Every finding on record at Martha Coker Green House Home

Based on observation, staff interview, record review, and facility policy review, the facility failed to maintain a clean and sanitary refrigerator, label, and date open items in the refrigerator and freezer for one (1) of six (6) houses and failed to check and record food temperatures before serving meals for four (4) of six (6) houses reviewed during survey. Findings Include: House #5 Review of the facility policy titled, Cleaning of Food and Nonfood Contact Surfaces with a revision date of 1/24, revealed under, Food Contact Surfaces . To prevent cross -contamination, kitchenware and food-contact surfaces of equipment shall be washed, rinsed, and sanitized after each use and following any interruption of operations during which time contamination may have occurred. Also revealed, Food Contact Surfaces (meaning: those surfaces of equipment and utensils which food normally comes in contact, and those surfaces from which food may drain, drip, or splash back onto food or surfaces normally in contact with food.) Review of the facility policy titled Dating and labeling of Food in Production undated, revealed under, Standard: All foods, including prepared items, bulk foods, frozen foods, and ingredients present in a (Proper Name) facility must be labeled at all times. Foods requiring a date mark shall be labeled with the common name, preparation date, discard date, and associate initials. Initial tour of the kitchen at House # 5 on 9/24/24 at 11:55 AM, revealed a white refrigerator in the pantry area contained an empty, brown, cardboard egg crate in the bottom of the refrigerator that was observed to be wet with a white substance. The shelf above held two (2) containers of milk that were not stored in an upright position which resulted in milk leaking into the bottom of the refrigerator and on the egg carton. An observation on 9/24/24 at 12:06 PM, of the refrigerator in the kitchen area of the House #5 revealed a dark red liquid that covered the interior bottom of the refrigerator pull out crisper drawer. The top crisper drawer contained a large package [5 pounds (lbs.)] of sliced cheese with a torn blue wrapper that was undated and was dried out and hard around the edges. The freezer side of the refrigerator held a large clear plastic bag of tater tots that had been opened and was unlabeled and undated. An interview with Shahbaz #3 on 9/24/24 at 12:11 PM, revealed that anyone could clean out the refrigerators when they were dirty and needed cleaning. She explained the red substance in the kitchen refrigerator crisper drawer was blood from raw ground beef that had been stored until it was cooked for lunch today. She stated, It must have leaked out of the bag. Shahbaz #3 confirmed the sliced cheese was not any good and should be thrown away. She revealed the cheese, and the tater tots had been opened and were not labeled and dated but should have been. She confirmed the pantry refrigerator had spilled milk that had saturated the lower refrigerator. Shahbaz #3 revealed all the issues identified could make the Elder's sick. House #1, #2, #4, and #6 Temperature Logs Review of the facility policy titled, Food Handling Guidelines (HACCP) Hazard analysis and critical control points, with a revision date of 1/24, revealed Minimum Safe Internal Temperatures: Hot food temperatures must be checked before the cooking process is ended. Hot Holding Temperatures: Foods should be held hot for service at a temperature of 135 degrees or higher. Cold Holding Temperatures: Foods should be held cold for service at a temperature of 41 degrees or less. Record review of the September 2024 Food Temperature Logs for House # 1 revealed the breakfast and lunch meal temperatures were not logged for the dates of 9/2, 9/9, 9/10, 9/16, and 9/23. The facility was unable to account for the meal temperature logs for the dates of 9/3, 9/4, 9/5, 9/6, 9/7, 9/8, 9/11, 9/12, 9/13, 9/14, 9/15, 9/17, 9/18, 9/19, 9/20, 9/21, 9/22, 9/24, and 9/25. Record review of the September 2024 Food Temperature Logs for House # 2 revealed the lunch and dinner temperatures were not logged for 9/1, 9/2, 9/7, and 9/8. The dinner temperatures were not logged for the following dates 9/3, 9/4, 9/5, 9/9, 9/10, 9/11, 9/12, 9/13, 9/14, 9/15, 9/16, 9/17, 9/18, 9/19, 9/20, 9/21, 9/22, 9/23, and 9/24. Record review of the August 2024 Food Temperature Logs for House #4 revealed the breakfast and lunch meal temperatures were not logged for the dates of 8/14, 8/15, 8/16, 8/17, 8/18, 8/19, 8/20, and 8/21. The facility was unable to account for the meal temperature logs from 8/22/24 until 9/25/24. On 9/24/24 at 12:00 PM, at House #4 an interview with Shahbaz #2 revealed she did not check the food temperatures for the lunch meal today. She revealed that she was sure she was trained to check the temperatures but confirmed she had not been checking them for any meal she had cooked in a long time. Record review of the September 2024 Food Temperature Logs for House #6 revealed the Dinner temperatures were not logged for the following dates 9/14, 9/16, 9/18, and 9/20. On 9/15 and 9/17 the temperatures were not logged for breakfast, lunch, or dinner. On 9/19 the temperatures were not logged for lunch and dinner. The facility was unable to account for the meal log for the dates of 9/1-9/13, 9/21, 9/22, and 9/23. An interview with Shahbaz #4 on 9/25/24 at 10:38 AM, in House # 6 revealed the food temperatures were to be checked before serving each meal and logged. She confirmed there was missing documentation in the logbook to prove that the temperatures were being checked with each meal. She explained that staff do the temperatures out of habit and then forget to log it down because they get busy and forget. Shahbaz #4 confirmed, if it is not logged, there would be no way to ensure that it was done. An Interview with Shahbaz #1 on 9/24/24 at 12:05 PM, revealed she was not safe certified and had no knowledge of checking the holding food temperatures. She voiced that she was not trained in that. An interview with the Registered Dietician (RD) on 9/25/24 at 12:51 PM, revealed that the Shahbaz's were trained upon hire on the duties in the kitchen including taking and logging holding food temperatures, cleaning and the storage of food products. He revealed this was part of their job responsibilities. He revealed each house has a safe serve certified Shahbaz that does the cooking. The RD confirmed that the food holding temperatures should be checked before serving every meal. He revealed all Shahbaz's were trained, and they have also had in-services on ensuring foods were labeled and dated when they opened. He revealed the blood left in the refrigerator crisper tray was not acceptable and should have been cleaned at the point it was observed. The RD confirmed these things discussed could make the elders sick. He stated, It could cause food poisoning, at the very least some upset stomachs. He then revealed he was unable to find any food temperature logs for the Month of September 2024 for House #4 and found blanks in the temperature logs for Houses #1, #2, and #6. In a follow-up interview with the RD on 9/25/24 at 3:05 PM, revealed the facility does not have any forms that the house's document the cleaning of the refrigerators. He revealed he audits the houses at least monthly for cleanliness, storage of items, items labeled and dated, and the problems were reported to the Administrator and the Shahbaz Coordinator. An interview with the Administrator (ADM) on 9/25/24 at 1:48 PM, revealed that they were making audits on the houses weekly to ensure the food temperatures were being done and logged but had since changed to monthly. She revealed the Shahbaz's knew that when things were opened, they must be labeled and dated and voiced they all had been in-serviced on this. She confirmed that when the refrigerator needed cleaning because of a spill, it should be cleaned and not left for someone else. The ADM explained that they go over all these things and the kitchen responsibilities monthly in the Shahbaz meeting. She confirmed that these issues discussed could cause spoilage of food or an infection for the Elders.

Based on record reviews, staff interviews, and facility policy reviews, the facility failed to submit a correct Pre-Admission Screening and Resident Review (PASRR) for an Elder identified as having a mental illness. This issue involved one (1) of three (3) elders reviewed for PASRR. Elder #8. Findings Included: A review of the facility's policy titled Resident Assessment-Coordination with PASARR Program revealed: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receive care and services in the most integrated setting appropriate to their needs. A record review of the PASRR, dated 12/27/23, for Elder #8 revealed that he had a diagnosis of Schizophrenia; however, question 31 was answered no, indicating that the Elder did not have a history of mental illness. Further review of the Pre-Admission Screening and Resident Review Determination (PASRR) for Elder #8 revealed the following outcome: Level 1 Outcome: Closed-Canceled/Withdrawn. Level 1 Outcome Comments: This PASRR will be canceled due to lack of documentation available to support the individual's diagnoses. A status change can be submitted upon retrieval of further information to support the individual's diagnoses. During an interview with Medical Records on 9/25/24 at 12:30 PM, confirmed that the PASRR had been completed incorrectly by indicating that Elder #8 did not have a mental illness. She also verified that there was no indication that a status change had been submitted to correct the error. In an interview with the Administrator on 9/25/24 at 1:16 PM, she agreed that a status change should have been submitted for Elder #8. She acknowledged that the purpose of a PASRR is to ensure the resident is properly placed and to make sure that the resident receives any additional interventions they may need. A review of the Admission Record revealed that the facility admitted Elder #8 on 12/19/23 with a diagnosis of Schizophrenia. Record review of the Minimum Data Set with an Assessment Reference Date of 9/13/24 Section I revealed a diagnosis of Schizophrenia.

Based on observation, elder and staff interview, record review, and facility policy review, the facility failed to implement a comprehensive care plan for nail care for two (2) of sixteen sampled elders. Elder #7 and #31 Findings Include: Review of the facility policy titled Comprehensive Care Plans date implemented 10/2022 revealed, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Resident #31 Record review of Elder #31's Care Plan with a revision date of 9/11/2024 revealed, Focus: Elder has an ADL (activities of daily living) self-care performance deficit r/t (related to) impaired balance, musculoskeletal impairment cervical disc disorder with myelopathy, paraplegia. Also, revealed under, Interventions: . Personal Hygiene . Elder is totally dependent on staff for personal hygiene . x (times) 1 staff assist q (every) shift. Keep nails clean and trimmed. On 9/24/24 at 11:25 AM, an observation and interview with Elder #31 revealed long jagged fingernails on both hands measuring approximately three-eighths (3/8) inch in length with a dark brown substance underneath. The elder revealed he would like his nails cut. An interview and observation, with Registered Nurse (RN) #1, on 9/24/24 at 11:32 AM confirmed Elder #31's nails were long and dirty. Record review of the Admission Record revealed the facility admitted Elder #31 on 1/05/24 with a medical diagnosis of Cervical Disc Disorder with Myelopathy. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/02/24 revealed, under section C, a BIMS summary score of 15, which indicated Elder #31 was cognitively intact. Resident #7 Record review of Elder #7's Care Plans revealed Focus: Elder has an ADL (activities of daily living) self-care performance deficit r/t (related to) Alzheimer's, confusion, dementia, limited mobility, bilateral contractures lower ext (extremities). Also, revealed under, Interventions: . Personal Hygiene . Elder is totally dependent on (2) staff for personal hygiene Provide nail care, keep clean and trimmed. An observation and interview, on 9/24/24 at 11:40 AM, with Elder #7 revealed long fingernails observed on both hands, measuring approximately one-half (1/2) inch in length. The elder voiced it had been a while since her nails had been cut and revealed she would like it done. On 9/25/24 at 7:40 AM, an interview with RN #1 confirmed Elder #7's nails were long and needed to be cut. Record review of the Admission Record revealed the facility admitted Elder #7 on 11/02/21 with a medical diagnosis of Alzheimer's Disease. Record review of the MDS with an ARD of 8/5/24 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 10, which indicated Elder #7 was moderately cognitively impaired. In an interview with the MDS Nurse on 9/25/24 at 2:32 PM, she stated the care plan provides the guided care the staff were supposed to follow. She confirmed the care plan was not followed, related to nail care for Elder's #7 and #31.

Based on observation, elder and staff interview, and facility policy review, the facility failed to provide the necessary nail care for an elder dependent on staff for assistance with Activities of Daily Living (ADL) for two (2) of sixteen sampled elders. Elder #7 and #31 Findings Include: Review of the facility policy titled, Nail Care dated 10/2022 revealed, Policy: The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health . 3. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis Resident #31 During an observation and interview on 9/24/24 at 11:25 AM, with Elder #31 revealed long jagged fingernails on both hands measuring approximately three-eighths (3/8) inch in length with a dark brown substance underneath. The elder revealed he would like his nails cut. On 9/24/24 at 11:32 AM, an interview and observation with Registered Nurse (RN) #1 revealed the Shahbaz's were responsible for cutting the elder's nails that were not diabetic. She explained that if an elder was a diabetic, the nails must be cut by a RN and diabetic nails were usually cut monthly. RN #1 revealed Elder #31 was a diabetic and confirmed his nails were long and dirty, which could result in skin injury and infection. Record review of the Admission Record revealed the facility admitted Elder #31 on 1/05/24 with a medical diagnosis of Cervical Disc Disorder with Myelopathy. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/02/24 revealed, under section C, a BIMS summary score of 15, which indicated Elder #31 was cognitively intact. Resident #7 During an observation and interview, on 9/24/24 at 11:40 AM, with Elder #7 revealed long fingernails observed on both hands, measuring approximately one-half (1/2) inch in length. The elder voiced it had been a while since her nails had been cut and revealed she would like it done. An interview with RN #1 on 9/25/24 at 7:40 AM, confirmed Elder #7's nails were long and revealed she could easily scratch herself. Record review of the Admission Record revealed the facility admitted Elder #7 on 11/02/21 with a medical diagnosis of Alzheimer's Disease. Record review of the MDS with an ARD of 8/5/24 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 10, which indicated Elder #7 was moderately cognitively impaired. An interview with the Administrator (ADM) on 9/25/24 at 1:48 PM, revealed, it was her expectation for nail care to be done daily. She explained that nail care was part of personal hygiene and should be looked at during bathing and done when needed.

Based on record review, staff interviews, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) assessment for discharge deposition for one (1) of 15 elder assessments reviewed. Elder #58 Findings included: Record review of Facility Policy titled, Conducting an Accurate Resident Assessment revealed, Policy: The purpose of this policy is to assure that all residents receive an accurate assessment . Record review of the Notice of Transfer/Discharge Notice dated 7/29/24, for Elder #58 revealed that the elder discharged to an alternative nursing home. Record review of Elder #58's Discharge return not anticipated MDS, with an Assessment Reference Date (ARD) of 7/29/24, revealed discharge status was coded as 04, indicating that the elder was discharged to a Short-Term General Hospital. During an interview with the MDS Coordinator on 9/25/24 at 10:47 AM, she confirmed that Elder #58 discharged to another long-term care facility and that the MDS was coded incorrectly. She stated it was a data entry error. She agreed that the importance of correctly coding the MDS accurately is to identify where the resident is located. An interview with the Administrator on 9/25/24 at 11:00 AM, revealed the MDS should have been coded correctly. Record review of the Admission Record revealed that facility admitted Elder #58 on 6/18/24 with a diagnosis of Diabetes Mellitus.

Based on observation, staff interview, record review, and facility policy review, the facility failed to use hand hygiene during wound care to prevent the possibility of the spread of infection for one (1) of four (4) care observations. Elder #44 Findings Include: Review of the facility policy titled Clean Dressing Change with no revision date revealed under, Policy: It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Record review of Elder #44's Treatment Administration Record (TAR) for September 2024, revealed an order dated 9/24/24, Apply collagen powder to wound bed. May dampen collagen powder with normal saline before application. Apply sureprep to peri area around wound, cover with bordered dressing daily until healed. every day shift for sacral wound. An observation of sacral wound care for Elder #44, with Licensed Practical Nurse (LPN) #1 on 9/25/24 at 11:40 AM, revealed she removed the soiled dressing from the sacrum and continued the treatment to the wound without performing hand hygiene and applying a new pair of gloves. An interview with LPN #1 on 9/25/24 at 11:47 AM, confirmed she did not wash her hands after removing Elder #44's soiled dressing. LPN #1 revealed she should have washed her hands to ensure the wound did not get infected. An interview with the Infection Control Nurse on 9/25/24 at 3:36 PM, confirmed improper hand hygiene during wound care was an infection control concern and could cause a wound infection. Record review of the Admission Record revealed the facility admitted Elder #44 on 2/09/21 with medical diagnoses that included Unspecified Dementia and Pressure Ulcer of Sacral region stage 3.

Based on observation, resident and staff interview, record review, and facility policy the facility failed to implement a resident's comprehensive care plan for fluid restriction for one (1) of 15 care plans reviewed. Resident #34 Findings include: A review of the facility policy titled Comprehensive Care Plans, revised 11/2017, revealed Policy: It is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment A record review of the care plan titled Elder has the potential for cardiovascular complications r/t (related to) CHF (Congestive Heart Failure), CAD (Coronary Artery Disease), HTN (Hypertension), AFIB (Atrial Fibrillation), SOB (Shortness of Breath) with exertion, with a revision date of 1/4/23, revealed Interventions: .1000ml fluid restrictions . A review of the medication record by for June 2023, revealed Resident #34 received more then the physician prescribed, 1000 mm fluid restriction, on 21 days from June 1st-26th. On 6/26/23 at 2:05 PM, an interview with Resident #34 revealed he had Congestive Heart Failure and was on fluid restriction. State Agency (SA) observed a glass of water with measurements on the side of the glass. SA observed 240 millimeters/mm of water in the glass. Resident revealed he was unsure of how much fluids he can have but he drinks what he is given. A review of the comprehensive care plans for Resident #34 with the Director of Nursing (DON) on 6/27/23 at 10:55 AM, she confirmed staff were not following the care plan for fluid restriction and revealed the purpose of the care plan is to direct the personalized care for each resident. An interview with the Registered Dietician (RD) on 6/27/23 at 3:07 PM, confirmed after looking at the record Resident #34 was receiving a lot more fluids daily than the physician recommended amount. A record review of the care guide for Resident #34 for June 2023 revealed How much fluid did the resident drink? revealed no directions related to fluid restrictions. Record review of the Admission Record revealed that the facility admitted Resident #34 to the facility on [DATE] with diagnoses of Acute on Chronic Combined Systolic and Diastolic Congestive Heart Failure and Chronic Obstructive Pulmonary Disease. Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 6/15/23, revealed that Resident #34 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated that he was cognitively intact.

Based on staff interviews, record review, and facility policy review, the facility failed to accurately complete section N of the Minimum Data Set (MDS) for a resident, as evidence by the incorrect coding of anticoagulant medication use during the 7-day observation look-back period for 1 (one) out of 19 residents sampled for anticoagulant use. Resident #10 Findings include: Review of the facility policy titled Resident Assessment -RAI with a revision date of 11/2016 revealed under, Policy: This facility makes a comprehensive assessment of each resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. Also revealed under, Policy Explanation and Compliance Guideline: . 2. The assessment will include at least the following: . n. Special treatments and procedures Record review of the Quarterly MDS with an Assessment Reference Date (ARD) of 6/01/23 revealed under section N, Resident #10 received seven (7) days of Anticoagulant medication for the observation look back period of 5/26/23 through 6/01/23. Record review of the Medication Administration Record (MAR) for the MDS 7 day observation look-back period for anticoagulant medication revealed Resident #10 did not receive anticoagulant medication between 5/26/23 and 6/01/23. An interview with the MDS Coordinator on 6/28/23 at 10:35 AM, confirmed that Resident #10 was coded for receiving 7 days of anticoagulant medication on the MDS. She revealed that Resident #10 received an antiplatelet medication and that the 7 days of anticoagulant medication was coded in error. An interview with the Director of Nursing (DON) on 6/28/23 at 1:55 PM, confirmed that the antiplatelet medication should not be coded under the anticoagulant section of the MDS assessment for Resident #10. Record review of the Admission Record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, and Encounter for Attention to Gastrostomy and Dysphagia. Record review of the MDS with an ARD of 6/01/23 revealed under section C, a Brief Interview for Mental Status (BIMS) score of 99, indicating Resident #10 was unable to complete the interview.

Based on observation, resident and staff interview, record review, and facility policy the facility failed to follow a resident's physician prescribed fluid restriction for one (1) of 15 resident records reviewed. Resident #34 Findings include: A review of the facility policy titled, Fluid Restriction, revised 03/23/23, revealed, Policy: It is the policy of the facility to ensure that fluid restrictions will be followed in accordance to physician's orders Compliance Guidelines: 1.) The nurse will obtain and verify the physician's order for the fluid restriction and an order written to include the breakdown of the amount of fluid per 24 hours An interview with Resident #34 on 6/26/23 at 2:05 PM, he revealed he had Congestive Heart Failure and was on fluid restriction. State Agency (SA) observed a glass of water with measurements on the side of the glass. SA observed 240 milliliters (ml) of water in the glass. Resident #34 revealed he was unsure of how much fluids he can have but confirmed he drinks what is given to him. An interview with Certified Nursing Assistance (CNA) #1 on 6/27/23 at 10:40 AM, revealed Resident #34 was on a fluid restriction and she believed it was 1500 milliliter (ml) a day. CNA #1 revealed Resident #34 is served a 360 ml glass and a 240 ml glass of fluids with each meal. CNA #1 revealed Resident #34 has not ever been angered or non-compliant with his fluid restrictions. CNA #1 revealed she was unsure of how she knew Resident #34 was on fluid restrictions. An interview and record review of Resident #34's Order Summary Report with Licensed Practical Nurse (LPN) #1 on 6/27/23 at 10:50 AM, revealed an order for fluid restriction dated 1/2/23 revealed she had obtained the order for the fluid restriction and revealed the order is for 1000 ml Fluid Restriction Intake Q (every) Shift and confirmed the restriction is supposed to be 1000 ml every 24 hours. An interview and record review of the physician's order for fluid restriction for Resident #34 with the Director of Nursing (DON) on 6/27/23 at 10:55 AM, confirmed the order reads to her 1000 ml fluid restriction intake Q (every) shift and she confirmed that a nurse reading the order would think that Resident #34 was allowed 1000 ml every shift equaling 3000 ml daily. The DON also revealed the dietary order read Regular texture, Regular/Thin consistency, 1000 ml FLUID RESTRICTION. The DON confirmed the fluid restriction order should have been written in a way easy for staff to understand and confirmed staff were not following the physician's specific fluid restrictions order correctly for Resident #34 and this placed Resident #34 at risk for fluid overload related to his congestive heart failure. A review of the progress notes for Resident #34 with the DON for the Months of May and June 2023 on 6/27/23 at 11:03 AM, revealed she could find no documentation of non-compliance with fluid restriction by resident. A review of the medication record by for June 2023, revealed 1000 ml fluid restriction Q SHIFT (every shift) no breakdown of the amount of fluids per 24 hours. A continued review revealed Resident #34 received more that the physician prescribed 1000 ml fluid restriction on 21 days from June 1st-26th. An interview with the Registered Dietician (RD) on 6/27/23 at 3:07 PM, he revealed Resident #34 is drinking 1000-1100 ml fluid at meals and is on a 1000 ml fluid restriction every 24 hours. After review of the medication record with the RD he revealed he had no idea the nurses documented the fluid intake on the medication record and confirmed he gets the average amount of fluid intake from the care guide that the CNA's document on. The RD confirmed after looking at the medication record Resident #34 was receiving a lot more fluids daily than the physician recommended amount. A review of the care guide for June 2023 revealed How much fluid did the resident drink? revealed no directions related to fluid restrictions. An interview with LPN #2 on 6/27/23 at 3:15 PM, revealed that Resident #34 is on a 1200 ml fluid restriction every 24 hours. SA asked how she knew how much fluid she was to give the Resident; LPN #2 revealed the amount should be on the medication record. LPN #2 then revealed the amount of fluid given is documented on the medication record and confirmed she gets the total for the shift she works from the amount of fluids the CNA gives Resident #34 and the amount of fluids given with medication administration. Record review of the Admission Record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses of Acute on Chronic Combined Systolic and Diastolic Congestive Heart Failure and Chronic Obstructive Pulmonary Disease. Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) on 6/15/23, revealed that Resident #34 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated that he was cognitively intact.

Based on observation, staff interview, and facility policy review, the facility failed to discard expired food, and label and date opened food items for four (4) of six (6) kitchens observed. Findings include: Review of the facility's Food and Supply Storage Procedures policy, dated ,[DATE], revealed all food, non-food items and supplies used in food preparation shall be stored in such a manner as to maintain the safety and wholesomeness of the food for human consumption. Most products contain an expiration date. The words sell-by or use-by should precede the date. The sell-by date is the last date that food can be sold. Do not sell products in retail areas or place on patient trays and/or resident plates past the date on the product. Cover, label, and date unused portions and open packages. Date and rotate items, first in, first out (FIFO). Discard food past the use-by date. House #1 On [DATE] at 10:45 AM, the initial tour of the kitchen in House #1 revealed, the refrigerator in the pantry behind the kitchen had four (4) bottles of eight (8) ounces banana nut flavor shake with an expiration date of [DATE]. An Observation of the refrigerator in the pantry revealed a five (5) pound container of sour cream with an expiration date of [DATE], a 5-pound container of cottage cheese with an expiration date of [DATE], and a six (6) pound container of mustard with an expiration date of [DATE]. On [DATE] at 11: 15 AM an interview with Shahbaz #6 confirmed four (4) banana nut shakes had an expiration date of [DATE], the sour cream had an expiration date of [DATE], the container of cottage cheese had an expiration date of [DATE], and the container of mustard had an expiration date of [DATE]. Shahbaz #6 confirmed all of the expired food should be thrown away. Shahbaz #6 revealed, anyone getting into the refrigerator should check for expired items and discard them if they are expired. On [DATE] at 2:20 PM an interview with the Licensed Dietician (LD) confirmed the Shahbaz were responsible for checking all food items in the pantry, freezer, and the refrigerator for expiration dates and throw them away if they were expired. The LD confirmed if the residents ate some expired food it could make them sick. House #5: On [DATE], at 2:36 PM, in House #5, the following pantry items were observed to be expired: Two (2) 15.25-ounce (oz) cans of black beans with an expiration date of [DATE]. One (1) box of buttermilk biscuit Mix 5 lb. with an expiration date of [DATE]. One (1) partially used open box of devil's food cake mix with a best if used by date of [DATE]. One (1) 20 oz. opened loaf of 100% whole wheat bread with a best by date of [DATE], with 17 slices in the bag. One (1) 20 oz. opened loaf of 100% whole wheat bread with best by date of [DATE] with 22 slices in the bag. The following items were open and unlabeled and/or dated: One (1) - 2.7 oz plastic jar of chocolate sprinkles ,[DATE] full. One (1) - 9 oz. box of mashed potatoes was opened approximately 2 inches on edge of the top lid and not sealed. On [DATE], at 3:02 PM, an observation of the kitchen refrigerator revealed a five (5) pound (lb.) bag of mozzarella shredded cheese opened and the bag was not labeled or dated. It contained about three (3) inches of cheese in depth in the bottom of the bag. A three inch by six inch slice of corn bread was loosely wrapped in crumpled aluminum foil with no label or date. One small 4 oz. bowl of ravioli labeled good thru [DATE], covered in clear plastic was in the refrigerator. An observation of a kitchen cabinet revealed three (3) large tea bags in a torn zip lock gallon bag with no date on the bag. Shahbaz #1 put them in a new zip lock bag and replaced the bag in the cabinet. She said, I'm pretty sure they will be used tomorrow. On [DATE], at 3:06 PM, during an interview with Shahbaz #1, she stated, It's not labeled so I'll throw it out. Shahbaz #1 stated, our policy is to date and label, we really don't have to label things that have an expiration date on it like bread or salt, coffee or tea. We have a certain amount of days things can be open, so you have to label them, so you know when to throw them out. We have three (3) days. We have a guide that lets us know the shelf life of products. On [DATE], at 12:07 PM, during an interview with Administrator, she stated the Shahbaz are responsible for making sure food is labeled, dated, or discarded when expired. No food should be served after the expiration date or use by date. House #2: On [DATE] at 10:45 AM, during initial tour, the following items were noted in House #2: In the Dry Food Pantry: One (1) bag of hamburger buns - open with no dated label. One (1) loaf of bread - open with no dated label. One (1) - large gallon of oil - open with no dated label. One (1) - large bottle of white vinegar - open with no dated label. One (1) - loaf of unopened bread on the floor behind the door of the pantry. In the kitchen refrigerator: Multiple pieces of stacked, sliced cheese - open, partially wrapped in plastic wrap, edges of cheese were dried and hard, no dated label. One (1) - container of blueberries - partially used with no dated label. House #3: In the Dry Food Pantry: Multiple individual coffee bags in a gallon plastic bag - open with no dated label. Two (2)- gallon bags of macaroni pasta - open with no dated label. Three (3) - gallon bags of white rice - open with no dated label. One (1) - gallon bag of spaghetti pasta- open with no dated label. One (1)- bag of corn chips - open with no dated label. In the pantry refrigerator: Two (2) - boxes of strawberries - partially used, with mold on them, juice from strawberries leaked out on the door shelf - open and no dated label. Two (2) - boxes of blueberries - open with no dated label Three (3) - heads of lettuce in a large clear bag - open with no dated label. One (1) - head of cabbage in a plastic grocery bag - open with no dated label. In the kitchen refrigerator: One (1) - bottle of grape jelly - open with no dated label. In the Kitchen freezer: One (1) - gallon of vanilla ice cream - open with no dated label. One (1) - box of popsicles - open with no dated label.

Based on observation, record review, facility policy review, and staff interview, the facility failed to preserve a resident's dignity by failing to provide meals to all residents at a table at the same time for one (1) of two (2) resident dinning observations, Resident #25. Findings include: Review of the facility's Resident Rights policy, dated November 2017, revealed the resident has a right to be treated with respect and dignity. Record review of physician's orders [REDACTED]. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/28/2019, indicated a Brief Interview for Mental Status (BIMS) was coded as 99. The MDS section G0110H1, eating self-performance was coded as 3 which is extensive assistance and section G0110H2, eating support provided was coded as 2, which indicated, one person physical assist. An observation of the dinner meal on 1/28/2020 from 11:30 AM until 12:30 PM, revealed the residents were all seated at the table by 11:30 AM. The first plate was delivered to the table at 11:40 AM. Certified Nursing Aide (CNA) #8 started assisting Resident #25 at 12:13 PM. Resident #25 sat at the table for 43 minutes and was not served her meal for 33 minutes. An interview with CNA #7 on 1/28/2020 at 1:48 PM, revealed If they don't like something, we will fix them soup and a sandwich. We have one that just wants soup, crackers, and ice cream every day. We give them whatever they want. An interview with CNA #8 on 1/28/2020 at 2:00 PM, revealed We take turns feeding Resident #25. She stated Resident #25 is not always last but, the table is so crowded we have to wait until some of them finish to feed her. An interview with the Director of Nursing (DON) on 1/28/20 at 3:50 PM, revealed Ideally we want everyone eating at the same time and if we need to rearrange the setting to accomplish that, we can. A review of the facility's Face Sheet revealed, the facility admitted Resident #25 on 8/20/19, with [DIAGNOSES REDACTED].

Based on observation, record review, staff interview, and facility policy review, the facility failed to implement an activity care plan, for one (1) of 18 resident care plans reviewed, Resident #5. Findings include: Review of the facility's Activity policy, dated 11/28/17, revealed it is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences of each resident. Facility sponsored group, individual, and independent activities will be designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, as well as, encourage both independence and interaction within the community. Review of the facility's Comprehensive Care Plans policy, dated November 2017, indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Record review of the care plan with a Problem and/or Need indicated, Resident #5 has a need for continuing group activity contact. She currently enjoys card games, playing Bingo, and watching game shows on television, and listening to music. The care plan interventions include Ensure that a variety of cards and other games are available at all times for leisure and group activities, and Engage resident in group activities. During an observation of the Hearth Area in House #5 on 1/28/20, from 10:00 AM to 11:20 AM, neither Morning Stretch nor Bingo occurred as indicated by the Activity Calendar. Review of the Activity Calendar posted at the kitchen counter revealed Morning Stretch was scheduled at 10:00 AM, and Bingo was scheduled for 10:30 AM. On 01/30/20 1:58 PM, an interview with the Director of Nursing (DON) revealed she could not say whether or not Resident #5's care plan was followed but there is no documentation of any Activities performed for the month of January (2020) in House #5. Review of the facility's Face Sheet revealed the facility admitted Resident #5 on 9/19/16. Resident #5's current [DIAGNOSES REDACTED]. Review of Resident #5's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/14/19, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognitive skills for daily decision making.

Based on observation, resident interview, staff interview, record review, and facility policy review, the facility failed to revise Resident #19's activity care plan for one (1) of 18 care plans reviewed. Findings include: Review of the facility's Comprehensive Care Plans policy, dated November 2017, indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs that are identified in the resident's Comprehensive Assessment. The Policy Explanation and Compliance Guidelines revealed, the comprehensive care plan will be reviewed and revised by the interdisciplinary team. Review of Resident #19's care plan revealed, she has been spending most of her time in bed due to recent decline in health. Resident #19 enjoys some activities such as; and there were no activities listed after this statement. The goal and target date of 12/12/19 revealed, Resident #19 will enjoy one on one activities of choice and show a physical sign of enjoyment following at least one activity. The care plan approaches included, place activity calendar in a room where it is easily accessible, encourage to attend activities, cue to activity, time and place as needed, assist to activity as needed, provide in room activities of resident choice such as card games, provide equipment and supplies for activity. On 01/28/2020 at 10:52 AM, during initial tour, Resident #19 was observed lying in her bed, facing the window. The window blinds were closed, and the lights were off. Resident #19 had her eyes open and was looking at the closed window. On 01/28/2020 at 2:50 PM, Resident #19 was observed lying in her bed, facing the door, with her eyes closed. The window blinds remained closed, and the lights are off in her room. On 01/29/2020 at 9:15 AM, Resident #19 was observed lying in her bed. The window blinds remained closed and the lights were on in her room. Resident #19 had her eyes opened and responded to her name being called with a smile. On 01/29/2020 at 4:05 PM, Resident #19 was observed lying in her bed facing the window with the blinds closed, the lights off, and she was looking at the window. On 01/29/2020 at 10:50 AM, during an interview with the Director of Nursing (DON), regarding activities for Resident #19, she indicated, She is hospice, and they come several times a week, and her daughter is here all the time. There is not an individual activity log for one activity for her. Review of resident #19's chart revealed [DIAGNOSES REDACTED]. Resident #19's Significant Change in Condition Status (SCSA) with an Assessment Reference Date (ARD) of 11/7/19 revealed a Brief Interview for Mental Status (BIMS) score was 6, indicating she was severely cognitively impaired.

Based on observation, staff interview, resident interview, record review and facility policy review the facility failed to provide activities on a scheduled basis for one (1) of 16 residents observed for activities, Resident #5. Findings include: Record review of the facility's Activities policy, dated 11/28/2017, revealed, Policy: It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences of each resident. Facility sponsored group and individual activities and independent activities will be designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, as well as, encourage both independence and interaction within the community. During observation of the common area in House #5 on 1/28/20, from 10:00 until 11:20 AM, neither Morning Stretch nor Bingo occurred per review of the Activity Calendar. On 01/28/20 at 11:20 AM, an observation in the Common Room revealed, Bingo did not occur at 10:30 AM. On 01/28/20, at 10:28 AM, during an interview with Resident #5 in the common area, she stated she loved it at the facility but there are no activities. She stated she loves Bingo and they stopped it a good while ago. The House Coordinator for House #5 on January 1 through February 29, 2020, Shahbaz #1 was listed for Activities per schedule posted on bulletin board next to the kitchen. On 01/29/20, at 3:45 PM, in an interview with Resident #5 in the common room, she stated that she enjoyed Bingo yesterday and that it was the first time they played in a long time. When asked if they had any activities this morning she stated, no, just sat here and looked at this TV. She stated that she had hoped to play Bingo again this morning and that she would love to play more often stating, I love Bingo. On 01/28/20, at 3:29 PM, during an interview with, Shahbaz #1, she stated, everyone is responsible for activities, I work the evening shift, no other, they just put you down as house coordinator for certain things. They have an activities person at the office that brings the stuff down for activities, they really want you to do them, but they bring what they want you to do. On 01/29/20, at 3:15 PM, during an interview with the Administrator in the kitchen area of House #5, she was looking for the Activity Log, but it was not in the book and staff did not know where it was for January. She confirmed that there was no Activity Log in the book for January for House #5. She stated, Bingo is big in this house, they love it here. In an interview on 01/30/20, at 1:10 PM, the Administrator stated, If it wasn't documented, it wasn't done, and that there was no Activity Log for the month of January for House #5. Record review of the facility's Face Sheet revealed, the facility admitted Resident #5 on 9/19/16 with [DIAGNOSES REDACTED]. Record review of Resident #5's Quarterly Minimum Data Set with an Assessment Reference Date of 10/14/19, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognitive skills for daily decision making.

Based on observation, facility policy review and staff interview the facility failed to prevent the possible spread of infection during medication pass for one (1) of three (3) medication administration observation. Findings include: Review of the facility's Standard Precautions Infection Control policy, dated 11/2018, did not address using a barrier for items taken into an elder's room during medication pass. On 01/29/20, at 08:59 AM, during an observation of medication pass, Licensed Practical Nurse #1 (LPN), placed eye drops and nasal spray bottle for Resident # 10 on the window ledge of the resident's room without a barrier. The eye drop box fell on floor. LPN #1 picked up the box after med pass was completed and placed the eye drop bottle into the box. She then walked to the sink in the resident's bathroom and placed the eye drop box and nasal spray bottle on the counter next to the sink while she washed her hands. She then took the items and replaced them in the medication cart. In an interview on 01/30/20, at 08:48 AM, the Director of Nursing (DON) stated that the LPN, should have used barrier and if the box was dropped it should have been cleaned before placed back in the cart. This would be an infection control issue and we will go wipe the entire cart down. 01/30/20 10:53 AM In an interview with Registered Nurse #1(RN), Clinical Coordinator-Infection Preventionist, she stated, Any time staff take anything in a room it should be on a barrier. That is part of the infection control policy but they don't have one specific to med pass.

Based on observation, staff interview, facility policy review, Assure Prism Multi Blood Glucose Monitoring System Reference Manual review, Super Sani Disinfectant Cloth Label review, and record review, the facility failed to disinfect the multi use glucometer in a manner to prevent the potential spread of infection for three (3) of four (4) glucometer cleaning prior to a finger stick. Resident #18, #39 and #41 Findings include: Record review of the facility's policy titled, Glucometer Disinfection undated, revealed the purpose of this procedure is to provide guidelines for the disinfection of capillary-blood sampling devices to prevent transmission of blood borne diseases to residents and employees. Disinfection is a process that eliminates many and all pathogenic microorganisms, except bacterial spores, on inanimate objects. Policy Explanation and Compliance Guidelines: 3. The glucometer should be disinfected with a wipe pre-saturated with an EPA (Environmental Protection Agency) registered healthcare disinfectant that is effective [MEDICAL CONDITION](Human Immunodeficiency Viruses), [MEDICAL CONDITION] and [MEDICAL CONDITION] virus. 5. Procedure: J. Using first wipe, clean first to remove heavy soil, blood, and/or other contaminants left on the surface of the glucometer. K. After cleaning, use second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, following the manufacturer's instructions. [MI] Use third wipe to wrap the glucometer to disinfect for two (2) minutes. Record review of the Assure Prism Multi Blood Glucose Monitoring System, Quality Assurance and Quality Control (QA/QC) Reference Manual, no date, revealed: Page 16. The disinfection procedure was needed to prevent the transmission of blood borne pathogens. A variety of the most commonly used EPA-registered wipes have been tested and approved for cleaning and disinfecting the Assure Prism Multi Blood Glucose Monitoring System. The disinfectant wipes listed below have been shown to be safe for use with this meter. Please read the manufacturer's instructions before using their wipes on the meter. (The list included the Professional Disposables International (PDI) Super Sani-Cloth Germicidal Disposable Wipe). Page 17. Disinfecting (The meter should be cleaned prior to disinfection.) Step 5. Open the towelette container and pull out 1 (one) towelette and close the lid. Step 6. Wipe the entire surface of the meter 3 (three) times horizontally and 3 (three) times vertically to remove blood-borne pathogens. Step 7. Dispose of the used towelette in a trash bin. Step 8. Allow exteriors to remain wet for the appropriate contact time and then wipe the meter using a dry cloth. (The contact time for the Super Sani-Cloth Germicidal Disposable Wipe is 2 (two) minutes per the included Disinfectant Brand Name and Contact Time chart listed under Step 8.) Record review of the Super Sani-Cloth container label directions for disinfecting revealed: Unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet for a full 2 minutes. Let air dry. On 4/3/19 at 11:00 AM, an observation revealed Licensed Practical Nurse (LPN) #1 wiped the Assure Prism Multi Glucometer, prior to Resident #30's finger stick glucose, with the Super Sani - Cloth for approximately five (5) seconds, and then placed the glucometer on a Kleenex to air dry. LPN #1 performed the finger stick glucose on Resident #30, and then returned to the medication cart and wiped the contaminated glucometer with the Super Sani - Cloth for approximately 10 seconds and placed the glucometer on a Kleenex to air dry. On 4/3/19 at 11:15 AM, an observation revealed LPN #1 cleaned the Assure Prism Multi Glucometer before she performed a finger stick glucose on Resident #18. LPN #1 cleaned the glucometer with the Super Sani - Cloth by wiping the glucometer for approximately 10 seconds. LPN #1 performed the finger stick glucose on Resident #18, and then returned to the medication cart and wiped the glucometer with the Super Sani - Cloth for approximately 10 seconds, and then placed the glucometer on a Kleenex. On 4/3/19 at 11:20 AM, an interview with LPN #1 revealed she usually cleaned the glucometer about 15 seconds, and then places it on the Kleenex to air dry until it appears dry, a few minutes, time differs. LPN #1 stated she cleaned the glucometer 15 seconds before performing the finger sticks on Resident #18 and Resident #30. On 4/3/19 at 3:28 PM, an observation revealed LPN #2 cleaned the Assure Prism Multi Glucometer by wiping the glucometer with the Super Sani - Cloth for approximately 30 seconds, and then placed the glucometer on a clean Kleenex. LPN #2 then performed the finger stick on Resident #41, and then returned to the medication cart. LPN #2 then wiped the glucometer with the Super Sani - Cloth for approximately 30 seconds before she placed the glucometer on a Kleenex. On 4/3/19 at 3:35 PM, an interview with LPN #2 confirmed she wiped the glucometer for 30 seconds prior to performing the finger stick on Resident #41. LPN #2 read the Super Sani - Cloth label directions at this time, and confirmed disinfecting required the surface of the object being disinfected stay wet for 2 (two) minutes, and she did not keep the glucometer wet for 2 (two) minutes. LPN #2 stated not keeping the glucometer wet for two (2) minutes could cause the spread of infection to other residents. On 4/3/19 at 3:55 PM, an interview with the Director of Nursing (DON) revealed she was not aware the directions for disinfecting the glucometer with the Super Sani-Cloth wipes required the glucometer to stay wet for two (2) minutes. On 4/4/19 at 8:30 AM, an interview with LPN #1 confirmed she kept the glucometer wet for approximately 15 seconds when she performed the finger sticks on Residents #18 and #30 and did not know she should keep the glucometer wet for 2 (two) minutes. LPN #1 revealed since she did not keep the glucometer wet for two (2) minutes it could cause the spread of an infection to other residents.

Based on observation, record review, interviews and facility policy review, the facility failed to implement an ongoing resident centered activities program that incorporates the resident's interests for four (4) of six (6) residents reviewed for activities, out of a total of 60 residents. Resident #28, #47, #8, and #27. Findings include: Review of the facility's policy titled, Activities- Martha Coker, dated 11/28/2017, revealed, 1. Each resident's interest and needs will be assessed on a routine basis . 2. Activities will be designed with the intent to: a. Enhance the resident's sense of well-being, belonging, and usefulness. e. Promote self-esteem, dignity, pleasure, comfort, education, creativity, success and independence. f. Reflect the resident's interests and age. h. Reflect the choices of the residents. 6. Residents are encouraged, but not mandated, to participate in scheduled activities. Resident #27 Observation on 01/30/18 at 04:30 PM, revealed Resident #27 was not socializing with others in the dayroom. A staff Certified Nursing Assistant (Shahbaz) was seated on the piano stool facing the residents, but not interacting with them. Resident #27 was asleep in a recliner, but once awakened by surveyor, Resident #27 smiled and answered questions appropriately. On 01/31/18 at 11:07 AM, interview with the resident's Responsible Party (RP), revealed the staff needed to have more activities that the resident enjoys. She stated she is concerned with the lack of staff interaction with the resident. The RP stated she has not observed any activities of interest to the resident being done by the facility. She stated she wished the staff would do more one (1) to one (1) activity with Resident #27. Observation on 02/01/18 at 09:15 AM, revealed Resident #27 seated in a recliner, sleeping. 02/01/18 at 10:10 AM, observation revealed the facility did devotion time activity with the residents. The Shahbaz staff did not encourage Resident #27 to participate. Resident #27 was asleep in the recliner. Observation on 02/01/18 10:45 AM, revealed Resident #27 seated in a recliner in the dayroom, sleeping with the television (TV) playing. There was no other activity in progress. Observation during the lunch meal, on 02/01/18 at 12:10 PM, revealed Resident #27 seated at the dining table eating lunch with other residents. Resident #27 was speaking to other residents and smiling. On 02/01/18 at 01:56 PM, observation revealed Resident #27 seated in the dayroom in a recliner. Resident #27 was alert and requested that staff assist her to the restroom. There was one (1) other resident in the dayroom, but no activities were in progress. Review of the activities calendar revealed for 02/01/18, the facility had a devotion scheduled for 10:00 AM, and crossword puzzles scheduled for 3:00 PM. Observation revealed an activities schedule on each resident's bedroom wall. The activity calendar listed two (2) activities per day. There was a scheduled activity at 10:00 AM, and another activity at 3:00 PM, each day. Observation on 02/01/18 at 03:18 PM, revealed a Shahbaz staff member handed out crossword puzzles to residents, but failed to ask or offer a crossword to Resident #27. The Shahbaz failed to have any interaction with Resident #27. Resident #27 remained seated in a recliner in the dayroom, with her head drooped and her eyes closed during the activity time. Interview on 02/01/18 at 03:25 PM, with Shahbaz #3, revealed she did not offer Resident #27 a crossword puzzle because she was more one on one (1:1) and stayed up at night. When asked why she was not offered a crossword, Shahbaz #3 stated that Resident #27 has poor eyesight and could not do a crossword. She stated the resident liked to talk about her family, so they do 1:1 and let her talk. Shahbaz #3 stated that the Shabazem were responsible for all of the activities in the home. She stated the facility does not have an Activity Person. When asked about following the resident's care plan, Shahbaz #3 stated they just know the residents and do not have a written care plan they follow for activities. Review of the Shahbaz job description revealed, under section 2, that the Shahbaz demonstrates an understanding and commitment to the Eden Alternative in creating a human habitat; participates to create ways to alleviate the three (3) plagues: loneliness, helplessness and boredom. On 02/01/18 at 03:31 PM, after the interview, Shahbaz #3 woke Resident #27 and took her to the dining table, and started visiting with the resident. Interview on 02/02/18 at 09:26 AM, with Licensed Practical Nurse (LPN) #1, revealed he was not over activities. He stated he was responsible for medications and treatments. He stated he was not aware of any dementia training called Hand in Hand. He said the facility provides training sometimes by video and sometimes by pamphlets. He stated the facility always gives them some handout to refer to after training. On 02/02/18 at 10:39 AM, an interview with the Activities Person revealed she stated she has been the Activity Director for about two (2) weeks. When asked about Resident #27's lack of activities, the Activity Director stated she was not aware of Resident #27 not receiving activities. Resident #8 Observation on 01/30/18 at 11:30 AM, revealed Resident #8 coming and going from her room, pushed by staff earlier today. At this time she is at the table with others eating lunch and conversational. On 01/30/18 at 11:00 AM, during a general conversation, the resident expressed she thinks they should have coffee socials, as it would be an enjoyable activity, and they have not offered such. She was by a career, a seamstress for many years. She expressed she would enjoy showing others in the house(s) her machine (would have to be brought from home), and how she monogrammed, along with other techniques. Observation on 01/31/18 at 10:15 AM, revealed Resident #8 participating in devotional activities in the hearth room. Observation during 02/01/18, revealed Resident #8 was mostly alone in her room, other than devotional and visiting with her son from out of state. Observation on 02/02/18 at 4:00 PM, revealed Resident #8 visiting with her son from out of state. Resident #8 was interviewed about activities and she stated. other than Bingo and Bible study, they really do not do anything. She stated that the group was scheduled to go to store tomorrow, but the weather was supposed to be bad, so they probably would not go. She said she might like to go fishing in good weather. Observation on 02/05/18 at 10:10 AM, revealed Resident #3 dressed and up in a wheelchair, without leg brace, participating in word/memory/puzzle activity with group. She was cheerful and smiling. Resident #28 Observation on 1/30/18 at 10:30 AM, revealed Resident #28 was sitting in a wheelchair in her room watching TV, with a flat affect. Observation on 1/30/18 at 10:47 AM, revealed Resident #28's Accucheck was performed and read 217. On 1/30/18 at 11:30 AM, Resident #28 was observed at a group dining table, non conversational, but seemed to be listening to others, and she ate most of her diet. On 1/31/18 at 11:20 AM, Resident #28 was observed leaving room, from watching TV, to the table for lunch at the group table. On 02/02/18 at 9:05 AM, Resident #28 was sitting in her room watching the news. General conversation led to her saying she would very much enjoy sharing some of her memories and stories with others as there were many funny stories. She stated that she had taught school, multiple grades and subjects. Record review of Resident #28's care plan included encouraging her to engage in talk and have conversations with others, but had no mention of her history as a school teacher as an activity. On 02/05/18 at 10:10 AM, Resident #28 was dressed and up in a wheelchair, participating in word/memory/puzzle activity with group. She was cheerful, smiling and happy. She said she very much enjoyed this activity today. Resident #47 An observation on 02/01/18 at 09:39 AM, revealed Resident #47 seated in her wheelchair in the day room area. The television was on. Resident #47 was fidgeting with a blanket covering her legs. the resident did not appear to be watching television. An observation on 02/01/18 at 10:19 AM, revealed Resident #47 seated in a wheelchair in the dayroom. Shahbaz#2 was reading a Bible study. The Bible study lasted approximately 10 minutes. Resident #47 was given a Bible Study guide, but appeared to have difficulty holding it, and placed the guide in her lap. An observation on 02/01/18 at 10:40 AM, revealed Resident #47 seated in her wheelchair in the dayroom with her eyes closed. The television was on the game show network. Shahbaz #1 commented the game show network was all the residents' favorite channel. An interview on 02/01/18 at 02:00 PM, with Licensed Practical Nurse #1, revealed Resident #47 could lets you know what she wants to do, if asked, and all residents are encouraged to do what they like. He stated when he sees her, she is usually sitting in the hearth area in front of the television. He stated he knows she liked participating in Bible study. An observation and interview on 02/02/18 at 8:25 AM, revealed Resident #47 seated in her wheelchair in the day room area with her eyes closed. The television was on with three (3) residents, including Resident #47, seated in front of the television, but all had their eyes closed. Resident #47 was spoken to and opened her eyes. When asked about activities, the resident stated she doesn't do a whole lot. The resident stated she's not interested in what is on television during the daytime but likes to watch television at night. Resident #47 stated she is not necessarily sleeping when sitting in the day room area, but just closes her eyes because there's nothing else to do. The resident stated she really enjoys reading, but due to problems with her hands, and needing to wear arm sleeves, she cannot hold books. Resident #47 stated no one had offered to read to her or ask her if she would like to listen to a book. The resident stated she thought she may be able to manage reading a book if she had a tray to put it on. The resident stated she didn't know if there were audio books available, no one had every asked her if she would like to listen to one, but she thought she might. An interview on 02/02/18 at 9:11 AM, with with Shahbaz #1 and Shahbaz #2, regarding activities, revealed both stated it was their responsibility to do activities with residents. Both stated residents like to play Bingo and watch the game show channel. They both agreed that Resident #47 doesn't pay attention to television and nods off or closes her eyes while up in the day room. The Shahbaz stated the Activities Director made a schedule and they were supposed to follow it. They stated the Activities Director didn't complete the activities, it was up to them. They stated that sometimes they couldn't get to what was scheduled, depending on what was going on. They had not considered audio books for Resident #47. They stated they do not ask residents about what activities they like, they just do what is on the schedule the best they can. They state they aren't sure how they would be able to do a bunch of different things for residents because they all might like different things, but instead, do what majority of residents like, for example two (2) of the three (3) ladies in the hearth area liked the game show network, so they put it on that channel. Shahbaz #2 stated Resident #47 gets a church bulletin every week from her church that she keeps tucked under her arm, but has trouble holding the bulleting to read with her geri- sleeves on. Shahbaz #2 thought the resident may be able to manage to read using a tray, but had not offered her one. An observation on 02/02/18 from 10:00 AM to 10:35 AM, revealed Resident #47 seated in front of the television with her eyes closed. A review of the activities schedule, for (MONTH) 2nd, revealed Catholic Mass was being held in another house at 10:00 AM. An interview on 02/02/18 at 10:35 AM, with Shahbaz #1, revealed that no one from this house goes to Catholic Mass and she didn't think anyone was Catholic in the house A review of Resident #47's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/18/17, revealed it was very important to the resident to have books, newspapers, and magazines to read, participate in religious services, and do her favorite activities. A review of Resident #47's care plan for activities revealed an onset date of 08/11/16, with the most recent review of the care plan dated 12/27/18. The care plan indicated the resident enjoyed activities such as reading, listening to music, keeping up with the news, doing things with groups of people, doing her favorite activity, going outside for fresh air when the weather is nice, and participating in religious services or practices. Interventions included to provide equipment and supplies for activity, and involving resident in planning activity of choice. An interview on 02/02/18 at 10:45 AM, with the Activities Director (AD) and the Director of Nursing (DON), revealed the AD had been in the position for two (2) weeks and was still being trained. The AD stated it was her responsibility to make the schedules and the facility relied on the Shabazem to carry out activities with residents. The Activities Director stated that she had not written Resident #47's current activity care plan and had not had any conversation with the resident about what she liked to do. The AD stated she had not completed the activities assessment for the resident. The DON stated the former AD had completed the assessment and care plan. The DON stated she had not had any conversation with the resident about what activities she liked to do. Activity logs were requested of the DON/AD. None were provided. An interview on 02/02/18 at 10:55 AM, with the Social Services Designee (SSD), revealed she did not participate in planning or implementation of activities for residents. She stated that she would order equipment if needed. The SSD stated she would purchase a tray to assist Resident #47 in reading. At 11:55 AM, the SSD stated Resident #47 already had a tray in her room that could be used to assist her in reading. The SSD stated there were no activity logs. The SSD provided assessment notes for the past year. These were the only activity notes provided. An interview on 02/02/18 at 02:30 PM, with the Administrator, revealed the AD actually held the title of Assistant AD (AAD) because she had not completed training. A former AD, who was certified, had been teaching the new AAD. The Administrator stated the Shahbaz were to complete activities, the AAD was to get supplies to the houses, complete assessments and care plans, and lead some activities, but had not begun to do that as she was being trained on how to complete the MDS assessments.

Based on observation, interview, record review, and policy review, the facility failed to ensure the care plan interventions were implemented consistently across all shifts for four (4) of six (6) residents reviewed for activities out of a total of 60 residents (Residents #28, #47, #8, and #27). Findings include: Review of the facility's policy titled, Care Plans- Martha Coker, dated 6/12/14, revealed, The Interdisciplinary Team is responsible for the periodic review and updating of care plans when there has been significant change or when desired outcome is not met. Resident #27 Review of the care plan revealed the facility care planned Resident #27 for approaches, Will continue to encourage elder to listen to mixture of music per her request, will encourage elder to read books of her preferences as she pleases, will encourage elder to participate in going outdoors, provide materials to start and finish activities, transport resident to activities. On 01/30/18 at 04:30 PM, observation revealed Resident #27 not socializing with others in the dayroom and facility Certified Nursing Assistant (CNA), also referred to as a Shahbaz, seated on the piano stool, facing the residents, but not interacting with the residents. Interview on 01/31/18 at 11:07 AM, with the resident's Responsible Party (RP), revealed the facility needed to have more activities that the resident likes. The RP was concerned with the lack of staff interaction with residents. The RP stated she had not observed any activities of interest to the resident being done by the facility staff. The RP stated she wished the staff would do more one to one activity with Resident #27. Observation, on 02/01/18 9:15 AM, revealed Resident #27 was seated in a recliner sleeping. Observation, on 02/01/18 at 10:10 AM, revealed Resident #27 did not participate in facility lead devotion with residents. Observation, on 02/01/18 at 10:45 AM, revealed Resident #27 was seated in recliner in dayroom sleeping with the television (TV) playing. There was no facility initiated encouragement for the resident to watch TV. Observation on 02/01/18 at 1:56 PM, revealed Resident #27 was seated in the dayroom in a recliner with staff in the kitchen area. Resident #27 was alert and requested that staff assist her to the restroom. There were no activities in progress. Observation on 02/01/18 at 3:18 PM, revealed there was no staff interaction with Resident #27. Staff member (Shahbaz #3) handed out a cross word puzzle to other residents, but failed to ask or offer a crossword to Resident #27. Resident #27 remained seated in recliner in the dayroom with head drooped and eyes closed. Interview on 02/01/18 at 3:25 PM, with Shahbaz #3, revealed she did not offer Resident #27 a crossword puzzle because she was more one on one (1:1) and stayed up a night. Shahbaz #3 stated they do not have a written care plan they follow for activities. She stated they just know the residents. On 02/02/18 at 09:26 AM, an interview with Licensed Practical Nurse (LPN) #1, revealed he was not aware of any of the residents' activity care plans. He stated the Shahbaz do activities with the residents. 02/02/18 at 10:39 AM, an interview with the Activity Director revealed she had been the Activity Director for about two (2) weeks. She stated she had not been in the position long enough to prepare any resident care plans. She stated that she had not received any special training for the Activity Director position. She explained that she was previously a Shahbaz, and when the Activity position came open, she applied because she felt like more activities could be done for the residents. Interview with Human Resources/Purchasing, on 02/02/18 at 02:21 PM, revealed she is a Certified Activities Director. She stated her role was Human Resources and she had never completed the activities section of the Minimum Data Set (MDS) or care planned activities for residents. She stated she was hired for Human Resources, but she had been helping the new Assistant Activity Director get her feet under her. Resident #8 On 01/30/18 at 11:30 AM, Resident #8 was observed coming and going from the room being pushed by staff earlier today. At this time, she was at the table with others eating lunch and conversational. On 01/30/18 at at 11:00 AM, during a general conversation, Resident #8 expressed she thinks they should have coffee socials, as it would be an enjoyable activity, and they have not offered such. She was by a career, a seamstress for many years. She expressed she would enjoy showing others in the house, or even bring others from other houses, and she would show them with her machine (would have to be brought from home), how she monogrammed and other techniques. Observation on 01/31/18 at 10:15 AM, revealed Resident #8 was participating in devotional activities in the hearth room. Observations on 02/01/18, revealed Resident #8 was mostly alone in her room doing devotionals and visiting with her son, who was visiting from out of state. Observation on 02/02/18 at 4:00 PM, revealed Resident #8 was visiting with her son from out of state. Resident #8 was interviewed about activities and stated other than Bingo and Bible study, they really do not do anything. Resident #8 stated that the group is scheduled to go to (name of local store) tomorrow but the weather is going to be bad, so they probably will not go. She said she might like to go fishing in good weather. Observation on 02/05/18 at 10:10 AM, revealed Resident #8 was dressed and up in a wheelchair without a leg brace, participating in word/memory/puzzle activity with group. She was cheerful, smiling, and happy. Said when she saw the doctor last Wednesday, he told her she could start reducing the hours each day out of the brace and remain in the wheelchair with no weight bearing yet. She said she was pleased with her progress. Resident #28 Observation on 01/30/18 at 10:30 AM, revealed Resident #28 with a flat affect sitting in a wheelchair in her room watching TV. Observation on 01/30/18 at 10:47, revealed an Accucheck was done for Resident #28. 1/30/18 at 11:30 AM, observation revealed Resident #28 in a group at the dining table, non- conversational, but seemed to be listening to others. She ate most of her diet. Observation on 02/1/18 at 2:15 PM, revealed Resident #28 was in her room. Observation on 01/31/18 at 11:20 AM, revealed Resident #28 was leaving her room, after watching TV, to the table for lunch at the group table. Observation on 02/02/18 at 9:05 AM, revealed Resident #28 was sitting in her room watching the news. General conversation led to her saying she would very much enjoy sharing some of her memories and stories with others, as there are many funny stories. She stated that she had taught school, multiple grades and subjects. Record review of Resident #28's care plan, included encouraging her to engage in and talk and have conversations with others, but had no mention of her history as a school teacher, as an activity. Observation on 02/05/18 at 10:10 AM, revealed Resident #28 was dressed and up in a wheelchair participating in word/memory/puzzle activity with a group. She was cheerful and smiling. She said she very much enjoyed this activity today. Noted she has a very quick mind. Resident #47 02/01/18 at 9:39 AM, Resident #47 was observed seated in the day room area, in a recliner, with her feet elevated and the television playing. The resident appeared comfortable, but fidgeted with a blanket covering her legs. Resident #47 did not appear to be watching television. 02/01/18 at 9:54 AM, Resident #47 was observed having conversation seated in a wheelchair with another resident seated in a recliner. She appeared engaged, animated and had a pleasant affect. 02/01/18 at 10:19 AM, Resident #47 was seated in a wheelchair in dayroom. A Shahbaz was engaging clients in a Bible study. Bible study lasted approximately 10 minutes. Resident #47 was given a Bible Study guide, but has difficulty holding it, and placed it in her lap. 02/01/18 at 10:40 AM, Resident #47 was seated in a wheelchair, seated in front of television, eyes closed, breathing deeply. The television was on a game show network. A Shahbaz commented this is all the residents' favorite channel. Record review of activity preferences, revealed Resident #47's preferences included games, music, reading, spiritual, being outdoors, television, conversation, and helping others. 02/01/18 at 2:00 PM, LPN #1 stated that Resident #47 can let you know what she wants, and all residents are encouraged to do what they like. He stated when he sees her, she is usually sitting in the hearth area in front of the television. LPN #1 stated that he knew she liked having Bible study. 02/02/18 at 8:25 AM, Resident #47 was seated in wheelchair in the hearth area of the cottage, eyes closed. The television was on, with three (3) residents, including Resident # 47, seated in front of the television, but all had their eyes closed. When spoken to, the resident opened her eyes. Interview with the resident, regarding activities, revealed she doesn't do a whole lot. She stated that she sleeps a lot because she stays up late. She stated that she's not interested in what is on television during the daytime, but likes to watch television at night. She stated that she is not necessarily sleeping when sitting in the hearth area, but just closes her eyes because there's nothing else to do. The resident stated she really enjoyed reading, but due to problems with her hands, and needing to wear a hand splint, she cannot hold books. She stated no one had offered to read to her or asked her if she would like to listen to a book. She thought she may be able to manage reading a book if she had a tray to put it on. Resident #47 stated she doesn't know if there are audio books available, and no one had ever asked her if she would like to listen to one, but she thinks she might. She stated that she was a school teacher, and certified to teach special education, never married, and had no children. 02/02/18 at 9:11 AM, interview with Shahbaz #1 and Shahbaz #2, regarding activities, revealed both Shabazem stated it is their responsibility to do activities with residents. Both stated that residents like to play Bingo and watch the game show channel. They both agreed that Resident #47 doesn't pay attention to television, and nods off or closes her eyes. Shahbaz #1 stated that Resident #19 and another Resident enjoyed watching the game show network. She stated that Activities Director makes a schedule, and we (Shabazem) are supposed to follow it. She stated that Activities Director doesn't complete the activities, that the Shabazem did, and sometimes they couldn't get to what was scheduled, depending on what was going on. The Shabazem stated they had not considered audio books for Resident #47. The Shabazem stated that they do not ask residents about what activities they like, just do what is on the schedule the best they can, and try to keep the residents happy. They weren't sure how they would be able to do a bunch of different things for residents, because they all might like different things, but they do what the majority like, for example two (2) of the three (3) ladies in the hearth area liked the game show network, so they put it on that channel. Shahbaz #1 stated that Resident #47 gets a church bulletin every week from her church, that she keeps tucked under her arm. She stated that Resident #47 had trouble holding the bulleting to read, with her geri sleeves on, and decreased range of motion of her left arm. She stated that the resident may be able to manage reading with a tray. On 02/02/18 at 10:00 AM, the SA arrived at the cottage to observe the activity scheduled. Looking through front door glass, there was no staff in sight, and three (3) residents, including Resident #47, were seated in front of the television, all eyes closed. Rang the doorbell three (3) times, and no one came to the door. On 02/02/18 at 10:08 AM, Staff were observed riding up on a golf cart to the side door, walked around to knock to get in, and no one answered. At 10:12 AM, let in at the front door by staff that drove up on golf cart. Staff stated that other Shahbaz are in room with a resident, and should be out shortly. Family members were visiting and coming out of a resident's room Shahbaz #1 came out of room [ROOM NUMBER], and stated she had been providing care for the resident. Observation on 02/02/18 at 10:21 AM, revealed Shahbaz #2 came from the back whirlpool, pantry area. The game show network was still on. Residents were seated in front of television, not watching. Shahbaz #1 prepared lunch in the kitchen, and Shahbaz #2 was charting on the kiosk. A review of the activities schedule revealed Catholic Mass was being held in another home. On 02/02/18 at 10:35 AM, Shahbaz #2 stated that no one from this building goes to Catholic Mass and she doesn't think anyone is Catholic in this building. On 02/02/18 at 10:27 AM, a nurse emerged from the chart room, talking on the telephone. Review of care plan for activities, for Resident #47, with an onset date of 08/11/16, and most recent review dated, 12/27/18, indicated the resident enjoyed activities such as reading, listening to music, keeping up with the news, doing things with groups of people, doing her favorite activity, going outside for fresh air when the weather is nice, and participating in religious services or practices. Interventions included cue to activity, time and place as needed, provide equipment and supplies for Activity, place activity calendar in room where it is easily accessible. Assist to Activity as needed such as participating in religious services or practices, doing things with groups of people, involve resident in planning activity of choice, provide in room activities as resident desires, and continue to encourage elder to sit outdoors for fresh air when the weather is good. On 02/02/18 at 10:45 AM, an interview was conducted with the Activities Director (AD) and Director of Nursing (DON), regarding Resident #49's activities. The Activities Director states she had only been Activities Director for two (2) weeks. She stated she makes the schedules and relies on Shabazem to complete activities. The Activities Director stated that she did not write the resident's current activity care plan, and had not had any conversation with the resident about what she likes to do. She stated that she had not completed the activities assessment, it had been completed by the former Activities Director. The DON stated the former AD had completed the assessment and care plan. The DON stated she had not had any conversation with the resident about what activities she liked to do. A request was made to review activity logs for Resident # 47. There were no activity logs. On 02/02/18 at 10:55 AM, interview with the Social Services Designee (SSD), revealed she did not participate in planning or implementation of activities for residents. She did state that she would order adaptive equipment if needed. She stated she could purchase a tray to assist Resident #47 in reading. At 11:55 AM, the SSD stated that the resident had a tray in her room that could be used to assist her in reading; it had been available, but was not utilized by Shahbaz. She stated that they had not been able to locate any activity logs, but provided assessment notes for the past year. These were the only activity notes provided. On 02/02/18 at 2:30 PM, interview with the Administrator revealed the AD held the title of Assistant AD, because she had not completed training. She stated a former AD, who is certified, has been teaching the new Assistant AD. The Administrator stated the Shahbaz are to complete activities. The Assistant AD is to get supplies to the buildings, complete assessments, and lead some activities, but had not begun to do that, as she was learning how to complete the MDS assessments. On 02/02/18 at 3:00 PM, interview with the SSD revealed the care plan was not followed, for Resident #47, because it had an intervention to provide equipment and supplies to assist the resident to participate in activities, and the available tray had not been used. The SSD stated that she did not participate in writing of care plan for activities.

Based on record review, staff interview, and facility policy review, the facility failed to act on a gradual dose reduction (GDR) recommendation, without clinical rationale from the physician, for one (1) of six (6) residents reviewed, for gradual dose reductions, Resident #45. Findings include: Review of Resident #45 physician's orders [REDACTED]. Review of Resident #45's [DIAGNOSES REDACTED]. Record review of Resident #45's plan of care revealed, Elder takes [MEDICAL CONDITION] medications for [DIAGNOSES REDACTED]. Pharmacy to review medications monthly and recommend gradual dose reduction as appropriate. Review of the care plan, revealed Resident #45 had a care plan for Alzheimer and Dementia with Behavior Disturbance. The plan of care revealed the resident displayed physically aggressive behavior toward other elders with no altercations (02/20/17). On 3/31/17 through 4/11/17, went to behavior health inpatient stay. On 10/5/17, it is noted he continues with behaviors. Review of Nurse's Notes, dated 11/21/17, revealed, on 6 AM-2 PM shift, the resident refused to get out of bed all day, would not eat, and refused staff to change his soiled clothes. The resident swung at and tried to hit staff when they tried to change him. Resident #45's nurse note, dated 11/08/17, revealed the resident had an unwitnessed fall to the floor in his room, would not answer when asked about pain, told staff to leave him alone, and would not permit staff to place him back in bed. The resident's Daughter arrived and was able to get him off floor, then he refused to be taken to the emergency room . Review of nurse's notes, dated 1/31/18, revealed Resident #45's brief was soiled, but refused to be changed. During an interview, on 02/02/18 at 11:15 PM, the physician said he was aware of the Black Box Warning, concerning [MEDICATION NAME], but was not aware of the details. He revealed he was not sure how or when the resident was put on [MEDICATION NAME], nor who started him on it. The Physician revealed he does not review all of the medications his Residents are on monthly. The Physician stated that his Nurse Practitioner (NP) usually reviewed his Residents medicine, and takes care of the GDR. Record review of a note from the pharmacist, to the attending physician, (printed and put on chart 10/29/17), revealed a request for a Gradual dose reduction on [MEDICATION NAME] 2.5 Milligram (mg) in the AM and 5 MG at 7:00 PM. The Physician had not made a mark to agree, disagree or other, but wrote continue current dose as is effective and dated 11/17/17. During an interview on 02/02/18 at 11:42 AM, the Pharmacy Consultant stated that she wrote the gradual dose reduction request for Resident #45, and she probably should of requested it earlier. She also confirmed she thought his reply to the request was adequate and did not know the physician had to go into more detail , nor did she know that a GDR had to be initiated, on [MEDICAL CONDITION] medication, within 14 days of a resident coming into a facility from a Geri-Psyche Unit. During an interview, on 02/02 18 at 10:53 AM, the Director of Nursing (DON) and the Registered Nurse (RN) Supervisor, said Resident #45 had a history of [REDACTED]. They said [MEDICATION NAME] was started when he was a patient at Behavior Health, and Mental Health had been following his medications. The DON also revealed she knows Zyrprexa is a high risk medication, but the mental health and Physician both wanted him on it and she did not have the authority to change it.

Based on observation, staff interview, record review and facility policy review, the facility failed to ensure foods were labeled and stored properly. The facility also failed to ensure equipment and kitchens were kept in a sanitary manner, to prevent the potential for food-borne illness for 4 (four) of 6 (six) homes reviewed, Houses #3, #4, #5 and #6. Findings include: Review of the facility's Area, and Equipment Cleaning policy, revised 01/14, revealed written procedures are available for detailing daily and weekly cleaning for all areas and equipment in the department. The director develops a reference manual on cleaning areas and equipment in the food and nutrition services/dining services department. Review of the facility's cleaning schedule policy, with a revision date of 9/12, revealed, all equipment and work areas are to be cleaned after every use, and on a routine basis. A cleaning schedule is provided, and monitored by the DM (Dietary Manager). Review of the facility's Sanitation and Inspection Control and Checklist policy, revised 01/14, revealed a basic sanitation inspection is conducted at least once a month to ensure procedures are being followed and that sanitation standards are followed. A quarterly food safety and sanitation audit is conducted using the Food Safety and Sanitation Audit form. Action Plans are developed for all areas not meeting standard. Findings are reported to all managers and department associates. Cleaning Schedules and frequencies are revised based on the inspection findings. Review of the facility's Food and Supply Storage Procedures policy, revised 01/14, revealed all food, non-food and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Most products contain an expiration date. The sell by or use by date should precede the date. The sell by date is the last day the food can be sold; do not place on patient trays or resident plates past the date on the product. See the Food Storage Chart in this policy to determine discard dates for the food items. Date and rotate items; the first in is the last out. Remove from storage any items for which the expiration date has expired. On a daily basis the spoiled pieces of produce should be removed. Wrap food tightly to prevent cross contamination. Frozen food should be kept no longer than 90 days for quality purposes. Review of the facility's Food Storage Chart, undated, revealed expiration dates printed by the manufacturer apply until the product is opened. Once opened the product is used by this time unless the manufacturer's date is earlier. The day the food is opened counts as day 1. According to manufacturer's expiration dates: oil - 30 days; syrup and peanut butter - 60 days; cereal - 6 months; all unopened canned, carton boxed, or bottled goods, and spices - within 1 year of delivery, or the manufacturer's expiration date, if sooner. Unused portions of ready-to-eat foods prepared on site that are not reheated for service, such as recipes that contain meat, milk, eggs, cheese, raw vegetables, and fresh fruit; cheese - all cheeses except hard cheese (14 days); salad dressings, mayonnaise - 30 days; ketchup, relish, pickles, natural peanut butter, and mustard. House #4: Observation of the kitchen in House #4, with Shahbaz #3, on 10/18/2016, at 10:45 AM, revealed an undated, half quart container of strawberries with white and black fuzzy material and shrinkage on each berry, located in the door of the refrigerator; one (1) container of Strawberry Parfait with an open date of 10/15/16 and a use by date of 10/08/16; a four (4) ounce (oz) container of yogurt with a manufacturer's expiration date of 10/05/16; a half bottle of (name of salad dressing) with an open date of 8/15/16 and use by date of 9/15/16; a third of an eight (8) oz bottle of Parmesan Cheese with a manufacturer's expiration date of 4/22/16, open date of 11/23/15, and use by date of 12/23/15; half of a five (5) pound (lb) container of peanut butter, with a manufacturer's expiration date of 4/29/16; one-third (1/3) of a 16 ounce bag of potato chips with a received on 9/20/16, and an opened date of 9/23/16, no manufacturer's expiration date was listed; a 24 ounce bag of Orange Gelatin Dessert Mix, received on 9/22/15, without a use by date or manufacturer's expiration date; an opened 24 ounce bag of Red Raspberry Gelatin Dessert Mix, opened 9/18/15, with a use by date of 10/08/15, and a green plastic container of shredded meat, without a label or a date. House #3: Observation of the kitchen on 10/18/2016 at 12:00 PM, in House #3, and interview with the Shahbaz Coach, revealed an undated, half quart container of strawberries with black and white fuzzy materials to each strawberry with shrinkage; an unzipped plastic bag with 15 frozen biscuits opened to air in the freezer; a large plastic zipped bag of cheerios with an open date of 6/14/16, and without a use by date or manufacturer's expiration date; and the refrigerator vent near the front door and next to the floor revealed a large build up of dust and brown fuzzy debris, brown spill stains to the front and top of the vent. The refrigerator vent was hanging onto the floor which revealed dust, food spills and food build up to the floor. Staff interview with the Shahbaz Coach, confirmed there is no explanation for food being expired. She confirmed House #3 had expired food, produce, and dirty areas to the refrigerator vent and the floor underneath the vent. House #4: Observation of House #4's kitchen and staff interview with Shahbaz #2, on 10/18/16 at 10:05 AM, revealed spilled brown food debris and grime caked on to the top of the interior dishwasher door and brown spills to the floor board of the island underneath the cabinets. The stainless steel stove top guard had dark brown and gray cooked on stains to the interior and exterior walls. There was red colored spillage to the lazy susan table under the kitchen counter. There was a 16 ounce bottle of red food coloring with an open date of 9/02/15 and a use by date of 12/02/15; a 28 ounce bottle of Nutmeg received on 02/25/14, with an open date of 9/30/16 and use by date of 9/30/16. Shahbaz #2 confirmed, the stove guard, lazy susan, interior door of the dishwasher, and floor of the island cabinets needed to be cleaned, and the Nutmeg and food coloring were expired and needed to be thrown away. Staff interview with the DM on 10/20/2016, at 1:40 PM, revealed she orders and brings the food to the six (6) houses, controls the dietary budget, and checks the dates and placed the received dates on all foods. She said the Shahbaz staff is responsible for dating food items with an open date and use by date. She stated she does inventory every Monday before she orders food, and throws away expired food. The DM said the RD (Registered Dietician), Shahbaz Coach and she are all responsible for making sure expired food is not on the shelves. She confirmed the aluminum stove top safe guard needed to be scrubbed clean. Staff interview with the Shahbaz Coach on 10/20/16, at 2:03 PM, revealed, she has an in-service nine (9) times a month, which covers all three (3) shifts. She said the dietary department is self-managed and should be cleaned at the end of the shift. She said no staff's food should ever be placed in the refrigerator, and resident's fruit is received weekly, and any spoiled fruit should be thrown away. Staff interview with the DM on 10/21/2016, at 9:39 AM, confirmed Red Raspberry Gelatin Dessert Mix is good for 6 (six) months. Staff interview with the RD, on 10/21/16, at 9:37 AM, revealed she performs weekly audits of the kitchens and pantries using a Dietary Audit and is aware of expired foods on the unit, and tells the staff to throw them away. The RD said she checks the next week to see if the problems have been corrected. We will write-up the Shahbaz staff and give them a verbal warning. The RD confirmed the Shahbaz staff failed to throw away expired foods, and adhere to the expiration dates, and use by dates of the resident's food. Staff interview on 10/21/16 at 10:00 AM, with the Administrator, revealed they always work on the labeling of the food in their (Shahbaz's) monthly in-services. She confirmed the facility should not have any spoiled, molded or expired foods. Home #6: On 10/18/16 at 10:45 AM, upon entrance to the home, immediate inspection of the kitchen with Shahbaz # 6, revealed the following findings and statements: When Shahbaz #6 saw surveyor entrance, she immediately began donning gloves. One (1) glove, for her left hand, dropped onto the floor and she picked it up and continued to place it on her left hand. She then walked to a book with documentation, completed this task and continued the tour without changing gloves. Observation of the kitchen drawers, cabinets, refrigerator, freezer and pantry revealed multiple findings of concern to include: The counter facing the Television/Fireplace room, included several drawers. The third drawer from the right contained 10 individual glass serving/storage bowls with one (1) containing a paperclip, one (1) contained stuck on, crusted crumbs/food particles and a black wavy hair. Three (3) more of the containers had visual crumb appearing food particles lying in them. The fourth drawer from the right, described by Shahbaz # 6 as an extra drawer for strips, contained two (2)Ecolab containers, two (2) Hydroin PH strips containers, one (1) Kit-Kat candy bar and one (1) Nestle's Crunch candy bar and multiple food appearing crumbs throughout the drawer. The center cabinet pullout drawer contained two (2) covered bins. One (1) contained sugar and the other flour. Both containers held inside a plastic cup, used for scooping, according to Shahbaz #6, who also said this is cause for cross-contamination. Also both containers had labels of an expiration date of 10/4/16 and Shahbaz #6 said this was also out of date. The island in the kitchen revealed four (4) of four (4) drawers containing a sticky to touch, dirty, drip appearing substance. One (1) drawer contained utensils with one (1) cloth glove, four (4) knives, a cutting board and a rolling pin, the drawer containing crumb/dirty appearing dark brown substance. Atop the island was one (1) baking sheet with thick black carbon build-up covering the entire surface. The dining room side of the island's cabinet top pull-out drawer, had visual gray dusty-fuzzy appearing substance described by Shahbaz # 6 as dusty/dirty A large mid-section of the top pull-out, the drawer contained a mixing bowl and the drawer was noted to contain a sticky, dusty residue. The bottom pull-out drawer contained, described by Shahbaz #6 as, a black human hair, dusty, dirty, stuck on dark substance, one red Dixie cup containing a paper napkin. Shahbaz #6 could not describe a possible purpose for the cup, nor an explanation for the condition of the cabinets and drawers. The stand-up side-by-side refrigerator in the kitchen, in the freezer section contained two (2) loose pieces of battered okra on two (2)different shelves and three (3) sausage appearing patties, unlabeled. Shahbaz # 6 said the sausage bag appeared pre-opened, closed, reopened and reclosed multiple times. The appliance refrigerator side, contained one (1) unlabeled and undated pour container containing a red liquid described by Shahbaz #6 as Kool-aid. Additionally, the refrigerator shelves contained one (1) large package of roast beef with an expiration date of 10/14/16, two (2) large packages of sliced yellow cheese with an expiration date of 10/7/6, one (1) large bag of shredded Mozzarella cheese with an expiration date of 10/15/16 and one(1) large bag of shredded cedar cheese with an expiration date of 10/14/16. The pantry room refrigerator contained a large bag of unlabeled/undated chopped lettuce, 14 of 15 cucumbers described by Shahbaz #6 as soft and mushy, with a white, mold appearing growth on them. The container holding the cucumbers says they are good through 10/22/16. There was one (1) container of bell peppers with one (1) of five being soft and mushy. A shelf in the refrigerator held a gallon sized plastic container of pickle relish with an expiration date of 10/17/16. One (1) of two (2) large bags of cut broccoli expired 10/8/16. The pantry room shelves, contained bins of vegetables, one (1) contained 10 of 16 sprouting sweet potatoes with soft spots, yellow onion bin contained two (2) of 14, bad and rotten onions. Shahbaz #6 continued by describing the white potato bin as being dusty and dirty. The flooring the pantry was dusty and dirty with a brown sticky substance around the refrigerator and cabinets. Upon the conclusion of the dietary tour, Shahbaz #6 described the newly present signs on the front of two (2) of two (2) dishwashers as not being present earlier and when asked, Shahbaz # 7 said according to the night shift this morning at shift change, the dishwashers are not reaching the required temperature of 135 degrees Fahrenheit. On 10/19/16 at 8:30 AM, a return visit made to House #6's dietary area, CNA #6 demonstrated appropriately how they have been hand-washing dishes using Echolab detergent to a pH of 300. A brief relook of 10/18/16's findings revealed the glass containers in the third drawer of the counter facing the Television/Fireplace room, remains with the same findings as the previous day's observation. Shahbaz #6 said the containers are for Elder's leftovers and that this remains as it was yesterday. Another observation revealed the pantry floor remained in the same condition as yesterday. House # 5: On 10/20/16 at 11:26 AM, with Shahbaz # 5, a dietary tour revealed in the pantry, bins, described by Shahbaz # 5, as four (4) of seven (7) cucumbers soft and bad, and three (3) of seven (7) green bell peppers soft and mushy. One (1) of 18 yellow onions was black and Shahbaz #5 said, I would not use it. In the kitchen area, one (1) of three (3) food processors on the counter contained, per Shahbaz #5, crumbs and was actually out-of-order and should have been thrown away about two (2) weeks ago. Shahbaz # 5 continued by saying she was sorry and should have already thrown the processor away. She said the findings in the pantry should have been handled previously and thrown away, as use of bad food could cause food borne illnesses. Shahbaz #5 stated there was no specific Shahbaz assigned to do specific tasks, they are all responsible, including her.

CI MS # Based in observation, record review, staff interview and policy review, the facility failed to provide adequate supervision for one (1) of six (6) elders in order to prevent a fall with a fracture to the pelvis. Elder #1 had a history of [REDACTED].#1). Findings include: Elder #1 Record review revealed that Elder #1 was admitted to the home on 3/2/10, and was readmitted to the home after a fall on 5/13/12, with [DIAGNOSES REDACTED]. Review of the 5 Day Minimum Data Set, after readmission, dated 5/23/12, documented Elder #1 had a fall and fracture. Review of the care plan for Risk for falls, dated 3/1/11, identified an approach for "1/4/12--Check elder every hour during the 11p - 7a shift. 1/19/12-- fell in bathroom; slipped off seat of walker... Maintain fall precautions: lock brakes on wheelchair before transferring, bed in low position, respond promptly to call for assistance ... Verbal reminders to elder to maintain safety awareness..." Review of the investigative file for Elder #1's fall on 5/13/12 revealed Elder #1 did have a non-witnessed incident that documented, "Elder sitting on floor beside bed. States "I was trying to go the bathroom & fell . " Elder states she hit her head on the bed when she fell . Elder c/o (complains of) severe pain in right knee, leg & hip. States "I think I broke my leg." The incident report documented Elder #1has a fall history and was on an adjustable bed. The incident happened according to the investigation at 3:43 a.m. on 5/13/12. The investigative file included a "Statement of Occurance" but it did not include an interview with staff to determine what was going on in the home at the time of the fall and why it was un-witnessed. Interview, via telephone, on 2/26/12 at 1:26 p.m. with the Shahbazim (Certified Nurse Aide) #1 revealed the facility did have a Shahbazim who floated on the night shift and there were (3) residents who required a lot of care in House 2. Review of the "Assessment for Risk for Falls", dated 4/23/12, documented Elder #1 had a score of 9 (7-18 - Resident is at high risk). After her fall on 5/13/12 Elder #1 was reassessed and scored 13 (still at high risk). Interview on 2/26/13 at 10:17 a.m. with the Director of Nursing (DON) regarding if the assessment was accurate, revealed the DON stated,"It was not." Interview on 2/26/13 at 10:22 a.m. with the Minimum Data Set (MDS) Nurse regarding the MDS assessments revealed she was not sure if she was supposed to code the MDS to include the falls (Section J1700 a, b, c and J 1800). Interview on 2/27/13 at 4:05 p.m. with the Director of Nursing revealed the staff had increased with a number of floaters on the night shift and they were put in place to assist with care at night. Interview on 2/27/13 at 4:14 p.m. with the Administrator revealed that the staffing is one (1) Shahbazim (Certified Nurse Aide) in each home. Five (5) nights a week there is one (1) floater and 2 nights there are two (2) floaters to assist. The Administrator stated there had been some layoffs of staff prior to the survey. Review of the updated care plan for "Risk for Falls" failed to include the intervention to provide more monitoring or closer supervision. Even the intervention to Check elder every hour during the 11p - 7a shift had been removed from the care plan, even though the fall with injury occurred on the night shift. Review of the investigative file for Elder #1's fall on 5/13/12 revealed Elder #1 did have a non-witnessed incident that documented, "Elder sitting on floor beside bed. States "I was trying to go to the bathroom & fell . Elder states she hit her head on the bed when she fell . Elder c/o (complains of) severe pain in right knee, leg & hip. States "I think I broke my leg." The incident report documented Elder #1 has a fall history and was on an adjustable bed. The incident happened according to the investigation at 3:43 a.m. on 5/13/12. The investigative file included a "Statement of Occurrence" but it did not include an interview with staff to determine what was going on in the home at the time of the fall and why it was non-witnessed. Interview on 2/26/13 at 1:26 p.m. with Shahbazim #8 revealed the facility did have a Shahbazim who floated on the night shift and there were three (3) residents who required a lot of care in Home #2. Review of section G of 51 Minimum Data Sets, revealed the home has 24 of 51elders who require extensive to total assistance of two (2) for activites of daily living including transfer, bed mobility and toileting. Review of section G documented 14 elders required extensive assistance of one (1) for activities of daily living.