Every finding on record at Keller Landing

Based on observation, interviews, record review, and review of a facility document titled, Hand Hygiene, the facility failed to ensure a licensed nurse washed her hands prior to administering Resident Identifier (RI) #15's medications, after touching contaminated items, including the door/door knob and privacy curtain. Further, after administering RI #15's medication, the licensed nurse removed her right glove, placed it in the garbage can, and returned to the medication cart, without first washing her hands. This deficient practice affected RI #15, one of three residents observed, and one of three licensed nurses observed during medication pass observations. Findings Include: A review of a facility policy titled, Hand Hygiene with a review date of 11/15/2018 revealed, .PURPOSE To . reduce the transmission of pathogenic microorganisms.PR[NAME]ESS 1. Perform hand hygiene: 1.1 Before patient care . 1.4 After patient care . RI #15 was admitted to the facility on [DATE]. On 6/19/19 at 9:40 a.m., the surveyor observed Employee Identifier (EI) #1, a Registered Nurse, during a medication pass. EI #1 entered RI #15's room, closed the door with both hands, touched the door knob with her right hand, and pulled the curtain to the left side of RI #15's bed with both hands, but did not wash her hands prior to giving RI #15's oral medication. After EI #1 gave RI #15's inhaler medication, the surveyor observed EI #1 walk out of RI #15's room with her right gloved hand holding RI #15's inhaler. EI #1 then removed her glove from the right hand, put the glove in the garbage can, and did not wash her hands. EI #1 placed RI #15's inhaler on top of the medication cart, and opened the Medication Administration Record [REDACTED]. On 6/19/19 11:41 at a.m., an interview was conducted with EI #2, a Registered Nurse/Infection Control Preventionist. EI #2 was asked what should you do prior to giving a resident a oral medication. EI #2 stated you should wash your hands. EI #2 was asked what should you do after giving a resident an inhaler medication, and removing gloves, prior to opening a Medication Administration Record [REDACTED]. EI #2 stated you should wash your hands. EI #2 was asked what is your facility policy on hand hygiene regarding patient care. EI #2 stated you should wash your hands prior to and after patient care. EI #2 was asked why should you perform hand hygiene prior to giving a resident a medication and after giving a resident a medication. [NAME] #2 stated it is to prevent cross contamination. On 6/19/19 at 12:09 p.m., an interview was conducted with EI #1. EI #1 was asked if she washed her hands after she entered RI #15's room, closed the door with both hands, and pulled the curtain, prior to giving RI #15's oral medication. EI #1 stated no, she did not wash her hands. EI #1 was asked why she did not wash your hands. EI #1 stated she was not thinking. EI #1 stated she should have washed her hands in order to prevent infection to a resident. EI #1 was asked if she washed her hands after she gave RI #15's inhaler medication and removed her glove and put it in the garbage can, prior to returning to the cart and touching the Medication Administration Record [REDACTED]. EI #1 stated she should have washed her hands in order to prevent infection to a resident.

Based on interview, review of Employee Identifier (EI) #1's personnel file, the facility's policy titled HR225 Licensure and Certification of Personnel and information received from the Alabama Board of Nursing, the facility failed to ensure EI #1, a Registered Nurse (RN) maintained a current (active) nursing license. On 11/29/2017, the Alabama Board of Nursing suspended EI #1's nursing license. The Administrator stated in an interview, nursing licenses should be checked prior to hire and yearly. The last time the facility had verified (checked) the status of EI #1's nursing license was 1/6/2017. This deficient practice had the potential to affect all 79 residents who currently resided in the facility. Findings include: On 10/25/2018, the Alabama State Survey Agency received an anonymous complaint that indicated Employee Identifier (EI) #1, a Registered Nurse (RN) was working in the facility with a suspended nursing license. According to the anonymous caller, EI #1 worked the medication cart and was occasionally assigned the weekend supervisor's position. The facility's policy titled HR225 Licensure and Certification of Personnel effective 6/1/1996 with a review date of 6/1/2018, documented POLICY Genesis HealthCare and its subsidiaries, collectively Company, requires those employees whose jobs require specific licenses or certifications to maintain their credentials in compliance with state and federal laws at all times . The Term license is used throughout this document to include professional license, certification or other credentials that are required to perform the job duties. PURPOSE To assure that employees are properly licensed, certified, and/or registered to perform their duties. SCOPE Applies to all employees whose positions require licensed, certifications, or educations credentials. PR[NAME]ESS 1. At the time of employment, employees who require a license, certification, or registration must present verification of such. 2. A copy of the current document is verified prior to employment and filed in the employee file. 3. A copy of the annual re-certification (as applicable) must be maintained in the employee's file . A review of EI #1's personnel file indicated EI #1's employment with the facility (hire date) was 10/20/2016. According to facility records, EI #1's nursing license was checked on 10/3/2016 and 1/6/2017. In an interview on 11/6/2018 at 2:38 PM, EI #2, the Administrator stated on 10/25/2018, she received a phone call from the Alabama Board of Nursing, asking if EI #1 was an employee of the facility. EI #2 stated when she confirmed that EI #1 was an employee of the facility, a representative with the Alabama Board of Nursing informed her that EI #1 did not have a nursing license. After the telephone call, EI #2 stated she contacted EI #1 via telephone and informed EI #1 of her termination from the facility. The Individual Performance Improvement Plan indicated on 10/25/2018 EI #1, whose position in the facility was a Registered Nurse (RN), employment with the facility was terminated for Gross Misconduct. According to the document, EI #1 Did not report license suspension . According to the Alabama Board of Nursing, EI #1's nursing license status was listed as suspension with a start date of 11/29/2017. On 11/6/2018 at 2:46 PM, EI #2, the Administrator informed the State Surveyor that EI #1 went on leave on 11/18/2017 and returned to the facility on [DATE] as the weekend supervisor. In an interview on 11/6/2018 at 3:10 PM, EI #3, the Center Nurse Executive (CNE) was asked when EI #1 returned to work on 4/28/2018, did the facility verify EI #1's nursing license. EI #3 said no. When asked if there was any documentation to verify EI #1's nursing license, EI #3 said no. On 11/7/2018 at 2:57 PM, EI #2, the Administrator informed the State Surveyor the facility's policy on checking license was that it be done before hire and then yearly. EI #2 acknowledged the last time the facility checked EI #1's nursing license was (MONTH) (YEAR). When asked why EI #1's nursing license was not checked (MONTH) (YEAR), EI #2 explained a new Human Resource (HR) person was hired (MONTH) (YEAR) and that person would not begin checking nursing licenses until (MONTH) (YEAR). This deficiency was cited as a result of the investigation of complaint/report number AL 922.

Based on observation, interviews, record review and review of a facility policy titled, Privacy Rights: Patient, the facility failed to ensure a Registered Nurse, Employee Identifier (EI) #2, did not leave Resident Identifier (RI) #52's Medication Administration Record [REDACTED]. This was observed on 09/11/18, during the morning medication administration pass. This deficient practice affected RI #52, one of five residents observed during the medication administration pass, and EI #2, one of four nurses observed administering medications. Findings Include: Review of a facility policy titled, Privacy Rights: Patient, with a revision date of 11/18/16, documented: POLICY The patient has a right to personal privacy and confidentiality of his/her personal and medical records. Personal privacy includes . medical treatments . RI #52 was admitted to the facility on [DATE], and readmitted on [DATE]. On 09/11/18 at 8:19 a.m., the surveyor observed an opened MAR indicated [REDACTED]. The MAR indicated [REDACTED]. EI #2 walked to the medication cart and the surveyor shared with EI #2 that RI #52's medical information was visible. The surveyor asked EI #2 what would it be considered when a resident's MAR indicated [REDACTED]. EI #2 said it would be a privacy issue. On 09/13/18 at 10:00 a.m., the surveyor conducted an interview with EI #1, the Director of Nursing. The surveyor asked EI #1 what should the nurse do, concerning the resident's MAR, when he/she left the medication cart. EI #1 said the nurse should close the MAR. The surveyor asked EI #1 what was it considered when the MAR indicated [REDACTED]. EI #1 said that would be a privacy concern.

Based on observations, interviews, record review and review of facility policies titled, Medication Administration: Oral and Linen Handling, the facility failed to ensure: 1) a medication nurse, Employee Identifier (EI) #2, sanitized her hands after administering medications to Resident Identifier (RI) #1, and before signing the Medication Administration Record [REDACTED] 2) linen did not touch the uniform of EI #3, a laundry staff member on 09/12/18, when EI #3 was folding the linen (sheets). These deficient practices affected RI #1, one of five residents observed during the medication administration pass, and EI #2, one of four nurses observed administering medications. It also affected EI #3, a laundry staff member and had the potential to affect the resident who would receive that linen. Findings Include: 1) A review of the facility policy titled, Medication Administration: Oral with a revision date of 05/04/15, revealed: .3. Administer medication . 4. Cleanse hands. 5. Document: .Administration of medication . RI #1 was admitted to the facility on [DATE], and readmitted on [DATE]. On 09/12/18 at 8:10 a.m., the surveyor observed EI #2 prepare all, except two, of RI #1's medications. EI #2 walked to where RI #1 was and administered the medications to RI #1. On 09/12/18 at 8:36 a.m., EI #2 went to central supply to obtain a stock medication for RI #1, then walked back to the medication cart. Without sanitizing her hands, EI #2 put gloves on, then opened and dated the stock medication. EI #2 prepared the other two medications for RI #1. On 09/12/18 at 8:43 a.m., EI #2 administered the medications to RI #1. On 09/12/18 at 8:46 a.m., EI #2 went back to the medication cart, and without sanitizing her hands, initialed the MAR. The surveyor asked EI #2 what should she have done before she initialed the MAR. EI #2 said used hand sanitizer. The surveyor asked EI #2 what could it be considered when she touched several items/things, then came back to the medication cart and initialed the MAR. EI #2 replied contamination. On 09/13/18 at 8:13 a.m., the surveyor conducted an interview with EI #5, the Infection Control Nurse. The surveyor asked EI #5 what should the nurses do, before touching anything, when returning to the medication cart after administering medications. EI #5 said use hand sanitizer or wash their hands, if they were visibly soiled. The surveyor asked EI #5 what would it be considered if that was not done. EI #5 replied, she guessed that would be cross contamination. 2) Review of a facility policy titled, Linen Handling, with an effective date of 09/01/04, documented: . PR[NAME]ESS . 3. Cleanse hands before handling clean linen; do not allow linen to touch uniform . On 09/12/18 at 10:36 a.m., the surveyor observed EI #3, a laundry staff member folding linen (sheets). EI #3 held the sheets up against her shirt and pants when folding them, then placed the sheets on a shelf. On 09/12/18 10:40 a.m., the surveyor observed EI #3 continue to fold sheets while holding the sheets up against her shirt and pants. The surveyor asked EI #3 how should linen be handled when being folded. EI #3 said staff's hands were washed before the linen was folded. The surveyor asked EI #3 should linen be held up against her clothes when being folded. EI #3 replied no. The surveyor asked EI #3 what would that be considered when linen was held up against her clothes. EI #3 said contamination. The surveyor shared with EI #3 the observation of her folding the sheets up against her shirt and pants. EI #3 said she did not realize she was doing that. On 09/12/18 at 10:45 a.m., the surveyor conducted an interview with EI #4, the Laundry Manager. The surveyor asked EI #4 should linen that was being folded be held up against staff clothing. EI #4 said no. The surveyor asked EI #4 how should the linen be held or folded. EI #4 replied, away from your clothes. EI #4 was asked when not held away from your clothes, what would that be considered. EI #4 said contamination. On 09/13/18 at 08:23 a.m., the surveyor conducted an interview with EI #5, the Infection Control Nurse. The surveyor asked EI #5 how should laundry staff handle linen when the linen was being folded. EI #5 said the linen was not supposed to touch a person's clothes or uniform when being folded.

Based on observations, interviews and reviews of the 2013 Food Code, and Department of Food & (and) Nutrition dishmachine monitoring log, the facility failed to ensure: 1. the sanitizing temperature did exceeded 194 degrees Fahrenheit (F) on two days which resulted in a failure to effectively sanitize, 2. to assure stored frozen food ,(individual cups of ice cream), received frozen were maintained frozen, 3. that food contact surfaces for three of three sectional plates observed on the tray line for plating, were air dried after cleaning/sanitizing and 4. staff used a light bulb with protective shielding (covered, coated or otherwise shatter resistant) in a refrigerator used to store food items and nourishments. These deficient practices had the potential to affect all 76 residents receiving meal trays from dining services. Findings Include: I. A review of the Food Code U.S. Public Health Service and FDA (Food and Drug Administration) 2013 revealed the following: . 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. (A) . the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than . (194 F) . A review of the facility form titled, MACHINE WAREWASHING SANITIZING LOG for the month of August 2017, revealed the sanitizing temperature exceeded 194 degrees F on two days, August 5 and August 7, 2017. On the morning of 8/5/2017, the final rinse temperature was documented as 198 F. At noon on 8/7/2017, the final rinse temperature was documented as 197 F. An interview was conducted with the CDM, (Certified Dietary Manager), Employee Identifier (EI) #3 on 8/10/2017 at 12:03 p.m. EI #3 was asked, what did the staff do when the sanitizing temperature was more than 194 degrees F. EI #3 said they did not do anything, they did not know. 2. A review of the Food Code U.S. Public Health Service FDA (Food and Drug Administration) 2013 revealed the following: . 3-501.11 Frozen Food. Stored frozen FOODS shall be maintained frozen. On 8/09/2017 at 11:43 a.m., the storage of individual cups of ice cream was observed in an individual unit. Two cups were tested and left finger indentations. The Director of Maintenance, EI #2, was present and stated, That's (that is) not solid. 3. A record review of the Food Code U.S. Public Health Service FDA (Food and Drug Administration) 2013 revealed the following: .4-901.11 Equipment and Utensils, . After cleaning and SANITIZING, .(A) Shall be air-dried . An observation on 8/09/2017 at 11:25 a.m. of the storage of cleaned/sanitized sectional plates stacked on a table behind the trayline, revealed three of three sectional plates contained rolling water. The Cook, Employee Identifier (EI) #4, was asked, what she saw and she verbalized, They got water in them. EI #4 was observed to turn the remaining four plates upside down. During an interview with EI #3, on 8/09/2017 at 12:20 p.m., she was asked why the sectional plates should be air-dried. EI #3 replied, moisture created an environment for bacteria. 4. A record review of the Food Code U.S. Public Health Service FDA (Food and Drug Administration) 2013 revealed the following: .6-202.11 Light Bulbs, Protective Shielding. (A) Except as specified in (B) of this section, light bulbs shall be shielded, coated, or otherwise shatter-resistant in areas where there is exposed FOOD; clean EQUIPMENT, UTENSILS . On 8/08/2017 at 1:15 p.m., an observation was made of a refrigerator containing pasta salad, pudding, and individual glasses of juice. At this time EI #2 was asked if the bulb in the refrigerator was coated. EI #2 said, no it was not. EI #3 was interviewed on 8/10/2017 at 12:20 p.m. EI #3 verified the bulb was not covered, coated nor shielded which created a potential risk for physical contamination of food stored in the unit.

Based on record review, interview, and review of the Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure Resident Identifier (RI) #6's Minimum Data Set (MDS) assessment included a completed assessment of RI #6's pain. This affected one of 13 residents for whom MDS assessments were reviewed. Findings Include: Review of the Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.14, dated October 2016, revealed the following: . SECTION J: HEALTH CONDITIONS Intent: The intent of the items in this section is to document a number of health conditions that impact the resident's functional status and quality of life. The items include an assessment of pain which uses an interview with the resident or staff if the resident is unable to participate. The pain items assess the presence of pain, pain frequency, effect on function, intensity, management and control . RI #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of RI #6's quarterly MDS assessment, with an Assessment Reference Date (ARD) of 6/2/2017, revealed Section J, related to pain, had not been completed. The assessment indicated the resident pain assessment interview should be conducted, but the questions related to pain presence, frequency, effect on function, and intensity were not completed. The staff assessment of pain was also not completed. Employee Identifier (EI) #1, MDS Coordinator, was interviewed on 8/10/2017 at 1:25 p.m. EI #1 was asked who completed section J of RI #6's MDS assessment with an ARD of 6/2/2017. EI #1 said, I did. EI #1 said, the information for the 6/2/2017 MDS in section J was not captured in the seven day look back time frame. When asked why it was important to assess the resident within the ARD time frame, EI #1 said, To have current information. EI #1 said the information should have been in section J.

Based on observation, interview and a review of the facility pre-planned menus, the facility failed to ensure the menu was followed for the lunch meal on 8/9/2017. The dessert portion of pineapple was insufficient. The plan was for l/2 cup serving (4 ounce (oz.), but staff portioned 1/4 cup (2 oz.) serving. This had the potential to affect 76 residents who received meal trays in the facility on 8/09/2017. Findings Include: A review of the pre-planned menu revealed a dessert plan for Pineapple Tidbits. The designed portion size prepared/packaged for distribution was l/2 cup. On 8/9/2017 at 11:50 a.m., during the preparation of the lunch trays, the pineapple serving was observed to be half of the planned dessert portion size of 1/2 cup. Employee Identifier (EI) #3, the Certified Dietary Manager (CDM), measured the portioned amount served in a #8 scoop. The scoop was observed to be only half full. Thus a serving of 1/4 cup or 2 ounces had been portioned for 76 residents instead of the plan for 1/2 cup or 4 ounces. At 11:50 a.m. on 8/9/2017, EI #3 verbalized that the scoop was only half full.

Based on observation, interview and record review the facility failed to ensure licensed staff pulled the privacy curtain and closed the door to Resident Identifier (RI) #2's room while performing a nursing procedure. This affected one of 10 sampled residents observed during the survey. Findings Include: A facility policy titled OPS123 Treatment: Considerate and Respectful with a revised date of 09/01/2013 documented .PROCESS .1.8) Privacy: Maintain patient privacy of body . RI #2 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 5/15/2016 documented a Staff Assessment for Mental Status indicated RI #2 was severely cognitively impaired. On 6/22/2016 at 4:13 PM the surveyor observed RI #2's door open and licensed staff were preparing to draw RI #2's blood. A CNA (Certified Nursing Assistant) knocked on the RI #2's door and said she was going to close the door. The surveyor observed privacy curtains on both sides of RI #2's bed were not drawn. A CNA left RI #2's room and and returned then a nurse left the room then returned and both left the door open and the privacy curtain was still not drawn. On 6/22/2016 at 4:30 PM an interview was conducted with Employee Identifier (EI) #1. EI #1 was asked why was the door to RI #2's room left partially open and the privacy curtain not drawn. EI #1 said all I can say is people kept coming in and out. Everytime someone would knock on the door we would have to catch it so it would not hit the bed. EI #1 also said she thought when they first entered the room the door was closed behind them, but people kept coming in and out. EI #1 was asked what was the facility policy on privacy while care was provided to a resident. EI #1 said the door should be shut and the curtain should be drawn so the resident could have privacy.

Based on record review and an interview the facility failed to ensure RI (Resident Indentifer) # 11's most recent Quarterly Minimum Data Set (MDS) was marked to show he/she was receiving Hospice services. This affected one of two residents sampled for Hospice. Findings Include: RI # 11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI # 11's most recent Physician order [REDACTED].Admit to .Hospice 10/09/15 . A review of RI # 11's most recent Quarterly MDS Section O, with an Assessment Reference Date (ARD) of 4/23/16 did not show RI # 11 was receiving Hospice services. An interview was conducted with Employee Indentifer (EI) # 2, MDS Coordinator on 6/23/16 at 10:30AM. EI # 2 was asked if RI # 11 was currently receiving Hospice services. EI # 2 replied yes. EI # 2 was asked if the MDS with an ARD of 4/23/16 was marked to show RI # 11 was receiving Hospice services. EI # 2 replied no and stated it should be marked. EI # 2 was asked why it was not marked. EI # 2 replied it was a data error. EI # 2 was asked what is the importance of marking the MDS to show a resident is receiving Hospice services. EI # 2 replied accuracy of the MDS.

Based on observations, interviews and record review, the facility failed to ensure food was stored, prepared and served in a manner to prevent the potential for cross-contamination. The facility failed to ensure: 1) a dietary staff member not wear a facial earring during preparation and service of food; 2) the thermometer probe was wiped off after food temperatures were taken and prior to placing into the food; 3) the thermometer was not dropped into the cooked pureed sloppy Joe with the dial touching the sloppy Joe; 4) a gallon of tea in the refrigerator was dated with a use by date, chicken breast in the freezer had a use by date, and sandwiches were not fully covered in the refrigerator; 5) staff accurately calibrate the thermometer by ensuring the stem probe did not touch the bottom or sides of the container; 6) a plate was clean prior to using; 7) resident's plates were covered when leaving the kitchen until served; 8) ice cream remained frozen; 9) yogurt temps were taken prior to placing them on the residents trays and were 40 degrees or lower (measured 58 degrees when checked); 10) dietary staff hair was covered by the hairnet (while in the food prep area); and 11) a dust mop and broom handle were not in the eye wash station sink. This had the potential to affect all 71 residents receiving meals from the kitchen. Findings Include: 1. On 5/5/15 at 11:15 AM, Employee Identifier (EI) #3 (Cook) was in the food prep area. EI #3 was observed at the stove and on the serving line. EI #3 had a small silver earring near her lip. At 12:20 PM, the surveyor asked EI #3 what was above her lip and EI #3 replied, "An earring." The facility policy titled, "Personal Hygiene" with a revision date of 10/1/14 revealed: "... Jewelry is limited to a wedding band and non-dangling earrings in ears; facial jewelry is not permitted ..." A review of the 2013 Food and Drug Administration's Food Code revealed, "2-303.11 Except for a plain ring such as a wedding band, while preparing FOOD, FOOD EMPLOYEES may not wear jewelry ..." On 5/6/15 at 5:00 PM, EI #2 (Dietary Manager) was asked what was the facility's policy on staff wearing jewelry in the kitchen and food prep area. EI #2 said, "They can wear studs and a wedding band." EI #2 was asked if she was aware EI #3 had an earring near her lip on 5/5/15 while serving food. EI #2 said she did not notice it until today (5/6/15). EI #2 said EI #3 told her and she (EI #2) told her to remove it. 2. On 5/5/15 at 11:55 AM, EI #4 (Cook) took the thermometer out of the pureed sloppy Joe and placed it into the cup of ice water and then back into the sloppy Joe without wiping the probe. At 11:58 AM, EI #2 rechecked the thermometer that was in the pureed sloppy Joe. EI #2 took the thermometer out of the sloppy Joe and said "It is not right" and placed it into the cup of ice water without wiping the probe. EI #2 took the thermometer out of the ice water and placed it back into the pureed sloppy Joe without wiping the probe. At 12:00 PM, EI #2 took the thermometer out of the cup of ice water and wiped it with a paper towel. EI #2 then placed the thermometer in the pureed sloppy Joe that was on the stove. The facility's policy titled, "Thermometer Usage" with a revision date of 04/01/14 revealed: "... Process: Thermometers are washed, rinsed, sanitized, and air dried before and after each use to prevent cross-contamination ..." A review of the 2013 Food and Drug Administration's Food Code 4-702.11 revealed, "... UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT shall be SANITIZED before use after cleaning ..." On 5/6/15 at 5:00 PM, EI #2 (Dietary Manager) was asked when checking food with the thermometer, should the probe be cleaned. EI #2 said it should. The surveyor asked EI #2 when should it be cleaned. EI #2 replied, "Before it goes into the food." EI #2 was asked what would be the potential harm if the probe was taken out of a food and placed into the cup of ice water without cleaning it. EI #2 replied, "Cross-contamination." EI #2 was asked if she was aware that staff had placed the probe into the ice water without cleaning it and EI #2 said she was not. EI #2 was asked if she realized she had placed the thermometer probe in ice water and back into the sloppy Joe without cleaning it and she said she did not remember. 3. On 5/5/15 at 11:58 AM, EI #2 was checking the temperature of the purees sloppy Joe. EI #2 dropped the thermometer into the pan of pureed sloppy Joe and the dial was observed lying in the sloppy Joe. EI #2 turned around to look at the thermometers in the cup of ice water while the thermometer remained in the sloppy Joe. At 12:00 PM, EI #2 picked the thermometer out of the pureed sloppy Joe and put it back into the ice water without wiping it. The facility's policy titled, "Thermometer Usage" with a revision date of 04/01/14 revealed: "...Process: Thermometers are washed, rinsed, sanitized, and air dried before and after each use to prevent cross-contamination..." A review of the 2013 Food and Drug Administration's Food Code 4-702.11 revealed, "...UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT shall be SANITIZED before use after cleaning..." On 5/6/15 at 5:00 PM, EI #2 (Dietary Manager) was asked if she was aware that she dropped the entire thermometer into the pan of pureed sloppy Joe when she was checking the temperature of it and EI #2 said she didn't know that. EI #2 was asked what would be the potential harm for dropping the thermometer into the food and EI #2 said, "Cross-contamination." 4. During initial tour on 5/5/15 at 7:15 AM, a gallon of tea was observed in the refrigerator not dated, a bag of chicken breast was in the freezer with no date and a tray of sandwiches was observed not fully covered. A review of the facility's policy titled, " Refrigerated/Frozen Storage" with a revision date of 10/06/13 revealed: "... Refrigeration: Prepared foods are labeled and dated with name of product, date prepared, and "use by" date ... Freezer: Food is dated when received ..." A review of the 2013 Food and Drug Administration's Food Code 3-501.17 revealed: "... refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold or discarded ..." On 5/6/15 at 5:00 PM, EI #2 was asked what was the facility's policy on labeling items in the refrigerator and freezer. EI #2 replied, "We label and date everything." EI #2 was asked why should items be labeled. EI #2 said to make sure the items were use timely. The surveyor asked EI #2 what would be the potential harm if items were not dated and EI #2 said they could be out of date. 5. On 5/5/15 at 11:15 AM, EI #4 (Cook) calibrated the thermometer prior to checking the temperatures of the food on the trayline. EI #4 adjusted the thermometer by the handle and placed it into a cup of ice water. The thermometer was laid against the side of the cup and the bottom was touching the bottom of the cup. EI #4 took the thermometer out of the pureed sloppy Joe and placed it into the cup of ice water and back into the sloppy Joe without wiping the probe. At 11:58 AM, EI #2 checked the thermometer that was in the pureed sloppy Joe. EI #2 took the thermometer and placed it in a cup of ice water and left it. The thermometer was lying against the side of the cup and the end of the probe was touching the bottom of the cup. A review of the facility's policy titled, "STEM THERMOMETER CALIBRATION METHODS (not dated), revealed, "Put the thermometer stem or probe into the ice water so the sensing area is completely submerged. Do not let the stem or probe touch the container's bottom or sides ..." On 5/6/15 at 5:00 PM, EI #2 was asked how were staff supposed to calibrate a thermometer. EI #2 said they put it into ice and get the temperature to 32 degrees. EI #2 was asked should the probe touch the containers bottom or sides. EI #2 said, "Yes, we put them in the ice and when it stops, we have to get the temps to 32 degrees Fahrenheit." EI #2 was asked why was the thermometer placed in a cup of ice and left. EI #2 replied, "That is the way we have always done it." 6. During observation of the trayline on 5/5/15 at 11:15 AM, EI #4 (Cook) picked up a scooped plate that had four black specs on it. The surveyor asked EI #4 what was on the plate. EI #4 never responded, and only wiped two of the specs off of the plate and put food onto the plate. A review of the facility's policy titled, "Food Handling" with a revision date of 03/16/15 revealed: "Policy: Foods are stored, prepared and served in a safe and sanitary manner. Purpose: To prevent bacterial contamination and the possible spread of infection ..." A review of the 2013 Food and Drug Administration's Food Code 4-601.11 revealed: "Equipment FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch ..." On 5/6/15 at 5:00 PM, EI #2 was asked should dinnerware/plates be clean prior to placing food on them. EI #2 replied, "Yes." The surveyor explained the observation of staff using a plate with black specs on it and asked what would be the potential harm for using it. EI #2 replied, "Cross-contamination-It's dirty." The surveyor asked EI #2 if staff should have use the plate and EI #2 said no. 7. On 5/5/15 at 12:20 PM, plates were observed on the tray cart in the kitchen. Dietary staff pushed the cart into the dining room without covering the food. Several staff in the dining room were observed passing out the un-covered plates of food with bare hands. The surveyor asked EI #4 if they covered the plates of food that went to the dining room. EI #4 replied, "No, we use to." The surveyor asked EI #4 why did they stop covering them. EI #4 said, "Not sure." A review of the facility's policy titled, "Food Handling" with a revision date of 03/16/15 revealed: "Policy: Foods are stored, prepared and served in a safe and sanitary manner. Purpose: To prevent bacterial contamination and the possible spread of infection ... Process: During transportation of food from the kitchen to the dining rooms ... care is taken to keep hot food hot and cold food cold and protected from contamination ..." A review of the 2013 Food and Drug Administration's Food Code 3-305.11 revealed: "... FOOD shall be protected from contamination ... where is is not exposed to splash, dust, or other contamination ..." On 5/6/15 at 5:00 PM, EI #2 was asked if food was covered until served. EI #2 said they covered it except for in the dining room. EI #2 said those plates were served immediately. The surveyor asked why were dome lids not used when plates were delivered to the dining room on 5/5/15. EI #2 said staff took them out and they were served immediately. The surveyor asked EI #2 if staff in the dining room were passing out plates with their bare hands. EI #2 said staff did help, but she was not sure if they wore gloves. The surveyor asked EI #2 why did they stop using the dome lids. EI #2 said they had not used them in the dining room unless it was something hard to keep tempted. The surveyor asked EI #2 if the food was not covered, would it be protected from contamination during transportation and distribution. EI #2 said she did not know. 8. During tray line observation on 5/5/15 at 12:06 PM, dietary staff placed ice cream on the resident's trays. Five ice cream containers were soft to touch. At 12:10 PM, the surveyor asked to see the ice cream in the freezer. Eight containers were observed to be soft when checked by the surveyor. A review of the facility's policy titled, "Refrigerated/Frozen Storage" with a revision date of 10/06/13 revealed: "... POLICY: Food stored under refrigeration/freezer storage are maintained in a safe and sanitary manner. PURPOSE: To prevent damage, spoilage, and contamination of products ..." A review of the 2013 Food and Drug Administration's Food Code 3-501.11 revealed: "... Frozen Food. Stored frozen FOODS shall be maintained frozen ..." On 5/6/15 at 5:00 PM, EI #2 was asked how should ice cream be when served. EI #2 replied, "Should be frozen." EI #2 said she was not sure what happened with the ice cream during tray line observation, but she moved it away from the freezer door. The surveyor asked EI #2 what was the facility's policy on ice cream remaining frozen. EI #2 said they tried to keep it frozen. 9. On 5/5/15 at 12:06 PM, the first cart was ready to leave the kitchen and the surveyor asked staff to check the temperature of the yogurt. The temperature measured 58 degrees. A review of a facility policy titled: "Hazard Analysis and Critical Control Points" (not dated) revealed: "... Cold Holding: Maintain food temp (Temperature) of 40 (degrees) F (Fahrenheit) or below. A review of the 2013 Food and Drug Administration's Food Code 3-501.12 revealed: "... Time/Temperature Control for Safety Food, Slacking ... (A) Under refrigeration that maintains the FOOD temperature at 5 degrees C (Celsius) (41 degrees F) or less ..." On 5/6/15 at 5:00 PM, EI #2 was asked if staff checked the temperature of yogurt prior to serving it. EI #2 said, "Not usually." EI #2 was asked what should the temperature be and EI #2 said below 40 degrees. The surveyor asked why did staff not check the yogurt temperature prior to the cart leaving the kitchen on 5/5/15. EI #2 said it was not listed on the production sheet as an item to check. 10. On 5/5/15 at 11:50 AM, EI #4 (Cook) began plating food on the tray line. EI #4's hair was exposed around the edges of the hairnet. At 11:58 PM, EI #2 was observed taking temps in the tray line area, at the steam table. EI #2's hair was not completely covered by the hairnet during this time nor was it covered when EI #2 reheated pureed sloppy Joe at the stove. A review of the facility's policy titled, "Personal Hygiene" with a revision date of 10/1/14 revealed: "... Process: Hair restraints such as hats, hair coverings or nets are worn to effectively keep hair from contacting exposed food ..." A review of the 2013 Food and Drug Administration's Food Code 2-402.11 revealed: "... Hair Restraints ... FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD ..." On 5/6/15 at 5:00 PM, EI #2 (Dietary Manager) was asked if she was aware that EI #4's hair was exposed around the hairnet while in the food prep area on 5/5/15. EI #4 said, "It may have blowed off in the cooler." EI #2 was asked if she was aware her hair was exposed out of the hair net on 5/5/15 while taking temperatures and heating the pureed sloppy Joe. EI #2 said she did not know it. EI #2 was asked what would be the potential harm for hair to be hanging out of the hairnet. EI #2 said, "Could get hair in the food." 11. During initial tour of the kitchen on 5/5/15 at 7:15 AM, the eye wash station sink was observed to have a duster and a mop/broom handle standing up in the sink. A review of information provided by the facility titled, "Logbook Documentation" dated 4/27/15 revealed: "... Eye Wash Stations ...Verify that the eyewash stations are accessible and unobstructed ..." On 5/6/15 at 5:00 PM, EI #2 was asked why was the mop/broom handle and the duster in the eye wash station sink. EI #2 replied, "I was cleaning the corner and I put it there so I could clean the floor." EI #2 was asked what would be the potential harm. EI #2 said she did not know.

Based on record review and interview, the facility failed to notify the sponsor of Resident Identifier (RI) #14 of an opened blister to the resident's left heel that was draining and required treatment. This affected one of 3 residents reviewed for notification. Findings include: The facility's policy titled, "NSG (Nursing) 210 Communication of Health Status", revised date 10/01/12, documented: " PURPOSE To facilitate patient/responsible party understanding of health status. PRACTICE STANDARDS 1. Advise patient and/or health care decision maker of any changes in his/her medical condition, medication orders or treatment orders ..." RI #14 was readmitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) Assessment, dated February 21, 2015 identified the resident with long and short term memory deficit and severely impaired in decision making regarding tasks of daily life. RI #14 was also identified with being totally independent in walking and locomotion on and off the unit. RI #14 did not have impairment of the upper and lower extremities. Review of RI #14's medical record revealed a "Change of Condition Documentation" form, dated 4/28/15. The reason given for calling the Physician was documented, "Blister Heel (Left)." The Nursing Progress Note located on the form was documented, "... nurse put a heel protector on to absorb the drainage next day ordered a doppler on both legs." The Physician notification date was documented for 4/28/15. The responsible party notification was documented for 5/2/15. Further review of the medical record revealed an Interdisciplinary Progress Notes form dated 5/5/15, "late entry Notified Sponsor on 5/2/15 of blister on (L) heel." On 05/7/15 at 10:00 AM, the nurse who identified the blister, Employee Identifier (EI) #7, Licensed Practical Nurse, was interviewed. EI #7 was asked when the blister was identified. EI #7 said on 4/28/15. EI #7 said she cleaned the area and got an order for [REDACTED]. EI #7 was asked when should a sponsor be notified. EI #7 said she should notify when anything is found wrong with the residents.

Based on observation, interviews, record review and review of a facility policy titled "Medication Administration: Injectable IM (Intramuscular), Sub-Q (Subcutaneous), Z-Track", the facility failed to ensure Employee Identifier (EI) #5, a RN (Registered Nurse) medication nurse, provided privacy for Resident Identifier (RI) #17 by closing the door and pulling the blinds before administering the resident an insulin injection on 05/06/2015. This affected one of two medication nurses observed during the Medication Administration Observation Pass. Findings Include: The facility's policy and procedure titled "Medication Administration: Injectable IM, Sub-Q , Z-Track", with a revised date of 12/08/14, documented: "... 3. Administer medication ... 3.2 Explain the procedure and provide privacy ..." RI #17 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of RI #17's Order Summary Report (physician's orders [REDACTED]. "... HumaLOG Solution 100 UNIT/ML (milliters) (Insulin [MEDICATION NAME] (Human) Inject 16 unit subcutaneously in the evening for Diabetes [MEDICATION NAME] R (Regular) Solution (Insulin Regular Human) Inject as per (by) sliding scale ... 200.0 - 249.0 = 4 ..." On 05/06/2015 at 5:00 p.m., the surveyor observed EI #5 check RI #17's blood sugar which was noted to be 200. EI #5 returned to the medication cart, retrieved RI #17's Humalog insulin pen, a syringe and RI #17's vial of [MEDICATION NAME] Regular insulin and reentered RI #17's room. EI #5 pulled the privacy curtain around RI #17's roommates bed but failed to close the door or the blinds at the window. RI #17 pulled up his/her shirt exposing his/her abdomen. EI #5 wiped RI #17's left abdomen with an alcohol wipe and administered 4 units of [MEDICATION NAME] Regular insulin. EI #5 next administered 16 units of Humalog insulin to RI #17's right abdomen after cleaning the area with an alcohol wipe. During this procedure EI #9, the RN (Registered Nurse) Unit Manager for the unit RI #17 resided on, came to RI #17's door and looked inside the room. The blinds at the window remained opened and staff could be observed on the outside of the window. On 05/06/2015 at 6:17 p.m., the surveyor conducted an interview with EI #5. The surveyor asked EI #5 how does she provide privacy when administering an injection. EI #5 replied she would take the resident to the room. EI #5 said if a resident was in the room she would tell them she was going to pull the privacy curtain and make sure the door was closed. EI #5 also said she would close the blinds at the window. The surveyor asked EI #5 did she realize that the door to RI #17's room and the blinds at the window were open when she administered him/her insulin injections. EI #5 stated she did not realize the blinds were open and she thought she had closed the door. The surveyor asked EI #5 why should the door and blinds have been closed. EI #5 replied, "For privacy." On 05/07/2015 at 2:03 p.m., the surveyor conducted an interview with EI #9. The surveyor asked EI #9, when administering an insulin injection to a resident, how are you to provide for privacy. EI #9 said you should take the resident in the room, close the door and pull the privacy curtain. EI #5 also said if the blinds at the window were open she would close them.

Based on interviews and record review, the facility failed to ensure Resident Identifier (RI) #6's Quarterly Minimum Data Set ((MDS) dated [DATE], accurately assessed that the resident was receiving the Antipsychotic medication [MEDICATION NAME]. The facility further failed to ensure RI #5's Annual MDS assessment, dated 07/15/2014, accurately assessed the resident's correct height. This affected RI #5 and #6, two of 17 residents whose MDS was reviewed. Finding Include: 1. RI #6 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of RI #6's hospital Discharge Medication Reconciliation sheet, dated 02/18/2015, documented: "... [MEDICATION NAME] 10 MG (milligram) ([MEDICATION NAME] 10 MG) 1 TAB (tablet) ORAL Bedtime ..." The Quarterly MDS assessment, with an ARD (Assessment Reference Date) of 02/25/2015, revealed RI #6 had not been assessed as receiving an antipsychotic medication during the 7 days of this assessment period. A review of RI #6's February 2015 MAR (Medication Administration Record) revealed the resident did receive the [MEDICATION NAME] 10 mg at bedtime during the seven day assessment period. On 05/07/2015 at 2:58 p.m., the surveyor conducted an interview with Employee Identifier (EI) #6, the RN (Registered Nurse) Clinical Reimbursement Coordinator. The surveyor asked EI #6 was RI #6 sent back to the facility (on 02/28/15) on [MEDICATION NAME] 10mg. EI #6 replied, "It appears so." The surveyor asked EI #6 should the antipsychotic medication have captured on RI #6's 02/25/15 MDS. EI #6 replied, "Yes Ma'ma." The surveyor asked EI #6 why the medication did not capture on the 02/25/15 MDS Quarterly Assessment. EI #6 replied it was a data entry error. 2. RI #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #5 "Hospital "Discharge Summary" included admission date of [DATE] and a discharge date of [DATE], documented the following: "Primary Care Provider: ... The patient is a [AGE] year old ... with history of [MEDICAL CONDITION], status left femoral popliteal bypass in the past, left above knee amputation in the past which has required multiple debridement's of the lt (left) above the knee amputation in the past ... Dr. ___ performed right below knee amputation on March 29, 2012, for gangrene right foot ... The patient will be transferred back to (name of nursing home) today ..." A review of RI #5's medical record revealed an Annual Minimum Data Set, with an ARD of 07/15/2014. A review of the Annual MDS in "Section K Swallowing / Nutritional Status Section K0200. Height and Weight ... 65 inches - A. Height (in inches). Record most recent height measure since the most recent admission/entry or reentry ... " A comparison review of RI #5's Quarterly MDS with an ARD of 04/17/2015, assessed RI #5 in Section K Swallowing / Nutritional Status, Section K0200. Height and Weight ... 33 inches - A. Height (in inches). Record most recent height measure since the most recent admission/entry or reentry ... " On 05/07/15 at 2:05 p.m., the surveyor conducted an interview with EI #13, the MDS Coordinator. The surveyor asked EI #13 who was responsible for coding section K on the MDS assessments. EI #13 said the RD (Registered Dietitian). The surveyor asked EI #13 what was RI #5's height coded on 4/17/15, on the Quarterly MDS assessment. EI #13 said 38 inches. The surveyor asked EI #13 if this was correct. EI #13 said yes. The surveyor asked EI #13 what is RI #5's height coded on 7/15/14, on the Annual MDS assessment. EI #13 said 65 inches. The surveyor asked EI #13 if the height was correct. EI #13 said no sir. The surveyor asked EI #13 why was this incorrect on the assessment. EI #13 said it's a coding error by EI #14's, the RD. EI #13 said EI #14 signed Section K by electronic signature. On 05/07/15 at 3:47 p.m., the surveyor conducted an interview with EI #14, the RD (Registered Dietitian). The surveyor asked EI #14 who was responsible for coding section K on the MDS assessments. EI #14 said she was responsible for coding Section K. The surveyor asked EI #14 what was RI #5's height coded on 4/17/15, the Quarterly MDS assessment. EI #14 said she believe the assessment said 38 inches. The surveyor asked EI #14 if the height was correct. EI #14 said according to nursing who puts that information in the computer, it's accurate for them. The surveyor asked EI #14 what is RI #5's height coded on the 7/15/14 Annual MDS assessment. EI #14 said if she remembered correctly it was 63 inches. EI #14 reviewed the MDS and then stated, "I think it was 65 inches." The surveyor asked EI #14 if the height was correct. EI #14 stated, "It doesn't appear to be." The surveyor asked EI #14 did she signed these assessments to be correct. EI #14 stated, "Yes, I did." The surveyor asked EI #14 would she say the MDS is inaccurate for July 15, 2014 versus April 15, 2015 for RI #5's height. EI #14 stated, "I changed it for the accuracy of the height."

Based on observations, interviews, record review and review of a facility policy titled "NSG (Nursing) 305 Medication Administration: General", the facility failed to ensure a medication nurse, Employee Identifier (EI) #5, did not initial the MAR (Medication Administration Record) before administering medications to Resident Identifier (RI) #16 on 05/06/2015. This affected one of two medication nurses observed during the Medication Administration Observation Pass. Findings Include: A facility policy titled "NSG (Nursing) 305 Medication Administration: General" with an effective date of 01/01/14, and a revision date of 01/02/14, documented: "POLICY A licensed nurse, Med (Medical) Tech (Technician), or medication aide, per state regulations, will administer medications to patients. Accepted standards of practice will be followed ... PURPOSE To provide a safe, effective medication administration process. PRACTICE STANDARDS ... Administer medications ... Document: 9.1 Administration of medication on Medication Administration Record (MAR); ..." RI #16 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of RI #16's Order Summary Report (physician's orders [REDACTED]. "[MEDICATION NAME] Tablet 3.125 MG (milligrams) (Carvedilol) Give 1 tablet by mouth two times a day ... [MEDICATION NAME] Sodium Tablet 100 MG Give 1 tablet by mouth two times a day ... [MEDICATION NAME] 40 MG ([MEDICATION NAME]) Give 1 tablet by mouth one time a day ... [MEDICATION NAME] Tablet 20 MG Give 1 tablet by mouth one time a day ... [MEDICATION NAME] Tablet 5-325 MG ([MEDICATION NAME]-[MEDICATION NAME]) Give 1 tablet by mouth three times a day ... Potassium Chloride Packet 20 MEQ (milliequivalents) (Potassium Chloride) Give one tablet by mouth two times a day ... [MEDICATION NAME] HCI ([MEDICATION NAME]) Give 1 tablet by mouth one time a day ..." On 05/06/2015 at 8:08 a.m., the surveyor observed EI #5 prepare the above medications for administration. Each time EI #5 removed a medication from the medication card or medication bottle, EI #5 initialed the MAR. On 05/06/2015 at 6:17 p.m., the surveyor conducted an interview with EI #5. The surveyor asked EI #5 what was the standard of practice for initialing a MAR. EI #5 replied, "Identify the pill, pop it out and then initial the MAR." The surveyor asked EI #5 should she initial the MAR before or after administering the medications. EI #5 said before she administered the medication she would initial the MAR. On 05/07/2015 at 2:03 p.m., the surveyor conducted an interview with EI #9, the RN (Registered Nurse) unit manager for Wings 2 and 3. The surveyor asked EI #9 what was the standard of practice nurses used after administering medications to a resident. EI #9 said the nurse should come out of the room, wash their hands and were suppose to initial to MAR afterwards. A review of Potter and Perry, "Fundamentals of Nursing", Eighth Edition, 2013, page 586, documents: "... Right Documentation ... After administering a medication, indicate which medication was given on the patient's MAR ... Record each medication on the patient's MAR as soon as you give medication to a patient ..."

Based on observations, interviews, record review and review of a facility policy titled "NSG (Nursing) 102 Care Plans", the facility failed to ensure Resident Identifier (RI) #6 worn non-skid socks as care planned. This was observed on two (2) of three (3) days of the survey. This affected RI #6, one of 13 residents whose plan of care was reviewed. Finding Include: RI #6 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A facility policy titled "NSG 102 Care Plans" with an effective date of 04/15/02, and a revision date of 01/02/14, documented: "... PURPOSE To provide necessary care and services to attain or maintain the patient's highest practicable physical, mental, and psychosocial well being ..." The Quarterly MDS (Minimum Data Assessment) assessment, with an ARD (Assessment Reference Date) of 02/25/2015, assessed RI #6 to score a 9 on the BIMS (Brief Interview for Mental Status) indicating moderately impaired cognition. A review of a care plan with the "Focus" of "Resident is at risk for falls: cognitive loss, lack of safety awareness ... Actual fall: 02/28/2015 ..." documented the following intervention: "... Non-skid socks Date initiated: 02/28/2015 ..." On 05/06/2015 at 2:44 p.m., RI #6 was observed sitting in a wheelchair near the entrance door of the faility. RI #6 was observed to be wearing a pair of white socks and house shoes. On 05/06/2015 at 3:40 p.m., the surveyor observed wound care being performed to RI #6's left heel. Employee Identifier (EI) #9, the RN (Registered Nurse) Unit manager for Wings 2 and 3 removed the white socks from RI #6's left foot in order to perform wound care. After the wound care was completed EI #9 went to the resident's drawer and removed a pair of clean white socks from the drawer and placed one on RI #6's left foot them the right foot. The surveyor asked EI #9 what type socks she placed on RI #6's feet. EI #9 replied cotton. On 05/07/2015 at 9:05 a.m., RI #6 was observed sitting in a wheelchair in the therapy room. RI #6 was wearing a pair of white cotton socks with house shoes on. On 05/07/2015 at 1:18 p.m., the surveyor conducted an interview with EI #12, the CNA (Certified Nursing Assistant) assigned to care for RI #6 on the 6:00 a.m. - 6:00 p.m. shift on 05/07/2015. The surveyor asked EI #12, according to RI #6's "At risk for fall care plan", was the resident care planned for non-skid socks. EI #12 looked at RI #6's care plan and replied, "That's what it says." On 05/07/2015 at 2:03 p.m., the surveyor conducted an interview with EI #9. The surveyor asked EI #9 was the use of non-skid socks on RI #6's "At risk for fall care plan." EI #9 replied yes. The surveyor asked EI #9 who would be responsible for ensuring RI #6 had on the non-skid socks. EI #9 said who ever got the resident out of bed.

Based on observations, record review and interviews, the facility failed to ensure Resident Identifier (RI) #6, a resident with a history of falls and lack of safety awareness, fall intervention to wear non-skin socks was consistently implemented. RI #6 was observed to not have on non-skin socks on two of three days of the survey. This affected RI #6, one of five (5) residents sampled for falls. Findings Include: RI #6 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set) assessment, with an ARD (Assessment Reference Date) of 02/25/2015, assessed RI #6 to score a 9 on the BIMS (Brief Interview for Mental Status) indicating moderately impaired cognition. A review of a care plan with the "Focus" of "Resident is at risk for falls: cognitive loss, lack of safety awareness ... Actual fall: 02/28/2015 Actual fall: 5 Actual fall: 04/14/15 ..." documented the following intervention: "... Non-skid socks Date initiated: 02/28/2015 ..." On 05/06/2015 at 2:44 p.m., RI #6 was observed sitting in a wheelchair near the entrance door of the faility. RI #6 was observed to be wearing a pair of white socks and gray house shoes. On 05/07/2015 at 9:05 a.m., RI #6 was observed sitting in a wheelchair in the therapy room. RI #6 was wearing a pair of white cotton socks with house shoes on. On 05/07/2015 at 1:18 p.m., the surveyor conducted an interview with EI #12, the CNA (Certified Nursing Assistant) assigned to care for RI #6 on the 6:00 a.m. - 6:00 p.m. shift on 05/07/2015. The surveyor asked EI #12 had RI #6 had any falls while a resident at the facility. EI #12 said some. The surveyor asked EI #12, according to the corrective actions from the investigation done on 02/28/2015, what interventions were put in place. EI #12 said, non-skid socks and instruction on asking for assistance. On 05/07/2015 at 2:03 p.m., the surveyor conducted an interview with EI #9, the RN (Registered Nurse) unit manager for the hall RI #6 resides. The surveyor asked EI #9 what was the root cause of RI #6's fall on 02/28/2015. EI #9 said it was improper foot wear that contributed to the fall. The surveyor asked EI #9 what type footwear did RI #6 have on. EI #9 replied, plain socks. The surveyor asked EI #9 what corrective actions were put in place. EI #9 replied, "Non-skid socks and instruction on asking for assistance."

Based on observation, interviews, and review of a facility policy titled "NSG (Nursing) 300 Controlled Drugs: Management of'", the facility failed to ensure a stock controlled injectable drug Lorazepam (Ativan) 2 mg (milligrams)/ml (milliliter) (2 vials), were stored in a locked box compartment permanently affixed in the refrigerator. This affected one of two medication rooms in the facility. Findings Included: A facility policy titled "NSG 300 Controlled Drugs: Management of'", with an Effective Date of 08/01/05, and a Revision Date of 05/15/14 documented the following: "POLICY ... The management of controlled drugs - including the ordering, receipt, storage, administration, ongoing inventory, and destruction - is conducted under the direction and ultimate responsibility of the Administrator and Director of Nursing, and follows safe practice and federal/state regulations ... 3. Storage and Maintenance of Controlled Drugs: ... 3.4 Maintain controlled drugs in a double locked box/cabinet separate from other medications. This includes controlled drugs stored in the medication refrigerator ..." On 5/6/15 at 3:55 p.m., during the observation of the medication room, the surveyor, the Director Of Nursing (DON) from a sister facility, Employee Identifier (EI) #1 and the Unit Manager of station 4, EI #8, observed the Ativan in the refrigerator. EI #8 opened the refrigerator and the "HOUSE STOCK REFRIGERATOR BOX" of medications was observed lying on a rack. The surveyor observed a sheet on the box which was titled "Refrigerator Box List" and the list included the controlled medication Ativan 2 mg/ml in 2 vials. This clear plastic box was sealed but was not attached to a rack in the refrigerator. The box and the rack was not permanently affixed and secured to the inside of the refrigerator. EI #1 lifted the clear plastic box off the rack and it was easily removed from the refrigerator. On 5/6/15 at 4:10 p.m., the surveyor conducted an interview with EI #8, the Unit Manager of station 4. The surveyor asked EI #8 how long Ativan had been in the box which was not permanently affixed to the refrigerator. EI #8 said since it (the Ativan) was delivered 5/5/15. On 5/6/15 at 4:13 p.m. the surveyor conducted an interview with EI #1, the DON from a sister facility. The surveyor asked EI #1 how should Ativan be stored in the refrigerator. EI #1 stated "In a permanently affixed box behind two locks." EI #1 asked the surveyor if they could take the box with the Ativan in it and lock the medication in the refrigerator on another unit. The surveyor explained that the survey team could not advise the facility what to do.

Based on observations, interviews and review of a facility policy titled "... Posting Staffing", the facility failed to post nurse staffing data at the beginning of each shift on three of three days of survey. This deficient practice had the potential to affect all residents residing in the facility. Findings include: A facility policy and procedure titled "... Posting Staffing" with an effective date of 12/27/05, and a revision date of 09/01/13, documented: "... PURPOSE To comply with federal and state regulations regarding posting nursing staffing levels. PROCESS ... 3. The posting should be: ... 3.2 completed on a daily basis at the beginning of each shift ..." 1. On 05/05/2015 at 1:06 p.m., (during the 6:00 AM - 6:00 PM and 7:00 AM - 7:00 PM shift), the nurse staff data posted was dated 05/05/2015 and included Day, Evening and Night shifts. On 05/06/2015 at 9:06 a.m., (during the 6:00 AM - 6:00 PM and 7:00 AM - 7:00 PM shift), the nurse staff data posted was dated 05/06/2015 and included Day, Evening and Night shifts. On 05/07/2015 at 9:10 a.m., (during the 6:00 AM - 6:00 PM and 7:00 AM - 7:00 PM shift), the nurse staff data posted was dated 05/07/2015 and included Day, Evening and Night shifts. 2. On 05/07/2015 at 3:15 PM, Employee Identifier #11 (Staffing Coordinator) was asked who was responsible for posting of staffing at the facility. EI #11 said she was. EI #11 was asked when was staffing supposed to be posted. EI #11 said. "First thing in the mornings." EI #11 was asked what was the facility's policy on posting of staff. EI #11 said "The way we do it is the policy." The staffing sheets were provided for EI #11 to review for 05/05/15, 05/06/15 and 05/07/15. EI #11 was asked if all shifts were normally posted at the same time and EI #11 said they were. The surveyor asked EI #11 if she was aware the regulation stated staffing should only be posted at the beginning of each shift. EI #11 said, "No, I didn't know that." On 05/07/2015 at 3:20 PM, EI #10 (Administrator) was asked who was responsible for the posting of staffing at the facility. EI #10 said the staffing coordinator was. EI #10 was asked when was the staffing supposed to be posted. EI #10 replied, "Before the shift for the day." EI #10 was asked if the staffing coordinator put all of the staffing on the staffing sheet for the entire day. EI #10 said, "Yes." EI #10 was asked what was the facility's policy on posting of the staffing. EI #10 said, "I have not had the opportunity to read it." EI #10 was asked if she was aware the regulation stated staffing should be posted at the beginning of each shift and EI #10 said she was.

Based on observation and interviews, the facility failed to ensure food was maintained at palatable temperatures when served in the dining room. This had the potential to affect 29 of 80 residents who receive their meals in the dining room during the noon meal. Findings included: 1) During the resident group meeting on 08/06/14 at 10:00 AM, three of the six participating residents complained the meals served in the dining room at lunch were not always warm. 2) On 08/06/14 at 4:00 PM, a family member reported to a surveyor, the food served in the dining room was cold on an on-going basis. 3) In response to the above concerns, the surveyor requested an evaluation of the dining room food (via test trays) at the completion of the lunch meal on 08/07/14 at 12:30 PM. The alternate entree, Liver and Onions with Gravy was unpalatably cool, with an observed temperature measurement of 110 degrees Fahrenheit. The food was delivered to the dining room residents, directly from the kitchen (just a few feet away). Dietary staff were observed to fully load two open-sided carts, with a total of 29 trays, prior to rolling them both out of the kitchen and into the dining room. (This procedure was found to take about five minutes per cart, or 10 minutes total for the two carts on the previous day.) None of these trays had a means of insulating the food temperatures at which they were plated from the steam table. At 12:55 PM, the Dietary Manager measured the Liver and Onions/Gravy in the kitchen. The pan of liver had just been removed from the steam table. The internal temperature measured 160 degrees Fahrenheit (50 degrees warmer than the liver tested in the dining room). At 1:00 PM, a Diet Aide (Employee Identifier/EI #1) was questioned whether or not the Kitchen staff used insulated lids and bases for the plated food in the dining room. EI #1 stated, "No" and explained the residents wanted immediate access to their food, and the trays could be served quickly. At 1:10 PM, the Dietary Manager (EI #2) confirmed the dining room trays were served without insulated lids or bases, due to the proximity of the kitchen to the dining room. When asked how the food temperatures could be improved in the dining room, EI #2 stated they could possibly use (insulated) bases and/or dome lids. At 1:30 PM, the surveyor asked the facility Administrator (EI #3) why no covers or bases were used with the service of dining room trays. EI #3 explained the food served in the dining room was passed immediately from the kitchen to the dining room (after the two carts were loaded) to ensure all residents were served at the same table, at the same time. When questioned about the length of time it took, EI #3 stated the tray delivery had not been timed or recorded, but delivery usually took no more than 10 minutes (a total of 20 minutes from the time the food was plated in the kitchen, until delivery in the dining room). When asked if there was anything the staff could do to improve the food temperature, EI #3 stated they might be able to pass the trays from the kitchen directly to the dining room staff through the kitchen 1/2-door, as each tray was prepared.

Based on observations and interview the facility failed to ensure the kitchen was free of dust above the steam table and of chipped paint in three areas of the kitchen where food was prepared or served. This had the potential to affect 72 of 74 residents receiving their meals from the kitchen. Findings include: During the initial kitchen tour on 6/18/2013 at 12:30 PM, the surveyor observed chipped paint on the ceiling above a double sink and a prep-table. On 6/19/2013 at 6:35 AM the surveyor entered the kitchen to observe the tray line. The surveyor observed the same areas to have chipped paint as on 6/18/2013 as well as chipped paint on the ceiling above the food carts which were prepared for meal delivery. The surveyor also observed dust on a pipe above the steam table. The steam table had sausage, pureed sausage, pureed eggs, gravy, and oatmeal in individual pans. At 7:02 AM the surveyor observed staff plating the breakfast meal for the residents on the 400 Hall. On 6/20/2013 at 9:00 AM, the surveyor and EI #2, Dietary Manager observed dust on the pipe above the steam table. The surveyor asked EI #2 when the pipe had been cleaned. EI #2 explained last week she had observed staff using a broom to clean the pipe. The surveyor asked EI #2 what was the potential for harm with the dust on the pipe above the steam table. EI #2 stated it could fall in the food. The surveyor and EI #2 observed the chipped paint above the double sink, the prep-table and the area where food carts were stored during the 6:35AM meal observation. The surveyor asked EI #2 who was responsible for ensuring the ceiling paint was not chipping. EI #2 said she was aware of it but she does not fix ceilings. The surveyor asked EI #2 what was the purpose of the double sink with the chipped paint above it. EI #2 explained frozen food is defrosted in the sink. The surveyor asked EI #2 what was the potential harm when the ceiling's paint was chipping in the above areas. EI #2 stated the paint could fall and go into the food.