water .15 .Use one area of the washcloth/wipe with each downward, cleansing stroke .16. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward . RI # 3 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/09/2015 documented the use of an indwelling catheter under the section for bowel and bladder. A review of a urine culture report with a urine specimen collection date of 11/09/2015, documented: .Result 1 Proteus Mirabilis . Greater than 100,000 colony forming units per Ml (milliliter) . This result was indicative of a UTI. There were instructions from the physician written on the laboratory report for two antibiotics, which were [MEDICATION NAME] and [MEDICATION NAME]. A review of RI #3's March 2016 physician orders [REDACTED]. On 3/30/2016 at 3:05 PM, an observation was made during the performance of catheter care/incontinent care for RI #3 with two CNA's, EI #4 and EI #5. EI #5 put water in a bath basin, added soap, and then used a washcloth to wipe down the labia four times without changing the washcloth or the position of the washcloth. Then EI #5 changed the position of the cloth and wiped downward two more times with bowel movement noted on the rag after the second wipe. EI #4 and EI #5 assisted resident onto his/her left side. EI #5 then washed her hands, re-applied gloves, emptied and refilled the bath basin, then used disposable wipes to clean the bowel movement. EI #5 put soap into the basin water, wet a washcloth and wiped at the base of the catheter twice without changing the position of the washcloth. EI #5 then used another washcloth and wiped the catheter tubing close to the insertion site twice, using an up and down motion and without changing the position of the washcloth between wipes. On 3/30/2016 at 4:06 PM, an interview was conducted with EI #5 about the catheter care/incontinent care observed for RI #3. The surveyor asked EI #5 what technique she was taught to use when performing catheter care. EI #5 answered that you get towels and soap, make sure to wash your hands, and make sure you clean around the vagina. The surveyor asked EI #5 how many times she should wipe using the same surface of the washcloth when cleaning genitalia such as the urethra and labia while performing incontinent care. EI #5 stated, One. The surveyor asked EI #5 how many times she wiped using the same surface of the washcloth. EI #5 stated, I wiped extra because she had some stuff up there. The surveyor asked EI #5 what the potential for harm to the resident would be when a CNA uses an up and down motion to clean catheter tubing and uses the same area of a washcloth for more than one wipe when performing incontinent care. EI #5 answered that it could cause a bacterial infection. On 3/30/2016 at 4:25 PM, an interview was conducted with EI #4 about the catheter/incontinent care observed for RI #3. The surveyor asked EI #4 if she observed EI #5 use a back and forth motion to clean RI #3's catheter tubing. EI #4 stated, Yes. The surveyor asked EI #4 what the potential for harm to the resident would be if a CNA uses a back and forth motion when cleaning catheter tubing and what the potential harm would be if a CNA does not change the position of the washcloth between wipes. EI #4 stated, Infection. On 3/31/2016 at 1:50 PM, an interview was conducted with EI #6, Licensed Practical Nurse (LPN)/Infection Control. The surveyor asked EI #6 what the facility policy was related to cleaning the catheter tubing near the urethral opening. EI #6 stated to take a washcloth with soap or a wipe and do one swipe down. The surveyor asked EI #6 if she was aware that a CNA used a back and forth motion on a resident's catheter tubing and used the same area of the washcloth more than one time to wipe. EI #6 answered that she was aware and that the CNA was going to get more training on catheter care. The surveyor asked EI #6 what the potential for harm to a resident would be if a CNA used a back and forth motion to clean a catheter and/or used the same area of a washcloth for more than one wipe. EI #6 answered that the risk would be infection. The surveyor asked EI #6 if RI #3 has had a UTI. EI #6 answered that the last one was in November 2015.

Based on observations, interviews and record review, the facility failed to ensure the following: 1) A CNA (Certified Nursing Assistant) removed her gloves and washed her hands after cleaning a bowel movement from RI #3; 2) an LPN (Licensed Practical Nurse) used a paper towel to turn off the faucet after washing her hands while performing wound care to RI #3; 3) an LPN cleaned and disinfected a resident's over bed table prior to it being used to set up another resident's (RI #3's) lunch tray. This affected one of two residents observed during incontinent/catheter care; one of two residents observed during wound care and one of twelve residents whose meals were observed. Findings included: 1) A review of a facility document dated 09/09 titled, Perineal Care documented: .The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections .Procedure .12. Remove gloves and discard .Wash and dry hands thoroughly. 13. Reposition bed covers. Make resident comfortable . RI # 3 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/30/2016 at 3:05 PM, EI #4 and EI #5, two CNA's, were observed giving catheter/incontinent care to RI #3. EI #5 cleaned bowel movement off of RI #3; then without removing her gloves and/or washing her hands, she fastened the clean brief, repositioned RI #3's clothes, and straightened the draw sheet that was on the bed. On 3/30/2016 at 4:06 PM, an interview was conducted with EI #5 regarding the care observed for RI #3. The surveyor asked EI #5 if she should use the same gloves, she wore to clean bowel movement from the resident, to put a clean brief on the resident. EI #5 stated, No. The surveyor asked EI #5 what could be the potential harm to the resident when a CNA wears the same gloves to clean bowel movement and then fastens a clean brief. EI #5 answered that it could cause a bacterial infection. On 3/30/2016 at 4:25 PM, an interview was conducted with EI #4 about the observed care for RI #3. The surveyor asked EI #4 what the facility policy was related to changing gloves after cleaning bowel movement from a resident. EI #4 answered that they are to always remove the gloves, wash their hands and put on new gloves. The surveyor asked EI #4 why EI #5 would not have removed her gloves and washed her hands after cleaning bowel movement from RI #3. EI #4 answered that she thought EI #5 was nervous. The surveyor asked EI #4 what the potential for harm to the resident would be because a CNA failed to remove her gloves and wash her hands after cleaning bowel movement and before touching clean items. EI #4 answered that there is a risk of infection. On 3/31/2016 at 1:50 PM, an interview was conducted with EI #6, Licensed Practical Nurse (LPN)/Infection Control. The surveyor asked EI #6 if EI #5 should have changed her gloves and washed her hands after cleaning bowel movement from RI #3. EI #6 answered, yes. The surveyor asked EI #6 if RI #3 has had a Urinary Tract Infection (UTI). EI #6 answered that RI #3 had a UTI in November 2015. 2) An undated facility document titled, Hand Hygiene documented: POLICY: Handwashing/hand hygiene is generally considered the most important single procedure for preventing healthcare-associated infections .PURPOSE: To decrease the risk of transmission of infection by appropriate hand hygiene .I. HANDWASHING .E. Dry hands with a clean paper towel. Use the paper towel to turn off the faucet, then discard . RI # 3 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/30/2016 at 2:45 PM, EI #1, an LPN/Treatment Nurse, was observed performing wound care on RI #3. Prior to beginning the care, EI #1 washed her hands with soap and water and turned the faucet off with her bare hand, then she obtained a paper towel and dried her hands. EI #1 removed the previous dressing from RI #3's right hip and removed her gloves. EI #1 then washed her hands with soap and water, turned the faucet off with her bare hand, and then obtained a paper towel to dry her hands. EI #1 then measured the wound and cleaned with normal saline, removed her gloves, washed her hands with soap and water, turned the faucet off with her bare hand and obtained a paper towel to dry her hands. EI #1 then applied skin prep around the wound, applied Santyl to the wound bed, and applied a Cosmopore dressing to the wound. EI #1 then washed her hands with soap and water, turned the faucet off with her bare hand, then obtained a paper towel to dry her hands. EI #1 removed the dressing from RI #3's left lower buttock and measured the wound. EI #1 then removed her gloves and washed her hands; she turned the faucet off with her bare hand, then obtained a paper towel to dry her hands. On 3/31/2016 at 1:30 PM, an interview was conducted with EI #1. The surveyor asked EI #1 what the facility policy was related to turning the water off after washing your hands. EI #1 answered that you are supposed to use a paper towel and that yesterday she knew she didn't. The surveyor asked EI #1 why she did not use a paper towel to turn the faucet off. EI #1 answered that she was just nervous. The surveyor asked EI #1 what was the potential harm to the resident if you touch the faucet without using a paper towel after washing your hands. EI #1 answered that you can spread germs. On 3/31/2015 at 1:50 PM, an interview was conducted with EI #6, LPN/ Infection Control. The surveyor asked EI #6 what she would expect the wound care nurse to do after completing handwashing related to the faucet. EI #6 answered that she should use her towel to turn it off. The surveyor asked EI #6 if she was aware that the wound care nurse failed to obtain a paper towel to turn the faucet off after washing her hands. EI #6 answered that she was aware, the wound nurse had told her. The surveyor asked EI #6 what the potential harm to a resident would be if a paper towel is not used when hands are washed prior to wound care. EI #6 answered that it may contaminate the wound. 3) On 3/30/2016 at 12:07 AM, RI #3 was wheeled to a common area by a Licensed Practical Nurse (LPN), EI #9. EI #9 obtained an overbed table from RI #2's room for use by RI #3. At 12:35 PM, EI #9 was asked and confirmed she had taken an overbed table from one resident's room to be used by a different resident. On 3/31/2016 at 8:35 AM the LPN, EI #9 was interviewed about the incident. EI #9 stated that she failed to properly disinfect the table with a facility sanitizer. She further stated she should have. EI #9 said there was a potential for cross-contamination and infection.

Based on observations, record review and an interview, the facility failed to ensure leftover foods in the walk-in refrigerator were labeled with information to include the name of the food, preparation date and the use-by (or discard) date, and further failed to ensure opened bags of lettuce and cheese were labeled with opened and use by dates. This observation was made during the initial tour of the kitchen on 2/23/15, and had the potential to affect 113 of 113 residents who receive meals from Dietary Services. Findings include: 1) Review of the Food and Drug Administration Food Code 2013, Chapter 3 Food, pages 92 and 94, revealed the following: "...3-501.17 Ready-to-eat, Time/Temperature Control for Safety Food, Date Marking on-premises preparation ? prepare and hold cold ... (A) ... refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, ... or discarded when held at a temperature of 5 degrees C (Celsius) (41 degrees Fahrenheit) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. commercially processed food ? open and hold cold ... B) ... refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and packaged by a FOOD PROCESSING 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 the PREMISES, ... or discarded ... ... 3-501.18 Ready-to-eat, Time/Temperature Control for Safety Food, Disposition. A) A FOOD specified in 3-501.17 (A) or (B) shall be discarded if it: ... (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is appropriately marked with a date or day that exceeds the temperature and time combination ..." During the initial tour of the kitchen on 02/23/2015 beginning at 4:43 PM, the following observations were made in the walk-in refrigerator: -A container of Apple Sauce with Use-by Date: 2/19/15 -A container of Orange slices dated 1/11/15 (No Use-by Date) -A container of Pineapple dated 2/12 and Use-by Date: 2/19/15 -A bowl of Pureed Ham dated 2/23 (No Use-by Date) -A bowl of Pureed Corn dated 2/15 and Use-by Date: 2/22/15 -A bowl of a light brown pureed substance; the label did not identify the food or specify preparation or use-by dates -A container of Chopped Chicken with an illegible preparation date and Use-by Date: 2/22/15 -A container of Cole Slaw dated 2/6 (No Use-by Date) -A container of C of C (Cream of Chicken) Soup dated 2/15 (No Use-by Date) -A container of Chopped Chicken dated 2/21 (No Use-by Date) -A container of Prince Edward Vegetables dated 2/10 and Use-by Date: 2/17/15 -A container of Vegetable Beef Soup dated 2/19 (No Use-by Date) -A container of Creamy Chicken Noodle Soup dated 1/26 (No Use-by Date) -A bowl of Pureed Chicken dated 2/23 (No Use-by Date) -A bag of shredded lettuce with no Open or Use-by Dates -A bag of sliced cheese with no Open or Use-by Dates; and -A bag of shredded cheese with no Open or Use-by Dates. A review of a facility policy titled "USE OF LEFTOVERS", dated 2005, reveals: "POLICY: Excess leftovers should be avoided. Leftovers will be properly handled and used. ... PROCEDURE: ... 2. Leftovers should be covered, labeled, and dated; then stored appropriately ..." During an interview on 2/26/15 at 9:10 AM, Employee Identifier (EI) #5, the Dietary Manager was asked about the procedure for leftovers. EI #5 explained leftovers should be stored in a container with a lid, labeled, placed in the refrigerator (when cooled to the appropriate temperature), and discarded after three days. When asked how leftovers should be labeled, EI #5 stated the label should include the name of the food, the date prepared, and the date to be discarded if not used; the label in use also included a space to record times and the staff should circle the day of the week the item should be discarded. EI #5 was then asked how bags of lettuce and cheese should be labeled; EI #5 replied with an "open date and date to discard if not used." EI #5 was asked if the all the items in the walk-in refrigerator were labeled as she explained they should be on 2/23/15, and EI #5 said, "They should have been, but they weren't." When asked what is the potential for harm if the policy is not followed, EI #5 replied they would not know whether the food was good or bad, and it might make someone sick.

Based on observations, record reviews, and interviews, the facility failed to follow: 1) the incontinence care plan for RI (Resident Identifier) #1 specifying the resident be checked and changed every two hours and as needed; 2) RI #8's care plan for the resident to wear a non-skid sock to the right foot at all times; and 3) RI #11's care plan for a gel cushion to be in the resident's scoot-n-go chair while the resident was in the chair. This affected three (3) of 21 sampled residents whose plan of care was reviewed. Findings Include: A review of a facility policy titled "Using the Care Plan" with a date of "09/09df", documented: "Policy Statement: The care plan will be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident. ... 2. Staff should follow the communicator, which is derived from the resident's care plan, when providing care to the resident. The communicator can be located inside the resident's closet door ..." 1. A review of the the RESIDENT CARE COMMUNICATOR for RI #1 documented under "ADLS" (Activities of Daily Living): "... 3. Toileting: Check and change every 2 hours and prn (as needed) ..." RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's most recent Quarterly Minimum Data Set (MDS) with an ARD (Assessment Reference Date) of 12/15/2014 revealed, under "Section C-Cognitive Patterns", a BIMS (Brief Interview for Mental Status) score of 3, indicating severe impairment in daily decision making. "Section G-Functional Status" revealed RI #1 was totally dependent on staff with a physical assist of one for toilet use, and "Section H-Bladder and Bowel" documented RI #1 was always incontinent of bladder and bowel. On 2/25/15 from 8:00 AM to 11:51 AM (a total of 3 hour and 51 minutes) the surveyor continuously observed RI #1 with the following documented observations: 8:00 AM--Resident observed in the Hall Dining Room in a geri chair eating breakfast. 9:03 AM--Staff member wheeled RI #1 from the Hall Dining Room to the Hall Living Room/TV Room while the surveyor followed. 9:58 AM--a CNA (Certified Nursing Assistant) transported RI #1 in the geri chair to a larger Dining Room on another Hall for Bingo and a devotional, while the surveyor followed behind 11:41 AM--After Bingo an Activities staff member was observed coming to RI #1, who was fidgeting and wanted to move. The surveyor followed as the Activities staff member wheeled RI #1 back to the Hall Nurses' Station, where she left the resident and spoke to a nurse. 11:44 AM--Employee Identifier (EI) #2, a CNA was observed transporting RI #1 from the Hall Nurses' Station to the Hall Dining Room. 11:51 AM--A CNA, EI #2 was observed transporting the resident in the geri chair from the Hall Dining Room to RI #1's room. The surveyor followed behind, and also observed EI #3 following along with a mechanical transfer lift. When asked by the surveyor what they were going to do, the CNAs stated they were going to change the resident. 11:57 AM--Another surveyor arrived and entered RI #1's room with the CNAs who provided incontinent care. On 2/25/15 at 11:57 AM the incontinent care for RI #1 was observed by another surveyor, who documented the resident's disposable brief as being moderately wet with urine. An interview was conducted on 2/25/15 at 12:25 PM with EI #3, a CNA. EI #3 was asked who was the CNA assigned to care for RI #1 on 2/25/15, and she said, "I am." EI #3 was asked what she found when she performed incontinent care for RI #1; EI #3 described the resident as moderately wet. EI #3 was asked what does the incontinent care plan for RI #1 call for; EI #3 replied that the resident should be checked every two hours. EI #3 was asked if she had followed the care plan for RI #1 on that day, and she replied, "No Ma'am, I didn't." EI #3 was asked what was the potential harm if a resident was not checked and changed every two hours; EI #3 answered, "... breakdown; skin will be real red." An interview was conducted on 2/26/15 at 9:28 AM with EI #4, the RN Unit Manager. EI #4 was asked if RI #1 was continent or incontinent; RI #4 answered "Incontinent." EI #4 was asked what does the incontinence care plan for RI #1 call for; EI #4 stated the resident should be checked and changed every two hours. EI #4 was asked what are the possible consequences for RI #1 if this is not done; EI #4 answered there could be skin breakdown and odor. 2. RI #8 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #8's Falls risk r/t (related to) Impaired Balance care plan, with a Problem Onset date of 10/13/2014, documented the following approach: "...* +Non-skid footwear to right foot at all times ..." A Quarterly MDS with an ARD of 01/19/2015, assessed RI #8 to score an 11 on the BIMS indicating moderately impaired cognition. Under Section G - Functional Status, RI #1 was identified to have impairment on one side to the lower extremity. On 02/24/15 at 3:44 p.m., the surveyor observed RI #8 lying in bed. RI #8 was observed to have a left above the knee [MEDICAL CONDITION]. There was not a non-skid sock observed on the resident's right foot. On 02/25/15 at 8:25 a.m., the surveyor observed RI #8 sitting on the side of the bed eating breakfast. There was no non-skid sock on RI #8's right foot. On 02/25/15 at 10:42 a.m., RI #8 was observed lying in bed. RI #8 still did not have a non-skid sock on the right foot. On 02/25/15 at 12:12 p.m., RI #8 was observed sitting on side of the resident's bed. There was no non-skid sock observed on the resident's right foot. On 02/26/15 at 8:29 a.m., RI #8 was observed in bed. There was no non-skid sock observed on RI #8's right foot. On 02/26/15 at 1:33 p.m., RI #8 remained in bed. The surveyor did not observe a non-skid sock on the resident's right foot at this time. On 02/26/15 at 1:48 p.m., the surveyor conducted an interview with EI #6, the CNA assigned to care for RI #8 on 02/26/15 on the 7-3 shift. The surveyor asked EI #6 did she bathe RI #8 that morning. EI #6 replied she had. The surveyor asked EI #6 did she put a non-skid sock on RI #8's right foot. EI #6 said she had not. The surveyor asked EI #6 what did RI #8's care plan say about non-skid socks. EI #6 read RI #8 care plan and replied, "Non-skid footwear to right foot at all times." The surveyor asked EI #6 how would she as a CNA know the type care RI #8 was to receive. EI #6 replied when you open the resident's door to their closet there was a piece of paper in it that told you the type care the resident was to receive. A review of RI #8's RESIDENT CARE COMMUNICATOR (the piece of paper located in the closet door) with a Reviewed date of 10/23/14, documented: "... SAFETY ... 2. Non skid sock/shoe on right foot at all times. Resident is a left above knee amputation ..." On 02/26/15 at 2:54 p.m., the surveyor conducted an interview with EI #7, the LPN (Licensed Practical Nurse) assigned to care for RI #8 on 02/26/15 on the 7-3 shift. The surveyor asked EI #7 what did RI #8's care plan say about non-skid socks. EI #7 replied, "Non-skid foot wear to right foot at all times." The surveyor asked EI #7 why was RI #8 to wear non-skid foot wear to the right foot at all times. EI #7 replied, "To prevent falls." 3. RI #11 admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #11's Self Care Deficit care plan, with a Problem Onset date of 07/01/2011, documented the following hand written approach: "... 2/19/15 - gel cushion to chair when up ..." A Quarterly MDS with an ARD of 01/26/2015, assessed RI #11 to score a 2 on the BIMS indicating severely impaired cognition. Under Section G - Functional Status , RI #11 was identified as using a wheelchair for mobility. On 02/24/15 at 9:12 a.m., the surveyor observed RI #11 sitting in a scoot-n-go chair in the sitting area on the unit the resident resides. There was no cushion observed in the seat of RI #11's chair at this time. On 02/24/15 at 3:46 p.m., RI #11 was observed sitting in the scoot-n-go chair in the sitting area on the unit. No cushion was observed in the seat of RI #11's chair. On 02/25/15 at 8:16 a.m., RI #11 was observed sitting in the scoot-n-go chair in the sitting area on the unit. The surveyor observed that RI #11 remained without a cushion in the seat of the chair. On 02/25/15 at 2:31 p.m., RI #11 remained in the scoot-n-go chair. No cushion was observed in the seat of the chair. On 02/26/15 at 8:32 a.m., RI #11 was observed sitting in the scoot-n-go chair in the sitting area. There still was no cushion observed to the seat of RI #11's chair. On 02/26/15 at 2:15 p.m., the surveyor conducted an interview with EI #9, the CNA assigned to care for RI #11 on 02/25/15 and 02/26/15 on the 7-3 shift. The surveyor asked EI #9 should RI #11 have a gel cushion to the seat of her wheelchair (scoot-n-go chair). EI #9 replied she had just seen that on RI #11's Communicator that day. EI #9 said restorative just put it (the Communicator sheet) in RI #11's room that day. The surveyor asked EI #9 what was the purpose of the gel cushion. EI #9 replied she was not sure. EI #9 said the cushion may be to keep pressure off of RI #11's buttocks. The surveyor asked EI #9, according to RI #11's care plan, when was the order written for the gel cushion. EI #9 looked at RI #11's Self Care Deficit care plan and said, "2/19/15." EI #9 replied that according to the Communicator on RI #11's door, it said 2/26/15. A review of RI #11's RESIDENT CARE COMMUNICATOR with a Reviewed date of 2/26/15, documented: "... SAFETY ... 6. Up to scoot and go with cushion ..." On 02/26/15 at 2:44 p.m., the surveyor conducted an interview with EI #10, the LPN assigned to care for RI #11 on 02/25/15 and 02/26/15 on the 7-3 shift. The surveyor asked EI #10, according to RI #11's care plan, should the resident have a gel cushion to the resident's chair. EI #10 replied, yes. The surveyor asked EI #10 what was the purpose for the gel cushion. EI #10 replied, "To prevent skin breakdown." The surveyor asked EI #10 why RI #11 did not have a cushion in the scoot-n-go chair. EI #10 replied she thought it was a lack of communication. EI #10 said the order was written on the 19th (2/19/15) by the restorative nurse. On 02/26/15 at 4:04 p.m., the surveyor conducted an interview with EI #11, the LPN Restorative Nurse. The surveyor asked EI #11, why was RI #11 written an order for [REDACTED].#11 replied she was making sure residents with old cushions got a new one. The surveyor shared with EI #11 that according to RI #11's care plan the resident should have a gel cushion in the chair when up. The surveyor also shared with EI #11 that the surveyor had observed for the past three days of the survey that RI #11 did not have a cushion to the seat of the chair. The surveyor asked EI #11 why was that. EI #11 replied the cushion could have been soiled. The surveyor asked EI #11 who was responsible for ensuring the cushion was in the resident's chair. EI #11 said it was on the Communicator. EI #11 said it was the responsibility of the charge nurse or whoever got the resident up to the chair. The surveyor asked EI #11 was the Communicator a way for the CNA's to know what type care the resident needs. EI #11 said it was.

Based on interviews and record review RI (Resident Identifier) #1 vocalized pain of the right hip to staff immediately after a fall on 6/1/2014 and throughout the day; however, the facility failed to follow their pain assessment protocol for assessing and evaluating a resident after sustaining a fall, as well as medicate RI #1 after the resident expressed pain, verbally and physically. RI #1 had been identified by the facility as being cognitively impaired, having a history of falls and at high risk for falls. On 6/1/14 at 7:15 AM a Licensed Practical Nurse, LPN, on the 7-3 shift observed RI #1 behind the nurses' station, on the floor, next to the scoot and go chair. EI #1 stated she went to check on RI #1 and directed EI #10, the Unit Clerk, to notify EI #6, the Registered Nurse (RN) Supervisor. EI #6 the RN Unit Supervisor, stated RI #1 verbalized having pain in the right hip. EI #6, she admitted she did not examine RI #1 from head to toe to determine if there were any injuries, as directed in the "Pain-Clinical Protocol." EI #6 stated she and a Certified Nursing Assistant (CNA), EI #5 lifted RI #1 from the floor and placed the resident back into the scoot and go chair. EI #6 admitted hearing RI #1 moan while being placed in the scoot and go chair. EI #6 asked RI #1 if there was pain. EI #6 stated RI #1 nodded, yes. Again, EI #6 failed to follow the Pain Protocol by failing to assess the severity level of the pain and medicate the resident to reduce or eliminate the pain. According to EI #18, the Risk Manager who investigated RI #1 s fall, RI #1 displayed openly signs and symptoms of pain, such as facial grimacing and clinched hands to the face, while being taken to the dining room for the lunch meal. A CNA, EI #9, stated she heard RI #1 moaning "every now and then" in pain, while sitting at the table. At 11:05 AM, RI #1 was taken to the room for x-rays. A CNA, EI #7 stated she and an LPN, EI #1 transferred RI #1 from the scoot and go chair and placed RI #1 onto the bed. EI #7 stated, RI #1 continuously moaned in pain during the transfer. An interview with the family of RI #1 revealed they heard a resident moaning and groaning in the shower room, later identifying the resident heard moaning and groaning as their family member. This family member stated as they approached the area where the moaning and groaning was heard they saw RI #1, and described the resident as white as a sheet. At this time the family member requested the facility staff medicate RI #1 for pain. According to RI #1's Medication Administration Record (MAR), and a nurses note, RI #1 did not receive any pain medication until 1:48 PM, more than six hours after RI #1 expressed pain. On 06/01/14 at 7:40 PM, more than 12 hours after RI #1 had fallen, RI #1 was transferred to the emergency room for evaluation and admitted with "Right [MEDICAL CONDITION] after a fall." The Medical Director, EI #20, confirmed RI #1's treatment was delayed and that the sad part to him was that the resident was hurting all that time. This deficient practice posed a serious and immediate threat to the health and safety of RI #1, one of ten residents sampled for pain management. On 07/11/14 at 2:58 PM, the facility's Administrator and Director of Nursing (DON) were notified of the findings of Immediate Jeopardy in Quality of Care at a "J" level. The Immediate Jeopardy began on 06/01/14 and was abated on 07/14/14 at 5:23 PM, after reviewing the facility's information provided in their Allegation of Credible Compliance (AOC). The scope and severity was lower to a "D" level to allow the facility time to monitor and/or revise their corrective actions as needed to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report AL 295. Findings include: Cross reference F 490. On 06/27/14 at 1:37 PM, the Department of Public Health's Division of Health Care Facilities received the following complaint: The complainant states a resident who was sitting at the nurses' station in a scoot chair sustained a fall during the weekend of 06/08/14. At the time of the fall, four nurses were at the nurses' station counting medication carts. The complainant states the resident laid in the floor for a long time and had to crawl around the desk to get help. The resident did suffered a fractured femur. The resident was reported to have excruciating pain, dementia and was receiving hospice care. On 07/08/14 at 10:20 AM, the complainant was interviewed by phone. When asked what was the main concern of the complaint, the complainant stated the facility was slow to respond and RI #1 laid in pain before getting treatment. The facility policy titled "Post Fall Assessment" dated 06/14, documented: "Purpose The purposes of this procedure are to provide guidelines for assessing a resident after a fall. ... Procedure ... g. Documentation will include any observed signs or symptoms of pain ... and any changes in level of responsiveness/consciousness and overall function. ..." The facility policy titled "Pain-Clinical Protocol" dated, 09/09, documented: "Assessment and Recognition ...2. The staff and ... will identify the nature and severity of pain including characteristics (location, intensity, frequency, duration...) ... b. The wong-baker faces will be used to evaluate the resident's level of pain by using the wong-baker faces pain scale when a resident is able to select a face in correlation with the pain they are experiencing. c. The staff and ... will evaluate nonverbal individuals for nonspecific signs and symptoms that could reflect pain; for example, grimacing while being repositioned ... Monitoring 1. The staff will reassess the individual's pain and consequences of pain at regular intervals; at least each shift for acute pain..." RI #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1's Annual Minimum Data Set ((MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 0 (zero) out of 15, indicating RI #1 was severely impaired in cognition. RI #1 required extensive assistance from staff for bed mobility and transfers. RI #1 required total assistance from staff for dressing, locomotion on and off the unit. RI #1 was documented as "not steady" only able to stabilize with staff assistance with moving from a seated position to standing position, walking and surface-to-surface transfers. RI #1's "Fall Risk Assessment" dated 12/3/2013 documented a "GRAND TOTAL" score of 12. A total score of 10 (ten) or more on this assessment "represents HIGH RISK ..." RI #1's "Fall Risk Assessment" dated 06/12/14 documented a "GRAND TOTAL" score of 18. Any score of 10 (ten) or more represented "HIGH RISK." A care plan for RI #1 with a problem onset date of 03/29/11 documented: "At risk for pain r/t (related to) [MEDICAL CONDITION], decreased mobility. The approaches listed for this problem were: " Assess for pain on each shift as ordered and document * Observe for and report non-verbal s/s (signs and symptoms) of pain: grimacing, groaning, moaning, ... ." The facility's "Departmental Notes" dated 6/1/14 at 11:35 AM, revealed, "On or about 0715 resident (RI #1) fell on the floor at the nusring (nursing) station. Resident stated that (RI #1) right hip was hurting. ... Dr. ordered x-ray for resident right hip pain ... x-ray was done ... on or about 1115 ... " Signed by EI #3 (LPN). A "Resident Incident Report" dated 06/01/14 at 7:15 AM, documented the following: "Called to assess resident following fall at nurses station. ... pt. (patient) responds "yes" when asked if hurting anywhere and states "my hip" when asked where. ... " Signed and reviewed by EI #18 (Risk Manager) and EI #19 (DON). RI #1's "Radiology Report" with a service date of 06/01/14 revealed the following: " ...Exam: HIP UNI-LAT (affecting one side) COMPLETE ... Findings: There is a [MEDICAL CONDITION] femoral neck with angulation. There is osteopenia. Conclusion: Angulated Fracture involving the right femoral neck ... " On 07/09/14 at 12:55 PM, during an interview with EI #1 (LPN), the surveyor asked what type of assessment was done after RI #1 fell on [DATE]. EI #1 said she checked for any head trauma, pulse, blood pressure and any bleeding. EI #1 stated she left the resident with EI #6 (RN Supervisor) because she had another resident to care for. On 07/09/14 at 1:43 PM,EI #6 (RN Supervisor) was interviewed. EI #6 stated RI #1 complained of the hip hurting. EI #6 stated she touched RI #1's hip with the palm of her hand. EI #6 stated when she first observed the resident, she asked RI #1 about pain. RI #1 said, "My hip." EI #6 stated she looked at the resident for skin tears and red areas. EI #6 said she did not do range of motion and only looked at the resident with her eyes. On 07/10/14 at 4:46 PM, EI #6 was interviewed again regarding RI #1. The surveyor asked how RI #1 was positioned when she first observed the resident. EI #6 replied RI #1 was resting on her right elbow and partially laying on the right hip and buttock. RI #1's legs were extended straight out. The surveyor asked EI #6 when did she ask RI #1 about pain. EI #6 replied, when she immediately saw the resident, she asked RI #1 was there pain and RI #1 replied my hip. EI #6 further stated she assumed RI #1 was referring to the right hip because of the way the resident was positioned. On 07/10/14 at 8:10 PM, during an interview EI #3 (LPN) stated she was sitting with RI #1 at the nurses' station, because the resident would try to get up out of her chair. EI #3 stated she left the resident in the chair at the nurses' station, when the outgoing nurse requested her to count medications. EI #3 stated after she began counting medications, she would look several times at the resident to see if RI #1 was trying to get up out of the chair. EI #3 stated the last time she looked up, maybe 10 minutes after she started when RI #1 fell . EI #3 stated RI #1 was laying on the right side and moaning. EI #3 also stated EI #1 asked the resident if the resident was hurting and RI #1 rubbed the right hip. EI #3 stated after 10 minutes EI #6 responded and asked RI #1 was there pain and RI #1 moaned and rubbed the right hip. On 07/10/14 at 9:20 AM, during an interview with EI #7 (CNA), the surveyor asked when did she see RI #1. EI #7 stated she was told by EI #5 (RI #1's assigned CNA) the resident had fallen at the nurse's station. EI #7 stated when she arrived at the nurses' station, RI #1 was laying on the back with arms and legs extended straight out. EI #7 stated RI #1 was frowning in pain. EI #7 stated when the nurses were examining RI #1, the resident moaned in pain. On 07/11/14 at 11:03 AM, during an interview with EI #5 (RI #1's assigned CNA) the surveyor asked who transferred the resident from the floor to the chair after falling. EI #5 replied she and EI #6 (Registered Nurse/RN Supervisor). The surveyor asked how did the resident respond during the transfer. EI #5 stated the resident moaned, "Oh" twice. EI #5 also stated EI #6 asked the resident was RI #1 hurting and the resident nodded, "Yes." A review of the facility's handwritten timeline (untitled & no date) revealed the resident was maneuvered on multiple occasions after falling without being provided medication for pain. The investigation timeline, completed by EI #18 (Risk Manager) revealed RI #1 was taken to the dining room at 7:22 AM; to the "porch" (facility's sitting/recreational area) at 8:30 AM; to the dining room at 10:37 AM; transferred from the scoot and go chair to the bed for x-rays and placed back into the scoot and go chair after the x-rays at 11:05 AM; taken back the "porch" at 1:08 - 1:11 PM; then to the shower room. Interviews with staff members revealed RI #1 vocalized and exhibited signs of pain. The following was noted: On 07/09/14 at 5:00 PM, during an interview with EI #9 (CNA), the surveyor asked when did she hear RI #1 complain of pain. EI #9 stated RI #1 was sitting at the table for lunch and moaned "every now and then." EI #9 stated this happened around 12 o'clock. The surveyor asked who did she report this to. EI #9 stated she could not remember if she told anyone or not. EI #9 also stated RI #1 rarely ever spoke and for the resident to moan was not normal. According to the facility's handwritten time line, completed by EI #18 (Risk Manager) at 11:05 AM, RI #1 was taken to the room for x-rays. On 07/10/14 at 9:20 AM, during an interview with EI #7 (CNA) the surveyor asked who put the resident to bed. EI #7 stated as she and EI #1 (LPN) picked RI #1 up and sat the resident on the bed, RI #1 moaned. EI #7 stated as she and EI #1 were laying RI #1 down on the bed, RI #1 continued to moan "Oh, Oh." The surveyor asked EI #7 if RI #1 ever stop moaning and groaning. EI #7 stated, "No ma'am." EI #7 stated she left the room to go to lunch and EI #8 finished assisting EI #1 with RI #1. On 07/10/14 at 4:00 PM, EI #8 (CNA), who assisted EI #1 with RI #1' s x-rays, was interviewed. EI #8 stated while RI #1 was repositioned by the x-ray technician, RI #1 was moaning. EI #8 also stated as she positioned RI #1, the resident moaned. On 07/10/14 at 11:35 AM, during an interview with EI #1 (Licensed Practical Nurse/LPN) the surveyor asked what happen when RI #1 was put to bed for x-rays. EI #1 replied after the resident was put to bed, RI #1's legs were bent at the knees and together. EI #1 stated the resident said moaned when their legs were separated. EI #1 also stated when she and the CNA tried to straighten RI #1's right leg, the resident said moaned twice and would not straighten the right leg. EI #1 stated the radiology technician proceeded to take the film. On 07/09/14 at 4:47 PM, EI #8 (CNA) was interviewed. EI #8 stated she recalled hearing RI #1 said, Oh, Oh, when her assigned CNA, (EI #5) was pushing the resident from the porch to the shower/bath room around lunch time. EI #8 stated she commented that the resident was complaining about the hip hurting. EI #8 stated EI #1 (LPN) and EI # 3 (LPN) were at their medication carts directly across from the porch/day room and both of them heard. On 07/11/14 at 11:03 AM, during an interview with EI #5 (RI #1's assigned CNA), the surveyor asked if she remembered RI #1 complaining of pain while she was taking RI #1 to the shower room. EI #5 replied she didn't. She recalled using the sit to stand lift to transfer the resident. EI #5 stated when she stood RI #1 up with the lift, RI #1 moaned, "Oh," in pain. EI #5 further stated when she pushed RI #1 back to the room she used the same lift to stand RI #1 up from the scoot and go chair to the bed. EI #5 stated when she stood RI #1 up with the lift, RI #1 moaned "Oh," again in pain. EI #5 stated one of RI #1's daughters, present at the time the resident was exiting the shower room was crying. EI #5 stated the other daughter was crying when RI #1 was transferred from the chair to the bed. On 07/07/14 at 9:55 AM, RI #1's family member (daughter of RI #1) was interviewed by phone. The family member was asked how was RI #1 when she arrived at the facility. The family member replied, she was headed towards the day room and could hear moaning and groaning coming from the shower room, and it sounded like RI #1. The family member stated when she saw RI #1, the resident was white as a sheet. The sponsor stated she asked why RI #1 was in the scoot and go chair and requested RI #1 be put to bed. The family member stated RI #1 cried the whole time they were transferring to the bed. The family member stated she requested nursing staff call the doctor and get something for pain. On 07/08/14 at 11:45 AM, RI #1's daughters were at the facility. During an interview with one of the daughters, she was asked to describe what RI #1 looked like when she saw RI #1 the day of the fall. The sister stated RI #1 was moaning and groaning, and white as a sheet. She also commented that when the staff went to lift RI #1, the resident hollered out in pain. On 07/10/14 at 11:35 AM, during an interview with EI #1 (LPN), the surveyor asked who requested pain medications for RI #1 on 06/01/14 in the afternoon. EI #1 stated RI #1's sponsor, the daughter. A review of RI #1's June 2014 "eMAR (Electronic Medication Administration Record) revealed the following: " ...TYLENOL EX-STR (extra strength) 500 MG (milligram) CAPLET, give 2 tablets by mouth every 6 hours as needed for pain Start Date: 6/01/14 ... [MEDICATION NAME] 7.5-325 TABLET. Give one tablet by mouth every 4-6 hours as needed for pain Start Date: 6/01/14 ... " A review of RI #1's June 2014 eMAR revealed no documentation of Tylenol administration on 06/01/14. A review of RI #1's June 2014 eMAR revealed RI #1 did not receive pain medication, [MEDICATION NAME] 7.5-325 mg, until 1:48 PM on 06/01/14. A review of the facility's "Departmental Notes" dated 06/01/14 at 7:44 PM, revealed the following: " ... (RI #1) left the facility at 7:40 PM ... ." RI #1's "Radiology Report" with a DOS (date of service) 06/01/14 revealed: " ... Exam: HIP UNI-LAT (affecting one side) COMPLETE... Conclusion: Angulated fracture involving the right femoral neck ... " A review of (Name of Hospital) Consultation revealed the following: " ... admitted : 06/01/14 ...admitting [DIAGNOSES REDACTED]. During an interview on 07/09/14 at 2:44 PM, EI #20, Medical Director, was asked if RI #1's treatment was delayed. EI #20 stated yes, it was. EI #20 added the sad part was that the resident was hurting all that time. ********************************************** On 7/14/14 at 4:45 PM the facility submitted the following allegation of credible compliance for F 309: F309: ? RI#1 was sent to the hospital on 6-1-14. She returned to the facility 6-6-14. Resident was assessed for pain q shift upon return by the LPN/RN charge nurse, it was documented on the MAR and she was medicated once on 6-7-14 and once on 6-8-14. Resident has had no evidence of pain according to the pain assessments documented on the MAR since 6-8-14. This resident was also assessed by 300 Wing RN unit manager on 7-11-14 and no pain was noted. Resident was discharged home with Hospice per family request on 7-12-14. ? All residents were assessed for pain using the Wong-Baker faces scale or the Behavior Pain Scale tool and any complaint or observation of pain was addressed immediately. This was completed on 7-11-14. 100 wing and 400 wing was done by the 100 wing/400 wing RN unit manager, 200 wing was done by the 200 wing RN unit manager, and 300 wing was done by 300 wing RN unit manager. ? All residents will be assessed for pain at the beginning of every shift by the LPN/RN charge nurses and documented on the MAR using the Wong Baker faces scale or the Behavior Pain Scale tool. Pain medication will be administered as ordered or if no orders are available, standing orders will be used for mild pain. If pain not relieved per standing order protocol, LPN/RN charge nurse will contact the physician for further orders immediately. ? All nurses, with the exception of 7-3 weekday shift, were inserviced by RN Consultant beginning at 8:00 pm on 7-11-14 and continuing on 7-12-14 and Staff Development RN will inservice 7-3 weekdays on 7-14-14 prior to starting their shift. All weekend and Baylor staff will be inserviced by 7/12/14. If there are any changes in staffing and that staff member has not received training they will be inserviced by the Weekend RN supervisor prior to beginning work. Anyone who has not had the inservice will be removed from the work schedule. They were inserviced regarding assessment and treatment of [REDACTED]. Inservice materials are attached. ? All certified nursing assistants were inserviced on the recognition and reporting of pain. All CNAs on duty 7-11-14 were inserviced by the end of the shift by the Care Plan RN and RN/ADON. All other CNAs will be inserviced upon arrival for their shift before taking their post by the weekend RN supervisor or RN Unit Manager. This will be completed on 7/14/14. Any CNAs that has not completed the inservice by 7/14/14 will be removed from the work schedule. ? All residents were assessed for pain per facility policy using the Wong Baker faces scale or the behavior pain scale tool on 7-11-14 by 100wing/400wing RN unit manager and 200 wing RN unit manager, and 300 wing RN Unit Manager and it was documented in the resident ' s nursing notes. ? Pain assessments are being monitored by the Risk Manager, DON, or their designee beginning 7-12-14. They are monitoring daily on first shift looking at the past 24 hours for compliance with pain assessment and follow-up by checking the pain assessments on the MAR for completion and checking the follow-up on residents that had pain to ensure that they were medicated and it was documented. ? EI# 6 was given a final written warning for failure to assure that the resident was medicated for complaint of pain and for failure to do a complete assessment following a fall and failure to ensure that the x-ray was completed. The warning was given by DON on 7-11-14. EI#6 was retrained by RN Consultant on 7-11-14 regarding pain assessment and fall/injury follow up and our policy regarding post fall follow up. On 7-12-14 EI#6 was suspended pending substantial compliance for F309/490. EI#6 will be reported to the Alabama Board of Nursing on 7-14-14 by DON. ? EI#1 was given a final written warning and suspended pending substantial compliance for F309/490 for failure to administer pain medication to RI#1 and failure to follow up on assessment of pain post fall. The warning and suspension was given by DON on 7-12-14. EI#1 was retrained by RN Consultant on 7-12-14 regarding pain assessment and follow up in accordance with facility policy. EI#1 will be reported to the Alabama Board of Nursing on 7-14-14 by DON. ? A written report of the monitoring of pain scale assessments on the MAR, documentation and follow up regarding medication administration and assessment of effectiveness will be given to the DON by the end of first shift Monday-Friday and the weekend monitoring will be given to the DON at the beginning of first shift on Monday. This will include the names of the residents checked and the outcome along with the correction for any noncompliance. If any noncompliance is found the DON will be notified immediately by phone. DON will instruct the RN Supervisor that reported the noncompliance on the appropriate disciplinary instructions. If DON is unavailable the ADON will be contacted by phone. ? All RN Supervisors will contact DON by phone immediately of any kind of incidents resulting in injuries or potential injuries. Upon notification, the DON will assess the situation to ensure that the following was completed: -Was a pain scale assessment completed using the Wong Baker scale or Behavior pain scale? -If pain was noted on pain scale assessment, was pain medication administered and documented? -Was a complete head to toe assessment for injury completed? What were the findings? -What interventions were implemented? -If an x-ray was indicated, when is the x-ray is expected to be completed? -Was the physician notified? -Was the family notified? -The RN supervisor will be instructed to call the DON immediately when the x-ray results become available. If the DON is unavailable, the ADON will be the designee to be contacted. ? The DON will follow up on any kind of incident resulting in injury or potential for injury by reviewing the incident report, nurses notes, the MAR, physician orders, and the resident. ? Administrator will meet with the DON daily, beginning 7/11/14, regarding incidents of any kind resulting in injury or potential for injury. On weekends and after hours the DON will notify the Administrator by phone. ***************************************************************** After reviewing and verifying the implementation of the facility's acceptable Allegation Of Credible Compliance, the immediate jeopardy was relieved on 07/14/14 at 5:23 p.m. The scope and severity was lowered to "D" level to allow the facility time to monitor/revise their corrective actions.

Based on interviews and record reviews, it was determined on 6/1/14 at 7:15 AM RI (Resident Identifier) #1 was found on the floor complaining of right hip pain. EI (Employee Identifier) #6, RN (Registered Nurse) Supervisor, responded to the fall however, she failed to examine RI #1 from head to toe to determine if there were any injuries or to treat RI #1's complaints of pain. At approximately 1:12 PM, the resident's family visited and observed RI #1 moaning and groaning in pain. The family stated they had to request that RI #1 receive pain medication from facility staff approximately 6 hours after she first expressed pain. The facility failed to ensure EI #6, RN Supervisor, followed the facility's policies and procedures titled, "Falls - Clinical Protocol" and "Pain - Clinical Protocol" to ensure RI #1 received the highest level of care following a fall that resulted in a right [MEDICAL CONDITION]. The RN Supervisor failed to: (1) assess RI #1's musculoskeletal function and to observe the resident for changes in normal range of motion; (2) ensure RI #1's received pain medication after repeatedly vocalizing and exhibiting signs and symptoms of pain/discomfort. This affected RI #1, one of ten residents sampled for pain management, as it was likely to cause serious injury, harm, or death. On 07/11/14 at 2:58 p.m., the facility's Administrator and Director of Nursing (DON) were notified of the findings of immediate Jeopardy in Administration at a "J" level. The Immediate Jeopardy began on 06/01/14 and was abated on 07/14/14 at 5:23 p.m., after reviewing the facility's information provided in their Allegation of Credible Compliance (AOC). The scope and severity was lower to a " D " level to allow the facility time to monitor and/or revise their corrective actions as needed to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report AL 295. Findings include: Cross reference F 309. A "Resident Incident Report" dated 06/01/14 at 7:15 AM, documented the following: "Called to assess resident following fall at nurses station. ... pt. (patient) responds 'yes' when asked if hurting anywhere and states 'my hip' when asked where. ... " Signed and reviewed by EI #18 (Risk Manager) and EI #19 (DON). A review of the facility job description for RN (Registered Nurse) Supervisor Job Description documented the following: "PURPOSE OF YOUR JOB POSITION The primary purpose of your job position is to ensure that the highest degree of quality care is maintained at all times. ... Nursing Care Functions ... 11. Review nurses' notes to ensure that they are informative and descriptive of the nursing care being provided, that they reflect the residents' response to the care, ... 12. Provide direct nursing care as necessary. ... 21. Ensure that all LPNs (Licensed Practical Nurse) comply with written procedures for the administration ... Of medications ... " A review of the facility's policy titled, "Falls - Clinical Protocol" revised 05/2012, revealed the following: "Assessment and Recognition ... 2. ... The nurse shall assess and document/report the following: ... c. Musculoskeletal function, observing for change in normal range of motion, weight bearing ... f. Pain ... " The facility policy titled "Post Fall Assessment" dated 06/14, documented: "Purpose The purposes of this procedure are to provide guidelines for assessing a resident after a fall. ...Procedure 1. After a Fall: ... g. Documentation will include any observed signs or symptoms of pain ... and any changes in level of responsiveness/consciousness and overall function. ..." The facility policy titled "Pain-Clinical Protocol" dated, 09/09, documented: "Assessment and Recognition ...2. The staff and ... will identify the nature and severity of pain including characteristics (location, intensity, frequency, duration ...) ... b. The wong-baker faces will be used to evaluate the resident's level of pain by using the wong-baker faces pain scale when a resident is able to select a face in correlation with the pain they are experiencing. c. The staff and ... will evaluate nonverbal individuals for nonspecific signs and symptoms that could reflect pain; for example, grimacing while being repositioned ... Monitoring 1. The staff will reassess the individual's pain and consequences of pain at regular intervals ..." A review of the facility's "Employee Warning Report" dated 07/11/2014 documented the following: "... Violation (Date): 6-1-14 (Time) 0715 ... After a resident fell this RN failed to do a complete assessment. She failed to assure resident was given pain medication after resident reported to (RI #1) in pain. ..." This document was signed by EI #6, RN Supervisor, EI #19, DON and EI #17, Administrator. On 07/10/14 at 4:46 PM, EI #6 (RN Supervisor) was asked about RI #1's fall. EI #6 explained that she observed RI #1 resting on the right elbow, partially laying on the right hip and buttock with legs extended straight outward immediately after the fall. When asked about the resident's lower extremities, EI #6 stated she did not palpate RI #6's lower extremities when assessing the resident after the fall. During a subsequent interview on 07/09/14 at 1:43 PM, EI #6 (RN Supervisor), was asked what RI #1 complained of (after the fall). EI #6 stated RI #1 said the hip was hurting. EI #6 further explained how she touched RI #1's hip with the palm of her hand. EI #6 stated she asked RI #1 if RI #1 was hurting anywhere and the resident replied, "My hip." EI #6 admitted she did not perform a range of motion assessment of RI #1 and only looked at the resident. EI #6 explained how she looked at the resident's skin for skin tears and red areas. The surveyor asked EI #6 about her responsibility as RN Supervisor. EI #6 stated her responsibility was to oversee resident's care and to make sure things are handled. When asked if she carried out her responsibilities as RN Supervisor regarding RI #1's fall on 06/01/14, EI #1 replied, "No I did not." On 09/11/14 at 3:14 PM, during an interview with EI #19 (Director of Nursing/DON), stated she made aware of RI #1's fall on Sunday, but she was not aware of the seriousness of the situation nor did she know the resident was in pain. RI #1's family called her on Monday, informing her how upset they were that RI #1 did not receive pain medications. As a result of the family's complaints, EI #19 stated a grievance was written and an investigation was started. The family's concerns were not being contacted when the fall occurred and it appeared to them that the facility's staff did not know how to recognize pain. The family also stated they were considering moving RI #1 to another facility. EI #19 stated EI #1, the LPN, never informed her that RI #1 was in any type of pain. The surveyor asked EI #19 about reviewing RI #1's Medication Administration Record (MAR) for pain medication administration. EI #19 stated she did not check the MARs, but she should have. When asked if reviewing the MAR was her responsibility as the DON, EI #19 replied yes. The surveyor asked EI #19 about her responsibility of ensuring residents receive appropriate care and services to maintain their highest quality of care. EI #19 replied, "I'm ultimately responsibility for care of these residents." During an interview on 07/09/14 at 2:44 PM, EI #20, Medical Director, was asked if RI #1's treatment was delayed. EI #20 stated yes, it was. EI #20 added the sad part was that the resident was hurting all that time. ******************************************************** On 7/14/14 at 4:45 PM the facility submitted the following allegation of credible compliance for F 490: F 490: ? RI#1 was sent to the hospital on 6-1-14. She returned to the facility 6-6-14. Resident was assessed for pain q shift upon return by the LPN/RN charge nurse, it was documented on the MAR and she was medicated once on 6-7-14 and once on 6-8-14. Resident has had no evidence of pain according to the pain assessments documented on the MAR since 6-8-14. This resident was also assessed by 300 Wing RN unit manager on 7-11-14 and no pain was noted. Resident was discharged home with Hospice per family request on 7-12-14. ? EI# 6 was given a final written warning for failure to assure that the resident was medicated for complaint of pain and for failure to do a complete assessment following a fall and failure to ensure that the x-ray was completed. The warning was given by DON on 7-11-14. EI#6 was retrained by RN Consultant on 7-11-14 regarding pain assessment and fall/injury follow up and our policy regarding post fall follow up. On 7-12-14 EI#6 was suspended pending substantial compliance for F309/490. EI#6 will be reported to the Alabama Board of Nursing on 7-14-14 by DON. ? All RN staff were inserviced regarding post fall/injury assessment. All RNs with the exception of two PRN RNs were inserviced on 7-11-14 by RN Consultant. The two PRN RNs will be inserviced by RN Unit Manager or Weekend RN Supervisor and if they do not complete the inservice they will be removed from the schedule. Inservice content is attached. ? The three residents that have had a fall in the last 72 hours were assessed by 100 Wing/400 Wing RN unit manager and 200 Wing RN unit manager for injury per nursing assessment on 7-11-14 and documented in the nursing notes. There were no falls on 300 Wing in the last 72 hours. ? Post fall/injury assessments will be monitored beginning 7-12-14 for accuracy and be completed by follow-up by the Risk Manager, DON, or their designee on a continuing basis. They will be monitoring for compliance with facility policy regarding post fall assessment and follow-up. ? A written report of the monitoring which will include the residents checked and the outcome along with the correction for any noncompliance will be given to the DON by the end of first shift Monday-Friday and the weekend monitoring will be given to the DON at the beginning of first shift on Monday. If any noncompliance is found the DON will be notified immediately. Noncompliance will be addressed with counseling and or retraining prior to the staff in violation returning to work. ? All RN Supervisors will contact DON by phone immediately of any kind of incidents resulting in injuries or potential injuries. Upon notification, the DON will assess the situation to ensure that the following was completed: -Was a pain scale assessment completed using the Wong Baker scale or Behavior pain scale? -If pain was noted on pain scale assessment, was pain medication administered and documented? -Was a complete head to toe assessment for injury completed? What were the findings? -What interventions were implemented? -If an x-ray was indicated, when is the x-ray is expected to be completed? -Was the physician notified? -Was the family notified? -The RN supervisor will be instructed to call the DON immediately when the x-ray results become available. If the DON is unavailable, the ADON will be the designee to be contacted. ? The DON will follow up on any kind of incident resulting in injury or potential for injury by reviewing the incident report, nurses notes, the MAR, physician orders, and the resident. ? Administrator will meet with the DON daily, beginning 7/11/14, regarding incidents of any kind resulting in injury or potential for injury. On weekends and after hours the DON will notify the Administrator by phone. ******************************************************** After reviewing and verifying the implementation of the facility's acceptable Allegation Of Credible Compliance, the immediate jeopardy was relieved on 07/14/14 at 5:23 p.m. The scope and severity was lowered to "D" level to allow the facility time to monitor/revise their corrective actions.