Every finding on record at Kenwood Health and Rehabilitation Center

50491 Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to provide a safe, clean, comfortable, and homelike environment for its residents. The findings include: Review of the facility's policy titled Floor Care procedures, dated September 5, 2017, revealed the facility would ensure floors would be cleaned, stripped and six to eight coats of finish applied; allowing each coat to dry completely before applying the next coat. Review of the facility's policy titled Housekeeping Procedures (HP), dated September 5, 2017, revealed the facility would ensure every room would be cleaned as it was the resident's home and should be treated as such. Further review revealed each resident's room would be deep cleaned at least once monthly. This would include to clean behind furniture, sanitize commode, tank, bowl, and base. Also sanitize sinks, light fixtures, mirrors, vents, cords, refrigerators, wheelchairs, and the curtains as needed. Review of the facility's Maintenance Technician (MT) job description, dated April 19,2024, revealed the Maintenance Department was responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner. Further review revealed maintenance was to protect the assets of the facility by diagnosing and performing preventative maintenance and repairs to the physical structures which may include ceilings, light bulbs, walls, doors, windows, floors, beds and miscellaneous. Review of the facility's Maintenance Director (MD) job description, dated April 19, 2024, revealed the MD was responsible for managing and supervising maintenance staff, coordinating, and performing activities of the Maintenance Department to ensure the center was attractive and maintained in good repair. The MD was responsible for work orders. Review of the facility's Administrator job description not dated revealed the Administrator was responsible for the direct day-to-day functions of the facility. Further review revealed the Administrator worked with and supervised personnel in the facility providing instruction, guidance, and counseling as necessary to ensure complete understanding of responsibilities. Review of the facility's Unit Manager (UM), job description revealed UM duties included conducted frequent rounds and maintained awareness of comfort and safety needs of the residents. Also, to investigate complaints and take necessary action to resolve problems. And to perform additional duties, which included submitting repair orders for the Maintenance Department. Observation on 06/06/2024 at 2:28 PM, of the Hallway E Shower Door revealed the kick plate towards the bottom had numerous blackish scuff marks across the bottom section. Continued observation of the E Hall revealed a thumb size hole in wall about 10 inches above the handrail between the shower door and Room E 11 door, that had been wallpapered and painted over to cover try to cover the hole. Further observation of the E Hall revealed the entire E Hallway had scuff marks on the tile all down the hallway. Additional observations of the E Hall revealed Room E 8 had a linear one-inch-long by two-foot area of black marring behind the door, approximately a foot off the floor, traveled about two feet linear along the wall. During an interview with the Housekeeping Supervisor (HS), on 06/06/2024 at 1:50 PM, she stated the facility had contracted through Health Care Services to provide housekeeping services, and Hallway E had not been stripped and waxed since last year. She stated stripping and waxing was routinely completed on the weekends and it was often pushed back because something else would come up. During continued interview, she stated she was responsible for overseeing the housekeeping needs of the facility and would participate in room rounds with the Administrator about three times a week to see what needed completed. In addition, she stated each unit supervisor was responsible for letting her know what needed to be cleaned and she added it to the work week schedule. She continued to state, each supervisor was responsible for checking to make sure the work was acceptable. During an interview with Maintenance Director (MD), on 06/06/2024 at 2:10 PM, he stated he was responsible for reviewing facility work orders and making needed repairs. The MD stated staff would let him know when repairs were needed when passing them in the halls, by calling him on his cell phone, or they placed work orders in TELS (the facility's computerized system). He stated he then would assess needed materials, go over the needed repairs with his team and made repairs as needed. He also stated a corporate representative came to the facility two or three times a month and made rounds with him, formulating a work list of needed repairs. After that list was completed, another round was done to look for other needed repairs. Review of Resident (R) 77's Admission Face Sheet revealed R 77 had been admitted to the facility on [DATE] with diagnosis to include progressive supranuclear ophthalmoplegia, unspecified anxiety disorder, and type 2 diabetes mellitus. Review of R 77's Admission Minimum Data Set (MDS), dated [DATE], revealed R 77 had a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated the resident was cognitively intact. Observation of Resident (R) 77's room on 06/03/2024 at 6:50 PM revealed a stained, scuffed wall with ripped wallpaper behind the bed. Continued observation of R 77's room on 06/04/2024 at 9:15 AM, on 06/05/2024 at 3:28 PM, and on 06/06/2024 at 11:05 AM revealed the scuffed area behind the bed was still there and had not been repaired. During an Interview with R 77 on 06/03/2024 at 6:55 PM, she stated the stained, scuffed marks had been there since she was brought into the room. R 77 stated when she asked staff about it, the solution was to put a sign up on the wall for staff to not put the bed against the wall. R 77 stated some management staff (she would not name those staff members) had seen the area behind her bed but had done nothing about it. R 77 stated this really doesn't seem to be very home-like to me. During an Interview with the Housekeeping Supervisor on 06/06/2024 at 1:33 PM, she stated each manager had a room rounding sheet which was completed daily. The Housekeeping Supervisor stated if something needed to be cleaned in a resident's room, the manager would complete the daily rounding form and give it to her in morning meeting. She stated when the areas were cleaned, the managers would follow back up on the next room round to ensure the area had been cleaned. She stated if repairs were needed, such as holes in the walls, peeling wallpaper, or scuffed area on walls, the housekeeping staff would report the issue to her and the nursing staff so they could put a work order in for maintenance staff to make the repairs. The Housekeeping Supervisor stated the housekeeping staff was unable to put in work orders to maintenance due to being contracted and unable to access the TELS computer system. During an Interview with the Maintenance Director on 06/06/2024 at 2:00 PM, he stated he was not sure which staff could put work orders into TELS computer system, but all staff could verbally let his staff know if repairs need to be made so any issues with floors, walls, and ceilings could be fixed in a timely manner. The Maintenance Director stated his staff tried to check the resident rooms frequently, but acknowledged it was a problem. The Maintenance Director stated a sister facility had put hard plastic on the walls behind resident's beds to prevent scuffing of the walls and the facility was currently looking into a similar solution but had not decided on how to correct the problem at this time. The Maintenance Director stated his staff tried to keep a rod behind the headboard to prevent the bed from bumping the wall but stated he was not aware if R 77's bed had a rod or not. The Maintenance Director stated he would expect to find any scuffed walls put in TELS so the needed repairs could be made, put on a room round sheet, or at the very least, verbally let his staff so the issue could be repaired. Interview with the Administrator on 06/06/2024 at 2:54 PM, she stated housekeeping were a contracted company. She stated if staff observed any areas needing repair, they should report it to the maintenance personnel or a member of management. The Administrator stated maintenance personnel were employed by the facility and were responsible for completing all needed repairs to include repairing environmental concerns such as walls, door facings, or anything else that needed repair. She continued to state all staff, except contracted staff had access to a computer and was able to put in a work order for maintenance to fix whatever was needed and maintenance staff should check it daily. The Administrator stated maintenance staff were responsible for conducting weekly, monthly, and yearly checks on all areas of the facility to include inspections on electric, plumbing, and fire alarms. Additionally, maintenance was responsible for performing fire drills on all shifts, checking the fire sprinkler system, beds, bathtubs, and performing disaster drills. The Administrator stated the disaster and emergency preparedness manual was updated at least annually to ensure the building was compliant. The Administrator further stated she expected the facility to be clean, and she expected all staff to be observing for any issues and to report those issues to maintenance so any problems could be repaired. She stated it was the responsibility of all staff to report any issues to maintenance personnel.

Based on observation, interview, record review and a review of the facility policy Infection Prevention and Control Policy and Procedure Subject: Novel Coronavirus it was determined the facility failed to follow their policy related to the use of Personal Protective Equipment (PPE) to prevent possible transmission of COVID-19 for one (1) of five (5) sampled residents (Resident #1). On 01/07/2021, two staff were observed to enter the room of Resident #1, who was in droplet precautions, on the facility designated COVID-19 unit without donning the required PPE (gown). In addition, the facility fail to ensure the safe disposal of PPE. Observation on 01/07/2021, upon entry to the building and during tour, revealed used PPE (gloves and surgical facemasks) was lying on the ground in the parking lot, on the front and back lawn, and in the facility courtyard. The findings include: A review of the facility policy for infection control titled Infection Prevention and Control Policy and Procedure Subject: Novel Coronavirus with a revision date of 11/03/2020 revealed the facility would conduct infection control and prevention strategies to reduce the risk of transmission of the [MEDICAL CONDITION]. According to the policy, COVID positive residents would be placed on the facility designated COVID unit under transmission based precautions. Further review of the policy revealed staff were required to utilize a gown, mask, goggles/face shield and gloves before entering a resident room on the COVID unit. 1. A review of the medical record for Resident #1 revealed the facility admitted the resident on 08/10/17, with [DIAGNOSES REDACTED]. Observation of the facility designated COVID unit, on 01/07/2020 at 9:25 AM, revealed two staff members (State Registered Nurse Aides (SRNA) #1 and SRNA #2) entered the room of Resident #1 without donning a gown, as required by the facility policy. Interview with SRNA #1, on 01/07/2021 at 1:05 PM, revealed the staff member did not recall if she donned the required PPE (a gown) before entering the Resident #1's room. According to SRNA #1, staff were required to wear full PPE before entering the residents' rooms on the COVID unit and remove the PPE and discard it when exiting the room to prevent the spread of the COVID-19 virus. Interview with SRNA #2, on 01/07/2021 at 1:07 PM, revealed she and SRNA #1 went into Resident #1's room to reposition the resident in bed and neither she nor SRNA #1 donned a gown before providing care to the resident because they were only in the room for a short time. According to the SRNA, full PPE, to include a gown was to be donned before entering the resident's room and removed and discarded when exiting the room because the resident had COVID-19 and it could be spread. An interview with the Director of Nursing (DON), who was also the backup Infection Preventionist, on 01/07/2021 at 1:22 PM, revealed all residents in the COVID unit were on droplet precautions. The DON stated staff were required to wear a mask and a face shield at all times in the unit and were required to put on gloves and gowns before entering residents' rooms on the COVID unit. Staff were to remove (PPE) gowns and gloves and discard when exiting the residents' rooms. According to the DON, she made rounds daily to monitor staff's use of PPE and had not identified any recent concerns. Further interview with the DON revealed if staff did not wear the correct PPE when required it was an infection control hazard that could potentially spread infections. 2. An interview with the Administrator, on 01/07/2021 at 3:10 PM, revealed the facility did not have a policy regarding picking up trash outside the facility; however, it was procedure for used PPE and trash to be disposed of in designated receptacles, trash cans and dumpsters. Observations during the initial tour, on 01/07/2021 from 9:05 AM to 10:05 AM, revealed a disposable glove was in the parking lot near the facility front entrance, three (3) disposable gloves and two (2) facemasks were on the ground in the facility courtyard. Further observation revealed four (4) disposable gloves and two (2) facemasks were on the grass on the east side of the building. Three (3) disposable gloves were observed lying on ground in the parking area on the south side of the building near the dumpster, and two (2) gloves and a surgical mask was lying in the grass on the west side of the building. Interview with Maintenance Staff, on 01/07/2021 at 2:21 PM, revealed maintenance occasionally tried to pick up trash outside the facility and to check for appearance and curb appeal. According to the Maintenance Staff, he had not noticed the PPE lying on the grounds of the facility. The Maintenance Staff member stated PPE not being disposed of properly and lying around outside could be an infection hazard. Interview with the Housekeeping Supervisor, on 01/07/2021 at 2:25 PM, revealed she had not been told to pick up any trash outside the facility recently and picking up trash outside was not on the cleaning schedule for housekeeping. The Housekeeping Supervisor stated she had seen the PPE lying on the ground outside, but had not told anyone. According to the Housekeeping Supervisor, the PPE lying on the ground outside could be an infection control hazard. An interview with the Administrator, on 01/07/21 at 3:10 PM, revealed the facility had a computerized maintenance task to have maintenance pick up trash and debris outside the facility weekly. According to the Administrator, he was not aware of the PPE lying on the ground outside until he arrived at the facility after being notified of the survey. Further interview with the Administrator revealed he checked the outside of the building weekly if weather permitted and had not noticed any build up of trash and debris. According to the Administrator, if trash and PPE were not disposed of properly, it was an infection control hazard.

Based on observation, interview, review of the facility's policy, and review of the Plan of Correction (POC) for the COVID-19 focused infection control survey, dated 09/23/2020, it was determined the facility failed to maintain a Quality Assurance Performance Improvement (QAPI) Program that developed and implemented effective plans of action to correct quality deficiencies. During a focused infection control survey with an exit date of 09/23/2020, the facility was cited at CFR 483.80 Infection Control (F-880). The facility submitted a plan of correction, which included staff training on the use of Personal Protective Equipment (PPE) for COVID-19 with a correction date of 11/16/2020. However, observation on 01/07/2020, revealed State Registered Nurse Aide (SRNA) #1 and SRNA #2 entered a resident room on the COVID unit without donning the appropriate PPE (a gown) as required by facility policy. Refer to F880. The findings include: A review of the facility policy for quality assurance titled Quality Assurance Performance Improvement Plan (QAPI) Standard of Practice with a revision date of June 2020 revealed the Quality Assurance committee met monthly to review data from audit tools gathered throughout the month. According to the policy, audits in quality review areas to include infection prevention and control were reviewed and performance improvement plans were developed in identified areas of concern. A review of the medical record for Resident #1 revealed the resident tested positive for COVID-19 on 12/29/2020 and resided in the facility's designated COVID unit. Observation of the facility designated COVID unit on 01/07/2021 at 9:25 AM, revealed two staff members (State Registered Nurse Aides (SRNA) #1 and SRNA #2) entered the room of Resident #1 without donning the required PPE. Both staff failed to don a gown in accordance with facility policy. Interview with SRNA #1, on 01/07/2021 at 1:05 PM, who provided care to Resident #1, revealed the staff member did not recall if she donned the required PPE (a gown) before entering Resident #1's room. Interview with SRNA #2, on 01/07/2021 at 1:07 PM, revealed she and SRNA #1 went into Resident #1's room to reposition the resident in bed and neither she nor SRNA #1 donned a gown before providing care to the resident. A review of the POC for the focused infection control survey with an exit date of 09/23/2020, revealed the facility alleged the deficient practice cited at F880 would be corrected as of 11/16/2020. The POC included corrective actions, which included in-service training for all staff on the use of PPE with return competency testing starting on 11/09/2020 and completed 11/15/2020. Further review of the POC revealed ten staff would be audited daily for four weeks to identify concerns with the staff use of PPE. A review of training records and competency test dated 11/13/2020, revealed SRNAs #1 and #2 were trained in the use of PPE and competency validated with a test. A review of daily PPE audits ending the first week of December 2020 and the weekly audit tools completed weekly for December 2020, revealed no concerns were identified with staffs' use of PPE. An interview with the Director of Nursing (DON), on 01/07/2021 at 1:22 PM, revealed that all residents in the COVID unit were on droplet precautions. Staff were required to wear a mask and face shield at all times on the unit and were required to put on gloves and gowns before entering resident's rooms on the COVID unit. According to the DON, daily audits of staff per the POC was conducted for four weeks, and then decreased to weekly audits. The DON stated the audit had been ongoing as a part of the routine quality assurance to monitor compliance with infection control. The DON stated no concerns with staff use of PPE had been identified. An interview with the Administrator, on 01/07/2021 at 3:10 PM, revealed the Administrator and the DON conducted the facility's Quality Assurance Program as a team (both served as coordinator of the program). In addition, the Administrator and the DON reviewed the audits as a part of the facility's ongoing Quality Assurance Program monthly. According to the Administrator, no recent concerns had been identified with the staffs' use of required PPE.

Based on observation, record review, staff interview and review of the State Provider Guidance Memo on Admission, Discharge and Transfer for Long-Term Facility Residents, the facility failed to follow their policy to ensure staff wore eye protection as required when entering the rooms of residents on Droplet precautions for unknown COVID-19 status due to being admitted from the hospital within the past 14 days for three (3) of seven (7) sample residents (Resident #5, #6 and #7) and failed to ensure one (1) of two (2) Housekeepers performed hand hygiene when exiting a resident room and before entering another room during one (1) of two (2) random observations of housekeeping. These failures occurred during a COVID-19 pandemic. The findings include: 1. During an interview with the Infection Preventionist on 9/21/20 at 4:30 p.m., she indicated that residents who were new admissions or readmissions were admitted to C Hall and placed on Droplet precautions for 14 days. She added that residents on [MEDICAL TREATMENT] remained on this hall on Droplet precautions and there were no COVID-19 positive resident's in the facility. During an observation on 9/21/20 from 5:06 p.m. - 5:16 p.m. Certified Nursing Assistant #1 (CNA #1) was observed going in and out of several rooms on C Hall to deliver beverages to residents in their rooms, prior to the evening meal. All nine (9) of the occupied rooms on C Hall had a droplet precautions sign at the door indicating that staff must wear a mask and eye protection when entering the room. CNA #1 was wearing a mask but did not put eye protection on during the observation, although she was wearing safety glasses on top of her head. One of the C Hall rooms CNA #1 was observed entering without eye protection was the room of Resident #5. CNA #1 was observed within three (3) feet of the resident while she interacted with him. On 9/21/20 at 5:11 p.m. Unit Manager #1 and CNA #1 were observed in Resident #6's room. They both brought the resident a beverage and spoke with her; Unit Manager #1 also provided some redirection to encourage the resident to remain in her room. Both Unit Manager #1 and CNA #1 were wearing mask during this interaction with the resident but they were not wearing eye protection. There was a droplet precautions sign at Resident #6's door which indicated eye protection was required when entering the room. On 9/21/20 at 5:12 p.m. and again at 5:16 p.m. Resident #7 was observed sitting in her wheelchair near the door to her room on C Hall with the over bed table in front of her. There was a droplet precautions sign at the door. Unit Manager # 1 was observed inside the room standing on the other side of the over bed table, talking with Resident #7. The Unit Manager was within approximately three (3) feet of the resident and wearing a mask but she was not wearing eye protection. During an interview with the Infection Preventionist on 9/22/20 at 11:30 a.m. she stated that she was new to the role and also worked as a Unit Manager (Unit Manager #2). She stated that newly admitted residents and readmitted residents were on Droplet precautions for 14 days and staff only had to wear eye protection if they were in the room for more than 15 minutes and when providing direct care. On 9/22/20 at 4:27 p.m. CNA #2 was observed in Resident #7's room. Resident #7 was still on Droplet precautions but CNA #2 was not wearing eye protection. CNA #2 was within approximately three (3) feet of the resident while interacting with her during this observation. During an interview with CNA #2 on 9/22/20 at 4:29 p.m., she stated that the newly admitted and readmitted residents on C Hall were on Droplet precautions. CNA #2 said that Droplet precautions for these residents meant that when she was the room for 15 minutes or more, or when providing direct care to these residents she was required to wear a gown, gloves, mask and eye protection. CNA #2 said that eye protection was not required if she was in the room for less than 15 minutes and not providing personal care. On 9/22/20 at 4:30 p.m. Unit Manager # 1 was observed in Resident #6's room. The resident was up wandering in her room and the Unit Manager was providing redirection. Resident #7 was still on Droplet precautions but Unit Manager #1 was not wearing eye protection during this observation. During an interview with the Director of Nursing (DON) on 9/22/20 at 4:35 p.m., she stated that Droplet precautions for newly admitted residents and readmitted residents meant that staff were to wear eye protection and a mask whenever they went in one of these rooms. She confirmed eye protection was required at all times when in these rooms and that the Droplet Precautions sign posted at these rooms and facility policy indicated this was required. She was unaware that some staff did not know eye protection was required to enter these room even when in the room for less than 15 minutes and when not providing personal care. The DON also confirmed that the facility policy for managing newly admitted and readmitted with unknown COVID-19 status was to follow the provider guidance memo dated August 28, 2020. During a telephone interview with the IP on 9/23/20 at 1:00 p.m. she indicated that she had been incorrect in her interview earlier about when eye protection was required for residents on Droplet Precautions and felt that was due to so many changes in guidelines and being new to the role. Review of the guidance memo dated August 28, 2020, which the facility used as their droplet precautions policy for newly admitted and readmitted residents revealed, Quarantine and monitor the resident for COVID-19 signs or symptoms for 14 days following admission. Wear facemask, eye protection and perform hand hygiene for all caregiver-resident interactions; add gown and gloves for any activity involving close contact with the resident or the resident's environment. 2. On 9/22/20 at 11:00 a.m. Housekeeper #1 was observed on a non-COVID unit wet mopping the floor in room D9. She exited the room, put the mop on her cart and completed some paperwork without performing hand hygiene. Housekeeper #1 got a plastic bag from the housekeeping cart and took a dust mop in Room D10 and closed the door. She exited room D10 with a plastic bag filled with garbage and placed the bag into the bin located on her cart. Another staff member then spoke with Housekeeper #1 and she used sanitizer from a dispenser on the wall in the hall to perform hand hygiene. During an interview with the Housekeeping Supervisor on 9/23/20 at 10:30 a.m., she stated that Housekeeping staff were expected to perform hand hygiene when exiting each resident room and before entering another resident room. She also indicated she had reviewed the hand hygiene guidance for housekeeping staff contained in the (Name of Housekeeping Contract Company) Infection Control Overview and Policy, and confirmed that it needed revision to include a clearly stated requirement for housekeeping staff to perform hand hygiene when leaving and before entering resident rooms.

Based on observation, interview, and facility policy review, it was determined the facility failed to provide housekeeping and maintenance services to maintain a sanitary and orderly interior. Observations on 11/11/15 revealed one wheelchair with a torn and scratched armrest, one door that was chipped, air conditioner filters and vents full of dust and debris, a broken bug guard, and a dirty water machine faucet. The findings include: Review of the facility's policy titled Procedure: Maintenance Work Orders, dated 01/31/14, revealed work orders were to be completed by any staff member that identified a need for maintenance or equipment repair. Interview with the Maintenance Director on 11/13/15 at 5:42 PM revealed there was no policy on preventive maintenance. The Maintenance Director stated he relied on the TELS computer system (system utilized by the facility to document maintenance concerns) for alerts regarding repairs or maintenance issues. Observations during the environmental tour on 11/13/15 at 3:19 PM revealed a wheelchair, being used by a resident, with a torn and scratched armrest. Further observation on 11/13/15 at 4:00 PM revealed the water faucet head in Hallway B which was available for staff, residents, and visitors to use, had black and orange colored buildup around the spout where the water came out and needed to be cleaned. Further observation on 11/13/15 at 4:10 PM revealed the bug guard covering a light hanging on the wall on A Hall outside of a resident's room was in need of repair. Further observation on 11/13/15 at 4:50 PM revealed air conditioner vents and filters in five resident rooms needing to be cleaned. Interviews with the Maintenance Director on 11/13/15 at 5:00 PM revealed he was aware of some concerns of a torn wheelchair needing repair. The Maintenance Director stated parts were ordered and he was waiting on them to come in. Further interview revealed the Maintenance Director did not document items that were identified to be in need of repair; however, the facility used the TELS system for staff to enter all work orders in the computer and the Maintenance Director ran a report every morning allowing him to see what needed repair. Interview with the facility's Administrator on 11/13/15 at 6:41 PM revealed he was not aware of the wheelchair and door in need of repair. Further interview revealed staff was required to report defects and equipment not working to Maintenance staff through the TELS system. Further interview with the Administrator revealed Maintenance staff was responsible for repairing and/or replacing all equipment in need of repairs.

Based on observation, interview, review of facility policies, and review of the 2009 United States FDA (Food and Drug Administration) Food Code, it was determined the facility failed to store, prepare, distribute, and serve food under sanitary conditions for twenty (20) of eighty-four (84) residents of the facility who received nutrition from the kitchen. Observations in the kitchen on 11/11/15 revealed dietary staff had touched up to twenty (20) cups and glasses on the lip contact areas with their bare skin while setting up resident trays on the tray line. In addition, staff was observed touching saucers on the food contact area and touching margarine pats with bare hands. Staff was observed not wearing hair nets in the kitchen or not wearing hair nets properly. The findings include: Review of the facility's policy titled Good Sanitation to Serve Food Safely, not dated, revealed staff was to handle glassware and dishes properly. Food contact areas of plates, bowls, or cups should not be touched. The policy directed that dishes should only be held by the bottom or the edge, cups should be held by their handles, and glassware should be held by the middle, bottom, or stem. Staff was directed to always wear gloves or use tongs when handling food that is cooked or ready to eat. In addition, the policy directed that staff keep all hair (including bangs) covered and pulled back. Review of the 2009 FDA Food Code revealed Chapter 4-904.11 stated, Cleaned and sanitized utensils shall be handled, displayed, and dispensed so that contamination of food and lip-contact surfaces is prevented. 1. Observations of the tray line on 11/11/15 at 11:53 AM revealed Cook #1 placing bread and butter pats onto saucers toward the end of the line. Cook #1 was not wearing gloves and was observed touching the food contact area of saucers and bowls at least ten times, picking up butter pats at least ten times with bare hands, and touching the exposed edges of the butter. Cook #1 was observed to leave the line at least three times and failed to wash his hands when returning to the line and continuing to serve resident food. During this meal service observation, Cook #1 was not wearing a hair net or a beard guard properly, leaving his beard and hair exposed while in the kitchen. Dietary Aide #2 was observed at the end of the tray line not wearing gloves. Dietary Aide #2 was placing glasses and cups on the trays and he was observed at least 20 times to touch the glasses and cups on the lip contact area with his bare hands. Dietary Aide #2 was also observed to leave the tray line at least four times. Dietary Aide #2 returned to the tray line without washing his hands or putting on gloves and continued placing cups/glasses on resident trays. The Dietary Aide was observed to touch his face five times during the tray line service and did not wash his hands after touching his face but continued placing cups/glasses on resident trays. Interview with Cook #1 on 11/11/15 at 12:18 PM revealed he had been employed at the facility less than two months. He stated he should have been wearing gloves and should have washed his hands when leaving the line. According to Cook #1, he thought he was wearing the hairnet properly. Interview with Dietary Aide #2 on 11/11/15 at 12:21 PM revealed he had been employed at the facility less than five months. The Dietary Aide said he should not have been picking the cups and glasses up from the top and should have washed his hands before returning to the line. According to Dietary Aide #2, he was nervous. 2. Observation on 11/12/15 at 8:09 AM revealed State Registered Nurse Aide (SRNA) #2 was inside the kitchen during breakfast tray line not wearing a hairnet. Interview with SRNA #2 at 11/12/15 at 8:13 AM revealed, I should have been wearing a hairnet while in the kitchen. Interview with the Dietary Manager (DM) on 11/13/15 at 9:06 AM revealed that she had been there over [AGE] years and staff was trained on kitchen sanitation upon hire and annually. Cook #1 and Dietary Aide #2 had received this training but failed to use proper sanitation when on the serving line. The Dietary Manager stated she monitored sanitation by observing employees while in the kitchen and had not identified any problems with hand sanitation but had noticed from time to time hairnets not being worn properly. Cook #1 and Dietary Aide #2 should have both washed their hands and really should not have been leaving the serving line. The Dietary Manager stated all staff should have hairnets on properly and beard guards tucking in all exposed hair when entering the kitchen. The Dietary Manager further stated staff should have been handling the cups and glasses by the bottom or middle, and not by the lip contact area, and should have been wearing gloves while on the line.

Based on observation, interview, and review of the facility's policy it was determined the facility failed to ensure a call light in the C Hall shower room was accessible. Observations on 11/13/15 revealed the communication system was blocked by a supply cart. The findings include: Observation of the C Hall shower room on 11/13/15 at 3:56 PM revealed the call light pull cord was blocked by a supply cart. Review of the Facility Policy titled Answering the Call Light, (undated) revealed that the call light was to be within easy reach of the resident. Interview with State Registered Nurse Aide (SRNA) #1 on 11/13/15 at 4:00 PM revealed that he had been employed by the facility since February 2015 and the supply cart had been in front of the call light since that time. Interview with the Housekeeping Supervisor on 11/13/15 at 4:05 PM revealed he was unaware of the supply cart blocking the call light. Interview with the Director of Nursing (DON) and Administrator on 11/13/15 at 6:41 PM revealed they were not aware that the call light system was blocked in the shower room.

Based on interview, record review, and review of the Social Services Director Position Description, it was determined the facility failed to ensure a Discharge Plan of Care was developed for one (1) of twenty (20) sampled residents (Resident #20). Resident #20 was admitted on [DATE], with plans to discharge back to the community. However, review of Resident #20's care plan revealed no discharge care plan had been developed by the facility. The findings include: Review of the Social Services Director Position Description, undated, revealed in the event a resident was discharged from the facility, the Social Services Director was responsible for developing an organized discharge plan. Review of the closed medical record for Resident #20 revealed the resident was discharged home from the facility on 11/03/15 with home health services to follow. Review of Resident #20's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident planned to be discharged home. Interview with the facility's Social Worker on 11/13/15, at 3:35 PM, revealed she was responsible for developing a discharge care plan for residents who planned to be discharged from the facility. The Social Worker stated Resident #20 planned to return home upon admission, and should have had a discharge care plan developed upon admission to the facility. The Social Worker stated she had just missed it. Interview conducted with the Administrator on 11/13/15, at 6:45 PM, revealed it was the Social Worker's responsibility to develop a discharge care plan when a resident planned to return home. The Administrator stated all discharged residents' medical records were reviewed after discharge, and the facility had not identified any concerns with discharge plans not being developed for residents. The Administrator stated Resident #20's medical record had not yet been reviewed.

Based on observations, interviews, record review, and review of the facility's policy, it was determined the facility failed to ensure that the residents' environment remained as free of accident hazards as possible for one (1) unsampled resident, Resident A, that the facility assessed to wander throughout the facility. On 11/13/15, an electrical circuit breaker box was discovered to be unlocked on the A Hall and accessible to residents of the facility. The findings include: Review of the facility's policy titled Procedure: Maintenance Work Orders, dated 01/31/14, revealed that work orders would be completed by any staff member that identifies a need for maintenance or equipment repair. Interview with the Maintenance Supervisor on 11/13/15 at 11:55 AM revealed the work order was completed by entering a maintenance order into the TELS system (system utilized by the facility to communicate maintenance needs) and was then assigned to the Maintenance Department. Once the Maintenance Department received the work order, the work was scheduled to be completed. Once the repairs were completed, the work order was closed. The policy stated the Administrator reviewed and monitored for incomplete work orders as necessary. However, the electrical circuit breaker box was not addressed in the policy. Observation conducted on 11/13/15 at 11:55 AM revealed that an electrical circuit breaker box on the A Hall was unlocked and accessible to residents on that hallway. Further investigation revealed there was an open space between the box cover and the electrical breakers when the door was open exposing electrical wiring. There were not any residents in the A Hall during the observations. Review of a list provided by the facility Administrator revealed the facility assessed one resident as a wanderer (Resident A) and stated this resident wandered throughout the facility, including the A Hall. Interview conducted with Maintenance Supervisor on 11/13/15 at 11:55 AM revealed the Maintenance staff was aware that the breaker box was unlocked. The Maintenance Supervisor stated the box should have been locked and was probably left unlocked when they installed a new ice machine on 11/05/15. Interview conducted with the Director of Nursing (DON) and Administrator on 11/13/15 at 11:49 AM revealed that the breaker box should have been locked and that it was an oversight that the box was unlocked.

Based on interview and record review and review of facility policy, it was determined the facility failed to ensure one (1) twenty (20) sampled residents (Resident #7) had the opportunity to receive routine dental services. Review of the medical record for Resident #7 revealed no evidence the resident received an annual evaluation by a dentist. The findings include: Review of the facility's policy titled Ancillary Services, undated, revealed each resident would receive routine dental care as needed, and the findings would be documented in the resident's medical record. Review of Resident #7's medical record revealed the facility admitted the resident on 10/31/14, with [DIAGNOSES REDACTED]. Review of a significant change in condition Minimum Data Set (MDS) assessment dated [DATE] revealed no concerns had been identified by the facility related to Resident #7's oral cavity. Interview with the Social Worker on 11/13/15, at 3:35 PM, revealed she was responsible for scheduling dental appointments for residents. The Social Worker stated Resident #7 had been on the list of residents sent to the dentist but when the dental service sent back a list of residents the dentist would be seeing, Resident #7 was not on the list. The Social Worker stated she was responsible for checking the list to ensure all residents who were required to be seen by the dentist were seen. She stated she had missed identifying that Resident #7 was not on the list. Interview conducted with the Director of Nursing (DON) on 11/13/15, at 6:40 PM, revealed the Social Worker was responsible for scheduling all dentist appointments and the Social Worker would schedule the resident for an appointment unless the resident or the family had refused. Interview conducted with the Administrator on 11/13/15, at 6:45 PM revealed the Social Worker was responsible for scheduling dental appointments for the residents. The Administrator stated he had not identified any concerns with residents not receiving routine dental care.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to afford the right to choose activities and schedules, consistent with his or her interests, assessments, and plans of care and make choices about aspects of his or her life in the facility that are significant for two (2) of nineteen (19) sampled residents (Resident #9 and Resident #15). The facility, after assessing Residents #9 and #15 as enjoying multiple different indoor activities, failed to afford the residents the opportunity to enjoy all indoor activities. Resident #9 was not afforded the opportunity to watch the news without being interrupted by another resident changing the channel, powering the television on and off, or changing the volume level. Resident #9 was also subjected to a religious program and rituals he/she did not want to listen to. Resident #15 was not afforded the opportunity to watch a religious program without being interrupted by another resident changing the channel, powering the television on and off, or changing the volume level. The findings include: Review of the facility's policy titled Bill of Rights, dated 07/01/09, revealed residents had the right to receive care from the facility in a manner that promotes, maintains, and enhances the residents' dignity. The policy also stated residents had the right to choose care that was consistent with the residents' assessments and plans of care. Review of Resident #9's medical record revealed the facility admitted the resident on 02/10/15 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's daily decision-making capabilities were intact which indicated Resident #9 was able to be interviewed. Review of the significant change MDS assessment dated [DATE] revealed Resident #9's activity preferences were as follows: doing things with groups of people, going outside, music, news, reading, animals, and participating in religious services or practices. Review of the resident's plan of care, revised on 09/28/15, revealed the following interventions for activities: State Registered Nurse Aides (SRNAs) and Activities staff would assist and provided Resident #9 with self-initiated activity and supplies as desires. Review of Resident #15's medical record revealed the facility admitted the resident on 08/03/14 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's daily decision-making capabilities were intact which indicated Resident #15 was able to be interviewed. Review of the Annual MDS assessment dated [DATE] revealed Resident #15's activity preferences were as follows: doing things with groups of people, going outside, music, news, reading, animals, and participating in religious services or practices. Review of the resident's Care Plan dated 10/12/15 revealed the resident preferred his/her own daily routine and groups as desired. The care plan had the following interventions for Resident #15 related to activities: State Registered Nurse Aides (SRNAs) and Activities staff would assist Resident #15 to engage resident in group activities, give the resident verbal reminders of activity before commencement of the activity, and offer activity programs directed toward specific interests of the resident. The care plan further stated that Resident #15 enjoyed TV, religion (Catholic), and visits. Observation on 11/12/15 at 8:50 AM in the room of Residents #9 and #15 revealed when Resident #9 adjusted the volume on his/her television, it also adjusted the volume on Resident #15's television. Observation on 11/13/15 at 11:05 AM revealed that Resident #15 used his/her remote to turn the television off and when he/she turned off the television, the television for Resident #9 came on. Observation further revealed the televisions were the same brand and model, and that both remotes would control both televisions. Interview with Resident #9 on 11/11/15 at 10:07 AM and 11/12/15 at 8:50 AM revealed that his/her roommate was Resident #15. Resident #9 stated he/she did not like the religious programs that Resident #15 watched and that Resident #15 controls the television and does not allow Resident #9 to watch the news at times. Resident #9 stated he/she reported this to staff several times. Interview with Resident #15 on 11/11/15 at 10:13 AM revealed that he/she tried to watch mass every morning, but Resident #9 sometimes changed the channel on his/her TV when watching mass. Interview with Licensed Practical Nurse (LPN) #5 on 11/13/15 at 4:35 PM revealed that she had worked at the facility for five years and last week Resident #9 made a comment that he/she did not want to be around Resident #15 because he/she was catholic and did not want to hear that stuff. Interview with LPN #6 on 11/13/15 at 3:16 PM revealed that she had worked at the facility for seven years. She stated that Resident #9 and Resident #15 usually fuss about the TV. Interview with the Director of Nursing (DON) on 11/13/15 at 6:45 PM revealed that she was aware that Resident #9 wanted a room change but the resident was never happy and always wanted to change rooms. The DON stated she was not aware of the issues with the remote controls. Interview with the Social Services Director on 11/13/15 at 5:59 PM revealed that she had been working at the facility for three months, and that Resident #9 had a prejudice against the Catholic faith. The Social Services Director further stated she was not aware of the severity of the conflict between Resident #9 and Resident #15.

Based on observation and interview, it was determined the facility failed to provide the necessary housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior. Observations conducted during the initial tour on 09/17/13 revealed soiled bathroom wall tiles on A Wing; a dark buildup along the edge of the bathroom floors and the wall tiles in bathrooms on A Wing, D Wing, and E Wing; stained/discolored floor tile in resident rooms on A Wing and D Wing; walls/baseboards in need of repair on A Wing; and stained, soiled grout around the base of the toilets in resident rooms on A Wing and E Wing. The findings include: An interview conducted on 09/18/13 at 3:50 PM with the Administrator, revealed the facility did not have written policy for cleaning the floors because the facility had a contract with Health Care Services for the cleaning of the facility. An interview conducted on 09/18/13 at 2:10 PM with the Maintenance Supervisor revealed he was the only maintenance man at the facility and had only been employed by the facility for six weeks. The interview revealed he completed work orders as they were submitted by staff and he did not have time to conduct routine room checks to monitor for repairs. Observations conducted during the initial tour on 09/17/13, from 10:30 AM until 12:00 PM revealed splatters of a brown substance on the wall tile in bathroom A10. The observation revealed approximately an inch of dark buildup along the edge of the floor tiles and the wall tiles in bathrooms A10, A2, A3, E11, E10, E4, D10, and D3. The grout around the base of the toilets in the bathrooms located in resident rooms A3 and E11was observed to be soiled and discolored yellow. The observations during the initial tour also revealed stained and discolored floor tile in resident rooms A9, A2, A3, D2, and D3. Further observations revealed the wall and baseboards in room A9 were in need of repair. An interview on 09/17/13 at 4:40 PM with the Housekeeping Manager revealed he worked for a contracted service that provided housekeeping services to the facility. The interview revealed all floors were swept and mopped every day and as needed. The Housekeeping Manager revealed the facility was divided into thirds for housekeeping purposes, and there were three housekeepers plus a floor technician assigned to provide housekeeping services. The interview revealed the manager worked Monday through Friday. The Housekeeping Manager reported housekeepers conduct a "deep clean" to each resident room once a month and as needed. The interview revealed a mop misses about an inch from the corners and edges of the floors and the housekeeping staff should use special cleaning equipment to clean the edge of the floors.

Based on observation and interview the facility failed to provide effective housekeeping/maintenance services to ensure a sanitary, comfortable interior. The shower rooms were observed to have broken tiles, soiled tile/grout, and areas of mold. Two doors were observed to have sharp, splintered edges and the baseboard in one resident room was separated from the wall. In addition, there was a buildup of soil in the hallway next to the baseboards on the A-B Wings. The findings include: An interview with the Regional Clinical Coordinator on 08/23/12, at 2:30 PM, revealed there was no maintenance policy for the facility. Observations of the facility on 08/21/12 and 08/23/12, revealed the following areas in need of maintenance/housekeeping services: 1. The A/B Wing shower room was observed to have mold on the tiles in the shower. The C Wing shower contained broken tiles and soiled tiles/grout. The shower room on the E Wing was observed to have a sharp, splintered edge on the entrance door. 2. The doors in resident rooms B-6 and E-6 were observed to have splintered door edges. 3. The baseboard in resident room B-7 was observed to have separated from the wall. 4. A buildup of soil was observed in the A/B hallway next to the baseboards and in the corners. An interview with the Environmental Services Supervisor at 11:00 AM on 08/23/12, revealed the shower rooms were to be "deep cleaned" on a weekly basis. The Environmental Services Supervisor stated he was planning to clean the corners/edges but had not "gotten to them yet." An interview with the Maintenance Supervisor (MS) on 08/23/12, at 11:00 AM, revealed he made rounds throughout the building frequently but had not noticed the rough door edges. According to the MS, staff was to complete a work order for maintenance needs and place it in a receptacle at the nurses' station. The MS stated he checked the work order box several times daily and no one had reported the rough edges on the doors or the separated baseboard to him.

Based on observation, interview, and record review, the facility failed to ensure services were provided based on individual needs and preferences for one of eighteen sampled residents (Resident #9). The Food Preference Record identified Resident #9 preferred chicken noodle soup to be provided with meals; however, the soup was not provided for the resident during the evening meal on 08/21/12. The findings include: Interview with the Registered Dietitian (RD) on 08/22/12, at 10:45 AM, revealed the facility did not have a policy/procedure to ensure food tray accuracy and food preferences were honored. Review of the medical record revealed the facility admitted Resident #9 on 04/30/08, with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment with a reference date of 06/10/12, revealed the resident was assessed to have a BIMS (Brief Interview for Mental Status) score of "0" and was not interviewable. Resident #9 was observed on 08/21/12, at 6:20 PM, to be served the evening meal. The resident's meal consisted of pureed meat with gravy, mashed potatoes, pureed vegetable, applesauce, and whole milk. Facility staff was observed to spoon feed the resident. A review of the resident's tray card revealed Resident #9's food preferences were identified for the dinner meal as gravy and chicken noodle soup; however, no soup was observed to be provided on the resident's tray. In addition, a review of the Food Preference Record maintained by the Dietary Department dated 04/04/11, revealed Resident #9 was identified on the record to prefer chicken noodle soup and cabbage. Interview with Certified Nurse Aide (CNA) #2 on 08/21/12, at 6:30 PM, revealed the CNA was responsible to check the resident's tray card to verify the correct diet was provided and to verify the food preferences were on the resident's tray. The CNA stated she had overlooked the soup item on Resident #9's tray card. Interview with the Dietary Manager (DM) on 08/22/12, at 1:20 PM, revealed the cook was responsible to ensure residents received the correct diet and food preferences. The DM also stated she did not know why the resident did not receive the soup on 08/21/12. Interview with the dietary cook on 08/22/12, at 1:10 PM, revealed Resident #1 should have received chicken soup on the evening meal tray. The dietary cook stated she did not know why the resident did not receive the soup during the evening meal on 08/21/12.

Based on observation, record review, interview, and a review of facility policy, it was determined the facility failed to provide appropriate treatment and services to maintain/restore as much bladder function as possible for one of eighteen sampled residents (Resident #8). Resident #8 was assessed as occasionally incontinent of bladder on 05/14/12. A quarterly assessment on 08/04/12, revealed the resident was assessed to always be incontinent. However, there was no evidence the facility had assessed Resident #8 to identify causative factors of the decline in the resident's bladder function in an attempt to restore as much bladder function as possible. The findings include: A review of the facility's Management of Urinary Incontinence policy, no date given, revealed the facility should identify pattern and frequency for a resident with suspected or known urinary incontinence. The policy directed staff to complete a three-day elimination tracking to determine a pattern and to complete a comprehensive bladder assessment using the Bladder Collection and Assessment tool. There were no specific staff members indicated by the policy who would be responsible to complete the procedures. A review of the medical record for Resident #8 revealed the facility admitted the resident on 05/07/12, with [DIAGNOSES REDACTED]. The comprehensive admission Minimum Data Set (MDS) assessment with an Assessment Reference Date of 05/14/12, revealed Resident #8 was occasionally incontinent of bladder with no toileting program or trial in progress. A quarterly MDS assessment with an Assessment Reference Date of 08/04/12, revealed Resident #8 was assessed to always be incontinent. There was no evidence a urinary toileting program/trial was in place for Resident #8 in an attempt to restore the resident's bladder function as much as possible. Further review of the medical record revealed there was no evidence a reassessment was completed when a change in continence was assessed. Observations of Resident #8 on 08/21/12, at 11:53 AM, revealed the resident to be in bed with an empty urinal on the overbed table and a strong odor of urine in the room. An interview with State Registered Nurse Aide (SRNA) #1 on 08/21/12, at 3:00 PM, revealed the direct care staff was to check on residents at least every two hours and to either offer toileting assistance or to perform incontinence care if the resident was incontinent. SRNA #1 stated Resident #8 was incontinent most of the time. SRNA #1 further stated the direct care staff used the "Care Tracker" to document care delivery. An interview with the Minimum Data Set Registered Nurse (MDS RN) on 08/23/12, at 3:55 PM, revealed the MDS RN reviewed the Care Tracker documentation for Resident #8 when she was assessing the resident's bladder function. The MDS RN stated the resident had a decline in continence when the quarterly assessment was completed on 08/04/12, but she did not "catch" it. According to the MDS RN, the facility had converted to a new computer program and the previous assessment was not included on the newer program. The MDS RN stated she was unaware there had been a decline in Resident #8's continence status because she did not compare the quarterly MDS assessment with the previous MDS assessment. An interview with the Director of Nursing (DON) on 08/22/12, at 2:10 PM, revealed the facility's procedure was for the admitting nurse or unit manager to complete a bladder assessment upon admission to the facility. The DON further stated residents were to be reassessed quarterly or if/when a change in continence occurred. The DON stated the facility also conducts a "Daily Clinical Review" to ensure assessed care needs have been addressed, but somehow nobody "caught" the decline in continence for Resident #8.

Based on observation, interview, record review, and facility policy review, the facility failed to maintain an Infection Control Program designed to help prevent the development and transmission of disease and infection for one of eighteen sampled residents (Resident #1). Facility staff failed to perform appropriate handwashing procedures when providing wound care for Resident #1. The findings include: A review of the Handwashing/Hand Hygiene policy/procedure (dated April 2012) revealed handwashing was considered the primary means to prevent the spread of infections. The policy noted handwashing should be performed under the following conditions: before and after changing a dressing, upon and after coming in contact with a resident's intact skin, and after contact with a resident's mucous membranes and body fluids or excretions. A review of the medical record revealed the facility readmitted Resident #1 on 07/01/12, with an unstageable wound to the coccyx. A skin assessment conducted on 08/22/12, at 10:00 AM, revealed Resident #9's coccyx area was red/excoriated with a small open area noted. Observation conducted during wound care for Resident #1 on 08/22/12, at 10:05 AM, revealed Registered Nurse (RN) #1 performed handwashing and put on gloves prior to initiating the wound care. RN #1 was observed to pour normal saline (N/S) over dry 4 x 4 gauze and clean the resident's wound with the gauze. The RN then dried the wound with different 4 x 4 gauze. RN #1 proceeded to apply Skin Barrier ointment to the open wound with the same gloved finger. The RN failed to perform handwashing or change gloves after cleaning the wound and before applying ointment to the resident's open wound. Interview conducted with RN #1 on 08/22/12, at 10:50 AM, revealed she was the treatment nurse for the facility. RN #1 stated she had been trained to perform handwashing and to change gloves when moving from a "dirty" area to a "clean" area during wound care. The RN stated the gloves were considered "dirty" after the wound had been cleaned and she should have washed her hands and changed gloves before applying the ointment to the wound.

Based on observation, interview, and record review, it was determined the facility failed to provide a sanitary, orderly, and comfortable interior. Observations revealed commode anchor screws were exposed, drywall was chipped and marred, lights over the bathroom sinks were not working, exhaust fans had an excessive buildup of dust, bathroom door facings were scraped exposing splintered wood, sink basins were stained, a faucet dripped continuously, a bathroom ceiling and wall were stained/soiled, a formica finish on a resident closet door was chipped, and cracks were observed in sink basins. The findings include: Review of the facility's policy titled Work Order Request/Inservice (not dated) revealed work order request forms were used to notify Maintenance and Housekeeping of areas that needed to be cleaned/repaired. The policy directed staff to complete the work order form to ensure Departments were notified of any area that could harm a resident, visitor, or employee. The work order forms were located at every nurses' station and were to be completed by any employee of the facility. During the environmental tour of the facility on 08/23-25/11, the following items were observed in need of repair: -Commode anchor screws were protruding one-half to two inches in the bathrooms located in resident rooms A4, B1, B7, B8 C5, D10, and E6. -The lights over the bathroom sinks in resident rooms A4, B2, and C8 did not work. -The ceiling in resident room C5 was observed to be soiled with a tan substance. -The bathroom door facings were scraped and exposed sharp, splintered wood in resident rooms A4, A6, B2, B7, B10, and D6, and in resident shower rooms A, B, D, and E. -The entry door to resident room A6 was chipped and exposed splintered wood. -The exhaust fan in resident bathrooms A10 and D6 were observed to have an excessive buildup of dust. -The vinyl overlay on the supply closet doors in shower rooms A and E was cracked and detached from the door at the door knobs and exposed sharp edges. -The sink basins in resident bathrooms B1, B2, and C9 were observed to have a rust-colored stain and the sink basins in resident bathrooms C4 and C8 were cracked. -The facet in resident room B1 was observed to drip continuously. -The drywall above both resident beds in room C2 was observed to have deep crevices and the drywall above resident bed 2 in room E9 was scraped. -The tissue paper bar was missing in resident bathroom C2. -A section of the floor linoleum was missing at the bathroom threshold in resident room C9. -Chipped formica was observed at the base of the closet doors in resident rooms C8 and C12. -The wall in resident room B6 was soiled with a dried brownish substance. -The tile grout in the D Wing shower room was observed to have a black substance on it. -The drywall was peeling underneath the air-conditioning unit in resident room E2. An interview conducted with the Maintenance Supervisor (MS) on 08/25/11, at 2:00 PM, revealed the facility utilized a work order system. The MS stated any staff member could obtain a work order at the nurses' station to inform the Maintenance Department of anything that needed to be repaired. The MS stated staff also informed him verbally or by phone of items in need of repair. The MS revealed rounds were conducted by the Maintenance Department approximately four times a day and the box that contained work orders and kept at the nurses' station was checked several times during the day. A review of facility work orders revealed the above concerns had not been identified by the facility. In addition, the MS confirmed work orders had not been completed for the identified concerns and had not been identified during the rounds made by the Maintenance staff.

Based on observation and interview, the facility failed to provide sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for two of twenty-two sampled residents (Residents #4 and #14). The findings include: 1. Resident #4 was observed on 08/23/11, at 11:00 AM, sitting in a wheelchair with both legs extended. A clock was observed to be on the wall facing the resident's bed. An interview was conducted with Resident #4 on 08/23/11, at 11:15 AM. The resident reported the direct care staff did not answer call lights timely due to not having enough staff. Resident #4 stated he/she had activated the call light during the breakfast meal on 08/23/11, and had to wait for one and one-half hours for staff assistance with toileting. The resident stated he/she had checked the clock in the resident's room to verify the time the resident had to wait. Resident #4 stated he/she had an incontinence episode due to having to wait for staff assistance and he/she felt "small and embarrassed." The resident further stated he/she had experienced incontinence episodes more than one time. An interview conducted with Certified Nurse Aide (CNA) #10 on 08/24/11, at 2:00 PM, verified Resident #4 waited for more than one hour on 08/23/11, for assistance with toileting due to staff not being available. CNA #10 stated resident call lights were not answered timely due to only two CNAs being scheduled and no one was available to assist with answering call lights during meal times. In addition, CNA #10 stated on some days all of the residents were not gotten out of bed daily, nail care could not be provided as needed, and some showers had to be carried over to the next shift or the next day. CNA #10 stated he/she had reported the staffing concerns to the administrator. Interview conducted with CNA #9 on 08/23/11, at 12:00 PM, revealed two CNAs were normally scheduled to work the 7:00 AM to 3:00 PM shift on the C Hall. CNA #9 stated the C Hall was considered the "Rehab" Hall and the residents required more assistance. CNA #9 further stated call lights could not be answered timely during meal times or when showers were provided for the residents due to lack of staff. An interview conducted with the Unit Manager (UM) on 08/25/11, at 4:00 PM, revealed residents on the C Hall were "heavy" care residents. The UM stated it was difficult for the two CNAs to provide all the resident care needs appropriately. The UM also stated she tried to assist the CNAs as much as possible, but staff was not able to deliver meals timely to the residents, to respond to call lights timely, and to provide showers as scheduled for the residents. The UM further stated she had discussed staffing concerns with administrative staff. 2. Resident #14 was observed lying in bed on 08/25/11, at 5:50 PM. The resident was observed to be obese and required a bariatric bed. Interview conducted with Resident #14 on 08/25/11, at 6:00 PM, revealed staff was slow to answer the call lights and to provide assistance with turning/repositioning. Resident #14 stated he/she had waited 20 to 25 minutes for staff to respond to the resident's call light. Resident #14 stated he/she was legally blind and wore a "talking" watch to determine the time. An interview was conducted with the Director of Nurses (DON) on 08/25/11, at 7:10 PM. The DON stated she had been employed at the facility since 07/11. The DON stated the staffing pattern for the C Hall was two CNAs during the 7:00 AM to 3:00 PM shift, two CNAs during the 3:00 PM to 11:00 PM shift, and one CNA for the 11:00 PM to 7:00 AM shift. The DON also stated the unit had 20 beds and had not been at 100 percent capacity until the past two weeks. The DON stated even though the unit was a "heavy" care unit, she had not received any reports from staff that resident care needs were not provided in a timely manner for the residents. An interview was conducted with the Facility Administrator on 08/25/11, at 7:50 PM. The Administrator stated the C Hall census fluctuated and the unit had recently been at 100 percent capacity. The Administrator stated he had not received any reports related to inadequate staffing.

Based on observation, interviews, and review of facility policy and Material Safety Data Sheets (MSDS), it was determined the facility failed to ensure residents' environment remained as free from accident hazards as possible. Observation during the environmental tour revealed the facility failed to ensure disinfectant spray, personal cleanser, mouthwash, shaving cream, deodorant, shampoo, disposable razors, denture cleanser tablets, and sharp manicure sticks were secured/locked and not accessible to residents. The findings include: Review of the facility policy entitled Hazardous Drug/Chemicals (revised 05/10/10) failed to reveal instructions related to storage of cleaning supplies or personal hygiene products. Observation on 08/24/11, at 10:40 AM, revealed a storage closet was unsecured/unlocked in the shower room located on the D Wing. A chain with a broken key was secured to the wall beside the storage closet door. The storage closet contained the following: a partially used spray container of Ecolab Disinfectant Cleaner, two 8-ounce containers of Secura Personal Cleanser, eleven 4-ounce containers of McKesson mouthwash, nine bottles of McKesson skin care lotion, fifteen 1.5-ounce cans of McKesson shaving cream, 11 containers of McKesson antiperspirant/deodorant, 19 bottles of McKesson shampoo/body wash, 45 disposable razors, an unopened box of McKesson denture cleanser tablets that contained 40 tablets, a box of approximately 50 sharp manicure sticks, and a commode plunger. Further observation of the Ecolab Disinfectant Cleaner container revealed in bold letters, "Do Not Drink," and a warning label to inform the product was hazardous to humans and domestic animals. Review of the facility's Census and Condition Record dated 08/23/11, revealed 45 residents had a [DIAGNOSES REDACTED]. 17 residents were assessed to exhibit wandering behaviors. Further observation revealed an unsampled resident's room (D10), located two doors from the unlocked/unsecured shower room closet, had a velcro stop sign door guard applied to the entry door frame to prevent wandering residents from entering the resident's room. Interview on 08/24/11, at 10:45 AM, with CNA #1 revealed she had given two residents a shower in the D Wing shower room. CNA #1 stated the key to the storage closet had been broken for approximately five months and she had verbally notified the Maintenance staff of the broken key. CNA #1 stated a work order should be completed but she had not had time to fill out the form. CNA #1 stated the items in the storage closet could harm residents if the items were swallowed. Interview on 08/24/11, at 10:50 AM, with the D Wing Unit Coordinator (UC) revealed the UC had no knowledge the storage closet key was broken. The UC stated she conducted routine checks of resident rooms but the shower rooms were not routinely monitored. The UC revealed the storage closet should be locked when not in use and residents should not have access to the items stored in the closet. Interview on 08/24/11, at 11:20 AM, with the Maintenance Supervisor (MS) revealed he had changed the locked on the shower room storage closet in the past. The MS stated staff frequently left the key in the lock and when the shower room door was opened the door would hit the storage closet door knob and break the key. The MS stated he did not know the key was broken but had worked on drywall in the closet recently and the door was not locked when he entered the shower room. The MS stated if residents drank any items stored in the closet it could be fatal to the resident. Observation on 08/24/11, at 1:00 PM, revealed a new door knob/lock had been installed on the storage closet door and the door was locked. A new key was attached to the chain beside the closet door. However, observation on 08/24/11, at 5:30 PM, revealed the storage closet was unsecured/unlocked. Review of the MSDS for Ecolab Disinfectant Cleaner revealed misuse of the disinfectant could cause severe eye irritation and the product could be moderately irritating to the respiratory system if inhaled. Further review of the MSDS information for Secura Personal Cleanser, Skin Care Cream, and Shampoo/Body Wash revealed the products could cause moderate irritation to the eyes and if ingested the products could cause gastric disturbances. Review of the MSDS information for Denture Cleanser Tablets revealed misuse of the product could cause moderate to severe irritation of eyes and skin. The MSDS directed staff to contact the Poison Control Center and seek medical attention immediately if the Denture Cleanser Tablets were ingested or inhaled. Interview on 08/24/11, at 5:50 PM, with CNA #2 and CNA #3 revealed the CNAs provided a shower to a male resident at approximately 4:30 PM. CNA #2 stated after the resident's shower was completed she obtained lotion from the storage closet for the resident. CNA #2 stated she failed to lock the door to the storage closet and the items stored in the closet could be harmful to residents. Interview on 08/24/11, at 6:05 PM, with the UC revealed the UC had monitored the shower room once since notified of the broken key at 10:50 AM, and the storage closet was locked. The UC stated showers had been provided to residents and the closet door should be kept locked at all times.

Based on observation, interview, and record review, the facility failed to promote care in a manner to maintain or enhance each resident's dignity and respect for one of twenty-two sampled residents (Resident #4). The findings include: 1. A review of the medical record revealed the facility readmitted Resident #4 on 12/28/10, with [DIAGNOSES REDACTED]. A review of the quarterly comprehensive assessment completed on 06/03/11, revealed Resident #4's Brief Interview for Mental Status (BIMS) score was 15, which indicated the resident was cognitively intact. Further review of the quarterly assessment revealed the facility assessed Resident #4 to require extensive assistance of two staff members for transfers, toileting, and personal hygiene needs. Resident #4 was observed on 08/23/11, at 11:00 AM, sitting in a wheelchair with both legs extended. The resident's right leg was observed to have surgical pins and a gauze/Ace wrap on the right leg. A clock was observed to be on the wall facing the resident's bed. An interview conducted with Resident #4 on 08/23/11, at 11:15 AM, revealed direct care staff did not answer call lights timely. Resident #4 stated he/she waited for one and one-half hours during the breakfast meal on 08/23/11, for staff to assist the resident with toileting. Resident #4 stated he/she verified the time by looking at the clock in the resident's room. Resident #4 stated he/she could not wait and had an accident as a result of the staff's slow response. Resident #4 further stated he/she felt "small and embarrassed" as a result of the incontinence episode. An interview conducted with Certified Nurse Aide (CNA) #10 on 08/24/11, at 2:00 PM, revealed Resident #4 turned on the call light during the breakfast meal on 08/23/11. CNA #10 stated she and another CNA were passing the breakfast trays and could not respond to the resident's call light. The CNA stated when the resident's call light was answered the resident had already had a bowel movement in the resident's brief. CNA #10 acknowledged the resident waited over an hour before staff responded to the resident. Interview conducted with the Unit Manager on 08/25/11, at 4:00 PM, revealed she was responsible to conduct resident rounds daily to ensure resident care needs were provided for each resident. The UM stated she was not aware of the incontinence episode for Resident #4 on 08/23/11.