Every finding on record at Ozark Health and Rehabilitation, LLC

Based on observation, record review, interviews, and review of facility policies, the facility failed to ensure that side were not used in a manner to physically restrain Resident #107. This affected one of one sampled residents reviewed for side rail use as a restraint. Findings included: A review of the facility's policy titled, Bedrail Use, effective 10/26/2022, revealed, PURPOSE: Bedrails are used to enable a resident/guest to become more functionally independent, and when the medical condition of the resident/guest requires the use of a bedrail. STANDARD: Bedrails could be considered a form of physical restraint; therefore, the need for bedrails should be identified in the resident/guest assessment, and the plan of care, per RAI [Resident Assessment Instrument] guidelines and regulatory requirements. This policy further indicated, Refer to Physical Restraint policy if deemed to meet restraint definition. A review of the facility's policy titled, Physical Restraints, effective 11/28/2016, revealed, PURPOSE: For each resident/guest to attain and maintain his/her highest practicable well being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident/guest has medical symptoms that warrant the use of restraints. STANDARD: Physical restraints are defined by federal regulations as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident/guest(s) body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. Physical restraints may include, but are not limited to: Using side rails to keep resident/guest from voluntarily getting out of bed. This policy further indicated, A physician's order should be obtained for the use of a restraint, however, the presence of a physician's order alone is not justification for restraint use in absence of documentation of a medical symptom indicating use. Physicians' orders should specify: When to use the restraint, How long to apply, Why it is to be used, Specific type of restraint to be used. A review of a Face Sheet revealed the facility admitted Resident #107 to the facility on [DATE]. A review of a Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/31/2023, revealed Resident #107 had a Staff Assessment for Mental Status (SAMS) that indicated the resident had severely impaired cognitive skills for daily decision making and had short-term and long-term memory problems. The MDS indicated the resident required extensive assistance of two staff for transfers and limited assistance of one staff for bed mobility. Further review revealed Restraints used in bed: bed rail were not used during the assessment period. A review of Resident #107's Care Plan, with a start date of 01/13/2021, revealed Resident #107 exhibited behaviors, including likes to lay on the floor on the mat. Further review revealed a Care Plan for Potential for Falls, with a start date of 01/09/2021. This care plan directed staff to encourage the use of handrails/appropriate assistive devices (started on 01/10/2021), observe the need for additional assistive devices (started on 01/10/2021), and to place mats on the floor while in bed (started on 11/26/2021). A review of a Restorative Review revealed that on 06/01/2023 at 2:08 PM, Registered Nurse (RN) #7 assessed Resident #107 to have weakness/paresis (muscle weakness) and limited range of motion in the bilateral upper and lower extremities. RN #7 documented Resident #107 was not steady when moving from a seated position to a standing position as well as surface-to-surface transfers. The box labeled Care Plan Reviewed and updated was left blank. A review of a Side Rail Evaluation, completed on 06/01/2023 at 2:09 PM by RN #7, revealed the Reason for Side Rail Use included Altered cognition, Ambulation with assistance, Balance deficit, Weakness, Incontinent. The Side Rail Evaluation indicated the side rail would assist the resident with bed mobility, transfers, and safety. The evaluation also indicated Side of Bed Side Rails Recommended For was Bilateral. The evaluation further indicated, Use of side rails can be considered a restraint which and can only be used after less restrictive assistance has been attempted is prohibited by regulation unless they are necessary to treat a resident's medical condition and, Residents who attempt to exit a bed through, between, over or around a side rail are at risk for injury or death. The Side Rail Evaluation did not specify the number of side rails or the size of siderails Resident #107 required. A review of Resident #107's Physician Orders for the month of June 2023 revealed there was no order for side rails or any type of restraint. Further review of Resident #107's comprehensive care plans revealed no updates to the care plan after the Side Rail Evaluation was completed on 06/01/2023, to instruct staff on the proper usage of side rails, including instruction on the number or size of siderails Resident #107 required. During an observation on 06/13/2023 at 10:35 AM, Resident #107 was lying in bed with their eyes closed and the head of the bed elevated approximately 45 degrees. All four side rails (a side rail on each side of the upper and lower portions of the bed) were in the raised position on the resident's bed. During an observation on 06/14/2023 at 11:01 AM, Resident #107 was lying in bed with their eyes closed and the head of the bed elevated approximately 45 degrees. All four side rails (a side rail on each side of the upper and lower portions of the bed) were in the raised position on the resident's bed. During an observation on 6/15/2023 at 1:12 PM, Resident #107 was lying in bed with their eyes closed and the head of the bed elevated approximately 30 degrees. All four side rails (a side rail on each side of the upper and lower portions of the bed) were in the raised position on the resident's bed. During an interview on 06/15/2023 at 1:18 PM, RN #8 stated Resident #107 used side rails for safety. RN #8 stated she was not aware that all four side rails were up and indicated that was considered a restraint. RN #8 stated the resident was bed-bound but could try to crawl over the bed rails, and the resident wiggled and turned sideways. RN #8 stated if a resident had side rails in use, the side rails should be included on the care plan. During an interview on 06/15/2023 at 1:23 PM, RN #20 (Unit Manager) stated Resident #107 should have half side rails to assist the resident in turning from side to side. RN #20 stated she was not aware the resident had all four side rails up and stated that would be considered a restraint. RN #20 stated she was responsible for updating the resident's care plan and indicated the use of side rails should be included on the care plan. At this time, RN #20 reviewed the resident's care plan in the Electronic Health Record (EHR) and stated the care plan did not address the use of side rails, but stated the resident had behaviors, and the use of the side rails was to prevent the resident from getting on the floor. During an interview on 06/15/2023 at 1:31 PM, RN #7 stated Resident #107 used side rails for safety and bed mobility. RN #7 stated she was unaware the resident had all four side rails up and indicated that would be considered a restraint. During an interview on 06/15/2023 at 1:41 PM, the Director of Nursing (DON) stated Resident #107 used side rails for bed mobility and to assist the resident with transferring out of bed. The DON stated she was not aware the resident had all four side rails in use and unless the resident had a specific diagnosis that required all four side rails, it would be considered a restraint. During an interview on 06/15/2023 at 1:53 PM, the Administrator stated Resident #107 used side rails for repositioning in bed and was not aware that the resident had all four side rails up. The Administrator stated using all four side rails was considered a restraint. The Administrator stated the nursing department was responsible for updating the resident's care plan and indicated the use of side rails should be included on the resident's care plan. The Administrator also stated the facility did not use all four side rails for residents.

Based on observations, interviews, record review, and facility policy review, the facility failed to revise a comprehensive person-centered care plan for (Resident #107). Specifically, the facility failed to revise a comprehensive care plan for Resident #107 to include the use of siderails as an enabler for bed mobility and transfers. This affected one of 26 sampled residents comprehensive care plans reviewed. Findings included: Review of a facility policy titled, Bedrail Use, effective on 01/01/2019, revealed: . PURPOSE of bedrails was to enable a resident/guest to become more functionally independent, and when the medical condition of the resident requires the use of a bedrail. The policy indicated . Bedrails could be considered a form of a physical restraint; therefore, the need for the bedrails should be documented in the resident's/guest's assessment, and plan of care . The policy also indicated a side rail evaluation should be completed upon implementation of the side rail and should be addressed in the resident's care plan. Review of a Face Sheet indicated the facility admitted Resident #107 on 01/08/2021. Review of a Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/31/2023, revealed Resident #107 had a Staff Assessment for Mental Status (SAMS) that indicated the resident had severely impaired cognitive skills for daily decision making and had short-term and long-term memory problems. The MDS indicated the resident required extensive assistance of two staff for transfers and limited assistance of one staff for bed mobility. Further review indicated the resident did not use bed rails for a restraint. Review of a Side Rail Evaluation, completed on 06/01/2023 at 2:09 PM by Registered Nurse (RN) #7, indicated the evaluation was completed for a MDS review. The evaluation revealed bilateral side rails were recommended for Resident #107. The reasons for side rail use for Resident #107 were for altered cognition, ambulation with assistance, balance deficit, weakness, and incontinence. The evaluation indicated side rails would assist the resident with bed mobility, transfers, and safety. Review of a Care Plan(s), with a start date of 01/09/2021, revealed Resident #107 was at risk for falls with an intervention that directed staff to encourage the use of handrails and/or appropriate assistive devices. The Care Plan, dated 01/13/2021, revealed Resident #107 exhibited behaviors of laying on the floor on a mat with a goal not to sustain any injuries from behaviors. The Care Plan did not address the use of side rails. Observations of Resident #107 on 06/13/2023 at 10:35 AM and on 06/14/2023 at 11:01 AM revealed the resident was lying in bed with their eyes closed and the head of the bed was elevated approximately 45 degrees. Also, an observation on 06/15/2023 at 1:12 PM, revealed that Resident #107 was lying in bed with their eyes closed and the head of the bed was elevated at approximately 30 degrees. During the observations, all four side rails (a side rail on each side of the upper and lower portions of the bed) were in the raised position on the resident's bed. During an interview on 06/15/2023 at 1:31 PM, Registered Nurse (RN) #7 stated Resident #107 used side rails for safety and bed mobility, but RN #7 stated she would have to look up the information regarding the use of side rails. RN #7 stated the Unit Manager (RN #20) was responsible for updating the resident's care plan if a resident had side rails in use, and the side rails should be care planned. During an interview on 06/15/2023 at 1:18 PM, Licensed Practical Nurse (LPN) #6 stated Resident #107 used side rails for safety, and stated the side rails were care planned. LPN #8 stated if a resident had side rails in use, the side rails should be care planned, and RN #20 was responsible for updating the resident's care plan. During an interview on 06/15/2023 at 1:23 PM, RN #20 stated Resident #107 used the side rails so the resident could turn from side to side, and the resident had half side rails in use. RN #20 stated she was responsible for updating the resident's care plan, and the side rails should be care planned. RN #20 reviewed the resident's care plan in the Electronic Health Record (EHR) and stated the care plan did not address the use of side rails, but the resident had behaviors, and the use of the side rails was to prevent the resident from getting on the floor. During an interview on 06/15/2023 at 1:41 PM, the Director of Nursing (DON) stated Resident #107 used side rails for bed mobility and to assist the resident with transferring out of bed. The DON stated if a resident used side rails, it should be care planned, and the care plan LPN and the Unit Managers were responsible for updating the resident's care plan. During an interview on 06/15/2023 at 1:53 PM, the Administrator stated Resident #107 used side rails for repositioning in bed. The Administrator stated the nursing department was responsible for updating the resident's care plan, and the side rails should be included in the resident's care plan.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure residents who required extensive to total assistance with personal hygiene were regularly offered trimming or shaving of facial hair and trimming of fingernails to maintain good grooming and hygiene. This affected two of five sampled residents reviewed for activities of daily living (ADLs) for (Resident #65 and Resident #107). Findings included: Review of a facility policy, titled, Nail Care, with an effective date of 10/01/2010, revealed, PURPOSE: Routine nail care helps reduce the potential for infection, prevents intrusion of the nail into the skin, prevents possible injuries and promotes a feeling of well being for the resident. Further review of the policy indicated, Nail care is a routine part of grooming each day. Review of a facility policy, titled, Shaving the Resident, with an effective date of 01/15/2010, revealed, PURPOSE: Shaving improves the resident's appearance and feeling of well-being. Further review of the policy indicated, Male and Female residents are shaved daily or as needed. 1. Review of a Face Sheet indicated the facility admitted Resident #65 on 01/30/2017 with diagnoses that included Schizoaffective Disorder, Schizophrenia, and a history of Transient Ischemic Attack (TIA) and Cerebral Infarction. Review of a Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/03/2023, revealed Resident #65 had short-term and long-term memory problems and moderately impaired cognitive skills for daily decision making based on the Staff Assessment for Mental Status (SAMS). The MDS indicated the resident was totally dependent on the assistance of one staff for personal hygiene. According to the MDS, Resident #65 had unclear speech with slurred or mumbled words, was sometimes understood, and sometimes understood others. Review of a Care Plan, with a start date of 01/31/2017, revealed Resident #65 required assistance to complete daily activities of care safely. Interventions instructed staff to assist the resident with shaving, bathing, brushing their teeth/oral care, and grooming the resident's hair. There were no interventions in the care plan related to nail care. Review of Resident #65's ADL [activities of daily living] Assistance and Support sheet, for 06/01/2023 through 06/14/2023, indicated Resident #65 had not been provided with personal hygiene care. During an observation on 06/13/2023 at 10:43 AM, Resident #65 was lying in bed with the head of the bed elevated approximately 30 degrees. The resident had facial hair that was approximately 1/4-inch long. The resident's fingernails were approximately 1/2-inch long with brown debris underneath the nails. An attempt was made to interview the resident; however, the resident only stated their name. During an observation on 06/14/2023 at 10:29 AM, Resident #65 was lying in bed and had the same appearance as the previous observation on 06/13/2023 at 10:43 AM related to facial hair and long nails. During an interview on 06/14/2023 at 10:31 AM, Certified Nursing Assistant (CNA) #1 and Licensed Practical Nurse (LPN) #2 stated that CNAs were responsible for shaving Resident #65 and providing nail care. Both CNA #1 and LPN #2 stated the resident was shaved on their assigned shower days. CNA #1 stated the resident's showers were provided on Mondays, Wednesdays, and Fridays during the day shift. Both CNA #1 and LPN #2 stated that the resident's nails were trimmed every Sunday. LPN #1 stated the care provided was documented on the resident's care board (the ADL Assistance and Support Sheet), which was in the resident's Electronic Health ecord. CNA #1 stated the resident was fully dependent for all care. During a concurrent interview and observation on 06/14/2023 at 10:39 AM, CNA #3 stated that CNAs were responsible for shaving Resident #65 and providing nail care. CNA #3 stated the resident was shaved every three days or when facial hair was noticeable and nail care was also provided every three days. CNA #3 stated the care provided was documented on the resident's care board (the ADL Assistance and Support Sheet), which was in the resident's Electronic Health Record. CNA #3 stated the resident was dependent for all care. At this time, the surveyor and CNA #3 entered Resident #65's room. CNA #3 observed Resident #65 and stated the resident had facial hair and needed to be shaved. CNA #3 observed the resident's fingernails and stated they needed to be trimmed and filed and stated they were approximately 1/2-inch long with debris underneath. CNA #3 also pointed to the resident's right middle finger, left middle finger, and left ring finger and stated the fingernails were all jagged. CNA #3 then asked Resident #65 if the resident would let her trim their nails and shave them and the resident said, Yes. During an interview on 06/15/2023 at 1:44 PM, the Director of Nursing (DON) stated CNAs were responsible for shaving Resident #65. The DON stated CNAs provided nail care for residents unless a resident was diabetic. The DON stated Resident #65 was to be shaved as needed and the resident's nails were to be trimmed and cleaned as needed or when the nails got too long. The DON stated that staff did not document specifically when nail care or shaving was completed; however, staff were responsible for documenting on the ADL Assistance and Support sheet, whether personal hygiene care, which included shaving and nail care, was provided. The DON stated if staff were to observe a resident with facial hair and long, jagged fingernails with debris underneath, she expected them to shave the resident and trim their nails. During an interview on 06/15/2023 at 1:56 PM, the Administrator stated that if staff observed a resident with facial hair and long, jagged fingernails with debris underneath, she expected the staff to trim and file the jagged nails and shave the resident as the resident allowed. 2. Review of a Face Sheet indicated the facility admitted Resident #107 on 01/08/2021 with diagnoses that included Mood Disorder. Review of a Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/31/2023, revealed Resident #107 had short-term and long-term memory problems and severely impaired cognitive skills for daily decision making based on the Staff Assessment for Mental Status (SAMS). The MDS indicated the resident required extensive assistance from one staff for personal hygiene. According to the MDS, Resident #107 did not speak, was rarely/never understood, and rarely/never understood others. Review of a Care Plan, with a start date of 01/11/2021, revealed Resident #107 required assistance to complete daily activities of care safely. Interventions directed staff to assist the resident with shaving and provide nail care as needed. Review of ADL [activities of daily living] Assistance and Support sheets, for 06/01/2023 through 06/14/2023, indicated Resident #107 had not been provided with personal hygiene care. During an observation on 06/13/2023 at 10:35 AM, Resident #107 was lying in bed with the head of the bed elevated approximately 45 degrees. The resident had facial hair that was approximately 1/4-inch to 1/2-inch long. The resident's fingernails were approximately 1/2-inch long. During an observation on 06/14/2023 at 11:01 AM, Resident #107 was lying in bed and had the same appearance as the previous observation on 06/13/2023 at 10:35 AM related to facial hair and long fingernails. During an interview on 06/14/2023 at 11:02 AM, Certified Nursing Assistant (CNA) #4 stated CNA #5 was responsible for shaving Resident #107 and providing nail care. CNA #4 stated Resident #107 was shaved and had nail care provided on the resident's shower days and the care was documented in the resident's Electronic Health Record (EHR). During a concurrent interview and observation on 06/14/2023 at 11:05 AM, CNA #5 stated the CNA assigned to the resident was responsible for shaving and trimming the resident's fingernails on the resident's shower days, which were scheduled on Mondays, Wednesdays, and Fridays during the second shift. CNA #5 stated that she provided the resident with a bed bath during the day shift and she shaved the resident when she saw facial hair or anytime the resident needed to be shaved. CNA #5 stated the resident's fingernails were trimmed about twice a week. CNA #5 stated that when the resident was shaved or had their nails trimmed, it was documented in the resident's EHR. At this time, the surveyor and CNA #5 entered the resident's room. CNA #5 observed the resident and stated the resident needed to be shaved but she had been busy answering call lights so shaving was not provided. CNA #5 stated the resident's facial hair was approximately 1/4-inch long and the resident's fingernails were approximately 1/2-inch long and needed to be trimmed. During an interview on 06/14/2023 at 11:42 AM, Licensed Practical Nurse (LPN) #6 stated the CNA assigned to provide the resident's care was responsible for trimming Resident #107's fingernails. LPN #6 said the resident's fingernails were to be trimmed and cleaned at least twice a week, sometimes three times a week, and staff were to trim and clean the resident's fingernails on their shower days. LPN #6 stated the resident was to be shaved every day or every other day. LPN #6 stated trimming of the nails and facial hair was documented in the resident's EHR. At this time, the surveyor and LPN #6 entered the resident's room. LPN #6 stated the resident's facial hair was 1/2-inch long and the resident's fingernails were also approximately 1/2-inch long. The resident's left hand, pinky and ring fingers had brown debris underneath the nails. During an interview on 06/15/2023 at 1:44 PM, the Director of Nursing (DON) stated CNAs were responsible for shaving Resident #107. The DON stated CNAs provided nail care for residents unless a resident was diabetic. The DON stated Resident #107 was to be shaved as needed and the resident's nails were to be trimmed and cleaned as needed or when the nails got too long. The DON stated that staff did not document specifically when nail care or shaving was completed; however, staff were responsible for documenting on the ADL Assistance and Support sheet, whether personal hygiene care, which included shaving and nail care, was provided. The DON stated if staff were to observe a resident with facial hair and long, jagged fingernails with debris underneath, she expected them to shave the resident and trim their nails. During an interview on 06/15/2023 at 1:56 PM, the Administrator stated that if staff observed a resident with facial hair and long, jagged fingernails with debris underneath, she expected the staff to trim and file the jagged nails and shave the resident as the resident allowed.

Based on observations and interviews the facility failed to ensure: 1. the residents' shower room on the [NAME] Hall did not have one-half of the paint peeled off and missing from the ceiling. 2. Resident Identifier (RI) # 1 and 8's bathroom door jambs were not rotten or disintegrating from the floor, five to six inches up the door jambs. This had the potential to affect 24 residents who used the shower room on [NAME] Hall, and two of eight sampled residents' bathroom door jamb. Findings Include: On 6/1/22 at 11:20 AM RI #1 reported that the wall beside the door to bathroom was rotted out about six to eight inches from floor. RI #1 said he/she told Employee Identifier (EI) #3, Maintenance Director over a year ago and he started working on it and never finished. On 6/1/22 at 11:30 AM an observation was made of RI #1's bathroom's doorway. The door jamb was observed deteriorating from the floor to about six inches up the frame. The door jambs was in disrepair. On 6/1/22 at 11:40 AM an observation was made with EI #4, Registered Nurse, of the shower rooms on [NAME] Hall. The shower room's ceiling, nearest to the linen closet, had about 50-60% of the popcorn paint ceiling peeled off and the areas was still peeling. EI #4 stated that about half of the ceiling's paint was peeled off and if this occurred at her house, she would peel it all off and fix it. On 6/1/22 at 4:30 PM an observation of the shower room on [NAME] Hall was observed with EI #3. EI #3 said the peeling and unpainted area was bad. EI #3 stated that all of the ceiling was in need of repair. EI #3 estimated that 60-70% of the popcorn paint had peeled off the ceiling. On 6/1/22 at 4:40 PM an observation with EI #3 of RI #8's bathroom's door, the metal frame was observed to be rusted and deteriorated from the floor up about five inches. EI #3 stated the door frame was old and deteriorated. On 6/1/22 at 4:50 PM an observation was made with EI #3 of RI #1's room. The bathroom's wooden door frame was rotten and in need of repair approximately six inches from the floor. EI #3 said it was rotten and in need of repair. On 6/2/22 at 12:50 PM an interview was conducted with EI #1, Administrator. EI #1 stated that she knew when residents were being moved some of the door jambs were bumped and needed repair. EI #1 said, the paint on the shower room ceiling should not be peeling off and the facility would [MEDICATION(S)] to correct it, but with the moisture, from showering, it was going to happen. EI #1 said, the ceiling paint peeling was a cosmetic appearance and it did not cause any harm. Also, EI #1 said the door jamb leading to residents' bathrooms was rotting and disintegrating, about five inches up from the floor. Again, EI #1 replied the area had a cosmetic appearance and it had not caused any harm. EI #1 said, the overall maintenance of the facility was the Maintenance Director and Assistant responsibility.

Based on record review, observation, interviews and review of facility policies titled, Medication Administration and Oxygen Administration, the facility failed to ensure a non licensed staff, Certified Nursing Assistant (CNA), did not turn on the oxygen concentrator and administer oxygen to Resident Identifier (RI ) #2. The failed practice had the potential to affect one of one sampled resident observed for oxygen therapy. Findings include: Review of the facility's policy titled, Medication Administration, revealed, . 1. Medications are administered only by licensed nursing . Another facility policy titled, Oxygen Administration, effective date (MONTH) 8, 2005, revealed Purpose: To administer high purity oxygen for the treatment of [REDACTED]. RI #2 was admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. On (MONTH) 28, 2019 at 9:06 am, the Surveyor observed Employee Identifier (EI) # 3, Quality Assurance CNA, turn the oxygen concentrator machine on and applied nasal cannula to RI#2 face. On (MONTH) 28, 2019 at 2:45 pm, the Surveyor conducted an interview with EI #4, CN[NAME] EI# 4 was asked, was applying oxygen and turning the oxygen concentrator on part of a CNA's job duties. EI# 4 replied, no. On (MONTH) 29, 2019 at 6:32 Pm, the Surveyor conducted an interview EI# 3. EI# 3 was asked, on (MONTH) 28, 2019 at 9:06 am during the Surveyor's observation of EI #3 assisting RI# 2 with a peri care, did she apply the nasal cannula to RI# 2 face and turn the oxygen concentrator machine on. EI# 3 replied, yes because it was off. EI# 3 was asked, should she have turned the oxygen concentrator on. EI# 3 replied, she felt like the resident needed it. EI# 3 was asked, what should should she have done. EI# 3 replied, she should have got the charge nurse. EI# 3 was asked, was oxygen categorized under medication. EI# 3 replied, yes. EI# 3 was asked, what would be the potential harm for non licensed staff to turn on the oxygen concentrator. EI# 3 replied, she could not say. EI #3 was asked if she checked to see what the liters was on. She replied, no. EI #3 was asked if she knew what RI #2's liters should be on. She replied, no. On (MONTH) 29, 2019 at 7:57 pm, the Surveyor conducted an interview with EI# 5, CN[NAME] EI# 5 was asked, if CNAs turned the oxygen concentrator machines on. EI# 5 replied, yes they did. EI# 5 was asked, what staff was responsible for turning the oxygen concentrator machine on. EI# replied, the CNA she believed. On (MONTH) 29, 2019 at 3:27 pm, the Surveyor conducted an interview with EI#2, Registered Nurse. EI # 2 was asked, did CNAs apply oxygen nasal cannula's and turn oxygen concentrators on. EI# 2 replied, no. EI# 2 was asked, what staff was responsible for applying oxygen by the nasal cannula and turn oxygen concentrators on. EI# 2 replied the nurses. EI# 2 was asked, what would be the potential harm with CNAs applying oxygen nasal cannula's and turning oxygen concentrations on. EI# 2 replied, the resident could get too much oxygen, especially if they had a [DIAGNOSES REDACTED].

Based on observation, interviews, review of a facility policy (Budget Guidelines) and the (YEAR) Food Code United States Public Health, the facility failed to: 1) routinely date and discard food items within a timely manner; 2) prevent the cross-contamination of food prior to service on the [DATE] and during the [DATE] lunch tray lines via contact with an unsanitized thermometer handle, and flies; 3) ensure all foods were checked for safe and sanitary temperatures prior to service on the [DATE] lunch tray line; and 4) re-heat food found to be below 135 degrees on the [DATE] lunch tray line. This had the potential to affect all 137 residents for whom meals were prepared and served at the time of this survey. Findings Included: 1) FOOD LABELING/TIMELY DISCARD The facility policy titled, Budget Guidelines (policy number DS. VI-6, with an effective date of [DATE]) specifies: h. Label and date leftovers and use leftovers before the 'use by' date . The (YEAR) Food and Drug Administration Food Code mandates under regulation ,[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) .refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded. During the initial Kitchen tour on [DATE] at 10:30 AM, the reach-in refrigerator included: a) a container of expired soft cheese (nacho type) with a labeled open date of [DATE] and a use by date (UBD) of [DATE]; and b) a five pound container of Potato Salad with an open date of [DATE] and a UBD of [DATE]; as well as a c) container of pears with a date of [DATE] and no UBD. On [DATE] at 10:40 AM, the Surveyor questioned the (Certified Dietary Manager) CDM (Employee Identifier) EI #6 about the dating of opened foods. EI #6 stated the facility company wanted them to use a three-day use by date, which was what she had always told staff to use. 2) CROSS CONTAMINATION Regulation ,[DATE].11 Food Contact with Equipment and Utensils. of the (YEAR) Food Code states: FOOD shall only contact surfaces of: (A) EQUIPMENT and UTENSILS that are cleaned . and SANITIZED . On [DATE] at 11:00 AM, staff had partially filled the steam table with food for lunch line. The steam table included a full-size pan of cooked English Peas. A thermometer with its detachable plastic handle was laying directly on top of the peas. The Surveyor asked the CDM, EI #6, what problem the thermometer handle would pose. EI #6 immediately responded, Cross Contamination. On [DATE] at 10:45 AM, the Cook (EI #12) dropped the handle of her thermometer into the pan of whole boiled okra as she checked food temperatures prior to the start of the tray line. EI #12 then let the handle of the thermometer dip into the pureed noodles. On [DATE] at 11:53 AM, the Surveyor asked the Cook (EI #12) what problem would the direct contact of the thermometer handle with the whole boiled okra and pureed noodles pose. EI #12 responded, Cross contamination. The (YEAR) Food Code regulation, ,[DATE].111 Controlling Pests. specifies: The PREMISES shall be maintained free of insects, rodents, and other pests. During the [DATE] lunch tray line (10:45 AM), flies landed in the cooked noodles as well as the beef tips, and on an oven mit. Throughout the tray line service, staff swatted flies out of their way, with as many as four flies seen at one time. On [DATE] at 11:45 AM, a fly landed on a filled hot pot containing a liquid sitting on the line. The lid was not on. The fly crawled inside the mouth of the pot, which the Surveyor pointed out to the CDM. 3) FOOD TEMPERATURES Food Code regulation, ,[DATE].16 Time/Temperature Control for Safety Food, Hot and Cold Holding. mandates the following: (A) Except during preparation, cooking, or cooling . TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 135 degrees F or above . Food Code regulation, ,[DATE].13 Plant Food Cooking for Hot Holding. Plant FOODS that are cooked for hot holding shall be cooked to a temperature of 135 degrees F. On [DATE] pureed Okra was placed on the steam table at 11:05 AM (after the line had started). A pan of cooked Squash was placed on the line at 11:12 AM. Neither pan of food was checked for temperature adequacy. On [DATE] at 11:21 AM, a pan of ground Chicken was removed from the steamer, and placed in the oven behind the steam table. Staff did not check the temperature prior to service (to at least one resident). The float staff person (EI #8) was asked if she had checked the temperature of the chicken. EI said no, explaining the tray line staff was responsible. The CDM (EI #6) was interviewed on [DATE] at 11:36 AM and asked why the food added late to the steam table (the ground chicken, squash and pureed okra) was not checked for temperatures. EI #6 stated the staff were supposed to check the temperatures before adding the food to the line. 4) REHEATING OF FOOD Food Code regulation, ,[DATE].11 Reheating for Hot Holding. (A) .TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is cooked, cooled and reheated for hot holding shall be reheated so that all parts of the FOOD reach a temperature of at least 165 degrees F for 15 seconds. On [DATE] at 11:36 AM, the CDM asked the Cook to check the temperature of the pureed okra (not previously checked). EI #6 checked the pureed okra (only) and discovered it was 120 degrees F. This item was not reheated. Neither the ground Chicken, nor the cooked Squash were checked for temperature adequacy.

Based on observation,interview, medical record review and review of a facility document titled Peri-Care the facility failed to ensure a Certified Nursing Assistant (CNA) did not clean bowel movement from Resident Identifier (RI) #128, a resident with history of a Urinary Tract Infection [MEDICAL CONDITION], then with the same gloves, place a clean brief on the resident. This was observed on 6/11/19 and affected one of two residents observed for incontinent care. Findings Include: A review of an undated facility document titled: PERI-CARE revealed: . 3. WASH HANDS AND APPLY GLOVES 4. WASH PUBIC AREA . 8. REMOVE GLOVES AND WASH HANDS--APPLY CLEAN GLOVES 9. TURN RESIDENT ON SIDE 10. WASH ANAL AREA . 12. REMOVE GLOVES AND WASH HANDS-APPLY CLEAN GLOVES . 14. PLACE CLEAN BRIEF . RI #128 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of a Physician order [REDACTED].BACTRIM DS TABLET ONE TAB (tablet) PO (by mouth) BID X 7 D (two times a day for 7 days) DX: (diagnosis) UTI (Urinary Tract Infection/ecoli) . A review of a facility laboratory form dated 5/21/19, revealed: .Procedure CULTURE URINE .Antimicrobial Susceptibility and Organism Identification Report Isolate Escherichia coli . On 6/11/19 at 4:09 PM, the surveyor observed Certified Nursing Assistants (CNAs) EI #3 and EI #4 performing peri-care for RI #128. The Staff Development nurse (EI #2) asked to observe. EI #3 performed the peri-care after EI #4 loosened the brief. EI #3 wiped the resident's front area, removed her gloves and washed her hands, then put on new gloves. Both CNAs turned RI #128 over to the left side. EI #3 wiped RI #128's buttock area until it was free of bowel movement, using a clean wipe each time. EI #3 picked up the clean brief with the same soiled gloves, and placed it under RI #128. EI #3 removed her gloves, washed her hands and put on clean gloves and continued placing and securing the brief. On 6/11/19 at 4:26 PM, an interview was conducted with EI #3. EI #3 was asked what was the policy for cleaning a resident during peri-care. EI #3 replied, wash hands, put on gloves and wipe the front, using a clean wipe each time; then remove your gloves and wash hands and put on new gloves. EI #3 explained they would then turn the resident, clean the back side and buttocks, remove the soiled brief, change gloves, wash hands and put on clean gloves then place the clean brief. EI #3 was asked if that was how she did the peri-care. EI #3 replied, no, she should have changed gloves before she placed the clean brief. EI #3 was asked why did she not wash hands and change gloves before placing the clean brief. EI #3 replied she was nervous. EI #3 was asked when should she change gloves and wash hands during peri-care. EI #3 replied, before starting, after cleaning the front, after cleaning the back, before placing the clean brief, then when finished. EI #3 was asked if RI #128 had a bowel movement. EI #3 replied, yes. EI #3 was asked what was the harm in her not changing gloves and washing hands before placing the clean brief. EI #3 replied, could transfer of germs or bowel movement On 6/13/19 at 10:45 AM, the surveyor asked EI #2 (Staff Development Nurse) what was the policy for hand washing during pericare. EI #2 replied, the staff was to wash hands, put on gloves before starting; after cleaning the front, remove gloves and wash hands, put on new gloves, then after cleaning the buttock area before they place the clean brief, and when finished. EI #2 was asked should staff clean bowel movement from a resident, then with the same gloves, place the clean brief. EI #2 replied, they should not. EI #2 was asked what would the harm be in the CNA placing a clean brief with the same gloves she cleaned bowel movement from the resident. EI #2 replied, the gloves were dirty and the CNA was touching a clean brief with a dirty glove; she cleaned well, so she did not think the CNA could spread germs. EI #2 was asked how could the CNA have been sure there was not bowel movement on her gloves after she cleaned the resident, that may have been transferred to the clean brief. EI #2 replied, it would not matter; the CNA should have changed her gloves after cleaning the buttock area and before placing the clean brief.

Based on record review, interview, review of Potter and Perry, FUNDAMENTALS OF NURSING, and review of the facility policy titled Pain Management and Assessment, the facility failed to ensure pain assessments were documented in RI #1's medical record at the time PRN (as needed) pain medications were administered to RI (Resident Identifier) #1 on 6/30/2017 through 7/3/2017. This affected one of three residents sampled for pain. Findings include: Potter and Perry, FUNDAMENTALS OF NURSING, Ninth Edition, copyright 2017, Chapter 44, Pain Management, page 1045 and 1046, documented: . Patient Outcomes. Effective communication of the assessment of a patient's pain and the response to intervention is facilitated by accurate and thorough documentation. The nurse caring for the patient has a professional responsibility to report the effectiveness of interventions for managing the patient's pain . A review of the facility policy titled Pain Management and Assessment with an effective date of 10/1/2010 revealed the following: . STANDARD: . A pain assessment should be completed through resident interviews . The assessment should . include the presence of pain, pain frequency, effect on function, and intensity. II. On-going Pain Assessment a) The alert resident should be asked to describe their pain on a scale of 1-10; . b) Have resident show you the location and radius of the pain. RI #1 was discharged from the hospital and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1's Nursing Admission Review with a date of 6/30/2017 and a time of admission, 1:28 p.m., documented RI #1's cognitive/mental status as alert and oriented to person, place, and time; independent with cognitive skills for daily decision making. A review of RI #1's admission orders [REDACTED]. A review of RI #1's June and July 2017 MAR (Medication Administration Record) revealed documentation that included an order and start date of 6/30/2017 for [MEDICATION NAME]-[MEDICATION NAME] 5mg/325mg to be administered every six hours prn due to pain. A review of RI #1's medication administration record notes from 6/30/2017 through 7/3/2017 revealed pain assessments were not documented to include: intensity and location of pain on nine doses of prn pain medication administered to RI #1. A review of RI #1's MAR and administration record notes revealed the following dates and times [MEDICATION NAME]-[MEDICATION NAME] 5mg/325mg was administered and no pain assessment was documented to reflect RI #1's level or location of pain. 6/30/2017 at 6:03 p.m. 7/1/2017 at 8:32 a.m. 7/1/2017 at 3:39 p.m. 7/1/2017 at 10:08 p.m. 7/2/2017 at 4:43 a.m. 7/2/2017 at 10:50 a.m. 7/2/2017 at 5:19 p.m. 7/3/2017 at 8:40 a.m. 7/3/2017 at 3:23 p.m. On 7/19/2017 at 4:55 p.m. an interview was conducted with EI (Employee Identifier) #4 LPN (Licensed Practical Nurse), who administered RI #1's prn pain medication on 6/30/2017 at 6:03 p.m. on the day of admission. EI #4 was asked what was required to be documented when a prn medication was administered. EI #4 stated to document the residents request, administration of the medication, and to ask the resident how bad the pain was on a scale of one to 10. When asked where the pain scale was documented, EI #4 said, Nurses notes, which I failed to do. EI #4 was asked if she had asked RI #1, at the time the pain medication was given, what the level of pain was on a scale. EI #4 replied, she had asked and RI #1 had reported a 15 out of 10. When asked why it would be important to record a pain scale for a new resident receiving their first dose of pain medication, EI #4 said, to see the level of pain and to be able to evaluate the effectiveness of the medication for the pain. On 7/20/2017 at 8:05 a.m. an interview was conducted with EI #3 LPN, who administered RI #1's prn pain medication on 7/3/2017 at 8:40 a.m. and 3:23 p.m. EI #3 reviewed the MAR and acknowledged she had administered medications for RI #1 as documented on the MAR. When asked how she assessed RI #1 when the medication was administered on 7/3/2017 at 8:40 a.m. EI #3 could not remember. When asked what should have been done, EI #3 said, she should have asked RI #1 what the level of pain was, the location, and the intensity. EI #3 said, she could not say why the pain assessment was not documented. Because the pain scale was not documented for the 3:23 p.m. dose of pain medication RI #3 could not say how much pain RI #1 had at that time. EI #3 said, RI #1 was very alert and oriented. On 7/20/2017 at 9:25 a.m. an interview was conducted with EI #5 LPN, who administered RI #1's prn pain medication on 7/1/2017 at 8:32 a.m. and 7/2/2017 at 10:50 a.m. When asked what she does after a resident reports pain, EI #5 said, get the resident to rate the pain, check the prn on the MAR, and give the resident what pain medication they could have. EI #5 was asked what type of assessment of the resident would be done at the time of the request for prn pain medication. EI #5 replied, perform a pain scale, specific location of pain, and type of pain. When asked why she had not documented an assessment at the time the prn pain medication was administered, EI #5 stated, I don't know. On 7/20/2017 at 10:00 a.m., EI #6 RN (Registered Nurse) Unit Manager, was asked what was to be included in an assessment for prn pain medication. EI #6 said, a pain level of one to 10 for severity, and several things could be asked of an alert resident. EI #6 was asked why nurses were not documenting prn pain assessments for RI #1. EI #6 said, I didn't know they were not.

Based on observations, interview, and review of the Food Code 2013, facility policy titled THREE COMPARTMENT SINK SANITIZATION, facility policy titled Cleaning of Miscellaneous Equipment and Utensils, facility policy titled Dish Machine Sanitization and facility temperature logs the facility failed to ensure: I. TIME/TEMPERATURE ABUSE: a. The facility failed to follow correct manual dishwashing procedures (three compartment sink) by not monitoring and documenting the final rinse temperature. b. Dishmachine - The facility failed to assure dishes and utensils were effectively sanitized to destroy potential food borne organisms by not monitoring and documenting wash and final rinse temperatures prior to use of the dishmachine. II. CROSS -CONTAMINATION - The facility failed to store wiping cloths in a sanitizing solution to prevent the potential for cross contamination. III. POOR CLEANING/SANITIZING of Equipment - The tea urn spigot was observed with a brown solid build up around the spigot plunger. Staff failed to disassemble all parts and thoroughly clean every 24 hours per regulatory standards. The above practices posed the potential for food contamination and compromised food safety. This had the potential to affect all 135 residents listed on the facility diet list as receiving meal trays from dining services. Findings include: I. TIME/TEMPERATURE ABUSE: a. The facility policy number DS.V28, with an effective date of April 30, 2007, titled: Three Compartment Sink Sanitization revealed: . PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses . PROCESS: . Third Sink Capital Sanitizing . Fill with hot water (at least 171 degrees F Fahrenheit) . The final rinse should be monitored for the proper temperature . A review of the facility's Three Compartment Sink monitoring log for May 2017 revealed there was no temperature documented for the lunch meal on 5/09/2017. On 5/18/2017 at 8:24 a.m., EI (Employee Identifier) #4, CDM (Certified Dietary Manager) was asked about manual dishwashing and when there were omissions in recording, how the facility could assure items were sanitized. EI #4 responded, someone would have to monitor and document. EI #4 was asked if staff were noncompliant with monitoring temperatures, what was the potential outcome. EI #4 said, potential for bacterial contamination. b. Dishmachine - A record review of the facility policy number DS.V.26, dated February 1, 2002, titled Dish Machine Sanitization revealed the . PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses PROCESS: .b. Dish machines using hot water for sanitizing may be used if the temperature of the wash water is maintained at the level specified . High temperature machines generally require wash tank temperatures of 140 - 160 degrees F and the rinse tank temperature should be 180 degrees F or greater. c. Dish machine wash and rinse temperatures should be recorded at the beginning of each dishwashing cycle . Review of the facility's policy titled DISH MACHINE TEMPERATURE LOG for May 2017 revealed there was no monitoring of the dish machine temperatures for the breakfast meal on 5/15/2017. On 5/18/2017 at 8:15 a.m. EI #4, CDM stated, staff should take the temperature and document it to assure the dish machine was effectively sanitizing dishes. She further stated it staff were not monitoring temperatures, there was a potential for bacterial contamination. II. CROSS -CONTAMINATION - A review of the Food and Drug Administration Food Code 2013, Chapter 3 Food revealed the following: . 3-304.14 Wiping cloths, Use Limitation .(B) Cloths in-use for wiping counters and other equipment surfaces shall be: (1) Held between uses in a chemical sanitizer solution at a concentration . On 5/17/17 at 11:05 a.m., two wiping cloths were observed in two areas not in sanitizing solution. EI #4 stated the cloths were not in a sanitizing solution but should have been due to a potential for cross contamination. III. POOR CLEANING/SANITIZING of Equipment - A review of the Food and Drug Administration Food Code 2013 Chapter 4 Equipment, Utensils, and Linens revealed the following: 4-601.11 Equipment, Food-Contact Surfaces, and Utensils. (A) Equipment Food-Contact Surfaces and Utensils shall be clean to sight and touch. Frequency 4-602.11 Equipment Food-Contact Surfaces and Utensils . (E) . surfaces of UTENSILS and EQUIPMENT contacting FOOD that is not TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cleaned: . (2) At least every 24 hours for iced tea dispensers . The facility policy number DS.V-34, dated March 17, 2016, titled Cleaning of Miscellaneous Equipment and Utensils, item 5. Coffee & Tea Urns: Daily cleaning .Wipe spigots with clean cloth soaked in sanitizing solution (100 ppm chlorine . On 5/17/17 at 11:00 a.m., the tea urn was observed. A request was made for Employee Identifier (EI) #4, The Certified Dietary Manager (CDM), to disassemble the two components. The spigot was observed with a brown build up around the plunger. The CDM was asked about the condition of the plunger, EI #4 stated: I know we do cleaning, but I know that there is some build-up on that one. A review of the facility Daily Cleaning Schedule for the week of May 15-21, 2017, indicated Clean all items listed at least daily, preferably after each use The log had a review date of 8/08. The tea urn was not listed on the this schedule. On 5/18/2017 at 8:35 a.m., the tea urn subject was revisited. EI #4 was asked, if the tea urns were listed on dietary's cleaning schedule. EI #4 responded No. EI #4 was asked if the cleaning policy described disassembling into two components, EI #4 said, do not disassemble. EI #4 was asked to describe her observations and what was a potential risk/outcome for failure to thoroughly clean. EI #4 said she saw brown stuff around the top of the spigot and that was potential for bacterial contamination.

Based on observations, interviews, review of the Director of Maintenance Job Description, and review of the facility's . Work Schedule ., the facility failed to ensure: 1) Room Locator (RL) # 1 was not missing portions of the door surface. Further, the door in RL #1 had a hole located on the hinge side at the lower part of the door; and 2) light fixtures across from RL #s 3, 4, and 5 were free of an accumulation of dead bugs and debris. These failures had the potential to affect four of four residents whose rooms were adjoined to RL # 1 and three light fixtures located on one of three units. Findings include: Review of the job description for the facility's Maintenance Director, reviewed 06/30/2003, revealed the following: . B. DEPARTMENTAL FUNCTIONS . 9. Maintain appearance of building and provide necessary repairs and painting as needed . 14. Inspect all overhead and bathroom lights . 1) On 5/16/2017 at 2:45 p.m. in RL #1 an observation was made of the resident bathroom door. A piece of the original paneling was removed exposing the unfinished panel beneath. At the bottom of the door was a triangular hole which extended the length of the lower hinge. The panel of the other side of the door was clearly visible through the hole, the door being of a cavity type construction. A piece of wood effect panel board had been used to repair the lower third of the door and was also broken. On 5/17/2017 at 5:00 p.m. an interview was held with Employee Identifier (EI) #6, Unit Manager, who was asked to relay to the surveyor what concerns she might have with RL #1. EI #6 replied that she noted the door panel on the resident's side facing into the bathroom was broken and needed repair. On 5/18/2017 at 8:25 a.m. an interview was held with the Maintenance Director, EI #3, who was asked how did staff notify him when they had a problem on the halls. EI #3 replied that they notified him using the maintenance book, orally or over the intercom. EI #3 was asked to comment on RL #1. He replied the bathroom needed a new door. 2) Review of the facility's . Work Schedule . revealed the lighting was scheduled for inspection every three months. On 05/17/2017 at 3:25 p.m. the light fixture on the ceiling outside of RL #4 was noted with greater than 25 brown areas inside the fixture that appeared to be dead bugs and other debris. At 3:27 p.m., the light fixture on the ceiling across from RL #3 was also noted to contain debris and what appeared to be dead bugs. On 05/17/2017 at 4:35 p.m. Employee Identifier (EI) #5, Housekeeping staff, was observed cleaning out the light fixture with the assistance of another staff member. EI #5 said the items she cleaned out of the fixture were dead bugs. A large pile of dead bugs and other debris were noted on the floor. When asked who was responsible for cleaning out the light fixtures, EI #5 said the surveyor would need to discuss that with Maintenance. At this time, the light fixture on the ceiling outside of RL #3 was noted to still contain an accumulation of dead bugs and debris. Another fixture across from RL #5 was also noted with 50 plus dead bugs and debris. EI #3, the Maintenance Director, was interviewed on 05/18/2017 at 2:00 p.m EI #3 stated he did not check light fixtures for bugs, but said the Certified Nursing Assistants might notify him. After discussing the observations of the light fixtures, EI #3 confirmed he had seen them as well. EI #3 said he saw staff cleaning them out. EI #3 said staff were raking . the dead bugs out of the fixture and there were quite a few. EI #3 said he did not know who was responsible for cleaning out the light fixtures, but said they should probably be checked at least monthly. EI #1, the facility's Administrator, was interviewed on 05/18/2017 at 2:20 p.m EI #1 said maintenance changes light bulbs, so he should also clean out the fixtures when that is done. EI #1 also said housekeeping could clean out the light fixtures. EI #1 said the light fixtures should probably be checked monthly to determine if they required cleaning. When asked why it was important to ensure the light fixtures did not contain dead bugs and debris, EI #1 said to make sure they were clean and cosmetically looked good.

Based on observation, interviews, and review of the Food Code 2013, the facility failed to ensure waste was properly contained in dumpster's (doors and lids closed), grounds were free of debris and maintained in a manner to prevent the harborage and feedings of pests. This deficient practice had the potential to affect all 139 residents who resided in the facility. Findings include: The 2013 Food Code by the United States Public Health Service (USPHS) and the Food and Drug Administration (FDA) included the following: . 5-501.15 Outside Receptacles. (A) Receptacles and waste handling units for REFUSE . 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 . shall be installed so that accumulation of debris and insect and rodent attraction and harborage are minimized and effective cleaning is facilitated around and . under the unit . On 5/17/2017 at 3:15 p.m., two green dumpster's were observed. One door on one dumpster was not closed. It was opened approximately six inches. The second dumpster was observed with food adhering to the metal structure and on the ground. Employee Identifier (EI) #4, the the Certified Dietary Manager (CDM) was asked what was the potential harm for the open door and food not contained. The CDM verbalized the potential harm was for the attraction of pest and a potential for the spread of bacteria. The CDM was asked, when should the food debris have been cleaned and by whom? The CDM responded: Whoever did it (spilled the food) and right then.

Based on observation, interview, and record review the facility failed to ensure licensed staff administered medications to RI (Resident Identifier) #25 on 4/14/2016, as prescribed by the physician. This affected one of four licensed staff, and one of six residents on one of four halls observed during medication pass. Findings included: The facility policy titled Oral Medications dated 3/2011 revealed the following: .Policy Oral medications are to be administered in a safe and accurate manner.Procedures 1. Pour/punch the correct number of tablets/capsules into the medication cup.2. If medication is a liquid . pour correct amount directly into a graduated medication cup . RI #25 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #25's annual MDS (Minimum Data Set) with an Assessment Reference Date of 1/27/2016 revealed a BIMS (Brief Interview for Mental Status Score) of 15 which indicated intact cognition. RI #25's April physician orders [REDACTED].Order Date . 12/17/15 .[MEDICATION NAME] 10 GM (grams)/15 ML (milliliters) SOLUTION GIVE 30CC (cubic centimeters) PO (by mouth) Q (every) DAY R/T (related to) CONSTIPATION. 1/01/15 . VITAMIN D 1,000 UNIT TABLET GIVE 2 TABLETS PO QDAY TO EQUAL 2,000 UNITS R/T VITAMIN D DEFICIENCY . On 4/14/2016 at 8:20 AM, EI (Employee Identifier) #3 LPN (Licensed Practical Nurse) was observed preparing RI #25's medication for administration. EI #3 poured from a bottle, one tablet of Vitamin D 1,000 units into a medication cup and from another bottle, she poured 10 cc of [MEDICATION NAME] liquid into another medication cup. EI #3 administered RI #25's medications and signed RI #25's MAR (Medication Administration Record) to document the 8:00 AM medications were given as ordered. On 4/14/2016 at 10:50 AM, after comparing the medications administered with RI #25's physician orders, EI #3 was asked why she had given RI #25 one tablet of Vitamin D 1,000 units. EI #3 said she looked at it wrong. When asked what was ordered for the Vitamin D 1,000 units, EI #3 said, two tablets were to be given. When asked why she had given RI #25 10 cc of [MEDICATION NAME] liquid, EI #3 said she was nervous. When asked what the ordered amount of [MEDICATION NAME] to be given was, EI #3 said, give 30 ml of the 10 gm/15 ml solution. When asked what the facility policy was for verification of medication prior to administration, EI #3 said, to look back and make sure the right amount was administered. When asked what the potential harm was for the resident if medications were not verified, EI #3 said, the resident might not get enough of the medicine.

Based on observation, interview, and record review the facility failed to ensure a change in RI (Resident Identifier) #11's diet order from mechanical soft to pureed was correctly transcribed from the communication from speech therapy to the physician orders. This affected one of nine residents whose meals were observed. Findings included: The facility policy titled Pureed Foods with an effective date of 8/15/2009 revealed the following: . STANDARD: The physician's orders [REDACTED]. RI #11 was readmitted to the facility on [DATE] with physician's orders [REDACTED]. A COMMUNICATION FORM for RI #11, dated 3/18/2016 from ST, Employee Identifier (EI #1) to nursing revealed a recommendation for discontinuation of the mechanical soft diet and change to a pureed diet. RI #11's Significant Change MDS (Minimum Data Set) with an Assessment Reference Date of 3/24/2016 revealed a BIMS (Brief Interview for Mental Status) score of 7 which indicated moderately impaired cognition. The MDS also revealed RI #11 .holds food in mouth/cheeks ., had .no natural teeth ., and had ongoing speech therapy that started 3/18/2016. The surveyor observed facility staff spoon feeding pureed meals to RI #11 on 4/13/2016 for breakfast at 7:50 AM, 4/13/2016 for lunch at 12:15 PM, and 4/14/2016 for breakfast at 7:55 AM. On 4/14/2016 at 11:00 AM, EI #4, LPN (Licensed Practical Nurse) was asked what diet RI #11 had. EI #4 said it was a pureed diet. When asked how long RI #11 had the pureed diet, EI #4 said it had been changed last week or the week before. When asked about the diet order, EI #4 said it was a mechanical soft diet dated 3/17/2016. EI #4 added that RI #11 had a trial of pureed diet that EI #1, SLP (Speech Language Pathologist) recommended. On 4/14/2016 at 11:05 AM, EI #1 was asked how long RI #11 was on a pureed diet. EI #1 said since RI #11 came back from the hospital on [DATE]. EI #1 was asked why the current diet on the physician's orders [REDACTED].#1 said, when she changed a diet she provided the communication form for nursing and dietary, and they are responsible for making changes in the computer. On 4/14/2016 at 1:25 PM, EI #2, RN/ADM (Registered Nurse/Administrator) was asked where the breakdown in communication had occurred for RI #11's diet. EI #2 said therapy gave a copy to dietary, placed it in a box for the unit manager, and it was not verified that the nurse actually received the communication.

Based on observation and interviews, the facility failed to ensure the condition of each resident's room was well maintained. This included Room Locator (RL) #s: 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12, 13 and 14; affecting 13 total rooms on four of seven wings. Findings included: During the initial tour on 03/03/15 between 9:45 AM and 11:00 AM, and throughout the survey (through 03/05/15), the following observations were made: 1) RL #1: The bathroom faucet ran continuously. The surveyor's attempt to turn off the flow of water was unsuccessful on 03/03/15 at 10:17 AM. The water was still running on 03/05/15 at 11:11 AM, when viewed again by the surveyor and facility staff. 2) RL #2: The third dresser drawer was off track (visibly tilted to one side), and would not slide open easily. 3) RL #3: The sliding closet door was stuck/would not open. 4) RL #4: The metal ceiling tile supports in the residents' bathroom were rusted. The plastic vented top of the heating and air-conditioning unit was broken, and the unit cover was partially detached. 5) RL #5: The thermostat control box in the residents' shared bathroom was missing the outer cover, and most of the internal mechanics. The sink was cracked on one side. 6) RL #6: The wall adjacent to the A bed and hall door had multiple areas of dried, yellowish brown-stained residue. 7) RL #8: The bedside cabinets for both the A and B bed residents, were frayed at the corners, due to deteriorating particle board composition. 8) RL #9: The wall at the foot of the bed (on which the television was mounted) was in need of painting due to a previous repair (spackling patch). 9) RL #10: The closet door was off track, and would not slide. 10) RL #11: The ceiling exhaust vent in the resident's bathroom contained a heavy accumulation of dust. An area of baseboard tile was missing in the bathroom. The area around the perimeter of the heating and air-conditioning unit was not sealed. 11) RL #12: The ceiling exhaust vent in the resident's bathroom contained a heavy accumulation of dust-like substance. 12) RL #13: The phone jack cover was missing and wires were exposed near the base of the wall between the A and B beds. 13) RL #14 The dresser drawers were scraped with areas of missing paint, particularly along the top edges. On 03/05/15 between 1:32 and 1:54 PM, the above concerns were shown to the Maintenance Supervisor and Administrator. On 03/05/15 at 4:36 PM, the Administrator (Employee Identifier/EI #2) and the Maintenance Director (EI #9) were interviewed. The surveyor asked who was responsible for making the needed repairs. EI #9 stated his staff was responsible, but he was not aware of the needed repairs in RL #1, 2, 3, 4, 5, 12, 13 and 14. EI #9 stated his staff walked each hall every day, they review the maintenance logs, or staff would verbally report their maintenance needs. When asked what potential harm could result from these unattended repairs, EI #9 stated the stuck closet doors could fall down, which would be dangerous.

Based on observation, interviews and record reviews the facility failed to ensure a (Certified Nursing Assistant) CNA provided incontinent care to (Resident Identifier) RI #2 in a manner to prevent cross contamination. This was observed on 1 of 2 sampled residents for incontinent care. Findings Include: A review of "Potter & Perry Fundamentals of Nursing Eighth Edition, Providing Perineal Care" Copyright 2013 Page 802: "...Male patient (a) apply pair of clean gloves...Gently raise penis...wash tip of penis...first... p. Remove soiled gloves and discard... q. wash back (1) Perform hand hygiene and apply clean pair of gloves... (5) clean buttocks and anus, washing front to back...Remove contaminated gloves..." RI #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The most recent (admission) Minimum Data Set assessment, dated 02/20/15, identified RI #2 as in need of extensive assistance for toileting needs. On 3/4/15 at 8:55 AM, during an observation of incontinent care (Employee Identifier) EI #3 (a CNA) was observed cleaning bowel movement first, then with same gloves, placed a clean brief on the resident. EI #3 turned the resident to his/her back to secure the brief. The surveyor intervened to ask if she was going to clean the resident's front side. EI #3 said yes, and continued to clean with same gloves that she had cleaned bowel movement with. On 3/4/15 at 9:05 AM, an interview was conducted with EI #3. EI #3 was asked should you clean bowel movement, then handle the clean brief and clean the front of the resident with the same gloves. EI #3 replied, no. EI #3 was asked did you change your gloves or wash your hands before touching the clean brief. EI #3 replied no. EI #3 was asked what was the risk for harm in not washing hands after cleaning bowel movement and before handling the clean brief. EI #3 replied, spreading infection. On 3/5/15 at 8:15 AM, an interview was conducted with EI #4, the Infection Control Nurse. EI #4 was asked to explain when gloves should be changed during the provision of incontinent care. EI #4 replied, don gloves upon starting, then when doing the back side and anytime gloves become soiled and before touching the clean brief. EI #4 was asked should a CNA clean bowel movement before placing a clean brief, then clean the front side of a resident with the same gloves. EI #4 replied no. EI #4 was asked what was the potential for harm in not washing hands or changing gloves after cleaning bowel movement, before handling a clean brief. EI #4 replied infection, cross contamination.

Based on observation, interview and record review, the facility failed to ensure the side doors on one of two dumpsters remained closed on all three days of the survey. The facility also failed to ensure the recycle dumpster was emptied on a routine basis, after completely filled. This affected one of one recycling dumpsters. Findings included: The facility policy related to "Garbage and Refuse" (#DS.V-38, dated 02/01/02) specifies their Standard as: "Garbage and refuse containers should be free from cracks or leaks and covered when not in use." The Process specifies: ... "e. Refuse containers and dumpsters kept outside the facility should have tightly fitting lids and should be kept covered when not being loaded. f. Dumpsters should be emptied according to the facility contract; garbage should not accumulate... g. The schedule for garbage pick-up should be revised, as needed, based on the volume of refuse." On 03/03/15 at 9:40 AM, the dumpster containing cardboard was filled to capacity and far above the top of the unit. The side door on one of two garbage dumpsters was open. On 03/04/15 at 7:30 AM, the unit in which cardboard was contained remained filled with flattened and intact boxes. The contents of the container were filled to double the capacity of the unit. Again, the side door of one of two garbage dumpsters was open, exposing the contents inside. On 03/05/15 at 10:50 AM, the surveyor alerted the Dietary Manager (Employee Identifier/EI #1) of the concern with the recycling unit and the garbage dumpster doors. EI #1 explained that several companies were responsible for emptying the unit containing cardboard, and it was done approximately once a week. On 03/05/15 at 11:45 AM, the side door of the dumpster was again left open, exposing the contents inside to rodent/pest infestation. On 03/05/15 at 2:40 PM, the facility Administrator (EI #2) was apprised of this concern. EI #2 stated it was the responsibility of each person who used the dumpster to close the doors. When asked how often the cardboard was picked up, EI #2 explained the local thrift stores are called when emptying is needed.

Based on observations, record review and interview: 1) The facility failed to assure food preparation equipment, dishes and utensils were effectively sanitized to destroy potential food borne organisms as evidenced by staff 's failure to monitor/document/ validate wash and rinse temperatures met standard prior to operation of the dish machine . 2) The facility staff failed to label/date frozen/thawed health shakes with a use by date as recommended by the manufacturer and the 2013 Food Code . 3) The facility staff failed to follow correct manual dishwashing procedures by not validating the final rinse water reached the correct temperature to sanitize. The above practices posed the potential for food contamination and compromised food safety. This had the potential to affect all 143 residents receiving meal trays from dining service. Findings include: 1) A review of the facility policy titled: "Dish Machine Sanitization, number DS.V-26" with an effective date of February 1, 2002, ...Process documented: "...b. Dish machines using hot water for sanitizing may be used if the temperature of the wash water is maintained at the level specified by the manufacturer ... High temperature machines generally require wash tank temperatures of 140-160 degrees F (Fahrenheit) and the rinse tank temperature to be 180 degrees F or greater. c. Dish machine wash and rinse temperatures should be recorded at the beginning of each dishwashing cycle and checked periodically during the dishwashing process ... d. Any observation of a wash or rinse temperature that is not within the desired range, should be reported immediately to the Dietary Manager ...Dishwashing should be suspended and action taken..." Machine dishwashing was observed on 8/5/2014 at 9:00 AM. The method observed for dish machine sanitizing was high temperature. A record review of the posted "Dish Machine Temperature Log" revealed no data/documentation had been recorded to assure 180 degree F had been reached. The Dietary Aide, EI #4 (with 9+ years of service) was asked, when did you begin washing dishes? EI #4 responded it was 8:45 AM and the task was about one-half finished. The machine gauges were viewed and read Wash 137, Rinse 195 degrees F. At 10:15 AM, Dietary Manager, Employee Identifier (EI) #5 called Maintenance. The Consultant Dietitian EI #3 directed staff to use paper when serving the noon meal. Residents were made aware of the situation. An interview was conducted with the Consultant Dietitian EI #3 on 8/06/2014 at 9:40 AM. EI #3 was asked: a) How does staff assure the dish machine is properly functioning to assure dishes are effectively sanitized to destroy potential food borne organisms? EI #3 responded, monitor wash/rinse temperature and record prior to beginning ... b) During an interview with the Consultant Dietitian, EI #3 was asked on 8/5/2014 at 9:30 AM, did staff follow facility procedures for monitoring/documenting wash/rinse temperatures? EI #3 responded, no. c) Was there a problem with the equipment? EI #3 responded, yes. d) What corrective action was taken after surveyor intervention? EI #3 responded, used paper disposable products and called repair/maintenance service. 2) The Food Code, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking indicated: "(B) Except as specified in (E) - (G) of this section, refrigerated, Ready-To-Eat Time/Temperature Control for Safety Food prepared and packaged BY A FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations..." Observations during the 8/04/2014, initial tour of dietary services revealed frozen/thawed Health Shakes were not marked with a use by date. The label date was the thaw date. During the tour of resident rooms, Resident Identifier (RI)#7 was observed on 8/04/2014 at 4:10 PM consuming a Vanilla Shake with a date of 8/01/2014. An interview with the Consultant Dietitian, EI #3 on 8/05/14 at 9:43 AM revealed: a) How is your staff dating frozen/thawed Health Shakes? EI #3 responded, we are putting the thaw date. b) What is manufacturer's direction? EI #3 responded, use within 14 days of thawing. c) Is there evidence nursing and dietary staff had received training to not use/destroy shakes after 14 days? EI #3 responded, no. d) Does standard of practice (Food Code) provide guidance for labeling? EI #3 responded, yes. EI #3 was asked if this method was utilized and she responded, no. 3) A review of the 2013 Food Code Chapter "4-501.111 Manual Warewashing Equipment, Hot Water Sanitation Temperature revealed: "If immersion in hot water is used for sanitizing in a manual operation, the temperature of the water shall be maintained at 77 degrees C (Celsius) (171 degrees F) or above". On 8/04/2014 at 3:50 PM, manual warewashing (pots/pans) was observed. High temperature was used for sanitizing. A record review of the facility "Sanitization Control Log - Three Compartment Sink" was reviewed. Omissions were found in 8 of 10 opportunities. No data was recorded for neither the breakfast nor noon opportunities for August 1, 2, 3, and 4, 2014. The Consultant Dietitian EI #3 was interviewed on 8/6/2014 at 9:45 AM. EI #3 was asked: a) What was the evidence to demonstrate staff followed correct manual dishwashing procedures (i.e. (for example) correct water temperature) on August 1, 2 ,3, and 4? EI #3 responded, there is none. b) How are staff to monitor/document test (water temperature) data? EI #3 responded, take 3rd sink temperature and record prior to beginning and assure it meets standards.

Based on observations, record review and interview: The facility failed to provide evidence that dietary staff were properly trained in food safety and competent as related to their assigned duties: 1) Machine dishwashing, 2) Manual dishwashing and 3) Proper labeling (dating) of frozen/thawed Health Shakes. This affected 2 of 9 Dietary Aides observed and 14 personnel folders reviewed. Findings include: A review of the 2013 Food Code at "2-103.11(J) Person in Charge" revealed that "The person in charge shall ensure that: Employees are properly sanitizing cleaned multiuse EQUIPMENT and UTENSILS before they are reused, through routine monitoring of solution temperature and exposure time for hot water sanitizing ..." Observations of staff performance on 8/4/2014 and 8/5/2014 resulted in sanitary citations of deficient practice. On 08/04/2014 at 3:50 PM manual dishwashing was observed and method of sanitation was high temperature. A review of the temperature log revealed no monitoring had been documented for 08/01-04/2014. On 08/05/2014 at 9:30 AM machine dishwashing was observed and there was no documentation of wash temperature or rinse temperatures that date and time. As a result the machine was not operating properly. On 8/05/2014 at 12:45 PM, the surveyor was presented with this documentation by the Consultant Dietitian EI #3: "On this date, (named surveyor) asked to see orientation records for Dietary employees, I (named EI #3) am temporarily filling in for (named CDM) during her lengthy illness. I (named EI #3) could not find orientation records and called (named CDM). She stated she does verbal orientation." A review of 14 Dietary personnel files revealed hire dates ranging from 4/18/88 to 7/30/14. These records were reviewed with the Assistant Dietary Manager and the Registered Dietitian. No information was found to validate what tasks staff had received training, when trained nor proficiency per return demonstration. The Consultant Dietitian EI #3 was interviewed on 8/06/2014 at 11:00 AM and asked: 1) Can you provide evidence that all dietary staff have received on-the-job training and demonstrated proficiency for assigned tasks i.e.. a) machine dishwashing, manual dishwashing and labeling/dating frozen/thawed Health Shakes? EI #3 responded, no. 2) What are the potential problems for not effectively performing these tasks? EI #3 responded, not effectively sanitizing.

Based on observation, interview and record review the facility failed to maintain dignity for RI (Resident Identifier) #'s 18 and 21, by not allowing residents of the opposite sex to enter their room through a shared bathroom. This affected two of 21 sampled residents. Findings include: Review of the facility policy "Federal Rights of Residents" with an effective date of 11/1/2001, revealed "...PURPOSE: All residents in long term care facilities have rights guaranteed to them under Federal and State law ...STANDARD: The resident has a right to a dignified existence ... " RI #18's was readmitted to the facility on [DATE]. Review of RI #18's most recent quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 6/23/2014 revealed that RI #18 had a BIMS (Brief Interview for Mental Status) score of 14 which indicated cognitively intact skills for daily decision making. RI #21 was readmitted to the facility on [DATE]. Review of RI #21's most recent quarterly MDS with an ARD of 6/4/2014 revealed that RI #21 had a BIMS score of 12 which indicated moderately impaired cognitive skills for daily decision making. RI #25 was readmitted to the facility on [DATE]. Review of RI #25's most recent quarterly MDS with and ARD of 5/22/2014 revealed that RI #25 had a BIMS score of 9, which indicated moderately impaired cognitive skills for daily decision making. On 8/4/2014 at 3:30 PM, RI #25 was observed in the hall wheeling self in a wheelchair. On 8/6/2014 at 11:00 AM, upon entering the room of RI #18 and #21, RI #18 began pointing to the bathroom door. The bathroom door would not close into the door frame. The surveyor asked the resident if the facility was aware of the door not closing and RI #18 stated that they knew about it (the door) and also stated "They knew it was like that when I came in. That (opposite sex resident) sometimes comes in here instead of (opposite sex residents) room, (the resident) is confused." The resident also stated that it does not feel right when a resident of the opposite sex comes into the room. RI #18 further stated that it needed to be a resident of the same sex in the other room. When RI #18 was asked about using the bathroom more if residents of the opposite sex were not using it, RI #18 stated, "I think I would." On 8/6/2014 at 2:00 PM, an interview was conducted with EI #1, LBSW (Licensed Bachelor of Social Work). EI #1 was asked what about the facility policy for resident of the opposite sex sharing bathrooms. EI #1 stated that if they use the bathroom independently they do not share a bathroom, and if they require staff assistance they can share a bathroom. EI #1 was asked what would be the potential harm if a resident of the opposite sex goes through the bathroom into the other adjoining room. EI #1 stated that they should have staff to assist them or they normally would not share. EI#1 was asked how it was determined that those residents of opposite sex would share a bathroom and EI #1 stated, "Based on need for assistance to go to the bathroom." EI #1 was asked how she would guarantee the residents would not enter the bathroom at the same time or enter each other's rooms through the bathroom and she stated, "You can't." EI #1 was asked what would be the reason not to place males and females in rooms sharing a bathroom and she stated, "They don't need to share a bathroom for dignity reasons."

Based on observation, interview, and record review the facility failed to ensure closet doors and a bathroom door were maintained in proper working condition for RI #18 and RI #21. This affected two of 21 sampled residents. Findings included: A review of the job description titled "Director of Maintenance" with a review date of 6/30/2003 revealed "...STANDARD REQUIREMENTS ...2. Knowledgeable of resident rights and ensures an atmosphere, which allows for the privacy, dignity, and well-being of all residents in a safe, secure environment ..." RI #18 was readmitted to the facility on [DATE]. A review of RI #18's most recent quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 6/23/2014 revealed that RI #18 had a BIMS (Brief Interview for Mental Status) score of 14 which indicated cognitively intact skills for daily decision making. RI #21 was readmitted to the facility on [DATE]. A review of RI #21's most recent quarterly MDS with an ARD of 6/4/2014 revealed that RI #21 had a BIMS score of 12 which indicated moderately impaired cognitive skills for daily decision making. On 8/6/2014 at 11:00 AM, upon entering the room of RI #18 and #21, RI #18 began pointing at the closet and bathroom doors. The closet door was off track and would not close properly and the bathroom door would not close into the door frame. The surveyor asked the resident if the facility was aware of the door not closing and RI #18 stated that they knew about the doors since the resident had moved into the room. On 8/6/2014 at 1:50 PM, the surveyor asked RI #21 how long the closet and bathroom doors had not been working properly and RI #21 stated, "Since I moved into this room." On 8/6/2014 11:15 PM, an interview was conducted with EI #2, Director of Maintenance. EI #2 was asked what was wrong with RI #18 and #21's closet door. He stated that it looked like it was off track. EI #2 was asked what was wrong with the bathroom door and he stated that the hinge was loose and the door was sticking. EI #1 was asked why was the bottom of the outer edge of the door a lighter color than the rest of the door. EI #2 stated that the bottom 1/3 of the door had been sanded so that it would shut, and that once before it was sticking so it was sanded so that it would shut. EI #2 was asked what the importance was of residents having bathroom doors shut properly. EI #2 stated that privacy was important since guys were on one side and ladies were on one side. EI #2 was asked what the importance was of closet doors being on track. EI #2 stated, "So they can shut properly, there is a dented place on the track where it jumps off of track."