Every finding on record at Jacksonville Health and Rehabilitation, LLC

Based on observation, interview, the facility's Dishwashing Machine Temperature Log, the 2022 United States (U.S.) Food and Drug Administration (FDA) Food Code, and the facility's policies for Food Receipt and Storage, Dish Machine Sanitization, Food Preparation Guidelines, and Tray Assembly; the facility failed to ensure food safety by the following: storing food less than six inches from the floor in the Walk-in Cooler, having soiled and dusty vent covers over the refrigeration fans in the Walk-in Cooler, not effectively monitoring and documenting the dishwashing machine's sanitizing final rinse temperature, and not maintaining the temperature of a pan of Pureed Turkey Sandwiches below 41 degrees Fahrenheit (F). This had the potential to affect all residents receiving meals in the facility, 151 of 151 residents. Findings include: The facility's policy for Food Receipt and Storage, dated 08/23/2017, included the following: . Purpose: Foods should be received and stored properly to prevent food borne illnesses. Process: . II. Storage of Foods: . c. Items in storage . should be kept at least 6 inches from the floor. The facility's policy for Dish Machine Sanitization, dated 08/10/2018, included the following: . Purpose: To prevent the spread of bacteria that may cause food borne illnesses. Process: . c. Dish machine wash, rinse, and internal surface temperatures should be recorded at the beginning of each dishwashing period and observed periodically during the dishwashing process. The facility's policy for Food Preparation Guidelines, dated 08/10/2018, included the following: . Purpose: . Food should be . at the proper temperature, as determined by the type of food, to ensure resident/guest(s) satisfaction. Process: . g. Food should be protected from contamination, while being stored, prepared and served to resident/guest(s). To prevent growth of pathogenic organisms: 1. Refrigerated at or below 41 (degrees) F . The facility's policy for Tray Assembly, dated 08/10/2018, included the following: . Purpose: An organized . tray line helps provide foods that are at proper temperature . The 2022 U.S. FDA Food Code included the following: . 2-103.11 Person in Charge. The PERSON IN CHARGE shall ensure that: . (I) EMPLOYEES are properly maintaining the temperatures of TIME/TEMPERATURE CONTROL FOR SAFETY FOODS during hot and cold holding through daily oversight of the EMPLOYEES' routine monitoring of FOOD temperatures; . (L) EMPLOYEES are properly SANITIZING cleaned multiuse EQUIPMENT and UTENSILS before they are reused, through routine monitoring of solution temperature and exposure time for hot water SANITIZING, and chemical concentration, pH, temperature, and exposure time for chemical SANITIZING; . 3-305.11 Food Storage. (A) . FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm [centimeters] (6 inches) above the floor. 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) . TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: . (2) At 5 C (41 F) or less. 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. (A) . in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90 C (194 F), or less than: . (2) . 82 C (180 F). 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. During the initial tour of the kitchen on 09/26/2023 at 10:00 AM, a bottom storage shelf in the Walk-in Cooler appeared to be lower than six inches from the floor. Employee Identifier (EI) #7, the Maintenance Supervisor, measured and verified that the front of the shelf was four inches from the floor and the back of the shelf was three inches from the floor. In addition, the two vent covers for the fans on the refrigerated unit blowing air into the Walk-in Cooler were soiled and covered with dust particles. EI #5, the Dietary Manager, was asked the problem with the dust/dirt build-up on the vent covers. EI #5 replied they should be cleaned to prevent particles from blowing onto the food. An observation of the Dishwashing Area was made on 09/26/2023 at 10:27 AM. Staff were actively engaged washing dishware and trays from the breakfast meal by operating a flight-type, heat sanitizing dishwasher. Two AM Aides, EI #10 and EI #11, were responsible for the dishwashing task and a third employee, the AM Cook, was giving assistance. The temperature reading on the rinse gauge was 138 degrees F and the temperature did not increase as three racks of dishes ran through the dishmachine. EI #5, the Dietary Manager, was asked why the temperature dial was not moving. EI #5 said she did not know and further said it was working fifteen minutes ago when she checked it. EI #5 hit the reset button on the dishmachine. The staff ran three additional racks through the dishwasher, but the temperature gauge still did not move from 138 degrees F. At 10:31 AM, the Dishwashing Machine Temperature Log for September 2023 was viewed. The 09/26/2023 log entries for for Breakfast, Lunch and Dinner were all filled out. At 10:32 AM, EI #10 was asked if she checked and recorded the dishmachine temperatures that morning and she said no. EI #11 was asked if she checked and recorded the dishmachine temperatures that morning. EI #11 said she did check and it read 180, but said she did not write it down. When asked why it was important to check the final rinse temp, EI #11 replied, To sanitize. EI #11 further said 180 degrees F was the required temperature for the final rinse cycle. At 10:41 AM, EI #7, the Dietary Manager, was asked the problem with the documentation on the Dish Machine Temperature Log. EI #7 said, It looks like they fudged it and they wrote it on the wrong day. EI #7 said not recording temperatures correctly meant there was no record. On 09/26/2023 at 5:20 PM, the supper trayline was observed with EI #6, the Registered Dietitian. The residents' plates were being served from the steamtable by EI #9, the Assistant Dietary Manager. The preparation of eight Pureed Diet meal trays were observed during the supper trayline. The Pureed Turkey Sandwiches were in a deep 1/3 pan, which had been placed on the counter of the steamtable by the edge of the Cold Well. The 1/3 pan was not in the Cold Well, nor was it on ice or under any refrigeration. At 5:54 PM, a temperature check of the pan of Pureed Turkey Sandwiches was performed by EI #9 with an electronic thermometer. The Pureed Turkey Sandwiches were at 66 degrees F. EI #9 said she did not understand why it was that temperature because it was by the Cold Well. On 09/27/2023 at 5:00 PM, EI #5, the Dietary Manager, was interviewed. When asked why it was important to keep an item like Pureed Turkey Sandwiches out of the food temperature danger zone, EI #5 said because it could make the residents sick. EI #5 also said if you let it go into the danger zone, it can grow bacteria and cause food borne illness. EI #5 further said the pan of Pureed Turkey Sandwiches could have been put on a pan of ice. EI #5 said the temperature of the Pureed Turkey Sandwiches should not have been over 41 degrees F. When asked if it was acceptable to have placed the Pureed Turkey Sandwiches on the counter of the steamtable; EI #5 said no, because it did not have anything to keep it cool. EI #5 was asked the potential danger if Dishmachine temperatures are not checked at the start of a dishwashing cycle and are not recorded. EI #5 said because they have to sanitize the dishes to kill diseases and it is a record to show that it has been done. EI #5 further said the Final Rinse temperature should be 180 degrees F. Upon being asked how far above the floor should food be stored; EI #5 said six inches, in order to prevent cross contamination. On 09/27/2023 at 5:15 PM, EI #6, the Registered Dietitian, was interviewed. EI #6 said it was important to keep an item like Pureed Turkey Sandwiches out of the food temperature danger zone to prevent food borne illness and bacterial growth. EI #6 said the Pureed Turkey Sandwiches should have been held at 41 degrees F or below. EI #6 also said it was not acceptable to have placed the pan of Pureed Turkey Sandwiches on the counter of the steamtable, because there was nothing to hold the temperature of the pan. EI #6 further said, if the pan of Pureed Turkey Sandwiches could not fit into the Cold Well, the temperature could have been maintained by an ice bath. When asked the potential danger if Dishmachine temperatures are not checked at the start of a dishwashing cycle and are not recorded, EI #6 said you can't ensure the dishes are being washed and sanitized properly. Upon being asked how far above the floor should food be stored; EI #6 said six inches, so you can clean under there.

Based on observations, interviews, and a facility policy titled Preventative Maintenance Strategy the facility failed to provide necessary maintenance services to maintain good repair of equipment and a home like environment. This deficient practice was observed on four of four days of the survey and had the potential to affect residents residing on the 100 hall, one of three halls in the facility. Findings include: A facility policy titled Preventative Maintenance Strategy dated 3/1/2010 documented: . 1. maintenance done on a scheduled routine basis with the emphasis on preventing maintenance problems, rather than correcting existing problems. On 9/26/2023, at 11:53 AM, Resident Identifier (RI) #66's air conditioning unit had broken plastic parts, and the vent was found to have accumulated dust and debris, as well as small white puffy balls within the unit. On 9/27/2023 at 11:31 AM, RI #66's air conditioner was observed with broken vent parts, as well as dust and food debris present in the vent. The door to the bathroom was noted to have missing paint and the door frame was scuffed. On 9/27/2023 at 11:37 AM, RI #62's air conditioner unit was observed to have debris and rust present in the vent. On 9/27/2023 at 2:45 PM, RI #66's door and door frame was observed with chipped paint and scuff marks. On 9/28/2023 at 3:29 PM the surveyor conducted an interview with Employee Identifier (EI) #7, Maintenance Supervisor, while conducting observations in RI #66's room. The surveyor asked about the condition of the air conditioner unit, to which EI #7 responded, it appeared to have food particles and required a new grill as well as cleaning. When asked if the air conditioner should look like that, EI #7 replied no. EI #7 was asked about the doors and door frames for RI #66's room. EI #7 said, they needed to be painted, but he had not made it to that unit. On 9/28/2023 at 4:06 PM the surveyor conducted an interview with EI #8, Housekeeping Supervisor, while conducting an observation of RI #62's room. The surveyor asked about the air conditioning unit and requested EI #8 observe and explain. EI #8 responded, the unit appeared trashy and dusty with visible dust and food particles. When asked about potential concerns for residents, EI #8 said, the inhalation of dust particles could potentially present a risk. EI #8 said, the air units should be cleaned monthly, but that one did not look like it had been. On 9/29/2023 at 6:27 PM the surveyor and EI #7 observed the dining room kitchen doors had paint chipping from the bottom of the door up to approximately three feet. Additionally, the door located on the 100 hall leading to the outside smoking area had paint chipping and scuff marks from the bottom of the door up to approximately three feet. When asked about the overall appearance of the paint chipping and scuff marks on the doors, EI #7 responded, it did not appear to be a homelike environment.

Based on observation, interview, the facility's Diet Guide Sheet for Spring 2023/Week 2/Tuesday/Day 10, and the facility's policy for Cycle Menus; the facility failed to provide a six-ounce portion of Pureed Turkey Sandwich for 8 of 8 pureed meals observed. The facility further failed to provide a full six-ounce portion of Pureed Cream of Broccoli Soup for 5 of 8 pureed meals observed. This had the potential to affect 8 of 20 residents receiving pureed meals during a Supper trayline observation on 09/26/2023. Findings include: The facility's policy for Cycle Menus, dated 10/01/2005, included the following: . Purpose: To meet the nutritional needs of resident/guest(s), in accordance with the recommended dietary allowances (RDA) of the Food and Nutrition Board of the National Research Council, standard menus are utilized. Process: . c. Menus should have portions stated in ounces, and/or measurements. A helpful conversion factors chart is attached as an exhibit to this policy. Menu Measurement Conversion Factors . 4 ounces . #8 scoop 6 ounces . #6 scoop ,,, . The facility's Diet Guide Sheet for Spring 2023/Week 2/Tuesday/Day 10 included the following for the Pureed Diet's supper meal: . Turkey Sandwich . Pureed #6 Scp (scoop) . Cream of Broccoli Soup . Pureed #6 Scp . On 09/26/2023 at 5:20 PM, the supper trayline was observed with Employee Identifier (EI) #6, the Registered Dietitian. The residents' plates were being served from the steamtable by EI #9, the Assistant Dietary Manager. The preparation of eight Pureed Diet meal trays were observed during the supper trayline. During eight of eight observations, a #8 scoop (four ounces), not a #6 scoop (six ounces), was being used for serving the Pureed Turkey Sandwich. During five of eight observations, the #6 scoop being used to serve the Pureed Cream of Broccoli Soup was not fully filled. On 09/27/2023 at 5:00 PM, EI #5, the Dietary Manager, was interviewed. EI #5 was asked for the potential problems in not using the correct portion size when serving resident meals. EI #5 said it could cause some weight loss if the proper size was not used. EI #5 also said it meant nutrition was being taken from the residents' meals. When asked if partially filled scoop was acceptable, EI #5 said no. EI #5 further said you have to level it off against the pan to get the correct serving size. On 09/27/2023 at 5:15 PM, EI #6, the Registered Dietitian, was interviewed. EI #6 said the potential problems in not using the correct portion size when serving resident meals were inadequate calories, protein, and nutrition. EI #6 also said a partially filled scoop was not acceptable to meet a specific food portion size and it would not provide what was required by the menu.

Based on interview and the facility's Tray Service Schedule, the facility had scheduled an excess of 14 hours between the service of the Supper meal and the service of the Breakfast meal. This affected three of three resident units and had the potential to affect all residents receiving meals in the facility, 151 of 151 residents. Findings include: On 09/26/2023, Employee Identifier (EI) #5, the Dietary Manager provided a copy of the Tray Service Schedule. The Tray Service Schedule included the following information: a.) The first cart for Unit #2's supper was to be delivered at 5:05 PM and the first cart for breakfast was to be delivered at 7:20 AM. The period of time between the supper and breakfast delivery was 14 hours and 15 minutes. b.) The first cart for Unit #1's supper was to be delivered at 5:20 PM and the first cart for breakfast was to be delivered at 7:40 AM. The period of time between the supper and breakfast delivery was 14 hours and 20 minutes. c.) The first cart for Unit #3's supper was to be delivered at 5:35 PM and the first cart for breakfast was to be delivered at 8:00 AM. The period of time between the supper and breakfast delivery was 14 hours and 25 minutes. On 09/28/23 at 2:47 PM, EI #5, the Dietary Manager, was interviewed. The times on the facility's Tray Service Schedule were reviewed with EI #5. EI #5 calculated the period of time between the service of the first cart for Unit #2's supper and the first cart for Unit #2's breakfast as 14 hours and 15 minutes. EI #5 agreed that the residents on Unit #2, who received their meals on the first cart, had to wait 14 hours and 15 minutes between Supper and Breakfast. EI #5 said the facility did not have prior approval from a resident body to allow a 16-hour period between the service of the supper meal to the service of the breakfast meal. EI #5 said the facility did not provide all residents with a substantial evening snack.

Based on observation, interviews, a review of the (YEAR) Food Code, the facility policy titled, Dish Machine Sanitization, the facility's Dish Machine Temperature Log, and the manufacturer's Dish Temp (irreversible thermometer) Calibration Certificate, the facility failed to ensure the dishmachine effectively sanitized dishes following the breakfast meal on 09/17/19. The final rinse water (sanitization) temperatures failed to rise to the minimum recommended temperature of 180 degrees Fahrenheit (F) during 10 of 10 cycles observed. This had the potential to affect 149 residents for whom meals were prepared and served at the time of this survey. Findings include: The (YEAR) Food and Drug Administration Food Code, section 4-501.112 revealed: Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. (A) .in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be less than: .(2) 180 degrees F. The facility's policy titled, Dish Machine Sanitization with an effective date of 08/10/18, specifies the following process: .b. Dish machines using hot water for sanitizing may be used if the temperature of the wash water is maintained at the level specified by the manufacturer . On 09/17/19 at 9:30 AM, the surveyor observed staff processing breakfast dishes, in the presence of the Certified Dietary Manager, Employee Identifier (EI) #4 and the Consultant Registered Dietitian, EI #3. The dish machine temperature gauges specified a minimum wash temperature of 160 degrees F, and a minimum rinse temperature of 180 degrees F. In all, 10 cycles of dish washing were observed, starting at 9:40 AM on 09/17/19, as follows: 1) Wash (W)=166 degrees F; Rinse (R)=165 degrees F. (Dome lids, plates, 4 monkey bowls.) 2) W=162 degrees; R=166 degrees (Dome lids) 3) W=168 ; R=170 (Trays) The surveyor requested the use of an Irreversible thermometer, which was included on this rack and registered a maximum temp of 158.5 degrees F (surface temperature of tray). 4) W=156 ; R=163 (Rack contents not documented) 5) W=158 ; R=168 (Rack contents not documented) 6) W=158 ; R=166 (Plates, lids). All of the above dishes were removed from the racks by the staff member at the clean end of the dish machine. None of the above items were observed to be re-processed by staff. On 09/17/19 at 9:47 AM, the surveyor questioned both the Certified Dietary Manager (EI #4) and the Registered Dietitian (EI #3), how often the staff used the irreversible thermometer. EI #4 stated it was used three times a day typically, and the staff would document the temperature on the temperature log. The Dish Machine Temperature Log was posted just outside of the dish room, and included documentation of the wash temperature as 170 and a rinse temperature of 180 degrees F, dated 09/17/19. Three additional cycles of the dish machine were observed as follows: 7) W=158 F; R=170 degrees F 8) W=157 F; R=170 degrees F 9) W=156 F; R=170 Staff was not observed to re-wash any of the previously processed items. At 9:50 AM, the surveyor asked what the goal temperature was for the irreversible thermometer. EI #3 responded 180 degrees (F). EI #3 explained the staff did not want the temperature to go over 190 degrees F. EI #3 then commented she had contacted the maintenance man (regarding a check of the dish machine). 10) W=160 F; R=166 F IRREVERSIBLE THERMOMETER=159 degrees F. The manufacturer's information related to the irreversible (Dish Temp) thermometer Calibration Certificate with a calibration date of 07/18/19, specified a Target Temperature of 160 degrees F On 09/18/19 at 3:45 PM, the surveyor interviewed EI #3 regarding the dish machine. The surveyor reviewed the 10 cycles of dish machine observations made on 09/17/19, all of which were below the recommended minimum sanitizing temperature of 180 degrees F. The final rinse temps registered between 163 to 170 degrees F. EI #3 stated she thought the booster heater went out, explaining they got the dish machine representative to check the dish machine. He got the temperature back up. The staff flipped the machine over to chemicals this (09/18/19) morning. The surveyor asked EI #3 how she could ensure the dishes were sanitized effectively at those low temperatures, to which EI #3 responded, she could not. When asked what water temperature did the dish washing policy specify to ensure proper sanitation, EI #3 stated, we want 180 degrees. The surveyor asked what potential hazard was associated with the low rinse temperatures. EI #3 responded, not sanitizing and infection control.

Based on observations, interviews, medical record reviews and review of a facility policy titled, Hand Hygiene, the facility failed to ensure: 1. a Certified Nursing Assistant (CNA) washed her hands after removing her gloves and before applying clean gloves during and after incontinence care for Resident Identifier (RI) #67 and 2. a CNA changed her gloves and washed her hands after providing incontinence care for RI #139 and before touching the resident's clean brief, bed covers, resident clothing and bed control. These deficient practices affected RI #139 and #67, two of three sampled residents observed for incontinence care. Findings Include: A review of a facility policy titled, Hand Hygiene, with an effective date of (MONTH) 1, (YEAR), documented: . III. Hand Hygiene . the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene. Before and after assisting a resident . with toileting . After contact with a resident . body fluids or excretions . after handling soiled or used linens, . after removing gloves . 1. RI #67 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 09/17/19 at 4:49 p.m., Employee Identifier (EI) #2, CNA was observed providing incontinence care for RI #67. EI #2 and EI #11, CNA washed their hands upon entering the room and put on clean gloves. EI #2 carried out the incontinent care and EI #11 assisted with turning RI #67. EI #2 provided incontinent care to RI #67's front perineal area. EI #2's gloves were not removed and her hands were not washed. RI #67 was turned to his/her left side and the rectal area and buttock area was cleaned. EI #2's gloves were not removed and her hands were not washed before a barrier cream was applied to RI #67's buttocks, a clean brief placed on the resident, pillows were touched and the resident was repositioned by EI #2. EI #2 pulled her gloves off and went out of the room without washing her hands and entered into another resident's room. On 09/19/19 at 10:08 AM, an interview was conducted with EI #2. EI #2 was asked if she washed and changed her gloves after cleaning the perineal area before she started cleaning the rectal area. EI #2 stated no. EI #2 was asked if she washed her hands and changed her gloves after cleaning the rectal area. EI #2 stated no. EI #2 was asked should she have washed her hands and changed her gloves after cleaning the rectal area. EI #2 stated yes. EI #2 was asked did she wash her hands and change her gloves after applying barrier cream to the buttocks. EI#2 said she changed gloves but did not wash her hands. EI #2 was asked should she have washed her hands and changed gloves after applying barrier cream to the buttocks. EI #2 replied yes. EI #2 was asked, during any part of the incontinence care for EI #67 did she wash her hands and change her gloves. EI #2 stated she washed them at the beginning but did not wash them in the middle or any other time. EI #2 was asked what was the potential harm in not washing her hands and changing her gloves during any part of the incontinent care. EI #2 stated cross contamination. 2. RI #139 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. On 9/18/2019 at 9:49 AM, an observation was made of incontinent care for RI #139. EI #1, CNA, entered RI #139's room washed her hands and put on gloves. EI #1 prepared incontinent supplies on the resident's over bed table. Upon unsecuring RI #139's brief, it was observed to be soiled with urine. EI #1 provided incontinent care to RI #139's front perineal area. EI #1 did not remove her gloves and wash her hands. RI #139 was turned to his/her right side and the rectal area and buttock area were cleaned and bowel movement (BM) was observed on the wipe. EI #1 continued cleaning the buttock area. EI #1 folded and removed the soiled brief from under RI#139. EI #1 did not change her gloves or wash her hands before placing a clean brief under RI #139. RI #139 was turned onto his/her back and the clean brief was secured. EI #1 proceeded to touch the resident's blanket, clothing and bed control without changing her gloves and washing her hands. On 09/18/19 at 10:04 a.m., an interview was conducted with EI #1. EI #1 was asked when should she change her gloves and wash her hands during incontinent care. EI #1 stated when she took the gloves off and once she was finished with the task. EI #1 was asked did she remove her gloves and wash her hands after she finished cleaning the front area, then move to the back area. EI #1 replied, no. EI #1 was asked if she took her gloves off and washed her hands after wiping stool from RI #139's rectum. EI #1 stated no, she should have taken her gloves off, washed her hands and then put the clean brief back on. EI #1 was asked what was the potential harm in not taking her gloves off and not washing her hands after cleaning a bowel movement. EI #1 stated the resident could get sick and she could spread infections. EI #1 was asked what was the potential harm in not taking her gloves off and washing her hands after she finished cleaning the front area then moved to the back area. EI #1 stated the spread infections. On 09/19/19 at 11:17 a.m., an interview was conducted with EI #10, Registered Nurse (RN)/Director of Nursing/Infection Control. EI #10 was asked when should CNAs wash their hands and change gloves during incontinent care. EI #10 said when they remove them, when changing areas of care (cleaning the front area to cleaning the back area), if they cross contaminate during care, in between residents or if they are soiled and after they complete the process. EI #10 was asked should a CNA change gloves and wash her hands after providing incontinence care before positioning the resident, pulling up covers, touching clothing, touching bed controls, when changing areas of cleaning (cleaning the front area to cleaning the back area) and going to another resident's room. EI #10 replied yes. EI #10 was asked should a CNA wash her hands when changing gloves before applying clean gloves. EI #10 stated yes. EI #10 was asked what was the potential harm with those things. EI #10 answered spread of infection and the spread of germs.

Based on observation, interview, record review and a facility policy titled, Person Centered Care Plans the facility failed to implement Resident Indentifer (RI) # 94's nutritional care plan for receiving supplements. This affected one of nine residents whose care plans were reviewed for nutritional concerns during the survey. Findings Include: A review of a policy titled, Person Centered Care Plans with an effective date of 8/15/18, documented: .Person centered plans of care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals of the resident/guest, consistent with the resident/guest(s) rights . RI #94 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI # 94's Physician order [REDACTED].ensure 1 can with each meal . A review of RI # 94's care plan documented the following: .PROVIDE SNACKS OR SUPPLEMENTS .8/13/19 . The Surveyor observed RI #94's lunch meal on 9/17/19 at 11:57 a.m. The lunch tray consisted of pork chops, cooked apples and yams, cabbage, cornbread, 8 ounces (oz) of chocolate milk, 8 oz of water, 8 oz of tea, cake and ice cream. No Ensure was observed on the lunch tray. The Surveyor observed RI #94's breakfast meal on 9/18/19 at 8:02 a.m. The breakfast meal consisted of fried eggs, sausage, biscuit with gravy, 8 oz of chocolate milk, 4 oz of orange juice. No Ensure was observed on breakfast tray. An interview was completed with RI #94 and his/her spouse on 09/18/19 at 5:15 p.m. Both RI #94 and his/her spouse stated RI #94 had never been offered Ensure with meals. RI #94 stated he/she would like to try the Ensure. On 9/19/19 at 9:50 a.m. an interview was completed with Employee Identifier (EI) # 3, Registered Dietician (RD). EI # 3 was asked if RI # 94 should be receiving ensure with his/her meals. EI # 3 stated yes. EI # 3 was asked what was the possible negative outcome of RI # 94 not receiving ordered supplements. EI # 3 stated potential for further weight loss. EI # 3 was asked if RI # 94's care plan was followed if he/she did not receive the ensure supplements. EI # 3 stated no it was not followed. EI # 3 was asked what was the importance of following the care plan. EI # 3 stated to make sure the facility is addressing weight loss appropriately for adequate weight gain.

Based on observation, interview, medical record review and a facility policy titled, Therapeutic Supplements, the facility failed to ensure Resident Identifier (RI) # 94, a resident at risk for weight loss, received an ordered supplement. This affected RI #94, one of nine residents who were sampled for weight loss concerns and who was observed during two meal observations. Findings Include: A review of a policy titled, Therapeutic Supplements with an effective date of 8/10/18, documented: .Resident/Guest(s) may require supplementation of their meal plan in order to attain or maintain acceptable parameters of nutrition .The need for therapeutic supplements should be determined based upon the resident/guest assessment, conducted by the Dietary Manager and the Registered Dietitian . RI # 94 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI # 94's Physician order [REDACTED].ensure 1 can with each meal . A review of RI # 94's care plan documented the following: .PROVIDE SNACKS OR SUPPLEMENTS .8/13/19 . The Surveyor reviewed RI #94's weight since 8/13/19. RI #94's admission weight was 203 pounds (lbs) and the weight on 9/9/19, was 195 lbs. RI #94 has had a 3.94% weight loss since admission. The Surveyor observed RI #94's lunch meal on 9/17/19 at 11:57 a.m. The lunch tray consisted of pork chops, cooked apples and yams, cabbage, cornbread, 8 ounces (oz) of chocolate milk, 8 oz of water, 8 oz of tea, cake and ice cream. No Ensure was observed on the lunch tray. The Surveyor observed RI #94's breakfast meal on 9/18/19 at 8:02 a.m. The breakfast meal consisted of fried eggs, sausage, biscuit with gravy, 8 oz of chocolate milk, 4 oz of orange juice. No Ensure was observed on breakfast tray. An interview was completed with RI #94 and his/her spouse on 09/18/19 at 5:15 p.m. Both RI #94 and his/her spouse stated RI #94 had never been offered Ensure with meals. RI #94 stated he/she would like to try the Ensure. On 9/19/19 at 9:50 a.m. an interview was completed with Employee Identifier (EI) #3, Registered Dietician (RD). EI #3 was asked if she completed the nutritional assessment for RI #94. EI #3 stated yes on 9/17/19. EI #3 was asked if RI #94 was at risk for weight loss. EI #3 replied yes. EI #3 further stated RI #94 has had weight loss since his/her hospitalization . EI #3 was asked what supplements he/she was receiving. EI #3 stated ensure with meals. EI #3 was asked why was the ensure ordered. EI #3 stated due to weight loss. EI #3 was asked who was responsible for placing the ensure on RI #94's tray. EI #3 stated the kitchen if the order was with meals. EI #3 was asked if RI #94's order stated with meals. EI #3 stated yes. EI #3 was asked if RI #94 should be receiving ensure with his/her meals. EI #3 stated yes. EI #3 was asked what was the possible negative outcome of RI #94 not receiving ordered supplements. EI #3 stated potential for further weight loss.

Based on record review and interviews, the facility failed to ensure Resident Identifier (RI) #196 received all ordered medication from the pharmacy on 5/18/18. This deficient practice was cited as a result of the investigation of complaint # AL 746 and affected one of one resident. Findings Include: RI #196 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. On 9/5/18 RI #196's record was reviewed. RI #196's Physician order [REDACTED]. The Medication Administration Records (MAR) for 5/18/18 through 5/20/18 were reviewed. The review revealed RI #196 was not given the [MEDICATION NAME] and [MEDICATION NAME] medications on 5/18/18, as ordered. On 9/06/18 03:23 PM, an interview was conducted with Employee Identifier (EI) #7, LPN. EI #7 was asked what was the facility policy for ensuring medications were available for newly admitted residents, as ordered. EI #7 replied, medications were ordered form backup, but she was not aware backup did not provide the medication before she left for that day. EI #7 was asked why was the [MEDICATION NAME] not pulled from the E-Kit. EI #7 replied, she normally gave them a form. EI #7 was asked what was the process. EI #7 replied, the staff needed a prescription from the Medical Doctor for the medication and the amount. If it was in the stat box then the staff was to send a face sheet for the ebox medications to the pharmacy, or the on call pharmacy, if after hours. Then they either (pharmacy) called or faxed back a code to the nurse to access the ekit. EI #7 was asked what should a nurse do if the medication did not come in by the time it was due to be given to a resident. EI #7 replied, the nurse should call the doctor or the pharmacy. EI #7 was asked why was it important to make sure residents had medications as ordered. EI #7 replied, the medication was necessary if the doctor ordered it. On 9/06/18 at 3:37 PM, an interview was conducted with EI #1, DON. EI #1 was asked why did RI #196 not receive the scheduled and ordered [MEDICATION NAME] and [MEDICATION NAME] on 5/18/18 at 9:00 PM, as ordered. EI #1 replied, she assumed it was not received from the pharmacy, but she was not sure. EI #1 was asked what should have been done. EI #1 replied, the nurse should have called the doctor. EI #1 was asked if the doctor was called. EI #1 replied, she did not know if the doctor was called. If he had been, it would have been documented, but she did not see any documentation indicating the doctor had been notified.

Based on observation, interview and review of facility policy, Standard Precautions, the facility failed to ensure: 1. A Certified Nursing Assistant (CNA) did not deliver trays to residents on the rehab unit without washing or sanitizing her hands between residents. This was observed on 9/4/18 and affected one of three units, and 2. A Licensed Practical Nurse (LPN) did not remove gloves from her uniform pocket to administer the [MEDICATION NAME] breathing treatment and did not place the vial of the medication in her name tag pouch while preparing Resident Identifier (RI) #92 and the nebulizer machine. This was observed on 9/5/18 and affected one of five nurses observed for medication pass. Findings Include: A review of a facility policy titled, Standard Precautions, with an effective date of 11/16 16 revealed, Purpose: It is the intent of this facility that .2) Standard Precautions will be used for all residents/guests. 1. On 9/04/18 at 5:25 PM, the surveyor observed Employee Identifier (EI) #2, CNA, entering into Room Locator (RI) #3 with the supper meal tray. EI #2 touched personal items on the resident's over bed table. EI #2 left the room and got another tray from the delivery cart and entered RL # 2. EI #2 did not wash or sanitize her hands between resident rooms. EI #2 left RL # 2 and got another tray from the delivery cart and entered RL #1, again without washing or sanitizing her hands. On 9/04/18 at 5:38, PM the surveyor conducted an interview with EI #2. EI #2 was asked what was the policy on hand washing while delivering trays. EI #2 replied, they should wash their hands, deliver a tray, then wash their hands and deliver the next resident tray. EI #2 was asked if she washed her hands. EI #2 replied, no. EI #2 was asked what was the risk in not washing hands between residents while delivering meal trays. EI #2 replied, could have touched something in one resident room then transferred those germs to the next resident room. 2. RI #92 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of RI #92's (MONTH) Physician order [REDACTED]. 5MG (milligram) /3 ML (milliliters) SOLN (solution)ADMINISTER 1 VIAL PER NEBULIZER 4 TIMES DAILY FOR CONGESTION . On 9/05/18 at 11:20 AM, EI #3, LPN was observed administering [MEDICATION NAME] medication to RI #92. EI #3 removed the [MEDICATION NAME] from the medication cart and placed the container inside her name tag pouch. EI #3 washed her hands, placed a barrier on the over bed table, then removed gloves from her pocket. EI #3 removed the medication from the name tag pouch and poured it into the medication cup on the nebulizer machine and started the treatment. On 9/05/18 at 11:45 AM, an interview was conducted with EI #3, LPN. EI #3 was asked what was the policy on where to get gloves during the medication pass. EI #3 replied, she should get them from a glove box on the medication cart or in resident rooms. EI #3 was asked where should the medication be placed while preparing to administer it. EI #3 replied, in her hand or on the table on a barrier. EI #3 was asked where did she place the medication before she administered it. EI #3 replied, in her name tag pouch. EI #3 was asked where did she get the gloves from. EI #3 replied, from her uniform pocket. EI #3 was asked what was the harm in using gloves from her uniform pocket. EI #3 replied, contamination because her uniform pocket was not clean. EI #3 was asked what was the harm in placing medication in her name tag pouch. EI #3 replied, possible contamination. On 9/06/18 at 10:58 AM, an interview was conducted with EI #1, Director of Nursing. EI #1 was asked what was the policy on hand washing while passing trays on units. EI #1 replied, to sanitize between each tray and after passing three trays they are to wash their hands with soap and water. EI #1 was asked when should staff deliver trays without washing or sanitizing hands between residents. EI #1 replied, they should never do that. EI #1 was asked what was the harm in staff not washing hands or sanitizing between residents while delivering trays. EI #1 replied, passing germs. EI #1 was asked what was the policy on where licensed staff should place a container of [MEDICATION NAME] while preparing the area before administering it to a resident. EI #1 replied, on a clean surface. EI #1 was asked when should licensed staff place the container of [MEDICATION NAME] inside her name tag pouch. EI #1 replied, they should not do that. EI #1 was asked what was the harm in placing a medication inside a name tag pouch. EI #1 replied, transmission of germs. EI #1 was asked where was staff to get gloves from that was required to be used during the medication pass. EI #1 replied, from a glove box. EI #1 was asked when should staff use gloves from their uniform pocket. EI #1 replied, never. EI #1 was asked would a uniform pocket be clean or dirty. EI #1 replied, dirty. EI #1 was asked what was the harm in using gloves removed from the uniform pocket for medication administration. EI #1 replied, transmission of germs.

Based on observation and interview, facility failed to ensure nurse staff posting was posted on two of three days of the survey. This had the potential to affected 141 of 141 residents. Findings Include On 9/04/18 at 5:30 PM, the Nurse Staff Posting was observed not posted for the evening shift. The day shift was the only posted shift on the sheet. On 9/06/18 at 7:26 AM, the Nurse Staff Posting was observed. Staffing was posted from 9/5/18, no staffing posted for the 9/6/18 day shift. On 9/06/18 at 7:30 AM, Nurse Staff Posting was posted. On 9/06/18 at 3:43 PM, an interview was conducted with Employee Identifier (EI) #1, Director of Nursing. EI #1 was informed of the 9/4 evening staffing not observed posted by the surveyors upon entering the facility on 5:30 PM. EI #1 was asked why the staff posting was not posted by that time. EI #1 replied, she did not know why. EI #1 was asked if the nurse staff posting should have been posted. EI #1 replied, yes. EI #1 was asked why was staffing not posted for the day shift on 9/6 by 7:26 AM. EI #1 replied, she did not know why. EI #1 was asked if the nurse staff posting should have been posted by that time. EI #1 replied, yes. EI #1 was asked why was it important to post the daily staffing for each shift in a timely manner. EI #1 replied, for residents, visitors and any one who may need to know the staffing.

Based on observation and interview, the facility failed to ensure two of three dumpster doors were closed, plastic bags were not hanging from two of the dumpster's and gloves and a milk carton were not laying on the ground outside of the dumpster's. The facility further failed to ensure the dumpster's were well maintained and did not have a broken door. This was observed on 9/4/18 and had the potential to affect 141 of 141 residents. Findings Include: On 9/04/18 at 5:15 PM, the surveyor observed three dumpster's. Two of the three dumpster's had doors that were not closed. Plastic bags were also observed hanging out of these two dumpster's, latex gloves were lying on the ground outside of the one dumpster, with the open door and a milk carton was lying on the ground. On 9/04/18 at 5:45 PM, the surveyor observed, with the Nutrition Manager/Supervisor, Employee Identifier (EI) #6, the dumpster's and the grounds around them. The milk carton was no longer on the ground, but the latex gloves were still on the ground. Two plastic bags were hanging out of side of dumpster's with the two doors still opened. EI #6 told the surveyor that the one door was broken. On 9/06/18 at 2:43 PM, during an interview with EI #6, she was asked if she recalled Tuesday evening after the initial tour of the kitchen going outside to view the dumpster and the grease container. EI #6 replied, yes. EI #6 was asked what was noticed. EI #6 replied, one of the dumpster doors was opened, it was broken. EI #6 was asked of the three dumpster's, how many had opened sliding doors. EI #6 replied, just one, jammed up the very back one. EI #6 was asked how many of the three had plastic bags hanging outside of them. EI #6 replied, two. EI #6 was what was lying on the concrete ground in front of the last of the three dumpster's. EI #6 replied, latex gloves. EI #6 was asked who was responsible for maintaining the area/grounds around the dumpster's. EI #6 replied, maintenance. EI #6 was asked who was responsible for closing the dumpster doors. EI #6 replied, whoever opened it. EI #6 was asked what was the risks of not keeping the doors to dumpster closed, of having used latex gloves on the ground and plastic garbage bags hanging outside of dumpster's. EI #6 replied, animals can get inside and it could draw flies.

Based on a review of the FDA (Food and Drug Administration) Code titled, Outside Receptacles and Cleaning Receptacles, observations and interviews, the facility failed to ensure the grease refuse container was clean and free of an odor and a buildup of a grease-like substance on the outside of the container. This was observed three of three days of the survey and had the potential to affect all residents who reside at the facility. Findings Include: A review of a document titled Food Code U.S. Public Health Service FDA 2013, with no date revealed the following: .5-501.15 Outside Receptacles. (A) Receptacles and waste handling units for REFUSE .outside the FOOD ESTABLISHMENT shall .have tight-fitting lids . .5-501.116 Cleaning Receptacles. . (B) Soiled receptacles and waste handling units for REFUSE .be cleaned at a frequency necessary to prevent them from developing a buildup .becoming attractants for insects and rodents . On 08/22/2017, 08/23/2017 and 08/24/2017, observations were made of the grease refuse container with a buildup of a grease-like substance on the outside of the container as well as a strong odor. Further observation was made on 08/22/2017 of a potholder visibly hanging from the inside of the grease refuse container. On 08/24/2017 at 8:40 a.m., an interview was conducted with EI (Employee Identifier) #2, Assistant Dietary Manager. EI #2 was asked who was responsible for ensuring the oil/grease refuse container was cleaned. EI #2 said maintenance. EI #2 was asked what was hanging out of the top opening of the oil/grease refuse container. EI #2 said a potholder. EI #2 was asked why the potholder was left in the top opening of the container. EI #2 explained so employees could raise the lid easier. EI #2 was asked what was on the oil/grease refuse container. EI #2 replied, It look like old grease. EI #2 was asked what was the facility's policy on how to clean/maintain the oil/grease container. EI #2 replied, I have no clue, honey. EI #2 was asked when was the last time the oil/grease refuse container was cleaned. EI #2 replied, I don't know. EI #2 was asked what was the potential harm for the oil/grease container not being cleaned. EI #2 said it could draw flies. On 08/24/2017 at 10:50 a.m., an interview was conducted with EI #9, Maintenance Supervisor. EI #9 was asked who was responsible for ensuring the oil/grease refuse container was cleaned. EI #9 said Dietary. EI #9 was asked what was the facility's policy on how to clean/maintain the oil/grease refuse container. EI #9 explained he had not read the policy. EI #9 further explained he did not know if the facility had a policy but he would look it up.

Based on observations, interviews and review of facility policies, Food Receipt and Storage, Sanitation Principles, Employee Personal Health and Hygiene, Hand-washing Guidelines and Cleaning of Miscellaneous Equipment and Utensils, the facility failed to ensure: 1) staff hair was completely inside of hair restraints, 2) items in the reach in cooler were properly labeled with open and use by date, 3) staff washed their hands when entering the kitchen and when picking up an item off the floor, 4) spoons, knife, and plates did not have water spots on them and 5) a built-up fork and bowl did not have food particles on them. This had the potential to affect 147 of 150 residents who received meals from the kitchen. Findings Include: 1) A review of a facility policy titled, Employee Personal Health and Hygiene with an effective date April 29, 2015 revealed: .PROCESS: . d. Hairnets- hair must be neatly styled and completely covered with an appropriate hair covering . On 8/22/2017 at 3:08 p.m., the surveyor observed EI (Employee Identifier) #2, EI #5, EI #4, EI #6, and EI #7 with their hair not properly restrained underneath the hairnet. EI #2's hair was hanging down in the back, on the sides and in the front. EI# 5's hair was loose in the back and on the sides. EI #4's hair was down in the front, back and sides. EI #6's hair was down in the back and on the sides. EI #7's hair was out on the sides and in the front. On 08/24/2017 at 8:52 a.m., an interview was conducted with EI #2, Assistant Dietary Manager. EI #2 was asked what was the facility policy on wearing hair restraints while in the kitchen. EI #2 replied, she was supposed to have all of her hair covered up at all times. EI #2 was asked why were hair restraints not used properly by five staff members in the kitchen. EI #2 replied, she did not know. EI #2 was asked, what was the facility policy on using hair restraints in the kitchen. EI #2 replied, she did not know. EI #2 was asked what was the potential harm for not wearing hair restraints properly in the kitchen. EI #2 replied, hair can get in the food. EI #2 was asked should all hair be enclosed in the hairnet. EI #2 replied, yes. On 08/24/2017 at 9:05 a.m., an interview was conducted with EI #3, Cook. EI #3 was asked what was the facility policy on wearing hair restraints while in the kitchen. EI #3 replied, hair was supposed to be completely covered. EI #3 was asked why was the hair restraint not used properly. EI #3 replied, it was used properly as far as she could tell. EI #3 was asked what was the potential harm for not using hair restraints properly in the kitchen. EI #3 replied, cross contamination and getting hair in the food. On 08/24/2017 at 9:09 a.m., an interview was conducted with EI #4, Relief Cook. EI #4 was asked what was the facility policy on wearing hair restraints while in the kitchen. EI #4 replied, all hair had to be covered. EI #4 was asked why was the hair restraint not used properly by her. EI # 4 replied, because sometimes it pushed backwards, and she had to adjust it. EI #4 was asked what was the facility policy on using hair restraints in the kitchen. EI #4 replied, if she was in the kitchen, she had to have a hairnet on and her hair had to be fully covered. EI #4 was asked was her hair fully covered then. EI #4 replied, there may be a string or two. EI #4 stated she may have to get a second net. EI #4 was asked what was the potential harm for not wearing hair restraints properly in the kitchen. EI #4 replied, hair could fall out and contaminate the food. On 08/24/2017 at 1:20 p.m., an interview was conducted with EI #5, Relief Cook for second shift. EI #5 was asked what was the facility policy on wearing hair restraints while in the kitchen. EI #5 replied, all hair was to be underneath the hair net. EI #5 was asked what was the facility policy on using hair restraints in the kitchen. EI #5 replied, it should be put in a bun and then tucked underneath the hair net. EI #5 was asked what was the potential harm for not wearing hair restraints properly in the kitchen. EI #5 replied, hair in the food, which was not safe. EI #5 stated that residents could choke on hair. EI #5 was asked should all her hair be enclosed in the hair net. EI #5 replied, it was supposed to be. On 08/24/2017 at 1:52 p.m., an interview was conducted with EI #6, Dietary Aide. EI #6 was asked what was the facility policy on wearing hair restraints while in the kitchen. EI #6 replied, always have their hair net on and hair covered. EI #6 was asked what was the facility policy on using hair restraints in the kitchen. EI #6 replied, to always have them on before entering the food preparation area. EI #6 was asked what was the potential harm for not wearing hair restraints properly in the kitchen. EI #6 replied, hair can fall into the food, or utensils or anything that will come into contact with the food. EI #6 was asked was all of her hair properly restrained now. EI #6 replied, as good as she could get it. On 08/24/2017 at 1:58 p.m., an interview was conducted with EI #7, Assistant Cook. EI #7 was asked what was the facility policy on wearing hair restraints while in the kitchen. EI #7 replied, they were supposed to wear the hair net all the way over their ears and their neck. EI #7 stated nothing was supposed to be hanging out. EI #7 was asked what was the facility policy on using hair restraints in the kitchen. EI #7 replied, always make sure all of their hair was under the hair net. EI #7 was asked what was the potential harm for not wearing hair restraints properly in the kitchen. EI #7 replied, hair can get in the food. 2) A review of a facility policy titled, Food Receipts and Storage with an effective date of August 21, 2013 revealed: .PROCESS: .II Storage of Foods: .k. Open food items should be covered, labeled, and dated; . On 8/22/2017 at 3:00 p.m., the surveyor observed in the reach in cooler, Turkey Bologna dated 8/8/2017, with no use by date. There was two large containers of peanut butter with no use by date. On 8/23/2017 at 8:48 a.m., the surveyor conducted an interview with EI #2, Assistant Dietary Manager. EI #2 was asked who was responsible for making sure items in the reach in cooler had an open date and use by date. EI #2 replied, whoever used it. EI #2 was asked what items in the reach in cooler did not have a use by date. EI #2 replied, the peanut butter and jelly and the [MEDICAL TREATMENT] turkey meat. EI #2 was asked why was the items not labeled. EI #2 replied, she did not know. EI #2 was asked what did the facility policy say about labeling food items placed in the reach in cooler. EI #2 replied, she did not know. EI #2 was asked what was the potential harm for not labeling food items. EI #2 replied, they would not know how long the food items was in the cooler. 3) A review of a facility policy titled, Hand-washing Guidelines with an effective date of February 1, 2002 revealed: PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses.PROCESS: I. Frequency of Hand-Washing: Hands should be washed in the following situations: Every time an employee enters the kitchen; .After hands have touched anything unsanitary .dirty . On 8/23/2017 at 9:36 a.m., the surveyors and EI #1, Dietician, returned to the kitchen. The surveyors washed their hands but EI #1 did not. EI #1 stood in the area where the surveyors were. She placed both of her hands in her pockets. She touched a saucer and the top of an ice cream cup. On 8/23/2017 at at 9:40 a.m., the surveyor observed EI #3, Cook, mixing cornmeal. She dropped the milk carton on the floor and picked it up and placed in the trash. She did not pull her gloves off or wash her hands. She continued to mix the cornmeal. On 8/24/2017 at 9:00 a.m., the surveyor conducted an interview with EI #3. EI #3 was asked what food product did she prepare on 8/23/2017 that was close to the trash can. EI #3 replied, cornbread. EI #3 was asked did she wash her hands after picking up the milk carton from the floor. EI #3 replied, no. EI #3 was asked did she change her gloves. EI #3 replied, no. EI #3 was asked what should she do after she picked something up off the floor and put it into the trash. EI #3 replied, take my gloves off, wash my hands and put on new pair of gloves. EI #3 was asked what was the potential harm when she picked up something off the floor and she did not wash her hands. EI #3 replied, cross contamination. On 8/24/2017 at 9:24 a.m., the surveyor conducted an interview with EI #1. EI #1 was asked when entering the kitchen from the outside, what should she do. EI #1 replied, she guess she should wash her hands. EI #1 was asked why should she wash her hands when entering the kitchen. EI #1 replied, potential for contamination. EI #1 was asked what did the facility policy say on handwashing. EI #1 replied, the policy said to wash her hands. EI #1 was asked what was the potential harm for not washing her hands while in the kitchen. EI #1 replied, potential for contamination. 4) A review of a policy titled, Cleaning of Miscellaneous Equipment and Utensils with an effective date of March 17, 2016 revealed: .8. Dishes: .Place dishes in dish rack; avoid overloading and nesting . On 8/23/2017 at 8:23 a.m., the surveyor observed dietary staff washing dishes. EI #5, Relief Cook, was putting plates in the warmer with water in them. The surveyor observed a total of five plates with water in them. On 8/23/2017 at 11:20 a.m., the surveyor observed three spoons, and one knife with water on them. On 8/24/2017 at 9:30 a.m., the surveyor conducted an interview with EI #1. EI #1 was asked how should utensils, saucers and plates dry. EI #1 replied, air dry. EI #1 was asked who was responsible for making sure utensils, bowls and plates were dry prior to placing them on the tray line. EI #1 replied, the employees. EI #1 was asked what did she see on three spoons and one knife and plates. EI #1 replied, water. EI #1 was asked what did the facility policy say about drying utensils, bowls and plates. EI #1 replied, they should air dry. EI #1 was asked what was the potential harm in serving food to residents on wet plates and wet utensils. EI #1 replied, potential for contamination. On 8/24/2017 at 9:38 a.m., an interview was conducted with EI #2. EI #2 was asked how were utensils and plates supposed to dry. EI #2 replied, air dry. EI #2 was asked what did the facility policy say regarding drying utensils and plates. EI #2 replied, they must air dry. EI #2 was asked what was the potential harm in serving food to residents on wet plates and using wet utensils. EI #2 replied, cross contamination. EI #2 was asked was there water in some of the plates. EI #2 replied, there was. EI #2 was asked were the plates stacked on top of each other wet. EI #2 replied, they were. On 8/24/2017 at 1:15 p.m., the surveyor conducted an interview with EI #5. EI #5 was asked how were utensils and plates suppose to dry. EI #5 replied, air dry. EI #5 was asked what did the facility policy say about drying utensils and plates. EI #5 replied, most things that we wash must be air dried. EI #5 was asked was there water in plates. EI #5 replied, yes. 5) A review of facility policy titled, Cleaning of Miscellaneous Equipment and Utensils, with an effective date of March 17, 2016, revealed: . Dishes: unload . food . by scraping off food from plates and bowls On 08/23/2017 at 11:20 a.m., the surveyor observed one built-up fork on the tray line with a food like particle on it. On 08/23/ 2017 at 11:45 a.m., the surveyor observed one bowl on the tray line with food like particles on it. On 08/24/2017 at 9:30 a.m., the surveyor conducted an interview with EI #1 Registered Dietician. EI #1 was asked what did she see on one built-up fork on the tray line. EI #1 replied, a particle of something. On 08/24/2017 at 2:12 p.m., the surveyor conducted an interview with EI #4 relief cook. EI #4 was asked what did she see in a bowl that was put to the side. EI #4 replied, two orange specks. EI #4 was asked why was it there. EI #4 replied, the bowl was not scrubbed clean. EI #4 was asked who was responsible for making sure dishes are clean. EI #4 replied, technically everybody, the dishwasher and the catcher. EI #4 was asked what was the facility policy on clean utensils and dishware. EI #4 replied, it needed to be cleaned and sanitized. EI #4 was asked what was the potential harm when utensils and dishes are dirty and given to the residents. EI #4 replied, in essence it was contaminated.

Based on observation and interview, the facility failed to ensure Room Locators (RL)# 1 through 10 were free of missing caulk, loose and broken tiles and scraped, chipped flaking paint on walls. This affected nine rooms and the hallway of Unit 3; two rooms on Unit 1, four rooms on Unit 2, three rooms on Unit 3 and the hallway of Unit 3. These observations were made on two of the three days of the survey. Findings Include: On 8/22/17 at 3:35 p.m., and on 8/23/17 at 9:00 a.m., RL #1's bathroom was noted with missing caulk and loose tiles from the wall. On 8/22/17 at 2:53 p.m., and on 8/23/17 at 9:05 a.m., RL #2 was observed with a large area of chipped and flaking paint on the wall beside bed A. On 8/22/17 at 2:50 p.m., RL #3 was observed with chipped paint on the bathroom wall. On 8/22/17 at 2:57 p.m., RL #4 was observed with chipped paint on the lower walls. On 8/22/17 at 3:10 p.m., an observation was made of RL #5 with chipped paint on the walls in the room. On 8/22/17 at 3:10 p.m., an observation was made of RL #6 with chipped and flaking paint at the bottom of the wall. On 8/22/17 at 3:00 p.m. and on 8/23/17 at 11:00 a.m., RL #7 was observed to have two drain covers in the hallway with turned up edges. On 8/22/17 at 3:25 p.m., RL #8 was observed with chipped paint on the wall at the headboard. On 8/22/17 at 3:36 p.m., RL #9 was observed with scrapes on the wall. On 8/22/17 at 3:40 p.m., RL #10 was observed with a broken floor tile at the bathroom door. On 8/24/17 from 10:45 a.m., until 11:10 a.m., a walk through observation and interview was conducted with Employee Identifier EI #9, Maintenance and Environmental Services Supervisor. EI #9 was asked what he observed at RL #1. EI #9 replied, loose tiles. EI #9 was asked what was the harm. EI #9 replied, no harm just did not look nice. EI #9 was asked what he saw at RL #2. EI #9 replied, chipped flaking paint on wall next to the bed. EI #9 was asked what the harm was. EI #9 replied, flaking paint could get on the resident and it was unsightly. EI #9 was asked what he saw at RL #3, 4, 5 and 6. EI #9 replied, chipped paint. EI #9 was asked what was the harm in chipped paint. EI #9 replied, it was an eye sore. EI #9 was asked who was responsible for chipped paint; EI #9 replied, maintenance. EI # 9 was asked what he observed at RL #7. EI #9 replied, upturned ends on two drain covers. EI #9 was asked what the harm was with upturned covers. EI #9 replied, could be a trip hazard. EI #9 was asked what he observed at RL #8. EI #9 replied, scraped paint behind the headboard. EI #9 was asked what he observed at RL #9. EI #9 replied, scraped missing paint. EI # 9 was asked what he observed at RL #10. EI #9 replied, a broken tile at the bathroom door. EI #9 was asked what was the harm in a broken tile. EI #9 replied no harm it was an eye sore. EI #9 was asked what the harm was with scraped chipped paint. EI #9 replied, it was an eye sore.

Based on observation and interview the facility failed to ensure laundry staff wore an apron on the dirty side of the laundry room while loading dirty laundry into the washer. This had the potential to affect 145 of 150 residents whose clothes were laundered by the facility. Findings Include: On 8/23/2017 at 10:40 a.m., the surveyor observed EI #8, Laundry Aide putting clothes in the washer on the dirty side with gloves on and no apron. As she put the clothes in the washer, some of the clothes were touching her clothes. On 08/23/2017 at 12:55 p.m., an interview was conducted with EI #8. EI #8 was asked what PPE (personal protective equipment) did she have on when putting dirty clothes in the washer. EI #8 replied, gloves on and no apron on. EI #8 was asked when should she wear PPE in the laundry room. EI #8 replied, back there in the wash room. EI #8 was asked why she did not have on an apron on the dirty side of the laundry room. EI #8 replied, she just did not have one on. EI #8 was asked why was it important to wear an apron on the dirty side. EI #8 replied, protect her from any kind of disease. EI #8 was asked who was responsible for training laundry staff. EI #8 replied, EI #9. EI #8 was asked what did the facility policy say when to wear an apron in the laundry room. EI #8 replied, when it is time for me to get the dirty linen out to put in the washer. EI #8 was asked what was the potential harm in not wearing an apron when putting dirty clothes in the washer. EI #8 replied, if I don't wear any gloves or apron the scent would get on my clothes. EI #8 was asked what was the potential harm when she did not wear PPE on the dirty side and went to the clean side to fold clothes. EI #8 replied, contaminate the fresh linen. On 8/23/2017 at 5:24 p.m., an interview was conducted with EI #9, Environmental Supervisor. EI #9 was asked when should staff wear PPE in the laundry room. EI #9 replied, on the dirty side they should wear their gloves and apron. EI #9 was asked why was it important to wear PPE on the dirty side of the laundry room. EI #9 replied, cross contamination. EI #9 was asked what did the facility policy say on when to wear PPE in the laundry room. EI #9 said he would have to look it up. EI #9 was asked what was the potential harm when staff did not wear PPE on the dirty side and go on the clean side to fold clothes. EI #9 replied, cross contamination. EI #9 was asked when was the last training held for staff. EI #9 replied, he did not know he would have to look at the records. EI #9 was asked did the facility provide gowns for staff to use. EI #9 replied, yes ma'am. EI #9 replied, one gown on the dirty side for the morning and evening shift worker.

Based on observation, interviews and record review, the facility failed to ensure Resident Identifier (RI) #25's and RI #26's physician's orders were followed for the provision of wound care. This affected two of three sampled residents reviewed for wound care. Findings include: Chapter 23 titled Legal Implications in Nursing Practice page 305 of Fundamentals of Nursing Eighth Edition with a copyright date of 2013, documented Health Care Providers' Orders . Nurses follow health car providers' orders unless they believe the orders are in error or harm patients . 1) On 8/25/2016, the State Agency received a complaint which indicated RI #25's hip incision dressing was not changed as ordered by the physician. The dressing was supposed to be changed daily. On 8/21/2016, the complainant visited the resident and found the hip incision dressing dated 8/19/2016. Resident Identifier (RI) #25 was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. RI #25's Physician Orders dated August 2016 documented the following: . 8/11/16 . LEFT HIP SX (surgery) SITE . CLEANSE WITH WC (wound cleanser). COVER WITH [MEDICATION NAME] PAD DAILY X 90 DAYS . RI #25's Minimum Data Set (MDS) with an assessment reference date of 8/18/2016 indicated the resident had a surgical wound. RI #25's Treatment Administration Record (TAR) dated August 2016 indicated Employee Identifier (EI) #13, a Licensed Practical Nurse (LPN) changed RI #25's left hip surgical dressing on 8/20/2016. In an interview on 8/29/2016 at 2:00 PM, EI #13, the LPN was asked if the dressing for RI #25's wound was changed on 8/20/2016. EI # 13 replied no. When asked, why the dressing was not changed, EI #13 replied it was a mistake. EI #13's CONFERENCE REPORT dated 8/24/2016 documented . NATURE OF VIOLATION: Above employee (EI #13) signed off treatments before completing the treatment. CORRECTIVE ACTION NECESSARY: Above employee will be more observant and careful with documentation and ensure the treatment has been completed before signing that it has been done. ACTION BEING TAKEN: One on one education . The One on One In-Service Education & Training Report dated 8/24/2016, indicated EI #13 received one on one education from EI #10 (Registered Nurse Unit Manager). The training report documented . (1) You (EI #13) signed off that you changed the dressing on 2 residents on 8/20/16 these dressing was not changed. (2) Do not sign off treatment orders until the treatment is completed. During an interview on 8/30/2016 at 11:30 AM, EI #10, the RN Unit Manger stated the LPN (EI #13) told her she (EI #13) did not complete the wound treatment for [REDACTED]. 2) RI #26 was readmitted to the facility on [DATE]. RI #26 has a medical history to include: unspecified [MEDICAL CONDITION]. RI #26's Admission Minimum Data Set (MDS) with an assessment reference date of 7/4/2016, indicated the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) of 13. The MDS revealed RI #26 had three venous and arterial ulcers present. RI # 26's physician's orders dated 7/15/2016, documented . STASIS ULCER LEFT LOWER LEG. CLEANSE WITH 0.9% NORMAL SALINE. APPLY SANTYL OINTMENT. COVER WITH [MEDICATION NAME] FOAM DSG (dressing) QD (every day) X 90 DAYS . Stop Date 9/28/16 . STASIS ULCER LEFT LOWER LATERAL LEG. CLEANSE WITH 0.9% NORMAL SALINE. APPLY SANTYL OINTMENT. COVER WITH [MEDICATION NAME] FOAM DSG QD X 90 DAYS . Stop Date 9/28/16 . RI #26's Treatment Administration Record (TAR) for July 2016 indicated RI #26's dressing was changed every other day beginning on 7/15/2016. According to the TAR, RI #26's dressing was not changed on 7/16/2016, 7/18/2016, 7/20/2016, 7/22/2016, 7/24/2016, 7/26/2016, 7/28/2016 and 7/30/2016. RI #26's local hospital wound care report dated 7/26/2016 documented . It is very important to follow your physician's recommendations regarding dressing changes. You may reinforce the dressings or change the outer dressings as often as needed. The primary dressing should be changed every: - day . RI #26's Treatment Administration Record (TAR) for August 2016 indicated RI #26's dressing was changed every other day beginning on 8/2/2016. According to the TAR, RI #26's dressing was not changed on 8/1/2016, 8/3/2016, 8/5/2016, 8/7/2016, 8/9/2016, 8/11/2016, 8/13/2016, 8/15/2016, 8/17/2016, 8/19/2016, 8/21/2016, 8/23/2016, 8/25/2016, 8/27/2016, 8/29/2016, 8/30/2016 and 8/31/2016. RI #26's local hospital wound care report dated 8/23/2016 documented . It is very important to follow your physician's recommendations regarding dressing changes. You may reinforce the dressings or change the outer dressings as often as needed. The primary dressing should be changed every: - day . During the initial tour of the facility on 8/28/2016 at 7:02 PM, RI #26 was observed in bed. The dressing to the resident's left lower leg was soiled with a black substance and dated 8/26/2016. RI #26 was asked, how often the nurses changed the dressing. RI #26 replied, they are supposed to change it every day. RI #26 further stated a nurse told him/her earlier that she (nurse) would come back and change it; however, it still has not been changed. During an interview on 8/30/2016 at 11:10 AM, Employee Identifier (EI) #10, the Registered Nurse (RN) Unit Manager was asked when should RI #26's dressing be changed. EI #10 stated, RI #26's dressing should be changed every day until 9/28/2016. When asked, how often has RI #26's been changed, EI #10 replied, RI #26's dressing has been changed every other day. EI #10 was asked, if the physician's order was followed and she said No. When asked, what the potential harm could be for not following the physician's order, EI #10 replied, Great harm (RI #26) could have infection and (RI) #26 is already facing amputation. In an interview on 8/30/2016 at 2:55 PM, RI #26's primary physician, EI #9 stated he had been treating RI #26 for more than a year. When asked, if he was aware the facility nursing staff was changing RI #26's dressing every other day and not every day as ordered, EI #9 stated he was not aware. EI #9 stated he had talked with the wound nurses and other staff at the facility; however, they didn't listen. EI #9 stated RI #26's dressing should have been changed every day. When asked, if the facility followed the physician's orders, EI #9 replied, No. During a telephone interview on 8/30/2016 at 4:41 PM, EI #11, the RN Wound Care Nurse was asked, if the physician's order to change RI #26's dressing every day was followed and she said no. In an interview on 8/30/2016 at 6:07 PM, after EI #14, the Director of Nursing, reviewed RI #26's physician's order and TAR, she acknowledged the nursing staff had only changed RI #26's dressing every other day and not every day as ordered. This deficiency was written as a result of the investigation of complaint/report number AL 626.

Based on observation, interviews and record reviews, the facility failed to provide treatment to Resident Identifier (RI) #25's left hip surgical site and RI #26's stasis ulcer on the left lower leg as ordered by the physician. These deficient practices affected RI #25 and RI #26, two of three sampled residents reviewed for wound care. Findings include: 1) On 8/25/2016, the State Agency received a complaint which indicated RI #25's hip incision dressing was not changed as ordered by the physician. The dressing was supposed to be changed daily. On 8/21/2016, the complainant visited the resident and found the hip incision dressing dated 8/19/2016. Resident Identifier (RI) #25 was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. RI #25's Physician Orders dated August 2016 documented the following: . 8/11/16 . LEFT HIP SX (surgery) SITE . CLEANSE WITH WC (wound cleanser). COVER WITH [MEDICATION NAME] PAD DAILY X 90 DAYS . RI #25's Minimum Data Set (MDS) with an assessment reference date of 8/18/2016 indicated the resident had a surgical wound. RI #25's Treatment Administration Record (TAR) dated August 2016 indicated Employee Identifier (EI) #13, a Licensed Practical Nurse (LPN) changed RI #25's left hip surgical dressing on 8/20/2016. In an interview on 8/29/2016 at 2:00 PM, EI #13, the LPN was asked if the dressing for RI #25's wound was changed on 8/20/2016. EI # 13 replied no. When asked, why the dressing was not changed, EI #13 replied it was a mistake. EI #13's CONFERENCE REPORT dated 8/24/2016 documented . NATURE OF VIOLATION: Above employee (EI #13) signed off treatments before completing the treatment. CORRECTIVE ACTION NECESSARY: Above employee will be more observant and careful with documentation and ensure the treatment has been completed before signing that it has been done. ACTION BEING TAKEN: One on one education . The One on One In-Service Education & Training Report dated 8/24/2016, indicated EI #13 received one on one education from EI #10 (Registered Nurse Unit Manager). The training report documented . (1) You (EI #13) signed off that you changed the dressing on 2 residents on 8/20/16 these dressing was not changed. (2) Do not sign off treatment orders until the treatment is completed. During an interview on 8/30/2016 at 11:30 AM, EI #10, the RN Unit Manger stated the LPN (EI #13) told her she (EI #13) did not complete the wound treatment for [REDACTED]. 2) RI #26 was readmitted to the facility on [DATE]. RI #26 has a medical history to include: unspecified [MEDICAL CONDITION]. RI #26's Admission Minimum Data Set (MDS) with an assessment reference date of 7/4/2016, indicated the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) of 13. The MDS revealed RI #26 had three venous and arterial ulcers present. RI # 26's physician's orders [REDACTED]. STASIS ULCER LEFT LOWER LEG. CLEANSE WITH 0.9% NORMAL SALINE. APPLY SANTYL OINTMENT. COVER WITH [MEDICATION NAME] FOAM DSG (dressing) QD (every day) X 90 DAYS . Stop Date 9/28/16 . STASIS ULCER LEFT LOWER LATERAL LEG. CLEANSE WITH 0.9% NORMAL SALINE. APPLY SANTYL OINTMENT. COVER WITH [MEDICATION NAME] FOAM DSG QD X 90 DAYS . Stop Date 9/28/16 . RI #26's Treatment Administration Record (TAR) for July 2016 indicated RI #26's dressing was changed every other day beginning on 7/15/2016. According to the TAR, RI #26's dressing was not changed on 7/16/2016, 7/18/2016, 7/20/2016, 7/22/2016, 7/24/2016, 7/26/2016, 7/28/2016 and 7/30/2016. RI #26's local hospital wound care report dated 7/26/2016 documented . It is very important to follow your physician's recommendations regarding dressing changes. You may reinforce the dressings or change the outer dressings as often as needed. The primary dressing should be changed every: - day . RI #26's Treatment Administration Record (TAR) for August 2016 indicated RI #26's dressing was changed every other day beginning on 8/2/2016. According to the TAR, RI #26's dressing was not changed on 8/1/2016, 8/3/2016, 8/5/2016, 8/7/2016, 8/9/2016, 8/11/2016, 8/13/2016, 8/15/2016, 8/17/2016, 8/19/2016, 8/21/2016, 8/23/2016, 8/25/2016, 8/27/2016, 8/29/2016, 8/30/2016 and 8/31/2016. RI #26's local hospital wound care report dated 8/23/2016 documented . It is very important to follow your physician's recommendations regarding dressing changes. You may reinforce the dressings or change the outer dressings as often as needed. The primary dressing should be changed every: - day . During the initial tour of the facility on 8/28/2016 at 7:02 PM, RI #26 was observed in bed. The dressing to the resident's left lower leg was soiled with a black substance and dated 8/26/2016. RI #26 was asked, how often the nurses changed the dressing. RI #26 replied, they are supposed to change it every day. RI #26 further stated a nurse told him/her earlier that she (nurse) would come back and change it; however, it still has not been changed. During an interview on 8/30/2016 at 11:10 AM, Employee Identifier (EI) #10, the Registered Nurse (RN) Unit Manager was asked when should RI #26's dressing be changed. EI #10 stated, RI #26's dressing should be changed every day until 9/28/2016. When asked, how often has RI #26's been changed, EI #10 replied, RI #26's dressing has been changed every other day. EI #10 was asked, if the physician's orders [REDACTED]. When asked, what the potential harm could be for not following the physician's orders [REDACTED].#26) could have infection and (RI) #26 is already facing amputation. In an interview on 8/30/2016 at 2:55 PM, RI #26's primary physician, EI #9 stated he had been treating RI #26 for more than a year. When asked, if he was aware the facility nursing staff was changing RI #26's dressing every other day and not every day as ordered, EI #9 stated he was not aware. EI #9 stated he had talked with the wound nurses and other staff at the facility; however, they didn't listen. EI #9 stated RI #26's dressing should have been changed every day. When asked, if the facility followed the physician's orders [REDACTED]. During a telephone interview on 8/30/2016 at 4:41 PM, EI #11, the RN Wound Care Nurse was asked, if the physician's orders [REDACTED].#26's dressing every day was followed and she said no. In an interview on 8/30/2016 at 6:07 PM, after EI #14, the Director of Nursing, reviewed RI #26's physician's orders [REDACTED].#26's dressing every other day and not every day as ordered. This deficiency was written as a result of the investigation of complaint/report number AL 626.

Based on observation, interviews and record review, the facility failed to ensure Employee Identifier (EI) #13, a Licensed Practical Nurse (LPN) did not document the completion of Resident Identifier (RI) #25's wound care before it was done. The facility further failed to ensure RI #26's physician order [REDACTED].#25 and RI #26, two of three sampled residents reviewed for wound care. Findings include: The facility's policy titled Charting and Documentation Guidelines (NM.IV-12) effective 10/1/2010, documented PURPOSE: Documentation in medical records of residents, by the interdisciplinary team, should provide: *Communication of the resident's care, treatment, response to the care, signs, symptoms and progress of the resident to providers of care *Assistance to the physician in prescribing medications and treatments *Assistance to the interdisciplinary team in the development of a plan of care *A legal record that protects the resident, physician, nurse and facility *A source to support charges to the resident for services rendered . 1) On 8/25/2016, the State Agency received a complaint which indicated RI #25's hip incision dressing was not changed as ordered by the physician. The dressing was supposed to be changed daily. On 8/21/2016, the complainant visited the resident and found the hip incision dressing dated 8/19/2016. Resident Identifier (RI) #25 was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. RI #25's Physician Orders dated August 2016 documented the following: . 8/11/16 . LEFT HIP SX (surgery) SITE . CLEANSE WITH WC (wound cleanser). COVER WITH [MEDICATION NAME] PAD DAILY X 90 DAYS . RI #25's Minimum Data Set (MDS) with an assessment reference date of 8/18/2016 indicated the resident had a surgical wound. RI #25's Treatment Administration Record (TAR) dated August 2016 indicated Employee Identifier (EI) #13, a Licensed Practical Nurse (LPN) changed RI #25's left hip surgical dressing on 8/20/2016. In an interview on 8/29/2016 at 2:00 PM, EI #13, the LPN was asked if the dressing for RI #25's wound was changed on 8/20/2016. EI # 13 replied no. When asked, why the dressing was not changed, EI #13 replied it was a mistake. EI # 13 explained that after it was brought to her attention by RI #25's daughter, RI #25's dressing was changed. EI #13's CONFERENCE REPORT dated 8/24/2016 documented . NATURE OF VIOLATION: Above employee (EI #13) signed off treatments before completing the treatment. CORRECTIVE ACTION NECESSARY: Above employee will be more observant and careful with documentation and ensure the treatment has been completed before signing that it has been done. ACTION BEING TAKEN: One on one education . The One on One In-Service Education & Training Report dated 8/24/2016, indicated EI #13 received one on one education from EI #10 (Registered Nurse Unit Manager). The training report documented . (1) You (EI #13) signed off that you changed the dressing on 2 residents on 8/20/16 these dressing was not changed. (2) Do not sign off treatment orders until the treatment is completed. During an interview on 8/30/2016 at 11:30 AM, EI #10, the RN Unit Manger stated the LPN (EI #13) told her she (EI #13) did not complete the wound treatment for [REDACTED]. In an interview on 8/30/2016 at 6:07 PM, EI #14, the Director of Nursing (DON) was asked if the TAR showing RI #25's wound treatment on 8/20/2016 as completed was correct. EI #14 replied it was checked that it was done; however, it was reported as not done. 2) RI #26 was readmitted to the facility on [DATE]. RI #26 has a medical history to include: unspecified [MEDICAL CONDITION]. RI #26's Admission Minimum Data Set with an assessment reference date of 7/4/2016, revealed RI #26 had three venous and arterial ulcers present. RI # 26's Physician Orders for August 2016, documented . 7/15/16 . STASIS ULCER LEFT LOWER LEG. CLEANSE WITH 0.9% NORMAL SALINE. APPLY SANTYL OINTMENT. COVER WITH [MEDICATION NAME] FOAM DSG (dressing) QD (every day) X 90 DAYS . Stop Date 9/28/16 . 7/15/16 . STASIS ULCER LEFT LOWER LATERAL LEG. CLEANSE WITH 0.9% NORMAL SALINE. APPLY SANTYL OINTMENT. COVER WITH [MEDICATION NAME] FOAM DSG QD X 90 DAYS . Stop Date 9/28/16 . RI #26's Treatment Administration Record (TAR) for July 2016 indicated RI #26's dressing was changed every other day beginning on 7/15/2016. RI #26's Treatment Administration Record (TAR) for August 2016 indicated RI #26's dressing was changed every other day beginning on 8/2/2016. On 8/28/2016 at 7:02 PM, RI #26's dressing to the left lower leg was observed. The dressing was soiled with a black substance and dated 8/26/2016. During an interview on 8/30/2016 at 4:35 PM, EI #14, the Director of Nursing stated when an order is put in, the staff has to enter an interval code. According to EI #14, the wound care nurse (EI #11) entered the wrong interval code; EI #11 entered every other day instead of every day. In a telephone interview on 8/30/2016 at 4:41 PM, EI #11, the Registered Nurse/Wound Care Nurse acknowledged that she entered RI #26's physician order [REDACTED]. EI #11 stated the order was for every day, but she entered the order to read every other day. This deficiency was written as a result of the investigation of complaint/report number AL 626.

Based on observations, interviews and record reviews the facility failed to ensure: 1. A Styrofoam cup was not in the sugar bin. 2. Vents and bulb coverings over the stove was free of a grease and dust like substance. 3. Hash rounds were labeled with a use by date. 4. Lima Beans in dry storage was sealed and labeled. 5. A dietary employee took the temperature of the okra before serving. This had the potential to effect 136 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 March 17, 2016 revealed: .Place scoops in covered containers or plastic zip lock bags .30. Hood Filter over Stove: (monthly) . Run screen or vent through dish machine (regular cycle) . A review of a policy titled, Food Receipts and Storage with an effective date of August 21, 2013 revealed: .K. Open food items should be covered, labeled, and dated; opened dry goods should be kept in tightly sealed containers. A review of a facility policy titled, Food Cooking and Serving Temperature with an effective date of May 25, 2012 revealed: b. Food temperatures should be recorded on the menu, after each food container is placed in the steam table. 1) On 07/19/2016 at 10:47 a.m., the surveyor observed a Styrofoam cup in the sugar bin. On 7/21/2016 at 8:25 a.m. the surveyor conducted an interview with EI #2 (Employee Identifier), Dietary Manager. EI #2 was asked what was in the sugar bin. EI #2 replied, a styrofoam cup. EI #2 was asked why was there a styrofoam cup in the sugar bin. EI #2 replied, someone got sugar out of it and left the cup in there. EI #2 was asked what was the facility policy on leaving items in the sugar bin. EI #2 replied, items are not suppose to be left in the sugar bin. EI #2 was asked who was resposible for making sure there was no item in the sugar bin. EI #2 replied, dietary manager, assistant dietary manager, and especially staff. EI #2 was asked when was the sugar bin checked last. EI #2 replied, she checked it on Monday. EI #2 was asked what was the potential harm when items are left in food containers. EI #2 replied, cross contamination. 2) On 7/19/2016 at 11:20 a.m., the surveyor observed the vents and bulb coverings over the stove had a grease and dust like substance on them. On 7/21/2016 at 8:31 a.m., the surveyor conducted an interview with EI #3, assistant dietary manager. EI #3 was asked when was the vents over the stove last cleaned. EI #3 replied, two or three weeks ago. EI #3 was asked what did she see on the vents and light bulb coverings. EI #3 replied, dust, grease and a bug in the bulb covering. EI #3 was asked why was there grease and dust in the vent and on the bulb covering. EI #3 replied, when they use the stove grease gets on it. EI #3 was asked who was responsible for cleaning vents and bulb coverings. EI #3 replied, maintenance. EI #3 was asked what was the potential harm when grease and dust was on vents and bulb coverings and the stove is located under the vents and bulb coverings. EI #3 replied, it can cause a fire. 3) On 7/19/2016 at 11:20 a.m., the surveyor observed in the walk in refrigerator a five pound bag of hashrounds with no use by date on them. On 7/21/2016 at 8:35 a.m. an interview was conducted with EI #3. EI #3 was asked what was opened in the walk in refrigerator in a brown bag. EI #3 replied, hashrounds. EI #3 was asked what label was on the bag. EI #3 replied no label was on the bag. EI #3 was asked what information was on the bag. EI #3 replied, none. EI #3 was asked why was there no labeled information on the bag. EI #3 replied, no one put it on there. EI #3 was asked who was responsible for labeling items. EI #3 replied employees. EI #3 was asked when should items be labeled. EI #3 replied, as soon as they are opened. EI #3 was asked what was the facility policy on labeling items once opened. EI #3 replied, when you open an item make sure you close it, tape it up securely and label it. EI #3 was asked what was the potential harm when items were not labeled. EI #3 replied they would not know when it will be out of date and the item lose texture and taste. 4) On 7/19/2016 at 10:47 a.m. the surveyor observed Lima Beans opened and not securely wrapped or in another container. The Lima Beans had no use by date on the bag. On 7/21/2016 at 8:44 a.m., the surveyor conducted an interview with EI #2. EI #2 was asked what kind of package was the lima beans in. EI #2 replied a brown paper bag. EI #2 was asked when were they opened. EI #2 replied July 11. EI #2 was asked when items are opened how should they be stored. EI #2 replied, securely closed, dated when opened and with a use by date. EI #2 was asked what was the facility policy on storing food items that had been opened. EI #2 replied, securely close the item or put in a container that is securely close. When opened, labeled with an open date and a use by date. EI #2 was asked who was responsible for making sure food items are stored properly. EI #2 replied, the person who opened it. EI #2 was asked what was the potential harm when food items are not stored properly. EI #2 replied, bugs, ants anything can get into it. 5) On 7/20/2016 at 11:15 a.m., the surveyor observed the cook taking temperatures of food items on the steam table. The cook started plating before she took the temperature of the okra. She plated two plates and the surveyor asked for the temperature of the okra. At this point, the cook took the temperature of the okra. On 7/21/2016 at 8:51 a.m., the surveyor conducted an interview with EI #4 dietary assistant cook. EI #4 was asked did she temp the okra at the beginning of tray line. EI #4 replied, no. EI #4 was asked why did she not take the temperature of the okra. EI #4 replied, she did not think about it. EI #4 was asked what does the facility policy say about taking the temperatures of food on the tray line. EI #4 replied, take the temperature of all food before serving it. EI #4 was asked when should food temperature be taken on the tray line. EI #4 replied, before we serve it. EI #4 was asked why should the temperature of food be taken on the tray line. EI #4 replied, to make sure it is hot enough. EI #4 was asked what was the potential harm when food temperatures are not taken and the residents receive the food. EI #4 replied, they can get cold food and it can cause sickness.

Based on investigation of complaint number AL 109 F282 was cited. Based on interviews and record reviews, the facility failed to ensure facility staff implemented RI (Resident Identifier) #1's careplan to provide a full body lift (or 2 person assist). On 4/30/14 and 5/1/14 the resident was improperly handled and transferred by facility staff. The resident later complained of pain on 5/1/14 and an X-ray revealed the resident had sustained an acute distal femur [MEDICAL CONDITION] leg and distal femur fracture of left leg. The fracture was caused due to improper transfer according to the physician interview. This affected 1 of 14 sampled residents. Findings Include: RI #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. RI #1 ' s most current Quarterly Minimum Data Set (MDS) assessment, dated 04/07/2014 was reviewed. The MDS identified the resident with a Brief Interview for Mental Status (BIMS) score of 4 out of a possible 15, indicating severely impaired cognition. The MDS also indicated RI #1 was totally dependent on two person physical assist with transfers. RI #1 was also coded for a [DIAGNOSES REDACTED]. Review of the Care Assessment Triggers (CAT) for falls also indicated RI #1 had impaired balance during transitions. RI #1 ' s care plans included a problem, dated 01/21/2011, for the resident requiring assistance to complete daily activities of care safely related to weakness, confusion and refusing showers. An approach included ... " Full body lift for transfers ... " The approach was not dated. The care plans also included a problem, dated 01/21/2011, for the potential for falls related to medications, weakness, history of falls and attempts to get out of bed unassisted. An approach included " Re-educate staff on two person assist with transfers. " The Certified Nursing Assistant (CNA) Activity of Daily Living (ADL) form for May 2014 included the care of " Full body lift for transfers." Nurse's Notes for RI #1 documented the following: "5/1/2014 at 2:15 PM, RESIDET WITH C/O (complaints of ) PAIN IN LEFT AND RIGHT KNEE WITH PRN (as needed) NARCO ADMINISTERED. (Employee Identifier (EI) #3, Physician) NOTIFIED WITH NEW ORDERS RECEIVED AND NOTED FOR X-RAY OF RIGHT AND LEFT LEG. SPONSOR NOTIFIED. RN SUPERVISOR NOTIFIED. 5/1/2014 at 11:28 PM, RECEIVED X-RAY RESULTS WITH CONCLUSION OF DISTAL FEMUR FRACTURE IN BOTH KNEES. PHYSICIAN WAS NOTIFIED ALONG WITH RESPONSIBLE PARTY... An x-ray of RI # 1's right and left knees were conducted 05/01/2014. Results of the right knee indicated an impacted metaphyseal [MEDICAL CONDITION] femur. The conclusion was she had sustained "acute distal femur fracture" of the right leg. The results of the left leg X-Ray indicated an acute moderately displaced and angulated [MEDICAL CONDITION] femoral diaphysis. The conclusion was a distal femur [MEDICAL CONDITION] leg. On 7/9/14 at 11:20 AM, a telephone interview was conducted with EI #14,CNA (Certified Nursing Assistant). EI #14 was asked if she was assigned to care for RI #1 on 4/30/14 or 5/1/14. EI #14 stated she was, on both days. EI #14 was asked what shift she worked and she stated 11 PM to 7 AM. EI #14 was asked what level of assistance was RI #1. EI #14 stated RI #1 was a two person assist. EI #14 was asked to describe how she transferred RI #1 on 4/30/14 or 5/1/14. EI #14 stated that she transferred RI #1 on 5/1/14 between 5:45 AM and 6:00 AM. EI #14 stated that she transferred RI #1 from her geri-chair to her bed without any assistance. EI #14 stated that she pulled RI #1's geri-chair up to the head of the bed and she rolled the head of the bed down as far as it would go. She stated she put RI #1's arms around her neck and bear hugged her and pivoted her to the bed. She further stated that she grabbed RI #1's legs with one arm and her head with the other arm and scooted RI #1 to the middle of the bed. EI #14 was asked how RI #1 was care planned to be transferred. EI #14 stated that the careplan indicated that she was a 2 lift person. She further stated that she had only been there a month or so although she had been a CNA for fourteen years but no one told her the requirements regarding the transfer of RI #1. She also stated they ( staff development coordinator, DON (Director of Nursing) and Administrator) just put her out there to do what she knew how to do so she relied on her previous training as a CNA. EI #14 also stated that she never used the lift to transfer RI #1 prior to 4/30/14. EI #14 stated she did not receive training on how to use the lift until after she transferred RI #1 without assistance. 7/10/14 at 12:00 PM, a second telephone interview was conducted with EI #14, CNA. EI # 14 was asked how did she ensure what type of care RI #1 required. EI #14 stated that she just did what she was used to doing. EI #14 was asked why she transferred RI #1 without any assistance. EI #14 stated it was because it was 6:00 AM and no one would help her. EI #14 was asked if transferring RI #1 without assistance was an improper transfer. EI #14 stated, " absolutely, she definitely needs to be a 2 person assist. " EI #14 was asked why did she indicate in her witness statement to the facility that RI #1 had no swelling to her knees on 4/30/14 but her knees were very swollen on 5/1/14. EI #14 stated that on 4/30/14 RI #1 had usual swelling of her knees, but when she came to work on the 11-7 shift on 5/1/14, RI #1's knees were huge. EI #14 was asked when she pivoted RI #1 while transferring her from the Geri-chair to the bed on 5/1/14, if her feet ever touched the floor. EI #14 stated RI #1 ' s feet did touch the floor, but she had to do all the work. EI #14 further stated that RI #1's leg could have easily hit the bed rail during the transfer. EI #14 was asked if she had ever transferred RI #1 prior to 4/30/14 or 5/1/14 and she stated no, that was her first time. EI #14 was asked what should she do if she was unsure about the type of care a resident should receive. EI #14 stated that she could not get into the kiosk due to her code not working. EI #14 stated she informed the staff development coordinator that she could not log-in to the kiosk, but did not receive a new code so she relied on her CNA training from previous years. On 07/10/14 at 10:40 AM, EI #4, Care Plan Coordinator, was interviewed. She was asked what type of transfer was RI #1 when she was in the facility. EI #4 said when the resident came to the facility she thought RI #1 was a standup lift with staff. By the time the resident left the facility she was a full body lift with staff assistance. EI #4 was asked how many staff would have been required. She replied two, a minimum of two. EI #4 was asked if there was an ADL book and where it was kept. She said there was one on each unit where the CNAs had access. EI #4 was asked what care plan intervention the CNAs should have been using for RI #1. She replied, "full body lift for transfers." EI #4 said as the resident declined in her ability to bear weight the care plan was updated to reflect that. EI #4 was asked how the staff, CNAs and LPNs assured that appropriate care was given. She said they would check the ADL book and the LPNs got report at the beginning of each shift, written as well as verbal. On 7/10/2014 at 11:05 AM, an interview was conducted with EI #3, Medical Director. EI #3 was asked in his medical opinion, how he thought the fractures happened. EI #3 stated that it wouldn't take much because of the degree of [MEDICAL CONDITION] and contributing factors. EI #3 was asked how much pressure would it take to cause the fractures. EI #3 stated that pulling the leg or pushing the leg could have done it. EI #3 was asked if RI #1 could bear weight on her lower extremities. EI #3 stated that RI #1 was a two person assist and could not stand and pivot. He further stated that there was a time when RI #1 was able to bear weight, but not recently. EI #3 was asked if RI #1 was careplanned for a two person transfer and one staff transferred her, was that an improper transfer. EI #3 stated that it was a more riskier transfer. EI #3 was asked in his medical opinion, how he thought the bilateral femur fractures of RI #1 occurred. EI #1 stated that RI #1 was not getting up on her own and he assumed it was from one of her transfers On 07/10/14 at 11:22 AM, EI #5, LPN Staff Development, was interviewed. EI #5 was asked how the CNAs would know the type care a resident was to receive. She answered there was an ADL book on each unit and in the computer, that way there was always a way to find out the care the residents required. EI #5 was asked if a resident was care planned for a full body lift, how should that person be transferred. EI #5 replied, "With a full body lift." EI #5 was asked was appropriate care given to RI #1 if she was care planned for a full body lift, two person transfer and was only transferred by one staff. She replied, " No, one would not have been appropriate. " On 7/10/14 at 2:40 PM, an interview was conducted with EI #2, RN (Registered Nurse) former DON (Director of Nursing). EI #2 was asked during the facility's investigation, did any staff admit to transferring RI #1 by themselves. EI #2 stated yes, EI #14. EI #2 was asked if RI #1 was care planned for a two person transfer and she was transferred with one staff, would that be an improper transfer. EI # stated ,"Yes." EI #2 was asked how does staff know how to properly transfer a resident. EI #2 stated that the information was in the kiosk. EI #2 was asked since she had worked with RI #1, how many staff were used to transfer her. EI #2 stated according to staff, two people. On 7/10/14 at 3:17 PM, an interview was conducted with EI #1, Administrator. EI #1 was asked during the facility's investigation, did any staff admit to transferring RI #1 by themselves. EI #1 stated yes, EI #14. EI #1 was asked if RI #1 was care planned for a two person transfer and she was transferred with one staff, would that be an improper transfer. EI #1 stated that EI #14 should have used two people if RI #1 was careplanned for a two person transfer.

Based on the investigation of complaint number AL 109 F323 was cited. Based on interviews and record reviews, the facility failed to ensure facility staff implemented RI (Resident Identifier) #1's careplan to provide a full body lift (or 2 person assist). On 4/30/14 and 5/1/14 the resident was improperly handled and transferred by facility staff. The resident later complained of pain on 5/1/14 and an X-ray revealed the resident had sustained an acute distal femur fracture of the right leg and distal femur fracture of left leg. The fracture was caused due to improper transfer according to the physician interview. This affected 1 of 14 sampled residents. The facility further failed to ensure the facility failed to ensure RI #18's, a resident with a [DIAGNOSES REDACTED]. This affected 2 of 14 sampled residents. Findings Include: RI #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. RI #1 ' s most current Quarterly Minimum Data Set (MDS) assessment, dated 04/07/2014 was reviewed. The MDS identified the resident with a Brief Interview for Mental Status (BIMS) score of 4 out of a possible 15, indicating severely impaired cognition. The MDS also indicated RI #1 was totally dependent on two person physical assist with transfers. RI #1 was also coded for a [DIAGNOSES REDACTED]. Review of the Care Assessment Triggers (CAT) for falls also indicated RI #1 had impaired balance during transitions. RI #1 ' s care plans included a problem, dated 01/21/2011, for the resident requiring assistance to complete daily activities of care safely related to weakness, confusion and refusing showers. An approach included ... " Full body lift for transfers ... " The approach was not dated. The care plans also included a problem, dated 01/21/2011, for the potential for falls related medications, weakness, history of falls and attempts to get out of bed unassisted. An approach included " Re-educate staff on two person assist with transfers. " The Certified Nursing Assistant (CNA) Activity of Daily Living (ADL) form for May 2014 included the care of " Full body lift for transfers. " Nurse's Notes for RI #1 documented the following: "5/1/2014 at 2:15 PM, RESIDET WITH C/O (complaints of ) PAIN IN LEFT AND RIGHT KNEE WITH PRN (as needed) NARCO ADMINISTERED. (Employee Identifier (EI) #3, Physician) NOTIFIED WITH NEW ORDERS RECEIVED AND NOTED FOR X-RAY OF RIGHT AND LEFT LEG. SPONSOR NOTIFIED. RN SUPERVISOR NOTIFIED. 5/1/2014 at 11:28 PM, RECEIVED X-RAY RESULTS WITH CONCLUSION OF DISTAL FEMUR FRACTURE IN BOTH KNEES. PHYSICIAN WAS NOTIFIED ALONG WITH RESPONSIBLE PARTY... An x-ray of RI # 1's right and left knees were conducted 05/01/2014. Results of the right knee indicated an impacted metaphyseal fracture of the distal femur. The conclusion was she had sustained "acute distal femur fracture" of the right leg. The results of the left leg X-Ray indicated an acute moderately displaced and angulated fracture of the distal femoral diaphysis. The conclusion was a distal femur fracture of the left leg. Nurse's noted for RI #1 documented the following: 5/2/2014 at 9:49 PM, SUMMONED TO RESIDENT'S ROOM @ 2:15 PM 5/1/2014 VIA EI #11 WITH C/O RESIDENT'S RIGHT AND LEFT KNEE SWOLLEN. ENTERED ROOM RESIDENT WAS IN RECLINER CHAIR ... RESIDENT WAS TRANSFERRED FROM RECLINER TO BED VIA FULL BODY LIFT PRIOR TO MD ENTERING ROOM VIA NURSING STAFF... 5/5/2014 at 6:37 PM, (Consulting Physician) VISITED RESIDENT. ASSESSED BOTH KNEES AND STATED THE KNEES APPEARED TO BE FRACTURED (ACUTE). (Physician) EXPLAINED TO THE SPONSOR THAT DUE TO HER OSTEOPOROSIS AND ARTHRITIS THAT THE FRACTURES COULD HAVE OCCURRED DURING TURNING OR TRANSFERS..." On 7/09/2014 at 8:00 AM, an interview was conducted with EI #11, CNA. EI #11 was asked if she was assigned to care for RI #1 on 4/30/14 or 5/1/14. EI #11 stated yes, both days. EI #11 was asked what shift she worked. EI #11 stated 7:00 AM to 3:00 pm. EI #11 was asked what level of assistance was RI #1. EI #11 stated that RI #1 was a two person assist with transfers. EI #11 was asked how long she had worked with RI #1. EI #11 stated six months to a year. EI #11 was asked during time did she ever use the full body lift with RI #1. EI #11 stated in the beginning, maybe. EI #11 was asked prior to 4/30/14, when was the last time she had used the full body lift to transfer RI #1. EI #11 stated that she couldn't say because she could not remember. EI #11 was asked to describe the condition of RI #1's lower extremities on 4/30/14 or 5/1/14. EI #11 stated that on 5/1/14, when she and two other CNA's transferred RI #1 to bed, her right leg looked deformed and her right knee cap was extremely swollen. When asked to describe the transfer, EI #11 stated that they actually lifted RI #1 onto the bed. EI #11 stated that one CNA held RI #1 under her right arm and a second CNA held her underneath the left arm then a third CNA cradled her legs and she was lifted into the bed. EI #11 was asked if she ever noticed RI #1's knees to be swollen before 4/30/14. EI #11 stated that RI #1's knees were always swollen, but on 5/1/14 they were more swollen. On 7/9/14 at 8:30 AM, an interview was conducted with , LPN. EI #7 was asked if she was assigned to take care of RI #1 on 4/30/14 or 5/1/14. EI # 7 stated that she believed she was on both days. EI #7 was asked what shift she worked and she stated 7 AM to 3 PM. EI # 7 was asked what level of assistance was RI #1. EI #7 stated that she was a total assist. EI #7 was asked how was RI #1 care planned to be transferred. EI #7 stated that as far as she knew, it was full body lift. EI #7 was asked to describe the condition of RI #1 ' s lower extremities. EI #7 stated that she couldn't remember which day it was, but EI #11 came to get her at approximately 2:15 PM and when she entered RI #1's room, she was sitting in the recliner chair and both knees were swollen. She further stated that she contacted the unit manager and the doctor was in the building and he ordered X-rays for RI #1. EI #7 was asked if she noticed RI #1's knees swollen prior to the day EI #11 notified her. EI # stated no. On 7/9/14 at 9:05 AM, an interview was conducted with EI #6 , RN (Registered Nurse) Unit Manager Hall 2. EI #6 was asked what level of assistance was RI #1. EI #6 stated she was an extensive two person assist. EI #6 was asked how RI #1 was normally transferred. EI #6 stated that she would have to look at care plan. EI #6 was asked to describe the condition of RI #1 ' s lower extremities. EI #6 stated that she did see RI #1's legs on 5/1/14 and both of her knees were swollen, one more than the other. She stated Dr. Yates did enter the room while she was present and assessed the resident. On 7/9/2014 at 10:19 AM, an interview was conducted with EI #12,CNA. EI #12 was asked if she was assigned to care for RI #1 on 4/30/14 or 5/1/14. EI #12 stated she was and that she gave RI #1 a shower on 5/1/14. EI #12 was asked what level of assistance was RI #1. EI #12 stated that she was a two person transfer. EI #12 was asked how was RI #1 normally transferred. EI #12 stated by 2 people with a pivot transfer. EI #12 was asked to describe how she transferred RI #1 on 5/1/14. EI #12 stated that she and EI #11 transferred RI #1 to the shower chair from the bed using pivot transfer. EI #12 stated the shower was given between 7:30 AM and 8:00 AM on 5/1/14. EI #12 further stated that she, EI #11 and a third CNA transferred RI #1 from the shower chair to the gerichair where 2 CNA's held the resident by each arm and EI #12 wiped her buttocks and pulled her pants up and then pulled gerichair underneath the resident and she sat down. On 7/9/14 at 10:35 AM, an interview was conducted with EI #13, CNA. EI #13 was asked if she was assigned to care for RI #1 on 4/30/14 or 5/1/14. EI #13 stated she was not assigned to her but was assisting the staff member assigned to her. EI #13 was asked what shift she worked and she stated 7:00 AM to 3:00 PM. EI #13 was asked what level of assistance RI #1 required. EI #13 stated total care assistance. EI #13 was asked how RI #1 was transferred that day, on 5/1/14. EI #13 stated she helped transfer her from geri-chair to shower chair, from shower chair back to geri-chair and then from geri-chair to bed on 5/1/14. EI #13 stated that when transferring RI #1 from geri-chair to shower chair, there were 3 CNA's involved where one CNA had one arm, another CNA had other arm, RI #1 was stood up and third CNA rolled the shower chair underneath RI #1 and RI #1 was sat down in the shower chair. EI #13 stated that in transferring RI #1 from shower chair to geri-chair, one CNA held the shower chair while she held one arm and another CNA had the other arm, RI #1 was stood up and pivoted to geri-chair. When transferring RI #1 from the geri-chair to the bed, EI #13 stated she cradled RI #1's legs and there was one CNA underneath each arm. EI #13 was asked to describe the condition of RI #1's lower extremities. EI #13 stated that she thought RI#1's left leg looked liked it was dislocated. EI #13 notified EI #7, LPN. EI #13 was asked if she ever noticed that RI #1's knees were swollen prior to that day of the shower day. EI #13 stated no, just the day of the shower. On 7/9/14 at 11:20 AM, a telephone interview was conducted with EI #14, CNA. EI #14 was asked if she was assigned to care for RI #1 on 4/30/14 or 5/1/14. EI #14 stated she was, on both days. EI #14 was asked what shift she worked and she stated 11 PM to 7 AM. EI #14 was asked what level of assistance was RI #1. EI #14 stated RI #1 was a two person assist. EI #14 was asked to describe how she transferred RI #1 on 4/30/14 or 5/1/14. EI #14 stated that she transferred RI #1 on 5/1/14 between 5:45 AM and 6:00 AM. EI #14 stated that she transferred RI #1 from her geri-chair to her bed without any assistance. EI #14 stated that she pulled RI #1's geri-chair up to the head of the bed and she rolled the head of the bed down as far as it would go. She stated she put RI #1's arms around her neck and bear hugged her and pivoted her to the bed. She further stated that she grabbed RI #1's legs with one arm and her head with the other arm and scooted RI #1 to the middle of the bed. EI #14 was asked how RI #1 was care planned to be transferred. EI #14 stated that the careplan indicated that she was a 2 lift person. She further stated that she had only been there a month or so although she had been a CNA for fourteen years but no one told her the requirements regarding the transfer of RI #1. She also stated they ( staff development coordinator, DON and Administrator) just put her out there to do what she knew how to do so she relied on her previous training as a CNA. EI #14 also stated that she never used the lift to transfer RI #1 prior to 4/30/14. EI #14 stated she did not receive training on how to use the lift until after she transferred RI #1 without assistance. On 7/9/14 at 11:57 PM, an interview was conducted with EI #8, LPN. EI #8 was asked if she was assigned to care for RI #1 on 4/30/14 or 5/1/14. EI #8 stated she thought she was on 5/1/14. EI #8 was asked what shift she worked and she stated 7 AM to 3 PM. EI # 8 was asked what level of assistance was RI #1. EI #8 stated total assist. EI #8 was asked how was RI #1 care planned to be transferred. EI #8 stated that she thought with a lift. EI #8 was asked to describe the condition of RI #1's lower extremities. EI #8 stated that her knees were swollen more than usual. EI #8 stated that at the time she saw RI #1's knees, the doctor already was aware of them. EI #8 was asked if she had noticed RI #1 ' s knees swollen to the extent they were prior to 5/1/14. EI #8 stated she had not. On 7/9/14 at 2:01 PM, an interview was conducted with EI #9, LPN. EI #9 was asked if she was assigned to take care of RI #1 on 4/30/14 or 5/1/14. EI #9 stated she was on both days. EI #9 was asked what assist level was RI #1. EI # stated she was a two person assist. On 7/9/14 at 3:22 PM, an interview was conducted with EI #15, CNA. EI #15 was asked if she was assigned to take care of RI #1 on 4/30/14 or 5/1/14. EI #15 stated she was on 5/1/14. EI #15 was asked what shift she worked and she stated 3:00 PM to 11:00 PM. EI #15 was asked what level of assistance did RI #1 require and she stated total care. EI #15 was asked how was RI #1 normally transferred. EI #15 stated at first she was a two person assist, then staff was educated and told to use the mechanical lift. EI #15 was asked to describe the condition of RI #1's lower extremities. EI #15 stated that both of her knees were swollen and one was more swollen than the other, she could not remember which. EI #15 was asked if prior to 5/1/14 had she noticed RI #1's knees to be as swollen as they were on this day and she stated not as swollen. On 7/10/14 at 7:55 AM, an interview was conducted with EI # 10, LPN. EI #10 was asked if she was assigned to take care of RI #1 on 4/30/14 or 5/1/14. EI #10 stated that she was. EI #10 was asked what level of assistance did RI #1 require. EI #10 stated two person assist. EI # was asked how RI #1 was normally transferred. EI #10 stated that RI #1 always required two people for transfers. EI #10 was asked if RI #1 was care planned as a two person assist for transfers and she was transferred by one staff member, was that an improper transfer. EI #10 stated yes. EI #10 was asked if RI#1 was transferred by one staff member, was that appropriate care. EI #10 stated no. EI #10 was asked what would be the potential harm if RI #1 was transferred with one staff member. EI #10 stated, " safety and anything could have happened." EI #10 was asked how do staff know how to properly transfer a resident. EI #10 stated that there is a CNA care plan book. EI #10 was asked when CNA ' s come on shift if they are required to look in the care plan book. EI # stated yes the CNA ' s know to look at the care plan book. On 7/10/14 at 8:17 AM, a second interview was conducted with EI # 7, LPN. EI #7 was asked how she ensured CNAs knew what type of care to render to the residents. EI # 7 stated that they have an ADL (Activities of Daily Living) book that refers to the levels of care. EI #7 was asked if RI #1 was able to stand and pivot. EI #7 said that she did not believe she was. EI #7 was asked with a two person transfer, if RI #1 was not able to stand and pivot, how was she transferred from bed to chair and vice versa. EI #7 stated that RI # 1 should have been transferred with a lift. EI #7 was asked if she felt it was safe to transfer RI #1 from bed to chair and vice versa with one staff member. EI #7 stated that it was not safe and RI #1 needed to be transferred by two people. EI #7 was asked what would be the potential harm if RI #1 was transferred with one staff member. EI #7 stated, " I don't think her body mechanics were good enough to be transferred with one person, she needed two at all times." EI # 7 was asked if RI #1 was care planned for a two person transfer and she was transferred by one staff, would you consider this an improper transfer. EI #7 stated," yes." On 7/10/2014 at 11:05 AM, an interview was conducted with EI #3, Medical Director. EI #3 was asked in his medical opinion, how he thought the fractures happened. EI #3 stated that it wouldn't take much because of the degree of osteoporosis and contributing factors. EI #3 was asked how much pressure would it take to cause the fractures. EI #3 stated that pulling the leg or pushing the leg could have done it. EI #3 was asked if RI #1 could bear weight on her lower extremities. EI #3 stated that RI #1 was a two person assist and could not stand and pivot. He further stated that there was a time when RI #1 was able to bear weight, but not recently. EI #3 was asked if RI #1 was careplanned for a two person transfer and one staff transferred her, was that an improper transfer. EI #3 stated that it was a more riskier transfer. EI #3 was asked if RI #1 was careplanned for a two person transfer and one staff transferred her, was appropriate care rendered to RI #1. EI #3 stated that it was still a more riskier transfer. EI #3 was asked in his medical opinion, how he thought the bilateral femur fractures of RI #1 occurred. EI #1 stated that RI #1 was not getting up on her own and he assumed it was from one of her transfers. On 7/10/14 at 11:14 AM, an interview was conducted with EI #16, CNA. EI #16 was asked if she was assigned to take care of RI #1 on 4/30/14 or 5/1/14. EI #16 stated she was on 5/1/14. EI #16 was asked what shift she worked and she stated 7 AM to 3:00 PM. EI #16 was asked what level of assistance was RI #1. EI #16 stated that she was a two person assist. EI #16 was asked how RI #1 was normally transferred. EI #16 stated by two people. EI #16 was asked to describe the condition of RI#1's lower extremities on 5/1/14. EI #16 stated both of RI #1's knees were red and swollen. She stated RI #1's left leg was turned outward. EI #16 was asked if before 4/30/14, she had noticed RI #1's knees to be red and swollen. EI #16 stated she had not. EI #16 was asked if RI #1 was able to stand and pivot. EI #16 replied no, not on her own. EI #16 was asked if RI #1 was care planned for a two person transfer and she was transferred with one staff, would that be an improper transfer. EI #16 stated "Yes, you couldn't move her on your own, she was heavy." EI #16 was asked if appropriate care was rendered when staff transferred RI #1 using only one staff member. EI #16 stated no, she couldn't stand. EI #16 was asked how did she know how to properly transfer a resident. EI # 16 stated that she could look at the kiosk on the wall and a care plan book also. EI #16 was asked if she felt it was safe to transfer RI #1 from the bed to the wheelchair or vice versa with one staff member. RI #16 stated, "no because she is really heavy and can't stand on her own. I wouldn't feel safe transferring her." On 7/10/14 at 12:00 PM, a second telephone interview was conducted with EI #14, CNA. EI # 14 was asked how did she ensure what type of care RI #1 required. EI #14 stated that she just did what she was used to doing. EI #14 was asked why she transferred RI #1 without any assistance. EI #14 stated it was because it was 6:00 AM and no one would help her. EI #14 was asked if transferring RI #1 without assistance was an improper transfer. EI #14 stated, " absolutely, she definitely needs to be a 2 person assist. " EI #14 was asked why did she indicate in her witness statement to the facility that RI #1 had no swelling to her knees on 4/30/14 but her knees were very swollen on 5/1/14. EI #14 stated that on 4/30/14 RI #1 had usual swelling of her knees, but when she came to work on 5/1/14, RI #1 ' s knees were huge. EI #14 was asked when she pivoted RI #1 while transferring her from the Geri-chair to the bed on 5/1/14, if her feet ever touched the floor. EI #14 stated RI #1 ' s feet did touch the floor, but she had to do all the work. EI #14 further stated that RI #1 ' s leg could have easily hit the bed rail during the transfer. EI #14 was asked if she had ever transferred RI #1 prior to 4/30/14 or 5/1/14 and she stated no, that was her first time. EI #14 was asked what should she do if she was unsure about the type of care a resident should receive. EI #14 stated that she could not get into the kiosk due to her code not working. EI #14 stated she informed the staff development coordinator that she could not log-in to the kiosk, but did not receive a new code so she relied on her CNA training from previous years. On 7/10/14 at 2:40 PM, an interview was conducted with EI #2, RN (Registered Nurse) former DON (Director of Nursing). EI #2 was asked during the facility's investigation, did any staff admit to transferring RI #1 by themselves. EI #2 stated yes, EI #14. EI #2 was asked if RI #1 was care planned for a two person transfer and she was transferred with one staff, would that be an improper transfer. EI #16 stated ,"Yes." EI #2 was asked how does staff know how to properly transfer a resident. EI #2 stated that the information is in the kiosk. EI #2 was asked had she ever known RI #1's knees to be swollen prior to 4/30/14 or 5/1/14. EI #2 stated not to that extent. EI #2 was asked since you have worked with RI #1, how many staff are used to transfer her. EI #2 stated according to staff, two people. On 7/10/14 at 3:17 PM, an interview was conducted with EI #1, Administrator. EI #1 was asked if the facility conducted an investigation and he stated yes. EI #1 was asked what the facility's investigation revealed. EI #1 stated that the facility was unable to determine the actual cause of the fractures. EI #1 was asked how did the facility conclude that the fractures occurred on the 7 AM to 3 PM shift. EI #1 stated that during the investigation, he found that on 5/1/14 around lunchtime, three CNA's put RI #1 into bed and noticed the awkwardness of her legs. EI #1 was asked during the facility's investigation, did any staff admit to transferring RI #1 by themselves. EI #1 stated yes, EI #14. EI #1 was asked if RI #1 was care planned for a two person transfer and she was transferred with one staff, would that be an improper transfer. EI #1 stated that EI #14 should have used two people if RI #1 was careplanned for a two person transfer. 2.) RI #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #18 could not talk and used a communication board and a sheet with which he pointed to letters to spell out words. RI #18's (fourteen day assessment) MDS with an Assessment Reference Date of 05/14/14 identified RI #18 as a 15 out of 15 on his BIMS (Brief Interview for Mental Status), cognitively intact. The MDS identified RI #18 as requiring total assistant of two (+) persons (physical assistance) for bed mobility, transfers, and for toileting. RI #18 was documented as being 66" tall (5 foot, 6") and weighed 199 pounds. On 07/10/14 at 10:15 AM, RI #18 began using his communication paper by pointing to letters to the surveyor. As he was pointing and communication, the built up arm rest for his left side paralyzed arm became loose and fell off his wheelchair. RI #18 began leaning to the left, and his arm, shoulder and upper body began to lean over the regular arm rest of the wheelchair. The surveyor caught the resident and hollered for help several times until some one came and helped. The build up arm rest was not physically attached but just sat upon the regular wheelchair arm rest with a small flap in the back of the arm rest. A male nurse and the Physical Therapist (PT) came to help sit the resident up and to affix the built up arm rest back on his wheel chair. I asked the Physical Therapy therapist, who had put that arm rest on his wheel chair. He said OT (Occupational Therapy) had. The build up armrest had two sides lengthwise approximately the length of RI #18's arm. The built-up armrest was made of thick plastic or light weight metal but it was not permanency affixed to his wheel chair. It had a small flap which can be laid or pushed to the end of the regular wheelchair's armrest, but it did not stay on his wheelchair. An interview with the Director of Nursing, EI #2 on 7/10/14 at 12:30 PM. EI #2 was informed of RI #18 almost falling out of chair because the built up arm rest for his paralysis arm was not permanently attached to his wheel chair and that he almost feel out of his chair due to this. EI #2 said she would look into this.