Every finding on record at Hunter Creek Health and Rehabilitation, LLC

Based on observation, interview and review of a facility policy Cleaning of Miscellaneous Equipment and Utensils, the facility failed to ensure the drying rack did not have dust and rust on it. This deficient practice had the potential to affect 74 of the 77 residents receiving meals from the kitchen. Findings Include A review of a facility policy, titled, Cleaning of Miscellaneous Equipment and Utensils with an effective date of September 3, 2019 revealed . PURPOSE: to prevent the spread of bacteria that may cause food borne illness. STANDARD: Equipment and utensils should be cleaned . 36. Shelving - Metal and Wood: (monthly or as needed) * Remove contents from shelves * Wash and scrub * Rinse and sanitize * Air dry . On 4/11/22 at 5:29 PM during the initial tour of the kitchen the surveyor observed the drying rack with rust and had visible dust particles. The rack contained a large stainless-steel bowl. On 4/14/22 at 9:45 AM, an interview was conducted with Employee Identifier (EI) #1, Dietary Manager. EI #1 was asked if she could describe what was on the pot rack. EI #1 replied, it was rusty and dusty. EI #1 was asked who was responsible for keeping the rack from being rusty and having dust on it. EI #1 replied they all were responsible for keeping the rack from being dusty and rusty. EI #1 was asked what was the policy for keeping the pot rack free from dust and rust. EI #1 replied, they were supposed to clean it and keep it free from the dust and the rust. EI #1 was asked what the harm was in having brown looking rust and dust on the rack. EI #1 replied, it could cause someone to get sick. Some of the particles could break off and get in the food. EI #1 was asked if it was sanitary; she replied, no it was not sanitary.

Based on medical record review, interview and a facility policy titled, Nursing Assessments, the facility failed to ensure a Quarterly MDS (Minimum Data Set) assessment was completed timely for RI (Resident Identifier) #1. This deficient practice affected RI #1, one of 25 residents reviewed for MDS assessments. Findings Include: A review of a facility policy titled, Nursing Assessments with an effective date of (MONTH) 15, (YEAR), revealed: .STANDARD: Comprehensive assessments should be completed on admission, quarterly and with a significant change in the resident .condition. PR[NAME]ESS: .III. Quarterly .Nursing Assessments include: (once every 3 months) . RI #1 was admitted to the facility on [DATE]. RI#1's Admission MDS assessment was done on 1/14/19. An interview was conducted with EI (Employee Identifier) #1, MDS Coordinator on 6/5/19 at 4:14 p.m. EI #1 was asked when should comprehensive assessments be done on residents. EI #1 said every 92 days. EI #1 was asked when was RI #1's last comprehensive assessment done. EI #1 said on 1/14/19. EI #1 was asked when should RI #1's next comprehensive assessment have been done. EI #1 said on 4/15/19. EI #1 was asked if RI #1's comprehensive assessment was done on 4/15/19. EI #1 said, No. EI #1 was asked why was RI #1's comprehensive assessment not done on 4/15/19. EI #1 said, I have a grid that I use, I just over looked it. EI #1 was asked what was the concern with comprehensive assessments not being completed on time. EI #1 said, CMS (Center for Medicare Services) would not know the resident was here and I would not know if there were any changes with the resident.

Based on medical record review, observations, interview, and a facility policy titled, Oxygen Administration, the facility failed to ensure staff dated oxygen tubing and stored the oxygen tubing in a plastic bag when not in use. This affected RI( Resident Identifier) #9 and RI #32, two of four residents sampled for receiving oxygen. Findings Include: A facility policy titled, Oxygen Administration with an effective date of (MONTH) 8, 2005, revealed: .PURPOSE: To administer high purity oxygen for the treatment of [REDACTED]. PR[NAME]ESS: . 11. Cannulas and masks should be changed weekly . 14. O2 (oxygen) cannuala (cannula)/mask should be stored in a plastic bag when not in use . 1) RI #9 was admitted to the facility on [DATE] and re-admitted on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #9's (MONTH) 2019 Physician order [REDACTED].REPLACE AND DATE NEBULIZER MASK AND HOLDING BAG Q (EVERY) THURSDAY ON 11-7 .REPLACE AND DATE O2 TUBING AND WATER BOTTLE Q THURSDAY ON 11-7 . On 06/04/19 at 1:54 p.m., the surveyor observed RI #9 receiving Oxygen at two liters per minute by nasal cannula. There was no date on the cannula tubing or the tubing connecting the concentrator to the water bottle. There was no date on the water bottle. There was a nebulizer on the bedside table. There was no date on the nebulizer mask tubing. The nebulizer tubing was not stored inside of a plastic bag. 2) RI #32 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #32's (MONTH) 2019 Physician order [REDACTED].@ (AT) 2 L (LITERS)/MIN (MINUTE) PER NC (NASAL CANNULA) TO KEEP SATS (SATURATION) ABOVE 92% FOR [MEDICAL CONDITIONS] . An observation was made of RI #32's room on 06/04/19 at 2:14 p.m. RI #32 was not in the room. Oxygen tubing was observed laying on a bedside table, not stored in a plastic bag. An interview was conducted on 06/06/19 at 9:53 a.m. with EI (Employee Identifier) #3, RN (Registered Nurse)/Unit Manager. EI #3 was asked, who was responsible for changing oxygen tubing. EI #3 replied, eleven to seven shift on Thursday nights. EI #3 was asked, how often should oxygen tubing be changed. EI #3 replied, it is once a week. EI #3 was asked, how did she know when it was time to change the oxygen tubing. EI #3 replied, there was an order that fired off to the MAR (Medication Administration Record) on Thursday nights for the eleven to seven shift to change it. EI #3 was asked, how should the tubing be labeled. EI #3 replied, with the date it was changed. EI #3 was asked, how should oxygen tubing be stored when not in use. EI #3 replied, it was supposed to be stored in zip lock bags and sealed, and labeled with the date and the resident's name on it. EI #3 was asked, what was the potential concern for not dating the oxygen tubing. EI #3 replied, some one may assume that it had already been changed. EI #3 was asked, what was the potential concern of the oxygen tubing not being changed weekly. EI #3 replied, infection control. EI #3 was asked, what was the potential concern of the oxygen tubing not being stored correctly when not in use. EI #3 replied, infection control.

Based on observation, interview, and a review of a facility policy titled, Garbage and Refuse, the facility failed to ensure the dumpster was not leaking and that liquid was not pooling on the ground around it. This affect one of three dumpsters and had the potential to affect 67 of 67 residents residing in the facility. Findings include: A facility policy titled, Garbage and Refuse, with an effective date of (MONTH) 1, 2002, revealed: PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses. STANDARD: Garbage and refuse containers should be free from cracks or leaks . An observation was made of the dumpster's on 06/04/19 at 1:48 p.m., while on tour of the kitchen with the Dietary Manager, EI (Employee Identifier) #2. Three dumpsters were located inside of a brown metal fence about three inches off of the ground. The second dumpster was observed to have a white milky substance leaking out of the bottom left corner, with a puddle approximately a foot long and about six inches wide. Around the white milky substance on the ground was a brown sticky substance. On 06/06/19 at 9:47 a.m., an interview was conducted with EI #2. EI #2 was asked, who was responsible for making sure the area around the dumpster was clean. EI #2 replied, the maintenance men. EI #2 was asked, did she observe the white milky substance leaking from the second dumpster, and pudding on the ground on 06/04/19. EI #2 replied, yes, she did. EI #2 was asked, should the dumpster leak. EI #2 replied, no. EI #2 was asked, what was the potential concern of the dumpster leaking. EI #2 replied, that it would leak out germs and bacteria. EI #2 was asked, what was the potential concern of liquids pudding on the ground around the dumpster. EI #2 replied, a bacteria hazard, and it could attract maggots and gnats.

Based on observations, interviews, a review of facility policies titled, Hand-washing Guidelines, Food Cooking and Serving Temperatures, Cleaning of Miscellaneous Equipment and Utensils, and review of a document titled, Lunch Menu Log, the facility failed to ensure: 1. staff washed their hands when entering the kitchen; 2. food temperatures on the tray line were taken and recorded on the menu log and 3. plates were not stacked wet. This had the potential to affect 67 of 69 residents who received meals from the kitchen. Findings Include: 1) A review of a facility policy titled, Hand-washing Guidelines with an effective date of 2/1/2002, revealed: .PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses PR[NAME]ESS: 1. Frequency of Hand-washing: Hands should be washed in the following situations: Every time an employee enters the kitchen; . On 6/6/18 at 8:05 a.m., EI (Employee Identifier) #5, the Dietary Manager along with the Surveyor, entered the kitchen. The dietary manager did not wash her hands. On 6/06/18 at 11:14 a.m., EI #6, Assistant Cook, entered the kitchen and did not wash her hands. The hand washing sink was located near the kitchen entrance. On 6/6/18 at 5:09 p.m., the surveyor conducted an interview with EI #6. EI #6 was asked when should she wash her hands in the kitchen. EI #6 replied, every time she did something different. EI #6 was asked why she did not wash her hands when she first entered the kitchen. EI #6 replied, she went to clock in. EI #6 was asked what was the facility policy on washing her hands in the kitchen. EI #6 replied, wash her hands every time they needed to be washed. EI #6 was asked why was it important to wash her hands when entering the kitchen. EI #6 replied, to prevent cross contamination and diseases. EI #6 was asked what was the potential harm to the residents when staff did not wash their hands in the kitchen. EI #6 replied, infection control, sickness [MEDICAL CONDITION]. EI #6 was asked did she wash her hand when she entered the kitchen. EI #6 replied, no ma'am. EI #6 was asked should she have washed her hands. EI #6 replied, yes ma'am. On 6/7/18 at 2:20 p.m., an interview was conducted with EI #5. EI #5 was asked did she wash her hands when entering the kitchen on 6/6/18. EI #5 replied, she did not. EI #5 was asked why she did not wash her hands. EI #5 replied, she was nervous. EI #5 was asked, when should she wash her hands in the kitchen. EI #5 replied, every time she entered the kitchen or touched something. EI #5 was asked, what did the facility policy say regarding washing her hands in the kitchen. EI #5 replied, when entering the kitchen, touching her body, changing gloves, or dealing with food. EI #5 was asked why was it important that she wash her hands when entering the kitchen. EI #5 replied, so she would not pass any bacteria, infection or germs to anyone else. 2) A review of a facility policy titled, Food Cooking and Serving Temperatures with a effective date of 8/23/17, revealed: .PURPOSE: Safe and sanitary food handling practices include effective control of food temperatures, in order to prevent food borne illnesses.PR[NAME]ESS: l. Food Cooking Temperatures: . b. The temperature of foods should be taken at the end of cooking, to ensure doneness.III. General Guidelines: .b. Holding temperatures of TCS (Temperature Control for Safety) foods, prior to meal service. (When replenishing or batching items to the steamtable, new product should not be mixed with existing product, and the temperature of the new product should be recorded). A review of a document titled, Lunch Menu Log with a date of 6/6/18, reveal the puree meat temperature was different from the temperature the surveyor recorded. On 6/6/18 at 11:17 a.m., the surveyor observed EI #7, the Cook taking temperatures of the food on the trayline. EI #7 did not record the food temperature as she took them. The surveyor and EI #7 observed the puree chicken finger temperature to be 165 degrees. When she recorded the puree temperature, she put a temperature of 180 degrees on the menu log. The surveyor observed EI #8, another cook, cooking chicken tenders. As she cooked the chicken tenders she did not take the temperature of the second batch of chicken tenders before putting it in the pan on the steam table. At 11:41 a.m., a third batch of chicken was put in the deep fryer. When the chicken was removed, no temperatures were taken and the chicken was placed in the pan on the tray line. Chicken from the fourth batch of chicken was not taken. When it was done, it was placed in a pan on the steam table with eight pieces of chicken tenders already in the pan. On 06/07/18 at 12:19 p.m., an interview was conducted with EI #7. EI #7 was asked what was the temperature of the puree chicken tenders. EI #7 replied,180 degrees. EI #7 was asked did she record the temperature as she took the food temperatures on the tray line. EI #7 replied, no. EI #7 was asked why she did not record the temperatures as she took them. EI #7 replied, because she was trying to hurry up and get the lunch meal out. EI #7 was asked what did the facility policy say regarding recording food temperatures on the tray line. EI #7 replied, record as soon as possible. EI #7 was asked who took the temperature of the second batch of chicken tenders. EI #7 replied, EI #8. EI #7 was asked who took the temperature of the third and fourth batch of chicken. EI #7 replied, she was not sure. EI #7 was asked was there chicken in a pan on the steam table and new chicken was placed in the pan that was on the steam table. EI #7 replied, yes. EI #7 was asked should new chicken be placed on top of chicken already in a pan. EI #7 replied, no. EI #7 was asked what did the facility policy say on placing new food items on top on old food items. EI #7 replied when bringing fresh chicken to the trayline, they should put it in a new pan. EI #7 was asked what was wrong with putting new chicken on top of old chicken. EI #7 replied, they were not using the first in first out method. EI #7 replied, the old chicken would have gotten cold. EI #7 was asked who was responsible for taking food temperatures. EI #7 replied, the cook. EI #7 was asked why was there a difference between the surveyor temperature of the puree chicken tenders and her temperature on the log. EI #7 replied she did not record her temperatures as soon as she took them and she mixed up the numbers. On 06/07/18 at 2:16 p.m. ,the surveyor conducted an interview with EI #8, the cook. EI #8 was asked who recorded and took the temperature of the second, third and fourth batch of chicken. EI #8 replied, no one. EI #8 was asked who was responsible for taking food temperature on the tray line. EI #8 replied, the cook (morning cook). EI #8 was asked should new chicken be placed on top of old chicken that was in a pan on the tray line. EI #8 replied she should have gotten another pan and brought it over to the line. EI #8 was asked why new chicken should not put place on old chicken. EI #8 replied, old chicken temperatures would have dropped, it would not be the same as the new chicken. EI #8 was asked did she put new chicken on top of old chicken already in a pan on the trayline. EI #8 replied, yes, she did. EI #8 was asked why did she put new chicken on top of old chicken. EI #8 replied, she was rushing trying to get trays out. EI #8 was asked what did the facility policy say regarding putting new chicken on top of old chicken. EI #8 replied, we were not suppose to do it. EI #8 stated we were supposed to get a pan and put it in a separate pan. EI #8 was asked what was wrong with putting new chicken on top of old chicken. EI #8 replied, contamination. 3) A review of a facility policy titled, Cleaning of Miscellaneous Equipment and Utensils with an effective date of 2/23/2017, revealed: .PURPOSE: .8. Place dishes in dish rack; avoid overloading and nesting On 6/7/18 at 8:45 a.m., the surveyor observed EI #5 stacking wet plates on top of each other and putting them in the dish warmer. The surveyor observed a total of 13 plates with water in them. On 06/07/18 at 2:54 p.m.,the surveyor conducted an interview with EI #5, Dietary Manager. EI #5 was asked what was stacked on top of each other in the plate warmer. EI #5 replied, plates. EI #5 was asked what was inside the plates. EI #5 replied, water. EI #5 was asked why was there water in the plates. EI #5 replied, the dishes just came out of the dish machine and did not sit long enough to air dry. EI #5 was asked how should dish ware be allowed to dry. EI #5 replied, take them out of the dish machine and put them on a rack to air dry. EI #5 was asked who was responsible for making sure dishes were air dried. EI #5 replied, everyone. EI #5 was asked what was the facility policy on wet plates stacked on top of each other. EI #5 replied, they should not be stacked on top of each other, they should be allowed to air dry. EI #5 was asked why should plates not be stacked when wet. EI #5 replied, it could cause bacteria to grow.

Based on observation and interview, the facility failed to ensure Room Locators (RL) # 1 was free of a missing dresser drawer, RL #2, 3 and 4 was free of missing caps on the commode bolts and RL #5 was free of scrapped and peeling sheetrock on the wall behind bed A. This affected five of 42 rooms in the facility. Findings Include: On 6/6/18 and 6/7/18, RL #1 was observed with the top dresser drawer on the left missing. 6/7/18 at 4:00 PM an observation and interview was done with EI (Employee Indentifer) #4, Maintenance Director. In RL#1, EI #4 was asked what did he see. EI #4 replied the top dresser drawer was missing. EI #4 was asked if there should be a drawer. EI #4 replied, yes. EI #4 was asked why was there no drawer. EI #4 replied, he had not had time to build a new one. EI #4 was asked what was the harm in no dresser drawer. EI #4 replied, there was no where for the resident to put things. On 6/6/18 and 6/7/18 an observation was made of RL #2, 3 and 4's commodes with missing caps over the bolts. On 6/07/18 4:10 PM an observation and interview was conducted in RL #2, 3 and 4. EI #4 was asked what did he see. EI #4 replied, the commode bolt caps were gone. EI #4 was asked if the bolts should be covered. EI #4 replied, yes. EI #4 was asked why where the bolts not covered. EI #4 replied, he was not sure. EI #4 was asked what were the risks for the bolts not being covered. EI #4 replied, it could result in a skin tear if a resident fell . On 6/6/18 and 6/7/18, observations were made of RL #5. There was scratched and peeling sheetrock on the wall at the head of the bed. On 6/7/18 at 4:20 PM, an observation and interview was made of RL #5. EI #4 was asked what did he see. EI #4 replied, scratches and peeling sheetrock behind the bed. EI #4 was asked why was there scratched and peeling paint behind the bed. EI #4 replied, staff had the bed too close to the wall when they let it up and down. EI #4 was asked what were the risks with the scratched and peeling sheetrock. EI #4 replied, there were no risks, but it was not appealing to look at. EI #4 was asked how was he notified of needed repairs. EI #4 replied, staff either told him or filled out a form and placed it in the maintenance folder and he would check the folder daily. EI #4 was asked if he had the policy on maintenance and repairs. EI #4 replied no, when staff noted the concerns he checked on them. EI #4 said some maintenance needs had priority over others.

Based on record review and review of facility policy titled,Non-Controlled Medication Destruction, the facility failed to ensure medication destruction for non-controlled medication for (MONTH) (YEAR) had two signatures. This affected one of 12 months of medication destruction sheets reviewed. Findings Include: A review of a facility policy titled, Non-Controlled Medication Destruction dated 3/11 revealed: .NON-CONTROLLED MEDICATION DESTRUCTION .Procedures .3. The registered nurse and/or pharmacist witnessing the destruction, .ensures that the following information is entered on the Record of Medication Destruction form . J. Signature of witnesses, two witnesses required for non-controlled substances, . in the designated areas on the destruction form On 6/6/18 at 9:00 AM, the surveyor reviewed the medication destruction sheets from (MONTH) (YEAR) through (MONTH) (YEAR). The destruction sheets for (MONTH) (YEAR) the non-controlled medications did not have the required two signatures. On 06/07/18 11:19 AM, an interview was conducted with Employee Identifier (EI) #1, Director of Nursing. EI #1 was asked what was the policy on signatures for medication destruction. EI#1 replied, on non-controlled medications, it was a nurse and the pharmacist. EI #1 was asked to review the non-controlled medication destruction sheet for (MONTH) (YEAR). EI #1 was asked how many signatures did she review. EI #1 replied, one only, the pharmacist. EI #1 was asked what was the risk of only one signature on the medication destruction sheets. EI #1 replied, it could lead to a possible diversion (an unauthorized rerouting).

Based on observation, interview and review of facility policy titled, Wound Care Procedure for Major Wounds, the facility failed to ensure licensed staff: 1. did not place a container of 4x4's on Resident Identifier (RI) #49's bed during wound care, and 2. licensed staff did not touch a pen pulled from another staff member's pocket then touch the hydrogel treatment for [REDACTED]. This was observed on 6/7/18 and affected one of one residents observed for wound care. Findings Include: A review of a facility policy titled, Wound Care Procedures for Major Wounds with an effective date of 12/1/09 revealed: PURPOSE: To provide guidelines for clean technique in doing wound care NOTE: . Care must be taken to prevent contamination of the supplies and surfaces used in wound care . RI #49 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. On 6/07/18 at 8:30 AM, Employee Identifier (EI) #2, Licensed Practical Nurse, was observed performing wound care for RI #49. EI #2 washed her hands and donned new gloves. EI #2 placed the container of premoistened 4 x 4 gauze on RI #49's bed. EI #2 cleaned the wound then discarded the container. EI #2 washed her hands and donned new gloves. The staff person assisting in holding RI #49 handed EI #2 a pen she took from her pocket. EI #2 marked the date and her initials on the outer dressing then with the same gloves, cut a piece of hydrogel dressing and placed it on RI #49's wound. EI #2 then placed the outer cover. On 6/07/18 at 9:11 AM, an interview was conducted with EI #2, she was asked what was the policy on placing supplies during wound care. EI #2 replied, she was to clean table, place a barrier then place clean supplies on the barrier. EI #2 was asked when would she place a 4x4 container on a resident's bed. EI #2 replied, she would not. EI #2 was asked if she placed the container on RI #49's bed. EI #2 replied, yes. EI #2 was asked when would you touch a pen for dating a dressing then handle hydrogel. EI #2 replied, she should have washed her hands, put on clean gloves, then picked up the hydrogel dressing. EI #2 was asked what would the harm be in placing a 4x4 container on a resident's bed and touching a pen, then touching clean hydrogel with the same gloves. EI #2 replied, risking cross contamination. On 6/07/18 at 2:49 PM, an interview was conducted with EI #3, Infection Control Nurse. EI #3 was asked what was the policy on placing supplies during wound care. EI #3 replied, place the supplies on a barrier on the bedside table. EI #3 was asked when would staff place a container of 4x4's on a resident's bed during wound care. EI #3 replied, should not unless a barrier was placed on the bed. EI #3 was asked when should a staff member touch a pen with gloved hands then touch hydrogel dressing to cut a piece and place it on a wound. EI #3 replied, never. EI #3 was asked what were the risks when staff placed a container of 4x4's on a resident's bed, touched a pen with gloved hands, then cut a piece of hydrogel and placed it on a resident's wound. EI # 3 replied, infection and transferring germs.

Based on observation, interview and a review of a facility policy titled Garbage and Refuse with an effective date of (MONTH) 1, 2002 the facility failed to ensure that the door of the dumpster was closed on 6/6/18. This had the potential to affect all 69 residents residing in the facility. Findings include: A facility policy titled, Garbage and Refuse with no effective date reavealed: .Purpose : to prevent the spread of bacteria that may cause food borne illnesses. Standard: Garbage and refuse containers should be free from cracks or leaks and covered when not in use Process: . e. Refuse containers and dumpsters kept outside the facility should have tightly fitting lids and should be kept covered when not being loaded On 06/06/18 at 8:25 a.m. the surveyor and EI (Employee Identifier) #5, the Dietary Manager observed three dumpsters. One dumpster was opened half way. On 6/7/18 at 2:53 p.m., the surveyor conducted an interview with EI #5. EI #5 was asked who was responsible for keeping the dumpster closed. EI #5 replied, everybody. EI #5 was asked what dumpster was opened on 6/6/18. EI #5 replied the first one. EI #5 was asked how far was the dumpster door opened. EI #5 replied half way opened. EI #5 was asked what was the facility policy on keeping the door closed. EI #5 replied it should stay closed at all times. EI #5 was asked why should the dumpster door be kept closed. EI #5 replied to keep anything from getting in there and it had hazard material in there.

Based on observation, interview and review of facility policies titled Food Receipt and Storage and Food Cooking and Serving Temperatures, the facility failed to ensure: 1) six cans of Ensure, two cases of Glucerna, one case of Two Cal and three cases of Nepro were not stored in the pantry past the expiration dates. This was observed during the initial tour on 4/25/17; and 2) the dietary aide did not check the temperature of the milk by puncturing the carton. This was observed during the lunch trayline on 04/26/17. These concerns had the potential to affect 68 residents receiving meals from the kitchen. Findings Include: 1) A review of a facility policy titled Food Receipt and Storage with an effective date of August 21, 2013 revealed: . STANDARD: Foods should be checked for freshness . and stored . On 04/25/17 at 7:05 p.m., during the initial tour of the facility these items were observed on the shelf in the pantry: 1. six cans of Ensure with expiration dates of March 1, 2017, 2. one case Glucerna with expiration date of April 1, 2017; 3. one case Glucerna with expiration date of March 1, 2017; 4. one case Two Cal with expiration date of March 1, 2017; 5. one case Nepro with expiration date of April 1, 2017; 6. one case Nepro with expiration date of March 1, 2017; and 7. one case Nepro with expiration date of January 2, 2016. On 04/25/17 at 7:20 p.m., an interview was conducted with Employee Identifier (EI) #4, the Evening Cook. EI #4 was asked if the Ensure, Glucerna, Nepro and Two Cal were currently used for residents. EI #4 replied yes, however she did not think the Two Cal and Nepro were being used. EI #4 was asked if those supplements should be in the pantry past the expiration dates. EI #4 replied no. On 04/26/17 at 4:20 p.m., an interview was conducted with EI # 3, the Dietary Manager. EI #3 was asked what was the policy on expired foods and supplements. EI #3 replied dates were to be checked and were not to be expired. EI #3 was asked who was responsible for ensuring supplements were not expired. EI #3 replied she was. EI #3 was asked when should expired foods be stored in the pantry. EI #3 replied foods and supplements should not be stored in the pantry if expired. EI#3 was asked what was the risk when having expired supplements in the pantry. EI #3 replied it could be served to the residents and make them sick. 2) A review of a facility policy titled Food Cooking and Serving Temperatures with an effective date of May 25, 2012 revealed: . PROCESS: . III. General Guidelines: a. Remove lids or covers . prior to temperature check . On 04/26/17 at 11:30 a.m., during observation of the lunch tray line, EI #5, a dietary aide was observed checking the temperature of the milk by puncturing the milk carton. On 04/26/17 at 4:20 p.m., an interview was conducted with EI #3 the dietary manager. EI #3 was asked how was the temperature of the milk to be checked. EI #3 replied they should open the carton and then check the temperature.

Based on observation, interview, record review, review of Potter and Perry's FUNDAMENTALS OF NURSING and a facility policy titled, Medication Administration - General Guidelines, the facility failed to ensure a medication cup containing a topical medication, [MEDICATION NAME] gel, was not left at Resident Identifier (RI) #12's bedside on 4/26/2017. This affected RI #12, one of six residents observed during the medication pass. Findings Include: A review of Potter and Perry FUNDAMENTALS OF NURSING, Ninth Edition, copyright 2017, Chapter 32, Medication Administration, page 626-627 documented: . Standards . Many medication errors can be linked in some way to an inconsistency in adhering to these six rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation Right Medication. Patients who self-administer medications need to keep them in their original labeled containers, . A review of the facility policy titled, Medication Administration - General Guidelines, dated 03/2011, revealed the following: . Procedures . 2. Medications are administered in accordance with written orders . 3. Medications are administered at the time they are prepared. 4. The person who prepares the dose for administration is the person who administers the dose. 9. Residents are allowed to self-administer medications when specifically authorized by the attending physician . 25. Once removed from the package or container, unused doses should be disposed of appropriately. RI #12 was admitted to the facility on [DATE]. A review of RI #12's April 2017 Physician Orders revealed an order, dated 04/06/2017, for [MEDICATION NAME] gel to be applied to the neck PRN (as needed) for pain. A review of RI #12's April 2017 MAR (Medication Administration Record) revealed the last documented dose of [MEDICATION NAME] gel was administered on 04/19/2017 at 9:35 a.m. by EI (Employee Identifier) #7, a LPN (Licensed Practical Nurse). On 04/26/2017 at 8:45 a.m., during the medication pass, the surveyor observed a plastic medication cup of white cream at RI #12's bedside. RI #12 reported rubbing the cream on his/her neck. EI #7 took the plastic cup of cream, stating, the cream should not be there. On 04/26/2017 at 10:30 a.m., EI #7 was asked why RI #12's cream was left at the bedside. EI #7 said the cream was a PRN medication and should not have been left at the bedside. Upon review of the April 2017 MAR, EI #7 said she had administered the last dose of [MEDICATION NAME] gel, that was signed out on 04/19/2017, and she had applied the [MEDICATION NAME] gel herself. EI #7 said RI #12 did not have an evaluation or order for leaving medications at bedside. When asked if it was usual for the cream to be left at the bed side, EI #7 stated, no ma'am. When asked what was in the cup, EI #7 said, it looked like [MEDICATION NAME] gel.

Based on observation, interviews, record review, review of Resident Identifier (RI) #4's Wound Assessment Report and review of a facility policy titled Dressing - Clean, the facility failed to ensure RI #4's pressure ulcers to the buttocks were covered with a dressing on 04/26/17. This deficient practice affected RI #4, one of two residents observed for wound care. The facility's RESIDENT CENSUS AND CONDITIONS OF RESIDENTS form, dated 04/25/17, revealed there were five residents in the facility with pressure ulcers. Findings Include: A facility policy titled ,Dressing - Clean, with an effective date of December 20, 2016, documented: PURPOSE: To provide guidelines for care of wounds . to decrease the potential for nosocomial infection . PROCESS: . 12. Place the gauze to cover broken skin . RI #4 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set assessment with an Assessment Reference Date of 02/06/17, assessed RI #4 to have short and long term memory problems with severely impaired cognitive skills for daily decision making. RI #4 was also assessed as needing extensive assistance with bed mobility and being always incontinent of bowel and bladder. Under Section M - Skin Conditions, RI #1 was identified to have an ulcer, scar or dressing and was coded as being at risk of developing a pressure ulcer during this assessment period. RI #4's Wound Assessment Report, with an Assessment Date of 04/24/17, documented: . Wound Type Pressure Ulcer Wound Location Left Buttock; REOPENED . The Wound Assessment Report for RI #4, with an Assessment Date of 04/24/17, documented: . Wound Type Pressure Ulcer Wound Location Right Buttock; REOPENED . On 04/26/17 at 9:30 a.m., the surveyor observed Employee Indentifer (EI) #2, the Licensed Practical Nurse (LPN)/Treatment Nurse and EI #1, a Registered Nurse (RN) Unit Manager, prepare to perform wound care for RI #4. RI #4 was positioned to the right side. There was no dressing observed on RI #4's buttocks at this time. EI #2 informed the surveyor that no one told her RI #4's dressing was off. On 04/26/17 at 2:36 p.m., the surveyor conducted an interview with EI #9, the Certified Nursing Assistant (CNA) assigned to care for RI #4 on the 7-3 shift on 04/26/17. The surveyor asked EI #9 if RI #4 received a bed bath or shower on her shift. EI #9 said RI #4 had received a bed bath. The surveyor asked EI #9, when she provided the bed bath, did RI #4 have a dressing on his/her buttocks. EI #9 replied, No Ma'am. The surveyor asked EI #9 what was the purpose of having a dressing on a wound. EI #9 replied, So it can get better. On 04/26/17 at 4:36 p.m., the surveyor conducted an interview with EI #1, the RN Unit Manager. The surveyor asked EI #1, this morning when RI #4's wound care observation was done, why was there no dressing on RI #4's buttocks. EI #1 said RI #4 could have soiled the dressing. The surveyor asked EI #1 should there have been a dressing on RI #4's pressure ulcer. EI #1 replied, Yes Ma'am. The surveyor asked EI #1 what was the purpose for having a dressing on a pressure ulcer. EI #1 replied, To help for wound healing and preventing it from getting worse. On 04/27/17 at 1:05 p.m., the surveyor conducted an interview with EI #10, the CNA assigned to care for RI #4 on the 11-7 shift on 04/25/17. The surveyor asked EI #10 did she remove the dressing from RI #4's buttocks on her shift. EI #10 said she did not. The surveyor asked EI #10 how she thought RI #4's dressing had come off the resident's buttocks. EI #10 said the dressing may have come off when RI #4 was being changed. The surveyor asked EI #10 what was the purpose of having a dressing on a pressure ulcer. EI #10 said the dressing was to protect the pressure ulcer from urine and bowel movement and to keep the pressure ulcer from getting worse than it was.

Based on observation, interview, record review, and review of the facility policy titled Urinary Drainage Bag Emptying, the facility failed to ensure RI (Resident Identifier) #7's urinary catheter bag was emptied prior to the end of first shift (7 a.m. to 3 p.m.) on 04/26/17. This deficient practice affected RI #7, one of two residents sampled for urinary catheters. The facility's RESIDENT CENSUS AND CONDITIONS OF RESIDENTS form, dated 04/25/17 revealed there were 5 residents in the facility with urinary catheters. Findings Include: Review of the facility policy titled Urinary Drainage Bag Emptying with an effective date of 5/1/2004, revealed the following: PURPOSE: The primary purposes for emptying the drainage bag are: a) To prevent the drainage bag from becoming full and allowing urine to flow back into the bladder. STANDARD: The urinary drainage bag should be emptied when it is full and at the end of the shift. RI #7 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #7's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/24/17, revealed a BIMS (Brief Interview for Mental Status) score of 14, which indicated intact cognition. The MDS also revealed RI #7 had an indwelling urinary catheter. RI #7's April 2017 Physician Orders revealed an order, dated 4/24/17, for: . SUPRAPUBIC CATHETER . [MEDICAL CONDITION] . On 04/26/17 at 3:15 p.m., RI #7 expressed concern to the surveyor that the catheter bag had not been emptied. RI #7's catheter bag was about half full. On 04/26/17 at 3:30 p.m., EI (Employee Identifier) #6, a CNA (Certified Nursing Assistant) working the second shift (3 p.m. to 11 p.m. shift), was in the hall outside RI #7's room. EI #6 was asked when were catheter bags emptied. EI #6 said, at the end of each shift. EI #6 went to check RI #7's catheter bag and reported emptying 500 cc's (cubic centimeters) of urine from the bag. On 04/26/17 at 3:35 p.m., EI #7, a LPN (Licensed Practical Nurse) was asked when catheter bags should be emptied. EI #7 said catheter bags should be emptied by the CNAs at the end of each shift. When asked who was responsible for emptying RI #7's catheter bag before the end of the shift at 3 p.m. on 4/26/17, EI #7 said it was EI #8, a CNA. EI #7 was not aware of any reason why RI #7's catheter bag had not been emptied. On 04/27/17 at 10:20 a.m., EI #8 was asked who was responsible for RI #7 on 04/26/17 from 7 a.m. until 3 p.m. EI #8 said she was. When asked why RI #7's catheter bag was not emptied at the end of the first shift on 04/26/17, EI #8 said she thought RI #7 would empty the bag. When asked why it was important to empty the catheter bags at the end of the shift, EI #8 said so they will not back up. When asked if she had encouraged RI #7 to empty the bag on 04/26/17, EI #8 said she had not.

Based on record review, observation and interview, the facility failed to ensure a licensed staff member did not place a [MEDICATION NAME] (diuretic) tablet into the garbage on the medication cart during medication administration on 3/30/2016. The facility further failed to ensure a licensed staff member checked placement of a [DEVICE] (gastrostomy) before administering 200 cc (cubic centimeters) of H20 (water) flush during medication administration on 3/30/2016. This affected two of three nurses observed during medication administration. Findings Include: A review of the Alabama Board of Nursing Alabama Administrative Code Chapter 610-X-6 Standards of Nursing Practice revealed: .610-X-6-.07 Medication Administration and Safety (1) The registered nurse or licensed practical nurse shall have applied knowledge of medication administration and safety . (2) The registered nurse or licensed practical nurse shall exercise decision-making skills when administering medications . (3) The registered nurse or licensed practical nurse shall exhibit skills when administering medications but not limited to: . (5) Administration of medications by routes beyond basic educational preparation .require a standardized procedure. A review of a facility policy titled, Medication Administration Medication Administration - General Guidelines with a date of 03/11 revealed: .Procedures . 25. Once removed from the package or container, unused doses should be disposed of appropriately. 1) On 3/30/2016 at 9:29 AM, EI (Employee Identifier) #4, LPN (Licensed Practical Nurse) was observed preparing medications. EI #4 dropped a [MEDICATION NAME] tablet onto the top of the medication cart. EI #4 picked the [MEDICATION NAME] tablet up and placed in into the garbage can on the medication cart. EI #4 continued to prepare medications and entered a resident's room to administer medications. On 3/31/2016 at 9:25 AM, an interview was conducted with EI #4. EI #4 was asked how she disposed of the [MEDICATION NAME] tablet she dropped on top of the medication cart on 3/30/2016. EI #4 said she put it in the garbage can. EI #4 was asked how she should have disposed of the [MEDICATION NAME]. EI #4 said she should have put it in the sharps container. EI #4 was asked what the potential harm was in placing the [MEDICATION NAME] tablet in the garbage can on the medication cart. EI #4 said someone else could get it and take it. EI #4 was asked what was [MEDICATION NAME] given for. EI #4 said a diuretic. A review of a facility policy titled, Medication Administration Procedures Enteral Tube Administration with a date of 03/11 revealed: .Procedures .4.Regardless of the type of tube, check for proper placement before administering medication or water. On 3/30/2016 at 4:01 PM, EI #5, LPN was observed administering a 200 cc H2O flush to a resident with a [DEVICE]. EI #5 placed the resident's tube feeding on hold, disconnected the [DEVICE] from the tube feeding and raised the head of the resident's bed. EI #5 then administered 200 cc H2O flush to the resident without checking the placement of the [DEVICE]. On 3/31/2016 at 11:16 AM, a telephone interview was conducted with EI #5. EI #5 was asked what should be done prior to administering flush to a resident with a [DEVICE]. EI #5 said to check placement. EI #5 was asked if he checked placement on the resident's [DEVICE] prior to giving the 200 cc flush. EI #5 said, No ma'am, I did not. EI #5 was asked why he did not check placement of the [DEVICE] prior to administering 200 cc H2O flush. EI #5 said he was nervous with people watching. EI #5 was asked what was the potential harm in not checking placement of the [DEVICE] before administering 200 cc of H2O flush. EI #5 said, The water will go somewhere else if tube is not in place, you don't want 200 cc of water floating around in the abdomen.

Based on observation, interview and record review, the facility failed to ensure a licensed staff member pulled the privacy curtain between RI (Resident Identifier) #19 and the roommate when administering eye drops to RI #19 during medication administration on 3/30/2016. This affected one of three nurses observed during medication administration. Findings Include: A review of a facility policy titled, Medication Administration Medication Administration - General Guidelines with a date of 03/11 revealed: . Procedures . 18. Provide privacy for resident if appropriate. A review of a facility policy titled, Federal Rights of Residents with an effective date of November 1, 2001 revealed: .STANDARD: . The facility strives to protect the rights of residents, including each of the following rights: . o) The resident has the right to personal privacy . RI #19 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #19's March 2016 physician's orders [REDACTED].[MEDICATION NAME] EYE DROPS GIVE ONE GTT (DROP) OU (BOTH EYES) BID (TWICE DAILY) . On 3/30/2016 at 9:29 AM, EI (Employee Identifier) #4, LPN (Licensed Practical Nurse) was observed administering [MEDICATION NAME] eye drops to RI #19. EI #4 administered the eye drops to RI #19 while the roommate was present in the next bed and watching EI #4 administer the eye drops. EI #4 did not pull the privacy curtain between the two residents. On 3/31/2016 at 9:27 AM, an interview was conducted with EI #4. EI #4 was asked what should be done when administering eye drops to a resident and the roommate was awake and present in the room. EI #4 said to pull the curtain. EI #4 was asked if she pulled the privacy curtain between RI #19 and the roommate when she gave the eye drops to RI #19. EI #4 said, I did not. EI #4 was asked why she did not pull the privacy curtain between the two residents when she administered the eye drops. EI #4 said, I did not even think about it. EI #4 was asked what the potential harm was in not pulling the privacy curtain between the two residents when she administered the eye drops. EI #4 said, The other resident knows what's going on with RI #19, HIPAA ( Health Insurance Portability and Accountability Act).

Based on record review and interview, the facility failed to resolve the issue of RI (Resident Identifier) #16 being subjected to resident-to-resident physical and verbal abuse. RI #16 informed the DON (Director of Nursing) of being hit on the arm by another resident. RI #16 stated the DON informed him/her nothing could be done due to the resident's mental status. This affected, RI #16, one of 19 sampled residents. Findings Include: A review of a facility policy titled, Federal Rights of Residents with an effective date of November 1, 2001 revealed: .STANDARD: . The facility strives to protect the rights of residents, including each of the following rights: . (p) The resident has the right to voice grievances .Such grievances include those with respect to treatment .and prompt efforts by the facility to resolve grievances the resident may have including those with respect to the behavior of other residents. A review of a facility policy titled, Resident and Family Grievances with an effective date of March 30, 2012 revealed: .STANDARD: Residents .may voice grievances, through a verbalized complaint to a facility staff member, .Grievances are an opportunity to explore the satisfaction of the resident . PROCESS: . (4) The Administrator or designee should conduct an investigation, and develop a plan of action, with appropriate staff members. (6) The Administrator should follow-up with the resident .to discuss actions to resolve the grievance RI #16 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #16's most recent Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 02/22/2016 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15, which indicated the resident was cognitively intact. On 3/30/2016 at 10:46 AM, RI #16 told the surveyor that another resident had been hitting her/him on the arm with their fist and calling them very vulgar names. RI #16 said she reported it to EI (Employee Identifier) #1, DON/Abuse Coordinator and EI #1 told RI #16 there was nothing that could be done due to the resident's mental status. On 3/30/2016 at 2:58 PM, an interview was conducted with EI #1. EI #1 was asked if any resident had complained to her about another resident hitting, kicking or cursing them. EI #1 said there were two residents that did not get along and one called the other one fat ass frequently. EI #1 said she could not keep the two residents from talking to each other, but she could encourage them to be nice. EI #1 was asked if RI #16 told her another resident hit her/him. EI #1 said yes. EI #1 was asked what she did with the information once she was told. EI #1 said she did an intervention on the resident's care plan. On 3/31/2016 at 9:14 AM, an interview was conducted with RI #16. RI #16 was asked when was the last time the other resident hit or cursed him/her. RI #16 said on Saturday, the other resident rammed his/her wheelchair into his/her wheelchair. RI #16 said he/she reported it to EI #1 on Monday and she said she would take care of it. RI #16 was asked what had the facility/staff been doing since EI #1 was made aware that another resident was hitting him/her. RI #16 said nothing. RI #16 said EI #1 told him/her there was nothing she could do because of the other resident's mental status. RI #16 was asked if the concern had been addressed to her/his satisfaction. RI #16 said no, his/her concerns and needs had not been met. On 3/31/2016 at 2:42 PM, a second interview was conducted with EI #1. EI #1 was asked what remedy had been given to RI #16. EI #1 said they were trying to figure it out then.

Based on record review and interview, the facility failed to ensure RI (Resident Identifier) #16 was free from verbal and physical resident-to-resident abuse. RI #16, an alert and oriented resdient, informed the faciiy that he/she had been hit by another resident and/or called vular names on several different occasions (10/6/2015, 10/12/2015, 10/13/2015, 10/20/2015, and 10/26/2015. This affected one of four sampled residents who were observed and their records reviewed for abuse. Findings Include: A review of a facility policy titled, Federal Rights of Residents with an effective date of November 1, 2001 revealed: .STANDARD: . z) The resident has the right to be free from verbal .physical .abuse . A review of a facility policy titled, Abuse, Neglect, Misappropriation of Resident Property, Injuries of Unknown Source with an effective date of August 1, 2015 revealed: .PURPOSE: . The facility's Policy strictly prohibits the abuse .of residents.This Policy against abuse .includes abuse by any other person, including, but not limited to: . other residents . The following are definitions of specific types of abuse: 1. Verbal-Verbal abuse is the use of oral, written or gestured language that includes disparaging and derogatory terms to residents .or within their hearing distance, regardless of their ages, abilities to comprehend, or the nature of their disabilities. 3. Physical-Physical abuse includes, hitting, slapping, pinching and kicking. RI #16 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #16's most recent Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 02/22/2016 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15, which indicated the resident was cognitively intact. RI #17 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #17's most recent Quarterly MDS with an ARD of 02/05/2016 revealed the resident had a BIMS of 10, which indicated the resident was moderately cognitively impaired for daily decision making. A review of RI #16's Departmental Notes revealed: .10/12/2015 10:12 PM . Approx (Approximately) 6:00 pm-Resident came to nurse and reported that a co-resident had struck her/him on her/his right arm while in line to be taken out for smoking. 10/13/2015 10:53 AM .Resident reported to nurse that co-resident hit her/him on the arm while in line for smoke break. 10/20/2015 10:59 AM .Resident reported to nurse that co-resident hit her/him on the arm while waiting in line for smoke break. 10/26/2015 3:00 PM .Careteam meet (met) with resident regarding the frequent verbal altercations between her/him and co-resident. A review of RI #17's Departmental Notes revealed: .10/6/2015 10:43 PM .Resident tried to kick another resident wheelchair earlier in this shift. Later on Resident grabbed someone elses (else's) wheelchair to prevent them from going outside before them, and tried to kick the chair .Resident is hard to redirect . 10/12/2015 10:23 PM .Resident hit another resident in the arm 3 times, because she/he was going to beat her/him outside to the smoking court . 10/13/2015 9:38 AM .It was reported and witness by other residents that RI #17 came into contract (contact) with another resident arm while exiting building to smoking (smoke) . 10/20/2015 1:25 PM .It was reported and witness by other residents that RI #17 came into contract (contact) with another resident arm while exiting building to smoking (smoke) . 10/26/2015 2:54 PM .Careteam meet (met) to review frequent verbal altercations amongst resident and co-residents. Resident has had to be rediected (redirected) and seperated (separated) numerous times. She/He has curse, threatened and degraded several residents. On 3/30/2016 at 10:46 AM, RI #16 told the surveyor that RI #17 had been hitting her/him on the arm with their fist and calling her/him very vulgar names. RI #16 said she reported it to EI (Employee Identifier) #1, DON (Director of Nursing)/Abuse Coordinator and EI #1 told RI #16 there was nothing that could be done due to RI #17's mental problems. RI #16 said she felt like RI #17 was abusing her/him. On 3/30/2016 at 2:58 PM, an interview was conducted with EI #1. EI #1 was asked if RI #16 told her RI #17 hit her/him. EI #1 said yes. EI #1 was asked what she did with the information once she was told. EI #1 said they did an intervention on RI #17's care plan. On 3/31/2016 at 9:14 AM, an interview was conducted with RI #16. RI #16 was asked when was the last time RI #17 hit or cursed him/her. RI #16 said on Saturday, RI #17 rammed his/her wheelchair into his/her wheelchair. RI #16 said she reported it to EI #1 on Monday and she said she would take care of it. RI #16 was asked what had the facility/staff been doing since EI #1 was made aware that RI #17 was hitting him/her. RI #16 said nothing. RI #16 said EI #1 told him/her there was nothing she could do because of RI #17's mental status. RI #16 was asked if the concern had been addressed to her/his satisfaction. RI #16 said no, her concerns and needs had not been met. RI #16 said she did not think EI #1 knew what to do. RI #16 was asked what remedy EI #1 had given to him/her after she was told about RI #17 hitting and cursing him/her. RI #16 said EI #1 said she would talk to RI #17. RI #16 was asked what EI #1 told him/her after she was made aware of RI #17 hitting and cursing RI #16. RI #16 said EI #1 said she would look into it. On 3/31/2016 at 2:42 PM, a second interview was conducted with EI #1. EI #1 was asked what changes had been made since RI #16 told her about RI #17 hitting and cursing him/her. EI #1 said RI #17's care plan was updated and now the resident was on one to one supervision. EI #1 said they were keeping RI #17 a distance from RI #16 during smoke breaks. EI #1 said they attempt to redirect RI #17. EI #1 was asked how were RI #17's behaviors being managed. EI #1 said one to one supervision, probably medication adjustments and more distraction techniques.

Based on record review and interview, the facility failed to ensure an allegation of verbal and physical resident to resident abuse involving RI (Resident Identifier) #16 and RI #17 was reported to the State Agency. RI #16, an alert and oriented resdient, informed the faciiy that he/she had been hit by another resident and/or called vular names on several different occasions (10/6/2015, 10/12/2015, 10/13/2015, 10/20/2015, and 10/26/2015. The resident on resident abuse was not reports to the approapriate authories. This affected one of four sampled residents who were observed and their records reviewed for abuse. Findings Include: A review of a facility policy titled, Abuse, Neglect, Misappropriation of Resident Property, Injuries of Unknown Source with an effective date of August 1, 2015 revealed: .PURPOSE: . Certain incidents and accidents involving residents must also be reported to the appropriate state agencies. Reportable incidents and accidents are those involving allegations of resident abuse . This Policy against abuse .includes abuse by any other person, including, but not limited to: .other residents . b) Investigation and Reporting Steps Notify the Administrator of any unusual situation in the facility, whether reportable or not. The Administrator will report to state agency per regulations. RI #16 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #16's most recent Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 02/22/2016 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15, which indicated the resident was cognitively intact. RI #17 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #17's most recent Quarterly MDS with an ARD of 02/05/2016 revealed the resident had a BIMS of 10, which indicated the resident was moderately cognitively impaired for daily decision making. A review of RI #16's Departmental Notes revealed: .10/12/2015 10:12 PM .Approx (Approximately) 6:00 pm-Resident came to nurse and reported that a co-resident had struck her/him on her/his right arm while in line to be taken out for smoking. 10/13/2015 10:53 AM .Resident reported to nurse that co-resident hit her/him on the arm while in line for smoke break. 10/20/2015 10:59 AM .Resident reported to nurse that co-resident hit her/him on the arm while waiting in line for smoke break. 10/26/2015 3:00 PM .Careteam meet (met) with resident regarding the frequent verbal altercations between her/him and co-resident. A review of RI #17's Departmental Notes revealed: .10/6/2015 10:43 PM .Resident tried to kick another resident wheelchair earlier in this shift. Later on Resident grabbed someone elses (else's) wheelchair to prevent them from going outside before them, and tried to kick the chair .Resident is hard to redirect . 10/12/2015 10:23 PM .Resident hit another resident in the arm 3 times, because she/he was going to beat her/him outside to the smoking court . 10/13/2015 9:38 AM .It was reported and witness by other residents that RI #17 came into contract (contact) with another resident arm while exiting building to smoking (smoke) . 10/20/2015 1:25 PM .It was reported and witness by other residents that RI #17 came into contract (contact) with another resident arm while exiting building to smoking (smoke) . 10/26/2015 2:54 PM .Careteam meet (met) to review frequent verbal altercations amongst resident and co-residents. Resident has had to be rediected (redirected) and seperated (separated) numerous times. She/He has curse, threatened and degraded several residents. On 3/30/2016 at 10:46 AM, RI #16 told the surveyor that RI #17 had been hitting her/him on the arm with their fist and calling her/him very vulgar names. RI #16 said she reported it to EI (Employee Identifier) #1, DON (Director of Nursing)/Abuse Coordinator and EI #1 told RI #16 there was nothing that could be done due to RI #17's mental problems. RI #16 said she felt like RI #17 was abusing her/him. On 3/30/2016 at 2:58 PM, an interview was conducted with EI #1. EI #1 was asked if RI #16 told her RI #17 hit her/him. EI #1 said yes. EI #1 was asked if she reported that incident to the State Agency. EI #1 said no. EI #1 was asked why she did not report the incident to the State Agency. EI #1 said they (the facility)determined it was not abuse because RI #17 intended no harm and scored an 11 on his/her BIMS. EI #1 said RI #17 did hit RI #16, but she did not feel it was abuse and did not feel it was reportable. EI #1 was asked what types of incidents should be reported to the State Agency. EI #1 said allegations of abuse, neglect or misappropriation. EI #1 was asked who was responsible for reporting allegations of abuse to the State Agency. EI #1 said herself or the Administrator. A review of a document titled, Online Incident Reporting System Report revealed an incident report had been submitted by (Name of Facility) at 3/30/2016 at 6:06 PM. It was an incident of verbal abuse by RI #17 toward RI #16. The report was submitted by EI #1.

Based on record review and interview, the facility failed to ensure the reporting component of the facility abuse policy was followed in order to report an allegation of verbal and physical abuse involving RI (Resident Identifier) #16 and RI #17. RI #16, an alert and oriented resdient, informed the faciiy that he/she had been hit by another resident and/or called vular names on several different occasions (10/6/2015, 10/12/2015, 10/13/2015, 10/20/2015, and 10/26/2015. This affected one of four sampled residents who were observed and their records reviewed for abuse. Findings Include: A review of a facility policy titled, Abuse, Neglect, Misappropriation of Resident Property, Injuries of Unknown Source with an effective date of August 1, 2015 revealed: .PURPOSE: . Certain incidents and accidents involving residents must also be reported to the appropriate state agencies. Reportable incidents and accidents are those involving allegations of resident abuse . This Policy against abuse .includes abuse by any other person, including, but not limited to: .other residents . b) Investigation and Reporting Steps Notify the Administrator of any unusual situation in the facility, whether reportable or not. The Administrator will report to state agency per regulations. RI #16 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #16's most recent Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 02/22/2016 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15, which indicated the resident was cognitively intact. RI #17 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #17's most recent Quarterly MDS with an ARD of 02/05/2016 revealed the resident had a BIMS of 10, which indicated the resident was moderately cognitively impaired for daily decision making. A review of RI #16's Departmental Notes revealed: .10/12/2015 10:12 PM .Approx (Approximately) 6:00 pm-Resident came to nurse and reported that a co-resident had struck her/him on her/his right arm while in line to be taken out for smoking. 10/13/2015 10:53 AM .Resident reported to nurse that co-resident hit her/him on the arm while in line for smoke break. 10/20/2015 10:59 AM .Resident reported to nurse that co-resident hit her/him on the arm while waiting in line for smoke break. 10/26/2015 3:00 PM .Careteam meet (met) with resident regarding the frequent verbal altercations between her/him and co-resident. A review of RI #17's Departmental Notes revealed: .10/6/2015 10:43 PM .Resident tried to kick another resident wheelchair earlier in this shift. Later on Resident grabbed someone elses (else's) wheelchair to prevent them from going outside before them, and tried to kick the chair .Resident is hard to redirect . 10/12/2015 10:23 PM .Resident hit another resident in the arm 3 times, because she/he was going to beat her/him outside to the smoking court . 10/13/2015 9:38 AM .It was reported and witness by other residents that RI #17 came into contract (contact) with another resident arm while exiting building to smoking (smoke) . 10/20/2015 1:25 PM .It was reported and witness by other residents that RI #17 came into contract (contact) with another resident arm while exiting building to smoking (smoke) . 10/26/2015 2:54 PM .Careteam meet (met) to review frequent verbal altercations amongst resident and co-residents. Resident has had to be rediected (redirected) and seperated (separated) numerous times. She/He has curse, threatened and degraded several residents. On 3/30/2016 at 10:46 AM, RI #16 told the surveyor that RI #17 had been hitting her/him on the arm with their fist and calling her/him very vulgar names. RI #16 said she reported it to EI (Employee Identifier) #1, DON (Director of Nursing)/Abuse Coordinator and EI #1 told RI #16 there was nothing that could be done due to RI #17's mental problems. RI #16 said she felt like RI #17 was abusing her/him. On 3/30/2016 at 2:58 PM, an interview was conducted with EI #1. EI #1 was asked if RI #16 told her RI #17 hit her/him. EI #1 said yes. EI #1 was asked if she reported that incident to the State Agency. EI #1 said no. EI #1 was asked why she did not report the incident to the State Agency. EI #1 said they (the facility)determined it was not abuse because RI #17 intended no harm and scored an 11 on his/her BIMS. EI #1 said RI #17 did hit RI #16, but she did not feel it was abuse and did not feel it was reportable. EI #1 was asked what types of incidents should be reported to the State Agency. EI #1 said allegations of abuse, neglect or misappropriation. EI #1 was asked who was responsible for reporting allegations of abuse to the State Agency. EI #1 said herself or the Administrator. A review of a document titled, Online Incident Reporting System Report revealed an incident report had been submitted by (Name of Facility) at 3/30/2016 at 6:06 PM. It was an incident of verbal abuse by RI #17 toward RI #16. The report was submitted by EI #1.

Based on observation, record review and interview, the facility failed to ensure resident's rooms were free of a missing board, chipped paint, and scratches. This affected RL (Room Locator) 1-10. Findings Include: A review of a facility's policy titled, Resident Environmental Quality with an effective date March 1, 2010 revealed: . PROCESS: a) Preventive maintenance schedules, for the maintenance of the building . should be followed to maintain a safe environment. On 03/31/2016 at 4:50 PM, the surveyor and the maintenance director EI (Employee Identifier) #3 made rounds in the facility. In RL #1, 6, 7, 8 and 9 there were scrapes on the outside of the door. In RL # 3, 4, 7 and 10 there were scrapes on the wall. In room RL #2 the board on the wall was cracked. In RL # 5 the paint under the window sill was chipping. On 3/31/2016 at 5:47 PM, the surveyor conducted an interview with EI #3. EI #3 was asked when was the last time he made rounds in the facility. EI #3 replied, everyday he did not go into every room. EI #3 follow up with a third of the rooms in the facility monthly. EI #3 was asked who was responsible for repairs in the facility. EI #3 replied, maintenance director. EI #3 was asked why should doors, window sill and walls be free of scratches, or chipped paint. EI #3 replied, to keep the resident or anybody from getting scratched. EI #3 was asked when should door, wall, and window sill be repaired. EI #3 replied if it was bad enough it should be repaired right then. EI #3 was asked to describe RL # 1. EI #3 replied a scraped door. EI #3 was asked to describe RL # 2. EI #3 replied the board across the bed was cracked. EI #3 was asked to describe RL #3. EI #3 replied, there was a missing board and scrapes on the wall. EI #3 was asked to describe RL #4. EI #3 replied the wall was scrapped and chipped. EI #3 was asked to describe RL #5. EI #3 replied, the window sill is flaking paint. EI #3 was asked to describe RL #7. EI #3 replied, the wood behind the bed is chipping. EI #3 was asked to describe RL #8. EI #3 replied, the door is chipped on the corner. EI #3 was asked to describe RL #6. EI #3 replied, a chipped door. EI #3 was asked to describe RL #9. EI #3 replied, there were chips on the door and the kick guard is hanging off the door. EI #3 was asked to describe RL #10. EI #3 replied, there were chips on the back walls and door.