Every finding on record at Kirkwood by the River

Based on interview, record review, and a review of Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User ' s Manual, the facility failed to ensure Resident Identifier (RI) #3's Minimum Quarterly Data Set (MDS), with an Assessment Reference Date (ARD) of 04/07/22 was accurately coded to reflect RI #3's skin conditions. This deficient practice affected RI #3, one of three sampled resident's whose MDS's were reviewed. Findings Include: A review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User ' s Manual, dated October 2019, revealed: .Section M: Skin Conditions Intent: The items in this section document the risk, presence, appearance, and change of pressure ulcers/injuries. This section also notes other skin ulcers, wounds, or [CONDITION(S)], and documents some treatment categories related to skin injury or avoiding injury . M0210: Unhealed Pressure Ulcers/Injuries . Coding Tips . If a resident with DM (Diabetes Mellitus) has a heel ulcer/injury from pressure and the ulcer/injury is present in the 7-day look-back period, code 1 and proceed to code items in M0300 as appropriate for the pressure ulcer/injury . RI #3 was admitted to the facility on [DATE] and readmitted on [DATE] and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of RI #3's Skilled Nursing Notes dated 03/13/22, revealed .Skin warm and dry to touch with opened area to left heel reported by CNA (Certified Nursing Assistant) . A review of orders dated 03/13/22, revealed Clean left heel with wound cleanser and cover with meplilex, assess daily for bleeding, infection and drainage. Review of care plan dated for 03/13/22 revealed . has actual skin breakdown pressure to L (Left) heel . A review of a quarterly MDS with an Assessment Reference Date of 04/07/22, Section M .0 coded for M0210. Unhealed Pressure Ulcers/Injuries. An interview was conducted with Employee Identifier (EI) #1, Registered Nurse (RN), MDS Coordinator on 05/25/22 at 4:29 PM. EI #1 admitted RI #3 had one or more unhealed pressure ulcers/injuries. When asked what should have been coded for M0210, EI #1 stated, one. She stated, It had to be a data entry error because she knew RI #3 had one. EI #1 stated, if she recalled it was on his/her heel. EI #1 stated, the concern of not coding the MDS correctly was not receiving the correct care. This deficiency was cited as a result of investigation AL 831.

Based on observation, interview, and review of the facility's Infection Prevention and Control Program, the facility failed to ensure Employee Identifier (EI) #3, laundry staff, changed gloves and sanitized her hands between residents during delivery of resident clothing, and did not place small baskets on the residents' dressers and return them to the clean laundry cart. This occurred on 10/6/21, one of three days of survey, and was observed while EI #3 was delivering clothing to four resident rooms. Findings Include: The facility's Infection Prevention and Control Program dated 9/12/17 documented . D. Hand Hygiene Protocol: 1. All staff shall wash their hands when coming on duty, between resident contacts, after handling contaminated objects, . J. Linens: 1. Laundry and direct care staff shall handle, store, process, and transport linens so as to prevent spread of infection. On 10/6/21 beginning at 3:26 PM, EI #3, housekeeping/laundry aide, was observed delivering clothing to four resident rooms while wearing the same gloves. EI #3 had on gloves prior to entering room [ROOM NUMBER]. She placed the hanging clothes in the closet, exited the room, got two baskets with folded clothes, and entered the same room. EI #3 placed a basket on each dresser, removed the clothes from the baskets and placed them in the drawers. EI #3 stacked the empty baskets and exited the room. With the same gloves on (no hand sanitizing or washing performed), EI #3 went to room [ROOM NUMBER], took the hanging clothes and placed them in the closet. EI #3 brought out the hangers from the closet, then took the basket of folded clothes in the room and placed them in the dresser drawers and exited the room. EI #3 then entered room [ROOM NUMBER] with the same gloves on. EI #3 took hanging clothes into the room, exited the room with empty hangers and then entered room [ROOM NUMBER] while wearing the same gloves. EI #3 took the hanging clothes in the room and placed them in the closets and brought the empty hangers out. EI #3 took the basket of folded clothes, entered the room and placed the clothes in the dresser, then exited the room. On 10/6/21 at 3:36 PM, EI #3 was asked, how should she deliver resident clothing. EI #3 replied, take hanging clothes in, put in the closet, bring empty hangers out, then take the basket of folded clothes into the room and put them in the dresser. EI #3 was asked, what did she do with the empty hangers when she brought them out of each room. EI #3 replied, she put them on the laundry cart. EI #3 was asked, what did she do with basket when she took it into each resident room. EI #3 replied, she put it on the dresser top then put the clothes in the drawers. EI #3 was asked, what did she then do with the baskets. EI #3 replied, she took the baskets out and put them on the laundry cart. EI #3 was asked if the laundry cart was clean. EI #3 replied, yes. EI #3 was asked, what happens when you place hangers you have taken from residents' rooms and place them on the clean laundry cart. EI #3 replied, the hangers could be contaminated from someone else handling them, and could contaminate the cart. EI #3 was asked, when should she put on gloves and sanitized her hands. EI #3 replied, after each resident's clothes. EI #3 was asked, when did she change gloves or sanitize her hands. EI #3 replied, she did not. EI #3 was asked, what was the harm in not changing gloves and sanitizing hands and going to four different resident rooms. EI #3 replied, cross contamination. On 10/6/21 at 4:53 PM, an interview was conducted with EI #2, Housekeeping Supervisor. EI #2 was asked, how should housekeeping/laundry staff deliver personal clothing. EI #2 replied, they should take each individual hanging clothes in, then the basket, hang the clothes in the closet, then take the basket in one at a time not sitting the basket down, hold the basket with one hand, take the clothes with other and place them in drawers. EI #2 was asked, when should housekeeping/laundry staff change gloves and sanitize hands. EI #2 replied, prior to entering a resident room with a new basket and hangers of clothing. EI #2 was asked, what should staff do with the basket with folded clothes when they enter a resident room. EI #2 replied, hold the basket in one hand use the other hand to put clothes in the drawer. EI #2 was asked, what was the harm in the staff placing the basket on residents' dressers then returning the basket to the laundry cart. EI #2 replied, potentially transferring germs from an unsanitized surface to a clean surface. EI #2 was asked, what was the harm of the staff person bringing the empty hangers from residents' closets and placing them on the laundry cart. EI #2 replied, could carry potential germs from hangers to the clean cart. EI #2 was asked, what was the harm of the staff wearing the same gloves to deliver clothing to four different rooms. EI #2 replied, potential of transporting harmful bacteria and germs from a resident room to the clean cart.

Based on observations, interviews, and a review of facility policies titled, FOOD Safety Requirements, Handwashing Guidelines Dietary Employees, Maintaining a Sanitary Tray Line, and Monitoring of Cooler/Freezer Temperatures, the facility failed to ensure: 1. food temperatures were taken prior to serving food from the tray line to residents on the skilled unit; 2. hands were washed by the kitchen worker serving tray line on the skilled unit while multi tasking; 3. refrigerator temperature was maintained to keep frozen food frozen solid; 4. employees hair was fully restrained and 5. green beans were not served to residents after a foreign object was removed from the green beans. These deficient practices had the potential to affect all 53 residents served meals from the kitchen. Findings Include: 1. Food temperatures were not taken prior to serving food from the tray line to residents on the skilled unit. A review of a facility policy titled, Maintaining a Sanitary Tray Line dated 11/10/2017, revealed: POLICY: This facility priorities tray assembly to ensure foods are handled safely and held at proper temperatures in order to prevent the spread of bacteria that may cause food borne illness. Compliance Guidelines: . 3. During tray line assembly, staff shall: .k. Periodically monitor food temperatures throughout the meal service to ensure proper hot (at or above 135 degrees) or cold holding temperatures (at or below 41 degrees) are maintained. A review of the temperature logs for the skilled unit revealed there were twelve days with no entries of food temperatures taken. The temperature logs also revealed multiple days were not documented that food temperatures were checked for one or two meals severed on those dates, however, not all three meals had temperatures documented on the logs. On 3/26/2019 at 4:50 PM, an observation was made of food coming from the second floor kitchen in portable oven warmers. The evening meal was observed being served from the tray line on the skilled unit. The surveyor observed none of the food items checked for temperatures prior to being served to the residents. The temperatures for the food were never observed being checked during the entire serving process on 3/26/2019. An interview was conducted on 3/27/2019 at 4:09 PM, with EI (Employee Identifier) #6, kitchen staff and tray line server for the skilled unit. EI #6 was asked if she checked any food temperatures prior to serving the evening meal on 3/26/2019. EI #6 replied she did not recall. This surveyor shared with EI #6 the observation she made on 3/26/2019 of the evening meal. The food being served to the residents was placed on the steam table and there were no temperatures checked prior to serving the food. EI #6 was asked what the concern was if foods that are supposed to be hot and maintain a certain temperature are not checked. EI #6 replied, germs she guessed. EI #6 was asked what she was trained to do when food was placed on steam table. EI #6 replied to check the temperature of the food. EI #6 was asked why she did not check the temperatures on 3/26/2019 prior to serving the evening meal. EI #6 replied she was running late. EI #6 was asked why was it important to check the temperature of the food being served. EI #6 replied because of contamination and germs. 2. Hands were not washed by the kitchen worker serving tray line on the skilled unit while multi tasking. A review of a facility policy titled, Maintaining a Sanitary Tray Line dated 11/10/2017, revealed: . Compliance Guidelines: . 3. During tray assembly, staff shall: .e. Wash hands before and after wearing or changing gloves. f. Change gloves when activities are changed, . or when the type of food being handled is changed, or when leaving the work station. g. Change gloves after sneezing, coughing, or touching face . An observation was made on 3/27/2019 at 12:15 PM, of Employee Indentifer (EI) #6, tray line food server multi tasking while plating for the lunch meal on the skilled unit. She was observed handling notebooks, dome covers and meal tickets, wearing the same gloves. EI #6 was also observed going to the plates to continue serving the residents meal plates after going to the sink to wash a pair of tongs. Another observation was made of EI #6 leaving the tray line, going to sink and washed a scoop, and returning to the tray line without removing her gloves and washing her hands. EI #6, while standing at the tray line, was then observed rubbing her upper chest area with her gloved left hand while holding a plate with food with her right hand. She then added more food to the plate without removing her gloves or washing her hands. In addition, EI #6 was observed picking up and holding meal cards while serving food from the tray line onto plates. EI #6 was never observed removing her gloves and washing her hands during the time of the tray service. On 3/27/19 at 4:09 PM, an interview was conducted with EI #6. EI #6 was asked when she was serving lunch that day, stepped to the sink to rinse utensils off, returned to the steam table and started serving again, was that the appropriate process to follow. EI #6 replied no she should have changed gloves and washed her hands. EI #6 was asked why should she have washed her hands and changed her gloves. EI #6 replied because of germs. An interview was conducted 3/28/2019 at 1:31 PM with EI #7 (Dietary Manager). EI # 7 was asked when hand washing should occur when serving food. EI #7 replied before serving food and then put on gloves, also, stating anytime something was touched away from the steam table, gloves should be removed and hands should be washed then clean gloves should be put on. EI #7 was asked about the following and what should be done by the tray line server: Serving plates and scratching chest area with a gloved hand, taking utensils to a sink washing them and returning to the tray line. EI #7 replied all of these scenarios would require the removal of the gloves, washing of the employees hands and re-gloving before returning to the tray line. 3. Freezer temperature was not maintained to keep ice cream frozen solid. A review of the facility policy titled, Monitoring of Cooler/Freezer Temperature, dated 03/14/2018. Policy: It is the policy of the facility to maintain temperatures and freezers at the appropriate temperature to promote food safety. Policy Explanation and Compliance Guidelines: 1. Logs for recording temperatures for each refrigerator or freezer will be posted in a visible location outside the freezer or refrigerator unit. a. Temperatures will be checked and logged at least twice per day . b. logs will be changed out and filed each month. 2. Thermometers shall be placed inside each cooler/freezer . 4. All freezer storage must be maintained at or -4* (degrees) F (Fahrenheit), unless otherwise specified by law. 5. If .or 10*F for freezer,the supervisor will be notified . b. Internal temperature readings of all perishables of potentially hazardous food shall be taken and discarded if not in an acceptable range 11. Refrigerated food shall be labeled, dated, and monitored so that it is used by the use by date, frozen, or discarded as applicable. On 03/27/19 at 9:19 AM, an observation was made of the refrigerator freezer in the kitchen area on the first floor skilled nursing unit. No thermometer was located in the freezer section and there were no temperature logs found for the freezer posted in a visible area. An observation was made of three single serving cups of sherbet with two of the individual cups soft to squeeze and not frozen solid. In addition, there were four single serving size ice creams that were soft to touch, as well as, two ice sandwiches soft to touch. On 03/27/19 at 11:29 AM, a second observation was made of the 1st floor kitchen refrigerator and freezer unit and all the findings observed on 03/27/19 at 9:19 AM remained the same. On 3/28/19 at 9:21 AM, an observation was made of the refrigerator log posted on the outside of the refrigerator unit on first floor and there no temperatures recorded for the refrigerator for 3/27/19 and 3/28/19. Also, there was no freezer temperature log posted and there was no thermometer located in the freezer unit. An interview with EI #7, the Dietary Manager was conducted on 3/28/2019 at 1:31 PM. EI #7 was asked why there were no temperatures entered on the refrigerator temperature log on the skilled unit for 3/27/2019 and 3/28/2018. EI #7 replied he did not know, the kitchen staff did not take care of that refrigerator, the nursing staff did. EI #7 was asked who provided the training for the nurses related to refrigerator and freezer temperatures. EI #7 replied he did not know who was responsible, he guessed it would be the kitchen staff, but he was not sure. 4. Employees hair was not fully restrained. A review of a facility policy titled, Maintaining a Sanitary Tray Line, dated 11/10/2017, revealed, Compliance Guidelines . 3. During tray line assembly, staff shall: . h. Wear hair restraints (bonnets, caps, nets to cover hair) when preparing or handling food. On 03/26/19 at 5:00 PM, an observation was made of the supper meal delivery in dining the room on skilled unit. The tray line server, EI #6 was observed with her hair not completely covered with a hair net. On 03/27/19 at 7:55 AM, another observation was made of EI #6. Her hair was observed not completely contained in a hair net. Another kitchen worker who was assisting EI #6 did not have her hair completely restrained in the hair net. 03/27/19 at 4:12 PM, an interview was conducted with EI #6. EI #6 was asked what was the facility's policy/ procedure for hair covering. EI #6 replied all of the hair should be covered. EI #6 was asked when would hair not be contained in a hair restraint. EI #6 replied never, it (hair) should always be covered when handling food. EI #6 was asked what was the harm if all hair was not contained in a hair restraint. EI #6 replied hair could fall in the food and contaminate it. 5. Green beans were served to residents after a foreign object was removed from the green beans. A review of a facility policy titled, Food Safety Requirements, dated 03/14/2018, revealed, Policy: . Food will also be stored, prepared, and served in accordance with professional standards for food service safety Definitions: . Contamination means the unintended presence of potentially harmful substance including, but not limited to . or physical objects. Policy Explanation and Compliance Guidelines: 1. Food safety practices shall be followed throughout the facility's entire food handling process. The process begins when food is received from the vendor and ends with delivery of the food to the resident. An observation was made on 3/27/19 at 12:06 PM, of the skilled nursing unit dining room/ kitchen on the first floor. During the serving of lunch from the tray line, an observation was made of a piece of foreign object that was removed from the green beans by EI #6. It appeared to be some type of plastic material. EI #6 removed the foreign object from the green beans and continued to serve additional residents. The dietitian entered the area and was asked to look at the foreign object removed from the green beans. She was told it was in the green beans and was removed by EI #6 and she continued to serve residents the green beans. An additional 14 residents had been served green beans from the pan. The dietitian was asked what the object was. She replied plastic. The surveyor asked if the green beans should have continue to be served. The surveyor was informed no, as the green beans were still being served. Later the dietitian was asked why were the green beans pulled from the tray line and a fresh pan brought from the main kitchen. She said the green beans with the plastic substance in them was contaminated. The green beans with the foreign object was removed and replaced with another pan of green beans. An interview was conducted with EI #6 on 03/27/19 at 4:09 PM. EI #6 was asked what was found in the green beans at the lunch meal. EI #6 replied it looked like a piece of plastic that maybe the green beans were in prior to cooking them. EI #6 was asked what should have been done when she found the plastic type material in the green beans. EI #6 replied she should have called the manager or chef. EI #6 was asked if there was any concern about continuing to serve the green beans she removed the plastic type material from. EI #6 replied she should have not continued serving those green beans because there could have been germs in the green beans from whatever that was she removed and if a resident received a piece of the material they possibly could have choked. An interview was conducted on 03/28/19 at 1:31 PM with EI #7. EI #7 was asked if a foreign object was found in a food being served to residents' what should be done. EI #7 replied the object should be removed and the food item would also be replaced. EI #7 was asked why the food would need to be replaced. EI #7 replied they would not know where the object came from and would not know if there was more in the food. EI #7 was asked why was it important to remove the food where the object was found. EI #7 replied because the food was considered contaminated at that time therefore serving more residents would be unsafe.

Based on observation, interview and review of a facility policy Maintaining a Sanitary Tray Line, the facility failed to ensure: 1. a Certified Nursing Assistant (CNA) did not touch a resident wheelchair with gloves then with the same gloves cut a resident's sandwich in quarters; and 2. a laundry aide did not deliver the resident clothing to the unit uncovered, did not take a small basket into multiple resident rooms then return it to the clean clothes cart and did not allow resident clothing to touch the floor as she carried them from the cart to the resident closet. This had the potential to affect one of one residents in the dining room and 41 residents whose laundry was done by the facility. Findings Include: 1. A review of a facility policy Maintaining a Sanitary Tray Line with effective date of 11/10/17 revealed Policy: This facility prioritizes tray assembly to ensure foods are handled safely . Compliance Guidelines: . 3. During tray assembly, staff shall: . c. Wear gloves when handling food items, particularly when direct contact between the hands and food occurs . such as .sandwiches . f. Change gloves when activities are changed . On 3/26/19 at 5:00 PM, EI # 4, CNA was observed in the dining room with gloves on placing drinks at residents places. With the same gloves EI #4 unlocked a resident wheelchair and moved the resident, holding to the wheelchair handles and then locked the wheelchair. EI #4, with the same gloves, served another resident's tray. The resident asked for the sandwich to be cut. EI #4 with the same soiled gloves touched the sandwich with her left hand, held the knife in her right hand and cut the sandwich in to quarters. On 3/27/19 at 3:12 PM, an interview was conducted with EI #4. EI #4 was asked what was the procedure for using gloves during passing meal trays. EI #4 replied, they are to have on gloves to pass the food then remove them before they feed a resident. EI #4 was asked when should she touch a resident wheelchair then handle resident food with the same gloves. EI #4 replied, never. EI #4 was asked when should she touch a resident sandwich with a glove she had on to unlock an resident wheelchair with. EI #4 replied, never. EI #4 was asked what was the harm in handling a resident wheelchair then with the same gloves touching a resident's sandwich. EI #4 replied, you would contaminate the sandwich. 2. On 3/27/19 at 11:00 AM, the surveyor observed EI #5, laundry aide, delivering resident clothing to the unit. The personal clothing cart was not covered. EI #5 was observed taking a small basket type container from the clothing cart with small clothing items in it into multiple resident rooms. EI #5 would place the basket on the resident dresser, remove the clothing and place in the resident dresser, then take the basket and enter the next resident room, place the basket on the dresser and remove the clothing, placing in the resident's dresser, then return the basket to the clean clothing cart in the hall. EI #5 was also observed taking a piece of clothing into a resident; the piece of clothing was observed touching the floor in the hall and in the resident room. On 3/27/18 at 11:20 AM, an interview was conducted with EI #5, the laundry aide. EI #5 was asked what was the procedure when delivering resident clothing to the unit. EI #5 replied, it should be covered. EI #5 was asked if the clothing cart was covered. EI #5 replied, no. EI #5 was asked what was in the small basket. EI #5 replied, resident clothes like socks and underclothing. EI #5 was asked if each resident had their own basket. EI #5 replied, no they have several residents' clothes in each basket. EI #5 was asked how did she handle the baskets when taking clothes into resident rooms. EI #5 replied, she took the basket in each room. EI #5 was asked when should the basket be taken in each room. EI #5 replied, it should not. EI #5 was asked why should the basket not be taken into each resident room. EI #5 replied, the basket could have germs where she placed it on the resident dresser then took to another resident room; it could cause contamination. EI #5 was asked when should clean clothing touch the floor. EI #5 replied, never because the floors may not be clean then the clothes could be contaminated. On 3/28/19 at 8:31 AM, an interview was conducted with EI #3, Registered Nurse, Infection Control. EI #3 was asked what was the policy on staff touching resident food with gloves used to touch a resident wheelchair. EI #3 replied, once staff touches a resident wheelchair they should remove those gloves and wash hands and put on clean gloves before they touch any resident food. EI #3 was asked when should staff touch a resident food with same gloves they had on to unlock a resident wheelchair. EI #3 replied, never. EI #3 was asked what would the harm be in staff touching a resident wheelchair then with same gloves touch a resident sandwich. EI #3 replied, they could pass bacteria or germs from the resident wheelchair to the other resident sandwich. EI #3 was asked how should laundry staff transport resident clean clothing. EI #3 replied, they are to bring the clothing to the unit on a covered cart. EI #3 was asked how should laundry aide handle the small baskets for small laundry. EI #3 replied, leave on the cart and remove the clothing and take into the resident room. EI #3 was asked when should the laundry aide take the small basket of clothing from one resident room to another. EI #3 replied, they should not, because they could pick up bacteria from one resident and take to the next resident room. EI #3 was asked when should resident clean clothes touch the floor. EI #3 replied, never because they could pick up germs from the floor that would get on the clothes then to the resident.

Based on interview, medical record review and a review of the facility's policy titled, Personal Cell Phones Policy, the facility failed to ensure staff did not use a personal cell phone during resident care. This affected Resident Identifier (RI) #207, one of 15 residents who were observed during the provision of care. Findings Include: A review of a facility's policy titled, Personal Cell Phones dated 04/22/2016, documented: . Cell phones are to be kept in your handbag or vehicle while on duty. They may not be kept on your person or work area . while working.You may not use your cell phone in any residential area . even if you are on break or off duty . RI #207 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 03/21/2018 at 12:10 p.m., the surveyor entered RI #207's room. RI #207 stated around 10 a.m. that morning, Employee Identifier, (EI) #2, the Certified Nursing Assistant (CNA), came in the room to change him/her brief because the resident had a bowel movement (BM). RI #207 stated before he/she was changed, the CNA stood in his/her room and talked on the cell phone. RI #207 stated when the CNA finished her conversation, she then changed his/her brief. The surveyor asked how did that make his/her feel. RI #207 stated he/she felt like he/she was not getting the attention he/she needed. An interview was conducted on 03/21/2018 at 2:33 p.m. with Employee Identifier (EI) #2 CNA. The surveyor asked EI #2 was she taking care of RI #207. EI #2 said yes she was. The surveyor asked EI #2 was RI #207 alert and oriented. EI #2 said yes. EI #2 was asked what was the facility's policy on cell phone usage. EI #2 said if staff have a cell phone, they should have it on silent mode. The surveyor asked EI #2 was she on the cell phone that morning when she went into RI #207's room. EI #2 said no, she was talking to EI #3, another CNA, in the adjoining bathroom about the cushion between RI #207's legs. The surveyor asked how would it make the resident feel if she was on the cell phone during resident care. EI #2 said the resident would feel like she did not want to take care of them. An interview was conducted on 03/21/2018 at 2:50 p.m., with EI #3, CNA. The surveyor asked EI #3 was she in the adjoining bathroom to RI #207's room that morning or anytime earlier today. EI #3 said no. The surveyor asked EI #3 when did she have a conversation with EI #2 regarding RI #207. EI #3 said after lunch she informed EI #2, that RI #207 was the resident she had previously taken care of. The surveyor asked EI #3 did she ever discuss the cushion between RI #207's legs. EI #3 said no. The surveyor asked EI #3 what was she doing at approximately 10:00 a.m. that morning. EI #3 said she was providing resident care, and it was not the resident with the adjoining bathroom to RI #207. An interview was conducted on 03/21/2018 at 3:01 p.m. with EI #1, Director of Nursing (DON)/Registered Nurse (RN) ). EI #1 was asked what was the facility's policy on cell phones. EI #1 said staff were not to be on personal cell phones during work hours. The surveyor asked EI #1 should staff be on the cell phone while in a resident's room. EI #1 said no. EI #1 was asked why should staff not talk on cell phones in the residents' room while providing care. EI #1 said because it was against the facility's policy. EI #1 was asked how would it make a resident feel if staff were talking on a cell phone in the resident's room. EI #1 said it would make the resident feel they had to wait. The surveyor asked EI #1 what issue did she think it was with staff talking on the cell phone in a resident's room while providing care. EI #1 said a dignity issue.

Based on observation, interview, medical record review and a review of the facility's policy titled, Medications Administration and a review of Potter and Perry's Fundamentals of Nursing, the facility failed to ensure staff obtained Resident Identifier (RI) #12's heart rate before administering [MEDICATION NAME]. This affected one of 11 residents observed during medication administration observation. Findings Include: A review of the facility's policy titled, Medications Administration dated 11/19/12 revealed the following: Policy Medications are administered as prescribed, in accordance with good nursing principles and practices. Procedure: . 2. Medications are administered in accordance with written orders of the attending physician . A review of Potter and Perry's Fundamentals of Nursing Eighth Edition, chapter 23, Legal Implications in Nursing Practice, page 305, revealed the following: Health Care Providers' Orders . Nurses follow health care providers' orders . RI #12 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of RI #12's Quarterly Minimum Data Set ((MDS) dated [DATE], revealed RI #12's Brief Interview for Mental Status (BIMS) score of 12, indicating moderate impairment in cognition. A review of RI #12's care plan revealed, (RI #12) has impaired cardiovascular status related to medical [DIAGNOSES REDACTED]. Obtain . vital signs as ordered . A review of RI #12's (MONTH) (YEAR) physician's orders [REDACTED]. [MEDICATION NAME] 25 MG (Milligram) GIVE 1 TAB (TABLET) BY MOUTH . FOR HEART RATE GREATER THAN 110 . On 03/21/18 at 1:13 PM, the following was observed during the medication administration observation: Employee Identifier (EI) #6, Licensed Practical Nurse/LPN administered [MEDICATION NAME] 25 MG to RI #12. EI #6 did not obtain the resident's heart rate before administering the medication. On 03/21/18 at 4:50 PM, during an interview with EI #6, the surveyor asked did she obtain RI #12's heart rate before giving the [MEDICATION NAME]. EI #6 said she did not, but she should have obtained the resident's heart rate before administering the [MEDICATION NAME]. The surveyor asked what was the importance of checking a resident's heart rate before administering [MEDICATION NAME]. EI #6 replied if the heart rate was below 60, the medication would decrease the heart rate more.

Based on observation, interview and a record review, the facility failed to ensure staff followed Resident Identifier (RI) #12's care plan titled, . impaired cardiovascular status related to medical [DIAGNOSES REDACTED].#12's heart rate/vital signs as ordered. This affected one of 11 residents observed during medication administration observation and one of 15 residents whose care plans were reviewed. Findings Include: RI #12 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of RI #12's Quarterly Minimum Data Set ((MDS) dated [DATE], revealed RI #12's Brief Interview for Mental Status (BIMS) score 12, indicating moderate impairment in cognition. A review of RI #12's care plan revealed, (RI #12) has impaired cardiovascular status related to medical [DIAGNOSES REDACTED]. Obtain . vital signs as ordered . A review of RI #12's (MONTH) (YEAR) physician's orders [REDACTED].[MEDICATION NAME] 25 MG (Milligram) GIVE 1 TAB (TABLET) BY MOUTH . FOR HEART RATE GREATER THAN 110 . On 03/21/18 at 1:13 PM, the following was observed during medication administration: Employee Identifier (EI) #6, Licensed Practical Nurse/LPN administered [MEDICATION NAME] 25 MG to RI #12. EI #6 did not obtain the resident's heart rate before administering the medication. On 03/22/18 at 6:14 PM, during an interview with EI #6, the surveyor asked was the care plan for RI #12 followed for obtaining vital signs/heart rate before administering [MEDICATION NAME]. EI #6 replied, No ma'am.

Based on observation, medical record review, interviews and a review of the facility's policies titled, Wound Care and Clean Dressing Change, the facility failed to ensure staff wiped Resident Identifier's (RI) #42's wound located on mid back from the inner to the outer aspect in one continuous wipe and cleaned the peri-wound area. This affected, RI #42, one of two residents observed during wound care. Findings Include: A review of the facility's policy titled, Wound Care dated 11/16/16 revealed the following: . Purpose The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Steps in the Procedure . 11. Wash tissue around the wound that is usually covered by the dressing, tape, gauze with wound cleanser or normal saline . A review of the facility's policy titled, Clean Dressing Change dated 10/16/16, revealed the following: . Policy: It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination . Policy Explanation and Compliance Guidelines: . 12. Cleanse the wound as ordered, taking care to not contaminate other skin surfaces or other surfaces of the wound ( . clean outward from the center of the wound). RI #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #42's (MONTH) (YEAR)'s Physician order [REDACTED]. WOUND TO MID BACK . A review of RI #42's Minimum Data Set ((MDS) dated [DATE] revealed RI #42's Brief Interview for Mental Status (BIMS) score of 15, indicating cognition intact. The MDS assessed RI #42 as having three pressure ulcers. On 03/22/18 at 9:50 AM, the following was observed during wound care for RI #42: Employee Identifier (EI) #4, Licensed Practical Nurse/LPN/Treatment Nurse and EI #5, Certified Nursing Assistant/CNA washed their hands and applied gloves. EI #4 removed RI #42's dressing to the resident's mid back wound. EI #4 moisten 4 x (by) 4's with Vashe wound cleanser, wiped RI #42's wound from top to bottom, in a dabbing in and out motion as she wiped the wound, loosing contact with the wound bed. EI #4 did not clean the peri-wound. EI #4 then applied Santyl ointment and [MEDICATION NAME] border dressing to the wound. On 03/22/18 at 10:45 AM, during an interview with EI #4, the surveyor asked what direction should a wound be wiped/cleaned. EI #4 said from inner to outer, but that was not what she had done, she wiped from top to bottom. The surveyor asked when should staff lose contact with a resident's skin when cleaning a wound. EI #4 stated staff should never lose contact with a resident's skin, but that was not what she had done. The surveyor asked what did that potentially cause. EI #4 said germs could be re-entered into the wound. The surveyor asked EI #4 when did she clean the periwound. EI #4 stated she did not, but she should have cleaned the periwound. The surveyor asked what was the potential for harm related to wiping a wound from top to bottom and loosing contact with skin. EI #4 said germs could enter into the wound.

Based on observation, medical record review, interview and a review of the facility's policies titled, Skin Care and Gloves, the facility failed to ensure staff changed soiled gloves after cleaning Resident Identifier (RI) #42's wound and before applying a clean dressing. The facility further failed to ensure staff washed hands after removing soiled gloves and before applying clean gloves. This affected RI #42, one of two residents observed during wound care. Findings Include: A review of the facility's policy titled, Skin Care dated 11/16/12 revealed the following: . Procedure I. Dressing-Clean Technique: . 9. Remove dressing and discard . Remove gloves and wash hands. 10. Apply clean gloves. 11. Cleanse area . 12. Remove gloves, wash hands . A review of the facility's policy titled, Gloves dated 03/23/06, revealed the following: . handwashing is to be done after removal of gloves. If gloves become soiled, change during care . RI #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #42's Minimum Data Set ((MDS) dated [DATE] revealed RI #42 had a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition was intact. The MDS assessed RI #42 as having three pressure ulcers. A review of RI #42's (MONTH) (YEAR)'s Physician order [REDACTED]. WOUND TO MID BACK . WOUND TO SACRUM . LEFT HEEL WOUND . On 03/22/18 9:50 AM, the following was observed during wound care for RI #42: Employee Identifier (EI) #4, Licensed Practical Nurse/LPN/Treatment Nurse and EI #5, Certified Nursing Assistant/CNA washed their hands and applied gloves. EI #4 cleaned and dried RI #42's left heel wound. EI #4 then applied Santyl ointment and a clean dressing. EI #4 did not remove her gloves or wash her hands after cleaning the left heel wound and before applying Santyl ointment and a clean dressing. On 03/22/18 9:50 AM, the following was observed during wound care for RI #42: EI #4 cleaned RI #42's sacrum wound and applied a clean dressing. EI #4 removed her gloves and applied clean gloves. EI #4 dated, timed and initialed the dressing. EI #4 did not wash her hands after she removed her soiled gloves and before applying clean gloves. On 03/22/18 at 10:45 AM, during an interview with EI #4, the surveyor asked after cleaning a wound and before applying a clean dressing what should be done with gloves. EI #4 said wash hands and apply clean gloves, but that was not what she had done. The surveyor asked what should be done after gloves were removed and before applying clean gloves. EI #4 stated wash hands, but that was not what she had done. The surveyor asked what was the potential for harm related to not changing gloves and washing hands. EI #4 said infection control.

Based on observation, record review, interview, and review of facility policies titled, Hair Restraints, and Food Handling and the review of the Food Code Manual, the facility failed to ensure the following: 1) A male staff wore a facial cover while working in the dietary department and 2) cool running water was used for raw chicken observed thawing in the two compartment sink. These deficient practices were observed during the initial tour on 02/14/16, having the potential to affect all residents receiving meals from the kitchen. Finding Include: 1. A facility policy titled: HAIR RESTRAINTS Policy# E002 with an Effective Date: March, 2013 .Policy: Associates will wear hair restraints regardless of length of hair or beard at all times in the Kitchen.Procedure: .food employees shall wear .beard restraints . that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. The : FOOD CODE MANUAL with a date of 2013, documented on page 51 .HYGIENIC PRACTICES Subparts . 2-402 Hair Restraints . 2-402.11 Effectiveness. (A) . 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 hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. On 02/14/17, during the initial tour of the kitchen at 11:10 a.m. a dietary male staff was observed in the walk in cooler without a beard cover. The male staff had facial hair observed on his chin approximately one inch long. An interview was conducted with Employee Identifier (EI) #1 Dietary Manager on 02/16/17, at 1:34 p.m. EI #1 was asked who was responsible for assuring male staff who had facial hair wore beard covers. EI #1 replied, anyone in the kitchen including myself who sees it. She was asked why a male staff in the walk in cooler during the initial tour of the kitchen was not wearing a beard cover. She replied, she did not know that they knew better. EI #1 was asked what the potential for harm was for residents who receive meals from the kitchen if a male employee did not cover facial hair. She replied, possibility of hair in the food. She was then asked if male staff who have facial hair wear a cover while working in the dietary department. EI #1 stated, Yes, always. 2. A facility policy titled: .FOOD HANDLING GUIDELINES (HACCP) Policy# CO19 with an effective date : January, 2015 documented .THAW FROZEN MEAT .Submerged under potable running water at a temperature of 70 degrees Fahrenheit or below with sufficient velocity to agitate and float off loose food particles into the overflow. (Duration of process should not exceed two hours.) The FOOD CODE MANUAL dated 2013, documented on page 88 titled: LIMITATION OF GROWTH OF ORGANISMS OF PUBLIC HEALTH CONCERN Subparts 3-501 Temperature and Time Control .page 89 . 3-501.13 Thawing TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be thawed: .(B) completely submerged under running water: (1) At a water temperature of 21 degrees Celsius (70 degrees Fahrenheit) or below, (2) With sufficient water velocity to agitate and float off loose particles in an overflow, and (3) For a period of time that does not allow thawed portions of READY-TO-EAT FOOD to rise above 5 degrees Celsius or (41 degrees Fahrenheit) On 02/14/17, during the initial tour of the kitchen at 11:10 a.m., raw chicken was observed in a bowl in the two compartment sink. There was no water observed running over the raw chicken. An interview was conducted with EI #1 on 02/06/17 at 1:34 p.m. EI #1 was asked why was there raw chicken observed in the two compartment sink without water running over it. EI #1 replied, she did not realize that was going on. EI #1 was asked why should raw chicken have cool water running over it if left in a bowl in the two compartment sink. She stated, For thawing purposes and help hold the temperature. EI #1 was asked what the potential for harm was for the residents served from the kitchen. She stated, It would be out of temperature and could cause a food born illness.

Based on observation, interview and review of a facility policy titled, Menu Editing, the facility failed to ensure the Puree Diet Menu was followed for the dinner meal on 02/14/17, by failing to serve Pureed Brownies and Soaked New Potatoes. Three sampled residents were affected by this deficient practice, Resident Identifiers (RI)'s 1, 2 , and 7. According to the Master Resident form, provided by the facility on what type of diets each resident receives, it was determined 12 residents were currently receiving Pureed diets. Findings Include: A facility policy titled: MENU EDITING .Policy# D 037 with an Effective Date: January, 2015 .Policy: Menus are checked to ensure compliance with the diet order. 1. RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Documented on the Master Resident list for diets, RI #1 was ordered to receive a regular puree diet. On 02/14/2017 at 5:16 p.m., the surveyor observed resident in Dining room being fed her evening meal. The divided plate contained pureed food. RI #1 had a chocolate pudding cup for dessert. 2. RI #2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #2's February 2017 physician's orders [REDACTED]. On 02/14/2017 at 5:21 p.m., the surveyor observed RI #2 eating the evening meal. The meal was pureed as ordered but there was no dessert on the tray. At 5:28 p.m., a staff member delivered a chocolate pudding cup to RI #2. 3. RI # 7 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI # 7's physicians orders dated 02/01/17 documented the following: .Diet .PUREED . On 2/14/17 at 5:20 p.m. RI # 7 was observed eating a pureed supper meal. The meal consisted of the following: Pureed meat, pureed green beans, pureed sweet potatoes, pureed bread and a pudding cup. At 5:30 p.m. the Surveyor asked the kitchen staff what the dessert was for the pureed diet. The staff responded the dessert for the pureed meal was pudding. A facility Menu was provided to the surveyor for the meals for week 1 Tuesday. The Puree meal documented: DINNER: Chicken, Green Beans, New Potatoes/Roll , Brownies .Alt. (Alternate) Pork Chop, Cauliflower and Zucchini . An interview was conducted with Employee Identifier (EI) #1 Dietary Manager on 02/16/17, at 1:34 p.m. EI #1 was asked what dessert item was on the menu for Tuesday. She stated, Brownies. EI #1 was asked why the residents on Puree Diets were served Chocolate Pudding instead of the Puree Brownie. She replied the staff did not realize the brownies did not have nuts and normally they do and she forgot to tell them. EI #1 was asked if the Menu was followed. She stated, No not that part for dessert. She was asked what kind of Potatoes the residents received on 02/14/17 dinner meal for Puree. She replied, Sweet Potatoes. EI #1 was asked if New Potatoes was served on the Puree Diet on Tuesday. She replied, no. EI #1 was asked why not. She replied we cannot puree potatoes with skin and that they normally used Potato Pearls and that they were out so she used Sweet Potatoes instead.

Based on interview and record review, the facility failed to ensure laboratory (lab) tests for Resident Identifiers (RI) #3, 5, 7, and 9 were drawn/resulted, as ordered. An interview with Employee Identifier (EI) #5, the Facility Administrator revealed the previous lab (laboratory) company was running some of the labs but not all of the labs that were ordered. This affected four of nine sampled residents whose lab tests were reviewed. Findings include: 1. RI #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #3's monthly physician's orders [REDACTED]. A review of RI #3's medical record revealed there was no lab report for the November lab work; however, there were results for labs drawn on 1/30/2017 (two months after the labs were supposed to have been drawn). 2. RI #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #5's physician's orders [REDACTED]. A review of RI #5's lab results revealed no results for an LFT or Lipid Panel in November 2016. 3. RI #7 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #7's physician's orders [REDACTED]. A review of RI #7's lab reports revealed there were no results for the HGBA1C from November 2016. 4. RI #9 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #9's physician's orders [REDACTED]. RI #9's medical record did not contain any lab reports for the November 2016 LFT and Lipid Panel. On 02/16/2017 at 11:10 a.m., Employee Identifier (EI) #5, the Facility Administrator, came to the conference room to explain the missing lab results. EI #5 stated the original lab company was running some of the labs but not all of the labs ordered. The facility had terminated services with that lab company in December 2016. On 02/16/2017 at 2:07 p.m., the surveyor interviewed EI #7, Registered Nurse (RN) Supervisor. EI #7 stated EI #5, the RN Infection Control Nurse was now responsible for ensuring labs were drawn timely. She further stated prior to EI #5 being responsible, the nursing staff was responsible for ensuring labs were drawn. EI #7 stated she was aware of missing labs and problems with the lab. She further stated the Administrator had terminated services with the lab due to multiple problems. On 02/16/2017 at 2:30 p.m., the surveyor interviewed EI #5, RN/Infection Control Nurse whose duties include monitoring lab results. EI #5 stated she was now in charge of monitoring the labs and had been for about one month. EI #5 stated she was working on correcting the lab results for RI #3, 5, 7 and 9. EI #5 stated she had called the lab about the results for these residents and they were not done. When asked what was the potential for harm in not drawing labs, she stated if labs were not drawn, and reviewed, the results could be high or out of normal ranges. When asked if RI #s 3, 5, 7, and/or 9 had had any adverse effect from lack of labs being drawn, EI #5 stated the labs were standing orders due to medications the residents were on and the residents were stable. On 02/16/2017 at 2:45 p.m., the surveyor interviewed EI #6, the Medical Director for the facility. EI #6 stated he was aware of problems with the previous lab company not running/reporting all the labs ordered. He further stated he was not aware of any issues with the new lab. EI #6 was asked what the potential for harm was in not obtaining the labs for RI #RI #3, RI #5, RI #7 and RI #9. He stated the problems could be from nothing to a slow and gradual liver problem. He further stated the HGBA1C was ordered to monitor Diabetes and the resident was getting insulin and blood sugar checks for this, so no problem. EI #6 stated the listed residents were pretty much stable. EI #6 further stated, . based on best practice, labs should be drawn and monitored to ensure the health of the resident.

Based on observation, interviews and review of facility policies titled, Peri-Care,Gloves and Hand Washing, the facility failed to ensure Employee Identifier (EI) #2, a Certified Nursing Assistant (CNA), washed her hands and changed her gloves during the provision of incontinence care for Resident Identifier (RI) #1 on 02/15/2017. This affected RI #1, one of two sampled residents observed for incontinence care. Findings include: A facility policy dated 06/06/2012, titled Peri-Care documented: .Procedure: .7. Wash your hands and put on gloves.Female Resident: a. Wash the perineum .14. Remove and dispose of gloves properly.16. Wash hands . A facility policy dated 03/23/2006, titled Gloves documented: . handwashing is to be done after removal of gloves . A facility policy dated 11/28/2016 titled Hand Washing documented: Policy: Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors.Hand Hygiene Table . Condition .After handling contaminated objects .Before applying and after removing personal protective equipment (PPE), including gloves .Before and after handling clean or soiled .linens .When, during resident care, moving from a contaminated body site to a clean body site . The Hand Hygiene Table lists the aforementioned times and further documents if these conditions are present,Either Antimicrobial Soap and Water or Alcohol Based Hand Rub . RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's Admission Minimum Data Set with a Reference Date of 01/20/2017 revealed RI #1 was totally dependent on staff for toileting needs. On 02/15/2017 at 10:24 a.m., the surveyor observed EI #2/CNA, provide incontinence care to RI #1. EI #2 washed her hands and put on gloves. EI #2 performed perineal care, touched the clean brief, turned RI #1 to the side, cleaned the buttocks, applied barrier cream, then applied the clean brief. EI #2 then put all soiled supplies in a plastic bag, removed her gloves, took the plastic bag to the Soiled Utility Room and then washed her hands. EI #2 did not wash her hands at anytime during the provision of incontinent care to RI #1. On 02/15/2017 at 10:37 a.m., the surveyor interviewed EI #2 the CNA who provided care to RI #1. EI #2 stated hands should be washed prior to putting on gloves and after removing gloves and she had not done so. EI #2 stated when providing incontinence care, hands should be washed and gloves should be changed after performing care to the front (perineal area) and before going to the back (buttocks area). EI #2 also stated prior to using her gloved hand to apply barrier cream, she should have changed her gloves. When asked why it was important to change gloves and wash hands during incontinent care, EI #2 stated for infection control purposes. On 02/16/2017 at 09:00 a.m., the surveyor interviewed EI #4, Registered Nurse (RN)/Infection Control Nurse. EI #4 stated hands should be washed every time there is contact, every time gloves are changed or removed, and when going from one area on a resident to another. EI #4 stated hands should be washed prior to putting on gloves and after removing gloves. EI #4 further stated after cleaning the perineal area and prior to cleaning the buttocks, gloves should be removed, hands washed and new gloves applied. EI #4 stated hands should be washed, gloves changed prior to applying barrier cream. EI #4 also stated before touching clean items such as the brief, residents clothes and linens, staff should remove gloves, wash their hands and apply new gloves. When EI #4 was asked why it is important to wash hands and change gloves during incontinent care, she stated to prevent the spread of any kind of bacteria.

Based on observation, record review, interview and review of the Food Code manual the facility failed to ensure the walk in freezer was free of a large build up of ice on the outside of the freezer door. There deficient practices were observed during the initial tour on 02/14/17, having the potential to affect all residents who receive meals from the kitchen. Findings Include: A record review of the Food Code manual dated 2013, page 131 . titled: MAINTENANCE AND OPERATION . Subparts 4-501 Equipment . 4-501 Good Repair and Proper Adjustment.(A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. On 02/14/17 at 11:10 a.m. during the initial tour of the kitchen the freezer door was covered with ice and the door was not closed. The door was hard to open related to the ice on the door. An interview was conducted with Employee Identifier (EI) #1 Dietary Manager on 02/16/17, at 1:34 p.m. EI #1 was asked what she observed on the outside of the walk in freezer door during the initial tour. EI #1 stated, Ice. She was asked if ice should be observed on the outside of the freezer door. EI #1 stated, No ma'am. EI #1 was asked what was the reason for ice on the outside of the freezer door . She replied the door is not shutting well causing ice build up. EI #1 was then asked what was the potential for harm for the residents who are served meals from the kitchen if the freezer door has an accumulation of ice. EI #1 stated, It could cause the food to thaw and be out of temperature and cause illness.

Based on observations, record review and interview: 1. The facility failed to prevent a potential storage Time/Temperature abuse as evidenced by the sliding door to the ice cream box (freezer) was left ajar and individual cups of ice cream were soft to the touch. Internal ice cream temperatures registered 11.9 degrees F. (Fahrenheit). 2. The facility failed to prevent potential cross-contamination as evidenced by: a. Wiping cloths were not stored in a sanitizing solution; b. Lack of cleaning and disinfecting of food delivery carts between use for soiled/clean trays; c. The light bulb in refrigerator with stored food was not covered, coated or shielded; d. Plastic dinnerware was not clean and in good condition. 3. The facility failed to assure equipment was maintained clean and in good working condition as evidenced by: a. Utensils were not properly cleaned and sanitized due to the lack of monitoring/documenting and validating the final rinse temperature of the dishmachine. b. Chemicals were used according to the manufacturer's recommendation. The above practices posed the potential for food contamination and compromised food safety. This had the potential to affect all 56 residents receiving meal trays from dining services. Findings include: The 2013 Food Code by the United States Public Health (USPH) and the Food and Drug Administration (FDA) included the following: 1. Temperature and Time Control 3-501.11 Frozen Food. Stored frozen FOODS shall be maintained frozen (solid). On 1/26/2016 at 8:30 AM, during the initial kitchen tour with the Certified Dietary Manager (CDM) Employee Identifier EI #1, the sliding door to the ice cream box was observed to not be completely closed. An individual cup of ice cream was removed. It was soft to the touch, leaving finger indentations. The internal temperature of the ice cream registered 11.9 degrees F. On 1/28/2016 at 11:04 AM, the CDM (EI #1) was interviewed about ice cream not being frozen solid. EI #1 indicated knowledge of the temperature standards of practice and said, No when asked if the observed cups of ice cream were frozen solid. EI #1 did quantify that, by saying those had been stored in the front part (approximately 1/3--1/4 of the available storage space). EI #1 was asked, what she thought was the causal factor for ice cream not having been frozen solid. EI #1 said that somebody left the box lid open. 2. a. The 2013 Food Code by the United States Public Health (USPH) and the Food and Drug Administration (FDA) included the following: 3-304.14 Wiping Cloths, Use Limitation. (B) Cloths in-use for wiping counters and other EQUIPMENT surfaces shall be: (1) Held between uses in a chemical sanitizer solution at a concentration . A wiping cloth was observed on 1/26/2016 at 11:05 AM, resting on the serving board (trayline). The cloth was not stored in a sanitizing solution. The plating of the lunch meal was in progress. On 1/28/2016 at 11:21 AM, the CDM (EI #1) was interviewed and asked to acknowledge regulatory standards for wiping cloths. EI #1 verbalized the facility cloth was not stored in a sanitizing solution and that staff were not using the cloth when viewed. b. The facility failed to assure effective disinfecting of food tray delivery carts between use due to a failure to adhere to the manufacturer's recommendation for use. There was no policy/procedure nor did facility staff have a thorough knowledge for use of the chemical. On 1/27/2016 at 10:05 AM, the breakdown of soiled trays was observed for the tall-tiered open carts. EI #3 was operating the dishmachine on the soiled side. EI #4 was working on the clean side. EI #4 was observed to towel dry water from inside the cart. When asked about the procedure EI #4 explained: She (EI #3) sprays them and I dry them out. EI #3 was asked how she sprayed the carts. EI #3 responded she used the hose on the wall or sink (dish) sprayer. There was no mention of a chemical sanitizer. Effective use of the chemical would be to clean the carts, rinse and then spray with the disinfectant and allow to saturate for 10 minutes per manufacturer's recommendation. On 1/28/2016 at 11:25 AM, the undated cleaning policy was reviewed. The policy specified: Food carts will be cleaned and sanitized immediately after each use. The procedure indicated: Each day, the inside and outside of all food carts will be cleaned and sanitized. What sanitizer to use, how to apply and time limits for the chemical sanitizer to remain on the cart surface were not addressed. The CDM (EI #1) was asked if the facility followed the chemical manufacturer's recommendation for use. EI #1 replied, No, Ma'am, the contact time is not appropriate. EI #1 stated the problem was due to a lack of knowledge of the manufacturer's sanitation directions. c. The 2013 Food Code by the United States Public Health (USPH) and the Food and Drug Administration (FDA) included the following: Functionality 6-202.11 Light Bulbs, Protective Shielding. (A) .light bulbs shall be shielded, coated, or otherwise shatter-resistant in areas where there is exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; or unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES . On 1/26/2016 at 8:47 AM the double door refrigerator was viewed for compliance that light bulbs should be covered, coated or shielded. The interior bulb was neither coated nor covered. On 1/28/2016 at 11:04 AM, EI #1 was interviewed and asked if the regulatory requirements were met. EI #1 stated the bulb not being coated, covered/shielded was a potential physical contamination of food (should the bulb break). d. The 2013 Food Code by the United States Public Health (USPH) and the Food and Drug Administration (FDA) included the following: 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch . On 1/26/2016 at 11:47 AM during an observation of the meal service delivery, a single plastic sectional plate was stored in the plate lowerator behind the steamtable. Upon examination, it was determined the side of the plate had a crack and the cross-sections were chipped. Again on 1/27/2016 at 10:26 AM, sectional plates were observed in the lowerator at the trayline. Three of five plates were found to be problematic. Two were chipped and one contained food debris. On 1/28/2016 at 11:21 AM, EI #1 was interviewed about the sectional plates. She indicated the plates were used to help residents feed themselves and keep the food separated. EI #1 was aked where the sectional plates were located, when viewed by the surveyor. EI #1 responded that they were in the plate warmer, behind the trayline. EI #1 was aked why 3 of 5 plates were not clean and in good condition. She responded the employee did not check.

Based on observation, interview and record review, the facility failed to assure waste was properly contained in the dumpster. Liquid and solid waste was visible and adhering to the outer wall surface beneath the door opening of the dumpster. Latex gloves were strewn on the ground. The unit was not maintained in a manner to prevent the harborage and feeding of pests. This deficient practice had the potential to affect all 56 residents residing in the facility at the time of this survey. Findings include: The 2013 Food Code by the United States Public Health (USPHS) and the Food and Drug Administration (FDA) included the following: . 5-501.15 Outside Receptacles. (A) Receptacles and waste handling units for REFUSE, recyclables, and returnables used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers. (B) Receptacles and waste handling units for REFUSE and recyclables such as an on-site compactor shall be installed so that accumulation of debris and insect and rodent attraction and harborage are minimized and effective cleaning is facilitated around and, if the unit is not installed flush with the base pad, under the unit. On 1/27/2016 at 9:28 AM, the Assistant Dietary Director, Employee Identifier (EI) #2 accompanied the surveyor to evaluate the waste/refuse disposal area. Beneath the door opening, food and fat debris was observed adhering to the outside surface. On the ground space between the container and a porch wall, multiple latex gloves were observed. On 1/27/2016 at 9:55 AM, the Certified Dietary Manager (CDM), EI #1 was advised that there was a concern with the waste disposal. EI #1 responded: Yes Ma'am, there was a hole in the bottom and maintenance has ordered a new one. On 1/27/2016 at 2:15 PM, the CDM, EI #1 was asked, what potential harm could result from the discarded gloves littering the ground, and food debris adhering to the container's outside wall. EI #1 responded, pests, rodents, etc. and said there was a potential for biological (contamination). EI #1 was asked why (cleaning) had not been done? EI #1 said it was a problem with miscommunication and there was a change in facility procedures.

Based on observations, interview, and review of facility policies, the facility failed to ensure: 1) dietary staff did not wear dangling, hoop-style earrings not contained by a hairnet; 2) chicken and ground beef thawed in the refrigerator were arranged in a manner to prevent potential cross contamination; 3) thawed mighty shakes and magic cups were labeled in a manner such that the use by date was evident; 4) bulk bread crumbs and dried lima beans were not stored past their use by date; 5) an angel food cake in the walk-in cooler was labeled with a date; and 6) the warming cabinet and a stainless steel work surface and storage unit were free of discolored buildup and accumulated food debris. This had the potential to affect all 56 of 56 residents residing in the facility. Findings Include: 1) Review of the facility's undated policy titled "Employee Sanitary Practices" revealed the following: "Policy: All kitchen employees will practice standard sanitary procedures. Procedure: All employees shall: 1. ... Jewelry is kept at a minimum of hand jewelry and hand jewelry is covered with gloves when handling food. Facial piercings are to be removed or covered..." During the initial tour of the kitchen on 12/2/2014 beginning at 9:35 AM, three employees were observed wearing dangling earrings not contained by a hairnet. The observations are as follows: 1) Employee Identifier (EI) #3, the Dietary Assistant Director, was observed in the kitchen in the food preparation area with dangling hoop-style earrings outside of her hairnet. 2) EI #4, a dietary staff member, was observed wearing two pairs of dangling hoop-style earrings, not contained by her hairnet. She was observed preparing orzo for the following meal. 3) EI #6, the Dietary Director, was observed with dangling hoop-style earrings not contained by her hairnet while arranging food items inside the walk-in cooler. During trayline observations on 12/2/2014 beginning at 4:15 PM, EI #7, a cook, was observed preparing food with one of two earrings not contained in a hairnet. EI #5, another dietary staff member, was observed on the trayline serving food onto trays. EI #5 was wearing dangling, hoop-style earrings not contained by a hairnet. EI #6, the Dietary Director, was asked what the facility's policy on jewelry was. EI #6 stated staff were not supposed to wear dangling earrings. When asked why, she explained the earrings could fall into the food. 2) Review of the Food and Drug Administration Food Code 2013 revealed the following: "... Preventing Food and Ingredient Contamination 3-302.11 Packaged and Unpackaged Food -Separation, Packaging, and Segregation. A) FOOD shall be protected from cross contamination by: (1) ... separating raw animal FOODS during storage... (2) Except when combined as ingredients, separating types of raw animal FOODS from each other such as beef, FISH, lamb, pork, and POULTRY during storage... (b) Arranging each type of FOOD in EQUIPMENT so that cross contamination of one type with another is prevented..." During the initial tour of the kitchen on 12/2/2014 beginning at 9:35 AM, chicken and ground beef were noted thawing in the reach-in cooler. The chicken was stored in a cardboard box on the shelf directly above the ground beef. An interview with EI #6, the Dietary Director, was conducted on 12/4/2014 at 7:30 PM. When asked how meat should be thawed in the refrigerator, EI #6 stated chicken should normally go on the bottom. When asked what potential harm could occur if chicken was thawing over the ground beef, EI #6 stated she had gone to look at it and the chicken should not have been placed on the shelf over the ground beef. EI #6 explained it could cause cross contamination or salmonella. 3) Review of the manufacturer's information for magic cups revealed that, once thawed, they were good for five days if stored in the refrigerator. Review of the manufacturer's information for mighty shakes revealed that, once thawed, they were good for 14 days if stored in the refrigerator. During the initial tour of the kitchen on 12/2/2014 beginning at 9:35 AM, 13 thawed mighty shakes and 9 thawed magic cups were noted in the small counter top reach-in cooler. No thaw dates or use by dates were noted. A plastic bin containing 14 thawed mighty shakes without thaw dates or use by dates was noted in the walk-in cooler . 4) Review of the facility's policy titled "FOOD STORAGE LABELING" revealed the following: "POLICY: The facility will ensure the safety and quality of food by following good storage and labeling procedures. PROCEDURE: ...3. Rotation... b. Foods stored in storage units will be surveyed routinely to identify and discard foods that have passed its manufacturer use by date or expiration date. Suggested time frames: Dry Storage- Weekly..." During the initial tour of the kitchen on 12/2/2014 beginning at 9:35 AM, the surveyor observed a plastic bin of bread crumbs labeled "Prepared date 3/5/14 Use by 9/5/14" and a bin of dried lima beans labeled " Prepared date 11/4/13 Use by 11/11/13." An interview with EI #6, the Dietary Director, was conducted on 12/4/2014 at 7:30 PM. When asked what procedures were in place to ensure items exceeding their use by dates were discarded, EI #6 stated she has someone designated to discard items once a week if needed. When asked what harm could occur if items were stored past their use by dates, EI #6 stated the foods would be stale. 5) Review of the facility's undated policy titled "Food Storage" revealed the following: "...14. Refrigerated Food Storage: ...f. all foods should be ... dated..." During the initial tour of the kitchen on 12/2/2014 beginning at 9:35 AM, an angel food cake was noted in the walk-in cooler without a use by date. During an interview with EI #6, the Dietary Director, on 12/4/2014 at 7:30 PM, the surveyor asked how items in the cooler should be labeled. EI #6 stated items should be labeled with the date pulled from the freezer. 6) During trayline observations on 12/2/2014 beginning at 4:15 PM, the surveyor noted the warming cabinet had a brown and white colored build-up along all sides of the equipment. The warming cabinet was in use at the time of the observation. A greasy film, food debris, and a rust colored substance were noted along the hinge side of the door. EI #3, The Dietary Assistant Director, was asked to use a damp cloth to wipe the surface of the warming cabinet. When EI #3 wiped the equipment a black/brown colored substance was noted to come off onto her rag. EI #3 explained the equipment was supposed to be wiped down weekly but stated it had taken longer than a week to get in that condition. The surveyor also noted a stainless steel work surface with cabinets with a rust colored substance and food debris in the grooves for the sliding doors. During an interview with EI #6, the Dietary Director, on 12/4/2014 at 7:30 PM, the surveyor asked how often equipment should be cleaned. EI #6 stated the equipment should be cleaned daily.

Based on observations, interviews and record review, the facility failed to ensure Resident Identifier (RI) #3 did not receive more than the prescribed amount of fluids on the 12/3/2014 breakfast tray. The facility further failed to ensure the prescribed fluid restriction order was followed on 10 of 21 days following the initiation of the written order. This affected RI #3, one of one resident sampled for fluid restrictions. Findings include: A review of a facility's policy titled "Fluid Restrictions Policy and Procedure" dated 10/20/2013 revealed the following: "Purpose: A resident's fluid intake may be restricted due to certain diseases or clinical conditions, as ordered by the attending Physican. Restriction indicates that they should have no more than the amount ordered. Standard: Residents should be encouraged to drink a minimum of six cups of liquid daily, unless fluids are restricted due to a disease process, as documented by the physician's orders [REDACTED]. Process: ...B. The fluid restriction should be specified in the physician's orders [REDACTED]. C. The amount of daily fluid prescribed by the physician should be divided between the dietary and nursing departments, in consideration of other care requirements. The amount required for medication administration should be communicated to the dietary department, whom subtracts nursing requirements from the daily meal plan for the resident. D. The division of liquids should be documented in the physician's orders [REDACTED]. F. Nursing instructions should be communicated via the MAR (Medication Administration Record)...." RI #3 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #3's physician's orders [REDACTED]. "... Fluid Restriction: 1000 mL (milliliters)/day 720 mL from dietary = (equals) 240 mL with each meal. 280 mL from nursing = 120 mL day shift, 120 mL evening shift, 40 mL night shift..." RI #3's care plan for "...potential for dehydration related to diuretic medication... fluid restriction 1000 mL/ (per) day...", updated 11/13/2014, listed an intervention of "*fluids as ordered by MD (doctor)". On 12/3/2014 at 7:43 AM, RI #3 was observed to receive eight ounces of milk, 8 ounces of water, and 6 ounces of juice on the breakfast tray delivered by dietary. Review of RI #3's "Daily Percentage of Food For Dining Room" for the dates of 11/13/2014 through 12/3/2014 revealed the fluid restriction of 240 mL from dietary per meal was not adhered to on the following 10 of 21 days: Breakfast Lunch Dinner 11/13/2014 240 480 480 11/15/2014 240 480 240 11/17/2014 *** 480 360 11/21/2014 120 360 480 11/22/2014 480 360 360 11/23/2014 *** 360 240 11/24/2014 240 240 360 11/29/2014 360 480 360 12/1/2014 480 480 360 12/3/2014 240 240 360 (Note: *** denotes not recorded and all measurements are in mL) Employee Identifier (EI) #9, the Director of Nursing, was interviewed on 12/4/2014 at 10:08 AM. When asked how residents with fluid restrictions should be addressed, EI #9 stated dietary provides part and nursing provides some to administer medications as specified in the physician's orders [REDACTED].#3's order stated regarding fluid restriction, EI #9 explained RI #3 should receive 1000 mL per day, 240 mL per meal from dietary for a total of 720 mL, and the remaining 280 mL from nursing. When asked why RI #3 had received eight ounces of milk, eight ounces of water, and six ounces of juice, EI #9 stated that exceeded RI #3's allowed amount and explained dietary gave her too much. When asked why RI #3 was on fluid restriction and what potential harm could occur if given too many fluids, EI #9 stated she believed the fluid restriction was due to [MEDICAL CONDITION] and if receiving too much could result in fluid overload. EI #9 then reviewed RI #3's "Daily Percentage of Food For Dining Room" and stated the recorded amounts were for the amount of fluid consumed. EI #9 stated RI #3 had consumed over the allowed amount of fluids per meal on the following days: 11/13, 11/15, 11/17, 11/21, 11/22, 11/23, 11/24, 11/29, 12/1, and 12/3. EI #6, the Dietary Director, was interviewed on 12/4/2014 at 7:30 PM. When asked how the dietary department addressed residents with fluid restrictions, EI #6 stated nursing told them how much to give from dietary. EI #6 then stated, for RI #3, dietary should have provided eight ounces per meal (240 mL). When asked why RI #3 had received eight ounces of milk, eight ounces of water, and a juice cup with breakfast on 12/3/2014, EI #6 stated it was an oversight on dietary's part. EI #6 then stated the dietary department needed to get some four ounce glasses.

Based on interviews and record review, the facility failed to ensure a care plan was completed for Resident Identifier (RI) #3's history of making a suicidal statement within seven days of completing the initial comprehensive assessment. The facility further failed to ensure RI #3's care plan was accurately updated on 11/12/2014 to reflect the new intervention for no sharp objects in room. This affected one of eight residents whose comprehensive care plans were reviewed. Findings Include: Resident Identifier (RI) #3 was admitted to the facility from an Assisted Living Facility on 07/02/2014. On 7/4/2014 RI #3 was transferred out of the facility for evaluation following a statement of intent to commit suicide and readmitted on [DATE] with new [DIAGNOSES REDACTED]. Review of RI #3's Admission Minimum Data Set (MDS) revealed the admission assessment had been completed on 07/23/2014. However, the care plan for RI #3's history of suicidal statements was not initiated until 08/12/2014. Employee Identifier (EI) #10, the Social Worker, was interviewed on 12/3/2014 at 2:50 PM. When asked why the care plan for suicidal statements was not created until 08/12/2014, EI #10 stated they had not completed the care plan within the allowed 21 days. EI #10 then said she had not placed as much urgency on suicidal statements as she should have. On 11/4/2014, RI #3 was transferred out of the facility after sustaining superficial lacerations to the neck. RI #3 was readmitted to the facility on [DATE]. RI #3's care plan for suicidal statements had been revised on 11/12/2014 to include an intervention for an actual attempt with the approach of "make sure all sharp objects" added. In an interview on 12/3/2014 at 9:00 AM, EI #10, the Social Worker, was asked what "make sure all sharp objects" was supposed to mean. EI #10 stated she had not completed her sentence. In an interview on 12/4/2014 at 8:15 AM, EI #2, the Care Plan Coordinator, was asked what the intervention of "make sure all sharp objects" meant. EI #2 stated she did not know. When asked how caregivers would know what to do, she stated they would not.

Based on observations, record review and interviews, the facility failed to ensure Resident Identifier (RI) #5's care plan intervention of "bed in lowest position" was implemented on 3 of 4 days of survey. This affected 1 of 8 residents whose comprehensive care plans were reviewed. Findings Include: Resident Identifier (RI) #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #5's falls care plan, reviewed 11/3/2014, listed an intervention of "keep bed in lowest position while resident is in bed." RI #5 was observed in the bed not in the lowest position during the survey at the following times: 12/2/2014 at 4:10 PM 12/3/2014 at 7:40 AM 12/4/2014 at 7:54 AM On 12/4/2014 Employee Identifier (EI) #1, a Certified Nursing Assistant (CNA), entered RI #5's room at 8:10 AM. When asked how staff knew which residents' beds needed to be lowered, EI #1 explained it should be listed on the care plan inside the closet. EI #1 then showed the surveyor RI #5's "CNA CARE PLAN REFERENCE SHEET", which did not indicate the intervention of "bed in lowest position." When asked who was responsible for updating the CNA care plans, EI #1 stated the Minimum Data Set (MDS)/Care Plan Coordinator was responsible. EI #1 then lowered RI #5's bed and stated it was not in the lowest position. EI #2, the MDS/Care Plan Coordinator was interviewed on 12/4/2014 at 8:15 AM. When asked what RI #5's fall interventions were, EI #2 stated the bed should be in the lowest position when the resident is in bed. EI #2 then explained that a bed would be considered in the lowest position if it was as far down as it could possibly go. EI #2 then reviewed RI #5's "CNA CARE PLAN REFERENCE SHEET" and stated the intervention of "bed in lowest position" was not reflected.

Based on observation, interview and record review, the facility failed to provide supervision for Resident Identifier (RI) #29 on 12/27/11. RI #29 was admitted to the facility on [DATE] after a fall with a fracture. Upon admission to the facility, RI #29 was assessed as a high risk for falls. On 12/27/11, RI #29 was left unsupervised on a back hallway by the Occupational Therapist. RI #29 was later found on the floor and sustained a left elbow fracture (fx). This affected RI #29, one of four residents sampled with falls. Findings Include: A review of the facility's policy and procedure titled "Fall Prevention," dated 03/20/06, revealed the following: "... I. Causes: Some causes of increased fall risk are: ... C. Poor safety practices increase fall risk; these include: 1. Environmental risks. ... 4. Transfer and mobility. ... II. Environmental: ... I. Transfer and mobility... 1. Unsafe transfer and mobility without staff assistance. Many residents fall when trying to transfer or walk alone. ..." RI #29 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the facility's assessment form titled, "FALL RISK," dated 09/23/11, revealed RI #29 had a total score of 12. According to the assessment form, a "Total score of 10 or above represents HIGH RISK." The assessment was signed by Employee Identifier (EI) #12 (a Licensed Practical Nurse/LPN). A review of the most current Quarterly Minimum Data Set (MDS), dated [DATE], revealed RI #29 had short and long term memory loss and had moderately impaired cognitive skills for daily decision-making. The MDS documented RI #29 required extensive assistance with transfers and walking in room/corridor. The MDS indicated RI #29's Functional Limitation in Range of Motion was impaired in the lower extremity on one side. The MDS indicated RI #29 was not steady, only able to stabilize with human assistance in the following: moving from seated to standing position; walking(with assistive device if used); moving on and off toilet; and surface-to-surface transfer (transfer between bed and chair or wheelchair). A review of RI #29's Fall Care Plan, dated 10/04/2011, included the following: "... Approaches ... ? Bed/chair alarm ? Give resident verbal reminders not to ambulate or transfer without assistance ..." A review of the facility's assessment form titled, "FALL RISK," undated, revealed RI #29 had a total score of 12. According to the assessment form, a "Total score of 10 or above represents HIGH RISK." The assessment was signed by Employee Identifier (EI) #6 (a LPN). On 01/22/12 at 2:00 PM, during an phone interview with EI #6, the surveyor asked what was the date of RI #29's fall risk assessment after RI #29 was readmitted to the facility. EI #6 asked if her name was on it (the fall risk assessment). The surveyor stated yes, her (EI #6's) name was on the assessment with the 11/11/11 readmission medical record. EI #6 replied, if the resident was admitted on the eleventh, then the assessment was done on 11/11/11. A review of RI #29's physician's orders [REDACTED]. "... (3) OT (Occupational Therapy), PT (Physical Therapy), ST (Speech Therapy) to screen, evaluate, and treat per MD (Medical Doctor) orders. ..." A review of the facility's form titled "INCIDENT/ACCIDENT REPORT" revealed the following: "... Date of incident/accident 12/27/11 Time of incident/accident 1600 (4:00 PM) Exact location of incident/accident ... Hallway ... Describe exactly what happened ... Found on L (left) side. Hit head & (and) skin tear to L elbow c/o (complaint of) general pain. ROM (range of motion) adequate 845P (8:45 PM) - L elbow swollen, bruised ..." A review of the form titled "Rehab Care Group Contract Therapy," dated 12/28/11, revealed the following: "... Pt. (Patient/RI #29) transferred to WC (wheelchair); O.T. (Occupational Therapist/Therapy) placed and activated chair alarm prior to leaving pt's room for conclusion of skilled OT. ... Pt was stationed in hallway across from rehab gym. O.T. left area (with) fell ow resident abruptly needing to toilet; upon return (Name of RI #29) had attempted to stand and had fallen ... (signature of EI #1, an Occupational Therapist) ... 12-28-11 cont'd (continued) ... laceration superficial noted on L elbow ... Pt has in the past attempted/removed alarm ... (signature of EI #1) ..." A review of the form titled "Rehab Care Group Contract Therapy," dated 12/28/11, revealed the following: "Pt experienced a fall ... Writer heard a 'thud' ... No alarm sounding. ... (signature of EI #7, a Certified Occupational Therapy Assistant) ..." A review of the facility's Nurses Notes revealed the following: "... Date: 12/27/11 Time: 11:30 ... Resident has remained by the nurses desk (high traffic area) so that she could be observed and helped if she tried to get up without assistance. She had been witnessed by staff twice this AM trying to remove her chair alarm from her shirt and trying to take off her shirt because it was attached to the alarm ... was trying to stand up. ... (signature of EI #12)" "... Date: 12/27/11 Time: 1600 Resident observed by this nurse to be on floor laying on left side. Resident in hall receiving therapy. Resident was in her wheelchair with chair alarm present prior to fall. Resident noted to have large bump on posterior left side of head. During assessment, found skin tear on left posterior side of elbow. ... (signature of EI #13, a LPN)" "... Date: 12/27/11 Time: 2000 (8:00 PM) ... this nurse found left elbow area to be bruised and swollen. ... (signature of EI #13)" "... Date: 12/27/11 Time: 2035 (8:35 PM) Upon further inspection of left elbow, xray ordered to rule out fracture. Left elbow is very swollen and bruised. Resident is now c/o pain during range of motion ... (signature of EI #13)" "... Date: 12/27/11 Time: 2100 (9:00 PM) (Name of Radiology Company) here to obtain Left elbow xray. ... (signature of EI #13)" "... (undated, hand-written entry listed under the nurses note entry for 12/28/11 at 0300) 0610 (6:10 AM) Received Xray results, faxed & called to MD, left message. ... (signature of EI #6)" "12/28/11 0630 (Name of physician) returned call (with) orders to send to ER (emergency room ). ... (signature of EI #6)" "12/28/11 0745 Ambulance has left (with) the resident for (Name of hospital) ... (signature of EI #12)" "... Date: 12/28/11 Time: 1400 (2:00 PM) ... Resident returned from (Name of hospital's ER) with daughter via ambulance. ...1/2 cast and sling to L arm. ... (signature of EI #12)" A review of the hospital's "EMERGENCY DEPARTMENT PHYSICIAN HISTORY AND PHYSICAL GENERAL ADULT, " dated 12/28/11, revealed the following: "... Date: 12-28-11 Time: (0839) Chief complaint: L elbow pain ... Pt presents c/o L elbow pain onset ... (after) fall yesterday during ... physical therapy. Pt denies head trauma, LOC (loss of consciousness), HA (headache), or Neuro (changes). Pt also has a mild abrasion that is ... dressed & (and) ... bruising around elbow. Pt denies any ... other complaints or Sx (symptoms) ... X-Ray L elbow xr (xray) ... + (positive) Fx/displacement olecranon process ... Physical Examination ... moderate-severe swelling tenderness & echymosis (ecchymosis) to L elbow, worse posteriorly. pt resists against active movement of LUE (left upper extremity) ... Additional documentation ... 0855 (8:55 AM) Morphine 2 mg (milligrams) IV (intravenous) Zofran 4 mg IV Posterior Long-Arm Splint L Arm (with) sling ...Primary [DIAGNOSES REDACTED]. EI #1 (an Occupational Therapist) was interviewed on 1/22/12 at 8:35 AM. EI #1 said she provided care for RI #29 to improve her ADLs (Activities of Daily Living) for bathing, grooming, hygiene, toileting, functional mobility, balancing, and functional transfers such as to and from the bed to the wheelchair or from the wheelchair to the shower chair or to the toilet. When asked what RI #29 was like, EI #1 said, "She was confused, irritable, and agitated at times. Impulsive at times. Other times she was lucid, cooperative. The socialization and her interaction with others, it fluctuated. Her mood was labile." EI #1 said RI #29 had a bed/chair alarm, which used a clip attached to the resident's clothing. When asked to describe how the alarm worked, EI #1 said, "You would position the alarm either on the headboard of the bed or the back of the wheelchair. At the end of the clip, which was attached to the clothing, there was a string, which was attached to a round magnet that attached to the alarm. If the resident were to stand up or flex their torso, the magnet would detach as the string became taut. Then the alarm would sound." When asked if RI #29 ever removed her alarm, EI #1 said she had a history of [REDACTED]. EI #1 replied, "She would potentially stand and fall." EI #1 said, due to the fluctuations in RI #29's mood and cognition, it was not an everyday occurrence for her to remove the alarm, but it had happened in the past. EI #1 said she sometimes saw RI #29 as she passed by the resident's room and that she intervened when she saw RI #29 trying to stand up from her wheelchair or bed. EI #1 said, "The stronger she got physically, the more restless she became." EI #1 said the alarm would go off when RI #29 tried to stand from her wheelchair or bed. When asked if she reported these observations, EI #1 said, "Yes, I would go to the nursing desk and let the nurse or her CNA (Certified Nursing Assistant) know that the resident was attempting to stand. Sometimes I would bring her out to the Nursing Station hallway (on the main hall). So that when she was in these restless moods, she could be observed." EI #1 said later in the interview, "They utilized the Nursing Station for monitoring." EI #1 was asked what happened when RI #29 fell on [DATE]. EI #1 said she was not in the hallway when RI #29 fell , because she had taken another resident to the bathroom. When asked where did she have to go to take the other resident to the bathroom, EI #1 used the map of the facility to indicate a room that was down on the other end of the main hallway from the Rehab Room. EI #1 further said, "I had worked with (Name of RI #29) prior to the fall. She was positioned in the hall by the Rehab Room, because she was awaiting Physical Therapy." EI #1 indicated RI #29's location on the map as being across from Room #125 (the Rehab Room), which was at the end of a short hall that was perpendicular to the main hallway. (Looking at the map: The short hall formed a "T" with the main hall. The Rehab Room was on an end of the top bar of the "T" and the room EI #1 took the other resident to was down at the base of the "T," two rooms from the end.) When asked if Physical Therapy (PT) knew RI #29 was waiting in the hall, EI #1 said no. EI #1 said no one was specifically asked to watch RI #29. EI #1 said RI #29 was wearing an alarm with a clip attached to her clothing. EI #1 further said therapists were in the Rehab Room about 15 feet away from RI #29, as she was positioned directly in front of it. When asked why was it okay to leave RI #29 there, EI #1 said it was not uncommon for a resident to wait in front of the Rehab Room to be seen and RI #29 had been positioned in the hall like that before. EI #1 further said it was not a desolate area, as staff were constantly going along this hallway. When asked if RI #29 could have removed her alarm, EI #1 said it was possible she could have removed it. EI #7 (a Certified Occupational Therapy Assistant) was interviewed on 1/22/12 at 10:35 AM. EI #7 said she sometimes provided treatment to RI #29 when EI #1 was not on duty. EI #7 said RI #29 had confusion, could be hard to re-direct, and had poor safety awareness. EI #7 said the resident's alarm was the type that attached to the chair and had a clip attached to her shirt. When asked if RI #29 ever removed the alarm, EI #7 said she had heard staff saying the resident removed it. EI #7 was asked why would removing the alarm be a problem. EI #7 replied, "Because the alarm is there for safety reasons and if she removes the alarm, the staff will not hear it to come to her aid." EI #7 was asked what happened when RI #29 fell on [DATE]. EI #7 said she was in the Rehab Room with a resident when she heard a thud and went to the doorway and saw RI #29 lying on the floor on her left side. When asked if she could see RI #29 from where she was in the Rehab Room, EI #7 said, "Not directly, I could see part of her because of where I was positioned in the room working with my patient. I was not aware she was out there until I heard the noise." EI #7 said only she and her patient were in the Rehab Room. EI #7 also said she did not hear an alarm. When asked if it was common for a resident to be sitting in that hallway alone, EI #7 said, "Usually they are with a therapist." At 11:15 AM on 1/22/12, EI #7 and the surveyor went to the actual site in the Nursing Home where RI #29 was found after the fall on 12/27/11. EI #7 indicated RI #29 was in the hallway across from the doorway of the Rehab Room. The surveyor observed that Rehab Room did not have any windows to view the hallway from within the room. On the facility map it was designated as Room #125 and had originally been a resident room. On 1/22/12 at 12:30 PM, EI #9 (a Licensed Practical Nurse) was interviewed. EI #9 said she worked on Saturdays and Sundays only and she had provided care to RI #29. EI #9 said the resident was very confused and required almost total care. EI #9 said RI #29 had a personal alarm with a magnet, string, and clip. EI #9 further said, "She could take off the alarm. ... Her alarm went off a lot. She tried to stand up and the alarm would go off. We tried to make it so she was highly visible when she was out of bed, due to the fact that she tried to stand up often. I know that she fidgeted a lot and she was capable of taking off her alarm ..." EI #9 said RI #29 was a high fall risk and had fall precautions that included the alarm, eating her meals in the dining area, and keeping the resident in a high visible area. When asked what was considered a highly visible area, EI #9 said, "At the Nursing Station or in the Dining Room when activities or meals are going on." On 1/22/12 at 1:10 PM, EI #8 (a Certified Nursing Assistant/CNA) was interviewed. EI #8 said she had provided care for RI #29 and that she worked both the 7:00 AM to 3:00 PM and the 3:00 PM to 11:00 PM shifts. When asked about RI #29's alarm, EI #8 said, "It was the type that had the clip you would put on her clothes. If she got up, it would go off. Most of the time we knew it was her if we heard an alarm." EI #8 said that before RI #29 fell the last time, her alarm went off a lot. EI #8 said RI #29 used to remove the alarm clip from her clothing when she was in her wheelchair. EI #8 said she had seen the resident do this. She would tell the resident she needed to put the clip back on and RI #29 said she did not need to, but EI #8 replaced the alarm clip to the resident's clothing. EI #8 had reported these incidents to the nurses. EI #8 said, "They (the nurses) would go in and talk with her and explain that it was something she needed to have on. She (RI #29) would tell them, 'Oh, no its not.'" EI #8 also said, "... After meals we would put her by the Nurses's Station while we cleaned up the Dining Room. Because if we put her in her room, she would get up on her own and no one would hear the alarm ..." EI #8 was asked if she would ever leave a resident, who needed to be in a highly visible area, on the back hall by the Rehab Room during the week (Monday through Friday). EI #8 said, "No, because how are you going to see them." On 01/22/12 at 1:28 PM, during an interview with EI #10 (a CNA), the surveyor asked if she had provided care for RI #29. EI #10 stated yes, only once or twice. EI #10 further stated the resident liked to get up out of her wheelchair. The surveyor asked what type of an alarm did the resident have. EI #10 stated the alarm was hooked on the back of her wheelchair with a string and clip attached to her clothing. The surveyor asked did the resident ever remove the alarm. EI #10 stated yes, the resident did and she (EI #10) had witnessed the resident remove the alarm. The surveyor asked who did she report this to. EI #10 stated the nurse was standing there when the resident removed her alarm. She also stated that when the resident would remove the alarm, staff would encourage the resident to stay in her seat, but the resident would refuse. The surveyor asked why would this be a problem. EI #10 stated the resident could fall and break something. The surveyor asked how often did the resident remove the alarm. EI #10 said I saw one time and I heard she did, so pretty much daily. On 01/22/12 at 2:45 PM, EI #4 (Director of Nursing) and EI #3 (Assistant Director of Nursing) were interviewed. The surveyor asked if it was appropriate for RI #29 to be left unattended on the back hallway and without notifying any staff that the resident was left unattended. Both EI #4 and EI #3 stated no. The surveyor asked what would staff have been expected to do. EI #4 replied she would have expected EI #1 to get someone else to watch the resident while she was gone. EI #3 replied RI #29 should have been in a common area where other staff could have watched the resident. The surveyor asked if the back hall by the Rehab Room would be considered a highly visible area. EI #3 stated no. She said a highly visible area would be considered the Nurses Station. On 01/22/12 at 3:05 PM, EI #5 (the Administrator) was interviewed. The surveyor asked was it appropriate to leave RI #29 unattended on the back hallway and without notifying any staff that the resident was left unattended. EI #5 stated no. The surveyor asked what would staff have been expected to do. EI #5 replied EI #1 should have had someone else take her place with the resident while she stepped away. The surveyor asked would the back hallway by the Rehab Room be considered a highly visible area. EI #5 stated no.

Based on observations, interviews, medical record reviews and review of the facility's policy entitled "Kirkwood by the River Abuse, Neglect and Exploitation Policy and Procedure", the facility's Abuse Coordinator failed to promptly implement the protection and reporting/response (two of seven) components of the policy and procedure: On [DATE], Resident Identifier (RI) #12 voiced a complaint against Employee Identifier (EI) #10, a Certified Nursing Assistant (CNA) to the surveyor and the Activity Director, EI #9. According to RI #12, EI #10 refused to change his incontinent brief (diaper) as requested, unplugged his call light and shut his room door, forcing him to yell out for help. When RI #12 began yelling out for help, EI #10 later came back to his room, handed him an incontinent brief and told the resident to shut up. EI #9 then reported RI #12's allegation to the Director of Nursing, EI #1. EI #1 stated she considered this an allegation of abuse/neglect. After the DON (EI #1), who is also the Abuse Coordinator, was made aware of the allegation, she only reassigned the alleged perpetrator (EI #10) to a different resident care area instead of removing the employee from resident care areas immediately, as listed in the facility's policy and procedure. EI #10 (CNA) was allowed to return to work on [DATE] 11PM - 7AM shift, without monitoring or supervision. After EI #10 finished her shift out on [DATE], she was then suspended pending outcome of the investigation (Protection); and On [DATE], EI #1, who is the DON and Abuse Coordinator, stated she became aware of an allegation that EI #3, a LPN, was giving male residents lap dances. EI #1 stated she did not report this allegation of sexual abuse because it was a stupid, ludicrous remark make by a vengeful employee (Reporting/Response). These deficient practices affected RI #3, RI #12, RI #16, RI #21 and RI #22, five of six sampled residents reviewed for abuse/neglect. The deficient practice of failing to promptly protect RI #12, placed the health and safety of this resident in immediate jeopardy, as it was likely to have caused serious injury, harm or death. On [DATE] at 5:20 PM, the Administrator, Assistant Administrator and Director of Nursing were notified that the survey team had identified immediate jeopardy in the area of Resident Behavior and Facility Practices, F 226 at a "J" level. Findings include: 1) The facility's policy titled "Kirkwood by the River Abuse, Neglect and Exploitation Policy and Procedure" dated [DATE] documented "Purpose: According to federal regulations, the resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. The resident has the right to be free from mistreatment, neglect and misappropriation of property. Standard: The Abuse Coordinator in the facility is the Director of Nursing ... "Neglect" means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness ... Procedure: The components of the facility abuse prohibition plan are discussed herein: ... IV. Response and Reporting of Abuse, Neglect and Exploitation: ... When abuse, neglect or exploitation is suspected, the Licensed Nurse should: ... 5. Remove the employee from resident care areas immediately. Suspend the accused employee pending completion of the investigation ... VI. Resident Protection after Alleged Abuse, Neglect and Exploitation: Examples of ways to protect a resident from harm during an investigation of abuse, neglect and exploitation may include, but are not limited to: 1. Remove the employee from resident care areas immediately. Suspend the accused employee pending completion of the investigation ... ." RI #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an assessment reference date of [DATE] identified RI #12 as being cognitively intact, with a BIMS (Brief Interview for Mental Status) score of 15. According to "CMS's (Centers for Medicare & Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 Manual" page C-14, a score of 13 - 15 indicates the resident is cognitively intact. RI #12 is assessed as being totally dependent on staff for toileting. RI #12 is further assessed as being occasionally incontinent of urinary (bladder) and bowel continence. Per this MDS, RI #12 did not display any behaviors during this assessment period. On [DATE] at 11:40 AM, RI #12 was observed sitting in the facility's dining area. RI #12 called the surveyor over and asked for her mailing address, stating he wanted to send the surveyor a letter. The surveyor asked RI #12 what he wanted to send the surveyor a letter about. RI #12 then stated, "How many times are you suppose to wee wee in your diaper before they will give you a clean one." RI #12 went on to tell the surveyor that around 11:00 PM or 12:00 PM last night ([DATE]), he pressed his call bell because his diaper (incontinent brief) was wet. RI #12 said a CNA (later identified as EI #10) came and checked him and said, "You are not wet" and left the room. According to RI #12, he pressed the call bell again and the same CNA came in the room and unplugged his call light (bell). The resident (RI #12) did not know the CNA's name but went on to describe her as being a big fat lady weighing about 400 pounds with freckles. RI #12 said he started yelling for help over and over again. After he yelled for help, EI #10 (CNA) came to his room and closed his door. The surveyor asked RI #12 what he did at that time. RI #12 replied that he just kept yelling help and the CNA (EI #10) finally came back, handed him an incontinent brief and told him to "shut up." When the surveyor asked RI #12, who he normally tells when he has a problem, he pointed towards the Social Worker's office. At 11:44 AM, the surveyor went to the Social Worker's office and found EI #9, the Activity Director, sitting in the office. The surveyor told EI #9 that RI #12 had something he needed to report. EI #9 went to the dining room and RI #12 proceeded to tell EI #9 what he had reported to the surveyor. On [DATE] at 12:05 PM, the surveyor observed EI #9 (Activity Director) in EI #1 (DON)'s office. EI #9 stated that she had reported RI #12's complaint to EI #1. According to EI #9, EI #1 told her that she would talk with RI #12 after he finished his lunch. In an interview on [DATE] at 12:06 PM, EI #9, the Activity Director, was asked what RI #12 reported to her. EI #9 said RI #12 asked her if he had to wait until his diaper (incontinent brief) was wet to have it changed. EI #9 said she told RI #12 if soiled yes or torn but, if perfectly good brief it didn't need changing unless he wanted it changed. According to EI #9, RI #12 provided a similar account of the incident as reported to the surveyor. EI #9 also reported that RI #12 alleged EI #10 took or disconnected his call light. The surveyor asked if RI #12 gave her a description of the CNA. EI #9 replied that RI #12 described the CNA as being very large with freckles all over her face. EI #9 was asked if anyone in the facility fits that description and she said yes. EI #9 further stated that RI #12 told her the CNA worked on the 11PM - 7AM shift. In an interview on [DATE] at 12:30 PM, EI #11, a Licensed Practical Nurse (LPN), was asked if the facility had an obese employee with freckles. EI #11 answered, "Yes that's (EI #10) and she works that back hall where (RI #12)'s room is at." A review of "Kirkwood by the River C.N.A. Worksheet ,[DATE]" dated [DATE], indicated that EI #10 was assigned to care for RI #12 on [DATE], the 11PM - 7AM shift. A review of EI #10's timesheet indicated she worked from 10:31 PM on [DATE] to 6:52 AM on [DATE]. On [DATE] at 5:32 PM, EI #1 (DON/Abuse Coordinator) presented the survey team with a typed statement that she and the ADON (EI #2) had taken from RI #12 on [DATE]. RI #12's typed statement dated [DATE] ([DATE]) at 1:40 PM, documented " ... I (RI #12) called for a diaper around 10:00 PM. That fat girl with freckles came in and checked my diaper and told me I was not wet. I told her I sure would appreciate one (incontinent brief), but she said I was not going to get one. I pushed my button again and she came in and said I was not wet and she left. I rang the button again, and I told her I wanted a diaper. She said I was not wet and left and shut the door. I started screaming and she came back ... She came back and said I was not wet and turned off the red button (call light). She put the red button somewhere and I could not find my call light ... This happened last night. ... Go get the list and read the names off to me and I can tell you who it was. ... Read off the list for ,[DATE]. It was (EI #10). She is the fat one with the freckles on her face ... I do not like (EI #10) at all. I think she is mean ... Assured (RI #12) I (EI #1) would take care of this problem for him ... ." The surveyor asked EI #1, how would she take care of this problem as listed. EI #1 started by explaining that EI #10 works tonight ([DATE]) and she will interview her (EI #10) and give EI #10 a chance to present what she has to say. EI #1 further stated that she would leave instructions so that EI #10 would not work on RI #12's section. On [DATE] at 5:55 AM, EI #8 (LPN) was asked to identify the CNAs on duty in the facility. EI #8 named four CNAs, one of which was EI #10. On [DATE] at 6:00 AM, EI #39, the other LPN working on the hall, was asked where is EI #10? EI #39 stated "she (EI #10) may be in 119 that's where her cart is parked." The door to room [ROOM NUMBER] was closed and a linen cart with observed on the outside of the door. At 6:13 AM, the door to room [ROOM NUMBER] was opened and a staff member fitting the description of EI #10 was observed coming out. In an interview on [DATE] at 8:30 AM, EI #10 (CNA) stated that she is normally assigned to rooms 124 through 132 (the section in which RI #12 resides). When asked, were you assigned to those rooms last night ([DATE]), EI #10 said no. The surveyor then asked, why and EI #10 replied "I don't know I was told to go to another section as of last night I didn't know." EI #10 was asked if she now knew why and she said yes, because a complaint from one of the residents. The surveyor asked which resident. EI #10 answered by saying RI #12. According to EI #10, EI #1 (DON) told her that RI #12 complained that she refused to give him resident care. EI #10 denied that she refused to give RI #12 resident care. EI #10 explained that about 11PM, another CNA answered RI #12's call light; however, this CNA could not understand what RI #12 wanted. EI #10 stated she then went in RI #12's room and the resident complained that it was a little hot in his room. EI #10 said she adjusted the heat and removed RI #12's covers. EI #10 stated it was at this time that RI #12 asked for an incontinent brief. According to EI #10 she told RI #12 that he already had an incontinent brief on, so she (EI #10) only fastened one side of the brief and left out of RI #12's room. EI #10 (CNA) stated it was about 30 minutes later when RI #12 pressed his call light and stated he needed an incontinent brief (diaper). EI #10 said she told RI #12 that he was not wet, after checking him for incontinence. EI #10 stated it was at this time, RI #12 became upset, so she (EI #10) left his room. According to EI #10, RI #12 started hollering out loud "I want a diaper I want a diaper help help." EI #10 stated RI #12 hollered for about five to 10 minutes. When the surveyor asked, did anyone hear RI #12; EI #10 replied that the other CNA asked her what was wrong with RI #12. EI #10 stated she told the other CNA that RI #12 was upset. EI #10 stated that RI #12 did not ring his call light anymore during the shift, but she continued to check on him at 1AM, 3 AM and about 5AM. EI #10 said on her last round about 5AM, RI #12 was wet, so she cleaned him up and changed his incontinent brief. In an interview on [DATE] at 8:25 AM, EI #1, DON/Abuse Coordinator, was asked what was she told about the incident with RI #12. EI #1 said she had been told that EI #10 (CNA) refused to change RI #12's diaper and that she (EI #10) had moved his call light. EI #1 stated she considered this an allegation of abuse. EI #1 was asked if EI #10 was removed from direct resident care or suspended. The DON/Abuse Coordinator (EI #1) replied that EI #10 as removed from the direct care of RI #12. EI #1 explained that EI #10 has been suspended and that she was allowing her (EI #10) to write her statement. The surveyor asked, when did you interview EI #10 about the incident and EI #1 replied "this morning ([DATE])." When asked, why was EI #10 not removed from direct care after she (EI #1) received a complaint against her, EI #1 restated that she did remove EI #10 from the direct care of RI #12. The surveyor asked, who EI #10 was allowed to work with on [DATE]. EI #1 responded by saying that she did not know what section EI #10 had but she was on a totally different section, which did not include RI #12's room. In an interview on [DATE] at 11:26 AM, EI #11 (LPN) was asked to help the surveyor determine which residents EI #10 was assigned to when she (EI #10) came in to work on [DATE]. EI #11 and the surveyor reviewed the documented observation conducted on [DATE] at 5:55 AM and then the surveyor asked, what would have been EI #10's assignment. EI #11 replied, "She (EI #10) would have been assigned to rooms 117A - 123B." EI #11 explained that she was not in the facility at that time, but based on the schedules and where the rest of the staff was, that's the rooms EI #10 was assigned to. A review of "Kirkwood by the River C.N.A. Worksheet ,[DATE]" dated [DATE], indicated that EI #10 was assigned to care for 13 residents residing in rooms 117A - 124A. A review of EI #10's timesheet indicated she worked from 10:35 PM on [DATE] to 8:52 AM on [DATE]. In an interview on [DATE] at 9:40 AM, EI #6 (Administrator/President) stated that EI #1 (DON/Abuse Coordinator) had made him aware of the allegation of abuse reported by RI #12. EI #6 stated the employee should have been suspended and an investigation conducted. The surveyor asked, should that employee (EI #10) have been allowed to return to work on [DATE]. EI #6 replied no, the employee should have been suspended. When asked what was done to protect the other residents from possible abuse, EI #6 stated that he didn't know. The surveyor then asked, would assigning the employee (EI #10) to another part of the facility be compliant with the facility's abuse policy. EI #6 (Administrator/President) answered, "Not until you've finished the investigation and it was determined unfounded." In a follow up interview on [DATE] at 10:30 AM, EI #1 stated that EI #10 was suspended the morning of [DATE]. When the surveyor asked why EI #10 was not removed from resident care areas immediately as listed in the policy. EI #1 stated that she did remove EI #10 (CNA) from the direct care of RI #12. The surveyor reminded EI #1 (DON/Abuse Coordinator) that she considered RI #12's complaint an allegation of abuse, and asked the DON/Abuse Coordinator (EI #1) what she did to protect other residents from possible abuse, while an investigation was being conducted. EI #1 replied, "According to the policy I did not. As DON, I take full responsibility." EI #1 (DON)'s job description dated [DATE], documented " .... DUTIES AND RESPONSIBILITIES: ... assumes responsibility for nursing service compliance to rules of the Alabama State Board of Health division of licensure and certification ... ." EI #10's personnel action dated [DATE] documented, " ... due to a resident complaint of CNA refusal of care @ (at) resident request. Suspended until further investigation ... ." On [DATE] at 11:35 AM, EI #1 (DON/Abuse Coordinator) stated that she considered RI #12's complaint as an allegation of physical abuse. EI #1 stated she told EI #39, the 3PM - 11PM LPN, to tell the oncoming 11PM - 7AM LPN to remove EI #10 from RI #12's care. The surveyor asked if she left any other instructions regarding monitoring EI #10 to the oncoming nurse; EI #1 said that no other instructions were given. When asked why she considered RI #12's complaint as an allegation of physical abuse, EI #1 stated it probably is more less neglect. In a follow up interview on [DATE] at 11:44 AM, the surveyor asked RI #12 how that made him feel when the CNA refused to change his brief and removed his call light. RI #12 stated that it made him feel like a second rate. When asked to explain what second rate meant, RI #12 explained that it meant he could be pushed around, that the CNA had no desire to make him happy and he could be treated any kind of way. 2) The facility's policy titled "Kirkwood by the River Abuse, Neglect and Exploitation Policy and Procedure" dated [DATE] documented " ... Standard: The Abuse Coordinator in the facility is the Director of Nursing. Report allegations or suspected abuse, neglect or exploitation immediately to: *State Agencies ... *Director of Nursing *Administrator ... "Sexual Abuse" includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault ... Procedure: The components of the facility abuse prohibition plan are discussed herein: ... III. Abuse Prevention ... 5. React to all allegations or questions of abuse by residents, family members, employees or visitors ... IV. Response and Reporting of Abuse, Neglect and Exploitation: Anyone in the facility can report suspected abuse to the abuse agency hotline. When abuse, neglect or exploitation is suspected, the Licensed Nurse should: ... 2. Notify the Director of Nursing and Administrator. ... 6. Contact the State Agency and the local Ombudsman office to report the alleged abuse ... The Administrator or Director of Nursing should follow up with government agencies, during business hours, to confirm the report was received, and to report the results of the investigation when final, as required by state agencies ... ." An "Intake Information"form, documented that on [DATE], the State Agency received a report of a Licensed Practical Nurse (LPN) exhibiting sexually inappropriate behaviors toward male residents. The complainant explained by saying Employee Identifier (EI) #3, a LPN, straddled male residents in their wheelchairs, touched her (EI #3) private area and asked the residents if they would like some of this. The male residents identified by the complainant were Resident Identifier (RI) #3 and RI #16. The complainant stated the male residents would tell EI #3 that she was disgusting. According to the complainant this sexually inappropriate behavior was witnessed by two LPNs, EI #19 and EI #20. Also, the complainant stated the behavior of EI #3 was reported to the Director of Nursing (DON); however, nothing was done about it. During an interview with RI #3 on [DATE] at 8:15 AM, he was asked if EI #3 (LPN) ever straddled him while he sat in his wheelchair, touched her private area and asked him if he wanted some of this. RI #3 stated that he does not remember anything like that happening and it sounded very unlikely. The resident's Quarterly Minimum Data Set (MDS) with an assessment reference date of [DATE], identified RI #3 as being severely impaired in cognitive skills for daily decision making, with a Brief Interview for Mental Status (BIMS) score of 2. According to "CMS's (Centers for Medicare & Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 Manual" page C-14, a score of 0 -7 indicates the resident has a severe impairment in cognitive skills. In a telephone interview on [DATE] at 9:10 AM, EI #19, a former LPN of the facility, was asked if she ever witnessed any of the staff acting sexually inappropriate with the residents and she said yes. EI #19 stated the name of the staff that acted sexually inappropriate was EI #3, a LPN. According to EI #19, there was a resident in a wheelchair and EI #3 would make humping gestures towards the resident. EI #19 stated EI #3 never touched the residents; she (EI #3) just made the motions. EI #19 stated that she could not remember the resident's name but that it had to be a male resident. In a telephone interview on [DATE] at 4:05 PM, EI #20, a former LPN of the facility, was asked if she ever witnessed any of the staff acting sexually inappropriate with the residents and she said yes. According to EI #20, EI #3 would sit on RI #22's lap, shake her (EI #3) butt, lean in, shake her (EI #3) breasts at RI #22 and ask the resident if she wanted some of this. EI #20 stated EI #3 would also do the same thing to RI #16 (a male resident) and RI #21 (a female resident). In a telephone interview on [DATE] at 11:28 AM, RI #21's responsible party stated that RI #21 went to the hospital on [DATE] and later expired on [DATE]. The surveyor stated that the State Agency had received a complaint that RI #21 may have witnessed a LPN being sexually inappropriate in front of male and female residents. RI #21's responsible party stated that her mother (RI #21) never said anything like that to her. On [DATE] at 11:50 AM, the surveyor attempted to interview RI #22 about the incident. RI #22 was asked if any staff had ever straddled her while she sat in her wheelchair and asked if she wanted some of this. RI #22 mumbled and was unable to respond appropriately to the question that was asked. The residents's Quarterly MDS with an assessment reference date of [DATE], identified RI #22 as being moderately impaired in cognitive skills for daily decision making, with long and short term memory problems. In an interview on [DATE] at 8:25 AM, EI #1 (DON) was asked if any staff member had reported to her anything about any staff straddling residents and performing lap dances. EI #1 stated the only thing that she has ever been told was during EI #18's termination on [DATE], EI #18 screamed to EI #2 (ADON) that she (EI #18) had reported that an employee was doing lap dances. EI #1 stated she asked EI #18 what she was talking about. When EI #18 called the name of EI #3 as the employee doing lap dances, EI #1 (DON) stated she asked EI #18 why she would make up such an accusation against another employee. The DON (EI #1) said that she questioned staff and all denied having knowledge of it. EI #1 explained that she did not send a formal investigation to the State Agency because she knew the allegation was untrue due to the fact that no one had ever told her anything about lap dancing and too because of EI #3's physical appearance of being heavy, she (EI #3) could not perform a lap dance. EI #1 was asked if she considered the statement made by EI #18 an allegation of sexual abuse. EI #1 (DON) replied, "Yes according to the policy. No, due to the fact that (EI #18) had a deep seated hatred for (EI #3)." EI #1 was asked, why did she not report this allegation to the State and she responded, "Because I thought it was a stupid, ludicrous remark made by a vengeful employee." This deficiency was cited as a result of investigation of complaint/report number AL 542. *************** On [DATE] at 6:30 PM, the facility submitted an acceptable allegation of compliance, which documented: F-226 1. (a) The CNA reported to have removed the resident's call device was placed on administrative leave on [DATE]. In accordance with ADPH guidelines, the CNA will be reported to the Abuse Registry based on the conclusion of the ongoing investigation into this matter. (b) By [DATE], a facility nurse will conduct a thorough body audit on the resident affected, RI#12. The facility interim Nurse Manager will be responsible for updating the resident's care plan, if necessary. The Administrator will be responsible for notifying the resident's attending physician and sponsor of the incident by [DATE]. 2. All residents have the potential to be affected. Please see systemic interventions and monitoring below. 3. Effective [DATE], all facility staff will be inserviced on facility policy regarding prevention, recognition and reporting abuse, including verbal and physical abuse, with an emphasis on recognizing and reporting sexual abuse, neglect and isolation. The inservices will be conducted by two outside consultants who are experienced in abuse allegations and reporting guidelines. No employee will be allowed to return to work until the required inservices are completed. Effective [DATE], the facility Administrator, Assistant Administrator, and interim Nurse Manager will receive directed inservice training on prevention, recognition and reporting of verbal, physical and sexual abuse, with emphasis on ADPH and CMS reporting requirements and compliance with those requirements. The inservices will be conducted by two outside consultants who are experienced in abuse allegation and reporting guidelines. With respect to the allegations related to RI#4, the investigation into this matter has been reopened effective [DATE]. Note: (outside consultant) will be on-site for his first consultation visit on Monday, [DATE]. The staff member involved in this matter was placed on administrative leave effective [DATE]. The investigation will be completed within 5 working days and the full investigative file, with conclusion, will be provided to ADPH on [DATE]. Because Kirkwood is unable to log into the ADPH reporting system, a written 24 report will be provided to the survey team. Results of the investigations, including all corrective actions implemented will be submitted to ADPH within five (5) working days. 4. Effective [DATE], all allegations of abuse will be immediately reported to the interim Nurse Manager in accordance with facility policy. The interim Nurse Manager will be responsible for reporting the allegation of abuse to an outside consultant (who is available on the weekend), and the interim Nurse Manager will also be responsible for reporting the allegation in accordance with ADPH policy and CMS rules and regulations. The interim Nurse Manager, with guidance from the outside consultant, will conduct a thorough investigation of the allegation, will prepare a full investigation summary, and will provide the summary to the outside consultant for full review prior to submission to ADPH. The interim Nurse Manager will also be responsible for ensuring that corrective actions are implemented in accordance with the investigation findings, with oversight from the outside consultant. The outside consultant, in conjunction with the administrator (see below), will be responsible for immediate corrective action regarding abuse investigation and reporting, if necessary. All allegations of abuse and neglect will also be reported to the facility administrator who will ensure that facility residents are protected from the potential for abuse or neglect during the pendency of the investigation in accordance with facility policy and procedure and the recommendations of the outside consultant. Results of all investigations will be provided to the facility's Quality Assurance Committee for additional review and additional corrective action, if necessary. Monitoring of abuse and neglect reporting and investigation by the outside consultant will continue for 6 months. Documentation of the outside consultant's review of all allegations of abuse and reporting will be maintained in the office of the interim Nurse Manager. Date of Abatement of Immediate Jeopardy: [DATE] *************** After reviewing the facility's information provided in their allegation of credible compliance (in-service records, disciplinary actions and staff interviews) completed as of [DATE], the immediate jeopardy was relieved and the scope and severity was lowered to a "D" level on [DATE] at 6:50 PM, to allow the facility time to monitor and/or revise their corrective actions to achieve substantial compliance.

Based record review and interviews, the facility failed to implement their policy and procedure for reporting an allegation of verbal abuse within 24 hours to the State agency after becoming aware. This affected Resident Identifier (RI) #26, one of four residents sampled for abuse. Findings Include: RI #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the most current Minimum Data Set (MDS), dated [DATE], revealed RI #26's BIMS (Brief Interview for Mental Status) was a 6, indicating a severe impairment in cognitive skills for daily decision-making. The MDS documented RI #26 required total assistance with Activities of Daily Living. A review of the facility's policy titled "Abuse, Neglect and Exploitation Policy and Procedure," dated 08/20/07, revealed the following: "...The Administrator or Director of Nursing should follow up with government agencies, during business hours, to confirm the report was received, and to report the results of the investigation when final, as required by state agencies. ..." A review of the Alabama Department of Public Health/Division of Health Care Facilities form titled, "REPORT OF ABUSE, NEGLECT, MISAPPROPRIATION OF RESIDENT PROPERTY AND INJURY OF UNKNOWN ORIGIN," dated 01/16/05, provided to the surveyors by the Consultant Registered Nurse revealed the following: "WHAT TO REPORT: the facility must ensure all alleged violations involving mistreatment, neglect, or abuse including injuries of unknown source, and misappropriation of resident property are reported immediately (as soon as possible but not to exceed 24 hours) ... and to other officials in accordance with State law through established procedures (including to the State survey and certification agency. ..." A review of the facility's report to the Alabama Department of Public Health Online Incident Reporting System revealed the following: "... Confirmation of Receipt of Online Incident Report... Date/Time Submitted: Thursday, January 12, 2012 3:43:10 PM ... Incident Type ... Select Category: Verbal Abuse ... Incident Detail ... Date and time of alleged incident: 01/09/12 ... 11:00 PM ..." A review of the facility's results of investigation revealed the following: "... On 01/10/12, a resident (name of RI #26) reported to facility nurses, ..." On 01/19/12 at 4:12 PM, during an interview with Employee Identifier (EI) #4 (Director of Nursing), the surveyor asked what does the policy and the procedure state in reference to a time frame for reporting an allegation of abuse. EI #4 stated she thought it was 24 hours and five days to get the report in to the state. The surveyor asked when was the facility made aware of the verbal allegation dated 01/09/12 involving RI #26. EI #4 stated 01/10/12. The surveyor asked when was the allegation of abuse reported to the state agency. EI #4 stated on 01/12/12. The surveyor asked was policy and procedure followed for reporting abuse. EI #4 stated no, policy and procedure was not followed, because the report was a day late. The surveyor asked who sent the report in. EI #4 stated she had sent the report in to the state. EI #5 (the Administrator) was interviewed on 01/20/12 at 10:10 AM. The surveyor asked EI #5 to review the two abuse allegations that had occurred since the plan of correction; one was reported in a timely manner and the other was not. The surveyor asked how soon should the State agency have been notified. EI #5 stated within 24 hours. EI #5 also stated he was not aware of that incident (referring to the allegation of verbal abuse with RI #26). The surveyor asked why was the incident not reported within 24 hours. EI #5 stated he did not know why. Patricia Lair, Registered Dietitian Evelyn Scott, Registered Nurse

Based on interviews and record reviews, the facility's management staff failed to ensure the written Plan of Correction (POC) for deficiencies cited during the 10/20/11 recertification survey for F 315, F 441 and F 498 were implemented. The facility alleged compliance with the implementation of their POC on 11/24/11. The facility further failed to ensure the documentation for the implementation of the POC provided to the State Agency's survey team was not falsified. On 11/28/11, the licensed nursing staff falsified the "Monitoring Sheet for Proper Catheter Care" indicating that 28 Certified Nursing Assistants (CNAs) had completed a return demonstration on proper catheter care, when in fact, nine of the 28 CNAs were not at work at the time the return demonstration was documented as being observed. This deficient practice affected, 23 of 28 CNAs working in the facility. On 12/01/11 at 5:20 PM, the Administrator, Assistant Administrator and Director of Nursing were notified that the survey team had identified immediate jeopardy in the area of Administration, F 490 at a "J" level. Findings include: The Provider's (facility's) Plan of Correction for 10/20/11 recertification survey documented "This plan of correction constitutes a written allegation of substantial compliance with federal Medicare and Medicaid requirements ... F 315 ... All CNAs will be in-serviced in the proper cleaning of the catheter and proper placement of catheter using leg strap by ADON or designee by 10/25/11. Each CNA will perform a return demonstration in the proper clearing of the catheter and proper placement of catheter using leg strap by 11/24/11 by DON, ADON or designee ... F 441 ... All CNAs will be in-serviced on proper technique of handing washing, the changing of gloves while doing peri-care, giving catheter care, proper placement of the leg strap, applying moisture barrier, applying clean incontinent brief and readjustment of the resident in bed by 10/25/11. Each CNA will perform a return demonstration on the proper procedure according to facility policy of hand washing, the proper procedure of when and how to change gloves while doing peri-care, giving catheter care, applying moisture barrier, applying a clean incontinent brief and readjusting resident in bed by 11/24/11 ... F 498 ... Upon completion of in-services and return demonstration, each employee will be given a certificate indicating they have successfully completed proper completion of catheter care ... In-service sheets will be kept in a binder in the Assistant Director of Nursing's office along with a copy of the certificate of completion and monitoring sheet ... ." On 11/29/11, EI #1 provided the survey team with the facility's POC with all supporting documentation. Contained within a book, entitled "In-service on Complation (Completion) of Incontinent Care and Catheter Care Training 2011", were 28 "Monitoring Sheet for Proper Catheter Care" with accompanying certificates for CNAs. The date on these monitoring sheets ranged from 10/20/11 to 11/22/11, and the return demonstration was documented as being observed by EI #2 (ADON) and EI #5 (Treatment/Restorative Nurse). In an interview on 11/29/11 at 4:25 PM, EI #23, a CNA, was asked if she had been trained in catheter care. The CNA (EI #23) stated that she was trained on last night (11/28/11) after the survey team left the facility. EI #23 was asked if she completed a return demonstration and she said no. Contrary to EI #23's interview, a review of her "Monitoring Sheet for Proper Catheter Care" provided to the survey team on 11/29/11, showed EI #23 was observed for proper catheter care on 11/02/11 by EI #5, the Restorative/Treatment Nurse (26 days prior to receiving the actual training without a return demonstration). On 11/29/11 at 5:55 PM, the surveyor handed the Treatment/Restorative Nurse (EI #5) the monitoring sheet of EI #25 (CNA) dated 10/30/11, and asked if she observed EI #25 perform a return demonstration on 10/30/11 as documented. EI #5 stated that she couldn't recall. A review of EI #25's timesheet indicated that she did not work in the facility on 10/30/11. In an interview on 12/01/11 at 2:40 PM, EI #42 (Administrative Assistant) verified that EI #25 did not work in the facility on 10/30/11. The surveyor provided EI #42 the dates that eight other CNAs were documented as having been observed performing proper catheter care, and asked to review the CNAs' timesheet to determine if the CNA was in the facility on the date in question. EI #42 verified that eight other CNAs (EI #15, EI #16, EI #26, EI #29, EI #37, EI #43, EI #44 and EI #45) did not work in the facility on the date the return demonstration was documented as being observed. The surveyor asked, if a CNA comes into work to attend an inservice does he/she have to clock in. EI #42 replied "if they are on the floor working no they don't but if they come in to an inservice or whatever they will clock in especially in mandatory, but yes they clock in." In a follow up interview on 11/30/11 at 10:15 AM, EI #5 (Treatment/Restorative Nurse) stated although she signed her name as observing the performance, she in fact did not. EI #5 stated that she did not observe the following CNAs perform a return demonstration: EI #25, EI #33, EI #34, EI #35, EI #36, EI #37 and EI #38. When the surveyor asked why she did not observe those CNAs, EI #5 replied that she didn't know that she was suppose to get a return demonstration of each CNA. EI #5 stated that the facility only has two residents with a catheter. The surveyor asked, what could have been used instead of a resident. EI #5 (Treatment/Restorative Nurse) responded that a mannequin could have been used. EI #5 also stated that EI #2 (ADON) handed her 10 monitoring sheets to sign her name on. The surveyor asked if EI #1 (DON) was aware that the monitoring sheets were being completed on 11/28/11, and EI #5 replied, "Yes, I'm sure she was." EI #5 stated that she witnessed the two MDS Coordinators (EI #21 and EI #22) and EI #2 (ADON) checking the forms. The "Resident Census and Conditions of Residents (Form CMS-672)" completed by EI #1 (DON) on 11/28/11, indicated the facility has two residents with an indwelling or external catheter. In an interview on 11/30/11 at 11:15 AM, EI #21 (LPN MDS Coordinator) admitted that she helped put the check marks on the monitoring sheet, but stated she did not sign her name to any of the forms. When asked, why she did this? EI #21 answered that she was specifically told by the DON (EI #1) to place check marks on the form without the names (CNA name) or signatures (observed by signature). The surveyor asked EI #21 if she should have been helping complete the catheter care monitoring forms and she answered, "No." The MDS Coordinator (EI #21) explained that she should not have been helping because she wasn't the person responsible for monitoring the catheter care. On 11/30/11 at 11:30 AM, the facility's other LPN MDS Coordinator (EI #22) was interviewed. During this interview, EI #22 admitted that she helped to complete the proper catheter care monitoring sheets by placing check marks on blank forms, as instructed by either EI #2 (ADON) or EI #21, another LPN MDS Coordinator. EI #22 stated this occurred about 5:30/6:00 PM on Monday, 11/28/11. EI #22 explained that she should not have helped complete the forms because she did not see the CNA perform the return demonstration. According to EI #22, she stated she completed 10 forms but identified 12 forms as possibly being completed by her; these forms were dated from 10/25/11 to 11/22/11. During an interview on 12/01/11 at 6:35AM, EI #29, a CNA, was asked if she received inservice training on catheter care, and she said no. When asked if EI #2 (ADON) had observed her perform a return demonstration on 10/21/11, EI #29 answered not that she could remember. A review of EI #29's "Monitoring Sheet for Proper Catheter Care" provided to the survey team on 11/29/11, documented that EI #2 (ADON) observed EI #29 perform proper catheter care on 10/21/11. A review of EI #29's timesheet indicated that she did not work in the facility on 10/21/11. On 12/01/11 at 2:40 PM, EI #42 (Administrative Assistant) verified that EI #29 did not work in the facility on 10/21/11. On 11/30/11 at 4:00 PM, EI #2 (ADON) admitted that she only watched five CNAs (EI #13, EI #14, EI #30, EI #40 and EI #41) complete a return demonstration for proper catheter care. EI #2 stated she was told by EI #1 (DON) to have each CNA complete a return demonstration. The ADON (EI #2) said that she did not know the reason that she had placed dates with the names of CNAs on 13 monitoring sheets. According to EI #2, the DON (EI #1) instructed both of the LPN MDS Coordinators (EI #21 and EI #22) to put check marks on the monitoring sheets on 11/28/11. The ADON (EI #2) admitted that 23 of the 28 monitoring sheets that were presented to the survey team on 11/29/11 had been falsified on 11/28/11. EI #2 was asked if EI #1 (DON) was aware that the monitoring sheets had not been completed in accordance with the POC. The ADON (EI #2) replied yes and explained that EI #1 (DON) knew this ever since the POC was developed. In a follow up interview on 11/30/11 at 12:05 PM, EI #2 (ADON) admitted that she placed the CNAs' name on each sheet, she and EI #5 (Restorative/Treatment Nurse) signed their names to the monitoring sheets as observing each CNA complete a return demonstration, while EI #21 and EI #22 (the two LPN/MDS Coordinator) placed the check marks beside each skill listed on the checklist. The ADON (EI #2) stated this was done because EI #1 (DON) had instructed them (EI #2, EI #5, EI #21 and EI #22) to get it done and put in the binder on 11/28/11. The surveyor asked EI #2 did she know that what she was doing was not being truthful. EI #2 commented, "I guess I really didn't think about it at that time, but then later after I got home I thought we should not have done that - I realized it wasn't truthful." On 11/30/11 at 5:35 PM, EI #1 (DON) stated the she and the administrative staff (EI #2, EI #6 and EI #7) all developed the facility's POC, with the established completion date of 11/24/11. The surveyor informed EI #1 that the nursing staff (EI #2, EI #5, EI #21 and EI #22) stated that the monitoring sheets were not completed until after the survey team left the faciity on [DATE] and asked, if she told her staff to complete the monitoring sheets and get them in the book. EI #1 (DON) replied, "I did not but as the DON I will take full responsibility." EI #1 further explained that she told the staff to make sure that the signed inservices were in the book, and that the book was in proper order. The DON (EI #1) admitted that she did not closely monitor the POC for implementation; she recalled looking at the book sometime in October. EI #1 stated that she was unaware that the monitoring sheets had been falsified when she presented the POC book with all supporting documentation to the survey team on 11/29/11. The surveyor asked EI #1 (DON) if she should have been monitoring the POC book for timely completion and she affirmed that she should have, by stating that she takes full responsibility as the DON. On 12/01/11 at 12:00 PM, EI #7 (Assistant Administrator) denied helping develop the POC because he was out of the state. EI #7 also denied having any knowledge that the monitoring sheets had been falsified. According to EI #7, he and EI #6 (Administrator) were responsible for overseeing the implementation of the POC; however, the Assistant Administrator (EI #7) acknowledged that he was out of town. The surveyor asked EI #7, what was he going to do now that he was aware that the POC had not been implemented. EI #7 answered, "I will make sure that the CNAs will be trained according to the POC and proper disciplinary action will be taken for the falsification of records and failure to implement the POC." On 12/02/11 at 6:30 PM, the facility presented to the survey team, a typed document on facility letterhead signed by EI #7 (Assistant Administrator) and dated 12/02/11, which documented that EI #1 (DON) was terminated from the facility on 12/01/11. The form further documented that EI #2 (ADON), EI #5 (Treatment/Restorative Nurse), EI #21 (LPN MDS Coordinator) and EI #22 (LPN MDS Coordinator) were terminated from the facility on 12/02/11. During an interview on 12/01/11 at 8:55 AM, EI #6 (President/Administrator) stated that he was not aware of the falsification of the monitoring sheets for proper catheter care, and of the POC not being implemented. When asked, what should have been done, EI #6 replied, "They (licensed nursing staff) should not have done anything and we (facility) would have just been non-complaint with our POC." In a follow up interview on 12/01/11 at 2:50 PM, EI #6 stated that he did not personally review the POC because he relied heavily on the DON (EI #1), but he will never do that again. *************** On 12/02/11 at 6:30 PM, the facility submitted an acceptable allegation of compliance, which documented: F-490 Part Two: Failure to Provide Oversight and Monitoring 1. Effective December 2, 2011, the Director of Nursing who was reported to the state survey team as directing facility LPNs to falsify documentation regarding inservice training was terminated. Effective December 2, 2011, the four facility LPNs who admitted to falsification of documentation regarding inservice training were terminated. In accordance with the rules and regulations of the Alabama Board of Nursing, by December 3, 2011, Kirkwood will report the actions of the former Director of Nursing and the four LPNs to the Alabama Board of Nursing via the Board's online reporting system. 2. All residents with indwelling catheters have the potential to be affected by the failure to provide oversight and monitoring of the facility's plan of correction for previously cited F-315. 3. By December 9, 2011, the outside consultant/designee will provide additional training regarding catheter care and infection prevention in accordance with the facility's plan of correction for F-315 for facility CNAs, including return demonstration using appropriate training mannequins. Following the required training session on or before December 9, 2011, no facility CNA will be allowed to return to work until training is completed. Note: Also by December 9, 2011, (outside consultant) his designee will inservice facility staff regarding the full plan of correction for the survey dated October 20, 2011. 4. Effective December 2, 2011, Kirkwood has contacted (outside consultants) to provide outside consultation services at the facility regarding oversight and implementation of the former POC and this AOC. At the present time, (consultant) and (outside consultant) are provided all training pursuant to this AOC (other than the incontinence return demonstration to be completed by December 9, 2011) and will provide initial review of the reportable incidents until (outside consultants) have formally been retained as consultants. Date of Abatement of Immediate Jeopardy: December 2, 2011 *************** After reviewing the facility's information provided in their allegation of credible compliance (in-service records, disciplinary actions and staff interviews) completed as of 12/02/11, the immediate jeopardy was relieved and the scope and severity was lowered to a "D" level on 12/02/11 at 6:50 PM, to allow the facility time to monitor and/or revise their corrective actions to achieve substantial compliance.