Every finding on record at Lafayette Nursing Home

Based on record review, interviews and review of a facility policy titled, Activity Programs, the facility failed to ensure an ongoing group activities program was offered on the weekends. This was identified by residents in attendance for resident council on 9/20/22. This affected RI (Resident Identifier) #'s 15,39, and 41, three of five residents who attended resident council on 9/20/22. Findings Include: A review of a policy titled Activity Programs with a revised date of June 2018 documented: .Activity programs are designed to meet the interests and support the physical, mental and psychosocial well-being of each resident. 11.group activities are provided that: b. Are offered at hours convenient to the residents, including evenings, holidays and weekends; . A review of Facility Activity Calendars for August 2022 and September 2022 showed no scheduled activities on Saturday and Sunday. A resident council meeting was held on 9/20/22. Five residents attended the meeting. When asked about facility activities on the weekend, RI #'s 15, 39 and 41 reported no scheduled activities on Saturday or Sunday. RI # 15 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of RI # 15's Activity Evaluation dated 7/29/22 documented he/she was an active participant in activities, preferred to be with people, enjoyed large groups and was able to make his/her needs known. A follow up interview was conducted with RI #15 on 9/20/22 at 11:58 AM. RI #15 was asked what type of activities he/she participated in on the weekend. RI #15 stated he/she watched television in his/her room. RI #15 was asked what type of activities he/she would like to do on the weekend, and he/she responded he/she liked dominos, checkers, bingo or a card game. RI #15 stated he/she would attend activities if they were offered on Saturday and Sunday. RI # 39 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI # 39's Activity Evaluation dated 8/23/22 documented he/she was an active participant in activities, preferred to be with people, enjoyed large groups and was able to make his/her needs known. A follow up interview was conducted with RI # 39 on 9/20/22 at 11:49 AM. RI #39 was asked if the facility provided activities on the weekend. RI #39 stated no activities were offered on the weekend and that he/she watched television in his/her room on the weekend. RI #39 was asked what type of activity he/she would like to do on the weekend. RI #39 stated he/she would attend bingo if it was offered. RI # 41 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI # 39's most recent Quarterly MDS with an ARD of 9/5/22 documented a BIMS score of 13/15. A review of RI # 41's Activity Evaluation dated 9/5/22 documented he/she was an active participant in activities, preferred to be with people, enjoyed large groups and was able to make his/her needs known. A follow up interview was conducted with RI # 41 on 9/20/22 at 12:00 PM. RI # 41 was asked what type of activities he/she did on the weekend. RI # 41 stated he/she watched television in his/her room. RI # 41 was asked if the facility offered any activities on Saturday or Sunday. RI # 41 responded no. RI # 41 further stated he/she would attend activities if they were offered on Saturday or Sunday. RI # 41 was asked what type of activities he/she world like the facility to offer on the weekend. RI # 41 stated he/she liked bingo, checkers, dice games and dominos. An interview was conducted with Employee Identifier (EI) # 1, Activity Director, on 9/19/22 at 10:00 AM. EI # 1 was asked why there were no scheduled activities for the weekends. EI # 1 stated that since Covid the church that had been coming on Sunday and conducting a Sunday School class had not started back. EI # 1 further stated no replacement activity had been found. EI # 1 was asked how many activity staff were employed by the facility. EI # 1 stated two total. EI # 1 was asked how many activity staff were scheduled for the weekend. EI # 1 stated no activity staff were scheduled for the weekend. RI # 1 was asked to review the activity calendar for August and September 2022 and confirmed no resident activities were scheduled for Saturday or Sunday. EI # 1 was asked why no activities were scheduled for Saturday or Sunday. EI # 1 stated the main reason would be no activity staff were scheduled. EI # 1 was asked if activity staff had ever worked on the weekend. EI # 1 stated yes, prior to COVID we had weekend activity staff. EI # 1 was asked the importance of having weekend activities scheduled for the residents. EI # 1 responded that it would give the residents something to do, allow them more interaction with each other and make the weekends go by faster for the residents.

Based on interviews conducted during the initial tour, comments from Resident Council attendees, tray line observation, a review of the facility policy titled Monitoring Food Temperatures for Meal Service, and interviews with staff, the facility failed to consistently serve food at palatable temperatures to residents. This affected 5 of 22 interviewable residents residing in the facility, including RI #25. Findings Include: A review of the facility policy titled, Monitoring Food Temperatures for Meal Service (2016) specified: . Procedure . 3. g. Meals that are served on room trays may be periodically checked at the point of service for palatable food temperatures. Food temperatures of hot foods on room trays at the point of service are preferred to be at 120 degrees F (Fahrenheit) or greater to promote palatability for the resident. Any complaint regarding food temperatures by residents will be documented on the Food Temperature Log. Complaints will be investigated by conducting a test tray for that meal to determine if foods are remaining above 120 degrees F. During the initial facility tour on 3/10/20 at 10:41 AM, RI #25 stated the food was always cold. On 3/11/20 at 10:00 AM, a Resident Council Meeting was conducted by survey staff. Of the 12 attendees, four residents affirmed food temperatures were not warm enough. On 3/11/20 at 10:35 AM, the surveyor observed the lunch tray line. All food temperatures were taken prior to the arrival of the surveyor, and documented as 144 degrees F or greater. Employee Identifier (EI) #5, the morning Cook, plated food directly from the pans resting on hot burners of the stove top, or from pans of food resting on top of two open oven doors, with no direct source of heat. Food items included Philly cheese steak, French fries, and pulled BBQ pork chop. Plastic (Melmac) plates were used (unheated) for each tray, and covered by plastic plate covers (with no thermal insulation) and no heated base. All trays of food were then transported to the halls and Dining Room on open-sided transfer (speed) racks. There was no visible means of maintaining food temperatures for the food once the item left the burners of the range top. On 3/11/20 at 11:12 AM, the last food cart was completed, at which time the surveyor requested EI #5 to check the temperature of the items stored on top of the open oven doors. The pulled (mechanical) BBQ Pork Chop (documented as 180 degrees F at the start of the tray line) was found to be 118 degrees F. The alternate Philly Cheesesteak (documented as 189 degrees F) registered 120 degrees F when checked by EI #5. On 3/11/20 at 11:30 AM the Dietary Manager (EI #6) and the surveyor checked the food temperatures of test trays, sent on the 100 Hall food cart. All trays had already been delivered by this time. The temperatures were as follows: REGULAR PORK CHOP: 100 degrees F ( taste acceptable). CREAMED CORN: 90 degrees F (tasted slightly warm). LIMA BEANS: 100 degrees F (tasted warm). PUREED CREAMED CORN: 80 degrees F (tasted like room temp; not warm enough). EI #6 agreed the temperature was not hot enough. PUREED LIMA BEANS: 85 degrees F. Burned taste; cool temperature. Not acceptable. EI #6 agreed it was only room temperature. PUREED BBQ PORK CHOP: 95 degrees F. Barely warm taste; room temperature. PHILLY CHEESE STEAK: 80 degrees F. Room temperature. EI #6 agreed. BBQ SHREDDED PORK CHOP: 94 degrees F. Warm. On 3/11/20 at 2:44 PM, the surveyor asked the Dietary Manager (EI #6) if she had completed any Food Satisfaction Surveys of the the residents over the past six months. EI #6 stated she had, but not very many residents complained. She affirmed RI #25 had complained the food was cold, but would not eat it when it arrived and refused to have it reheated. EI #6 stated that RI #6 had also complained about cool food temperatures. When asked if the cook had the ovens turned on, EI #6 stated the temperatures were usually on low, like a warming temperature. The surveyor asked how often she conducted a test tray and what their goal temperature would be (for the residents). EI #6 responded she had never done a test tray, but would like to make sure the temperatures were staying warm. EI #6 stated the goal temperature was 120 degrees F.

Based on observations, interviews and review of facility policies Handwashing/Hand Hygiene and Food Safety Requirements, the facility failed to ensure: 1. facility staff did not transport foods to residents on the halls during an activity, uncovered and using the same glovesbetween resident food distribution, and 2. during incontinent care for Resident Identifier (RI) #10, a Certified Nursing Assistant (CNA) washed her hands between glove changes, two CNAs did not touch clean linens and briefs with soiled gloves, and a CNA did not leave a resident room without washing her hands, enter a linen closet to get a clean brief then return to the resident room. This was observed on 3/10/20 and affected seven of seven residents receiving ice cream and cake during the afternoon activity, and one of one residents observed for incontinent care. Findings Include: 1. A review of a facility policy titled Food Safety Requirements date 2019, revealed, . Policy Explanation and Compliance Guidelines: . 5. Foods and beverages shall be delivered to residents in a manner to prevent contamination. a. Covering all foods with lids or plate covers. c. Washing hands properly before distributing . d. Washing hands between contact with residents . On 3/10/20 at 1:42 PM, the surveyor observed a staff person pushing a gray cart with 10 bowls of ice cream and cake on it down the 100 hall. The bowls of ice cream and cake were uncovered. The staff person had on blue gloves, she entered a resident room and placed a bowl on the overbed table. She returned to the gray cart with 9 bowls of ice cream and cake uncovered. Wearing the same gloves, she rolled the cart to another room and placed a bowl of ice cream and cake on the overbed table then left the room. She returned to the cart with eight bowls of ice cream and cake, wearing the same gloves she rolled the cart and entered another room, took a bowl of ice cream and cake inside the room and placed it on the overbed table. She left the room, returned to the gray cart with seven bowls of ice cream and cake remaining on the cart uncovered and wearing the same gloves, rolled the cart to the back hall (200 hall) and went in and out of four more rooms delivering uncovered ice cream and cake in bowls while wearing the same gloves. The surveyor observed three bowls remaining on the cart and asked her who received the ice cream and cake. She replied, some that did not attend the monthly birthday party in the activity room so she took it to their rooms. On 3/10/20 at 2:00 PM, an interview was conducted with Employee Identifier (EI) #4, medical records clerk. She was the staff person helping with the activity; she delivered the ice cream and cake to the residents that did not attend the group activity. EI #4 was asked, how many ice cream and cakes did she deliver. EI #4 replied, she had 10 but only gave out seven bowls. EI #4 was asked, how were the bowls covered. EI #4 replied, they were not. EI #4 was asked, where did she deliver the bowls of cake and ice cream to. EI #4 replied, residents on the front (100 hall) and back (200) halls. EI #4 was asked, what should be done to food being delivered on the halls. EI #4 replied, it should have a cover over it. EI #4 was asked, when should she change gloves when delivering food or care to a resident. EI #4 replied, every time she came out of a room she should have washed her hands and put on clean gloves. EI #4 was asked, how many times did she change gloves when exiting the resident rooms that she took ice cream and cake into. EI #4 replied, she did not, she had on the same gloves. EI #4 was asked, what was the potential harm in delivering the ice cream and cake to the residents on the hall uncovered. EI #4 replied, something in the air could get on the food and contaminate it. EI #4 was asked, what was the potential harm in using the same gloves to go in and out of seven residents rooms. EI #4 replied, she touched the cart and it may not have been clean, and she may have touched something in those residents rooms to which she could have contaminated the food. 2. A review of a facility policy titled Handwashing/Hand Hygiene, revised date August 2019, revealed, Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation . 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors.7. b. Before and after direct contact with residents; . j. After contact with blood or bodily fluids; . m. After removing gloves. 9. The use of gloves does not replace handwashing/hand hygiene. RI #10 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 3/10/20 at 4:11 PM, the surveyor observed RI #10 yelling help me. Staff entered the room to comfort the resident. RI #10 was found incontinent of urine and bowels. On 3/10/20 at 4:20 PM, the surveyor observed incontinent care performed by EI #3, CNA and EI #2, CNA. EI #3 brought wipes into the room and placed a bag on the foot of the bed. EI #2 brought clean linens and a brief into the room and placed two bags open in the chair beside the bed. EI #3 turned RI #10 to the left side. EI #2 removed the linens from one side of the bed rolling towards the middle of the bed and placed the clean bottom sheet. EI #2 assisted in removing RI #10's pants and wet soiled brief. EI #2 wiped the bowel movement (bm) from the buttock area, changed gloves and with out washing her hands put on clean gloves, then wiped the front area and the buttock again until clean from the bm. EI #2 prepared the draw sheet, cloth pad and clean brief and placed them on top of the bottom sheet then under RI #10. Both CNAs turned RI #10 to the right side. EI #3 removed the soiled linens from the bed. EI #3 placed the clean linens to the other side of the bed and under RI #10 with the same gloves she handled the soiled linens. Upon turning RI #10 to the back position they noted RI #10 to have soiled the clean brief. EI #2 removed her gloves and left the room without washing her hands. The surveyor followed EI #2 to the clean linen closet. EI #2 got a clean brief from the shelf, and returned to RI #10's room. EI #2 opened the clean brief and placed it on the bed beside RI #10. EI #2 put on gloves, cleaned the bm from RI #10 again, then with the same gloves placed the clean brief under RI #10. EI #2 did not wash her hands between gloves changes, after touching soiled linens and a soiled brief, before touching clean linens and a clean brief, and EI #2 did not wash her hands before leaving the room and going to the linen closet. When EI #2 returned to the room she put on gloves and cleaned the resident again and placed the second clean brief without washing her hands or changing gloves. EI #3 removed the soiled linens from the bed then with the same gloves placed the clean linens over the bed. On 3/10/20 at 4:50 PM, an interview was conducted with EI #2, CNA. EI #2 was asked, when should they wash hands during incontinent care. EI #2 replied, every time they changed gloves. EI #2 was asked if she washed her hands every time she changed gloves. EI #2 replied, no. EI #2 was asked, why did she not wash hands after changing gloves. EI #2 replied, she put on clean gloves. EI #2 was asked, when should she touch clean linens and a clean brief with soiled gloves. EI #2 replied, they should not, they should wash hands after cleaning and changing gloves before putting on clean gloves. EI #2 was asked, how was the resident soiled. EI #2 replied, wet and bowel movement. EI #2 was asked, when should she leave a room without washing her hands. EI #2 replied, they should not. EI #2 was asked, when should she go into a clean linen closet without washing her hands. EI #2 replied, she should not. EI #2 was asked, what was the harm in changing gloves without washing hands. EI #2 replied, could cause contamination. EI #2 was asked, what was the harm in leaving the room and going into the linen closet without washing her hands. EI #2 replied, could contaminate the linens in the closet. EI #2 was asked, what was the harm in touching the clean linens and clean brief with the same soiled gloves she had on to clean the resident. EI #2 replied, could have had something on the gloves then contaminate the clean linens and could cause infection. On 3/11/20 at 3:30 PM, an interview was conducted with EI #3, CNA. EI #3 was asked, when should she wash her hands while helping with incontinent care. EI #3 replied, if she touched dirty. EI #3 was asked, when should she remove dirty linens and a soiled brief from the bed then with the same gloves place the clean linen on the bed. EI #3 replied, she should have taken the wet linen off then removed her gloves, washed her hands, put on clean gloves, then pulled the clean sheet over the bed. EI #3 was asked, what was the harm in removing the soiled linen, then with the same gloves placing the clean sheet over the bed. EI #3 replied, she could contaminate the clean linens. On 3/12/20 at 9:32 AM, an interview was conducted with EI #1, Licensed Practical Nurse, Infection Control. EI #1 was asked, when should staff go in and out of several resident rooms wearing the same gloves. EI #1 replied, never. EI #1 was asked, when should staff transport and deliver activity food on halls uncovered. EI #1 replied, never. EI #1 was asked, what was the harm in staff going in and out of several resident rooms while wearing same gloves. EI #1 replied, possible contamination. EI #1 was asked, what was the harm in activity staff transporting and delivering food to residents on the halls uncovered. EI #1 replied, contamination. EI #1 was asked, when should staff change gloves during incontinent care. EI #1 replied, they should wash hands before starting then put on gloves, after removing soiled brief and cleaning the resident, remove gloves and wash hands put on clean gloves before placing clean linens and the brief. EI #1 was asked, when should staff wash hands during incontinent care. EI #1 replied, anytime gloves are removed, after cleaning the resident, after handling soiled items, before placing clean linens and the brief, and when the procedure was completed they should wash their hands before leaving the resident room. EI #1 was asked, what should staff do after handling dirty linen and soiled briefs. EI #1 replied, remove their gloves, wash their hands, and put on new gloves, then place the clean linen and brief. EI #1 was asked, what should staff do before handling clean linen and clean a brief. EI #1 replied, wash their hands, and put new gloves on. EI #1 was asked, when should staff touch clean linens and a clean brief with the same gloves used to clean the resident. EI #1 replied, never. EI #1 was asked, what should staff do if they have to leave a resident room for more supplies. EI #1 replied, remove the gloves, wash their hands then leave the room. EI #1 was asked, when should staff leave a resident room and enter the linen closet without hand washing. EI #1 replied, never. EI #1 was asked, what would the potential for harm be in staff touching clean linen and briefs with soiled gloves. EI #1 replied, contamination. EI #1 was asked, what would the potential for harm be in staff leaving a resident room without washing their hands, then entering the linen closet for more supplies. EI #1 replied, contamination.

Based on observations, interviews and review of Resident Identifier (RI) #44's medical record, the facility failed to develop an individualized care plan for RI #44, a resident totally dependent on staff for all Activities of Daily Living (ADLs), to address RI #44's right leg that was turned outward laterally and rested on the bed, when the resident was placed on bedrest on 10/4/18. The facility further failed to ensure RI #44's use of bilateral heel booties (Posey Heel Pillows), worn daily for the protection and prevention of pressure ulcers, were addressed in RI #44's care plans. These failures to develop and implement interventions to address RI #44's positioning and pressure relief caused RI #44 to develop a facility-acquired Stage IV pressure ulcer on the right outer (lateral) ankle on 11/26/18 that measured 1.8 centimeter (cm) by 1.4 cm with 0.4 cm of depth. The pressure ulcer was assessed as having minimal drainage, no odor and exposed bone. These deficient practices affected RI #44, one of 16 sampled residents and placed RI #44 in immediate jeopardy, as these failures were likely to cause serious injury, harm or death. On 1/22/19 at 8:40 PM, the Assistant Administrator, Director of Nursing (DON), Assistant Director of Nursing, Social Service Designee and Secretary were notified of the findings of immediate jeopardy in the area of Comprehensive Resident Centered Care Plans, F656. Findings include: RI #44 was admitted to the facility on [DATE], with a medical history to include [DIAGNOSES REDACTED]. RI #44's Quarterly Minimum Data Set (MDS) with an assessment reference date of 9/27/18, revealed RI #44 was totally dependent on staff for all ADLs and had range of motion limitation in the upper and lower extremities on both sides of his/her body. According to this MDS, RI #44 did not have any unhealed pressure ulcers but was at risk for developing pressure ulcers. RI #44's care plan titled Potential Alteration in Skin Integrity R/T (related to) thin, fragile skin, decreased mobility, incontinence . last reviewed 10/1/18, did not include an approach for the use of the Posey Heel Pillows used by the resident or approaches to address pressure relief for RI #44's right leg that was turned outward and rested on the bed. In an interview on 1/17/19 at 12:57 PM, Employee Identifier (EI) #8, a Certified Nursing Assistant (CNA) who routinely cared for RI #44 during the first shift (7:00 AM to 3:00 PM), stated when she was assigned to care the resident, she would keep the heel protectors (Posey Heel Pillows) on RI #44. On 1/18/19 at 9:17 AM, RI #44 was observed wearing heel protectors on both feet. On 1/18/19 at 9:40 AM, EI #5, a Registered Nurse (RN)/Treatment Nurse, was asked to describe RI #44's right leg. EI #5 explained RI #44's right leg was turned which caused the right leg and ankle to lay on the lateral side. When asked how long RI #44's leg has been that way, EI #5 stated for as long as she had known the resident, about five to six years. When asked how long RI #44 has been wearing the heel booties, EI #5 stated the heel booties were on RI #44 when she (EI #5) started working at the facility. In an interview on 1/18/19 at 12:52 PM, EI #21, a Licensed Practical Nurse (LPN) was asked if there was any guidance in RI #44's care plans related to how the resident's legs were positioned. EI #21 stated she was not familiar with that. In an interview on 1/18/19 at 1:37 PM, EI #2, the Director of Nursing (DON) stated RI #44 has a care plan for skin integrity but the heel booties were not addressed on that care plan. When asked if the care plan should have addressed RI #44's use of bilateral heel booties, EI #2 said yes. When asked to describe RI #44's leg and how it was positioned, EI #2 stated RI #44 had feet contractures and the resident use to do leg lifts all the time but then one day, the resident stopped. An x-ray was ordered and a Computed Tomography (CT) scan confirmed a fracture. EI #2 was asked why RI #44 was placed on bed rest on 10/4/18. EI #2 replied, when the final report was received that confirmed RI #44 had a fracture, the physician, EI #1, wanted to see if bed rest would give the fracture a chance to heal. When asked why bedrest was discontinued on 11/27/18, EI #2 replied, because of the presence of the pressure ulcer. RI #44's physician's orders [REDACTED]. Bed rest 10/4/18 . RI #44's NURSE'S NOTES dated 11/27/18, written by EI #2, the DON documented 3p (3:00 PM) - DON spoke (with) (EI #1) & he agreed to D/C (discontinue) bedrest. In an interview on 1/18/19 at 4:22 PM, EI #13, a LPN was asked what preventative measures were in place before a pressure ulcer was identified on RI #44 on 11/26/18. EI #13 stated, (heel) booties. When asked how long RI #44 had worn the heel booties, EI #13 stated a long time. EI #13 was asked if there was any guidance in RI #44's care plans related to how the resident's legs were positioned. EI #13 said she didn't know of any. In a follow-up interview on 1/19/19 at 9:50 AM, EI #8, a CNA was asked to describe RI #44's and how they are positioned. EI #8 stated RI #44's feet are turned in and the resident presses his/her feet down into the bed. When asked why RI #44's wore the bilateral heel booties (Posey Heel Pillows), EI #8 said RI #44 wore them to keep from getting pressure sores on his/her feet while in the bed. During an interview on 1/19/19 at 10:33 AM, EI #6, a CNA who routinely cared for RI #44 during the first shift, was asked how often RI #44 wore the heel booties. EI #6 stated, every day for the protection from sores and wounds. In an interview on 1/19/19 at 11:08 AM, EI #9, a CNA who routinely cared for RI #44 during the third shift (11:00 PM to 7:00 AM), was asked why RI #44 wore heel booties. EI #9 stated to protect the resident's feet from pressure sores. When asked who often RI #44 wore the heel booties, EI #9 stated every night she worked with RI #44, the resident had them on. On 1/19/19 at 11:53 AM, EI #22, a LPN stated RI #44 always had the heel booties on while in bed. According to EI #22, in (MONTH) (YEAR), EI #8, a CNA came to her and informed her RI #44 had a place on his/her ankle. EI #22 stated she told EI #8 to let EI #2, who was at the time, the Assistant Director of Nursing (ADON) know. EI #22 stated EI #2 later informed her the place on RI #44's ankle was a Stage IV pressure ulcer. RI #44's WOUND RECORD revealed a Stage IV pressure ulcer on the resident's right outer (lateral) ankle was first observed on 11/26/18 by EI #2, the DON. The pressure ulcer measured 1.8 centimeter (cm) by 1.4 cm with 0.4 cm of depth. The pressure ulcer was assessed as having minimal drainage, no odor and exposed bone. During a telephone interview on 1/19/19 at 1:17 PM, EI #12, a CNA who routinely cared for RI #44 during the 2nd shift (3:00 PM to 11:00 PM), stated RI #44 used to be able to lift both legs but after an x-ray, the resident could not move his/her right leg anymore. According to EI #12, she reported it to a nurse but didn't know if anything was done about it. When asked how often RI #44 wore the heel booties, EI #12 stated, every day. In an interview on 1/19/19 at 2:07 PM, EI #2, the DON was asked why RI #44 wore heel booties. EI #2 said for protection; RI #44 had a history of [REDACTED].#44 had worn the heel booties, EI #2 said she was not sure. When asked why the heel booties were not care planned, EI #2 said she just overlooked them. EI #2 was asked should the heel booties have been care planned. EI #2 replied, yes they should have been. When asked what information should have been included on RI #44's care plan related to the heel booties, EI #2 said when and how often to apply and check for skin integrity. EI #2 explained RI #44 used to do leg lifts but after (MONTH) (2018), the resident stopped moving the right leg. When asked what was done after RI #44 stopped moving the right leg to relieve pressure, EI #2 said nothing new. When asked who was responsible to ensure interventions were implemented, EI #2 stated it was all of our responsibility. EI #2 was asked why nothing was implemented and she replied, nobody did anything. When asked if RI #44's care plan related to the resident's fracture addressed any approaches for positioning and/or pressure relief, EI #2 said no. EI #2 was asked why there was no individualized approaches for positioning and/or pressure relief. EI #2 replied it was overlooked. When asked should there have been any individualized approaches to address RI #44's leg positioning and/or pressure relief, EI #2 said yes. During an interview on 1/20/19 at 3:49 PM, EI #14, a LPN familiar with RI #44's care, was asked what interventions should have been included to RI #44's care plans to address pressure ulcer development, EI #14 said to keep something under RI #44's feet so that the resident's feet were off the bed. On 1/20/19 at 5:05 PM, RI #44 was observed in bed with bilateral heel booties on. RI #44's right leg was turned out laterally with the right ankle resting in the heel pillow on the bed. On 1/20/19 at 5:05 PM, RI #44 was observed in bed wearing bilateral heel pillows. RI #44's right leg was turned out laterally with the right lateral ankle resting on a heel pillow on the bed. There was a pillow between the resident's legs with the left lower leg on top of the pillow and the right lower leg under the pillow. In an interview with RI #44's sponsor on 1/21/19 at 10:47 AM, she was asked how long had RI #44 wore the heel booties. RI #44's sponsor the whole time RI #44 had been in the facility. RI #44's sponsor explained RI #44 wore them all the time, whether in or out of bed. In a follow-up interview with RI #44's sponsor on 1/22/19 at 2:59 PM, she was asked what position was RI #44 in when she visited. RI #44's sponsor stated RI #44 was in bed on his/her back, with the head of bed elevated, heel booties on with the right lateral ankle laying on the bed. RI #44's sponsor explained that when RI #44 was found to have a fracture, the facility placed the resident on bed rest to not strain the fracture. During an interview on 1/22/19 at 1:09 PM, EI #2, the DON was asked what was done to prevent pressure ulcer development when RI #44 was placed on bed rest on 10/4/18. EI #2 replied, nothing new; there was no change in the resident's care plans. EI #2 explained there was a care developed for the fracture but it didn't address any new interventions. When asked who was responsible for updating RI #44's care plans with interventions after 10/4/18, EI #2 stated it would have been her. On 1/22/19 at 3:35 PM, RI #44 was observed in bed wearing heel booties. RI #44's right lateral ankle was positioned on the bed. RI #44 was observed lifting his/her left leg up and down. ************************* On 1/24/19 at 5:20 PM, the facility submitted an acceptable Allegation of Compliance (A[NAME]), which documented: Allegation of Compliance-Care Plan Resident #44 Plan of Care was updated to include 6 inch Skil-Care Standard Foot Elevator to right lower leg and Posey Heel Pillows/Foot Positioner to left foot. Skin integrity checks are to be performed every two hours and documented on TAR by charge nurse that completed the check. Completed 01/23/2019 All Care Plans on Skin integrity to be evaluated by Care Plan team to assure all adaptive equipment for pressure relief is care planned for appropriate use of equipment including q (every) 2 hours skin integrity checks. Care Plans are to be revised as needed. Oversight to be completed by DON. Completed on 01/24/2019 All members of the MDS/Care Plan Committee are to be re-educated by DON regarding the necessity of formulating care plans to be specific to residents and that the Care Plan address the resident's individual needs. Completed on 01/24/2019 ************************* After reviewing the facility's information provided in their A[NAME] and verifying the immediate actions had been implemented, the scope/severity level of F656 was lowered to a D level on 1/25/19, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on observation, interviews, review of Resident Identifier (RI) #44's medical record, the facility's policy titled Prevention of Pressure Ulcers/Injuries and the manufacturer's information for the Posey Heel Pillows/Foot Positioner WOUND PREVENTION, the facility failed to address pressure relief for RI #44's right leg that was turned outward and rested on the bed. RI #44, a resident totally dependent on staff for all Activities of Daily Living (ADLs) and at risk for pressure ulcer development, was placed on bed rest on 10/4/18. When placed on bed rest, there were no changes in RI #44's treatment plan to address the resident's right leg. According to staff interviews, RI #44 wore bilateral heel booties (Posey Heel Pillows) every day. The facility further failed to follow the manufacturer's recommendations to remove the Posey Heel Pillow every two hours and check for skin integrity. On 11/26/18, RI #44 develop a facility-acquired Stage IV pressure ulcer on the right outer (lateral) ankle on 11/26/18 that measured 1.8 centimeter (cm) by 1.4 cm with 0.4 cm of depth. The pressure ulcer was assessed as having minimal drainage, no odor and exposed bone. These deficient practices affected RI #44, one of five sampled residents reviewed for pressure ulcers and placed RI #44 in immediate jeopardy, as these failures were likely to cause serious injury, harm or death. On 1/22/19 at 8:40 PM, the Assistant Administrator, Director of Nursing (DON), Assistant Director of Nursing, Social Service Designee and Secretary were notified of the findings of immediate jeopardy in the area of Quality of Care - Treatment/Services to Prevent/Heal Pressure Ulcer, F686. Findings include: The facility's policy titled Prevention of Pressure Ulcers/Injuries with a revised date of (MONTH) (YEAR), documented Purpose The purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors . Risk Assessment 1. Repeat the risk assessment . upon any changes in condition . Prevention . Monitoring 1. Evaluate, repot and document potential changes in the skin. 2. Review the interventions and strategies for effectiveness on an ongoing basis . RI #44 was admitted to the facility on [DATE], with a medical history to include [DIAGNOSES REDACTED]. RI #44's Quarterly Minimum Data Set (MDS) with an assessment reference date of 9/27/18, revealed RI #44 was totally dependent on staff for all ADLs and had range of motion limitation in the upper and lower extremities on both sides of his/her body. According to this MDS, RI #44 did not have any unhealed pressure ulcers but was at risk for developing pressure ulcers. In an interview on 1/17/19 at 12:57 PM, Employee Identifier (EI) #8, a Certified Nursing Assistant (CNA) who routinely cared for RI #44 during the first shift (7:00 AM to 3:00 PM), was asked what preventative measures were in place for RI #44 prior to pressure ulcer being identified on the resident's ankle. EI #8 stated when she was assigned to care the resident, she would keep the heel protectors (Posey Heel Pillows) on RI #44. EI #8 stated she didn't know how the pressure sore happened (developed). According to EI #8, RI #44 stayed real wet from sweating and the resident pressed his/her leg down on the bed. In an interview on 1/17/19 at 1:58 PM, EI #6, a CNA who routinely cared for RI #44 during the first shift, was asked if she saw RI #44's skin prior to the pressure ulcer being identified on 11/26/18. According to EI #6, there were times the resident's ankle was red and she informed a nurse, but didn't know which nurse she told. During an observation of wound care on 1/18/19 at 9:17 AM, EI #5, a Registered Nurse (RN)/Treatment Nurse described RI #1's pressure ulcer on the ankle as a healing Stage IV wound. At 9:40 AM, EI #5 was asked to describe RI #44's right leg. EI #5 explained RI #44's right leg was turned which caused the right leg and ankle to lay on the lateral side. When asked how long RI #44's leg has been that way, EI #5 stated for as long as she had known the resident, about five to six years. When asked how long RI #44 has been wearing the heel booties, EI #5 stated the heel booties were on RI #44 when she (EI #5) started working at the facility. In an interview on 1/18/19 at 11:11 AM, EI #10, a Licensed Practical Nurse (LPN) was asked what preventative measures were in place before RI #44 was identified as having a Stage IV pressure ulcer on 11/26/18. EI #10 replied, we would turn the resident side to side and kept (heel) booties on the resident's feet. When asked how long RI #44 had worn the heel booties, EI #10 said the resident was supposed to always have them on. When asked what caused the wound on RI #44's ankle, EI #10 said pressure. In an interview on 1/18/19 at 4:22 PM, EI #13, a LPN was asked what preventative measures were in place before a pressure ulcer was identified on RI #44 on 11/26/18. EI #13 stated, (heel) booties. When asked how long RI #44 had worn the heel booties, EI #13 stated a long time. When asked what may have cause RI #44 to develop a pressure ulcer on the right lateral ankle, EI #13 stated the way the leg was positioned, with the ankle pressed down on the bed. EI #13 was asked how often the skin should be checked of a resident who wore heel booties. EI #13 replied, every shift. When asked who was supposed to check the resident's skin, EI #13 said the nurses. In a follow-up interview on 1/19/19 at 9:50 AM, EI #8, a CNA was asked to describe RI #44's and how they are positioned. EI #8 stated RI #44's feet are turned in and the resident presses his/her feet down into the bed. When asked why RI #44's wore the bilateral heel booties (Posey Heel Pillows), EI #8 said RI #44 wore them to keep from getting pressure sores on his/her feet while in the bed. When asked when skin checks were to be done, EI #8 stated the CNAs didn't do them, that body audits were done by the nurses. When asked what she had been told about checking a resident's skin, EI #8 said she hadn't been told anything but if there is breakdown to let someone know. During a follow-up interview on 1/19/19 at 10:33 AM, EI #6, a CNA was asked how often RI #44 wore the heel booties. EI #6 stated, every day for the protection from sores and wounds. When asked what she was supposed to do for residents who wore heel booties, EI #6 said take them off during the bath, wash the feet and put them back on. EI #6 acknowledged that she was assigned to care for RI #44 in the days prior the pressure ulcer being found. When asked if she looked at RI #44's ankles during care, EI #6 said she did and saw there was some redness and reported it to a nurse but couldn't recall the name of the nurse she reported it to. In an interview on 1/19/19 at 11:08 AM, EI #9, a CNA who routinely cared for RI #44 during the third shift (11:00 PM to 7:00 AM), was asked why RI #44 wore heel booties. EI #9 stated to protect the resident's feet from pressure sores. When asked who often RI #44 wore the heel booties, EI #9 stated every night she worked with RI #44, the resident had them on. EI #9 was asked if she checked RI #44's skin when she was assigned to care for the resident. EI #9 replied that she only checked the resident's skin when she bathed RI #44. In an interview on 1/19/19 at 2:07 PM, EI #2, the DON was asked why RI #44 wore heel booties. EI #2 said for protection; RI #44 had a history of [REDACTED].#44 had worn the heel booties, EI #2 said she was not sure. EI #2 explained RI #44 used to do leg lifts but after (MONTH) (2018), the resident stopped moving the right leg. When asked what was done after RI #44 stopped moving the right leg to relieve pressure, EI #2 said nothing new. When asked who was responsible to ensure interventions were implemented, EI #2 stated it was all of our responsibility. EI #2 was asked why nothing was implemented and she replied, nobody did anything. When asked if RI #44's care plan related to the resident's fracture addressed any approaches for positioning and/or pressure relief, EI #2 said no. EI #2 was asked why there was no individualized approaches for positioning and/or pressure relief. EI #2 replied it was overlooked. When asked should there have been any individualized approaches to address RI #44's leg positioning and/or pressure relief, EI #2 said yes. EI #2 was asked why the facility was not following the manufacturer's recommendations for the Posey Heel Pillows. EI #2 replied that she had not read it. When asked who was responsible for ensuring nursing products utilized in the facility were used according to the manufacturer's specifications, EI #2 replied she was. When asked why she had not read the manufacturer's recommendations, EI #2 stated because she didn't have it in the facility. The manufacturer's information for the Posey Heel Pillows/Foot Positioner WOUND PREVENTION documented HEEL PILLOW Posey Heel Pillows help protect heels and ankles from skin irritation and [MEDICAL CONDITION]. MONITORING WARNING Be sure to follow your facility's policies and guidelines for frequency of patient monitoring. Posey recommends that this product be removed at least every two (2) hours to check for skin integrity, proper circulation and range of motion . During an interview on 1/19/19 at 3:05 PM, EI #1, the facility's Administrator and Medical Director, also RI #44's physician, was asked how long did it take for a Stage IV pressure ulcer to develop on RI #44. EI #1 replied, as debilitated as RI #44 was, probably only a few days. When asked why the wound was not discovered it was a Stage IV, EI #1 stated there was not a Treatment Nurse and RI #44's leg turned out laterally and the staff were afraid to move it. EI #1 was asked how the facility-acquired Stage IV pressure ulcer could have been prevented. EI #1 answered, if the staff had followed the manufacturer's guidelines and inspected RI #44's ankles frequently. EI #1 explained it would have been ideal for the nursing staff to follow the manufacturer's recommendations. In a follow-up interview on 1/21/19 at 1:40 PM, EI #1, the facility's Administrator and Medical Director, also RI #44's physician, stated RI #44's Stage IV pressure ulcer was avoidable. In an interview on 1/20/19 at 2:55 PM, EI #6, a CNA was shown the manufacturer's information for the Posey Heel Pillow and asked if anyone in the facility had ever gone over with her the manufacturer's recommendations. EI #6 replied no ma'am. When asked if she had ever been told to monitor and remove the heel pillows every two hours to check for skin integrity, EI #6 said no ma'am. EI #6 was asked if she removed RI #44's heel booties every two hours to check for skin integrity and she answered no. EI #6 explained she was told RI #44 was supposed to have the heel booties on all time whether in the bed or chair. On 1/20/19 at 3:13 PM, EI #8, a CNA was asked what guidance the facility had given her on how to remove RI #44's heel booties and check the resident's skin. EI #8 replied, they haven't. EI #8 was shown the manufacturer's information for the Posey Heel Pillow and asked if anyone in the facility had ever gone over with her the manufacturer's recommendations. EI #8 replied no. When asked if she had ever been told to monitor and remove the heel pillows every two hours to check for skin integrity, EI #8 said no. EI #8 was asked if she removed RI #44's heel booties every two hours to check for skin integrity and she answered no. In an interview on 1/20/19 at 3:35 PM, EI #12, a CNA was asked what guidance the facility had given her on how to remove RI #44's heel booties and check the resident's skin. EI #12 replied, they haven't. EI #12 was shown the manufacturer's information for the Posey Heel Pillow and asked if anyone in the facility had ever gone over with her the manufacturer's recommendations. EI #12 replied no. When asked if she had ever been told to monitor and remove the heel pillows every two hours to check for skin integrity, EI #12 said no. EI #12 was asked if she removed RI #44's heel booties every two hours to check for skin integrity and she answered no. On 1/20/19 at 3:49 PM, EI #14, a LPN was asked what guidance the facility had given her on how to remove RI #44's heel booties and check the resident's skin. EI #14 replied, the Treatment Nurse would put in an order for [REDACTED]. EI #14 was shown the manufacturer's information for the Posey Heel Pillow and asked if anyone in the facility had ever gone over with her the manufacturer's recommendations. EI #14 replied she had never seen it. When asked if she had ever been told to monitor and remove the heel pillows every two hours to check for skin integrity, EI #14 said no. EI #14 was asked what could have been done to prevent the skin breakdown on RI #44's ankle. EI #14 answered, we should have all been checking more thoroughly and removing the heel booties to check the resident's skin. On 1/20/19 at 9:18 AM, EI #9, a CNA was asked what guidance the facility had given her on how to remove RI #44's heel booties and check the resident's skin. EI #9 replied, none. EI #9 was shown the manufacturer's information for the Posey Heel Pillow and asked if anyone in the facility had ever gone over with her the manufacturer's recommendations. EI #9 replied no. When asked if she had ever been told to monitor and remove the heel pillows every two hours to check for skin integrity, EI #9 said no. EI #9 was asked if she removed RI #44's heel booties every two hours to check for skin integrity and she answered no. In an interview on 1/21/19 at 9:30 AM, EI #15, a LPN was asked what guidance the facility had given her on how to remove RI #44's heel booties and check the resident's skin. EI #15 replied, maybe it was listed in the Treatment book. (There were no orders in RI #44's Treatment Administration Record for the use of bilateral heel booties.) When asked what caused RI #44's pressure ulcer to form and be identified as a Stage IV, EI #15 replied no checking the resident's skin. When asked when skin checks were to be done, EI #15 stated there were no guidelines. EI #15 was shown the manufacturer's information for the Posey Heel Pillow and asked if anyone in the facility had ever gone over with her the manufacturer's recommendations. EI #15 replied she had never seen that information. When asked if she had ever been told to monitor and remove the heel pillows every two hours to check for skin integrity, EI #15 said she didn't recall. In an interview on 1/21/19 at 11:23 AM, EI #13, a LPN was asked what guidance the facility had given her on how to remove RI #44's heel booties and check the resident's skin. EI #15 replied, none. When asked what caused the ankle pressure ulcer to form on RI #44's, EI #13 replied no support under the resident's leg to lift it up off the bed. EI #13 was asked how often she checked RI #44's skin integrity on the resident's feet. EI #13 answered that she didn't look under the heel booties. EI #13 was shown the manufacturer's information for the Posey Heel Pillow and asked if anyone in the facility had ever gone over with her the manufacturer's recommendations. EI #13 replied she had never seen that information. When asked if she had ever been told to monitor and remove the heel pillows every two hours to check for skin integrity, EI #13 said no. EI #13 explained that she didn't do it because she had never been told to. EI #13 was asked what could have been done to prevent the pressure ulcer from developing. EI #13 replied with such a bony prominence, being out of bed more and using pillows to float the feet. RI #44's WOUND RECORD revealed a Stage IV pressure ulcer on the resident's right outer (lateral) ankle was first observed on 11/26/18 by EI #2, the DON. The pressure ulcer measured 1.8 centimeter (cm) by 1.4 cm with 0.4 cm of depth. The pressure ulcer was assessed as having minimal drainage, no odor and exposed bone. During an interview on 1/22/19 at 1:09 PM, EI #2, the DON was asked what was done to prevent pressure ulcer development when RI #44 was placed on bed rest on 10/4/18. EI #2 replied, nothing new. RI #44's physician's orders [REDACTED]. Bed rest 10/4/18 . In a telephone interview on 1/22/19 at 4:01 PM, with EI #1, the facility's Administrator and Medical Director, also RI #44's physician, he was asked what the purpose of the heel pillows for RI #44. EI #1 said it was padding for the resident's feet and ankle to protect the heels and ankles. EI #1 explained RI #44's right leg turns outward laterally and presses on the bed. When asked why he felt RI #44's pressure ulcer was avoidable, EI #1 stated if the aides (CNAs) had been inspecting the resident's ankle at least a couple times a day, they would have recognized the discoloration and a treatment could have been ordered. When asked to explain why he felt it would have been ideal for the staff to follow the manufacturer's recommendations, EI #1 replied obviously if they had been using the guidelines they would have seen a change in color and skin. EI #1 was asked what caused the pressure ulcer and he stated after RI #44 sustained a fracture, the resident became immobile and was unable to move that right leg. The right leg was rotated outward and the lateral portion of the ankle rested on the bed. ************************* On 1/24/19 at 5:20 PM, the facility submitted an acceptable Allegation of Compliance (A[NAME]), which documented: Allegation of Compliance on Pressure Ulcer-01/23/2018 (01/23/2019) Physical Therapist from Tri-Rehab to evaluated resident #44 for pressure relief devices to alleviate pressure from stage IV wound on right ankle. Completed on 01/23/2019 New order received for 6 inch Skil-Care Standard Foot Elevator to right lower leg and Posey Heel Pillow/Foot Positioner to left foot per PT (Physical Therapy) recommendations and implemented. Every two hours checks to remove devices and check skin integrity are to be completed and documented on the TAR (Treatment Administration Record) by the charge nurse completing the skin check. Oversight will be completed by DON. Completed 01/23/2019 Direct care R.N.'s, L.P.N.'s and C.N.A's of resident #44 educated on use of 6 inch Skil-Care Standard Foot Elevator and Posey Heel Pillow/Foot Positioner per manufacturers guidelines and policy and procedure by D.O.N. and A.D.O.N. Completed 01/23/2019 American Medical Technologies re-educated D.O.N., A.D.O.N. and Staff R.N. on Identifying Residents at Risk for Pressure Ulcers and Skin Integrity issue. Completed 01/23/2019 Body audits on all resident are to be completed by licensed nurse to reassure no other residents have any unidentified skin issue/ulcers. In addition, all residents that are potential at risk will be identified and pressure relief devices are to be implemented as needed and used according to manufactures guidelines. Completed 01/23/2019 In-service on Body Audits for R.N.'s and L.P.N.'s to be held 01/24/2019 at 3:00pm to re-educate nursing staff on the importance completing Body Audits on a weekly basis for all residents will be provided by D.O.N. and A.D.O.N. All R.N.'s and L.P.N.'s that fail to come to in-services will not be allowed to return to work until they attend an in-service for re-education provided by D.O.N. or A.D.O.N. To be completed on 01/24/2019 A.D.O.N. to assure all weekly body audits are completed on all resident weekly. Licensed nurses are to document on MAR indicated [REDACTED].D.O.N. will keep a log with completed Body Audits for continued compliance. The log and Body Audits are to reviewed by DON and complied in a binder and kept in DON office. Oversight by DON. Started 01/23/2019 and ongoing A Mandatory Adaptive Equipment In-Service to re-educate R.N.'s, L.P.N.'s and C.N.A.'s on the appropriate use of 6 inch Skil-Care Standard Foot Elevator and Posey Heel Pillow/Foot Positioner is to be provided by D.O.N. and A.D.O.N. at 3:00pm on 01/24/2019. D.O.N. and A.D.O.N. were re-educated on 01/23/2019 by Physical Therapist from Tri-Rehab. To be completed on 01/24/2019 D.O.N. and A.D.O.N. will provide in-service on Prevention of Pressure Ulcers to R.N.'s, L.P.N.'s and C.N.A.'s at 3:00pm on 01/24/2019 at 3:00pm. All R.N.'s, L.P.N.'s and C.N.A.'s that do not attend will not be allowed to return to work until they attend an in-service for re-education provided by D.O.N. and A.D.O.N. To be completed on 01/24/2019 ************************* After reviewing the facility's information provided in their A[NAME] and verifying the immediate actions had been implemented, the scope/severity level of F656 was lowered to a D level on 1/25/19, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on interviews and review of the JOB DESCRIPTION DIRECTOR OF NURSING SERVICES and JOB DESCRIPTION ADMINISTRATOR, the facility's Administrator, responsible for the day-to-day operatios of the facility and the Director of Nursing, responsible for the overall operation of the Nursing Service Department, failed to ensure there was a policy to address the use of adaptive devices used to relieve pressure utilized by the facility. The facility's administrative staff futher failed to ensure they were aware of the manufacturer's recommendations for the Posey Heel Pillow applied to Resident Identifier (RI) #44's bilateral lower extremities. Lastly, the administrative staff failed to ensure the staff were educated on the manufacturer's recommendations to remove every two hours to check for skin integrity, proper circulation and range of motion. RI #44, a resident totally dependent on staff for all Activities of Daily Living (ADLs) and at risk for pressure ulcer development, was placed on bed rest on 10/4/18. When placed on bed rest, there were no changes in RI #44's treatment plan to address the resident's right leg. According to staff interviews, RI #44 wore bilateral heel booties (Posey Heel Pillows) every day. On 11/26/18, RI #44 develop a facility-acquired Stage IV pressure ulcer on the right outer (lateral) ankle on 11/26/18 that measured 1.8 centimeter (cm) by 1.4 cm with 0.4 cm of depth. The pressure ulcer was assessed as having minimal drainage, no odor and exposed bone. These deficient practices affected RI #44, one of five sampled residents reviewed for pressure ulcers and placed RI #44 in immediate jeopardy, as these failures were likely to cause serious injury, harm or death. On 1/22/19 at 8:40 PM, the Assistant Administrator, Director of Nursing (DON), Assistant Director of Nursing, Social Service Designee and Secretary were notified of the findings of immediate jeopardy in the area of Administration, F835. Findings include: Refer to F656 and F686 The unsigned JOB DESCRIPTION DIRECTOR OF NURSING SERVICES documented . PURPOSE OF YOUR JOB POSITION The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Services Department in accordance with current Federal, State and local standards, guidelines, and regulations that govern our facility, and as may be directed by the Administrator and the Medical Director, to ensure that the highest degree of quality care is maintained at all times . In an interview on 1/19/19 at 2:07 PM, EI #2, the DON was asked why RI #44 wore heel booties. EI #2 said for protection; RI #44 had a history of [REDACTED].#44 had worn the heel booties, EI #2 said she was not sure. When asked why the heel booties were not care planned, EI #2 said she just overlooked them. EI #2 was asked should the heel booties have been care planned. EI #2 replied, yes they should have been. When asked what information should have been included on RI #44's care plan related to the heel booties, EI #2 said when and how often to apply and check for skin integrity. EI #2 explained RI #44 used to do leg lifts but after (MONTH) (2018), the resident stopped moving the right leg. When asked what was done after RI #44 stopped moving the right leg to relieve pressure, EI #2 said nothing new. When asked who was responsible to ensure interventions were implemented, EI #2 stated it was all of our responsibility. EI #2 was asked why nothing was implemented and she replied, nobody did anything. When asked if RI #44's care plan related to the resident's fracture addressed any approaches for positioning and/or pressure relief, EI #2 said no. EI #2 was asked why there was no individualized approaches for positioning and/or pressure relief. EI #2 replied it was overlooked. When asked should there have been any individualized approaches to address RI #44's leg positioning and/or pressure relief, EI #2 said yes. EI #2 was asked why the facility was not following the manufacturer's recommendations for the Posey Heel Pillows. EI #2 replied that she had not read it. When asked who was responsible for ensuring nursing products utilized in the facility were used according to the manufacturer's specifications, EI #2 replied she was. When asked why she had not read the manufacturer's recommendations, EI #2 stated because she didn't have it in the facility. During a follow-up interview on 1/22/19 at 1:09 PM, EI #2, the DON was asked what was done to prevent pressure ulcer development when RI #44 was placed on bed rest on 10/4/18. EI #2 replied, nothing new; there was no change in the resident's care plans. EI #2 explained there was a care developed for the fracture but it didn't address any new interventions. When asked who was responsible for updating RI #44's care plans with interventions after 10/4/18, EI #2 stated it would have been her. The unsignedJOB DESCRIPTION ADMINISTRATOR, documented . PURPOSE OF YOUR JOB POSITION The primary purpose of your job position is to direct the day-to-day functions of the facility in accordance with current Federal, State and local standards, guidelines, and regulations that govern the Long-Term Care Facility to assure that the highest degree of quality care can be provided to our residents at all times . During an interview on 1/19/19 at 3:05 PM, EI #1, the facility's Administrator and Medical Director, also RI #44's physician, was asked why the wound was not discovered it was a Stage IV, EI #1 stated there was not a Treatment Nurse and RI #44's leg turned out laterally and the staff were afraid to move it. EI #1 was asked how the facility-acquired Stage IV pressure ulcer could have been prevented. EI #1 answered, if the staff had followed the manufacturer's guidelines and inspected RI #44's ankles frequently. EI #1 explained it would have been ideal for the nursing staff to follow the manufacturer's recommendations. In a follow-up interview on 1/21/19 at 1:40 PM, EI #1, the facility's Administrator and Medical Director, also RI #44's physician, stated RI #44's Stage IV pressure ulcer was avoidable. In a telephone interview on 1/22/19 at 4:01 PM, with EI #1, the facility's Administrator and Medical Director, also RI #44's physician, he was asked what the purpose of the heel pillows for RI #44. EI #1 said it was padding for the resident's feet and ankle to protect the heels and ankles. EI #1 explained RI #44's right leg turns outward laterally and presses on the bed. When asked why he felt RI #44's pressure ulcer was avoidable, EI #1 stated if the aides (CNAs) had been inspecting the resident's ankle at least a couple times a day, they would have recognized the discoloration and a treatment could have been ordered. When asked to explain why he felt it would have been ideal for the staff to follow the manufacturer's recommendations, EI #1 replied obviously if they had been using the guidelines they would have seen a change in color and skin. EI #1 was asked what caused the pressure ulcer and he stated after RI #44 sustained a fracture, the resident became immobile and was unable to move that right leg. The right leg was rotated outward and the lateral portion of the ankle rested on the bed. ************************* On 1/24/19 at 5:20 PM, the facility submitted an acceptable Allegation of Compliance (A[NAME]), which documented: Allegation of Compliance-Administration 01/23/2019 Policy and Procedure for Posey Heel Pillow/Foot Positioners for(NAME)Nursing Home was developed by D.O.N. Policy and Procedure describes the purpose for the Posey Heel Pillows/Foot Positioners to protect heels and ankles form skin irritation, friction and pressure injuries as well as assisting with the healing process of existing wounds. Furthermore, the Policy and Procedure instructs how to use the Posey Heel Pillow/Foot Positioners according to manufactures guidelines. Also included is how to care for the Posey Heel Pillow/Foot Positioners. Completed on 01/23/2019 Policy and Procedure for 6 inch Skil-Care Standard Foot Elevator for(NAME)Nursing Home was developed by D.O.N. Policy and Procedure describes the purpose for the 6 inch Skil-Care Standard Foot Elevator to lift resident's heels off surface (bed/chair) to eliminate pressure as well as allowing air circulation to aid in faster healing process. Furthermore, the Policy and Procedure instructs how to use the 6 inch Skil-Care Foot Elevator according to manufactures guidelines. Also included is how to care for the 6 inch Skil-Care Foot Elevator. Completed on 01/23/2019 R.N.'s, L.P.N.'s and C.N.A.'s will be educated on Posey Heel Pillow/Foot Positioners policy and procedures at Mandatory in-service to be held 01/24/2019 at 3:00pm. R.N.'s, L.P.N.'s and C.N.A's will also be re-educated on Weekly Body Audit policy and procedure at this time. Employee that fail to attend will not be allowed to work until they attend an in-service provided by D.O.N. or A.D.O.N. Completed on 01/24/2019 D.O.N. and A.D.O.N. will review all pressure relief devices within the facility and assure appropriate policy's and procedures are in place. D.O.N. and A.D.O.N. will assure all R.N.'s, L.P.N.'s and C.N.A's are educated on such policies and procedures at 3:00pm on 01/24/2019 by D.O.N and A.D.O.N. D.O.N. will also assure that policies and procedure are appropriate and the purpose, use and care are based on manufactures guidelines. All newly developed policy's and procedure will be reviewed by Medical Director. Completed on 01/24/2019 ************************* After reviewing the facility's information provided in their A[NAME] and verifying the immediate actions had been implemented, the scope/severity level of F835 was lowered to a D level on 1/25/19, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on observations and interviews, the facility failed to provide sufficient nursing staff to consistently meet the needs of the residents. This deficient practice had the potential to affect all 59 residents currently residing in the facility. Findings include: Refer to F583 and F880 On 1/13/19 at 7:08 AM, EI #7, a Certified Nursing Assistant (CNA), was asked how many CNAs usually worked on the 3rd shift (11:00 PM to 7:00 AM). EI #7 said, when she started in (MONTH) it was just her. When asked how often she worked with just one CNA, EI #7 said, a couple of nights a week. On 1/13/19 at 7:31 AM, EI #8, a CNA, was asked how many CNAs the facility usually had working on 3rd shift. EI #8 replied, sometimes it was one, sometimes two, and sometimes three. EI #8 was asked if the Registered Nurses (RNs) or License Practical Nurses (LPNs) ever helped the CNAs. EI #8 said, no, not on the 3rd shift. When asked how often she checked and changed her residents, EI #8 replied, every two hours. When asked if she had ever had to work at night by herself, EI #8 replied yes. EI #8 was asked if she was able to make her rounds every two hours on the nights she had to work by herself. EI #8 replied, no, it was impossible. EI #8 explained it would be 3:00 AM before she would finish her first round. EI #8 was asked how she found the residents on the nights she worked by herself. EI #8 replied, some of them would be down in the bed, some would be soiled and some would be wet. EI #8 was asked about what percent of the residents would be wet or soiled. EI #8 replied, about 50 percent. On 1/13/19 at 8:00 AM, EI #9, a CNA was asked how many CNAs usually worked the third shift. EI #9 said, usually two unless someone volunteered. EI #9 was asked, how long it took to check and change her assigned residents. EI #9 replied, she could only do one round if she was the only one and the residents were usually wet and the heavy wetters were usually soaked. When asked how many residents were usually found soiled, EI #9 said, 40 to 50 percent were found wet. EI #9 said, if she was the only CNA on the shift she did not bathe any residents. EI #9 was asked if she was able to get to every resident timely and she replied, even with two people, somebody is not getting what they need. When asked what care she had seen residents lacking when she arrived for her shift, EI #9 said residents were left wet. On 1/14/19 at 9:39 AM, during the Resident Council meeting, Resident Identifier (RI) #30 voiced a complaint of lack of staff. When asked how it affected him/her, RI #30 said baths were delayed and you may not receive one until first shift arrived instead of the usual time of 5:30 or 6:00 AM. RI #30 said he/she was having to stay soiled until staff could get to him/her for a bath. On 1/14/19 at 3:55 PM, RI #40 voiced a problem with the night shift not answering the call light and having to wait to get changed. On 1/23/19 at 3:45 PM, RI #25 said the facility was short-staffed about three days per week, and residents could not get their baths. She said the CNAs are worked short and are were not able to give a full bath, only a wipe off. On 1/23/19 at 4:16 PM, EI #20, a CNA, stated she had been working at the facility for about a month and they were usually short of staff. EI #4, the Assistant Administrator, was interviewed on 1/24/19 at 10:36 AM. She indicated she had been responsible for scheduling/staffing of nurses and CNAs since January. EI #4 said there was not any consistent care being given to residents. When asked how it was determined the number of CNAs required on each shift based on resident care needs, EI #4 said first shift needed five CNAs and an extra for vitals, ice, snacks and assistance with feeding; second shift needed four CNAs with an extra; and third shift needed three. However, EI #4 did not know how those numbers were determined. When asked what happened if there was not an extra CNA for the tasks she mentioned, EI #4 said the CNAs would have to do their own vitals and ice, and the nurses would have to help pass snacks or feed. EI #4 also stated if there was only two CNAs at night, it caused delays with baths. On 1/24/19 beginning at 11:13 AM, EI #2, the Director of Nursing was asked if there was a system in place to determine the number of CNAs required for each shift based on the residents' care needs. EI #2 said no. When asked how the facility's staffing was adjusted based on census, EI #2 said it was not adjusted, but they were trying to hire more staff. EI #2 said staffing for second and third shift was a problem throughout the week. EI #2 also indicated the CNAs had voiced concerns to her about the staffing and residents had complained they were having to wait on call lights to be answered. When asked how working short staffed affected the resident's care needs being met, EI #2 said residents may not be turned and positioned and may receive rushed care. EI #2 also said if second or third shift are short, baths may get pushed off until the first shift. When asked how being short of staff affected the quality of care and services the residents received, EI #2 said she was sure it did not meet the residents' expectations and was below the level of care the residents should receive. This deficiency was cited as a result of the investigation of complaint/report number AL 948.

Based on interview and review of the(NAME)Nursing Home, LLC Facility Assessment, the facility failed to ensure the facility assessment included an evaluation of the overall number of facility staff needed to ensure a sufficient number of qualified staff were available to meet each resident's needs. This deficient practice had the potential to affect all 59 residents currently residing in the facility. Findings include: The undated, unsigned(NAME)Nursing Home, LLC Facility Assessment documented . SERVICES AND CARE OFFERED . Staff nurses that consist of RN's (Registered Nurses) and LPN's (Licensed Practical Nurses). Certified nurse assistants on all shifts. On call nurse on weekend as well as an RN . In an interview on 1/24/19 11:13 AM, Employee Identifier (EI) #2, the Director of Nursing was asked did the facility assessment include a determination of the level of staffing needed to meet each resident's needs. EI #2 replied, the facility assessment did not specify the number of staff, just that the facility had Certified Nursing Assistants on all shifts.

Based on interviews and review of the facility's policy titled Quality Assurance and Performance Improvement (QAPI) Committee, the facility failed to ensure the QAPI Committee met quarterly to identify concerns and develop plans of actions to address any concerns identified. This deficient practice had the potential to affect all 59 residents currently residing in the facility. Findings include: The facility's policy titled Quality Assurance and Performance Improvement (QAPI) Committee, dated (MONTH) (YEAR), documented Policy Statement The facility shall establish and maintain a Quality Assurance and Performance Improvement (QAPI) Committee that oversees the implementation of the QAPI Program. Policy Interpretation and Implementation 1. The Administrator shall delegate the necessary authority for the QAPI Committee to establish, maintain and oversee the QAPI program . Committee Meetings 1. The committee will meet monthly at an appointed time . On 1/19/19 at 2:52 PM, Employee Identifier (EI) #2, the Director of Nursing (DON), said the facility had not had a Quality Assessment (QA) meeting since (MONTH) (YEAR). In a follow-interview with EI #2, the DON on 1/21/19 at 9:45 AM, she was asked if she was aware the QA meetings were not being held. EI #2 replied yes. According to EI #2, the previous DON would come around with a paper for us to sign stating we had a QA meeting. EI #2 stated she refused to sign it because it wasn't right. In a telephone interview with the previous DON on 1/21/19 at 12:10 PM, she was asked who scheduled and attended the facility's QA meetings. The previous DON stated the meetings were usually done every three months and the department heads attended; the physician would attend if the meeting was held on a Thursday. The previous DON further stated the meetings were done informally. She explained that the staff would turn in their part and she would compile them and get the attendance log signed. During an interview on 1/22/19 at 4:01 PM, EI #1, the facility's Administrator and Owner was asked why the QA committee was not meeting quarterly. EI #1 said he could not say. According to EI #1, the DON was responsible for QA. When asked why the facility was unable to provide evidence of QA meetings, EI #1 again said he could not say. According to EI #1, the DON would be better able to answer questions related to QA.

Based on observations, interviews, and review of the facility's policy titled Resident Rights Guidelines for All Nursing Procedures, the facility failed to ensure Employee Identifier (EI) #6 and EI #9, both Certified Nursing Assistants (CNAs) provided personal privacy to Resident Identifier (RI) #9, RI #24, RI #35, RI #40 and RI #58 during incontinence care and/or bathing on 1/13/19. These deficient practices affected five of seven sampled residents reviewed for privacy. Findings include: The facility's policy titled Resident Rights Guidelines for All Nursing Procedures, revised (MONTH) 2010, documented Purpose To provide general guidelines for resident rights while caring for the resident . General Guidelines 1. For any procedure that involves direct resident care, follow these steps: . f. Close the room entrance door and provide for the resident's privacy . 1) On 1/13/19 at 5:00 AM, EI #9, a CNA, was observed providing incontinence care to RI #58. RI #58 was lying in bed without clothes and was not covered with a sheet. The resident's room door was open and the curtain between the beds had not been pulled (closed). RI #58's roommate was awake and looking around. On 1/13/19 at 8:00 AM, EI #9 was asked what the facility's policy was for providing privacy during incontinent care. EI #9 said you should pull the curtain and close the door. When asked why she had not done that, she stated she came in the room and started doing the care. During an interview on 1/21/19 at 2:10 PM, EI #2, the Director of Nursing (DON) was asked how CNAs should provide privacy to residents when performing resident care tasks. EI #2 said the CNAs should close the door, the blinds, and pull the privacy curtain between the residents. 2) On 1/13/19 at 6:10 AM, EI #9, a CNA, was observed providing a bed bath to RI #24. During the bath, RI #24 was exposed nude, with no privacy curtain pulled and the resident's room door was opened. RI #24's roommate was also present in the room, awake and alert. In an interview on 1/13/19 at 8:09 AM, EI #9, a CNA was asked why she left RI #24 exposed during the bath, with the privacy curtains not closed and the resident's roommate in the room. EI #9 stated she was moving too fast and didn't think to pull the curtain. When asked why it was important to pull the privacy curtain, EI #9 said privacy for the resident. On 1/14/19 at 1:39 PM, RI #24 was asked how it made him/her feel when he/she was left exposed during care and the privacy curtain was not pulled. RI #24 said it made him/her feel bad, but was unable to elaborate. During an interview on 1/21/19 at 2:10 PM, EI #2, the DON was asked how CNAs should provide privacy to residents when performing resident care tasks. EI #2 said the CNAs should close the door, the blinds, and pull the privacy curtain between the residents. 3) On 1/13/19 at 6:50 AM, EI #9 was observed providing a bed bath to RI #40. The resident's privacy curtain was not pulled and the door was not completely shut. RI #40's roommate was present in the room during the bed bath, awake and alert. At 7:05 AM, the DON, EI #2, entered the room and pulled the privacy curtain and shut the door. In an interview on 1/13/19 at 8:09 AM, EI #9, a CNA was asked why she did not close the privacy curtain and shut the door during RI #40's bath. EI #9 stated she was moving too fast and didn't think to pull the curtain and shut the door. When asked why it was important to pull the privacy curtain and shut the door, EI #9 said privacy for the resident. On 1/14/19 at 3:47 PM, RI #40 was asked how it made him/her feel when staff did not pull the curtain to provide privacy during a bath. RI #40 said he/she should not have to ask them to pull the curtain, because they know they should, especially when the resident is naked. RI #40 said he/she was used to it because it happened all the time. During an interview on 1/21/19 at 2:10 PM, EI #2, the DON was asked how CNAs should provide privacy to residents when performing resident care tasks. EI #2 said the CNAs should close the door, the blinds, and pull the privacy curtain between the residents. 4) On 1/13/19 at 7:00 AM, EI #6, a CNA, was observed pushing RI #35 to the bathroom in a wheelchair. RI #35 was wearing a hospital gown that was not tied in the back. As EI #6 assisted RI #35 to stand, the resident's back side and buttocks were exposed. RI #35's roommate was facing the bathroom and was able to observe RI #35's exposed body. In an interview on 1/13/19 at 7:10 AM, EI #6, a CNA was asked what she should have done before transferring RI #35 onto the commode. EI #6 replied, she should have closed the door. When asked why it was important to close the door, EI #6 replied, so the resident wouldn't be exposed. On 1/16/19 at 9:15 AM, RI #35's roommate, RI #9 was asked how she felt when the CNA (EI #6) took RI #35 into the bathroom and the resident's buttocks and backside were exposed. RI #9 said he/she felt bad for the resident and it made him/her feel uncomfortable. When asked if it happened often, RI #9 said no the staff usually closed the door. During an interview on 1/21/19 at 2:10 PM, EI #2, the DON was asked how CNAs should provide privacy to residents when performing resident care tasks. EI #2 said the CNAs should close the door, the blinds, and pull the privacy curtain between the residents.

Based on observations, interviews and review of the facility's policies titled Laundry and Bedding, Soiled, Diapers/Underpads and Infection Control Guidelines for All Nursing Procedures, the facility failed to ensure soiled linen was not left on the floor. This was observed on one of 13 days of the survey. The facility further to ensure Employee Identifier (EI) #9, a Certified Nursing Assistant (CNA) washed her hands after removing gloves, in between residents and resident care tasks performed. This deficient practice affected Resident Identifier (RI) #8, RI #16, RI #24, RI #25 and RI #40, five of 16 sampled residents. Findings include: 1) The facility's policy titled Laundry and Bedding, Soiled dated (MONTH) 2009, documented Policy Statement Soiled laundry/bedding shall be handled in a manner that prevents gross microbial contamination of the air and persons handing the linen. Policy Interpretation and Implementation . 2. Place contaminated laundry in a bag or container at the location where it is used . The facility's policy titled Diapers/Underpads dated (MONTH) 2010, documented Purpose The purpose of this procedure is to provide guidelines for the proper handling of diapers and underpads . Steps in the Procedure In Resident Rooms . 8. Place diaper or underpad into designated hamper/container. 9. Discard disposable equipment and supplies in designated containers . During the initial entrance of the facility, on 1/13/2019 at 5:00 AM, soiled linen was observed on the floor, not in a plastic bag, in the hallway outside RI #16's room. At 5:20 AM, the same soiled linen remained in the floor, and the linen was observed to contain a soiled incontinent brief inside of it. At 5:31 AM, a CNA, EI #7, picked the soiled linen up from the floor, separated the soiled incontinent brief from the linen and placed them both in a plastic bag. 1/13/2019 at 7:08 AM, EI #7 was acknowledged that she picked the soiled linen up off the floor. When asked was it supposed to be on the floor, EI #7 said no. When asked why not, EI #7 cross contamination and soiled linen should not be on the floor. 2) The facility's policy titled Infection Control Guidelines for All Nursing Procedures, revised (MONTH) 2012, documented Purpose To provide guidelines for general infection control while caring for residents . General Guidelines . 3. Employees must wash their hands for ten (10) to fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: a. Before and after direct contact with residents; . c. After contact with blood, body fluids, secretions, mucous membranes, or non-intact skin; d. After removing gloves; e. After handling items potentially contaminated with blood, body fluids, or secretions; . 4. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub . for all of the following situations: a. Before and after direct contact with residents; . g. After contact with a resident's intact skin; h. After handling used dressings, contaminated equipment, etc.; i. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; and j. After removing gloves . On 1/13/19 at 5:57 AM, EI #9 was observed to take the linen cart and trash bag down the hall to RI #8's room. While wearing gloves, EI #9 removed the dirty linen from RI #8's bed. Without changing gloves or washing her hands, EI #9 wore the same gloves to place clean linen on RI #8's bed and place the resident's call light on the bed. EI #9 removed her gloves and took the bag of soiled linen to the soiled utility room. After leaving the soiled utility room, EI #9 proceed to RI #24's room. Without washing her hands, EI #9 put on gloves and proceeded to bathe RI #24. After the bath, putting the resident's clothes on, removing soiled linen from the bed and separating the soiled linen and incontinent brief, EI #9 removed her gloves and walked to the linen closet on the 200 hall. After completing RI #24's care, EI #9 entered RI #40's room and without washing her hands, she put on a pair of gloves to bathe RI #40. After completing care for RI #40, EI #9 removed her gloves but did not wash her hands, then began providing care to RI #16. After completing care for RI #16, EI #9 took the soiled linen bags to the dumpster outside. When EI #9 re-entered the facility, she assisted RI #25 to the dining room. Once all these tasks had been completed, EI #9 was observed to go into the staff lounge and wash her hands. During an interview on 1/13/19 at 8:09 AM, EI #9, a CNA was asked why she didn't wash her hands between tasks and each resident. EI #9 stated she didn't have time, she just changed her gloves. When asked why she should have washed her hands, EI #9 said to keep germs and infections down. In an interview on 1/21/19 at 2:10 PM, EI #2, the Director of Nursing was asked what did she expect a CNA to do after removing gloves. EI #2 replied, they should wash their hands or use hand gel to prevent the spread of infections. When asked what infection control measures should the CNA utilize between tasks and providing care to different residents, EI #2 said they should wash their hands. When asked what was the harm in not handwashing, EI #2 said, spreading infections.

Based on observation, interview and review of the facility's policy titled Medication Storage, Employee Identifier (EI) #10, a Licensed Practical Nurse (LPN) failed to ensure medications were not left on top of the medication cart and the medication cart was locked when out of the nurse's view. This deficient practice was observed on one of 13 days of the survey. Findings include: The facility's policy titled Medication Storage, dated (MONTH) 2001, documented POLICY: . The facility is responsible for maintaining proper storage. PR[NAME]EDURE: . All medications will be stored according to state and federal laws and regulations . It is the responsibility of the facility to keep the medication cart locked and secure at all times when not in use (during times other than medication pass and in between residents during medication pass) . Medications or sharps CANNOT be stored on top of the medication cart. All safety measures must be taken to protect the residents from accessing medications and other objects that could potentially harm the resident or others . On 1/13/2019 at 5:00 AM, the medication cart for the 200 hall was observed with medication on top of the cart and the Licensed Practical Nurse (LPN) was not within view of the cart. There was a small plastic medication (med) cup containing a small white pill and a plastic drinking cup containing three pills. When the LPN, Employee Identifier (EI) #10, returned to the medication cart, she identified the pills as [MEDICATION NAME] M, [MEDICATION NAME] and [MEDICATION NAME]. On 1/13/2019 at 5:40 AM, the medication cart for the 200 hall was observed to be unlocked and the LPN, EI #10, was not within view of the medication room. In an interview on 1/13/2019 at 6:30 AM, EI #10, a LPN was asked should medication be left on top of the medication cart. EI #10 replied no because a resident might get it. When asked what the facility's policy was for locking the medication cart, EI #10 said it should be locked when out of the nurse's sight. When asked if she could see the medication cart, EI #10 said no.

Based on observations and interviews, the facility failed to ensure nurse staffing data was posted at the beginning of each shift. This deficient practice was observed on two of 13 days of the survey. Findings include: On 1/13/19 at 5:30 AM, the nurse staffing data posted was dated 1/11/19. On 1/25/19 at 6:15 AM during the 11:00 PM to 7:00 AM shift, the nurse staffing data was not posted. On 1/24/19 at 12:43 PM, Employee Identifier (EI) #2, the Director of Nursing was asked when should nurse staffing data be posted. EI #2 replied, at the beginning of each shift. When asked who was responsible for posting nurse staffing data, EI #2 said she and the Charge Nurse on the front hall were responsible. EI #2 was asked why the nurse staffing data was not posted for 1/13/19. EI #2 stated that would have been the responsibility of EI #16. When asked why it important to post nurse staffing data, EI #2 said it gave reassurance to the visitors and residents for how many people were caring for them. In an interview on 1/25/19 at 6:34 AM, EI #16, a Licensed Practical Nurse (LPN) Charge Nurse acknowledged that she had been responsible; however, she had not been posting the nurse staffing data on the weekends. EI #16 stated she only posted the nurse staffing data at the end of the shift.

Based on observations, interviews and a review of facility policies titled Food Storage, Dishwashing: Machine, the facility failed to ensure: 1) Food items in the cooler were labeled with an opened and used by date, 2) Dishes were not placed in the cabinet wet. This had the potential to affect 53 of 55 residents who received meals from the kitchen. Findings Include: 1) A review of a facility policy titled Food Storage with an 2011 edition date revealed .Procedures: 1. General storage guidelines to be followed: All food items will be labeled. The label must include the name of the food and date by which it should be .consumed, or discarded. On 12/12/2017 at 5:24 p.m., the surveyor observed Chicken Finger and Country Fried Steak in the Cooler. The food products were out of there original containers. There were no opened or used by date on the food products. There were about 50 Chicken Fingers in a bag and about 35 Country Fried Steaks in a bag. On 12/14/2017 at 12:27 p.m., the Surveryor conducted an interview with (Employee Identifier) EI #4, second shift cook. EI #4 was asked what items in the cooler were not labeled. EI #4 replied, Chicken Tender and Chicken Fried Steak. EI #4 was asked why was the items not labeled. EI #4 replied, someone put it back and did not label it. EI #4 was asked who was responsible for labeling items in the refrigerator. EI #4 replied, if we take something out, the cooks put the date on it. EI #4 was asked what did the facility policy say about labeling food items in the refrigerator once they had been taken out of there original container. EI #4 replied, put in a separate bag and put a date on it. EI #4 was asked when were the items put in the refrigerator. EI #4 replied, she did not have an idea. EI #4 was asked what was the potential harm when items were put in the cooler with no dates on it. EI #4 replied, food poison. On 12/14/2017 at 12:30 p.m., the surveyor conducted an interview with EI #5, Dietary Manager. EI #5 was asked what did the facility policy say regarding labeling food items in the cooler once they were out of there original container. EI #5 replied, put the food items in a freezer or refrigerator safe container, put the expiration date on the box, and what the items was. EI #5 was asked what was the potential harm when items were put in the refrigerator with no dates on it. EI #5 replied, it was harmful to the residents and they did not know how long it had been there. 2) A review of a facility policy titled Dishwashing: Machine with a 2011 edition date revealed .Procedure: f.allow to air dry before putting dishes away for storage. On 12/14/2017 at 8:44 a.m., the surveyor observed EI #6 on the clean side of the dish room putting plates in the cabinet wet. EI #6 placed six plates in the cabinet wet. The worker was asked to pull plates from the cabinet to look at. On 12/14/2017 at 12:15 p.m., the surveyor conducted an interview with EI #6. EI #6 was asked how show plates dry. EI #6 replied, air dry. EI #6 was asked why did she stack plates in the cabinet wet. EI #6 replied, she did not realize they were wet. EI #6 was asked what was in the plates she were stacking into the cabinet. EI #6 replied, water and one plate was stained. EI #6 was asked what was the facility policy on stacking plates wet. EI #6 replied, they were not suppose to stack them wet. EI #6 was asked who was responsible for putting plates away. EI #6 replied, the person that pulled them from the dish machine. EI #6 was asked what was the potential harm to the residents when food was put on wet plates. EI #6 replied, bacteria, germs and other harmful parasites. On 12/14/2017 at 12:20 p.m., the surveyor conducted an interview with EI #5. EI #5 was asked what was the facility policy on stacking plates wet. EI #5 replied, not suppose to, should air dry. EI #5 was asked when was staff inserviced on wet nesting. EI #5 replied, six months ago.

Based on interview and a facility policy titled, Resident Right to Vote the facility failed to ensure residents were provided the opportunity to vote in the 12/12/2017 election. This affected three of 11 residents present for the 12/13/2017 resident council meeting who required assistance with voting needs. Findings Include: The facility's voting policy titled, Resident Right to Vote (undated) documented the following: Policy: Each resident has the right to exercise his or her rights as a resident of the facility, and as a citizen of the United States. Policy Explanation and Compliance Guidelines: 1. All residents will be given equal right to vote . 2. All residents should have access to timely information about upcoming elections. 4. The social worker, social service designee, or staff member should be familiar with voting requirements .absentee ballots . On 12/13/2017 at 10:00 a.m., a resident council meeting was conducted. The residents were asked if they voted in the election held on 12/12/2017. The residents said no. When asked how many wanted to voted, Three out of eleven said they wanted to vote. The surveyor asked why they did not vote, the residents said no one asked them about voting. On 12/13/2017 at 10:50 a.m., an interview was held with Employee Identifier (EI) #3, the Social Service Director. EI # 3 was asked how many residents were offered to vote. EI #3 replied she replied, none. EI #3 was asked how many residents voted in the facility. EI #3 answered one, the daughter took them. EI #3 was asked why the residents did not vote. EI #3 stated she did not realize there was an election. EI #3 was asked if she received any education or in-service on resident's voting. EI #3 replied yes, it was covered in the Resident's Rights on January 16, 2017.

Based on interviews, record reviews and a review of documents titled, CMS (Center for Medicare & Medicaid Services), RAI (Resident Assessment Instruction) Version 3.0 Manual and CMS Submission Report MDS 3.0 NH (Nursing Home) Final Validation, the facility failed to ensure Residents's (RI) #1's 3, 4, 9, 13, 19, 28, 33 and 36 MDS's (Minimum Data Sets) were transmitted in a timely manner. This affected nine of ten sample residents. Findings Include: A review of a document, CMS RAI Version 3.0 Manual, Chapter 5, Submission and . of the MDS Assessments revealed: Transmitting Data: . Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date . All other MDS Assessments must be submitted within 14 days of the MDS completion Date . A review of the CMS Submission Report MDS 3.0 NH Final Validation for January 2017, July 2017, September 2017, and October 2017 revealed: A. January 2017 1) RI #4's ARD date was 11/25/16 and the MDS was transmitted on 01/10/17. 2) RI #13's ARD date was 11/24/16 and the MDS was submitted on 01/10/17. 3) RI #9's ARD date was 12/15/16 and MDS was submitted on 01/10/17. 4) RI #36's ARD date was 11/11/16 and the MDS was submitted on 1/10/17. 5) RI #19's ARD date was 11/02/16 and the MDS was submitted on 1/10/17. B. July 2017 1) RI #13's ARD date was 05/23/17 and the MDS was submitted on 07/05/17 2) RI #28's ARD date was 06/16/17 and the MDS was transmitted on 07/11/17 September 2017 1) RI # 33's ARD Date was 08/21/2017 and the MDS was submitted on 09/14/2017 2) RI #3's ARD date was 08/22/17 and the MDS was submitted on 09/14/17 3) RI #36's ARD date was 09/08/17 and the MDS was submitted on 10/11/17 C. October 2017 1) RI #36's ARD date was 09/08/17 and the MDS was submitted on 10/11/17 2) RI #1's ARD date was 09/05/17 and the MDS was submitted on 10/02/17 3) RI #33's ARD date was 09/20/2017 and the MDS was submitted on 10/11/17 An interview was conducted on 12/14/17 at 3:50 p.m., with EI #2/Assistant Director of Nursing/MDS Coordinator. EI #2 was asked when should MDS be completed and submitted to CMS. EI #2 stated 14 days after the ARD date of if it is an admission assessment it has to be done by the 14 day. EI #2 was asked who was responsible for ensuring the MDS assessments are submitted to CMS in the proper time frame. EI #2 replied the DON (Director of Nursing) and me. EI #2 was asked to review the MDS 3.0 Submitter Final Validation reports for May 2017, July 2017, and October 2017 and determine how many assessment were late. EI #2 state assessments were late. EI #2 was asked why were these residents MDS assessments submitted late to CMS. EI #2 state, That I do not know. A telephone interview was conducted on 12/14/17 at 5:58 p.m., with EI #5. EI #5 was asked if she was responsible for submitting /transmitting the MDS assessments to CMS. EI #5 stated yes she was responsible for the data entry for the MDS. EI #5 was asked if she was aware that the facility had submitted MDS assessment late. EI #5 stated she was not aware the facility had submitted MDS assessment late until the Submission Form Reports were printed. EI #5 was asked if she was aware that the Submission Form Report had to be printed. EI #5 stated she was not aware of that. EI #5 was asked why were the MDS Assessments submitted late. EI #5 stated, I don't know, I think I submitted them to CMS at the same time I did to the state. I think I duplicated some and submitted some that I had already done. An interview was conducted on 12/14/17 at 6:30 p.m., with EI #1/Administrator. EI #1 was asked who was ultimately responsible for ensuring the MDS assessment are transmitted to CMS in the proper time frame. EI #1 stated that would be her.

Based on observation, record review, and interview, the facility failed to make a referral to mental health for Resident Identifier (RI) #1, a resident with a [DIAGNOSES REDACTED].#11, one of two sampled residents identified by the facility as having a [DIAGNOSES REDACTED]. Findings include: RI #11 was admitted to the facility on [DATE] with a medical history to include: Situational Depression. RI #11's social service progress note dated 7/25/2016, documented . Resident has voiced saddeness (sadness) states (he/she) feels abandonded (abandoned). States (he/she) feels depressed every day and stated (he/she) has periods of restlessness . Has [DIAGNOSES REDACTED]. RI #11's SOCIAL SERVICE PROGRESS NOTES dated 7/28/2016 documented Resident's mother . in SSD (social service director) office voicing concerns for (RI #11). Stated (RI #11's spouse) has left town and they cannot get in touch . She states she is worried about (RI #11) becoming too depressed . During the resident interview on 10/6/2016 at 3:30 PM, RI #11 displayed a flat affect throughout the interview. In an interview on 10/7/2016 at 9:25 AM, Employee Identifier (EI) #2, the Social Service Director was asked, if she had to talked with RI #11 about a referral to mental health. EI #2 replied, no but after yesterday (10/6/2016) a referral to mental health was made. RI #11's SOCIAL SERVICE PROGRESS NOTES dated 10/7/2016, documented Spoke (with) resident . Discussed possible Mental Health consult, (he/she) stated that will be OK (with) (him/her). Maybe it will help me some.

Based on record reviews, observations, and interviews the facility failed to ensure on 11-16-15: 1) prepared tuna salad had a use by date. 2 cornbread squares had a preparation date and a use by date. 3) cucumbers in the cooler did not have a white substance on them. 4) two large bags of loaded baked potatoes soup was not thawing in the sanitizer sink on 11-18-15. This had the potential to affect 55 of 56 residents who receive meals from the kitchen. Findings Include: 1) A facility's policy titled, Food Storage with an Edition date of 2011 revealed: .Procedure: 1. General storage guidelines to be followed: All food items will be labeled. The label must include the name of the food and the date by which it should be . consumed, or discarded. Discard food that has passed the the expiration date, and discard food that has been prepared . On 11/16/2015 at 5:00, the surveyor observed prepared tuna salad in the cooler with no use by date. On 11/18/2015 at 4:15, an interview was conducted with the Dietary Manager, EI #10 (Employee Identifier). EI #10 was asked what was the used by date on the tuna salad on 11/16/2015. EI #10 replied, there was no use by date. EI #10 was asked why was there no use by date on the tuna salad. EI #10 replied, the staff know in three days the food had to be discarded. EI #10 was asked who was responsible for labeling food items. EI #10 replied, whoever made it. EI #10 was asked what was the facility's policy on labeling. EI #10 replied, use the first in first out method. EI #10 was asked what was the potential harm when there was no use by dates on food items. EI #10 replied, for someone who does not know the policy to discard something in three days, they would not know when to discard food items. On 11/16/2015 at 5:00 PM, there was cornbread in a large plastic bag in the freezer with no preparation date or use by date. On 11/18/2015 at 3:00 PM, an interview was conducted with the dietary manager. EI #10 was asked what was the preparation date and use by date on the cornbread. EI #10 replied, they have no idea of knowing. EI #10 was asked what was the facility's policy on labeling items in the cooler. EI #10 replied, label the items in the cooler with the dates they were put in there. EI #10 was asked why the cornbread in the freezer was not labeled. EI #10 replied, whoever put it in there failed to label it. EI #10 was asked when should food items be labeled. EI #10 replied, when we received them or prepare them. EI #10 was asked how should food items be labeled. EI #10 replied, date when we receive the items or prepare them. EI #10 was asked what was the potential harm when food items in the freezer was not labeled. EI #10 replied, you do not know when they may expire. On 11/16/2015 at 5:00 PM, the surveyor observed six cucumbers in the cooler with no use by date. On 11/18/2015 at 3:00 PM, the dietary manager was interviewed. EI #10 was asked what was the use by date on the cucumbers. EI #10 replied, there was no use by date on the bag. EI #10 was asked what was the white substance on the cucumber. EI #10 replied, it was the process of the food spoiling. EI #10 was asked what was the facility's policy on labeling items in the cooler. EI #10 replied, label the items in the cooler with the date they were put in the cooler. EI #10 was asked why the food items in the cooler was not labeled. EI #10 replied, whoever put it in there failed to label the item. EI #10 was asked what was the potential harm when food items was not labeled in the cooler. EI #10 replied, you do not know when they may expire. 2) A facility's policy titled, Guidelines for Staff Preparing Food Fundamentals to Prevent Food Borne Illness with an Edition date of 2011 revealed: .Thaw Food Correctly . Foods are thawed in the refrigerator, under freely flowing, room temperature water or in the microwave . On 11/18/2015 at 8:20 AM, the surveyor observed loaded bake potatoes soup in the sanitizer sink. There were dirty dishes in the wash sink and dishes in the rinse sink. On 11/18/2015 at 2:05 PM, an interview was conducted with EI #11, (Employee Identifier) a cook. EI #11 was asked what type of food was in the sanitizer sink. EI #11 replied, loaded bake potatoes soup. EI #11 was asked why was food being thawed in the sanitizer sink. EI # 11 replied, It was frozen and she was trying to unthaw it. EI #11 was asked what was the facility's policy on thawing frozen food. EI #11 replied, we put it in a pan and run water over it or put it in the refrigerator. EI #11 was asked who was responsible for thawing frozen food. EI #11 replied, the first and second cook. EI #11 was asked how should frozen food be thawed. EI #11 replied, take it out of the freezer the day before and put it in the refrigerator. EI #11 was asked what was in the first sink when food was in the sanitizer sink. EI #11 replied, dirty dishes. EI #11 was asked what was the potential harm when food is thawed improperly in the sink. EI # 11 replied, Salmonella.

Based on record review, observation and interview, the facility failed to ensure: 1) a licensed staff member washed her hands and changed her gloves during the instillation of eye drops to RI (Resident Identifier) #8 on 11/18/2015. The facility further failed to ensure a licensed staff member did not place the cap of the eye drops on the unclean bedside table without a barrier, and then placed the cap on the eye drops without cleaning it on 11/18/2015. 2) the facility also failed to ensure two CNAs (Certified Nursing Assistant) washed their hands and changed their gloves after cleaning RI #2's buttocks and before touching a clean pad and placing it underneath the resident during incontinent care on 11/18/2015. These actions affected two of four residents observed receiving care from staff members. Finding Include: A review of a facility policy titled, Instillation of Eye Drops with a revised date of January 2014 revealed: .General Guidelines . 2. Should both eyes require instillation, wash and dry your hands thoroughly before treating each eye. A review of a facility policy titled, Administering Medications with a revised date of December 2012 revealed: .22. Staff shall follow established facility infection control procedures (e.g. (for example), handwashing, .gloves .) for the administration of medications, . A review of a facility document titled, (NAME OF FACILITY) INSERVICE PROGRAM revealed EI (Employee Identifier) #8, LPN (Licensed Practical Nurse) attended an infection control in-service on 8/03/2015. 1) RI #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #8's most recent Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/19/2015 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 12, which indicated the resident was moderately impaired for daily decision making. On 11/18/2015 at 8:20 AM, EI #8 was observed administering [MEDICATION NAME] eye drops to RI #8. EI #8 sanitized hands and donned gloves. EI #8 removed the top of the [MEDICATION NAME] eye drops and placed it on the unclean bedside table without a barrier on it. EI #8 placed an eye drop into the resident's right eye and then the left eye without washing her hands or changing gloves in between the two eyes. EI #8 picked the top off of the table and placed it back on the eye drops without cleaning it. On 11/19/2015 at 10:40 AM, an interview was conducted with EI #8. EI #8 was asked what should have been done with the top of the eye drops when she removed it. EI #8 said it should have been on a barrier on the table or in her hands. EI #8 was asked what she did with the top of the eye drops when she removed it. EI #8 said she could have put it on the table. EI #8 was asked what she should have done with the top of eye drops after she picked it up from the table before she placed it back on the eye drops. EI #8 said she should have wiped it off. EI #8 was asked what the potential harm was if she put the top back on the eye drops without cleaning it after placing it on an unclean table. EI #8 said infection or cross contamination. EI #8 was asked what the facility policy said about administering eye drops to both eyes. After reading the policy, EI #8 said she washed her hands before she gave the eye drops and afterward, but not in between giving them. EI #8 was asked what the potential harm was if she did not change gloves or wash her hands in between administering eye drops to both eyes. EI #8 said possible cross contamination. On 11/19/2015 at 11:36 AM, an interview was conducted with EI #1, DON (Director of Nursing). EI #1 was asked what should be done when a nurse administered eye drops to both eyes of a resident. EI #1 said wash her hands. EI #1 was asked if it was an acceptable practice of that facility for a nurse to administer eye drops to both eyes of a resident and not wash her hands in between each eye. EI #1 said no ma'am. EI #1 was asked what the potential harm was if a nurse administered eye drops to both eyes of a resident and did not wash her hands in between each eye. EI #1 said infection. EI #1 was asked what should be done with the cap of the eye drops after it was removed from the medication. EI #1 said it should be placed on a barrier on a clean surface. EI #1 was asked if it was an acceptable practice of that facility for a nurse to place the cap of the eye drops on the unclean bedside table without a barrier then recap the eye drops without cleaning the cap. EI #1 said no ma'am. EI #1 was asked what the potential harm was if a nurse recapped the eye drops after placing the cap on the unclean bedside table without a barrier and did not clean the cap. EI #1 said it could contaminate the eye drops. A review of a facility policy titled, Handwashing/Hand Hygiene with a revised date of April 2012 revealed: .5. Employees must wash their hands .under the following conditions: . q. After contact with a resident's mucous membranes and body fluids or excretions; . 8. The use of gloves does not replace handwashing/hand hygiene A review of a facility document titled, (NAME OF FACILITY) INSERVICE PROGRAM revealed EI #4, CNA, attended an infection control in-service on 8/03/2015. 2) RI #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #2's most recent Annual MDS with an ARD of 10/06/2015 revealed the resident was moderately cognitively impaired for daily decision making. The MDS further revealed the resident was totally dependent on staff for all ADLs (Activities of Daily Living). The MDS also revealed the resident was always incontinent of bowel and bladder. On 11/18/2015 at 12:30 PM, EI #4 and EI #5, CNA, were observed performing incontinent care for RI #2. EI #4 unsnapped the resident's brief and pulled it down. The surveyor asked EI #4 what was present in the resident's brief. EI #4 said urine. EI #4 wiped across the top of RI #2's perineal area, then down the left and right side of the perineal area with one disposable wipe. RI #2 was rolled onto the right side and EI #4 wiped downward on the resident's buttocks two times. EI #4 touched and placed a clean pad underneath the resident without changing her gloves or washing her hands. RI #2 was again incontinent of urine. The resident was rolled to the left side and EI #5 wiped downward on the resident's buttocks two times. EI #5 touched and placed a clean pad underneath the resident without changing her gloves or washing her hands. On 11/18/2015 at 2:18 PM, an interview was conducted with EI #4. EI #4 was asked what should she have done after she cleaned RI #2's buttocks and before she touched the clean pad and placed it underneath the resident. EI #4 said she should have changed her gloves and washed or sanitized her hands. EI #4 was asked if she changed her gloves and washed or sanitized her hands after cleaning RI #2's buttocks and before she touched the clean pad. EI #4 said no. EI #4 was asked why she did not change her gloves or wash her hands after cleaning RI #2's buttocks and before she touched the clean pad. EI #4 said she was nervous. EI #4 was asked what the potential harm was if she did not wash her hands or change gloves after cleaning a resident's buttocks and before touching a clean pad and placing it underneath a resident. EI #4 said the pad was still dirty and soiled. On 11/18/2015 at 2:37 PM, an interview was conducted with EI #5. EI #5 was asked what she should have done after she cleaned RI #2's buttocks and before she touched a clean pad and placed it underneath the resident. EI #5 said change gloves and sanitize or wash her hands. EI #5 was asked if she did that. EI #5 said no. EI #5 was asked what the potential harm was if she did not change gloves or wash/sanitize her hands after she cleaned RI #2's buttocks and before she touched a clean pad and placed it underneath the resident. EI #5 said the gloves and hands were dirty and the resident could catch an infection. On 11/19/2015 at 11:14 AM, an interview was conducted with EI #9, LPN, Infection Control Nurse. EI #9 was asked how the facility prevented infections. EI #9 said they promoted hand washing, changed linens frequently, gave verbal reminders and observed staff. EI #9 was asked how infections were controlled in the facility. EI #9 said hand washing, in-services and verbal reminders. EI #9 was asked how infections were investigated in the facility. EI #9 said they observed closely for hand washing and the changing of gloves. EI #9 was asked if direct care staff were washing their hands and changing gloves according to facility protocol. EI #9 said when she observed staff, they were but she could not say what they did when she was not there. EI #9 was asked how she monitored direct care staff to ensure they were washing their hands according to facility protocol. EI #9 said she, as well as the nurses on the floor monitored the staff. EI #9 said if she saw something that was not right, she would tell staff they needed to change it. On 11/19/2015 at 11:32 AM, an interview was conducted with EI #1. EI #1 was asked what should be done when a CNA performed perineal care and cleaned a resident's buttocks before touching a clean pad and placing it underneath the resident. EI #1 said wash their hands. EI #1 was asked what the potential harm was if a CNA performed perineal care and cleaned a resident's buttocks then touched a clean pad and placed it underneath the resident without changing gloves or washing their hands. EI #1 said infection.

Based on observation, interview, and record review, the facility failed to ensure Employee Identifier (EI) #12, a Certified Nursing Assistant (CNA), was not standing to feed Resident Identifier (RI) #15 during the evening meal on 11/17/2015. Findings Include: A review of a facility policy titled, Assistance with Meals with a revised date of September 2013 revealed the following: 3. Residents Requiring Full Assistance . b. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity . (1) Not standing over residents while assisting them with meals; . RI (Resident Identifier) #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #15's most recent Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 10/19/2015 revealed the BIMS (Brief Interview of Mental Status) should not be conducted (resident is rarely/never understood). The MDS revealed RI #15 was totally dependent on eating and required one person physical assist with eating. On 11/17/2015 at 5:30 PM, the surveyor was walking down the hall and walked by a room and observed EI #12, a CNA standing at RI #15's bedside feeding the resident. On 11/17/2015 at 5:33 PM, the surveyor observed EI #12 feeding RI #15 while standing. On 11/17/2015 at 5:35 PM, the surveyor observed EI #12 still standing at the bedside of RI #15 feeding the resident the supper meal. On 11/18/2015 at 3:20 PM, an interview was conducted with EI #12. EI #12 was asked what position was she in while feeding RI #15 the evening meal on 11/17/2015. EI #12 stated, I was standing. EI #12 was asked should you have been sitting while feeding RI #15 the evening meal. EI #12 answered, Yes, I am pretty sure. EI #12 was asked what does the facility's policy say about standing while feeding a resident. EI #12 stated, not sure.