Every finding on record at Montgomery Children's Specialty Center

Based on observation, interview, the facility's policy for Dispose of Garbage and Refuse, and the United States (U.S.) Food and Drug Administration (FDA) 2022 Food Code; the facility failed to ensure the side door of the dumpster was closed on 5/22/2023 at 6:45 PM to prevent the potential for rodents being attracted to and possibly entering the facility. This had the potential to affect 45 of 45 residents in the facility. Findings include: The facility's policy for Dispose of Garbage and Refuse, dated August 2017, included the following: Policy Statement All garbage and refuse will be collected and disposed of in a safe and efficient manner. The U.S. FDA 2022 Food Code included the following: . 5-5 Refuse, Recyclables, and Returnables . 5-501.13 Receptacles. (A) . receptacles and waste handling units for REFUSE, recyclables, and returnables and for use with materials containing FOOD residue shall be durable, cleanable, insect- and rodent-resistant, leakproof, and nonabsorbent. 5-501.15 Outside Receptacles. (A) Receptacles and waste handling units for REFUSE, recyclables, and returnables used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers. (B) Receptacles and waste handling units for REFUSE and recyclables . shall be installed so that accumulation of debris and insect and rodent attraction and harborage are minimized . 5-501.110 Storing Refuse, Recyclables, and Returnables. REFUSE, recyclables, and returnables shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. 5-501.111 Areas, Enclosures, and Receptacles, Good Repair. Storage areas, enclosures, and receptacles for REFUSE, recyclables, and returnables shall be maintained in good repair. 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: . (B) With tight-fitting lids or doors if kept outside the FOOD ESTABLISHMENT. On 05/22/2023 at 6:45 PM, the facility's dumpster area was observed. One of one dumpster had one side door fully open. Food-related garbage and trash were observed inside the dumpster. On 5/23/2023 at 9:51 AM, Employee Identifier (EI) #3, the Dietary Manager, was interviewed. EI #3 said she was not aware that the dumpster was left open, but said it was a hard jam. The Dietary Manager further said the dumpster was not supposed to be open because it would cause a problem with rodents. During a follow-up interview on 5/24/2023 at 12:17 PM, EI #3 was asked how residents could be affected if rodents were attracted to the dumpster due to the door being left open. EI #3 said there was a possibility the rodents could enter the building.

Based on observation, interview, review of the facility's policy for Menus, the facility's menu and diet guides for Week 1, Tuesday (Day 3) for Lunch on 5/23/2023, the residents' Diet Cards (sub-heading: Category Information) for Lunch on 5/23/2023, and the residents' Tray Tickets for Lunch on 5/23/2023; the facility failed to ensure food was portioned as specified by the approved menu for lunch on 5/23/2023. The facility also failed to ensure nutritional adequacy and appropriate modification of texture by not consulting with the Registered Dietitian before making substitutions to the menu for lunch on 5/23/2023. This had the potential to affect 7 of 17 residents receiving meals from the kitchen at the facility. Findings include: The facility's policy for Menus, dated September 2017, included the following: Policy Statement Menus will be planned in advance to meet the nutritional needs of the residents/patients in accordance with established national guidelines. Menus will be developed to meet the criteria through the use of an approved menu planning guide. Procedures 1. Menu cycles will be developed and tailored to the needs and requirements of the facility. 4. Menu cycles will include nutrient analysis to ensure that all client (adolescent, adult, geriatric) nutritional needs are met in accordance with the most recent edition of the Food and Nutrition Board, Institute of Medicine, National Academies, and the Dietary Guidelines for Americans, 2015-2020 edition. 5. A Registered Dietitian/Nutritionist (RDN) or other clinically qualified nutrition professional reviews and approves the menus. The RDN or other clinically qualified nutrition professional will adjust the individual meal plan to meet the individual requests, including cultural, religious, or ethnic preferences, as appropriate. 6. Menus will be served as written, unless a substitution is provided in response to preference, unavailability of an item, or a special meal. 7. A menu substitution log will be maintained on file. On 5/23/2023 at 9:51 AM, the Dietary Manager, Employee Identifier (EI) #3. was asked for a copy of the menus with serving sizes, including the menus for therapeutic and texture modified diets. A Week-At-A-Glance menu was provided, but for the therapeutic/texture modified diets and serving sizes EI #3 printed individual tray tickets for Tuesday, Week 1, Day 3 (W1-D3). EI #3 highlighted the names of the residents on the lunch tray tickets who would be receiving the lunch meal. The other residents would be in school. However, EI #3 said these would not be the tickets on the resident trays. EI #3 then printed out and provided tickets for each resident for Tuesday Lunch 5/23/2023 with the sub-heading Category Information. When asked why the Category Information ticket was used for trayline, EI #3 said this was what they use and have always used. The Week-At-A-Glance menu for Week 1, Tuesday Lunch, dated 5/23/2023, listed the following: Cheeseburger on a Bun Lettuce & (and) Tomato Ketchup Pickle Spear Tater Tots Marinated Cucumber Salad Fruit Cocktail The tray tickets of the residents identified to be receiving lunch on 5/23/2023 were all modified consistency diets to include Dysphagia Pureed, Dysphagia Mechanical Soft, and Dysphagia Advanced. According to the provided tray tickets for Tuesday, Week 1, Day 3 (W1-D3), which were not to be used on the resident trays, but that identified the texture modified food items and serving sizes; the following information was included for the three modified consistency diets: Dysphagia Pureed Diet #8 scoop (equivalent to 1/2 cup) of Pureed Cheeseburger for Bun #8 scoop Pureed Hamburger Bun #10 Scoop (equivalent to 3/8 cup) of Pureed Marinated Green Bean Salad 1/2 cup (equivalent to a #8 scoop) of Mashed Potatoes #10 scoop of Pureed Fruit Cocktail Dysphagia Mechanical Soft Diet 3/8 cup (equivalent to #10 scoop) of Ground Cheeseburger for Bun #8 scoop Pureed Hamburger Bun 1/2 cup Marinated Green Bean Salad 1/2 cup of Mashed Potatoes #10 scoop Pureed Fruit Cocktail Dysphagia Advanced Diet 3/8 cup of Ground Cheeseburger for Bun Hamburger Bun 1/2 cup Marinated Green Bean Salad 1/2 cup of Mashed Potatoes 1/2 cup of Ground Fruit Cocktail Lunch trayline was observed on 5/23/2023 beginning at 11:48 AM. The pureed items on the trayline were pureed beef patties, pureed bread, pureed sweet peas, and mashed potatoes. EI #2, the AM Cook, said the pureed sweet peas was the substitute for the cucumber salad and the lettuce/tomato on the sandwich. EI #2 was using a green-handled #12 scoop (equivalent to 1/3 cup) for serving the Pureed Beef, a yellow-handled #20 scoop (equivalent to 3 and one-fifth Tablespoons) for the Pureed Bread, a grey-handled #8 scoop (equivalent to 1/2 cup) for the Pureed Sweet Peas, and an ivory-handled #10 scoop (equivalent to 3/8 cup) for the Mashed Potatoes. Beef patties were ground for the Dysphagia Mechanical Soft and the Dysphagia Advanced diets. The Dysphagia Mechanical Soft and the Dysphagia Advanced diets received a regular two-piece hamburger bun, one slice of American cheese, and one green-handled #12 scoop of Ground Beef to make a sandwich, which was cut into quarters for four pieces. In addition, the Dysphagia Mechanical Soft and the Dysphagia Advanced diets received a grey-handled #8 scoop of Tater Tots, a 1/2 cup of diced Marinated Cucumber Salad, a relish assortment (tomato slice/lettuce/2 dill pickle chips), and Sliced Peaches. On 5/23/2023 at 12:40 PM, the AM Cook (EI #2) was interviewed. EI #2 said she had worked at the facility for almost two years. When asked how she knew which size scoops to use to serve the residents' food; EI #2 said she used the yellow (#20 scoop) for the bread and green (#12 scoop) for meat and ivory (#10 scoop) for veggies, the way she was taught. On 5/23/2023 at 12:46 PM, EI #3, the Dietary Manager was interviewed. When asked if there was anything that was written to tell the cooks what size scoops to use for resident meal service, EI #3 said, on the production sheets. A stack of production sheets on the counter in the kitchen, which included one titled, 2023 Diet Guide Sheet for Tuesday (Day 3) were reviewed. The production sheet did not include any information for Pureed or Dysphagia Pureed or Dysphagia Mechanical Soft or Dysphagia Advanced diets; therefore there were no serving sizes or scoop sizes for menu items on these diets. Regular and Consistent Carbohydrate Diabetic diets were referenced on the production sheet, but only measuring cup portions and ounces were used for serving sizes, not any scoop sizes. There was no conversion chart observed in the kitchen for exchanging ounces or cup portions for scoop sizes. When asked if there was anything posted or available to show the staff how to convert a 1/2 cup serving to the equivalent scoop size, EI #3 said, No. On 5/24/2023 at 9:45 AM, EI #3 provided a different version of the 2023 Diet Guide that included the Dysphagia Pureed, Dysphagia Mechanical Soft, and Dysphasia Advanced diets for Tuesday (Day 3), which had a print date of 5/24/2023 at 9:37 AM. EI #3 was asked if the cooks were aware of this version yesterday. EI #3 said, No. During a follow-up interview on 5/24/2023 at 12:17 PM, EI #3, the Dietary Manager, was asked if the consultant Registered Dietitian (EI #7) approved the following substitutions made for the lunch menu on Tuesday, May 23, 2023 (Menu #1, Day #3): Marinated Cucumber Salad for Marinated Green Bean Salad on the Dysphagia Advanced and Dysphagia Mechanical Soft diets, Pureed Sweet Peas for Pureed Marinated Green Bean Salad on the Dysphagia Pureed diet, Sliced Peaches for Ground Fruit Cocktail on the Dysphagia Advanced diet, Sliced Peaches for Pureed Fruit Cocktail on the Dysphagia Mechanical Soft diet, and Tater Tots for Mashed Potatoes on the on the Dysphagia Advanced and Dysphagia Mechanical Soft diets. EI #3 said the substitutions had not been approved by the Registered Dietitian, but usually the substitutions were okay when the Registered Dietitian reviewed the substitution log each week. The resident ticket with the subtitle Category Information, which was being used on the resident trays for meal preparation, was called the Diet Card by EI #3. EI #3 said the Diet Card identified what the resident liked and disliked along with allergy information and adaptive equipment needed, but it did not list the food or the portion sizes to be served for the meal. EI #3 said the cook would have to use the production sheet (2023 Diet Guide Sheet) to know what and how much to serve each resident. The other resident tray ticket, which was not used on the tray line, was called the Tray Ticket by EI #3. When asked what information the Tray Ticket provided, EI #3 said it included allergies, adaptive equipment, and the actual portion size of what the resident should be served. When asked which ticket would be more helpful to the cook for meal service, EI #3 said the Tray Ticket. Upon being asked why was the Diet Card being used instead of the Tray Ticket; EI #3 said she was trained on Diet Cards and that is what she had used for seven years, the Tray Ticket came with the new menus, which started a week ago. EI #3 said she had instructed staff to use the following when serving pureed food items on the resident trayline: a 3-ounce portion for pureed meat by using a grey-handled #8 scoop, a 2-ounce portion for pureed bread by using a red-handled scoop (unable to identify size number) or the spoon labeled with 2 oz. on the handle, and a grey-handled #8 scoop for vegetables. EI #3 further said a green-handled #12 scoop was sometimes used for vegetables, but did not think a yellow-handled #20 scoop was regularly used. On 5/24/23 at 4:15 PM, the facility's consultant Registered Dietitian (EI #7) was interviewed by phone. EI #7 said she had not approved the following substitutions for the lunch menu on Tuesday, May 23, 2023: Marinated Cucumber Salad for Marinated Green Bean Salad on the Dysphagia Advanced and Dysphagia Mechanical Soft diets, Pureed Sweet Peas for Pureed Marinated Green Bean Salad on the Dysphagia Pureed diet, Sliced Peaches for Ground Fruit Cocktail on the Dysphagia Advanced diet, Sliced Peaches for Pureed Fruit Cocktail on the Dysphagia Mechanical Soft diet, and Tater Tots for Mashed Potatoes on the on the Dysphagia Advanced and Dysphagia Mechanical Soft diets. When asked if the facility could check with her by phone about substitutions, EI #7 said, Yes. Also, by e-mail. I go in every week. It was shared with EI #7 that the AM Cook had said she was taught to use the yellow-handled scoop (#20) for bread, the green-handled scoop (#12) for meat, and the ivory-handled scoop (#10) for vegetables. When asked if these portions would meet the nutritional requirements for the residents per the established menu, EI #7 said the menus were not being followed as written. On 5/24/2023 at 5:18 PM, EI #6, the contract food service's Director of Operations, was interviewed. EI #6 said either she or a District Manager visited the facility two to four times a month. EI #6 said the staff received monthly inservices that were provided electronically, via either a tablet or EI #3's desktop computer. EI #6 further said the staff's proficiency was checked by monthly electronic inservices with test questions. EI #6 was asked why the Diet Card was being used instead of the Tray Ticket for meal preparation during trayline. EI #6 said normally they use tray tickets across their facilities and the diet cards were used as a back-up. EI #6 also said for the purposes of portion size they like to use the tray tickets. EI #6 further said the facility had just started using the new Spring menu and the Dietary Manager (EI #3) was supposed to have started using the tray tickets with the new menu.

Based on observation, interview, the United States (U.S.) Food and Drug Administration (FDA) 2022 Food Code, the facility's policies for Food: Preparation and Equipment, and the facility's inservice information for Time and Temperature Control and Recording Inservice; the facility failed to prevent possible cross-contamination from a soiled manual can opener and a food preparation sink drain without an air gap on 5/23/2023. The facility further failed to ensure the food thermometer was properly checked and calibrated to check food temperatures accurately on 5/23/2023. This had the potential to affect 17 residents receiving meals from the kitchen and 17 of 45 residents in the facility. Findings include: The facility's policy for Food: Preparation, dated September 2017, included the following: Policy Statement All foods are prepared in accordance with the FDA Food Code. The facility's policy for Equipment, dated September 2017, included the following: Policy Statement All foodservice equipment will be clean, sanitary, and in proper working order. Procedures 1. All equipment will be routinely cleaned and maintained in accordance with . training materials. 1.) Manual Can Opener The U.S. FDA 2022 Food Code included the following: . 3-304.11 Food Contact with Equipment and Utensils. FOOD shall only contact surfaces of: (A) EQUIPMENT and UTENSILS that are cleaned as specified under Part 4-6 of this Code and SANITIZED as specified under Part 4-7 of this Code; . 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. 4-701.10 Food-Contact Surfaces and Utensils. Equipment food-contact surfaces and utensils shall be sanitized. The U.S. FDA 2022 Food Code, Annex 3, page 177 included the following: . 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur . 4-602.11 Equipment Food-Contact Surfaces and Utensils. Microorganisms may be transmitted from a food to other foods by utensils, cutting boards, thermometers, or other food-contact surfaces. Surfaces of utensils and equipment contacting food that is not time/temperature control for safety food . must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. During a tour of the kitchen on 5/23/2023 at 10:08 AM, the manual can opener was observed with a line of dark build-up on the cutting blade. Employee Identifier (EI) #3, the Dietary Manager, was asked how the can opener was cleaned. EI #3 pointed to the double preparation sink and said, We usually just run it through the water at the sink. When asked what was the problem with build-up on the can opener blade, EI #3 said, Cross contamination. On 5/24/2023 at 5:18 PM, EI #6, the contract food service's Director of Operations, was interviewed. Upon being asked about cleaning a manual can opener, EI #6 said they expected it to be run through the dishmachine after each meal so that cross contamination and physical contamination did not occur. 2.) Food Preparation Sink Drain The U.S. FDA 2022 Food Code included the following: . 5-402.11 Backflow Prevention. (A) . a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. During a tour of the kitchen on 5/23/2023 at 10:10 AM, the drain pipe of the double sink used for food preparation was observed to be inside the floor drain, approximately a half-inch below floor level, without an air-gap. EI #3, the Dietary Manager, was asked what would be the problem if there was a back-up in sewage. EI #3 said, Cross contamination. On 5/23/2023 at 10:24 AM, EI #4, the Maintenance Supervisor, was asked to measure the drain from the Double Preparation Sink. EI #4 measured how far the drain extended down into the floor drain from the floor level. EI #4's measurement confirmed there was no air gap, as the drain extended 0.5 inch into the floor drain. 3.) Bimetallic Food Thermometer The facility's inservice information for Time and Temperature Control and Recording Inservice, undated, included the following: . Importance of Time and Temperature Control Bacteria and other foodborne pathogens can grow quickly in the temperature 'Danger Zone' of 41-135 (degrees) F (Fahrenheit). Proper thawing, cooking, cooling, reheating, holding, and transport of food is critical for resident safety and wellness. Thermometers The first step in avoiding temperature abuse is to maintain a properly calibrated thermometer. Calibration and Testing Using Ice-Point Method 1. Fill a large container with crushed ice. Add clean tap water until the liquid reaches the level of the ice. 2. Put the thermometer stem or probe into the ice water . 3. If the temperature is at 32 (degrees) F, remove the thermometer. It is now ready for use. 4. On a bimetallic thermometer, if the temperature is not at 32 (degrees) F, hold the calibration nut securely with a wrench or other tool and rotate the head of the thermometer until it reads 32 (degrees) F. The U.S. FDA 2022 Food Code included the following: . 4-502.11 Good Repair and Calibration. (B) FOOD TEMPERATURE MEASURING DEVICES shall be calibrated in accordance with manufacturer's specifications as necessary to ensure their accuracy. On 5/23/2023 at 11:19 AM, EI #5, the PM Cook, was assisting EI #2, the AM Cook, in the kitchen. At 11: 21 AM, EI #2 was asked how they calibrated the bi-metallic food thermometer. EI #2 said, We put it (the thermometer) in ice water so when we test the meat we know it is at the right temperature. When asked what should the temperature reading be in ice water, EI #2 said, Zero degrees. The bi-metallic food thermometer was observed to be marked with a F on the face of the dial to indicate it was a Fahrenheit thermometer. There were no markings in degrees Celsius observed on the bi-metallic food thermometer. At 11:29 AM, EI #2 and EI #5 were trying to check the temperature of the bi-metallic food thermometer with a cup of ice water. The surveyor requested the Policy and Procedure for Thermometer Calibration from EI #6, the contract food service's Director of Operations, and EI #3, the Dietary Manager, who were nearby in the foodservice office. At 11:31 AM, EI #7, the Consulting Registered Dietitian, came into kitchen and assisted by instructing EI #2 and EI #5, the AM and PM Cook, how to calibrate the bi-metallic food thermometer. Neither EI #2 nor EI #5 knew how to calibrate the bi-metallic food thermometer. On 5/24/23 at 12:17 PM, EI #3, the Dietary Manager, was interviewed. EI #3 said the bi-metallic food thermometer should be checked every day and calibrated as needed. EI #3 said the cook should check the bi-metallic food thermometer every day and, if it was not right, they should let her know. EI #3 further said the cook should be able to calibrate it as well. When asked if there were any calibration records for the bi-metallic food thermometer, EI #3 said, No. On 5/24/23 at 5:18 PM, EI #6, the contract food service's Director of Operations, was interviewed. EI #6 said either she or a District Manager visited the facility two to four times a month. EI #6 said the staff received monthly inservices that were provided electronically, via either a tablet or EI #3's desktop computer. When asked how did the facility ensure competency for calibration of a bi-metallic food thermometer, EI #6 said by return demonstration. EI #6 further said the staff's proficiency was checked by monthly electronic inservices with test questions.

Based on resident record review, interviews, and review of the Centers for Medicare & Medicaid Services Long Term Care Facility Resident Assessment Instrument Manual, the facility failed to ensure Resident Identifier (RI) #7's quarterly Minimum Data Set (MDS) dated [DATE] and RI #29's quarterly MDS dated [DATE] were coded accurately to reflect current diagnosis. This affected two of 12 residents for whom MDS assessments were reviewed. Findings include: Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.17.1, dated October 2019, revealed: . SECTION I: ACTIVE DIAGNOSES Intent: The items in this section are intended to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status . RI #7 was readmitted to the facility on [DATE] with a diagnosis of Sepsis. RI #7's quarterly MDS assessment with an Assessment Reference Date (ARD) of 3/2/2023 documented RI #7 had an active diagnosis of Septicemia, during the last seven days, at the time of the assessment. On 5/24/2023 at 11:10 AM the MDS Coordinator, Employee Identifier (EI) #1 was asked when RI #7 was diagnosed with Sepsis. EI #1 said, RI #7 said, 5/14/2021. EI #1 said, Sepsis was not a current diagnosis. EI #1 said the MDS dated [DATE] was coded for active Sepsis and it should not have been. EI #1 said the diagnosis of Sepsis transferred and should not have. EI #1 was asked how was the MDS accurate if coded for Sepsis and the resident did not have a current diagnosis of Sepsis. EI #1 said, it would not be. When EI #1 was asked about the policy for coding the MDS accurately, she said they referred to the RAI manual. EI #1 said, the concern with the MDS not coded accurately was reimbursements, and it would not be accurate if there was no current diagnosis of Sepsis. 47408 RI #29 was readmitted to the facility on [DATE] with diagnoses to include Pneumonia. RI #29's quarterly MDS assessment with an ARD of 4/19/2023 documented RI #29 had an active diagnosis of Pneumonia, during the last seven days, at the time of the assessment. On 5/24/2023 at 12:06 PM EI #1 MDS Coordinator was asked when RI #29 was diagnosed with pneumonia. EI #1 stated RI #29 was admitted with the diagnosis of Pneumonia. EI #1 was asked if Pneumonia was a current diagnosis for RI #29. EI #1 stated no, it was not. EI #1 was asked if Pneumonia was coded on the MDS dated [DATE] and she stated that it was. EI #1 was asked why Pneumonia would be coded if Pneumonia was not a current diagnosis. EI #1 stated it transferred over. EI #1 stated she did not realize the historical diagnoses were transferring over. EI #1 said she would have to go in and edit them. EI #1 was asked how the MDS was accurate if Pneumonia was coded, and the resident did not have a current diagnosis of Pneumonia. EI #1 stated that it was not accurate. EI #1 was asked what the policy was for coding the MDS accurately. EI #1 said that they follow the RAI manual. EI #1 was asked what the concern was for an inaccurately coded MDS. EI #1 stated it could affect the funding and reimbursement.

Based on interviews and review of the job description for the Director of Nursing Services and the Administrator, the Administrator and Director of Nursing (DON) failed to ensure systems were in place to assure all required COVID-19 staff testing was performed as required based on county positivity rate. Further, neither the Administrator or Director of Nursing, the only two staff with access to COVID-19 lab reports, followed up on testing results to ensure positive results were reviewed and acted upon as needed in a timely manner. As a result of this systematic failure, the facility failed to identify and act upon a contracted housekeeper (HSK #1)'s positive routine COVID-19 test result. On 8/6/2021, a contracted housekeeper (HSK #1) COVID-19 specimen was collected. The positive result was finalized and available to facility staff on 8/7/2021 at 2:14 PM; however, the facility did not implement a system to review this information to ensure the positive result were acted upon until the following Tuesday, 8/10/2021. This resulted in HSK #1 continuing to work in the facility while positive for COVID-19 during a pandemic and potentially exposing residents as well as other staff members. Furthermore, the Administrator and DON failed to ensure all unvaccinated staff were tested for COVID-19 two times per week, beginning the week of 7/26/2021 when the county positivity rate exceeded 10% as required by regulations and facility policy. These failures placed all 40 residents currently residing in the facility in immediate jeopardy for serious injury, harm, impairment, or death. On 8/19/2021 at 3:31 PM, the facility's Administrator and DON were given a copy of the Immediate Jeopardy template and notified of the findings of immediate jeopardy level in the area of Administration, F835. Findings include: On 8/6/2021, a contracted housekeeper (HSK #1) COVID-19 specimen was collected for testing. The positive result was finalized and available to facility staff on 8/7/2021 at 2:14 PM; however, the facility did not implement a system to review this information to ensure the positive result were acted upon until the following Tuesday, 8/10/2021. This resulted in HSK #1 continuing to work in the facility while positive for COVID-19 during a pandemic and potentially exposing residents as well as other staff members. Furthermore, the facility has a total of 53 employees, of which 27 are unvaccinated. Twice a week, routine testing of unvaccinated staff is indicated when the facility's county positivity rate is greater than 10%. Beginning the week of 7/26/2021, when the facility's county positivity rate was 13.4%, until the present time, the facility failed to test 23 of 27 unvaccinated employees as required and indicated in the facility's policy. Refer to F886. The undated, unsigned job description for the Director of Nursing Services documented Purpose of Your Job Position The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as many be directed by the Administrator and the Medical Director, to ensure that the highest degree of quality care is maintained at all times . In an interview on 8/18/2021 at 9:02 AM, EI #2, the Director of Nursing (DON) was asked what determines the frequency of (COVID-19) testing. EI #2 replied, the county positivity rate. When asked how often the county positivity rate was checked, EI #2 stated it was checked daily by the Administrator. When asked when and how often staff are tested , EI #2 stated on 7/26/2021 because of the county positivity rate, they began testing the staff twice a week on Mondays and Fridays. EI #2 explained that testing begins at 7:00 AM and goes until 4:30 PM, so that specimens can be ready for the courier to pick up to transport to the lab between 6:00 PM and 9:00 PM. When asked when are results available, EI #2 stated usually the next day but within 48 hours. EI #2 was asked, how are the results received and she stated by way of a lab portal. When asked who has access to the lab portal, EI #2 replied she and the Administrator. When asked who was responsible for checking the lab portal, EI #2 stated the Administrator usually pulls the results from the lab portal. The results are then printed and reviewed. EI #2 was asked who checks the lab portal on the weekends. EI #2 answered, she and the Administrator both have the ability to check the portal 24 hours a day, seven days a week. When asked who was responsible for ensuring all COVID-19 test results have been received and reviewed, EI #2 said it was her and the Administrator's responsibility. EI #2 was asked, what was the process for notifying an employee of a positive COVID-19 test result. EI #2 replied, immediately the employee is called because they cannot work. EI #2 explained the employee would need to quarantine for 10 days and if they remain asymptomatic, they can return to work after the 10-day quarantine. When asked if the housekeeping services staff are employees of the facility or contractors, EI #2 replied, they were contractors. EI #2 acknowledged that HSK #1 was tested on [DATE] and that she was not sure when the results were received. EI #2 stated she thought the Administrator notified HSK #1's Supervisor of the positive test result. EI #2 stated she was unsure why it took longer than 48 hours to notify HSK #1 of the COVID-19 test result. When questioned about four of the 23 unvaccinated residents as to why they were not tested according to regulations and the facility's policy, EI #2 stated she was unsure. In a follow-up interview on 8/19/2021 at 9:32 AM, EI #2, the DON was asked who was responsible for ensuring all employees that should be tested are tested (for COVID-19). EI #2 answered, she and the Administrator was responsible. When asked if all employees that are required to be tested have been tested at the frequency required, EI #2 replied no. When asked why testing was not being done as required, EI #2 stated she was not sure. The undated, unsigned job description for the Administrator documented Purpose of Your Job Position The primary purpose of your job position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern long-term care facilities to assure that the highest degree of quality care can be provided to our residents at all times . During an interview on 8/18/2021 at 10:30 AM, EI #1 the Administrator was asked why was HSK #1 not notified of her positive COVID-19 test result, if the results were available on 8/7/2021. EI #1 replied, that she didn't see the results until 8/10/2021. EI #1 explained the facility should have been made aware of the test result by 8/8/2021 since the employee was tested on Friday, 8/6/2021; however, that was a weekend and she didn't check the lab portal. When asked if checked the lab portal on Monday, 8/9/2021, EI #1 said no she didn't. When asked why, EI #1 replied because she was off that day. EI #1 was asked who else was responsible for checking the lab portal and she stated, it was her responsibility to check it. When asked what the facility's process was to ensure Fridays lab results and followed up on over the weekend, EI #1 stated the process was for her to check the lab portal. When asked why would be important to have a system in place to follow up on (COVID-19) lab results over the weekend, EI #1 replied, she guessed there needed to be a back-up person in place to ensure no COVID-19 positive employee was working in the facility. EI #1 was asked when should HSK #1 have been notified of her positive COVID-19 test result. EI #1 answered, she should have been notified by 8/8/2021. When asked why she was not notified, EI #1 replied because she didn't check the lab portal. EI #1 was asked, why it was important to know that all results have been received. EI #1 replied, to ensure that no employee that tested positive (for COVID-19) was in the facility. When asked what potential harm this could cause the residents, EI #1 replied, the residents could be exposed to COVID-19. In a follow-up interview on 8/19/2021 at 10:27 AM, EI #1, the Administrator was asked how often she checks the lab portal for COVID-19 test results. EI #1 replied, daily. When asked who checked the lab portal on the weekends, EI #1 stated she did as it was her responsibility. EI #1 explained that over the weekend of 8/7/2021 and 8/8/2021, she only checked the lab portal the morning of 8/7/2021. EI #1 stated she didn't check the lab portal on Sunday, 8/8/2021 or Monday, 8/9/2021 because she was off. When asked when she became aware of HSK #1's positive COVID-19 lab result, EI #1 replied on Tuesday, 8/10/2021. According to EI #1 after becoming aware of HSK #1's positive COVID-19 lab result, EI #1 notified the HSK Supervisor. HSK Supervisor then notified HSK #1 of the positive test result, that she could not return to work, and to determine if HSK #1 was experiencing any symptoms. EI #1 then informed resident families and staff, completed Alabama Department of Public Health online report card, and began outbreak testing on all staff and residents. ************************* On 8/20/2021 at 2:37 PM, the facility submitted an acceptable removal plan which documented: . On 8/19/2021 a QAPI (Quality Assessment Performance Improvement) meeting was held with the NHA (Nursing Home Administrator), DON (Director of Nursing), HR (Human Resource) Director, and MDS (Minimum Data Set) Nurse and a PIP (Performance Improvement Plan) was developed titled, COVID Policy and Procedure. The PIP addresses the root cause of the facility's failure to test all employees of the facility biweekly as dictated by the county's positivity rate, the facility's plan to improve the process, and how the facility will monitor the outcomes of the change in process, and the root cause of the facility's failure to promptly notify a positive employee of his/her results. On 8/20/2021 a QAPI meeting will be held and PIP will be discussed as well as removal plan. ADM, DON, Medical Director (via telephone), Regional Director of Operations (RDO), (via phone), Regional Nurse (via phone). Education provided by the RDO and Regional Nurse to the Administrator and Director of Nursing on the Testing Policy and requirements for testing and reviewing lab results. (completed 8/19/21 at 5:49 PM). Education included following testing guidance for ALL facility staff as outlined in CMS Memorandum Ref: QSO-20-38-NH dated August 26, 2020 and revised April 27, 2021 based on the county's positivity rate. (completed 8/19/2021 at 5:49 pm). Education included ensuring the testing portal is reviewed twice per day (in the morning and afternoon) to ensure all results are received timely and to ensure notifications can be made timely in the event of any positives. (completed 8/19/21 at 5:50 PM). Education included NHA and DON's responsibility to ensure that testing is conducted per the county's positivity rate and to ensure that required notifications are made promptly to prevent the spread and possible outbreak of Covid 19. RDO and Regional Nurse will review testing trackers weekly for 4 weeks and then monthly for 2 months with the Administrator during weekly meetings to ensure all testing is completed and results received timely with notifications of any positive results made. Trackers will be maintained in a binder in the NHA office after being reviewed with the aforementioned. If noncompliance is noted, reeducation will be provided. If noncompliance continues disciplinary actions will follow. Results will be reviewed monthly for 3 months in the QAPI meeting. ************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F835 was lowered to a F level on 8/20/2021, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 485.

Based on interviews, review of the Centers for Medicare & Medicaid Services (CMS) Center for Clinical Standards and Quality/Survey & Certification Group Ref: QSO-20-38-NH, the facility's policy titled COVID-19 Testing Guidance, other facility documents and a complaint received, the facility failed to timely identify and act upon an unvaccinated, asymptomatic contracted housekeeper's positive COVID-19 test result. On 8/6/2021, a contracted housekeeper (HSK #1) COVID-19 specimen was collected. The positive result was finalized and available to facility staff on 8/7/2021 at 2:14 PM; however, the facility did not implement a system to review this information to ensure the positive result were acted upon until the following Tuesday, 8/10/2021. This resulted in HSK #1 continuing to work in the facility while positive for COVID-19 during a pandemic and potentially exposing residents as well as other staff members. Furthermore, the facility failed to ensure all unvaccinated staff were tested for COVID-19 two times per week, beginning the week of 7/26/2021 when the county positivity rate exceeded 10% as required by regulations and facility policy. Serious injury, serious harm, serious impairment or death is likely as a result of this noncompliance, as prompt action to address COVID-19 positive lab results is necessary to prevent further spread of the disease. Further, without consistently implementing a system to ensure all staff members are tested at the required frequency based on county positivity rate, it is likely an unidentified positive case could lead to an ongoing outbreak amongst staff and residents. Promptly acting upon positive COVID-19 test results, and properly performing staff testing is necessary to protect the resident population from COVID-19 and prevent further outbreak status. These deficient practices had the potential to affect all 40 residents who currently reside in the facility and placed them at risk for serious injury, harm, impairment or death. On 8/19/2021 at 3:31 PM, the facility's Administrator and Director of Nursing (DON) were given a copy of the Immediate Jeopardy template and notified of the finding of immediate jeopardy in the area of COVID-19 Testing - Residents and Staff, F886. Findings include: 1) The Centers for Medicare & Medicaid Services (CMS) Center for Clinical Standards and Quality/Survey & Certification Group Ref: QSO-20-38-NH revised 4/27/2021, documented . GUIDANCE Testing of Nursing Home Staff and Resident To enhance efforts to keep COVID-19 from entering and spreading through nursing homes, facilities are required to test residents and staff based on parameters and a frequency set forth by the HHS (Health and Human Services) Secretary. Facilities can meet the testing requirements through the use of rapid point-of-care (POC) diagnostic testing devices or through an arrangement with an offsite laboratory . Facility staff includes employees, consultants, contractors, volunteers, and caregivers who provide care and services to residents on behalf of the facility . Routine Testing of Staff Routine testing of unvaccinated staff should be based on the extent of the virus in the community. Fully vaccinated staff do not have to be routinely tested . Facilities should use their county positivity rate in the prior week as the trigger for staff testing frequency . Table 2: Routine Testing Intervals Vary by Community COVID-19 Activity Level indicates at the High activity level, the county positivity rate is greater than 10% and the minimum testing frequency for unvaccinated staff is twice per week. *This frequency presumes availability of Point of Care testing on-site at the nursing home or where off-site testing turnaround time is <48 hours . The facility's policy titled COVID-19 Testing Guidance dated 8/10/2021, documented There are two types of tests available for COVID-19: diagnostic tests and antibody blood tests . The CDC (Centers for Disease Control and Prevention) and CMS (Centers for Medicare & Medicaid Services) have both issued guidance for who should be tested and when . If sent to an outside laboratory for sample analysis or processing, then the results should be available in less than 48 hours from time of collection . We will test our residents and staff per guidelines . These guidelines are intended to prevent widespread transmission within our communities and to mitigate potential risk from our residents and staff . On 8/12/2021, the State Survey Agency received a complaint which alleged the facility failed to timely notify a housekeeper (HSK) that she had tested positive for COVID-19. According to the complainant, the facility tested HSK #1 on 8/6/2021 and she was not notified of the positive test result until five days later, on 8/11/2021. On 8/17/2021 at 4:52 PM, a telephone interview was conducted with HSK #1, a housekeeper who works Hall A and part of Hall B in the facility. HSK #1 was asked when she tested positive for COVID-19. HSK #1 replied, she took the test on 8/6/2021 and was notified on 8/11/2021 the result was positive. HSK #1 was asked where she was when notified by the facility of the positive test result. HSK #1 replied, she was at home. HSK #1 was asked when she worked after 8/6/2021. HSK #1 replied, she worked 8/7/2021, 8/8/2021, and 8/9/2021. HSK #1 was asked why the facility took so long to notify her of the positive test result. HSK #1 replied, she did not know. HSK #1 was asked what symptoms of COVID-19 she had. HSK #1 replied, she had no symptoms. HSK #1 was asked what her concern was with not being notified in a timely manner of her COVID-19 positive test results. HSK #1 replied, because she was around the residents. HSK #1 was asked what contact she had with the residents. HSK #1 replied, she talked to them and had to go into their rooms to clean. HSK #1's ATTENDANCE REPORT . indicated HSK #1 worked in the facility on 8/6/2021, 8/7/2021, 8/8/2021 and 8/9/2021 from 8:00 AM to 3:00 PM each day. In an interview on 8/18/2021 at 9:02 AM, EI #2, the Director of Nursing (DON) was asked what determines the frequency of (COVID-19) testing. EI #2 replied, the county positivity rate. When asked how often the county positivity rate was checked, EI #2 stated it was checked daily by the Administrator. When asked when and how often staff are tested , EI #2 stated on 7/26/2021 because of the county positivity rate, they began testing the staff twice a week on Mondays and Fridays. EI #2 explained that testing begins at 7:00 AM and goes until 4:30 PM, so that specimens can be ready for the courier to pick up to transport to the lab between 6:00 PM and 9:00 PM. When asked when are results available, EI #2 stated usually the next day but within 48 hours. EI #2 was asked, how are the results received and she stated by way of a lab portal. When asked who has access to the lab portal, EI #2 replied she and the Administrator. When asked who was responsible for checking the lab portal, EI #2 stated the Administrator usually pulls the results from the lab portal. The results are then printed and reviewed. EI #2 was asked who checks the lab portal on the weekends. EI #2 answered, she and the Administrator both have the ability to check the portal 24 hours a day, seven days a week. When asked who was responsible for ensuring all COVID-19 test results have been received and reviewed, EI #2 said it was her and the Administrator's responsibility. EI #2 was asked, what was the process for notifying an employee of a positive COVID-19 test result. EI #2 replied, immediately the employee is called because they cannot work. EI #2 explained the employee would need to quarantine for 10 days and if they remain asymptomatic, they can return to work after the 10-day quarantine. When asked if the housekeeping services staff are employees of the facility or contractors, EI #2 replied, they were contractors. EI #2 acknowledged that HSK #1 was tested on [DATE] and that she was not sure when the results were received. EI #2 stated she thought the Administrator notified HSK #1's Supervisor of the positive test result. EI #2 stated she was unsure why it took longer than 48 hours to notify HSK #1 of the COVID-19 test result. On 8/18/2021 at 9:42 AM, an interview was conducted with the Housekeeping (HSK)Supervisor. She was asked when she was notified of HSK #1's COVID-19 positive test result. HSK Supervisor replied, on 8/10/2021 about 9:20 AM just after the morning meeting. When asked, who notified her, she replied, Employee Identifier (EI) #1, the Administrator. After becoming aware, HSK Supervisor stated she called HSK #1 at home as she was off that day. HSK Supervisor stated she informed HSK #1 that she had tested positive and had to be off work for 10 days. When asked if HSK #1 reported any symptoms, HSK Supervisor stated HSK #1 reported none; she felt good. In a follow-up interview on 8/19/2021 at 9:24 AM, HSK Supervisor was asked if she was sure is was 8/10/2021 that she became aware of HSK #1's positive test result. HSK Supervisor replied, yes, it was a Tuesday, so she was positive it was 8/10/2021. During an interview on 8/18/2021 at 10:30 AM, EI #1 the Administrator was asked why was HSK #1 not notified of her positive COVID-19 test result, if the results were available on 8/7/2021. EI #1 replied, that she didn't see the results until 8/10/2021. EI #1 explained the facility should have been made aware of the test result by 8/8/2021 since the employee was tested on Friday, 8/6/2021; however, that was a weekend and she didn't check the lab portal. When asked if checked the lab portal on Monday, 8/9/2021, EI #1 said no she didn't. When asked why, EI #1 replied because she was off that day. EI #1 was asked who else was responsible for checking the lab portal and she stated, it was her responsibility to check it. When asked what the facility's process was to ensure Fridays lab results and followed up on over the weekend, EI #1 stated the process was for her to check the lab portal. When asked why would be important to have a system in place to follow up on (COVID-19) lab results over the weekend, EI #1 replied, she guessed there needed to be a back-up person in place to ensure no COVID-19 positive employee was working in the facility. EI #1 was asked when should HSK #1 have been notified of her positive COVID-19 test result. EI #1 answered, she should have been notified by 8/8/2021. When asked why she was not notified, EI #1 replied because she didn't check the lab portal. EI #1 was asked, why it was important to know that all results have been received. EI #1 replied, to ensure that no employee that tested positive (for COVID-19) was in the facility. When asked what potential harm this could cause the residents, EI #1 replied, the residents could be exposed to COVID-19. In a follow-up interview on 8/19/2021 at 10:27 AM, EI #1, the Administrator was asked how often she checks the lab portal for COVID-19 test results. EI #1 replied, daily. When asked who checked the lab portal on the weekends, EI #1 stated she did as it was her responsibility. EI #1 explained that over the weekend of 8/7/2021 and 8/8/2021, she only checked the lab portal the morning of 8/7/2021. EI #1 stated she didn't check the lab portal on Sunday, 8/8/2021 or Monday, 8/9/2021 because she was off. When asked when she became aware of HSK #1's positive COVID-19 lab result, EI #1 replied on Tuesday, 8/10/2021. According to EI #1 after becoming aware of HSK #1's positive COVID-19 lab result, EI #1 notified the HSK Supervisor. HSK Supervisor then notified HSK #1 of the positive test result, that she could not return to work, and to determine if HSK #1 was experiencing any symptoms. EI #1 then informed resident families and staff, completed Alabama Department of Public Health online report card, and began outbreak testing on all staff and residents. According to a document provided by the facility, HSK #1's Molecular PCR (Polymerase Chain Reaction) Summary Lab Report indicated a COVID-19 specimen was collected on 8/6/2021 at 3:00 PM. According to the report on 8/7/2021 at 2:14 PM, the laboratory reported to the facility that HSK #1 was COVID-19 positive. According to documentation provided by the facility, since becoming aware of HSK #1's positive COVID-19 test result, the facility has completed round one of Outbreak Testing. Round one of Outbreak Testing revealed, two additional staff members as testing positive for COVID-19. At the present time, no residents have tested positive for COVID-19. 2) The Centers for Medicare & Medicaid Services (CMS) Center for Clinical Standards and Quality/Survey & Certification Group Ref: QSO-20-38-NH revised 4/27/2021, documented . DEFINITIONS Fully vaccinated refers to a person who is (greater than or equal to) 2 weeks following receipt of the second dose in a 2-dose series, or (greater than or equal to) 2 weeks following receipt of one dose of a single-dose vaccine. Unvaccinated refers to a person who does not fit the definition of fully vaccinated, including people whose vaccination status is not known, for the purposes of this guidance . Routine Testing of Staff Routine testing of unvaccinated staff should be based on the extent of the virus in the community. Fully vaccinated staff do not have to be routinely tested . Facilities should use their county positivity rate in the prior week as the trigger for staff testing frequency . Table 2: Routine Testing Intervals Vary by Community COVID-19 Activity Level indicates at the High activity level, the county positivity rate is greater than 10% and the minimum testing frequency for unvaccinated staff is twice per week. According to an unlabeled, undated document provided the facility during the survey, the facility has a total of 53 employees. Of the 53 employees, 27 are not fully vaccinated. An undated facility document with a handwritten title of MCSC (Montgomery Children's Specialty Center) Covid Positivity Rate documented . 7/26/2021 * Positivity rate week ending 7/20/2021 is 13.4% . All unvaccinated employees will be tested twice this week . 8/2/2021 * Positivity rate for week ending 07/27/2021 is 17.8% so unvaccinated staff are testing twice a week . 8/9/2021 * Continued testing for surveillance testing. Testing staff twice a week. Positivity rate is 19.6% for week ending 8/3/2021 . 8/16/2021 . * County positivity rate is 22% for week ending 8/10/2021 . A review of all 27 unvaccinated employees Molecular PCR Summary Lab Report revealed 23 out of 27 unvaccinated employees were not tested according to regulations and the facility's policy beginning the week of 7/26/2021 until present, when the facility's county positivity rate was greater than 10%. In an interview on 8/18/2021 at 9:02 AM, EI #2, the DON was asked what determines the frequency of (COVID-19) testing. EI #2 replied, the county positivity rate. When asked when and how often staff are tested , EI #2 stated on 7/26/2021 because of the county positivity rate, they began testing the staff twice a week on Mondays and Fridays. EI #2 was asked, who was responsible for the testing of staff. EI #2 replied, she was. When questioned about four of the 23 unvaccinated residents as to why they were not tested according to regulations and the facility's policy, EI #2 stated she was unsure. During an interview on 8/19/2021 at 9:07 AM, EI #4, an unvaccinated Certified Nursing Assistant (CNA) asked if there was ever a time, she was not tested twice a week. EI #4 replied yes. EI #4 was asked why it was important to test twice a week for COVID-19. EI #4 replied, it was important to know if you were positive because you do not want to work with the residents if you are positive. When asked what the risk was to the residents if she was not tested twice a week, EI #4 replied, she could be positive and expose the residents to COVID-19. During a telephone interview on 8/19/2021 at 5:00 PM, EI #8, an unvaccinated CNA was asked if she was tested twice a week. EI #8 replied, she was tested at least once per a week. In a follow-up interview on 8/19/2021 at 9:32 AM, EI #2, the DON was asked who was responsible for ensuring all employees that should be tested are tested (for COVID-19). EI #2 answered, she and the Administrator was responsible. When asked if all employees that are required to be tested have been tested at the frequency required, EI #2 replied no. When asked why testing was not being done as required, EI #2 stated she was not sure. ************************* On 8/20/2021 at 2:37 PM, the facility submitted an Acceptable Removal Plan which documented: . Removal Plan for Immediate Jeopardy F886 On 8/19/2021 a QAPI (Quality Assessment Performance Improvement) meeting was held with the NHA (Nursing Home Administrator), DON, HR (Human Resource) Director, and MDS (Minimum Data Set) Nurse. A PIP (Performance Improvement Plan) was developed titled, COVID Policy and Procedure. The PIP addresses the root cause of the facility's failure to test all employees of the facility biweekly as dictated by the county's positivity rate, the facility's plan to improve the process, how the facility will monitor the outcomes of the change in process, and the root cause of the facility's failure to promptly notify a positive employee of his/her results. On 8/20/2021 a QAPI meeting will be held with the NHA, DON, Medical Director (via telephone), Regional Director of Operations (RDO), (via phone), Regional Nurse (via phone). PIP will be discussed as well as removal plan. Education was provided by the RDO and Regional Nurse to the Administrator and Director of Nursing on the Testing Policy and requirements for testing and reviewing lab results. This was completed on 8/19/21 at 5:49 PM. Education included following testing guidance for ALL facility staff as outlined in CMS Memorandum Ref: QSO-20-38-NH dated August 26, 2020 and revised April 27, 2021 based on the county's positivity rate. Education included ensuring the testing portal is reviewed twice per day (in the morning and afternoon) to ensure all results are received timely and to ensure notifications can be made timely in the event of any COVID-19 positives. Education will be provided to all staff on the policy for testing to include: If not tested according to the testing policy and the county positivity rates, the staff member will not be allowed to work until tested . This began on 8/19/2021 at 4:00 PM. Education will be conducted in the following manners: Small group in person huddles by the DON, NHA, and/or managers, Onshift blasts to all clinical staff by the NHA (staff will be asked to provide a current cell phone number or email address to ensure that they are receiving the text message), and postings at the timeclock and in break areas. Education will be completed on 57% /30 employees by 8/20/21. The remaining employees will be educated as scheduled to work. Completion of education will be monitored by the HR Director. Education training forms will be provided to the HR director to compare to current employee listing. If noncompliance is noted the NHA and/or DON will be notified for completion. If noncompliance continues, disciplinary process will be followed. Current staff were reviewed to ensure testing has been performed according to the current positivity rates for the week ending 8/21/2021. This will be completed on 8/20/2021. To ensure that all employees are tested the following has been implemented: A) Additional testers have been added to include: DON, MDS nurse, and nurse managers. B) A testing tracker has been developed that includes the following: All employee names. (a list of current employees will be provided by HR each testing day), date when test is performed, results of the test, who received the results, date and time received and date and time the employee was notified of any positive result. All tests performed will be documented on the testing tracker including PCR and rapid tests. Trackers will be maintained in a binder in the NHA office after being reviewed by the Regional Director. To ensure that all positive results are received as soon as practical, the lab has set up alerts to be sent to the email of the NHA and DON. This will be completed by 8/20/21. The community has identified an additional staff member, HR Director, to have access to the lab portal. This was completed on 8/19/21 at 5:50 PM. Education on the process to check the lab portal will be provided to the HR Director by the NHA to include the process of checking outstanding results, documentation of the results on the tracker, acknowledgment of the laboratory results on the portal, calendar rotation and notification of the backup person, prompt notification of any positive results to NHA and/or DON. This will be completed 8/20/2021. A calendar has been created to identify which staff member is responsible for reviewing the lab portal twice per day, once in the morning and once in the afternoon, to ensure any COVID positives are acted upon timely. The calendar will provide a rotation between the NHA, DON, and HR Director. It also notates the backup for each person on every day. Each individual will communicate their inability to check the portal and the need for the backup person to check. This was completed on 8/19/21 at 5:50 PM. Testing trackers will be reviewed daily Mon-Fri in morning stand up meeting to identify employees who have failed to test by the NHA and HR director and notified by the DON that they will not be allowed to work until they have been tested . The payroll manager will notate the employee's name and notify the NHA immediately if an employee worked that has been previously noted to be ineligible to work due to failure to test. Results will be reviewed weekly in the facility's PIP meeting for 4 weeks and then monthly in the facility's QAPI meeting for 3 months. RDO and/or Regional Nurse will review testing trackers weekly for 4 weeks and then monthly for 2 months with Administrator during weekly meetings to ensure all testing was completed and results received timely with notification of any positive result made. Trackers will be maintained in a binder in the NHA office after being reviewed with the aforementioned. If noncompliance is noted, re-education will be provided to the NHA and DON. If noncompliance continues, disciplinary actions will follow. Results will be reviewed monthly for 3 months in the QAPI meeting. ************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F886 was lowered to a F level on 8/20/2021, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 485.

Based on observation, interview and review of a facility policy titled, CLEAN (ASEPTIC) TREATMENT TECHNIQUE, the facility failed to ensure Employee Identifier (EI) #1, Registered Nurse (RN), Assistant Director of Nursing (ADN), Infection Control Nurse, did not place a clear plastic wound measuring tool that was lying on the resident's overbed table without a barrier, against the resident's skin to measure the resident's wound. This affected RI #6, one of two residents sampled with pressure ulcers in the facility. Findings Include: A facility policy titled, CLEAN (ASEPTIC) TREATMENT TECHNIQUE, with a revised date of 4/2018, stated: .II. Set up a clean field . e. Place a pad on the table, a water resistant pad or a clean towel on the table. f. Put all needed supplies (dressings, topical medications, cleansing solutions, etc.) on the clean field . RI #6 was readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. On 10/08/2019 at 4:40 p.m., the surveyor observed wound care being provided by EI #1 to RI #6. During the observation, no barrier was placed on the overbed table. All items were opened and remained on packaging except for the wound measuring tool. The wound measuring tool was lying on the overbed table with no barrier. EI #1 measured the wound with the wound measuring tool that was lying on the overbed table. The wound measuring tool touched RI #6's open pressure ulcer on the right greater trochanter (hip area). On 10/08/19 at 5:00 p.m., the surveyor conducted an interview with EI #1. The surveyor asked EI #1 what would be the concern of the measuring tool laying on the overbed table, without a barrier then being placed on the wound to measure it. EI #1 replied contamination. On 10/09/19 at 4:13 p.m., a follow up interview was conducted with EI #1. The surveyor asked EI #1 what was the facility policy on wound dressing changes. EI #1 replied, explain procedures to the resident, identify the resident, wash hands, gather all equipment, place a shield or clean towel on the surface, set up supplies on the clean surface, wash hands and apply gloves. EI #1 was asked how did she measure the wound on RI #6, yesterday, during the dressing change observed by the surveyor. EI #1 replied, the measurement tool was on the bedside table and after the LPN (Licensed Practical Nurse) charge nurse had cleaned the wound, she used the measuring tool to measure the wound. EI #1 was asked if the wound measuring tool was lying on a clean barrier. EI #1 replied no. EI #1 was asked what the concern would be of placing the wound measuring tool that had been lying on the resident's overbed table on the wound to measure the wound. EI #1 replied, possible contamination.

Based on observation, medical record review and interview, the facility failed to ensure a licensed staff member did not pick up a paper towel from the floor then touch the clean feeding syringe while returning it to the clean plastic bag. This deficient practice affected Resident Identifier (RI) #16, one of the four residents observed during medication administration. Findings include: RI #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 10/10/19 at 8:19 a.m., the surveyor observed Employee Identifier (EI) #2, Licensed Practical Nurse (LPN) give RI #16 his/her medication. EI #2 rinsed the feeding syringe and gathered brown paper towels to dry the feeding syringe. EI #2, while drying the syringe, dropped one of the brown paper towels on the floor, picked the brown paper towel up, then placed the clean syringe into the plastic bag. While holding the contaminated brown paper towel, EI #2 touched the feeding syringe. On 10/10/19 at 10:22 a.m., the surveyor conducted an interview with EI #2. The surveyor asked EI #2 how did she clean the syringe after giving RI #16 the medications. EI #2 said with water then dried it. The surveyor asked EI #2 what did she use to dry the syringe. EI #2 said brown paper towels. The surveyor asked EI #2 what happened with one of the brown paper towels while drying the syringe. EI #2 said she dropped it on the floor. The surveyor asked EI #2 did she pick the brown paper towel up from the floor. EI #2 said yes, ma'am. EI #2 acknowledged after touching and picking up the brown paper towel from the floor, she put the syringe inside of the clean plastic bag. The surveyor asked EI #2 what were the issues with this. EI #2 said infection control. On 10/10/19 at 11:31 a.m., the surveyor conducted an interview with EI #1, Infection Control Nurse. The surveyor asked EI #1 when should a nurse pick up a brown paper towel from the floor and place it in her hand while holding a syringe that she returned to a clean plastic bag. EI #1 said she should not. The surveyor asked how should she have dried the syringe before returning it to the clean plastic bag. EI #1 said she should have dried the syringe by separating it from the plunger then she should have returned it to the plastic bag. The surveyor asked EI #1 what were the issues with this. EI #1 said possible contamination from the dirty paper towel.

Based on interviews and record review, the facility failed to ensure Resident Identifier (RI) #2's physician order, dated 10/01/18, for [MEDICATION NAME] 0.5 mg (milligram) to be administered every eight hours, was administered as ordered. RI #2's [MEDICATION NAME] was not started until 10/24/18, causing RI #2 to miss 22 days of the [MEDICATION NAME]. This deficient practice affected RI #2, one of seven sampled residents. Findings Include: RI #2 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #2's Clinic Notification Report dated 10/01/18, revealed: . Home Meds (medications) at Discharge Take These medications: [REDACTED] [MEDICATION NAME] Instructions: 0.5 milligrams(s) orally every 8 hours . RI #2's Progress Note dated 10/01/18 at 19:54 (7:54 p.m.) revealed: . Resident came back form (his/her) appt. (appointment) . [MEDICATION NAME] was prescribed 0.5 mg q (every) 8 hrs. (hours) . Electronically signed by Employee Identifier (EI) #3, the nurse assigned to care for RI #2 on 10/01/18. A review of RI #2's Outpatient Visit Summary, dated 10/22/18, revealed: . 5. Suppose to be on [MEDICATION NAME] 0.5milligrams every 8 hrs-not on facility medication list-please check on this . RI #2's Progress Note dated 10/23/18 at 16:11 (4:11 p.m.) revealed: . I have called (name of RI #2's physician) to follow-up on the [MEDICATION NAME] order for (RI #2) . This entry was electronically signed by EI #1, the Director of Nursing (DON). A review of RI #2's (MONTH) (YEAR) E-MAR (Electronic Medication Administration Record) revealed the [MEDICATION NAME] was not started until 10/24/18, 22 days after the order was prescribed. On 01/24/19 at 5:11 p.m., the surveyor conducted an interview with EI #1. The surveyor asked EI #1 had RI #2 been administered the medication [MEDICATION NAME] while a resident at the facility. EI #1 said it looked like RI #2 was started on the [MEDICATION NAME] on 10/24/18. The surveyor asked EI #1 when should the [MEDICATION NAME] have been started. EI #1 said 10/01/18. The surveyor asked EI #1 who would have been responsible for ensuring the order was carried out. EI #1 said EI #3. The surveyor asked EI #1 were RI #2's physician orders [REDACTED]. EI #1 said no. On 01/24/19 at 6:22 p.m., the surveyor conducted an interview with EI #3. The surveyor asked EI #3, looking at RI #2's Clinic Notification Report dated 10/01/18, did RI #2 have an order for [REDACTED].#3, according to RI #3's (MONTH) (YEAR) E-MAR, when did RI #2 start the [MEDICATION NAME]. EI #3 said on 10/24/18. The surveyor asked EI #3 when should the [MEDICATION NAME] order have started. EI #3 said on 10/01/18 or as soon as the order was received. This deficiency was cited as a result of the investigation of complaint/report #AL 004.

Based on record review and interviews, the facility failed to ensure Resident Identifier (RI) #1's sponsor was notified when RI #1's 10/31/18, BPD ([MEDICATION NAME] Disease) clinic doctors appointment was rescheduled for 11/12/18. This deficient practice affected RI #1, one of three residents sampled for review of appointment schedules. Findings Include: RI #1 was admitted to the facility on [DATE], and readmitted on [DATE], with a [DIAGNOSES REDACTED]. On 01/04/19, the Alabama State Survey Agency received a complaint which revealed the following: . We were notified by the DHR (Department of Human Resources) worker that (RI #1) was hospitalized locally in(NAME)in late October. The 10/31/18 appointment in BPD Clinic was changed to 11/12/18. The DHR supervisor brought (RI #1's) mother to the appointment on 10/31/18, as DHR (who has custody of the child) was unaware the appointment had been changed . On 01/23/19 at 4:34 p.m., the surveyor conducted an interview with Employee Identifier (EI) #2, the Social Worker Director. The surveyor asked EI #2 was RI #1's DHR worker notified that RI #1's 10/31/18 appointment had been changed to 11/12/18. EI #2 said no. When asked should the DHR worker have been notified, EI #2 said yes. On 01/24/19 at 5:11 p.m., the surveyor conducted an interview with the Director of Nursing (DON), EI #1. When asked if RI #1's DHR worker should have been notified when the 10/31/18 appointment was rescheduled for 11/12/18, EI #1 replied, yes. On 01/24/19 at 6:45 p.m., the surveyor attempted to contact RI #1's DHR worker without success. A telephone interview was conducted with RI #1's DHR worker on 01/25/19 at 10:11 a.m., when the DHR worker returned the telephone call. The DHR worker said she was not notified when RI #1's doctor's appointment was rescheduled for 11/12/18. This deficiency was cited as a result of the investigation of complaint/report #AL 004.

Based on observation, interview, record review and a review of a facility policy titled, Using the Care Plan, the facility failed to develop and implement a baseline care plan for Resident Identifier (RI) #202 for the use of a divided plate and straw. This affected one of 14 residents observed during meals. Findings Include: A review of the facility's policy titled, Using the Care Plan with a revised date of (MONTH) 2006, revealed the following: Policy Statement The care plan shall be used in developing the resident's daily care routines . RI #202 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #202's NURSING ADMISSION/READMISSION DATA COLLECTION form dated 10/11/18 revealed: .Eating Needs Focus: The resident has an ADL Self Care Performance Deficit .Intervention: EATING: The resident requires total assistance to eat. A review of RI #202's ADL(Activities of Daily Living) Self Care Performance Deficit care plan was initiated on 10/11/18, but the intervention of .EATING: . (RI #202) requires assistance with eating; provide a divided plate and straw with meals . was not initiated until 10/16/18. A review of RI #202's current (MONTH) Order Summary Report dated 10/18/18, revealed the following: .Other Order Summary . Divided plate and straws with all meals . Order Status Active Order Date 10/15/2018 . On 10/16/18 at 5:15 PM, RI #202 was observed in the C-hall dining room. RI #202's tray did not have a divided plate nor did the the tray have a straw. RI #202 was observed to pick up a glass of lemonade several times and spill it onto the tray, himself/herself and the floor. On 10/16/18 at 5:45 PM, during an interview with Employee Identifier (EI) #4, Certified Nursing Assistant/CNA, the surveyor asked what type of plate should RI #202 have. EI #4 stated, Divided Plate. The surveyor asked what else should RI #202 have on his/her tray. EI #4 stated, A straw. The surveyor asked EI #4 how did she know what RI #202 should have on the tray. EI #4 stated, Because the tray cards says that. The surveyor asked when RI #202 received the tray, was there a divided plate and a straw on the tray. EI #4 stated, No.

Based on observation, interview and a review of Potter and Perry's FUNDAMENTALS OF NURSING, the facility failed to ensure a licensed staff member washed her hands after removing unclean gloves and before applying clean gloves. This affected one of five nurses and RI (Resident Identifier) #49, one of six residents observed during medication administration. Findings Include: A review of Potter and Perry's FUNDAMENTALS OF NURSING Ninth Edition, Copyright (YEAR), page 458 revealed: .Hand Hygiene .3. If hands are not visibly soiled .use an alcohol based, waterless antiseptic agent for routinely decontaminating hands in the following clinical situations: Before, after, and between direct patient contact . After removing gloves . RI #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/17/18 at 8:40 AM, the following was observed during medication administration: Employee Identifier (EI) #6, Licensed Practical Nurse/LPN, assisted RI #49 from the dining room to the therapy gym for privacy. EI #6 washed her hands, applied gloves, obtained a wipe and wiped RI #49's hands. EI #6 removed her gloves and applied clean gloves. EI #6 did not wash or sanitize her hands after the removal of the gloves. EI #6 obtained RI #49's fingerstick blood sugar. EI #6 removed her gloves, sanitized her hands and gloves were applied. EI #6 applied a Band-Aid to RI #49's finger, removed her gloves and applied clean gloves. EI #6 did not wash or sanitize her hands after the removal of the gloves. EI #6 opened several medication cart drawers, locked the medication cart and assisted RI #49 back to the dining room. EI #6 did not wash or sanitize her hands after she removed her gloves. On 10/17/18 at 8:45 AM, during an interview with EI #6, the surveyor asked what should be done after gloves were removed and before clean gloves were applied. EI #6 stated, Wash hands. The surveyor asked was that what she had done every time she removed her gloves. EI #6 stated, No ma'am. The surveyor asked what was the potential for harm. EI #6 stated, Infection.

Based on observations, interviews, record review and a review of the facility's policy titled, Assistive Devices, the facility failed to ensure Resident Identifier (RI) #202 received a divided plate and a straw for the supper meal on 10/16/18. This affected one of 14 residents observed during meals. Findings Include: A review of the facility's policy titled, Assistive Devices with a revised date of 09/17, revealed the following: Policy Statement Assistive devices/utensils will be provided as identified in the individualized plan of care to maintain or improve a resident's/patient/s ability to eat or drink independently. RI #202 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #202's Tray Card revealed the following for Breakfast, Lunch and Dinner: .(RI #202) - C-Hall . DIVIDED PLATE STRAW . A review of RI #202's current (MONTH) Order Summary Report dated 10/18/18, revealed the following: .Other Order Summary . Divided plate and straws with all meals . Order Status Active Order Date 10/15/2018 . A review of RI #202's care plan with a focus of : . has an ADL (Activities of Daily Living) Self Care Performance Deficit Date Initiated: 10/11/2018 . Interventions . EATING: . requires assistance with eating; provide a divided plate and straw with meals . On 10/16/18 at 5:15 PM, RI #202 was observed in the C-hall dining room. RI #202's tray did not have a divided plate nor did the the tray have a straw. RI #202 was observed to pick up a glass of lemonade several times and spill it onto the tray, himself/herself and the floor. On 10/16/18 at 5:45 PM, during an interview with Employee Identifier (EI) #4, Certified Nursing Assistant/CNA, the surveyor asked what type of plate should RI #202 have. EI #4 stated, Divided Plate. The surveyor asked what else should RI #202 have on his/her tray. EI #4 stated, A straw. The surveyor asked EI #4 how did she know what RI #202 should have on the tray. EI #4 stated, Because the tray cards says that. The surveyor asked when RI #202 received the tray, was there a divided plate and a straw on the tray. EI #4 stated, No.

Based on record reviews, interviews and a review of the facility's policy titled, ABUSE, PREVENTION AND PROHIBITION OF, the facility failed to ensure an allegation of abuse was reported to the Administrator or the State Agency within a two hour time frame. This affected Resident Identifier (RI) #39, one of one sampled resident reviewed for abuse. Findings Include: A review of the facility's policy titled, ABUSE, PREVENTION AND PROHIBITION OF with a revised date of 8/13, revealed the following: .Reporting/Response The facility employee . who becomes aware of abuse . shall immediately report the matter to the facility Administrator and/or the Director of Nursing. An employee .may directly make a report to the state agency . The facility .employee .who has reasonable cause to believe any resident with whom they have direct contact has been subjected to abuse .or any allegation of abuse shall report or cause a report to be made to the mandated state agency per reporting criteria . Abuse means the willful infliction of injury, . intimidation, . with resulting . mental anguish . Verbal Abuse is defined as the use or oral . language that willfully includes disparaging and derogatory terms to residents .or within the hearing distance . RI #39 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #39's current Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/12/18, revealed RI #39 had a Brief Interview for Mental Status (BIMS) score of 12, indicating cognition was intact. A review of the Facility Reported Incident revealed the following: Confirmation of Receipt of Online Incident Report . Date/Time Submitted: Thursday, (MONTH) 06, (YEAR) 7:22:38 PM . Incident Type . Mental Abuse Incident Detail . Name(s) of resident(s) involved: (RI #39) . Name of suspected offender(s): (Employee Identifier (EI) #2, Certified Nursing Assistant (CNA)) Date and time of alleged incident: 08/28/2018 Time: 2:00 AM . A review of the facility's Conclusion to Investigation dated (MONTH) 11, (YEAR), revealed the following: . During the investigation, it was noted that (EI #2) was orienting (EI #3, CNA) . while assigned to (RI #39) on (MONTH) 24, (YEAR). EI #3 confirmed that she was in the room with (EI #2) and that (EI #2) did indeed say that the resident was too big and needed to lose weight. (EI #3) .did feel that the comment was inappropriate and abusive. NHA (Nursing Home Administrator) inquired as to if the CNA knew the facility's policy and procedure on reporting abuse. CNA acknowledged that she did but did not report it because it was her first or second day. The facility feels that the allegation of mental abuse agaist (against) (EI #2) is substantiated . A review of a telephone statement taken by EI #1, Administrator from EI #3, revealed the following: 9/11/18 @ (at) 3:15 pm (1) Did (EI#2) orient you during the orientation process? (EI #3):Yes she did, the first two nights. (2) Do you remember being assigned to (RI #39)? (EI #3): Yes (3) Did (EI #2) say anything about (his/her) weight while you were present? (EI #3): Yes, she said that (RI #39) was getting to (too) big for the staff to turn & (and) that (he/she) needed to lose weight . (5) Do you think that it was inappropriate? (EI #3): Yes. (6) Do you think that it was abusive? (EI #3): Yes. (7) Do you think that it made (RI #39) feel bad? (EI #3): Yes, bc (because) it would make me feel bad. (8) Why didn't you report it? Were you aware that you were supposed to report it to me? (EI #3):Yes, I just didn't . (signature of EI #1/Administrator) On 10/17/18 at 3:40 PM, during an interview with RI #39, the surveyor asked him/her what happened with the staff that made a statement regarding his/her weight. RI #39 stated, CNA that used to work here, (EI #2), said I was fat and I needed to lose weight. This happened about 2-3 months ago. I told (EI #1). The surveyor asked who else did he/she tell. RI #39 stated, Some of the staff. I told (CNA) she recently left and another one, don't know her name, but she still works here. The surveyor asked what was done after he told the Administrator. RI #39 stated, Told me she would take care of it because she would not have nobody talking to us like that. On 10/18/18 at 10:29 AM, during a telephone interview with EI #3, the surveyor asked what happened. EI #3 said she was working night shift in orientation with EI #2 and they were providing care to RI #39. EI #3 said they were getting RI #39 dressed to get up out of bed for school that morning. EI #3 said EI #2 was trying to turn RI #39 and EI #2 said something about RI #39's weight. EI #3 said EI #2 said RI #39 was getting too big for staff to turn and that he/she needed to lose weight. The surveyor asked EI #3 where were staff positioned when EI #2 made the statement. EI #3 stated, At the resident's bedside. The surveyor asked EI #3 when did this happen. EI #3 stated, I don't remember, but I was in orientation with (EI #2) for about 4 days when this happened. The surveyor asked EI #3 who did she report the statement that EI #2 made to. EI #3 stated, I did not report this to anyone .I heard her when she said it, but I did not report it. The surveyor asked EI #3, looking back on the situation, what type of situation would she consider this as. EI #3 stated, Its abuse, verbal abuse. On 10/18/18 at 12:39 PM, during an interview with EI #1, Administrator, the surveyor asked asked when was she first made aware of the situation with RI #39. EI #1 stated, On (MONTH) the 6, when (RI #39) finally told the social worker.

Based on record reviews, interviews and a review of the facility's policy titled, ABUSE, PREVENTION AND PROHIBITION OF, the facility failed to ensure Employee Identifier (EI) #3, Certified Nursing Assistant (CNA), followed the reporting component of the abuse policy in order to report an allegation of abuse immediately to the facility Administrator, EI #1 and/or the Director of Nursing (DON) on 8/28/18. This affected Resident Identifier (RI) #39, one of one sampled resident reviewed for abuse. Findings Include: A review of the facility's policy titled, ABUSE, PREVENTION AND PROHIBITION OF with a revised date of 8/13, revealed the following: .Reporting/Response: The facility employee . who becomes aware of abuse . shall immediately report the matter to the facility Administrator and/or the Director of Nursing . Abuse means the willful infliction of injury, . intimidation, . with resulting . mental anguish .Verbal Abuse is defined as the use of oral . language that willfully includes disparaging and derogatory terms to residents .or within the hearing distance . RI #39 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #39's current Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/12/18, revealed RI #39 had a Brief Interview for Mental Status (BIMS) score of 12, indicating cognition was intact. The State Agency received a Facility Reported Incident on 10/14/18, regarding a statement being made by EI #2, CNA to RI #39 about him/her needing to lose weight that made RI #39 upset. A review of the facility's Conclusion to Investigation dated (MONTH) 11, (YEAR), revealed the following: . During the investigation, it was noted that (EI #2) was orienting (EI #3) . while assigned to (RI #39) on (MONTH) 24, (YEAR). EI #3 confirmed that she was in the room with (EI #2) and that (EI #2) did indeed say that the resident was too big and needed to lose weight. (EI #3) .did feel that the comment was inappropriate and abusive. NHA (Nursing Home Administrator) inquired as to if the CNA knew the facility's policy and procedure on reporting abuse. CNA acknowledged that she did but did not report it because it was her first or second day. The facility feels that the allegation of mental abuse agaist (against) (EI #2) is substantiated . On 10/17/18 at 3:40 PM, during an interview with RI #39, the surveyor asked him/her what happened with the staff that made a statement regarding his/her weight. RI #39 stated, CNA that used to work here, (EI #2), said I was fat and I needed to lose weight. This happened about 2-3 months ago. I told (EI #1). The surveyor asked who else did he/she tell. RI #39 stated, Some of the staff. I told (CNA) she recently left and another one, don't know her name, but she still works here. The surveyor asked what was done after he told the Administrator. RI #39 stated, Told me she would take care of it because she would not have nobody talking to us like that. On 10/18/18 at 10:29 AM, during a telephone interview with EI #3, the surveyor asked what happened. EI #3 said she was working night shift in orientation with EI #2 and they were providing care to RI #39. EI #3 said they were getting RI #39 dressed to get up out of bed for school that morning. EI #3 said EI #2 was trying to turn RI #39 and EI #2 said something about RI #39's weight. EI #3 said EI #2 said RI #39 was getting too big for staff to turn and that he/she needed to lose weight. The surveyor asked EI #3 where were staff positioned when EI #2 made the statement. EI #3 stated, At the resident's bedside. The surveyor asked EI #3 when did this happen. EI #3 stated, I don't remember, but I was in orientation with (EI #2) for about 4 days when this happened. The surveyor asked EI #3 who did she report the statement that EI #2 made to. EI #3 stated, I did not report this to anyone .I heard her when she said it, but I did not report it. The surveyor asked EI #3 how long after the incident did the facility interview her. EI #3 said, They called me after my last day working The surveyor informed EI #3, according to her personnel file, her last day working was 9/9/18. EI #3 said, I think that's right. The surveyor asked EI #3, looking back on the situation, what type of situation would she consider this as. EI #3 stated, Its abuse, verbal abuse On 10/18/18 at 12:39 PM, during an interview with EI #1, Administrator, the surveyor asked asked when was she first made aware of the situation with RI #39. EI #1 stated, On (MONTH) the 6, when (RI #39) finally told the social worker.

Based on record reviews, interviews and a review of the facility's policy titled, ABUSE, PREVENTION AND PROHIBITION OF, the facility failed to ensure a staff member did not verbally abuse Resident Identifier (RI) #39 on 8/28/18, during the provision of care. This affected RI #39, one of one sampled resident reviewed for abuse. Findings Include: A review of the facility's policy titled, ABUSE, PREVENTION AND PROHIBITION OF with a revised date of 8/13, revealed the following: Abuse means the willful infliction of injury, . intimidation, . with resulting . mental anguish . Verbal Abuse is defined as the use of oral . language that willfully includes disparaging and derogatory terms to residents . or within the hearing distance . RI #39 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #39's current Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/12/18, revealed RI #39 had a Brief Interview for Mental Status (BIMS) score of 12, indicating cognition was intact. A review of a Facility Reported Incident revealed the following: Confirmation of Receipt of Online Incident Report . Date/Time Submitted: Thursday, (MONTH) 06, (YEAR) 7:22:38 PM . Incident Type . Mental Abuse Incident Detail . Name(s) of resident(s) involved: (RI #39) . Name of suspected offender(s): (Employee Identifier (EI) #2, Certified Nursing Assistant (CNA)) Date and time of alleged incident: 08/28/2018 Time: 2:00 AM Narrative summary of incident: Resident states that staff told (him/her) that (he/she) was too big and getting too heavy. Has this incident had a negative impact on the resident's mental, physical, or psychosocial status? Yes How has it negatively impacted the resident? Resident has lost way (weight) bc (because) (he/she) is not eating. A review of the facility's Conclusion to Investigation dated (MONTH) 11, (YEAR), revealed the following: . During the investigation, it was noted that (EI #2,) was orienting (EI #3, CNA) . while assigned to (RI #39) on (MONTH) 24, (YEAR). EI #3 confirmed that she was in the room with (EI #2) and that (EI #2) did indeed say that the resident was too big and needed to lose weight. (EI #3) .did feel that the comment was inappropriate and abusive. The facility feels that the allegation of mental abuse agaist (against) (EI #2) is substantiated . On 10/17/18 at 3:40 PM, during an interview with RI #39, the surveyor asked him/her what happened with the staff that made a statement regarding his/her weight. RI #39 stated, CNA that used to work here, (EI #2), said I was fat and I needed to lose weight. This happened about 2-3 months ago. I told (EI #1, Administrator). The surveyor asked who else did he/she tell. RI #39 stated, Some of the staff. I told (CNA) she recently left and another one, don't know her name, but she still works here. The surveyor asked what was done after he told the Administrator. RI #39 stated, Told me she would take care of it because she would not have nobody talking to us like that. The surveyor asked RI #39 how that made him/her feel. RI #39 stated, Bad, I stopped eating for a few weeks. The surveyor asked who did he/she talk to regarding the situation and how it made him/her feel. RI #39 stated, Staff and they told me to start back to eating and the administrator told me the same thing, The surveyor asked RI #39 did he/she start back eating. RI #39 stated, Yes. On 10/18/18 at 10:29 AM, during a telephone interview with EI #3, the surveyor asked EI #3 what happened. EI #3 said she was working night shift in orientation with EI #2 and they were providing care to RI #39. EI #3 said they were getting RI #39 dressed to get up out of bed for school that morning. EI #3 said EI #2 was trying to turn RI #39 and EI #2 said something about RI #39's weight. EI #3 said EI #2 said RI #39 was getting too big for staff to turn and that he/she needed to lose weight. The surveyor asked EI #3 where was staff positioned when EI #2 made the statement. EI #3 stated, At the resident's bedside. The surveyor asked EI #3 when did this happen. EI #3 stated, I don't remember, but I was in orientation with (EI #2) for about 4 days when this happened. The surveyor asked EI #3, looking back on the situation, what type of situation would she consider this as. EI #3 stated, Its abuse, verbal abuse. On 10/18/18 at 12:39 PM, during an interview with EI #1, Administrator, the surveyor asked asked when was she first made aware of the situation with RI #39. EI #1 stated, On (MONTH) the 6th, when (RI #39) finally told the social worker. The surveyor asked what was done regarding staff after the facility was made aware of this allegation. EI #1 stated, All staff inserviced on abuse. The surveyor asked what was done regarding EI #2. EI #1 stated, She was terminated. The surveyor asked EI #1 what was EI #3's hire date. EI #1 said 8/22/18 was the first date of hiring and orientation for EI #3.

Based on observation, interviews with staff and a review of the 2013 Food & (and) Drug Administration Food Code, and facility's policies related to Food: Preparation and Thermometer Use, the facility failed to ensure staff prevented the potential for cross contamination in that: 1) Individual portions of canned fruit were refrigerated without a protective cover; 2) The drip head of the coffee pot was not cleaned prior to storage; 3) The probe of the digital thermometer was not sanitized between use on the 10/11/17 supper trayline; and 4) Food preparation staff did not completely cover hair during the preparation of pureed vegetables on 10/11/17. This had the potential to affect all 17 residents for whom meals were prepared and served at the time of this survey. Findings included: 1) FOOD STORAGE The 2013 Food Code mandates under 3-302.11: Packaged and Unpackaged Food . (A) . food shall be protected from cross contamination by: . (4) . storing the food in packages, covered containers, or wrappings . During the initial tour of the Kitchen on 10/11/17 at 9:55 a.m., a sheet pan containing individual portions of canned regular and pureed fruit (six) and chocolate pudding (three) were stored in the walk-in refrigerator. The bowls of fruit were unwrapped. The surveyor questioned the Cook, Employee Identifier (EI) #1 as to why the portions were not wrapped. EI #1 affirmed the lack of a protective wrap and stated she did usually cover food items. On 10/12/17 at 9:20 a.m., the Dietary Manager (in training), Employee Identifier (EI) #2 was questioned about the potential hazard resulting from a failure to wrap ready-to-eat food. EI #2 stated air-borne objects could contaminate the food. 2) CLEAN EQUIPMENT The 2013 Food Code regulation #4-601.11 Equipment, Food-Contact Surfaces, Nonfood- Contact Surfaces, and Utensils specifies the following: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. The facility's policy titled, Food: Preparation (#015, undated) states the following: It is the center policy that all foods are prepared, in accordance with the guidelines of the USDA (United States Drug Administration) Food Code. Action Steps . 3. The Food Services Director or Cook(s) is resposible to ensure that all utensils, food contact equipment, and food contact surfaces are cleaned and sanitized after every use. On 10/11/17 at 9:45 a.m., the drip head of the one pot coffee maker contained a heavy accumulation of coffee residue, evidence of the lack of several days' cleaning. On 10/11/17 at 5:30 p.m., the surveyor showed the drip head to the Dietary Services, District Manager, EI #4. He affirmed it appeared the equipment had not been cleaned in a good while. 3) SANITIZATION The facility's policy related to Thermometer Use (undated) specifies: . Thermometer must be sanitized following each use of measurement using quat (quaternary ammonia) food sanitizer or thermometer wipes. During the 10/11/17 supper trayline (at 4:30 p.m.), the Cook (EI #1) calibrated the digital thermometer in a cup of ice water. Without first sanitizing the probe, EI #1 inserted the thermometer probe into a steamtable pan of pureed green beans to check the temperature. EI #1 wiped the food residue off the thermometer probe with a napkin, then placed the probe back into the cup of ice water. Again, without sanitizing the probe, EI #1 inserted the thermometer into a pan of pureed pizza casserole. On 10/11/17 at 5:05 p.m., the surveyor asked EI #1 how she typically sanitized the thermometer. EI #1 stated she wiped with a napkin, then stated she was to use an alcohol swab. When asked why she had not used an alcohol swab initially, EI #1 stated she forgot. The surveyor asked why it was important to sanitize the thermometer between foods. EI #1 responded, Cross contamination. EI #1 stated their policy specified the use of alcohol swabs. On 10/12/17 at 9:20 a.m., the Dietary Manager (EI #3) affirmed the policy specified the use of quaternary ammonia or alcohol swabs to sanitize the thermometer between uses. EI #4 stated cross contamination might result if the thermometer was not sanitized. 4) HAIR RESTRAINTS The 2013 Food Code, regulation #2-402.11 related to hair restraints Effectiveness states the following: (A) . FOOD EMPLOYEES shall wear hair restraints . that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, and linens . On 10/11/17 at 5:03 p.m., near the end of the trayline plating, the hair of EI #2/Dietary Manager in training, had fallen out of both the right and left sides of her hair restraint. The Cook ran out of pureed green beans. EI #2 assisted by pureeing three portions of green beans, with thickener and water. The surveyor questioned EI #2 about her uncovered hair. EI #2 was not aware her hair had fallen out of the cap. On 10/12/17 at 9:20 a.m., the surveyor asked the Dietary Manager (EI #3) what she expected of staff in regard to hair restraints. EI #3 replied staff were to wear a net and cover all of their hair, or else they would not be allowed inside the kitchen.

Based on observation, record review and interviews the facility failed to ensure that Resident Identifier (RI) #2 did not receive Shrimp on the 10/06/2015 dinner meal tray, which was identified as a dislike. Furthermore, RI #2 was not offered an alternate meat after not eating the Shrimp. This affected one of five sampled residents whose meals were observed. Findings included: The facility policy titled, Resident Food Preferences with a Revised date of December, 2008 specified: . 2. The Dietician will discuss resident food preferences with the resident when such preferences conflict with a prescribed diet. The resident has the right not to comply with the prescribed diet or dietary restrictions. 4. The resident's clinical record (orders, care plan, or other appropriate locations) will document the residents likes and dislikes and special dietary instructions or limitations . RI #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent Quarterly MDS (Minimum Data Set) with a Assessment Reference Date of 09/23/2015 indicated that RI #2 had a Brief Interview for Mental Status indicating the resident was moderately impaired. The functional level of Activity of Daily Living Assistance for Eating was coded as Self-Performance (feeds self) with supervision-oversight, and setup help only. A record review of the Nutritional Quarterly Data Collection form dated 9/24/2015 identified RI #2's food preferences and dislikes. RI #2's meat/protein dislikes was identified as shrimp. A record review of RI #2's care plan indicated that RI #2 will be provided and served diet as order each meal. If RI #2 fails to eat, offer an alternate meal. On 10/06/2015 at 5:15 PM, Employee Identifier (EI) #1, a Licensed Practical Nurse (LPN)/Restorative Nurse was observed to take the dinner meal tray off the cart and assist RI #2 with meal set-up. During the dinner meal observation, RI #2 was observed to have been served fried shrimp, red potatoes, mixed vegetables, roll, pineapple tidbits. RI #2's fluids were orange juice, water, and milk with thickened nectar. On 10/06/2015 at 6:15 PM, an interview with RI #2 was conducted. When asked why RI #2 did not eat the vegetables and the shrimp, RI #2 stated, I don't like shrimp. On 10/07/2015 at 10:30 AM, during an interview with EI #1, she revealed RI #2 received red potatoes, roll, vegetables, and shrimp for the dinner meal. EI #2 replied, Yes, ma'am he/she did. When asked if the resident requested anything different to eat, EI #1 stated, no he/she did not, he/she ate a snack before supper. On 10/07/2015 at 1:41 PM, an interview with the Dietary Manager, EI #2 was conducted. EI #2 was asked if she reported to the surveyor that two residents should not get shrimp during the dinner meal on 10/06/2015. EI #2 replied, yes. When asked which residents had she reported should not get the shrimp and why, EI #2 stated that one of those residents was RI #2 and it was due to a dislike of shrimp. When asked why RI #2 received the shrimp on the 10/06/2015 dinner meal, EI #2 stated, I do not know why.

Based on observations, interviews and record reviews, the facility failed to ensure an Licensed Practical Nurse (LPN) diluted the crushed medications prior to administration via Gastrostomy (G)-tube, to Resident Identifier (RI) #8 and RI #9 on 10/06/15. This affected 2 of 3 sampled residents observed for medication administration via [DEVICE]. Findings include: A review of Potter and Perry's Fundamentals of Nursing, Eight Edition, copy right date 2013, page 594, Chapter 31, Medication Administration revealed: .PROCEDURAL GUIDELINES Giving Medications Through an Enteral Tube ( .[DEVICE] .) . 10. Grind simple compressed tablets to a fine powder. Open hard gelatin capsules and pour powder into a medication cup. Dissolve crushed tablets contents of capsules, and powders in 15 to 30 ml of sterile water. A review of the facility's document titled, Administering Medications through an Enteral Tube with a revision date of 2001 revealed: . The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube. 23. Dilute the crushed or split medication with 15-30 ml (milliliter) (cc/cubic centimeter) sterile water . 1.) RI #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/09/15, revealed RI #9 was severely impaired for cognitively skills for daily decision making. A review of RI #9's Medication Administration Record [REDACTED] .[MEDICATION NAME] 10 MG (milligram) TABLET Give 5 mg via [DEVICE] four times a day for muscle [DIAGNOSES REDACTED] . On 10/06/15 at 11:45 AM, an observation was made of Employee Identifier (EI) #1, an LPN, administering [MEDICATION NAME] via [DEVICE] to RI #9. EI #1 crushed the [MEDICATION NAME] and put it in a medication cup. EI #1 did not dilute the [MEDICATION NAME] in water. EI #1 checked the [DEVICE] for placement and flushed RI #9's [DEVICE] with 10 cc of water. EI #1 then administered the undiluted [MEDICATION NAME] to RI #9. 2.) A review of the medical record revealed RI #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Quarterly MDS, with an ARD of 10/01/15, revealed RI #8 was severely impaired for cognitively skills for daily decision making. A review of RI #8's MAR indicated [REDACTED] .[MEDICATION NAME] Tablet 10 MG Give 1 tablet via [DEVICE] one time a day for [DIAGNOSES REDACTED] . On 10/06/15 at 12:10 PM, an observation was made of EI #1, an LPN, administering [MEDICATION NAME] via [DEVICE] to RI #8. EI #1 crushed the [MEDICATION NAME] and put in a medication cup. EI #1 did not dilute the medication with water. EI #1 checked [DEVICE] for placement and attempted to flush RI #8's [DEVICE] with 10 cc of water. EI #1 stated she felt resistance when she attempted to flushed RI #8's [DEVICE]. EI #1 poured the 10 cc of water out of the feeding syringe and put it back into the syringe. EI #1 pushed the 10 cc of water through the [DEVICE]. EI #1 then administered the crushed, undiluted [MEDICATION NAME] via [DEVICE]. An interview was conducted with EI #1 on 10/07/15 at 2:15 PM. EI #1 was asked if she dissolved the [MEDICATION NAME] prior to administrating the medications to RI #8 and RI #9. EI #1 stated, No ma'am. The surveyor asked EI #1 why not. EI #1 stated, . I was nervous. The surveyor asked what the concern was when crushed medications were not diluted prior to administration via [DEVICE]. EI #1 stated, The concern would be they would not get the right amount of medication. An interview was conducted with EI #4 the Director of Nursing of the facility, on 10/07/15 at 4:40 PM. The surveyor asked EI #4 should a crushed medication be diluted prior to administration via [DEVICE]. EI #4 stated, Usually we dissolve it in 5-10 cc of water. The surveyor asked EI #4 why should the medications not be administrated undiluted. EI #4 stated, There is a potential for the tube to malfunction.

Based on an observations, interviews and reviews the facility failed to ensure the Licensed Practical Nurse (LPN) flushed (Resident Identifier) RI #8 and RI #9's G (Gastrostomy)-tube with the prescribed amount of water, as ordered by the physician on 10/06/15. Findings include: A review of Potter and Perry's Fundamentals of Nursing, Eight Edition, with the revision date of 2013; Chapter 31 Medication Administration, page 594, revealed: PROCEDURAL GUIDELINES Giving Medications Through an Enteral Tube ( . [DEVICE] .) . 4. Perform hand hygiene and prepare medication . 15. Flush tube with at least 15 ml of sterile water. 16. Draw up medication in syringe. 18. Administer medication . 19. Flush tube with at least 15 ml of sterile water between each medication. 20. After giving all the medications, flush tube with at least 15 ml of sterile water . 1) A review of the medical records revealed RI #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Quarterly MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 09/09/15, revealed RI #9 was severely impaired for cognitively skills for daily decision making. RI #9 was totally dependent on staff for all ADLs (Activities of Daily Living). A review of RI #9's Order Summary Report dated October 7, 2015 revealed: .Flush [DEVICE] with 30 cc (cubic centimeters) of water before and after each med (medication) pass; and 10 cc between medications every shift . A review of RI #9's MAR (Medication Administration Record) dated 10/01/15-10/31/15 revealed: .Flush [DEVICE] with 30 cc of water before and after each med pass; and 10 cc between medications every shift . On 10/06/15 at 11:45 AM, an observation was made of EI (Employee Identifier)#1, an LPN administering a medication via [DEVICE] to RI #9. EI #1 checked [DEVICE] placement and flushed RI #9's [DEVICE] with 10 cc of water, and then administered a medication via [DEVICE]. An interview was conducted with EI #1 on 10/07/15 at 2:15 PM. The surveyor asked EI #1 how she determined the amount of flush to administer to a resident via [DEVICE]. EI #1 stated, It's on the MAR. The surveyor asked EI #1 what amount of flush she administered to RI #9 during the medication observation on 10/06/15. EI #1 stated, I am not sure. I think I gave 30 cc. The surveyor shared the above observation and then looked at the order that revealed to flush with 30 cc before and after the medication administration. 2) A review of the medical records revealed RI #8 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Quarterly MDS, with an ARD of 10/01/15, revealed RI #8 was severely impaired for cognitively skills for daily decision making. RI #8 was totally dependent on staff for all ADLs. RI #8's MDS revealed the resident had an indwelling catheter. A review of RI #8's Order Summary Report dated October 7, 2015 revealed: .Enteral Feed Order every shift {Enteral} Flush [DEVICE] with 30 ml (cc) (cubic centimeters) of water before and after administration of medication pass . A review of RI #8's MAR indicated [REDACTED] .Enteral Feed Order every shift {Enteral} Flush [DEVICE] with 30 ml (cc) of water before and after administration of medication pass . On 10/06/15 at 12:10 PM, an observation was made of EI #1, administering a medication via [DEVICE] to RI #8. EI #1 checked the [DEVICE] for placement and flushed RI #8's [DEVICE] with 10 cc of water. EI #1 then administered the medication. EI #1 stated she felt resistance when she attempted to flushed RI #8's [DEVICE]. EI #1 poured the 10 cc of water out of the feeding syringe and then pour and pushed the 10 cc of water through the [DEVICE]. EI #1 then administered the medication. An interview was conducted with EI #1 on 10/07/15 at 2:15 PM. The surveyor asked EI #1 what amount of flush she administered to RI #8 during the medication observation on 10/06/15. EI #1 stated, I am not sure. The surveyor shared the above observation when EI #1 administered 10 cc of water prior to administering the medication. The surveyor asked EI #1 what the concern was when the ordered amount of flush was not given prior to administration of a medication via [DEVICE]. EI #1 stated, We would definitely need to monitor the intake, especially with the resident with a catheter, to avoid dehydration. An interview was conducted with EI #4, the facility's Director of Nursing, on 10/07/15 at 4:40 PM. The surveyor asked EI #4 what amount of flush was routinely administered via [DEVICE] during a medication pass. EI #4 stated, 30 ml before and 30 ml after. The surveyor asked EI #4 what the concern was when residents were not administered the required flush. EI #4 stated, Hydration could be a concern.

Based on observation, interviews and record reviews, the facility failed to ensure Employee Identifier (EI) #17 (Certified Nursing Assistant (CNA)) did not look away while providing care with the side rail down to Resident Identifier (RI) #2, a resident identified with squirming and jerking movements, resulting in a fall with injury. On 09/15/11, RI #2 was transported to the hospital ER (emergency room ) for evaluation and was admitted to the hospital with [REDACTED]. On 09/16/11, RI #2 had an ORIF (Open Reduction Internal Fixation) surgery. This affected RI #2, one of two residents sampled for falls. The facility further failed to ensure the wheelchair arm rest of 1 of 16 sampled residents were free of the potential to cause skin tears due to large tears with jagged edges and exposed fiber filling in the upholstery of the wheelchair arm rest. This affected RI #7. Findings Include: 1.) RI #2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the Annual Minimum Data Set (MDS), dated [DATE], revealed RI #2 had short and long term memory loss and had severely impaired cognitive skills for daily decision-making. The MDS documented RI #2 was totally dependent on staff for Activities of Daily Living with one person physical assist. The MDS indicated RI #2's Functional Limitation in Range of Motion was impaired on both sides, upper and lower extremities. The MDS also documented RI #2's weight was 93 pounds and height was 62 inches. A review of RI #2's CAAs (Care Area Assessment) Summary Note signed 09/08/11 revealed the following: "Falls: He has had no falls, but is at risk due to..., total lack of awareness for safety, balance problems...uncoordinated movements and hx (history) seizure disorder..." A review of RI #2's Falls Care Plan, dated 09/07/11, revealed the following: "...Category Problem...Falls, at risk for. Goal: Falls will be avoided and safety will be maintained x 90 days Target date 12/01/2011 Intervention ... Side rails up x 2 when in bed ... Transfer using ... or 2 persons as needed to provide a safe, smooth transfer ... Environmental Hazards/risks will be identified and removed..." A review of the facility's form entitled, "RESIDENT FALL RISK ASSESSMENT," revealed the following: 6-12 Points Low Risk Update Care Plan, Kardex 13-19 Points Moderate Risk Update Care Plan, Kardex... Over 20 Points High Risk Update Care Plan, Kardex..." RI #2's total score for the following dates were: 3-22-11, 6-14-11 and 9-6-11 was "10" 9-15-11 was "30" A review of the (Name of Hospital) "Operative Report" dated 09/16/11 revealed the following: "... ADM (admit) DATE: 09/15/2011... DATE OF PROCEDURE; 09/16/2011 PREOPERATIVE DIAGNOSES 1. Bilateral mandibular subcondylar fractures. 2. Left mandibular parasymphysis fracture. PROCEDURES: ORIF (Open Reduction Internal Fixation) of left parasymphysis..." A review of RI #2's "Care Area Assessment" dated 9/08/11 revealed the following: "...11. Falls...[DIAGNOSES REDACTED].#2) is at risk for falls due to ... uncoordinated movements his history of seizure disorder..." On 10/2/11 at 2:10 PM, during an interview with Employee Identifier (EI) #17 (a CNA), the surveyor asked what happened with the fall on 9/15/11 with RI #2. EI #17 stated that she was providing AM care to RI #2. EI #22 and EI #23 were also in the room, applying AFOs (ankle/feet orthoses) on two other residents in the room with RI #2. EI #17 stated that RI #2 would sometimes tilt his head backwards during care. EI #17 said that after she put the resident's clothes on, she was positioned at the resident's waist when he tilted his head upward. As RI #2 tilted his head upward, he came up so fast and began to fall off the bed. EI #17 said that she tried to grab the resident, but the resident just slipped through her hands and she could not hold him. EI #17 stated one side rail was up and the other siderail was down, where she was positioned. She also stated that she was having a conversation with EI #22 (CNA). As she turned her head to talk with EI #22, RI #2 fell . The surveyor asked would it be correct to say that she (EI#17) had taken her eyes off RI #2 right before he fell out of the bed. EI #17 stated yes, but just for a second. The surveyor asked when did RI #2 have the jerking type movements. EI #17 stated that the resident always jerked like that, that was his movement. She also stated that someday's RI #2 would have those jerking movement, tilting his head backwards and moving from left to right, while care was being provided. The surveyor asked when he fell and you lost control, what direction did he fall. EI #17 stated that the resident's head came straight down and his (RI #2's) upper body hit her feet area and the resident was shaking. She also stated that RI #2 was laying crossways her feet with his face against the floor. At that time, EI #22 yelled and she (EI#17) told her to go get help and EI #20 (a Licensed Practical Nurse) came and assessed the resident. The surveyor asked after the nurse assessed RI #2, did she (EI # 20) instruct her to pick the resident up. EI #17 stated no, she and EI #23 put the resident back in bed after RI #2 fell . She also stated that they were not supposed to move patients after a fall, but she could not think right then. The surveyor asked what was the potential for harm to move a resident after a fall and before a resident is assessed. EI #17 stated that more damage could be done. On 10/2/11 at 2:45 PM, during an interview with EI #20 (a LPN), the surveyor asked what happened with the fall on 9/15/11 with RI #2. EI #20 stated that one of the CNA's came to her and stated that RI #2 had fallen out of the bed. She also stated that when she went into the room, the resident was in the bed. EI #20 stated she asked what happened and EI #17 (CNA) said that RI #2 had squirmed and fallen out of bed at her feet. EI #20 then stated she assessed the resident and noted that RI #2 had blood trickling from his left nare. She also stated that during that time, EI #1 (the Director of Nursing (DON)) notified the doctor and the doctor gave orders to transport the resident out of the facility to the hospital. On 10/2/11 at 4:00 PM, during an interview with EI #21 (the Minimum Data Set (MDS) Coordinator), the surveyor asked who made the documentation on RI #2's fall care plan under the note/outcome section. EI #21 stated that she had made the note and did not date the entry, but it was probably 9/15/11. She also stated that they were trying to tell staff that RI #2 was more mobile and they could not put their hand on him and turn around to get something; they could not push the resident to the other side of the bed and step back. They could not do any of those things with RI #2. On 10/2/11 at 4:55 PM, during an interview with EI #22 (a Restorative CNA), the surveyor asked what happened with the fall with RI #2 on 9/15/11. EI #22 stated that she and EI #23 (a CNA), were applying AFO's to two other residents in the room. She also stated that EI #17 had finished with RI #2's care. EI #22 stated that when she looked up, RI #2 was falling and EI #17 was trying to catch him, but she (EI# 17) could not. The surveyor asked what was EI #17 doing prior to the fall. EI #22 stated EI #17 had just finished AM care and was talking with EI #23 and herself. The surveyor asked when did EI #17 look at her during the conversation. EI #22 stated that EI #17 looked over at her and while talking, the resident fell . After the resident fell , EI #17 and EI #23 put the resident back to bed and the nurse was notified. On 10/4/11 at 8:30 AM, during an interview with EI #23, the surveyor asked what happened with the fall on 9/15/11 involving RI #2. EI #23 stated that she was putting a resident's AFO's on and EI #22, EI #17 and she were having a conversation. EI #17 had finished giving AM care to RI #2 and EI #17 was standing by the bed, with the side rail down. EI #17 turned to her left to talk to EI #22 and within the blink of an eye, she heard a noise and when she looked up, she saw RI #2 down on the floor. EI #23 said she jumped up and ran over to the bedside where EI #17 and RI #2 were. EI #23 stated that EI #17 and she picked the resident up and put him back in the bed. Afterwards, EI #22 left the room to get the nurse. The surveyor asked what did she notice after the resident was put back in the bed. EI #23 stated that RI #2 was crying but, she did not notice any injuries. The surveyor asked had she ever taken care of RI #2. EI #23 stated yes, she had. The surveyor asked what type of movements had she observed or were aware of that the resident exhibited. EI #23 stated kicking his feet and moving his arms. She said that the resident was very strong with his legs, because he had split a fiberglass board that was connected to the foot of his bed. On 10/4/11 at 9:40 AM, during an interview with EI #1 (the DON), the surveyor asked what were the responsibilities of the Director of Nursing. EI #1 stated to supervise and manage the nursing staff who directly supervise specific departments. The surveyor asked her to explain what is care. EI #1 stated the needs to maintain quality of life and a high standard of living for the children. The surveyor asked (EI #1) what did she determine happened with the fall on 9/15/11 with RI #2. EI #1 stated the resident fell out of bed. When she went in the room, the resident was in the bed and EI #20 (a Licensed Practical Nurse) was assessing RI #2. EI #1 stated she assisted EI #20 with the assessment. An immediate concern, that she noticed, was the blood trickling from RI #2's nose, but she did not see any bruising. When the resident was turned over, there was a light reddish area on the left side of his face. EI #20 stated the resident was hard to assess because the formation of his nose is irregular. She said that she kept looking at his picture, above his bed, to try to distinguish if there were any changes. She stated that she spoke with the CNAs, who were at his bedside, and asked EI #17 (CNA), what had happened. EI #17 stated that the resident had fallen and hit her leg/foot and then the resident hit the floor, his face hit the floor. The resident is contorted, so it was difficult to do ROM (Range of Motion). The resident also does not talk, therefore it was difficult to assess pain. EI #1 said the resident kept thrusting his head backward with a tightening motion and she assessed that movement as nonverbal pain. EI #1 stated she notified EI #8 (the Medical Doctor) and informed him of the fall. EI #8 gave orders to transport the resident. She also stated that she contacted the sponsor and informed the sponsor of what happened with RI #2. Afterwards, she told the staff the resident would be going out to the hospital for evaluation. The surveyor asked what did she determine was the cause of the incident/fall. EI #1 stated that EI #17 took her eyes off of RI #2, while having a conversation with other staff in the room. The surveyor asked what measures were put in place to prevent further falls. EI #1 stated inservices were conducted to have two people to provide care with rails down for RI #2. Maintenance checked beds to make sure there were no issues with the beds. Also, we inserviced on paying attention to resident and not talking to each other, but to the resident. The surveyor asked who put the resident back to bed. EI #1 stated the CNAs did, before the resident was assessed. The surveyor asked was that policy. EI #1 stated the CNAs should not have moved the resident before the nurse assessed the resident, because the CNAs did not know the extent of the injury and it was not within the CNAs scope to assess residents. The surveyor asked what other measures were put in place as far as the care plan. EI #1 stated there was an order for [REDACTED].#2 hits himself a lot. The surveyor asked how do staff know what type of care a resident requires with safety. EI #1 stated the information is on the resident's care sheet. The surveyor asked, after reviewing the fall care plan, where was the intervention to pay attention to the resident, not talking to each other but to the resident. EI #1 stated that she did not put that intervention on the care plan. After reviewing the care plan, the surveyor asked, EI #21 (the MDS Coordinator) wrote a note in reference to RI #2's squirming, how long has the resident had this type of movement. EI #1 stated the resident had the squirming movement since coming to the facility, about 7 months ago. The surveyor asked did staff know about the squirming movement. EI #1 stated that staff should know by the documentation on the care plan. The surveyor asked was that policy and procedure. EI #1 stated yes, it is policy and procedure for us to provide an accurate plan of care. The surveyor asked was policy and procedure followed with the fall. EI #1 stated no, because the behavior of squirming was not on the care plan. The surveyor asked the fall care plan did not have the intervention to pay close attention to the resident, not to talk with each other but to the resident, is the potential for falls still there with this resident. EI #1 stated yes, it is. The surveyor asked what should be done. EI #1 stated to put the intervention on the care plan and the care sheet. A review of RI #2's Falls Care Plan revealed the following update: "...9/15 (2011) Do not let SR (side rail) (down) until ready to care for child. Gather all supplies etc (et cetera). If possible keep SR partially up ... 9/15 (2011) Use 2 staff when providing care & (and) siderails down... Note/outcome (without a date) (Name of RI #2) is a squirmer, can easily move away from staff. Also has uncontrolled movements. Be Aware - He is slippery." 2. RI #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the medical record revealed a Quarterly assessment with a reference date of 8/17/11, which listed the resident's cognitive status was severely impaired. RI #7 had short and long term memory problems and was staff dependent for all activities of daily living. RI #7 required total staff assistance with transfers, bed mobility, locomotion, dressing, eating, hygiene, and bathing. RI #7 had limited range of motion in the lower extremities but moved the upper extremities with and without purpose. RI #7 was was identified as blind and would put things into her mouth. A review of the current physician's orders [REDACTED]. ..." RI #7 was observed on 10/02/11 at 8:17 AM, during an initial tour of the facility, seated in a wheelchair in her room. The wheelchair arm rest were observed with large tears in the upholstery with white fiber filling protruding out of the holes/tears. RI #7 was observed on 10/03/11 at 7:55 AM, during AM care, seated in a wheelchair in her room. The wheelchair arm rests were observed, black upholstery with large tears in them. The left arm rest had a large tear and 2 smaller tears exposing white fiber filling. The right arm rest had a medium tear,exposing white fiber filling. RI #7 was repeatedly rising and lowering her arms on or near the arm rests. The tears in the upholstery created a potential for skin tears for RI #7. RI #7 was observed on 10/02/11 at 8:00 AM, RI #7 was fed a breakfast meal seated in her wheelchair with the multiple tears. The wheelchair arm rests were observed with large tears in the upholstery with white fiber filling protruding out of the holes/tears. The resident was observed to rise and lower her arms frequently in a playful matter while being fed. An interview with EI #7 (a Speech Pathologist/ Therapy) on 10/03/11 at 12:54 PM, when asked who replace torn wheelchair arm rests, she replied, we have work orders for PT (Physical Therapy) and OT (Occupational Therapy) to use and we have a company that comes in and does clinic (for wheelchair needs). We had work orders for August the 16th, 23rd, and 30th. When asked what happened to the needed supplies, EI #7 was unable to answer the question.