Every finding on record at Lauderdale Christian Nursing Home

Based on record review, interviews, the Alabama Department of Public Health Online Incident Reporting System, review of a facility investigative file, and review of a facility policy titled Medication Administration, the facility failed to ensure Employee Identifier (EI) #3 Licensed Practical Nurse (LPN), administered morphine pain medication to Resident Identifier (RI) #1 as ordered by physician. This was cited as a result of the investigation of complaint/report number AL00043318 and had the potential to affect RI #1, one of three sampled residents who received the pain medication, morphine at the facility. Findings include: On 2/8/2023 the State agency received a report from the facility on the Online Incident Reporting System. The report documented the incident type as Abuse-Neglect. The narrative summary of the incident documented: . (EI #3) LPN, is accused of not giving a resident . 12am (12:00 AM) morphine. The date and time of the occurrence was reported to be 2/2/2023 at 12:00 AM. A facility policy titled Medication Administration with a revised date of 1/10/2023 documented: Policy: Medications are administered by licensed nurses, . as ordered by the physician and in accordance with professional standards of practice, . Policy Explanation and Compliance Guidelines . 17. Sign MAR (Medication Administration Record) after administered. RI #1 was admitted to the facility on [DATE] and had diagnoses of Cerebral Palsy and Chronic Pain. RI #1's PHYSICIAN ORDERS documented an order dated 9/15/2021 for 2.5 milliliters (ml) per 5 milligrams (mg) of Morphine Sulfate to be given to RI #1 by mouth every six hours at 6:00 AM, 12:00 PM (noon), 6:00 PM, and 12:00 AM (midnight) for pain. Review of the facility investigative file for RI #1 revealed a typed document titled Accusation of Failure to Administer Resident Medications that was signed by EI #1 DON and dated 2/14/2023 and signed by EI #3 LPN. Review of this document revealed the following: 2/7/23 Social Services was interviewing residents and staff regarding alleged verbal abuse . A resident . stated she (EI #3) does not always bring . the midnight dose of . medications. A fell ow charge nurse was able to substantiate the allegation. . (EI #3) was called in . and questioned about the medication violation. She agreed that she did not always give the midnight dose of morphine due to resident sleeping. I questioned her how often this happens and she said, a couple of nights a week. She has been documenting on the EMAR (Electronic Medication Administration Record) that she was administering said dose. 2/8/23 . I pulled the resident's . (RI #1) EMAR back to 12/16/22 along with the controlled substance inventory record. Nurse (EI #3) signed both documents indicating medication administration. I spoke with resident, and (he/she) stated (he/she) only got (his/her) midnight dose when the weekend nurse was working. (He/She) said, I don't see (EI #3) until 0545 (5:45 AM) in the morning. Administrator . DON (EI #1), were present with (EI #3) and Pharmacist (EI #5) was on conference call. Questions were asked related to the whereabouts of the medication that was documented but not dispensed. (EI #3) stated several times that she does not know. She admitted again to signing it out on the EMAR and the inventory record. I had printed proof and showed her each time that is was shown to be administered by her. She stated, a habit of clicking through the EMAR and logging on substance inventory record. She stated on rounds at approx. 1130pm (approximately 11:30 PM) resident would be asleep. She admitted she never went back at midnight to administer the morphine, which was scheduled for midnight. She would then document on said records but never drew up the medication. The count was always correct, and she could not explain how that was. Employee was brought back in . liabilities explained. She was informed that grounds for termination were based on . allegations made by a resident, falsifying documents on the EMAR . Narcotic Inventory Record, . not following MD (medical doctor) orders and no follow up as to why. On 9/18/2023 at 2:31 PM RI #1 was asked about receiving morphine. RI #1 said, it was every six hours. RI #1 said, sometimes he/she did not receive the midnight dose if EI #3 was working. The surveyor was unable to reach EI #3, Licensed Practical Nurse (LPN) for interview after multiple attempts. On 9/19/2023 at 5:30 AM, EI #4 LPN was interviewed. She said she worked with EI #3 a few nights a week. EI #4 said, when interviewed by the social worker, she had reported to her that when they worked together she did not see EI #3 open the medication cart or narcotic drawer to get the morphine for RI #1 at midnight. When asked how many residents received medication at midnight, EI #4 said, she was not sure, but RI #1 was to get morphine every six hours at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM. EI #4 stated she never destroyed or counted narcotics with EI #3. On 9/19/2023 at 9:55 AM EI #2 Social Service and Abuse Coordinator, said she was told by EI #4 about EI #3 not giving medications at night. EI #2 said, when she interviewed RI #1, the resident said sometimes he/she got the medication at midnight and sometimes did not. EI #2 said, she looked in RI #1's medical record and realized morphine was a routine order. EI #2 said, RI #1 reported to her that EI #3 gave it at 5:30 AM or 6:00 AM. EI #2 said, EI #3 was signing it out as given at the 12:00 AM dose but was not giving it. On 9/19/2023 at 3:38 PM EI #5 Pharmacist, was interviewed. EI #5 said, she was on the phone call when EI #3 was asked about the morphine she did not give and several times EI #3 said, she did not know. EI #5 said, while on that call EI #3 said that on rounds about 11:30 PM, RI #1 would be asleep and she would document the morphine as given. On 9/19/2023 at 3:40 PM EI #1 Director of Nursing (DON) was asked about the investigation into RI #1's morphine. EI #1 said, the order was morphine 2.5 ml/5 mg, it was due routinely every six hours at 6:00 AM, 12 Noon, 6:00 PM, and 12:00 midnight. EI #1 said, EI #3 told them in an interview that she had not given the morphine a couple nights a week. EI #1 said, the medication was signed off on the MAR. EI #1 said, EI #3 was asked what she did with the morphine, and EI #3 repeatedly said she did not know but agreed she, EI #3, did not always give the morphine if RI #1 was sleeping. EI #1 said, they had EI #3 back at the facility on 2/14/2023 and she admitted she was signing it off on the Medication Administration Record and out in the narcotic record, but would not tell what she was doing with it. EI #1 said, they asked EI #3 if she was using it herself and she kept saying she did not know. EI #1 said, the facility discovered EI #3 was not giving RI #1 the morphine on 2/4/2023 during interviews. EI #1 said, the morphine was signed out as given every time. When EI #1 was asked about the policy for nurses giving medications, EI #1 said, they were to follow doctor orders, give to the resident, the right medication, route and time. EI #1 was asked how EI #3 followed the doctor's orders when the morphine midnight dose was not given. EI #1 said, she did not and also did not notify the Medical Doctor. EI #1 said, the concern for the resident if the nurse did not give scheduled medication ordered by the physician was the resident could have more pain. The facility took immediate actions to correct the non-compliance by: ____________________________________________ Plan of correction * Terminated Employee EI #3, LPN on 2/8/23 * Interviewed residents with BIMS of 15 as to getting scheduled medications * Educated all nurses regarding medication administration policy, falsifying resident records and the medication hold process to be completed by 2/15/23. * Monitored nurses for medication administration competency, comparing the correct medication and dose with the MAR. * A narcotic count by the ADON or designee. Monitored all nurses for one week to be completed by 2/15/23. * Pharmacist will do audit of all narcotics to be completed by 2/15/23 * Results will be reviewed by DON and reported to QAPI on Emergency meeting 2/15/23 To be completed at the quarterly meeting 4/19/23.

Based on observation, interviews, review of Resident Identifier (RI) #1's medical record, the facility's policy titled Prevention of transmission of Bloodborne Pathogens with fingerstick Glucometers and the Glucometer Competency Checklist, the facility failed to ensure Employee Identifier (EI) #2, a Licensed Practical Nurse (LPN) did not place a glucometer on top of the medication cart and RI #1's overbed (bedside) table without placing a barrier prior to obtaining RI #1's fingerstick blood sugar. The facility further failed ensure EI #2, an LPN, did not dispose of a used blood glucose test strip, alcohol wipe and Kleenex containing blood in RI #1's trash can. These deficient practices affected RI #1, one of three residents observed for medication pass administration. Findings include: The facility's policy titled Prevention of transmission of Bloodborne Pathogens with fingerstick Glucometers reviewed March 2020, documented: . 1. Wash hand (soap and water or alcohol-based rub). Place Barrier, then place meter on barrier . Glucometers . 4. Dispose of used test strip into sharps container . An undated facility document with a procedure title of Glucometer Competency Checklist, documented: . Place barrier, then place glucometer (equipment) on barrier . Dispose of lancet, alcohol wipe and test strip into sharps container . RI #1 was admitted to the facility on [DATE]. RI #1 has a medical history to include a [DIAGNOSES REDACTED]. During medication pass observation on 8/4/2020 at 7:59 AM, EI #2, an LPN cleaned the glucometer and placed it on top of the medication cart without a barrier. Once EI #2 entered RI #1's room, she placed the glucometer on RI #1's overbed (bedside) table without a barrier. EI #2 pricked RI #1's finger and obtained a blood glucose reading of 144. EI #2 used an alcohol wipe to wipe the blood along the resident's finger and a Kleenex to stop the bleeding. EI #2 was observed to roll the bloody alcohol wipe and Kleenex into her gloves, then she placed the gloves into the trash can in the resident's room. EI #2 returned to her medication cart to clean and disinfect the glucometer. When asked where she placed the used test strip, EI #2 stated in the sharps container. EI #2 was then asked to return to RI #1's room and retrieve the gloves she had placed in the resident's trash can to see the items that were rolled into the gloves. When EI #2 unrolled the gloves, she had removed from the trash can, she found the bloody alcohol wipe, bloody Kleenex, and the used test strip that contained blood. EI #2 stated, That (used test strip) should be in (the) sharps. I shouldn't have done that. In an interview on 8/4/2020 at 2:54 PM, EI #2, an LPN, was asked how should blood glucose test strips be discarded after obtaining a resident's fingerstick blood sugar (FSBS). EI #2 said they should be discarded in the sharps container only. EI #2 was asked where any items with blood products should be discarded. EI #2 stated in the sharps or red bag container. EI #2 was asked why any items containing blood products should not be placed in a resident's trash can in their room. EI #2 replied that anyone could rummage through the trash can and if they had any open areas to their skin they could contract any disease that could contain a bloodborne pathogen. EI #2 was asked where she placed RI #1's glucometer after cleaning it before obtaining RI #1's FSBS. EI #2 said on top of her cart. EI #2 was asked did she place a barrier down before placing the glucometer on the cart. EI #2 said no. EI #2 was asked where she placed the glucometer when she entered RI #1's room. EI #2 said on the resident's bedside table. EI #2 was asked did she clean the surface or place a barrier before placing the glucometer on the table. EI #2 stated that the bedside table was cleaned after picking up RI #1's breakfast meal. EI #2 was asked did she observe RI #1's bedside table from the time it was cleaned until she checked his/her FSBS. EI #2 said no, she was not able to visualize the bedside table to ensure it was not contaminated because it was not in her constant visual line of sight. EI #2 was asked was a bedside table considered a potentially contaminated surface. EI #2 stated yes. EI #2 was asked what she should do before placing a glucometer or any other equipment on a potentially contaminated surface. EI #2 replied it should have a barrier. EI #2 was asked what the concern was with the things discussed. EI #2 answered cross contamination and infection control. On 8/4/2020 at 3:52 PM, an interview was conducted with EI #1, Registered Nurse (RN)/Assistant Director of Nursing (ADON)/Infection Control Preventionist (ICP). EI #1 was asked where should used test strips be discarded after obtaining a resident's FSBS. EI #1 said they should be placed in the sharps container. EI #1 was asked where alcohol wipes or Kleenex containing blood products should be placed. EI #1 replied in the sharps container or red bags. EI #1 was asked should any medical equipment, including glucometer be placed on potentially contaminated surfaces after being cleaned. EI #1 stated no. EI #1 was asked where should clean equipment be placed prior to use. EI #1 said a barrier should be placed. EI #1 was asked what the concern was with items containing blood products being placed in a resident's trash can. EI #1 said there was a potential for any other infection or people touching those contaminated items since blood-borne pathogens could be on it. EI #1 was asked what the concern was with the situations discussed. EI #1 answered infection control and cross contamination.

Based on observations, interviews, and a facility policy titled, Dietary Employee Personal Hygiene, the facility failed to ensure a dietary cook wore a hair net to completely cover all hair on her head while serving residents' food for the supper meal on the tray line in the kitchen area. This had a potential to affect all fifty-eight residents in the facility receiving meals from the kitchen. Findings Include: A review of a facility policy titled, : Dietary Employee Personal Hygiene, with a revised date of (MONTH) 22, (YEAR), revealed . Policy Explanation and Compliance Guidelines: . 4. Hair Restraints . c. All hairs . must be completely covered by restraint. On 7/22/2019 at 4:42 p.m., the surveyor observed EI#1, a dietary cook, while serving residents' food on the trayline in the kitchen area for the supper meal. EI #1 wore a hair net with her hair not covered on the front of her head and not covered on the back of her head. EI #1 had her hair net on the center of her head, which the hair was covered by the hair net, but the front of her hair and the back of her hair, lying on her neck, was not covered by the hair net. EI #1 continued serving residents' plates on the tray line in the kitchen area for the super meal with her hair net on her head, but her hair was not completely covered. EI #2, Dietary Manager, was also present during this observaton. EI #2 was asked if all of EI #1's hair was contained in her hair net while serving food on the tray line. EI #2 said no, it was not completely covered. EI #2 was then asked what was the potential harm with EI #1's hair not being contained and completely covered in the hair net while serving food on the tray line. EI #2 replied that the hair could fall in the food and contaminate the food. On 7/24/2019 at 5:55 p.m., the surveyor conducted an interview with EI #1. EI #1 was asked, on (MONTH) 22, 2019 at 4:42 p.m. while she was serving/ plating the supper meal on the tray line, was all of her hair restrained in her hair net. EI #1 replied that she thought it was, but it was not. EI #1 was then asked why was all of her hair not restrained in the hair net. EI #1 replied that she was hot and sweating, so she stepped away from the tray line, reached up and wiped her head so the sweat would not fall in the food. EI #1 then said she must have moved the hair net at that time. EI #1 was then asked why should all of her hair be restrained in the hair net while serving/ plating food on the tray line. EI #1 stated that it would be cross contamination if the hair fell in the food. EI #1 further stated that the facility policy stated that all hair must be completely covered by restraints.

Based on observation, interview, and review of a facility policy titled LABELING, DATING AND STORAGE OF FOODS, the facility failed to ensure 17 four ounce yogurts were not stored past the manufacturer's use by date of [DATE]. This had the potential to affect forty-eight of forty-eight residents receiving meals in the facility. Findings Include: A review of the facility policy titled LABELING, DATING AND STORAGE OF FOODS with a revised date of [DATE] documented: Purpose: To ensure food is stored in a manner to prevent food-borne illness . 2. Food with expiration dates are used prior to the date on the package . On [DATE] at 04:35 p.m. during the initial kitchen tour, the surveyor observed the following items in the walk in cooler in an opened cardboard box stamped with a manufacture's use by date of [DATE]: 1. 9 Strawberry four ounce yogurts with a manufacture's use by date of [DATE] on each container, and 2. 8 Strawberry Banana four ounce yogurts with a manufacture's use by date of [DATE] on each container. On [DATE] at 08:11 a.m., an interview was conducted with Employee Identifier (EI) #1, a Dietary Manager. EI #1 was asked what manufacture's use by date did the 9 Strawberry four ounce yogurt cups and the 8 Strawberry Banana four ounce yogurt cups have on each container and on the box in the walk in cooler. EI #1 replied that the yogurts were dated [DATE]. EI #1 was asked what does the [DATE] manufacture's use by date mean. EI #1 stated that the yogurts were out of date and needed to be discarded. EI #1 was asked what was the facility policy for having expired items in the walk in cooler. EI #1 stated that expired items should be discarded by the use by date. EI #1 was asked if the facility policy was followed. EI #1 replied no. EI #1 was asked what was the potential harm to have expired items in the walk in cooler. EI #1 replied that residents could get a food borne illness.

Based on observations, interview, and review of facility policies, the facility failed to ensure: 1) Plates were not stored for use with dried food debris or while still wet; and 2) Dietary staff did not wear earrings while serving food for the 04/06/2016 lunch meal. These failures had the potential to affect all 58 residents for whom meals were prepared and served during the survey. Findings include: 1) Review of the facility policy titled Policy and Procedure for Washing and Sanitizing in Dish Machine, revised 04/07/2015, revealed the following: POLICY: Dishes and cookware will be washed and sanitized after each meal. PROCEDURE: . 5. Rinse dishes thoroughly in sink . 9. Allow dishes to dry on racks . 11. remove dishes and inspect for cleanliness and dryness. Put dishes away if clean. 12. if dishes are not clean repeat steps . During the initial tour of the kitchen on 04/05/2016 beginning at 1:30 PM, staff were observed utilizing the dish machine. After washing a rack of plates, staff did not allow the plates to air dry. Instead, staff stacked the wet plates one on top of the other into the plate warmer (wet nested) in preparation for the next meal. The surveyor asked Employee Identifier (EI) #4, the Certified Dietary Manager (CDM), to remove 3 or 4 plates for inspection. EI #4 removed a total of 8 plates, all of which were wet. Two of the eight plates were noted with dried food debris. When asked if the plates were wet, EI #4 said they were going to be wet because they stack them in there to dry then move them to the serving line. EI #4, the CDM, was interviewed on 04/07/2016 at 8:57 AM. EI #4 explained if staff observe food debris on dishes they should run them back through the dish machine because the food debris could cause foodborne illness. She also stated she had reviewed multiple manuals on plate warmers and said she did not see where it addressed using one to dry plates. (NOTE: Review of the Manufacturer's Information for the facility's plate warmer revealed no documentation that the equipment was intended for use to dry dishes.) 2) Review of the facility's untitled policy, effective 06/2007, revealed the following: POLICY: ALL KITCHEN EMPLOYEES WILL PRACTICE STANDARD SANITARY PROCEDURES PROCEDURE: All employees shall: 1. Jewelry is kept at a minimum of plain wedding band, and no dangle earrings. Facial piercings are to be removed . During trayline observations on 04/06/2016 beginning at 11:00 AM, EI #7, a dietary worker, was observed taking temperatures of the foods on the steam table and serving trays. She was wearing quarter sized earrings with a small back not contained in her hairnet. The earrings extended past the end of her ear lobes. EI #4, the Dietary Manager, was interviewed on 04/07/2016 at 8:57 AM. When asked what hazard was involved in wearing earrings for food preparation and serving, EI #4 explained the backs could fall off or the earrings could fall in the food.

Based on observation, record review, and interviews, the facility failed to ensure Employee Identifier (EI) #6, an LPN (Licensed Practical Nurse), washed her hands and put on gloves prior to administering [DEVICE] (Gastrostomy Tube) medications to Resident Identifier (RI) #2 on 4/5/2016. This affected one of one residents observed receiving medications by [DEVICE]. Findings Include: A facility policy titled, HANDWASHING, dated 6/2004, documented: Purpose: 1. Medical asepsis to control infection 2. To reduce transmission of organisms from resident to resident 3. To reduce transmission of organisms from nursing staff to resident 4. To reduce transmission of organisms from resident to nursing staff Hands should be thoroughly washed before .providing resident care General infection control Guidelines: . 2. Wash your hands before and after all procedures . 4. Wear gloves when coming in contact with . body fluids . A facility policy titled, Administration of meds (medications) via [DEVICE], dated 10/99, documented: Purpose: .provide guidelines for administration of medication via gastrostomy tube 5. Wash hands. 6. Apply gloves. 7. Check [DEVICE] placement by auscultation and/or aspiration . RI #2 was readmitted to the facility on [DATE]. RI #2's Quarterly Minimum Data Set Assessment, dated 04/02/2016, indicated RI #2 had choking and swallowing difficulties and had a gastrostomy tube. During the medication pass observation on 04/05/2016 at 5:05 PM, the surveyor observed Employee Identifier (EI) #6, an LPN, administering [DEVICE] medications to RI #2. EI #6 entered RI #2's room, placed the medications on a towel-covered over bed table. EI #6, with bare hands, folded down the top of RI #2's pants and lifted RI #2's shirt to expose the [DEVICE]. The gauze around the [DEVICE] was observed to have a green drainage. EI #6 lifted the [DEVICE] and placed a towel under it. EI #6 washed and dried her hands, but did not put on her gloves. EI #6, with bare hands, used a stethoscope and a syringe to check for placement of the [DEVICE]. EI #6, without washing hands, then put on her gloves and completed the administration of [DEVICE] medications. On 04/05/2016 at 5:30 PM, the surveyor interviewed EI #6. When asked when should gloves be worn during the administration of [DEVICE] medications, EI #6 stated before the tube is touched. When asked when did she apply her gloves, EI #6 stated, After I touched the tube . EI #6 further explained because she touched the the tube without gloves, she should have washed her hands. When asked when should hands be washed during administration of [DEVICE] medications, EI #6 stated before and after you give the medication. EI #6 was asked what should be done prior to checking [DEVICE] placement. She stated wear gloves. When asked what should you do before applying gloves, EI #6 replied wash and dry hands. EI #6 was asked what is the potential harm in not wearing gloves when checking the placement of a [DEVICE]. She replied, bacteria from my hands could get on the resident and vice versa. When asked what is the potential for harm in not washing hands prior to [DEVICE] medication administration, she stated bacteria and cross contamination. On 04/07/2016 at 9:20 AM, the surveyor interviewed EI #3, the Infection Control Nurse. EI #3 was asked when should hands be washed during the administration of [DEVICE] medications. She replied before you start the procedure. When asked when should gloves be worn during the administration of [DEVICE] medications, she responded after you wash hands, before auscultation. When asked the potential harm in not washing hands or wearing gloves prior to the administration of [DEVICE] medications, EI #3 responded, infection issues and cross contamination.

Based on observations, record review, and interviews, the facility failed to ensure Resident Identifier (RI) #2 was provided a sippy cup with meals to assist and/or enable the resident to consume fluids with meals. This affected RI #2, one of three sampled residents that required the use of adaptive eating equipment. Findings include: RI #2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #2's Quarterly Minimum Data Set Assessment, dated 04/02/2016, indicated RI #2 had upper extremity range of motion limitations on one side. RI #2's Activities of Daily Living (ADL) care plan, dated 07/15/2015, indicated RI #2 was able to hold a sippy cup. RI #2's comprehensive care plans also listed the following intervention: .Resident is provided with sip cup all meals . RI #2's April 2016 physician's orders [REDACTED]. On 04/05/2016 at 5:12 PM, staff were observed feeding RI #2 the supper meal. RI #2's fluids were provided in a regular cup, not a sippy cup as care planned. On 04/06/2016 at 8:00 AM, staff were setting up RI #2's breakfast tray. The staff member, Employee Identifier (EI) #1, a Certified Nursing Assistant (CNA), was observed mixing RI #2's chocolate milk with a Carnation Instant Breakfast and placing it in a regular cup. RI #2 also received coffee and water in regular cups. EI #1 had to hold the cups to RI #2's mouth so the resident could drink from them. EI #1 was interviewed on 04/06/2015 at 8:35 AM. EI #1 was asked if RI #2 required a sippy cup with meals. EI #1 said she knew they had used a sippy cup for RI #2 in the past but did not know if he/she required one. EI #1 explained usually if a resident required a sippy cup, it would be listed on the tray card. RI #2's traycard was then reviewed and EI #1 said it was not listed. EI #2, the Care Plan Coordinator, was interviewed on 04/06/2016 at 2:20 PM. EI #2 said RI #2 should be provided a sippy cup at all meals. When asked how CNAs know to provide the sippy cup, EI #2 said it should be listed on the tray card but she was unsure why RI #2's information was cut off. EI #3, the Assistant Director of Nursing, was interviewed on 04/06/2016 at 2:37 PM. EI #3 said RI #2 should be provided a sippy cup at meal times and when providing hydration. When asked what purpose the sippy cup served, EI #3 said it provided RI #2 some control and allowed the resident to be able to do for him/herself.

Based on observations, record review, and interviews, the facility failed to ensure Resident Identifier (RI) #2's care plan intervention of sippy cup with all meals was implemented for two of three meals observed. This affected RI #2, one of thirteen residents for whom care plans were reviewed. Findings include: Review of the facility's policy titled Comprehensive Care Plans, issued 10/2015, revealed the following: Objective: Plans of Care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals for the resident related to clinical [DIAGNOSES REDACTED]. The facility develops a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental/psychosocial needs that are identified in the comprehensive assessment . RI #2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #2's Quarterly Minimum Data Set Assessment, dated 04/02/2016, indicated RI #2 had upper extremity range of motion limitations on one side. RI #2's Activities of Daily Living (ADL) care plan, dated 07/15/2015, indicated RI #2 was able to hold a sippy cup. RI #2's comprehensive care plans also listed the following intervention: .Resident is provided with sip cup all meals . On 04/05/2016 at 5:12 PM, staff were observed feeding RI #2 the supper meal. RI #2's fluids were provided in a regular cup, not a sippy cup as care planned. On 04/06/2016 at 8:00 AM, staff were setting up RI #2's breakfast tray. RI #2's fluids were provided in regular cups. EI #2, the Care Plan Coordinator, was interviewed on 04/06/2016 at 2:20 PM. EI #2 explained RI #2's sippy cup should be offered with all meals and said it helped the resident not to spill.

Based on observations and interviews, the facility failed to ensure Resident Identifier (RI) #10 was not made to wait for 20 minutes on a supper tray while the two other residents at the same table were eating. This affected RI #10, one of ten residents whose meals were observed. Findings include: RI #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #10's Annual Minimum Data Set Assessment, dated 02/22/2016, indicated RI #10 had severely impaired cognition and required set-up help only for eating. RI #10's supper meal was observed on 04/05/2016. At 4:40 PM, RI #10 was observed seated at a table with two other residents. The resident seated directly across from RI #10 was already served and eating at this time. The resident to the right of RI #10 received a tray at 4:45 PM. RI #10 stated, I sure hope they bring my barbeque sandwich and chips. RI #10 then asked the surveyor to find out why they were not bringing his/her tray because he/she was tired of waiting on it. At 4:50 PM, RI #10 was still waiting for a tray while the other two residents at the table were eating. RI #10 was hollering out to staff saying, I know you know what I want . No staff responded at this time. At 4:55 PM, RI #10 still had not received a supper tray. At this time, RI #10 said, If they won't bring me what I want, I'm going to stop coming in here to eat. They can make me a sandwich out of anything. At 5:00 PM, twenty minutes after the other residents at the table began eating, staff provided RI #10 a tray. RI #10 received a tray consisting of the regular planned items for the meal. Employee Identifier (EI) #8, the Certified Nursing Assistant that provided RI #10's tray, was interviewed on 04/05/2016 at 5:40 PM. EI #8 explained residents at the same table were supposed to get trays right at the same time. EI #8 was unaware of when the other two residents at the table received their trays and did not know how long RI #10 sat waiting on a tray while they ate. The surveyor informed EI #8 it was a period of twenty minutes. EI #8 said, That's way too long. When asked why it was important to ensure residents seated at the same table were served at approximately the same time, EI #8 said you do not want one eating in front of the other. EI #5, the Director of Nursing, was interviewed on 04/07/2016 at 10:55 AM. When asked what the facility's policy was regarding serving trays in the Dining Room, EI #5 stated they usually served a table at a time. When asked why it was important to serve residents seated at the same table at approximately the same time, EI #5 said it was a dignity issue. EI #5 explained you did not want one resident sitting there without food while the other residents around were eating. EI #5 then said, That's proper manners. EI #2, the Assistant Director of Nursing, was also present at this time and stated you did not want the resident to feel left out.

Based on observation, record review, and interview, the facility failed to assure equipment (the food processor) was cleaned and air dried between use to prevent potential biological contamination, a risk factor for foodborne illness. Findings include: The 2013 Food Code by the United States Public Health (USPHS) and the Food and Drug Administration (FDA) included the following: "Drying 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface SANITIZING solutions), before contact with FOOD..." On 4/07/2015 at 3:40 PM, the (blender) food processor was observed stored on a counter with the lid (cover) secured. Water was observed pooled on the bottom and would roll around when tipped. The Certified Dietary Manager (CDM), Employee Identifier (EI) #5, was asked, if it (the processor) was dry and the response was, "No, Ma'am, not dry." A review of the facility policy "Policy and Procedure for Washing and Sanitizing In Dishmachine," with a revised date of March 15, 2013 and revised on April 7, 2015 revealed the following: Item #9 under procedure documented: "...9. Allow dishes to dry on racks ..." A review of the schedule "Plating and Serving Time all Meals" documented the evening meal service began at 4:25 PM and breakfast plating was at 6:45 AM. Accordingly the potential exists for the processor to sit with standing water for 14+ hours. On 4/08/2015 at 4:50 PM, an interview was conducted with the CDM. E I #5 was asked what were the four elements needed for food contamination. EI #5 responded, Poor Personal (Hygiene) Time/Temperature control , Physical Contamination, Chemical Contamination and Bacterial Contamination. EI #5 was asked what the Food Code indicated about air drying. EI #5 responded, after wash/sanitize - do not use towels. Allow to air dry. EI #5 was asked to explain what was needed for the growth of bacteria. EI #5 responded: food, acidity, time/temperature, oxygen and moisture. EI #5 was asked what elements were created for potential food borne illness. EI #5 responded, moisture, food, oxygen and temperature. EI #5 was asked were conditions present and what was the risk. EI #5 responded, yes, potential for the growth of bacteria. 6. The CDM EI #5 was asked, why the water remained or why it was standing. EI #5 responded, evidently it was put up there to store for the night while still wet. It (the processor) was turned right side up. They (staff) were more than likely in a hurry.

Based on observation, interview, and record review, the facility failed to ensure a CNA (Certified Nursing Assistant) washed her hands and changed her gloves during incontinence care in a manner to prevent cross contamination. This affected RI (Resident Identifier) #2, one of one residents observed for incontinence care. Findings include: The facility policy titled, "Incontinence Care," with a most recent review date of 6/12, revealed the following: "...Procedure: ...18. Take gloves off and apply new gloves 19. Apply new incontinence product: diaper..." The facility policy titled, "HANDWASHING," with a most recent review date of 6/12 revealed the following: "...General infection control Guidelines: 1. ...Follow the Centers for Disease Control (CDC) Guidelines for hand washing..." The facility policy titled, "GLOVE USE," with a revised date of 1/2014, revealed the following: "...II. MISCELLANEOUS...E. Perform hand hygiene after removing gloves..." Educational Inservice on handwashing provided to the staff on 10/15/2014 and 10/16/2014 included the following: "CDC Recommendations for Long Term Care Handwashing...1. Indications for hand washing and hand antisepsis...B. ...use an alcohol-based hand rub for routinely decontaminating hands in the following clinical situations...8. After removing gloves. (Alternatively), wash hands with an antimicrobial soap and water..." RI #2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #2's most recent quarterly MDS (Minimum Data Set) with an Assessment Reference Date of 2/23/2015 revealed severe cognitive impairment and total dependence on staff for toilet use. On 4/8/2014 at 6:10 PM, an observation was made of EI (Employee Identifier) #4, a CNA, providing incontinence care for RI #2. EI #4 changed her gloves twice during incontinence care without hand hygiene. While wearing the same gloves during incontinence care, EI #4 cleaned RI #2's buttocks, removed the soiled brief, and then placed a clean brief under the resident. EI #4 removed her gloves after incontinence care and, without washing her hands, began to reposition RI #2, while also observed touching the bed, call light, linens, pillows, over bed table, and also placed the perineal spray in RI #2's cabinet. On 4/8/2015 at 6:23 PM, EI #4 was asked when she washed her hands. EI #4 stated before and after the care. EI #4 was asked when was she trained to wash her hands and she said, before and after you change a resident. When asked why she did not wash her hands when she changed her gloves, EI #4 said she did not know she was supposed to while in the process of cleaning. On 4/9/2015 at 1:35 PM EI #2, RN (Registered Nurse), was asked why the glove use policy was not followed during incontinence care. EI #2 said that the CNA went by the skills on the incontinence check list. When asked why the CNA put the clean brief under the resident while wearing the same gloves used for incontinence care, EI #2 stated that the CNA was nervous and she should have put on clean gloves. When asked what was the harm in not following the policy for handwashing and glove use, EI #2 said, infection.

Based on observation, interview, and record review, the facility failed to ensure RI (Resident Identifier) #16 was assessed for self administration of nebulizer treatments. This affected one of one residents observed with nebulizer treatments. Findings include: The facility policy titled "Self Administering Medications" with a revision date of 5/10/2010 revealed the following: "...Procedure: 1. Facility should comply with...State Operations Manual with respect to Self-Administration of medications...2. Facility, in conjunction with the Interdisciplinary Care Team, should assess and determine, with respect to each resident, whether Self-Administration of medications is safe and appropriate...8. ...Facility, in conjunction with the Interdisciplinary Care Team, should routinely assess the resident's cognitive, physical and visual ability to carry out this responsibility..." RI #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #16's most recent Annual MDS (Minimum Data Set) with an Assessment Reference Date of 2/1/2015 revealed severe cognitive impairment and rarely/never able to understand others. RI #16's CAA (Care Area Assessment) revealed a problem of alteration in cognition manifested by "...Cannot complete task, ...Inattentin: Difficulty focusing, easily distracted..." RI #16's physician order [REDACTED]. On 4/8/2015 at 5:12 PM, RI #16 was observed to be left alone wearing a mask for/during a nebulizer treatment . EI (Employee Identifier) #3, LPN (Licensed Practical Nurse), charge nurse, said that the resident could be left alone with the mask and that the doctor writes orders for the resident to be left alone. On 4/8/2015 at 6:00 PM, EI #1, DON (Director of Nursing), was asked where the assessment for self administration of medication was for RI #16. EI #1 said there was not a written assessment. On 4/9/2015 at 2:00 PM, EI #1 was asked why there was not any documentation that RI #16 was able to be left alone for the nebulizer treatments. EI #1 said there was a doctor's order for the resident to be left alone during nebulizer treatments and it was not routine to document an assessment.

Based on observations, interview and record review, the facility failed to ensure residents' medical records were not left in a place that was easily accessible to residents, visitors, or other unauthorized persons. This had the potential to affect all 57 residents currently residing in the facility. Findings include: The facility's policy "Storage of Medical Records" with a revision date of 7/2003 documented, "1. The facility will maintain privacy of the resident's medical record ... ." On 5/6/14 at 2:00PM, the surveyor observed the residents medical charts out in the open on an open cart. The records were accessible to residents, visitors and employees. On 5/7/14 at 9:30 AM,the surveyor observed the residents medical charts out in the open on an open cart. The records were accessible to residents, visitors and employees. On 5/8/14 at 9:50 AM, the surveyor observed the residents medical charts out in the open on an open cart. The records were accessible to residents, visitors and employees. During this observation housekeeping staff was observed standing in front of the medical records the records were easily accessible. In an interview on 5/8/14 at 10:00 AM, Employee Identifier (EI) # 1, the Director of Nursing was asked if all residents medical charts are maintained on the racks in the hallway by the nursing desk. EI # 1 stated yes but it is part of the nursing station. EI #1 was asked if the records were accessible to staff, visitors and residents. EI # 1 stated not visitors and staff such as housekeeping, dietary and Maintance have signed HIPAA (Health Insurance Portability and Accountability Act) agreements. EI #1 was asked if staff, visitors, or residents could look at the records. EI # 1 stated the records are stored within the nursing station.

Based on observation, interview and document review, the facility failed to ensure food was stored and served in a manner to prevent the potential for food-borne illness by the following: 1.) staff did not document use-by dates on items in the refrigerator; 2.) frozen sweet potatoes were not sealed properly to prevent ice accumulation; 3.) the dishmachine sanitizing temps (temperatures) were not consistently 180 degrees F (Farenheit) or above; and 4.) two items on the 03/13/13 lunch trayline were not checked for proper temperature. This had the potential to affect all 57 of 57 residents who receive meals from the kitchen. Findings include: 1.) The facility's policy and procedure titled: "Use of Leftovers" dated 04/2011, revealed: "... Procedures: ... 2. Leftovers should be covered, labled, and dated: then stored appropriately (refrigerated or frozen if necessary within 1/2 hour. ... 4. Do not serve leftovers that have not been properly stored. (When in doubt, throw it out). 5. Any food that is leftover (food served for a meal, but was not all served), shall be used as follows: ... Use leftovers within 3 days or discard." During the initial tour of the kitchen on 03/12/13 at 5:08 PM, the stand alone refrigerator contained a plate of grilled cheese with the date 3-12. EI (Employee Identifier) #1 (Certified Dietary Manager) said they were leftover from that night's supper. There was a bag of biscuits with a label that contained the date 3-12. The label had a line for the "use by" date, but there was no use -by date documented. There was a bowl of pickle chips with plastic wrap covering it and had a date of 1-2 on the label line for "use by." EI #1 said that was the date the container of pickles came to the facility. There was a container of sweet potatoes that had the date 3-6 on the "use by" line. A container of whipped topping had a date of 2-27. A container of ham had a date of 3-10. A container of tomatoes and okra was dated 3-11. A container of puree cream of chicken had a date of 3-11 on the "use by" line. There were three trays of eggs with no use by date. EI #1 was asked if she could see a use by date on the trays. She said she could not. EI #1 explained that there was supposed to be a date on the lip of the trays. There was also a container of vanilla pudding that had a date of 3-4. On 03/13/13 at 9:32 AM, one of the dietary aides (EI #2) was dating boxes and putting away new stock. The walk-in cooler contained eight covered cups on a rolling food rack. There was no label or date on them to identify what the items were and when the use-by dates were. EI #2 was asked what they were. She said puree fruit from that morning. EI #2 was asked how she knew when it was made. She said it was made the day before, because the dietary staff always make it the day before it is to be used. On 03/13/13 at 10:04 AM, EI #2 was asked what the date meant on the pickles inside the stand alone refrigerator. She said that was the day they were placed in the refrigerator. EI #2 explained that all the dates were the dates they place them in the containers. EI #2 said they should have the use-by dates on the items, but the staff knew to use them within five to seven days. There were five containers of chicken stew in the refrigerator with a date of 3-1. There was one hamburger stew with a date of 3-6 on the "use by" line. EI #2 said she understood the confusion with the way the items were dated. EI #2 was asked who usually documents the dates on the leftovers. She said the cook. On 03/13/13 at 10:07 AM, the cook (EI #3) was asked how she was trained to put dates on leftovers. She said she writes the day it goes into the refrigerator and the date to use it. EI #3 was asked if the corn beef hash was supposed to be used by 3-11. She said it was not, that the date documented was the day it was put in there. EI #3 said if it is not used within three days they discard it. Other items in the stand alone refrigerator were: tomatoes and okra dated 3-11; sweet potatoes dated 3-6 on the use-by line; puree cream of chicken dated 3-11 on the use by line; chocolate pudding dated 3-8; weenies and sauerkraut dated 3-12; puree tomatoes dated 3-10; tomato paste 3-6; and corn dated 3-10. EI #3 was asked how she knew when to discard items. She said they discard after three days, but she thought it was lengthened to five or seven days. EI #3 was asked how she was trained to date items placed in the refrigerator. She said she was trained to put the date it goes in the refrigerator. EI #3 was asked if she would just do the math in her head. She replied, "Yes." On 03/14/13 at 9:45 AM, EI #1 was asked who was responsible for labeling and dating items in the refrigerator and freezer. She said everyone who puts anything in the refrigerator or freezer should label and date the items. EI #1 was asked how the staff were trained to label and date items. She said they are to put the day it is prepared or the day it comes off the truck. EI #1 was asked how staff know when the use-by day is. She said it is thrown out after three days if it is potentially hazardous. She said if it has a long shelf life they put the date it comes into the facility. EI #1 said she goes through and pulls out all the food each morning to use what she can for leftovers. EI #1 was asked how they know when to discard items since there was no use-by date. EI #1 said she knew their labels were confusing. EI #1 was asked why they do not document the use-by date when their labels have a line for it. EI #1 said it was partly her fault for not instructing her staff to do it. She explained that the dates are all the prepare dates, not the use-by dates. EI #1 was asked if she just expected her staff to do the math and discard items after three days. She replied, "Yes." EI #1 said she also goes through the food every morning and discards what needs to be discarded. 2.) During the initial tour of the kitchen on 03/12/13 at 5:08 PM, the freezer located outside had a box that contained sweet potato patties in a blue bag. The bag was not sealed. There was an accumulation of ice on the potatoes. EI #1 was asked if the bag was closed or just wadded. She said it was just wadded up. On 03/14/13 at 9:45 AM, EI #1 was asked how frozen items are re-sealed after opening. She said they just fold the wrapper around the food or they will put the item in a different bag when it gets low. EI #1 was asked if they put a twist tie on them. She said they do not, but sometimes they tie a knot with the bag. EI #1 was informed the sweet potatoes had ice on them, and asked EI #1 if air could have gotten to them. EI #1 responded, "Yes ma'am." 3.) The facility's policy and procedure titled, "Dishwasher" (undated) documented: "1. Check all temperature(s) on dish machine before operating. ... Rinse temperature 180 degrees or above. ..." On 03/13/13 at 9:20 AM, a dietary worker (EI #4) was operating the dishmachine to clean pots, bowls, cups, and plate holders. EI #4 was asked what temperature the sanitizing cycle had to be. She replied, "A hundred and seventy-five; somewhere around there." EI #4 was asked if she documents the temps. She said she does on the board. EI #4 was asked if the sanitizer and rinse cycle were the same cycle. She said she thought they were. A review of the "Dish Machine Temperature Log" for March 2013 revealed the sanitizing temps were not consistently 180 degrees or above for the breakfast dishes. March 1st: 177 degrees March 3rd: 178 degrees March 12th: 177 degrees March 13th: 178 degrees EI #4's initials were by the temps for the 12th and 13th. On 03/14/13 at 9:45 AM, EI #1 was asked what the sanitizing temp should be for the dishmachine. She said 180 degrees. EI #1 was asked if anyone monitored the dishmachine workers to make sure the temps are at least 180. She said the workers are supposed to notify her if it gets below 180. EI #1 was asked if anyone monitored the documentation. She said she does. EI #1 was asked if she was aware before 03/13/13 that the temps were documented below 180. She said she was not. EI #1 was asked if EI #4 had been trained that the temps must reach 180. She responded, "Yes." EI #1 explained that they have to run it through several cycles to get it hot enough in the morning. 4.) The facility's policy and procedure titled: "Food Temperatures" (undated) revealed: "... 3. Hot food items may not fall below 135 degrees after cooking. If temperature falls below 135 degrees food must be reheated to a temperature of 165 degrees for 15 seconds. ...6. Hot food will be held 165-180 degrees or higher when removed from the heat source. ..." On 03/13/13 at 10:50 AM, lunch trayline was observed. The cook (EI #3) took the temperatures of all the items that were on the trayline. EI #3 heated up two individual bowls (one containing chicken broth and one containing leftover cream of chicken soup) then placed them on the trayline. EI #3 did not check the temperatures of the two individual items. At 11:17 AM, the cream of chicken soup was placed on a tray and put in the cart. As the cart was going out the door, EI #3 was asked if she checked the temperature of the soup. She said she did not. The temp of the soup was then checked and was 153 degrees F. The soup was re-heated in the microwave. The temp was then measured as 164 degrees F. It was placed on the cart and went out of the kitchen. The chicken broth was placed on the cart. EI #3 was asked if she took the temperature of it. She said she did not. It was re-heated in the microwave and was 201 degrees F. On 03/14/13 at 9:45 AM, EI #1 was asked what the potential harm was if food did not reach the proper temp. She said it is to kill harmful bacteria.

Based on observation, record review and interviews, the facility failed to ensure staff provided privacy for Resident Identifier (RI) #16 and #17 during the administration of eye drops. This affected 2 or 2 residents observed receiving eye drops during medication pass. Findings include: 1) RI #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #16's most recent quarterly Minimum Data Set with an assessment reference date of 12/23/2011 revealed a Brief Mental Interview Status score of 12 indicating that the resident's cognitive status is moderately impaired. During medication pass on 3/13/2012 at 4:20 PM, Employee Identifier (EI) #1, Licensed Practical Nurse (LPN) was observed administering RI # 16's eye drops. EI #1 failed to pull RI #16's privacy curtain or shut the resident's door while administering the resident's eye drops. A review of a facility policy titled "General Dose Preparation and Medication Administration" with a revision date of 05/01/10 revealed "...Observe each resident's privacy and rights in accordance with Applicable Law (e.g.,knocking before entering the room, pulling privacy curtains, informing resident what is to occur before administration);" An interview was conducted via telephone with EI #1 on 03/15/2012 at 9:45 AM. EI #1 was asked what the facility policy said about providing privacy. EI #1 stated "We are suppose to provide privacy..." 2) RI #17 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #17's most recent quarterly Minimum Data Set with an assessment reference date of 02/05/2012 revealed the resident's cognitive status was severely impaired. During medication pass on 03/14/2012 at 8:23 AM, Employee Identifier (EI) #2, Registered Nurse (RN) was observed administering eye drops to RI #17. RI #17's door was open, the privacy curtain was not pulled and the blinds were open. A review of a facility policy titled "General Dose Preparation and Medication Administration" with a revision date of 05/01/10 revealed "...Observe each resident's privacy and rights in accordance with Applicable Law (e.g.,knocking before entering the room, pulling privacy curtains, informing resident what is to occur before administration);" A phone interview was conducted on 03/15/2012 at 10:55 AM with EI #2. EI #2 was asked if RI #17's door and blinds should have been closed and privacy curtain pulled. EI #2 replied "I didn't know I had to do that when she was in the privacy of her room". An interview was conducted with EI #3, Director of Nurses on 03/15/2012 at 2:38 PM. EI #3 was asked what the facility policy said about providing privacy when administering medications such as eye drops. EI #3 replied, the policy says staff should provide privacy. EI #3 was then asked if staff was expected to ensure privacy when administering medications such as eye drops. She replied, "yes".

Based on observation, record review and interviews the facility failed to ensure licensed staff practiced hand hygiene when transitioning from giving by mouth medications to eye drop administration. This affected Resident Identifier (RI) #16, 1 of 2 observations of eye drop administration during medication pass. Findings include: On 03/13/2012 at 4:20 PM, Employee Identifier (EI) #1 was observed administering eye drops to RI #16. EI #1 washed her hands and applied gloves before giving RI #16's by mouth medications. After giving the medications by mouth, EI #1 administered RI #16's eye drops. EI #1 did not perform hand hygiene or change gloves after the administration of RI #16's by mouth medications. EI #1 then administered RI #16's eye drops. A review of the facility policy titled "Adminsitration of eye meds" with an issue date of January 2000 revealed "...Eye medication administration should be done as follows: 1. Wash hands immediately before and after administration of medication..." A review of Potter and Perry's, Fundamentals of Nursing, 7th Edition (page 725) from "Administering Ophthalmic Medications" revealed "...Steps...9 Take medication to client at correct time, and perform hand hygiene..." An interview was conducted with EI #3, Director of Nurses, on 03/15/2012 at 10:10 AM. EI #3 was asked if hand hygiene should be performed after giving the by mouth medications and before administering eye drops to RI #16. EI #3 stated, if hand hygiene was not performed by EI #1, it should have been.

Based on observation, interview and record review the facility failed to ensure Posted Nurse Staffing was correctly filled out for 3 of 3 days of survey. This had the potential to affect all visitors, staff and residents residing in the facility. Findings include: On 3/13/12 at 4:05 PM the surveyor observed the Posted Nurse Staffing Sheet above the nursing desk. The sheet displayed listed the staffing for 3/12/12. On 3/14/12 at 8:20 AM the surveyor observed the Posted Nurse Staffing Sheet above the nursing desk. The sheet displayed the projected numbers for the entire day. The actual number of staff for the 11:00 PM - 7:00 AM shift was not listed. On 3/15/12 at 8:10 AM the surveyor observed the Posted Nurse Staffing Sheet above the nursing desk. The sheet displayed the projected number of staff for the entire day. The actual number of staff for the 11:00 PM - 7:00 AM and 7:00 AM- 7:00 PM shifts were not listed. An interview with EI (Employee Identifier) #3, Director of Nurses was conducted on 3/15/12 at 9:55 AM. EI #3 was asked who is responsible for posting the nurse staffing for the facility and she stated the charge nurse for 11 PM - 7 AM and if it changes we make updates during the day. EI #3 was asked to review the staffing sheet from 3/14/12 to see if the actual number of staff was posted for the 11:00 PM - 7 AM shift. EI #3 stated the actual number is not posted. EI #3 was asked to review the staffing sheet from 3/15/12 to see if the actual number of staff was posted for the 11:00 PM - 7:00 AM and 7:00 AM - 3:00 PM shift. EI # 3 stated the actual numbers were not posted.