Every finding on record at Palm Gardens Health and Rehabilitation, LLC

Based on interviews, review of the facility's policy titled, Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, and the facility's investigation file, the facility failed to ensure Employee Identifier (EI) #2, a Certified Nursing Assistant (CNA) did not use Resident Identifier (RI) #2's debit card without the resident's permission for personal use. This deficient practice affected RI #2; one of three sampled residents reviewed for misappropriation of resident's property. Findings include: The facility's policy titled, Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, with an effective date of February 8, 2018, revealed, PURPOSE: .All of our resident/guest(s) have the right to be free from abuse, neglect, exploitation and misappropriation of resident/guest property. This policy against abuse, neglect, exploitation and misappropriation of resident/guest property includes abuse by any other person, including, but not limited to: any member of the facility staff . D. Misappropriation of Resident/Guest Property. Misappropriation of resident/guest property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident/guest(s) belongings or money without the resident/guest(s) consent. or the use of resident/guest(s) funds including credit cards . RI #2 was admitted to the facility on [DATE]. RI #2's Quarterly Minimum Data Set with an assessment reference date of 08/27/21, revealed, the resident was cognitively intact, with a Brief Interview for Mental Status of 15. Facility report titled, VERIFICATION OF INVESTIGATION revealed . DETAILED DESCRIPTION OF INCIDENT / ALLEGATION: On August 30, 2021 Administrator and SW (Social Worker) responded to resident request, to a report that (his/her) Direct Express Card(#l) had unauthorized charges noted. (name of RI #2) reported that (he/she) had given the Direct Express card to (name of staff member), employee (#1), on August 21, 2021 to get (his/her) a iPhone charger and that the employee brought (his/her) charger to (his/her) the same day and returned (his/her) debit card. Admin (Administration) contacted employee and suspended her pending the investigation. Employee stated that this is the only time she used the card and returned it to (name of RI #2) immediately upon returning from Wal-Mart. On August 30, 2021, Administrator reported this event to ADPH (Alabama Department of Public Health) and reported this event to Mobile County Police Department. (Officer name). Administrator asked officer if he wanted to interview (Name of RI #2) and he stated not at this time. On August 30, 2021 Social Worker printed account summary of Direct Express Card (#1). (name of RI #2) identified 3 Unauthorized charges: 5.43-Wal Mart, 83.00 ATM, and 10.99 Shell. On August 30, 2021(name of RI #2) notified Social Worker and Admin that (he/she) had another card, (Name of personal bank card) Visa (#2). (He/she) was assisted by SW to obtain statements to review for any unauthorized purchases. Resident identified the following unauthorized purchases on (Name of Personal bank card) Visa (#2). Unauthorized charges: 101.50 T-Mobile, 202.00 Alabama Power, 15.15 Shell Oil, 30.34 Shell Oil. August 31, 2021, Administrator Contacted Mobile County Police Department to inquire about update and obtain case number. (Officer name) arrived at (name of Facility) and interviewed (name of RI #2) and obtained information and assigned case number (Case number). On September 1, 2021 (name of EI #2), employee (#2), reported to the Admin office and confessed to the unauthorized spending on the Direct Express Card. (Name of RI #2) had identified 3 Unauthorized charges that were made on August 28, 2021 (5.43 to Wal Mart, 83.00 ATM withdrawal, and Shell 10.99). (Name of EI #2) confessed and indicated that she did make the 3 Unauthorized charges that were made on August 28, 2021 (5.43 to Wal Mart, 83.00 ATM withdrawal, and Shell 10.99). (Name of EI #2) stated that she did not use the other debit card (#2). Administrator discharged employee at this time. On September 1, 2021 Administrator contacted Mobile County Police Department to update about confession and spoke to financial fraud investigator assigned to this case, (name of Officer), and he indicated that he would follow up with (name of EI #2) and keep me informed . On 12/14/2021 at 3:23 PM, an interview was conducted with EI #2, CNA. EI #2 stated, on 08/27/2021, RI #2's cards were on the floor. EI #2 stated, she kept two cards, a white one and a green one. When asked how she got RI #2's pin number; EI #2 stated, RI #2 gave it to her once when he/she asked her to go get food. EI #2 stated her intentions weren't to go spend anything, but that's what she did. She stated, she used the cards to retrieved money from the ATM, went to store, Walmart, paid her Alabama Power and T-Mobile bills with cards. When asked if, RI #2 gave her permission to use the cards, EI #2 stated, No. EI #2 stated, she returned the cards the same shift. EI #2, stated the total unauthorized charges on the cards were between $300-$400. EI #2 admits taking RI #2's cards and using them without permission is misappropriation. On 12/15/2021 at 3:40 PM, an interview was conducted with RI #2. RI #2 was asked when the unauthorized charges were noticed. RI #2 stated that on 8/29/21 he/she was trying to order some lunch from door dash and the card kept declining. RI #2 stated he/she called on Monday, 08/30/2021, and was informed of the wrong pin number. RI #2 changed the pin number back to the original pin number and was then able to hear the unauthorized charges. RI #2 stated, there was a shell charge, ATM withdrawal and a Wal-Mart charge. RI #2 stated he/she informed the social worker, who informed the administrator and the local police department was called. Later, RI #2 checked his/her local bank card and noted a charge for a power bill for $204, a T-Mobile bill for $100 and a charge to a shell gas station. RI #2 stated on that Wednesday, 09/01/2021, EI #2 came into his/her room while RI #2 was talking to another employee about what happened. When the other employee left, EI #2 stated she did it and offered to give RI #2 money. On 12/16/2021 at 3:35 PM, an interview was conducted with EI #4, Administrator/Abuse Coordinator. EI #4 stated, he became aware of allegations on 08/30/2021. RI #2 informed the facility that he/she had unauthorized charges on his/her card and listed charges. RI #2 stated he/she had given his/her card to a EI #1 to go and get a phone charger. RI #2 told them EI #1 brought back the charger, card and receipt. EI #1 was suspended pending investigation. EI #4 stated, the local police department were notified, and a report was made to the state agency. EI #4 stated, it was later found that unauthorized charges were also noted on RI #2's personal banking account card. There were three charges to this card. EI #4 stated, on 09/01/2021 EI #2 came to his office and confessed to unauthorized spending on RI #2's Direct Express Card but denied charges on the personal banking account card. EI #4, stated that EI #2 was immediately discharged . EI #4 stated there were a total of six charges on two cards for a total of $448.41. In a follow-up interview conducted with EI #4 on 12/16/2021 at 6:15PM, EI #4 was asked what would the use of RI #2's debit cards without his/her permission be considered. EI #4 stated, Misappropriation of resident's funds. ************************* Once the allegation of misappropriation was reported to the facility's Administrator, the following corrective actions were implemented EI #1 was placed on suspension 08/30/2021. On 08/30/2021, the facility reported the allegation of misappropriation to the State Survey Agency 08/30/2021, reported to Local Police Department RI #2 informed SW and Administrator that he/she had another card, He/she was assisted and noted unauthorized charges. 08/30/2021 SW and Administrator assisted RI #2 with contacting bank to dispute charges. 08/30/2021-09/03/2021 staff development and nursing administrator continued in-servicing for employees on Abuse/Neglect/Exploitation. 09/01/2021 EI #2 confessed to unauthorized spending on RI #2's Direct Express card and EI #2 's employment with the facility was terminated on 09/01/2021. 09/01/2021, SW met with all residents and inquired about debit/credit cards. Offered to secure the belongings for each. 09/02/2021, RI #2's Alabama Power bill paid with Administrator's Debit card ($337.43) 09/03/2021, facility re-imbursed RI #2 remaining $110.98 in cash and the money was secured in lock box in the administrator's office. ************************* After review of the facility's investigation file, in-service/education records, staff and resident interviews, the facility implemented corrective actions from 08/30/2021-09/03/2021, thus past non-compliance was cited. This deficiency was cited as a result of the investigation of complaint/report number AL 561 and AL 562.

Based on interviews, review of a facility incident investigation report, and review of the facility policy titled, Incidents and Accidents, the facility failed to determine the reason a resident sustained [REDACTED]. This affected Resident Identifier (RI) #1, one of three resident's sampled for falls. Findings include: A review of the facility policy titled, Incidents and Accidents with an effective date of 11/10/14, revealed, . STANDARD: . II. Documentation . b) An Incident/ Accident report should be completed. c) Develop a brief investigation plan. (Include obvious interviewees, questions to be asked and information to be gathered) Be sure to include documentation of interviewee and interviewer, with date, time and place on the statement. d) Initiate an investigation. RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1 was assessed with [REDACTED]. This score indicated RI #1 was moderately impaired for cognition for daily decision making skills. A review of the Resident Incident Report for RI #1 dated and timed 10/30/18 2:45 PM revealed, . Incident Type: Fall w (with)/head injury Type of Injury Laceration- deep Location Resident room . Non-Witnessed Incident Reported by: (name of a Certified Nursing Assistant {CNA}) Report Prepared by (name of Licensed Practical Nurse {LPN}) Narrative of incident and description of injuries: RESIDENT WAS SCREAMING HELP AND AID WITNESS THE RESIDENT ON THE FLOOR AFTER THERAPY (STAFF MEMBER) LEFT THE ROOM RESIDENT WAS ON THE FLOOR NEAR THE DOOR (HE/SHE) HAD A DEEP LACERATION ON THE BACK OF HER HEAD .(NAME OF D[NAME]TOR THAT WAS ON SIGHT) WAS PRESENT IN THE ROOM AND ADVISE(D) ME TO SEND RESIDENT OUT Immediate Actions Taken: RESIDENT WAS SENT OUT TO (NAME OF HOSPITAL) FOR CT (COMPUTED TOMOGRAPHY) SCAN TO THE HEAD . Actions Taken First Aid by: (named of the LPN) Type of Aid: DEEP LACERATION ON BACK OF HEAD NOTED . Resident Condition at Time of Incident . Meds (Medications) . Hypoglycemic's . Diuretics . Mobility: Ambulates-staff asst (assists) Medical risk factors Fall History . Confusion/Disorientation . Incontinency . B&B (Bowel and Bladder) Urgency . During review of this incident report investigation, only one witness statement with any knowledge of the incident was contained in the report. It was the CNA's statement that included, . I heard the Resident yelling, as I walk into (his/her) room (he/she) was on the floor. During the review of this report of RI #1's fall revealed no interview questions were posed; no evaluation of hazards present at the time of the fall were documented; no description of the environment was noted; no documented review of associated risks to include previous falls was found and no root cause analysis for the fall was identified. On 5/10/19 7:53 PM, an interview was conducted with EI #1, the Director of Nursing (DON). EI #1 was asked who was responsible for investigating the fall with injury RI #1 sustained on 10/30/19. EI #1 answered (names of EI #s 3 and 2) and added she verifies that everything is completed. EI #1 was asked what was determined to be the root cause of the fall. EI #1 answered RI #1 was left in the room by themselves. EI #1 was asked if a root cause should be in the report. EI #1 answered if it can be determined. EI #1 was asked where was the documented root cause of the fall. EI #1 answered in the narrative. It was noted that therapy had left the room, so she was by herself. EI #1 was asked who looked at investigations/accidents after they are completed and she answered she did. EI #1 was asked what she expected to find included in the investigation. EI #1 answered she expected to try to get a complete picture of what transpired. EI #1 was asked what care plan interventions were in place at the time of the fall. She replied, clutter free environment, assist to bathroom/ toileting/ mobility as needed. Observe need for additional assistive devices or positioning devices, therapy consult as needed, bed at lowest position, keeping call light in reach, place in area of high visibility when up. EI #1 was asked what reason did the resident give for why he/she was on the floor. She reported, it did not say in the report. EI #1 was asked should RI #1 have been asked, she answered yes. EI #1 was asked if she considered the investigation was completed thoroughly. EI #1 answered she could have used a little more information. On 5/11/19 at 12:33 PM, a telephone interview was conducted with EI #2, the Registered Nurse (RN)/Unit manager responsible for investigating the fall with head injury. EI #2 was asked if she was the person responsible for investigating the fall on 10/30/18 of RI #1 and she answered yes ma'am. EI #2 was asked what was determined as the root cause of the fall. EI #2 answered it was reported by the nurse that the resident got out of the chair and was on the floor. Then was left unattended. EI #2 was asked if she understood what root cause was and she answered yes. The surveyor then pointed out that falling was the occurrence and then EI #2 was asked again what caused the fall. EI #2 answered RI #1 was left in her room alone unattended. EI #2 was asked according to the Federal guidelines, should a root cause have been determined or identified, she answered yes, adding that should be part of the investigation. EI #2 was asked who looked at investigations of accidents after they were completed. She answered her Director of Nursing. EI #2 was asked what was included in a fall investigation. EI #2 answered, to look at the incident report, interview the nurse and CNAs and review the nurses' note. Make sure the Doctor was aware and the family, ask the family for input. She added to look at the room or area where any incident occurred to see if they could come up with an intervention. EI #2 was asked should the resident have been asked what occurred at the time of the fall, she answered yes, if the resident was alert and could answer. EI #2 was asked why was the resident not asked. EI #2 answered she did not know the resident was not asked. EI #2 was asked if she considered the investigation was completed thoroughly, she answered yes ma'am. On 5/11/19 at 1:00 PM, a follow-up interview was conducted with EI #1, the DON. EI #1 was asked what were the elements of an incident/accident investigation. EI #1 answered to assess the resident adding the report had to be completely filled out by the nurse that initiated it, gather witness statements, talk with the resident if able and look at the environment. EI #1 was asked if a resident interview was documented and she answered no. EI #1 was asked if the resident should have been interviewed and she answered yes. EI #1 was asked if the environment at the time of the fall was documented and she answered no. EI #1 was asked if there was a documented root cause of the fall and she answered no. EI #1 was asked if it should have been and she answered yes. EI #1 was asked what the policy indicated about investigating an incident or accident. EI #1 answered it just says to initiate an investigation. EI #1 was asked considering there was no documented root cause, evaluation of the environment, or resident interview, if she would consider the investigation thorough, she answered no.

Based on observations, interviews and review of facility policies titled, Handling Serviceware/Silverware,Nursing Pantry Foods, and Hand-washing Guidelines the facility failed to ensure: 1) spoons, forks and knives were not in utensil bags wet; 2) 29 thickened waters were not in the resident/supplement refrigerator expired and; 3) staff washed their hands when entering and while in the kitchen. This had the potential to affect 76 or 76 residents who received meals from the kitchen. Findings Include: 1) A review of a facility policy titled, Handling Serviceware/Silverware with an effective date of [DATE] revealed: .PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses. On [DATE] at 11:31 a.m., the surveyor observed spoons, forks and knives in nine ready to go bags to be placed on the resident's trays. Spoons, forks, and knives were in a canister wet when brought from the dish room. On [DATE] at 3:56 p.m.,an interview was conducted with (Employee Identifier) EI #1,Dietician Consultant. EI #1 was asked why were spoons forks and knives wet in silverware bags. EI #1 replied, the aide filled the silverware bags before they were air dried. EI #1 was asked who was responsible for making sure utensils were dry. EI #1 replied, the aide was responsible for dish washing. EI #1 was asked how should utensils be allowed to dry. EI #1 replied, they have to air dry. EI #1 was asked was a worker putting wet silverware in a utensil bag. EI # replied, yes. EI #1 was asked why was a worker putting wet silverware in utensil bags. EI #1 replied, she did not know why the worker put wet silverware in the bags. On [DATE] at 9:01 a.m., the surveyor conducted an interview with EI #7, dietary aide. EI #7 was asked why were spoons, forks and knives wet in silverware bags. EI #7 replied, because they were not dry. EI #7 was asked who was responsible for making sure utensils were dry. EI #7 replied, the second aide in the dish room. EI #7 was asked how should utensils be allowed to dry. EI #7 replied, they should let them air dry. EI #7 was asked was she putting wet utensils in silverware bags. EI #7 replied, yes. EI #7 was asked what was potential harm to the residents when silverware was placed in silverware bags wet. EI #7 replied, cross contamination. EI #7 was asked why was she placing wet utensils in a silverware bag wet. EI #7 replied, she was moving to fast. EI #7 was asked were silverware in the silverware holder wet. EI #7 replied, some of the silverware was wet. 2) A review of a facility policy titled, Nursing Pantry Foods, with an effective date of [DATE] revealed: .PURPOSE: Food are made available at each nursing station for residents who may feel hungry between meals.PR[NAME]ESS: .b. Food items should be rotated (First In, First Out Method) to preserve freshness. On [DATE] at 9:40 a.m., the surveyor along with EI #2 , Dietary Manager toured the north unit residents/supplement refrigerator. The surveyor observed 29 four fluid ounces of nectar consistency lemon flavored thickened water with an use by date of [DATE]. On [DATE] at 3:56 p.m., the surveyor conducted an interview with EI #2. EI #2 was asked what was in the resident's refrigerator out of date. EI #2 replied, thickened liquid. EI #2 was asked what was the use by date on the thickened liquid/water. EI #2 replied, [DATE]. EI #2 was asked what did the facility policy say regarding expired food items in the residents refrigerator. EI #2 replied, discard expired food items. EI #2 was asked who was responsible for removing expired items out of the resident's refrigerator. EI #2 replied, whoever was assigned to clean the refrigerator. EI #2 was asked when should expired food items be removed from the resident's refrigerator. EI #2 replied, immediately. EI #2 was asked when serving residents food, should residents be given the best quality food. EI #2 replied, yes. On [DATE] at 9:20 a.m.,an interview was conducted with EI #8, (Register Nurse) RN Unit Manager. EI #8 was asked who was responsible for making sure there were no expired food items in the supplement refrigerator on the unit. EI #8 replied, the Unit Manager. EI #8 was asked why there were expired thicken waters in the supplement refrigerator. EI #8 replied, she must have over looked it. EI #8 was asked what did the facility policy say regarding expired food items in the resident's refrigerator. EI # replied, to remove it. EI #8 was asked should residents be given expired food from the resident's/supplement refrigerator. EI #8 replied, no ma'am. 3) A review of a facility policy titled, Hand-Washing Guidelines, with an effective date of [DATE] revealed: .PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses.PR[NAME]ESS: I Frequency of Hand-washing; Hands should be washed in the following situations: Every time an employee enters the kitchen; . On [DATE] at 11:05 a.m., the surveyor observed EI #7, dietary aide, by the three compartment sink. She was observed to touch the trash can lid and place trash in the can and then pulled up her pants. EI #7 touched a container with lids in it and she did not wash her hands. EI #7 left the kitchen and came back with a mop and bucket and did not wash her hands. The surveyor observed EI #9, Food and Nutrition cook, coming in the side door of the kitchen with her purse. EI #9 put on a torn hair net and did not wash her hands. EI #9 went into the dining room. On [DATE] at 4:00 p.m., the surveyor conducted an interview with EI #2, Dietary Manager. EI #2 was asked when should staff wash their hands in kitchen. EI #2 replied, after clocking in and before starting their shift. EI #2 was asked why should staff wash their hands while in the kitchen. EI #2 replied, to prevent cross contamination. EI #2 was asked should staff wash their hands after touching the trash can lids while in the kitchen. EI #2 replied, yes. EI #2 was asked should staff wash their hands when entering the kitchen from the dining room. EI #2 replied, yes. EI #2 was asked what did the facility policy say regarding staff washing their hands while in the kitchen. EI #2 replied, staff have to wash their hands to prevent cross contamination. EI #2 was asked what was the potential harm to the residents when staff did not wash their hands while in the kitchen or dining room. EI #2 replied, food contamination. On [DATE] at 8:42 a.m., an interview was conducted with EI #7. EI #7 was asked when should staff wash their hands in the kitchen. EI #7 replied, when they enter and exit the kitchen. EI #7 was asked why should staff wash their hands in the kitchen. EI #7 replied, to prevent bacteria spread from utensil and other equipment in the kitchen that could cause harm to the residents. EI #7 was asked should staff wash their hands after touching the trash can lid while in the kitchen. EI #7 replied, yes. EI #7 was asked did she touch the trash can lid and then not wash her hands. EI #7 replied, she could not remember. EI #7 was asked what was the potential harm to the residents when staff did not wash their hands while in the kitchen or dining room. EI #7 replied, cross contamination to the residents. On [DATE] at 10:51 a.m., the surveyor conducted an interview with EI #9. EI #9 was asked did she wash her hands when first entering the kitchen. EI #9 replied, no she put her hair net on. EI #9 was asked what was the potential harm to the residents when staff do not wash their hands in the kitchen. EI #9 replied, they (residents) could get germs or salmonella.

Based on record review, interview and a review of a facility policy titled, Nursing Assessments, the facility failed to ensure care plans for recurrent UTI's (Urinary Tract Infection) and Depression were developed for RI (Resident Identifier) #22. This had the potential to affect 1 of 24 samples residents whose care plans were reviewed for care areas. Findings Include: A review of a facility policy titled, Nursing Assessment, with an effective date of 8/15/2018, revealed: PURPOSE: The facility conducts, a comprehensive, standardized assessment of each resident .functional capacity necessary to develop a person centered care plan and to modify the care plan and care/service based on the resident .status and resident .goals and preferences, future discharge . RI #22 was readmitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A review of RI #22's (MONTH) (YEAR) Physician order [REDACTED]. The order date was 7/13/18. The order also included the medication [MEDICATION NAME] for UTI recurrences. The order date was 8/01/18. On 09/12/18 08:09 AM, a chart review revealed the resident's urine was collected and grew out e-coli . The order was given for [MEDICATION NAME] on 8/1/18 and to hold for seven days while Microbid was given for 7 days. [MEDICATION NAME] was started on the 8th day. When reviewing RI #22's care plans, there were no care plans developed for the resident's recurrent UTI's, or depression. On 09/13/18 at 10:03 AM, Employee Identifier (EI) #3 Licensed Practical Nurse/Minimum Data Set assessment nurse was interviewed. EI #3 was asked why RI #22 was not care planned for depression or UTI's. She replied it was her oversight. EI #3 was asked who was responsible for care planning residents for care areas, such as depression and UTI's. She replied that would be her. EI #3 was asked why it was important to care plan residents for care areas. EI #3 replied, it was very essential so they (staff) could treat their (residents) diagnoses, their person physical, mental, and emotional issues, so repeat incidents did not reoccur. EI #3 further commented they wanted to monitor their (residents) medication for adverse reaction and the needs for adjustment of medication. She was asked when should residents be care planned for care areas. EI #3 replied, when a problem presented itself. She was asked what was the potential harm to the residents when they were not care planned for care areas. EI #3 replied, adverse reactions to the illness. EI #3 was asked what did the facility policy say regarding care planning residents for care areas. EI #3 replied, care areas should be addressed to meet the needs of the residents.

Based on observation and interview the facility failed to ensure: 1. Laundry staff wore a protective apron while handling soiled linen, and 2. Staff did not allow clean linens to touch their dirty uniform while folding them. This was observed on 9/12/18 and had the potential to affect 84 of 84 residents who received services from the laundry department. Findings Include: 1. On 9/12/18 at 2:35 PM, the surveyor observed Employee Identifier (EI)#5, Director of Environmental Services, loading soiled linen into the washing machine. EI#5 was observed wearing no apron and soiled linen touching her uniform. On 09/12/18 at 2:45 PM, an interview was conducted with EI #5. EI #5 was asked what was the policy for wearing aprons while handling soiled laundry. EI#5 replied, sometimes they do wear aprons, but it gets so hot back here. EI #5 added staff was suppose to put them on when they came into the laundry. 2. On 9/12/18 at 2:50 PM, the surveyor observed EI# 6, housekeeping staff, folding clean sheets. EI #6 was observed allowing the clean sheets to touch her uniform as she folded them. On 9/12/18 at 2:55 PM, an interview was conducted with EI# 6. EI# 6 was asked what time did she come into work. EI# 6 replied, 7:00 AM. EI#6 was asked what were her duties. EI# 6 replied, cleaning residents rooms and then going to laundry to fold clothes and linen. EI# 6 was asked what was the policy on folding clothes and linen. EI# 6 replied, you should not hold them against you. EI# 6 was asked if the sheet touched her uniform. EI# 6 replied, yes. EI# 6 was asked if her uniform was clean or dirty. EI# 6 replied dirty. EI# 6 was asked what was the harm in allowing the clean linen to touch her uniform as she folded them. EI# 6 replied cross contamination. On 9/12/18 at 2:59 PM, an interview was conducted with EI# 5. EI# 5 was asked what was the policy for folding clothes and linens. EI# 5 replied, there was no policy, only to keep them off the floor and keep them away from your clothes. EI# 5 was asked was the staff uniforms considered clean or dirty. EI# 5 replied, dirty. EI# 5 was asked what was the harm of clean clothes or linen touching staff uniforms while folding them. EI# 5 replied, spreading germs. Eliesabeth Lindsey<BR/(NAME)McCray<BR/(NAME)Hillard

Based on record review, interview and review of the facility procedure Resident Assessment Instrument Manual, the facility failed to ensure Resident Identifier (RI) #30's Significant Change Minimum Data Set (MDS) Assessment, dated 4/12/18, was coded for hospice. This was reviewed on 9/12/18 and affected one of two residents reviewed for hospice. Findings Include: A review of the policy the facility used revealed .RAI Version 3.0 Manual . A Significant Change in Status Assessment (SCSA) is appropriate when: .If a resident is admitted on the hospice benefit .the facility should complete the .assessment, checking the Hospice care item Section O . RI#30 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of RI #30's (MONTH) (YEAR) physician orders [REDACTED].OK TO ADMIT TO .HOSPICE WITH DX OF [MEDICAL CONDITION]. A review of a Significant Change MDS, dated [DATE], revealed Section O Hospice was not checked. On 9/12/18 at 10:22 AM an interview was conducted with Employee Identifier (EI) #3, Licensed Practical Nurse/MDS. EI #3 was asked to review the MDS dated [DATE] with the surveyor. EI #3 replied, it was done for a significant change to hospice. EI #3 was asked when was RI #30 admitted to hospice. EI #3 replied, 4/4/18. EI #3 was asked when was the Significant Change MDS related to hospice done. EI #3 replied, the change was done on 4/12/18, however hospice was not checked. EI #3 was asked who was responsible for coding hospice on the MDS. EI #3 replied, she was. EI #3 was asked if hospice should be coded on the MDS. EI #3 replied, yes. EI #3 was asked what was the risk in not having hospice coded on the MDS. EI #3 replied, it would not reflect the resident was on hospice,

Based on review of the Records of Medication Destruction, an interview, and review of the facility policy titled, Disposal of Medications, the facility failed to ensure: 1) two signatures were documented as required on the Record of Medication Destruction form for non-controlled drugs. This was observed on 5 of 12 months of Records of Medication Destruction forms reviewed; and the facility failed to 2) indicate the method of destruction as required on the Record of Medication Destruction form for controlled drugs. This was observed on 10 of 12 months of Records of Medication Destruction forms reviewed. Findings Include: 1) A review of the facility policy titled, Disposal of Medications Non-Controlled Medication Destruction, with a copyright date of 2011, revealed: . Policy Discontinued medications, expired medications, and medications left in the facility after a resident has expired or has been permanently discharged are destroyed or disposed of per federal/state regulations. Procedures . 3. The registered nurse and/or pharmacist witnessing the destruction, or their preparation for environmental service pickup, ensures that the following information is entered on the Record of Medication Destruction form . J. Signature of witnesses, two witnesses required for non-controlled substances (for example, a pharmacist in Alabama and a registered nurse) in the designated areas on the destruction form. A review of pages 1-5 of the Record of Medication Destruction for non-controlled drugs dated 7/14/16, revealed only the Pharmacy Consultant signature. No signature by a Registered Nurse was documented. A review of pages 1-3 of the Record of Medication Destruction for non-controlled drugs dated 8/17/16, revealed only the Pharmacy Consultant signature. No signature by a Registered Nurse was documented. A review of pages 1-8 of the Record of Medication Destruction for non-controlled drugs dated 9/16/16, revealed only the Pharmacy Consultant signature. No signature by a Registered Nurse was documented. A review of pages 1-6 of the Record of Medication Destruction for non-controlled drugs dated 4/26/17, revealed only the Pharmacy Consultant signature. No signature by a Registered Nurse was documented. A review of pages 1-6 of the Record of Medication Destruction for non-controlled drugs dated 6/28/17, revealed only the Pharmacy Consultant signature. No signature by a Registered Nurse was documented. An interview was conducted with Employee Identifier (EI) #3, the Director of Nursing, on 7/13/17 at 6:25 p.m EI #3 was asked what signatures were required regarding destruction of non-controlled drugs. EI #3 answered two. EI #3 was asked how many were present on the pages in question. EI #3 answered one. EI #3 was asked what was the concern of drugs being disposed of without the required signatures. EI #3 answered possibility of diverting and not following the policy. 2) A review of the facility policy titled, Disposal of Medications Controlled Drug Destruction, with a copyright date of 2011, revealed: . Policy Discontinued medications, expired medications, and medications left in the facility after a resident has expired or has been permanently discharged are destroyed per federal/state regulations. Procedures . 6. The registered nurse and pharmacist should ensure that the following information on the Record of Medication Destruction is correct by signing in the appropriate space on the form: . H. Method of destruction. A review of pages 1-8 of the Record of Medication Destruction for controlled drugs dated 8/17/16, revealed six of eight pages had no documentation of the method of destruction. A review of pages 1-3 of the Record of Medication Destruction for controlled drugs dated 9/16/16, revealed no documentation of the method of destruction. A review of pages 1-8 of the Record of Medication Destruction for controlled drugs dated 10/18/16, revealed no documentation of the method of destruction. A review of pages 1-3 of the Record of Medication Destruction for controlled drugs dated 11/14/16, revealed no documentation of the method of destruction. A review of pages 1-8 of the Record of Medication Destruction for controlled drugs dated 12/21/16, revealed no documentation of the method of destruction. A review of pages 1-7 of the Record of Medication Destruction for controlled drugs dated 2/20/17, revealed no documentation of the method of destruction. A review of pages 1-4 of the Record of Medication Destruction for controlled drugs dated 3/23/17, revealed no documentation of the method of destruction. A review of pages 1-7 and 1 of 1 of the Record of Medication Destruction for controlled drugs dated 4/26/17, revealed no documentation of the method of destruction. A review of pages 1-2 of the Record of Medication Destruction for controlled drugs dated 5/31/17, revealed no documentation of the method of destruction. A review of pages 1-4 of the Record of Medication Destruction for controlled drugs dated 6/28/17, revealed no documentation of the method of destruction. An interview was conducted with EI #3 on 7/13/17 at 6:25 p.m EI #3 was asked what method of destruction was used for disposal of controlled drugs. EI #3 answered flushing. EI #3 was asked where the method used was documented on the Records of Medication Destruction forms. EI #3 answered it was not. EI #3 was asked what was the concern of incomplete documentation of how controlled drugs were disposed of. EI #3 answered the possibility of diverting and not following the policy.

Based on interviews and record reviews, including an Incident Report and a Job Description, the facility failed to ensure a resident was not transferred from bed to shower chair with a sit-to-stand lift instead of a hoyer lift, resulting in a fall on 3/21/17 for RI (Resident Identifier) #1. This affected RI #1, one of four residents sampled for falls. Findings Include: On 07/05/2017 the State Agency received a complaint regarding an incident where a resident was allegedly dropped from a lift and indicated only one staff member assisted the resident during the transfer instead of two staff members. A review of the medical record revealed RI #1 had an original admission date of [DATE] and a readmission date of [DATE]. RI #1's [DIAGNOSES REDACTED]. A review of RI #1's annual MDS (Minimum Data Set) assessment, dated 01/25/2017, revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15 out of 15. This indicated the resident was cognitively intact for daily decision making skills. RI #1 was assessed for total dependence of transferring and required two people to assist. RI #1 required extensive assistance with bed mobility and required two people to assist. RI #1 required extensive to total assistance with ADLs (Activities of Daily Living) except with eating which required supervision and set-up only. A review of RI #1's Comprehensive Care Plans revealed a problem onset date of 3/05/15, with a readmit review date of 4/04/17, for the following: Requires assistance to complete daily activities of care safely R/T (related to) weakness, impaired mobility . Approaches *Transfer requires---assist of two Hoyer . Further review of RI #1's Comprehensive Care Plans revealed a problem onset date of 3/05/15, revised on 3/21/17, for the following: Potential for falls r/t weakness impaired mobility Approaches *3/21/17 Staff education to use 2 assistanta (assistants) and Hoyer left (lift) for transfers . A Resident Incident Report, dated 3/21/17, for RI #1 was reviewed. The report revealed: (Name of CNA-Certified Nursing Assistant) REPORTED TO STAFF THAT RESIDENT WAS BEING TRANSFERRED FROM BED TO SHOWER CHAIR. CNA STATED THAT RESIDENT WAS MOVING AROUND WHILE BEING TRANSFERRED AND THEY COULD NOT MAKE IT FULLY INTO SHOWER CHAIR. THEY SLID (him/her) ONTO FLOOR AND CALKED (called) FOR HELP TO GET (him/her) UP. NO EAD (head) INJURY NOTED. VITALS WERE STABLE AND SKIN TEAR WAS TREATED. ASSESSMENT WAS DONE.5 IN (INCH) SKIN TEAR TO RT (right) FOREARM. A Departmental Note for RI #1 was attached to the Resident Incident Report and was dated 4/3/17 and timed 1:32 P.M The note revealed: ON 3/21/17, (name of RI #1) WAS BEING TRANSFERRED FROM BED TO SHOWER CHAIR USING THE STANDER LIFT. (Name of RI #1) WAS MOVING AROUND WHILE BEING TRANSFERRED AND SLID ONTO THE FLOOR. (He/she) WAS ASSESSED BY LPN (Licensed Practical Nurse). RN (Registered Nurse) IN ROOM TO ASSIST. (He/she) WAS TRANSFERRED BACK TO BED VIA HOYER LIFT AND 3 ASSIST. ONCE CALM, (he/she) WAS TRANSFERRED TO THE SHOWER BED FOR A SHOWER, THEN BACK TO BED. (His/her) RIGHT FOREARM SUSTAINED A SMALL SKIN TEAR WHICH WAS CLEANED AND STERI STRIPS APPLIED. (He/she) HAD A LARGE BLISTER ON (his/her) LEG THAT BROKE DURING THE INCIDENT. THE AREA WAS CLEANED AND A DRESSING APPLIED. (Name of doctor) OFFICE NOTIFIED, SON (name of son) NOTIFIED. A review of a facility document titled, JOB DESCRIPTION JOB TITLE: Certified Nursing Assistant, with a review date of 9/01/09, revealed: GENERAL PURPOSE Under direction and supervision of Charge Nurse of the assigned area is continuously responsible for providing quality nursing care to residents.ESSENTIAL JOB FUNCTIONS .2. Knowledgeable of the individualized Care Plan for residents and provide support to the resident according to the Care Plan .7. Ambulate residents, assists in transfers of residents. Lift, move, and transport residents, using proper body mechanics or lifting devices for accident prevention according to residents plan of care. On 7/12/17 at 3:12 p.m., EI (Employee Identifier) #1, a CNA, was interviewed. EI #1 was asked if RI #1 required assistance with transferring and she stated yes. EI #1 was asked how was RI #1 supposed to be transferred and she stated Hoyer lift with two to three people, but at least two people. EI #1 was asked if there was an incident where RI #1 was dropped from a Hoyer lift. EI #1 stated it was a sit-to-stand lift. EI #1 stated that towards the end, the resident could not stand. When asked when this incident occurred, EI #1 stated she was a shower tech (technician) and she did not know RI #1's ADL had changed because she had not been working the floor. EI #1 stated RI #1 used the sit-to-stand but then changed to the Hoyer lift. EI #1 further stated she did not know the resident was changed to the Hoyer lift. EI #1 stated EI #4, a CNA, assisted her. EI #1 was asked what happened with the incident. EI #1 stated she had another aide in the room with her. EI #1 stated she was getting RI #1 up into the shower chair using the sit-to-stand lift, and as they tried to place the resident in it, RI #1 gave up. EI #1 indicated RI #1 was still connected to the lift, it couldn't hold the weight up, so they lowered RI #1 to the floor. EI #1 explained CNAs had an ADL book she should have looked at, because RI #1 was changed to a Hoyer lift from sit-to-stand. EI #1 was asked if the care plan was followed. EI #1 stated they were not told what the care plan stated but they go by what was in the ADL book. EI #1 stated she was not told RI #1 had been changed. When asked what was the concern of not following the resident's care plan, EI #1 stated they could fall, get skin tears. On 7/13/17 at 5:03 p.m., EI #4, CNA, confirmed she assisted EI #1 with getting RI #1 up. EI #4 could not recall the date of the incident, but said they used the sit-to-stand lift when the incident occurred. On 7/13/17 at 9:16 a.m., EI #2, an LPN, was interviewed. EI #2 was asked how should RI #1 have been transferred and she stated Hoyer lift. When asked when RI #1 changed from a sit-to-stand lift to a Hoyer lift, EI #2 stated she did not know but the resident was supposed to use a Hoyer lift. EI #2 was asked if RI #1 had a fall and she stated staff controlled RI #1 as the resident went down but still called it a fall and an incident report was completed. EI #2 was asked when did the incident occur and she stated 3/21/17. EI #2 stated EI #1, the CNA, said the resident was wiggling and lost control. When EI #1 saw the resident couldn't stand, RI #1 was eased to the floor. EI #2 was asked if the fall was avoidable. EI #2 stated if the CNA would have used the hoyer lift instead of the sit-to-stand lift, it would have been avoided. EI #2 was asked if the care plan was followed in regards to the fall on 3/21/17. EI #2 stated no, the CNA admitted she should have used the Hoyer lift but used the sit-to-stand lift instead. EI #2 further stated that she assumed the CNA did not look at the ADL book since the CNA admitted to using the other lift. On 7/13/17 at 3:22 p.m., EI #3, the DON (Director of Nursing), was interviewed. EI #3 was asked how was RI #1 to be transferred and she stated by Hoyer, two people. EI #3 was asked if RI #1 had a fall and when. EI #3 stated yes, on 3/21/17. When asked what occurred, EI #3 stated the CNA tried to transfer the resident and RI #1 got weak and they slid the resident to the floor. EI #3 was asked if the resident was transferred with the Hoyer lift and EI #3 stated no, according to the incident report. EI #3 was asked how was RI #1 transferred and she stated, according to the incident report, by a sit-to-stand lift. EI #3 stated the CNA did not review the ADL book before, so she used the sit-to-stand lift. EI #3 was asked if the care plan was followed and she stated no. EI #3 was asked if RI #1's fall was avoidable. EI #3 stated with the correct transfer method, it could have possibly been avoided.

Based on interviews and record reviews, including an Incident Report and Job Description, the facility failed to ensure a care plan for transferring a resident was implemented. On 3/21/17, RI (Resident Identifier) #1 was transferred via a sit-to-stand lift to a shower chair instead of a Hoyer lift as care planned, resulting in a fall. This affected RI #1, one of four residents sampled for falls. Findings Include: On 07/05/2017 the State Agency received a complaint regarding an accident where a resident was allegedly dropped from a lift and indicated only one staff member assisted the resident during the transfer instead of two staff members. A review of the medical record revealed RI #1 had an original admission date of [DATE] and a readmission date of [DATE]. RI #1's [DIAGNOSES REDACTED]. A review of RI #1's annual MDS (Minimum Data Set) assessment, dated 01/25/2017, revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15 out of 15. This indicated the resident was cognitively intact for daily decision making skills. RI #1 was assessed for total dependence of transferring and required two people to assist. RI #1 required extensive assistance with bed mobility and required two people to assist. RI #1 required extensive to total assistance with ADLs (Activities of Daily Living) except with eating which required supervision and set-up only. A review of RI #1's Comprehensive Care Plans revealed a problem onset date of 3/05/15, with a readmit review date of 4/04/17, for the following: Requires assistance to complete daily activities of care safely R/T (related to) weakness, impaired mobility . Approaches *Transfer requires---assist of two Hoyer . Further review of RI #1's Comprehensive Care Plans revealed a problem onset date of 3/05/15, revised on 3/21/17, for the following: Potential for falls r/t weakness impaired mobility Approaches *3/21/17 Staff education to use 2 assistanta (assistants) and Hoyer left (lift) for transfers . A Resident Incident Report, dated 3/21/17, for RI #1 was reviewed. The report revealed: (Name of CNA-Certified Nursing Assistant) REPORTED TO STAFF THAT RESIDENT WAS BEING TRANSFERRED FROM BED TO SHOWER CHAIR. CNA STATED THAT RESIDENT WAS MOVING AROUND WHILE BEING TRANSFERRED AND THEY COULD NOT MAKE IT FULLY INTO SHOWER CHAIR. THEY SLID (him/her) ONTO FLOOR AND CALKED (called) FOR HELP TO GET (him/her) UP. NO EAD (head) INJURY NOTED. VITALS WERE STABLE AND SKIN TEAR WAS TREATED. ASSESSMENT WAS DONE.5 IN (INCH) SKIN TEAR TO RT (right) FOREARM. A Departmental Note for RI #1 was attached to the Resident Incident Report and was dated 4/3/17 at 1:32 P.M The note revealed: ON 3/21/17, (name of RI #1) WAS BEING TRANSFERRED FROM BED TO SHOWER CHAIR USING THE STANDER LIFT. (Name of RI #1) WAS MOVING AROUND WHILE BEING TRANSFERRED AND SLID ONTO THE FLOOR. (He/she) WAS ASSESSED BY LPN (Licensed Practical Nurse). RN (Registered Nurse) IN ROOM TO ASSIST. (He/she) WAS TRANSFERRED BACK TO BED VIA HOYER LIFT AND 3 ASSIST. ONCE CALM, (he/she) WAS TRANSFERRED TO THE SHOWER BED FOR A SHOWER, THEN BACK TO BED. (His/her) RIGHT FOREARM SUSTAINED A SMALL SKIN TEAR WHICH WAS CLEANED AND STERI STRIPS APPLIED. (He/she) HAD A LARGE BLISTER ON (his/her) LEG THAT BROKE DURING THE INCIDENT. THE AREA WAS CLEANED AND A DRESSING APPLIED. (Name of doctor) OFFICE NOTIFIED, SON (name of son) NOTIFIED. A review of a facility document titled, JOB DESCRIPTION JOB TITLE: Certified Nursing Assistant, with a review date of 9/01/09, revealed: GENERAL PURPOSE Under direction and supervision of Charge Nurse of the assigned area is continuously responsible for providing quality nursing care to residents.ESSENTIAL JOB FUNCTIONS .2. Knowledgeable of the individualized Care Plan for residents and provide support to the resident according to the Care Plan. On 7/12/17 at 3:12 p.m., EI (Employee Identifier) #1, a CNA, was interviewed. EI #1 was asked if RI #1 required assistance with transferring and she stated yes. EI #1 was asked how was RI #1 supposed to be transferred and she stated Hoyer lift with two to three people, but at least two people. EI #1 was asked if there was an incident where RI #1 was dropped from a Hoyer lift. EI #1 stated it was a sit-to-stand lift. EI #1 stated that towards the end, the resident could not stand. When asked when this incident occurred, EI #1 stated she was a shower tech (technician) and she did not know RI #1's ADL had changed because she had not been working the floor. EI #1 stated RI #1 used the sit-to-stand, but then changed to the Hoyer lift. EI #1 further stated she did not know the resident was changed to the Hoyer lift. EI #1 stated EI #4, CNA, assisted her. EI #1 was asked what happened with the incident. EI #1 stated she had another aide in the room with her. EI #1 stated she was getting RI #1 up into the shower chair using the sit-to-stand lift and as they tried to place the resident in it, RI #1 gave up. EI #1 indicated RI #1 was still connected to the lift, it could not hold the weight up, so they lowered RI #1 to the floor. EI #1 explained CNAs had an ADL book she should have looked at, because RI #1 was changed to a Hoyer lift from a sit-to-stand lift. EI #1 was asked if the care plan was followed. EI #1 stated they were not told what the care plan stated but they go by what was in the ADL book. EI #1 stated she was not told RI #1 had changed. When asked what was the concern of not following the resident's care plan, EI #1 stated they could fall, get skin tears. On 7/13/17 at 5:03 p.m., EI #4, CNA, confirmed she assisted EI #1 with getting RI #1 up. EI #4 could not recall the date of the incident, but said they used the sit-to-stand lift when the incident occurred. On 7/13/17 at 9:16 a.m., EI #2, an LPN, was interviewed. EI #2 was asked how RI #1 should have been transferred and she stated Hoyer lift. When asked when did RI #1 change from a sit-to-stand lift to a Hoyer lift, EI #2 stated she did not know but the resident was supposed to use a Hoyer lift. EI #2 was asked if RI #1 had a fall and she stated staff controlled RI #1 as the resident went down but still called it a fall and an incident report was completed. EI #2 was asked when did the incident occur and she stated 3/21/17. EI #2 was asked if the care plan was followed in regards to the fall on 3/21/17. EI #2 stated no, the CNA admitted she should have used the Hoyer but used the sit-to-stand lift instead. On 7/13/17 at 3:22 p.m., EI #3, the DON (Director of Nursing), was interviewed. EI #3 was asked how should RI #1 be transferred and she stated by Hoyer, two people. EI #3 was asked if RI #1 had a fall and when. EI #3 stated yes, on 3/21/17. When asked what occurred, EI #3 stated the CNA tried to transfer the resident and RI #1 got weak and they slid the resident to the floor. EI #3 was asked if the resident was transferred with the Hoyer lift and EI #3 stated no, according to the incident report. EI #3 was asked how was RI #1 transferred and she stated, according to the incident report, by sit-to-stand. EI #3 stated the CNA did not review the ADL book before so she used the sit-to-stand. EI #3 was asked if the care plan was followed and she stated no.

Based on record reviews and interviews, the facility failed to ensure the activity care plan was reviewed and revised to meet the individual needs for a severely, cognitively impaired resident. This affected RI (Resident Identifier) #12, one of thirteen sampled residents whom Care Plans were reviewed. Findings include: A review of Potter-Perry Fundamentals of Nursing, 7th Edition, Chapter 19, pages 281 and 282, and titled, Implementing Nursing Care, revealed: .Implementation Process . Reviewing and Revising the Existing Nursing Care Plan After reassessing a client, review the care plan, compare assessment data to validate the nursing diagnoses, and determine whether the nursing interventions remain the most appropriate for the clinical situation. An out-of-date or incorrect care plan compromises the quality of nursing care. 1. Revise data in the assessment column to reflect the client's current status. Date any new data to inform other members of the health care team . A review of RI #12's medical record revealed, the resident was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #12's Quarterly Minimum Data Set Assessment, with an Assessment Reference Date of 04/20/2016, revealed RI #12 was comatose and totally dependent on staff for all ADLs (activities of daily living). A review of RI #12's Activity Care Plan, with a problem onset date of 11/14/2013, revealed: .Activity plan needed due to resident spending little or no time involved in leisure activities related to current health . The last review date for the Activity Care Plan for RI #12 was 01/29/2016, prior to the survey date of 06/30/2016. An interview was conducted with Employee Identifier (EI) #1, the Care Plan Coordinator, on 06/30/2016 at 3:05 PM. EI #1 was asked what was the facility's policy regarding Residents Activities. EI #1 stated, Everyone should be provided activities. EI #1 was asked what was the facility's policy regarding the review and revision of residents' care plans. EI #1 said they should be reviewed/revised at least quarterly and as needed. The surveyor asked EI #1 how often RI #12's activity care plan was reviewed and revised. EI #1 stated, At least every ninety days until 01/29/2016. The surveyor asked when was the last time RI #12's activity care plan was reviewed or revised prior to 6/30/2016. EI #1 stated, 1/29/2016. An interview was conducted with EI #2, the facility's Activities Director, on 06/30/2016 at 3:20 PM. EI #2 was asked who provided the activities for RI #12. EI #2 stated, The activity staff members. The surveyor asked how did the staff know what type of activities to provide for RI #12 and when to provide them. EI #2 stated, It's in his/her daily plan of care, staff would provide social contact. EI #2 was asked what was the facility's policy regarding the review and revision of resident's care plans. EI #2 stated, Should be done quarterly, annually, or a significant change. The surveyor asked EI #2 how often was RI #12's Activity Care Plan revised. EI #2 stated. Quarterly or more often until 1/29/2016.

Based on observations, interviews, and document reviews, the facility failed to ensure the dumpster was not observed with the lids having an opening of approximately 2 to 3 inches, preventing closure. This was observed on 2 of 4 survey days, and 2 flies were observed at the dumpster on 1 of the 2 observation days. This had the potential to affect all 85 residents in the facility. Findings included: A review of the 2013 U. S. (United States) Public Health Service Food Code revealed, .5-501.15 Outside Receptacles. (A) Receptacles and waste handling units for REFUSE, .containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers. A review of the facility's document titled, DIETARY SERVICE MANUAL, with an effective date of February 1, 2002 revealed, . Policy Title: Garbage and Refuse . PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses. STANDARD: Garbage and refuse containers should be free from cracks or leaks and covered when not in use. During the tour of the kitchen on 6/2/2015 at 8:05 AM, the dumpster was observed with an opening between the lids of approximately 2 to 3 inches, preventing the lids from closing. Two flies were observed flying around the dumpster at this time. EI #6, the Dietary Manager informed the surveyor, The concern is pest control. On 6/3/2015 at 10:30 AM, the dumpster was still observed with a 2 to 3 inch opening in the lids preventing closure. EI #6 informed the surveyor, (A) New dumpster (is)to be delivered between 6/2 and 6/9. During an interview on 6/5/2015 at 2:10 PM, EI #6 was asked what was observed with the dumpster lids on 6/2/15 and 6/3/15. EI #6 replied, Had a gap in it, preventing it from coming together. This could cause pest control.

Based on observations, interviews, and document reviews, the facility failed to ensure: 1) Dietary staff members did not wear jewelry such as a watch, wedding rings, earrings uncovered, and necklaces while working in the kitchen. Staff members were also observed working in the kitchen wearing a stretch-type key ring with car keys around the neck, and a lanyard around the neck, also with keys. This was observed on 3 of 4 survey days. 2) Dietary staff was not observed working in the kitchen with hair partially uncovered by bonnets on the sides and the nape of the neck, and facial hair was not covered by a beard guard. This was observed on 3 of 4 survey days. 3) Left-over pork was not observed in the reach-in cooler past it's use by date, and green beans were not observed in the cooler with the lid not closed. This was observed on 1 of 4 survey days. 4) 34 Vanilla Health Shakes were not observed thawed in the walk-in cooler without thaw and/or use by dates on 1 of 4 survey days. 5) Ground Nutmeg and Red Food Coloring was not observed in the kitchen with other spices, past their use by or expiration dates as observed on 1 of 4 survey days. These deficient practices had the potential to affect 77 residents served meals from the kitchen. Findings included: 1) A review of the 2013 U. S. (United States) Public Health Service Food Code revealed, .Jewelry 2-303.11 Prohibition. Except for a plain ring such as a wedding band, .FOOD EMPLOYEES may not wear jewelry including medical information jewelry on their arms and hands. A review of the facility's policy with an effective date of April 29, 2015 revealed, . Policy Title: Employee Personal Health and Hygiene. PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses. PROCESS: . g. Jewelry should be minimized. Food service employees may not wear jewelry on their arms and hands (with the exception of a plain band). Earrings if worn must be small and non-dangling. On 6/2/2015, the following was observed: At 7:40 AM, EI (Employee Identifier) #4, a Cook, was observed in the kitchen with silver hoop earrings in both ears, uncovered by her blue hair bonnet. At 7:55 AM, EI #6, the DM (Dietary Manager), was observed in the kitchen with blue, stud earrings in both ears, uncovered by her hair bonnet. On 6/3/2015 at 10:26 AM, the following was observed in the kitchen: EI #6 was observed wearing a gold chain around her neck with a cross, a silver watch on her left wrist, wedding rings on the left 4th finger, and red, stud earrings in both ears, uncovered by her hair bonnet. EI #7, the RD (Registered Dietitian), was observed wearing a tan colored, beaded necklace with a pendant. EI #7 was also wearing a purple lanyard around her neck with keys hanging from the lanyard. EI #4, a Cook, was observed wearing silver hoop earrings in both ears, uncovered by her hair bonnet. EI #8, a Dietary Aide, was observed with a stretch type key chain with car keys, around her neck. On 6/3/2015 at 11:17 AM, the following was observed in the kitchen: EI #9, a Dietary Aide, was observed with 2 pairs of hoop earrings in each ear, uncovered by her hair bonnet. EI #11, the PM Cook, was observed with blue stud earrings in her ears that were approximately 1 ½ cm (centimeters), and uncovered by the hair bonnet. EI #8, a Dietary Aide, was observed with the stretch key chain with car keys, around her neck. EI #6, the DM, was observed with silver and red stud earrings in her ears, uncovered by the hair bonnet, a gold chain with a cross around her neck, a silver watch on the left wrist, and silver wedding rings on her left 4th finger. On 6/3/2015 at 12:04 PM, EI #7 was in the kitchen observing the tray line, and observed wearing the tan colored beaded necklace with a pendent and the purple lanyard around her neck with keys. In an interview on 6/5/2015 at 2:10 PM, EI #6 was asked what was the facility's policy on jewelry in the kitchen. EI #6 stated, Wedding bands and small earrings. No big loop earrings. Can wear a watch if not fixing food. If fixing food, take watch off and put in pocket. EI #6 was asked what the potential harm was of earrings uncovered while working in the kitchen, and she stated, Could come off and fall in the food, or something. EI #6 was asked what the potential harm was of wearing necklaces, lanyards and keys hanging around the neck and worn in the kitchen. EI #6 replied, Potential hazard of coming off and falling in the food. EI #6 was asked what the potential harm was of wearing wedding rings and watches in the kitchen. EI #6 replied, Bacteria and germs. I'm the only one wearing wedding rings and a watch, but when I'm working with food, I take them off. The surveyor shared an of observation an incident observed when she did not remove them. An interview was conducted with EI #7 on 6/5/2015 at 3:05 PM. EI #7 was asked what the facility's policy was on jewelry in the kitchen. EI #7 replied, They are allowed to wear a band without stones, small earrings and a wrist watch and necklace, I believe. EI #7 was asked what was the potential harm of earrings being uncovered while working in the kitchen, and she replied, No potential harm if the earrings meet our policy. EI #7 was asked what the potential harm was of wearing necklaces, lanyards and keys hanging around the neck while working in the kitchen. EI #7 stated, If long and preparing food, if dangling it could dangle across the food. EI #7 was asked what the potential harm was of wearing wedding rings and watches while working in the kitchen. EI #7 replied, The stone in the wedding ring could get dislodged and fall into the food. (With the) Watch, there's nothing potentially harmful if the watch is secured to the wrist. The surveyor shared the Food Code instructions with EI #7. 2) A review of the facility's document titled, DIETARY SERVICE MANUAL, with an effective date of April 29, 2015 revealed, . Policy Title: Employee Personal Health and Hygiene. PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses. PROCESS: . d. Hairnets - Hair must be neatly styled and completely covered with an appropriate hair covering. Facial hair must be covered with proper restraint. On 6/2/2015 at 7:40 AM, EI #5, a Dietary Aide, was observed in the kitchen with hair on the sides uncovered by her blue hair bonnet. On 6/3/2015 at 10:26 AM, EI #8, a Dietary Aide, was observed with the sides of her hair uncovered by her hair bonnet. On 6/3/2015 at 11:17 AM, EI #10, a Dietary Aide, was observed with a small amount of hair on his chin, and not wearing a beard guard. EI #12, a Dietary Aide, was observed with a small amount of hair hanging from the back of her head, uncovered by the hair bonnet. On 6/3/2015 at 11:40 AM, EI #8 was observed with some hair at the nape of her neck, uncovered by the hair bonnet. During the interview on 6/5/2015 at 1:20 PM with EI #4, she was asked what the policy was on hair coverings in the kitchen. EI #4 replied, All hair is to be covered. Facial hair should be covered also for the protection of the resident's food. During the interview on 6/5/2015 at 2:10 PM, EI #6 was asked what the policy was of hair coverings in the kitchen. EI #6 stated, Hair nets. All hair is to be fully covered. EI #6 was asked what the potential harm was of all hair not being covered by bonnets while working in the kitchen. She stated, Some could break off and fall somewhere. EI #6 was asked what the potential harm was of facial hair uncovered while working in the kitchen, and she replied, Possibility of breaking off and getting into food. During the interview on 6/5/2015 at 3:05 PM, EI #7, the RD, was asked what the policy was on hair coverings in the kitchen. EI #7 replied, The hair must be covered in the food preparation area. EI #7 was asked what the potential harm was of all hair not being covered by bonnets while in the kitchen, and she replied, Hair could fall into food. EI #7 was asked what the potential harm was of facial hair being uncovered while working in the kitchen, and she stated, Hair could potentially fall into food. 3) A review of the facility's document titled, DIETARY SERVICE MANUAL, with an effective date of August 15, 2009, revealed, . Policy Title: Leftover Food Storage and Use . PURPOSE: To assure food borne illnesses are avoided. PROCESS: . b. Leftover foods should be covered, labeled and dated. c. Refrigerated leftover foods should be used within 72 hours (three days). If not used within 72 hours, refrigerated foods should be discarded. These foods should monitored. During the tour of the kitchen on 6/2/2015 at 7:40 AM, observed in the reach-in cooler were: 1) A food item observed in a plastic container and labeled, Pork 5-27-15 Use by 5-29-15. 2) Green Beans 5-31-15 Use by 6-3-15, was observed in a plastic container and the lid was not closed on the container. EI #4 informed the surveyor the items, Needs to be gone. 3) An opened carton of Easy Eggs was observed with no open or use-by date. 4) An opened package of sliced cheese was observed in a zip locked bag with no open or use by dates or manufacturer's date on the package. During the interview at 1:20 PM on 6/5/2015, EI #4 was asked what the facility's policy was on labeling food items. EI #4 stated, Labeled so no one will get food that's outdated, or food poisoned. You should put the dates on when you put it in the fridge (refrigerator), and the date it's to be thrown out. EI #4 was asked when the leftover green beans should be used by if placed in the cooler on 5/31/2015. EI #4 replied, 6/2/15. The ones we saw said throw away on 6/3, so that wasn't dated right. EI #4 was asked what the potential harm was of the green beans being observed in the cooler on 6/2/2015, and dated use-by 6/3/15, and the lid not being closed. EI #4 replied, With the lid not on, bacteria growing in them. With them being outdated, it could harm a patient. EI #4 was asked what the potential harm was of the pork being observed in the cooler on 6/2/2015, with a use by date of 5/29/2015. EI #4 stated, It was out of date. It could have made someone sick being in there past the date. EI #4 was asked what date should be put on the Easy Eggs when they were opened, and she stated, The date you open them, and then 3 days later. EI #4 was asked why the carton of Easy Eggs was observed opened and without a date. EI #4 replied, I'm not sure. Somebody wasn't going by the rules and regulations, and that's a no-no. EI #4 was asked what the potential harm was of the Easy Eggs being opened and without an open or use-by date. EI #4 stated, No one would know when they were opened and put in there. You'd be taking a chance using something without a date. During the interview on 6/5/2015 at 2:10 PM, EI #6 was asked what the facility's policy was on labeling food items. EI #6 replied, 3 days for cooked foods, from the day it's put in. Meats with dates pulled out of (the)freezer and the date it's to be used by. Three days for that to be used or cooked with. EI #6 was asked when the leftover green beans should be used by if placed in the cooler on 5/31/2015. She stated, 6/2/15. EI #6 was asked what the potential harm was of the green beans observed in the cooler on 6/2/2015, dated use-by 6/3/15, and the lid not being closed. EI #6 stated, It should have been used up on the 2nd. The lid not being closed means not sealed properly. EI #6 was asked what the potential harm was of the pork being observed in the cooler on 6/02/2015 with a use-by date of 5/29/2015. EI #6 replied, Contamination. It should have been discarded. EI #6 was asked what date should be put on the Easy Eggs when they were opened. She stated, If in the original carton, 30 days from the date it's (carton) opened. EI #6 was asked why the carton of Easy Eggs was observed opened and without a date. EI #4 replied, I can't tell you. Normally there's none left when a carton is opened. EI #6 was asked what the potential harm was of the Easy Eggs being opened and without an open or use by date. EI #6 replied, It could be contaminated. During the interview on 6/5/2015 at 3:05 PM, EI #7 was asked what the facility's policy was on labeling food items. EI #7 stated, All food items must be labeled and dated. Leftovers have a 3 day use-by date. EI #7 was asked when the leftover green beans should be used by if placed in the cooler on 5/31/2015. She replied, 6/2/15. EI #7 was asked what the potential harm was of the green beans observed in the cooler on 6/2/2015, dated use-by 6/3/15, with the lid not closed. EI #7 stated, If the lid's not closed properly and on a lower shelf, something could fall into them. EI #7 was asked what the potential harm was of the pork being observed in the cooler on 6/2/2015 with a use-by date of 5/29/2015. EI #7 stated, Expired meat could be potentially harmful if served to a resident. EI #7 was asked what date should be put on the Easy Eggs when they were opened, and she replied, The use-by date should be 7 days, I believe. EI #7 was asked what the potential harm was of the Easy Eggs being opened and without an open or use-by date. EI #7 responded, Our policy is they should have a use-by date. 4) A review of the manufacturer's guidelines for nutritional supplements for Unintended Weight Loss, revealed, (Name of manufacturer). FROZEN SHAKES. Frozen Shakes are great tasting, nutrient dense milkshake supplements. Shelf Life: . Once thawed refrigerated shelf life - 14 days . Storage and Handling: Keep frozen until ready to serve. Thaw in refrigerator prior to serving. Shake carton and pour into cup. Discard leftover product. During the tour of the kitchen on Tuesday, 6/2/2015 at 7:40 AM, 34 thawed Vanilla Health Shakes were observed in the Walk-In cooler without dates. EI #4, the cook informed the surveyor, (They) Came in May 2015 is what (the) box says. EI #4 informed the surveyor the shakes were, Thawed Sunday. After joining the surveyor and EI # 4 at 7:55 AM, EI #6 informed the surveyor regarding the shakes, (They) Took them out last night. On 6/3/2015 at 10:30 AM, EI #6 informed the surveyor that the Health Shakes were, Good for 10 days after thawing. During the interview on 6/5/2015 at 2:10 PM, EI #6 was asked what the facility's policy was on dating of health shakes, and what dates should be on them. EI #6 stated, 10 days when removed from (the) freezer. We are to put the use-by dates on them. EI #6 was asked how many days the health shakes were good after they were thawed, and she replied, 10 days. EI #6 was asked when were the 34 Vanilla Shakes that were observed in the cooler on 6/2/15 thawed. EI #6 replied, That evening before. They didn't date the whole case. EI #6 was asked why the shakes were not dated, and she stated, My staff just didn't do it, apparently. EI #6 was asked why the shakes were discarded, as she stated they had been. EI #6 replied, If no date on them, we didn't know when they came out (of the freezer), and we couldn't use them. EI #6 was asked what the potential harm was of the health shakes having no thaw dates on them. EI #6 stated, You don't know when they were taken out and when to use them. On 6/5/2015 during the interview at 3:05 PM, EI #7 was asked what the facility's policy was on dating of health shakes, and what dates should be on them. EI #7 replied, We date them the day they are thawed and with a 10 day use-by date. EI #7 was asked how many days the health shakes were good after they were thawed, and she stated, According to the manufacturer, 14 days. 5) During the tour of the kitchen on 6/2/2015 at 8:00 AM, ground nutmeg was observed labeled, 12/1/13 12/1/14. There was a manufacturer's label dated, 4/16/13. EI #6 informed the surveyor, 4/16/13 (was) the date (it was) shipped to me. EI #6 informed the surveyor the nutmeg was, Good for 2 years. It's gotta go. Red food Coloring was observed with a date of, 10/25/14. EI #6 informed the surveyor the food coloring was, Shipped to me 8/2/12. On 6/5/2015 at 2:10 PM, EI #6 was asked what the facility's policy was on spices. EI #6 stated, Date (them) 1 year from the date you open them. EI #6 was asked what the concern was with the ground nutmeg and red food coloring past their manufacturer's or facility's expiration dates. EI #6 replied, Contaminating whatever we prepared with them. During the interview on 6/5/2015 at 3:05 PM, EI #7 was asked what the facility's policy was on spices. EI #7 replied, They have a shelf life of 1 year. EI #7 was asked what the concern was with the ground nutmeg and red food coloring past their manufacturer's or facility's expiration dates. EI #7 stated, It wouldn't be as effective as coloring or flavoring the food.

Based on observations, interviews, and document reviews, the facility failed to ensure: 1) Medications were not observed left at residents' bedsides on 1 of 4 survey days. This had the potential to affect RI (Resident Identifier) #'s 2 and 12, two of sixteen sampled residents. 2) Medications were signed out when removed from the facility's STAT Box. This was observed on 1 of 4 survey days, and affected 1 of 2 medication rooms in the facility. Findings included: 1) A review of the facility's policy dated 03/11, and titled, .Medication Administration - General Guidelines, revealed, .Procedures 1. Medications are administered only by licensed nursing, medical, pharmacy, or other personnel authorized by state laws and regulations to administer medications. 3. Medications are administered at the time they are prepared. 4. The person who prepares the dose for administration is the person who administers the dose. 9. Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. A review of the facility's policy dated 03/11, and titled, Storage of Medications and Biologicals, revealed, . Policy Medications and biological are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. A review of the medical records indicated RI #12 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #12's Quarterly MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 04/06/2015, revealed a BIMS (Brief Interview for Mental Status) score of 3 out of 15 possible points. This score indicated RI #12 was severely impaired for daily decision making skills. This MDS also indicated RI #12 could transfer independently and required supervision or set-up staff assistance for all other activities of daily living. A review of RI #12's June 2015 physician's orders [REDACTED]. During the tour of the facility on 6/2/2015 at 8:35 AM, RI #12 was observed sitting in a wheelchair at the doorway of RI #12's room. The oxygen concentrator was on in (RI #12's) room, and an unopened vial of Iprat-Albut was observed on the over-bed table. EI (Employee Identifier) #3, the Assistant Director of Nursing informed the surveyor, (The medication) Should not be left at (the) bedside. EI #3 informed the surveyor the potential harm was, Another resident could grab it. A review of RI #2's medical records revealed the resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #2's Quarterly MDS, with an ARD of 04/13/2015, revealed a BIMS score of 15 out of 15 possible points. This score indicated RI #2 was cognitively intact for daily decision making skills. This MDS indicated RI #2 required extensive staff assistance with dressing and toileting, limited assistance with hygiene, but could feed self after meals were set up. A review of RI #2's June physician's orders [REDACTED]. During the tour of the facility on 6/2/2015 at 8:50 AM, RI #2 was observed in bed. An unopened vial of Iprat-Albut was observed on the over-bed table. EI #3 informed the surveyor, (RI #2) likes to do (RI #2's) own thing, but that's a no-no. On 6/5/2015 at 10:26 AM, an interview was conducted with EI #19, a Licensed Practical Nurse. EI #19 was asked what the facility's policy was on administering medications. EI #19 replied, You go by the MAR (Medication Administration Record) as ordered by the doctor. You give it (the medication) to the resident. EI #19 was asked if she had RI #'s 2 and #12 on the morning of 6/2/2015. EI #19 stated, I did, and got off around 8:00 AM, that morning. EI #19 was asked what medication had been left at the bedside for RI #2 on the morning of 6/2/2015. EI #19 stated, It may have been the breathing treatment (RI #2) asked for. (RI #2) was getting a bed bath or getting cleaned up and I was going to go back to give it to (RI #2). EI #19 was asked what medication had been left at the bedside for RI #12 on the morning of 6/2/2015. EI #19 replied, (RI #12), I didn't leave any med (medications). (RI #12) called and complained of shortness of breath and I replaced (RI #12's) oxygen at that time. I didn't take any meds into (RI #12's) room. I have no idea where any meds came from in (RI #12's) room. EI #19 was asked if RI #12 got breathing treatments, and she stated she wasn't aware of the resident getting any treatments. EI #19 was asked why the medications were left at RI #2's bedside. EI #19 stated the resident stated a breathing treatment was needed, but when she went into the resident's room, RI #2 seemed fine. EI #19 indicated it was her intention to give the treatment, however the resident had no apparent signs or symptoms of SOB. She stated she thought the treatment could have been given later if needed. EI #19 was asked where the Iprat-Albut medication should be stored until administered to the residents, and she stated, In the medicine cart. EI #19 was asked when RI #2 and RI #12 had been authorized to self administer medications. EI #19 replied, There are no self-administration orders at (Named Facility). That's not a thing (Named Facility) advocates. EI #19 was asked what the potential harm was of medications being left at the residents' bedside. EI #19 replied, Someone else could get hold of it, improper administration, the wrong orifice, just a variety of things that could go wrong with it. An interview was conducted with EI #3 on 6/5/2015 at 10:40 AM. EI #3 was asked what was the facility's policy on administering medications. EI #3 replied, By licensed personnel for administration of meds. EI #3 was asked what medication was observed left at the bedside for RI #2 on 6/2/2015 during the tour. EI #3 stated, The Albuterol treatment. EI #3 was asked what medication was observed left at the bedside for RI #12 on 6/2/2015 during the tour, and she replied, The Albuterol treatment, as well. EI #3 was asked who had left the medications at the resident's bedsides, and she replied, (EI #19). EI #3 was asked why the medications were left at the residents' bedside. She stated she didn't know. EI #3 was asked where the Iprat-Albut medication should be stored until administered to the residents. She replied, In the medication cart. EI #3 was asked when RI #2 and RI #12 had been authorized to self administer medications, and she stated that neither of them had been authorized to self medicate. EI #3 was asked what the potential harm was of medications being left at the residents' bedsides. EI #3 responded, (The) Possibility of another resident getting or obtaining the medication. 2) A medication room observation was done with EI #18, a LPN (Licensed Practical Nurse), on 6/5/2015 at 4:00 PM. The count was not correct for two medications that were not signed out on the Emergency Box Sign-Out Form. The following was observed: Medications on the list: Medications observed: 6 - Instant Glucose 5 - Instant Glucose 3 - Ativan 2 mg(milligram) 2 - Ativan 2 mg IM IM (intramuscularly) The surveyor asked EI #18 if the above medications were signed out on the emergency box sign out form. EI #18 said he did not see where the medications had been signed out. An interview was conducted with EI #14, the Director of Nursing of the facility, on 6/5/15 at 4:15 PM. The surveyor discussed the concern regarding the above observation. EI #14 stated, They should be signed out. You don't know who got the medication. You don't know who signed it out. A review of a facility's form titled: Emergency Control Drug Record, that was dated 5/29/15, revealed: Ativan 2 mg IM was administered on 5/29/2015 to an un-sampled resident. A second form titled: Prescription Request, revealed: Ativan was used from the Emergency Box on 5/29/2015 with the un-sampled resident's name on the form. The Ativan had not been replaced a week later after being removed from the Emergency Box. The surveyor discussed the concern regarding the Ativan that was removed from the Emergency Box on 5/29/15 and was not replaced a week later on 6/5/15. No response was voiced by EI #14 and the other facility staff present during the discussion.

Based on observations, interviews, and record reviews, the facility failed to ensure: 1. A nurse washed her hands and changed gloves during a medication pass observation on 6/2/15. This affected RI (Resident Identifier) #8, one of seven residents observed for medication administration. 2. The syringe and plastic ziploc bag used for enteral feedings was not observed wet with a pool of a tan colored liquid in the bag. This affected RI #8, one of one residents sampled for enteral feedings and was observed during three observations on 6/4/15. 3. Paper towels were available in a medication room in the facility on 6/5/15. This affected one of two medication rooms, and was observed on one of four survey days. Findings include: 1. A review of the Centers for Disease Control and Prevention recommendations with most recent update of November 9, 2011 revealed: .Protocol for Hand Hygiene and Glove Use Observations.Recommendations Hand hygiene. 3. Examples of situations when hand hygiene is indicated: 1. Before and after direct patient contact 2. After completing tasks at one patient station before moving to another station. 6. After contact with items/surfaces at patient stations. Glove use 1. In general, gloves should be worn prior to contact with patients at the treatment station and potentially contaminated surfaces. Gloves should always be changed between patients and between clean and contaminated sites on the same patient. A review of RI 8#'s medical record revealed RI #8 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Nursing Admission Review for RI #8 with the date of 5/26/15, revealed RI #8 had long and short term memory problems and was moderately impaired for cognitive skills for daily decision making. During a medication pass observation on 6/3/15 at 5:10 AM, EI (Employee Identifier) #17, an LPN (Licensed Practical Nurse), was observed to set up and administer medications for RI #8. EI #17 washed her hands and went to the medication cart and documented RI #8's pain level. EI #17 obtained a pain pill from the medication cart and put it in a medication cup. She opened the plastic pill crush bag with her right index finger and crushed the medication. EI #17 put the crushed medication in the medication cup. She took the medication and two empty medication cups in the resident's room and placed them on the resident's bedside table. EI #17 washed her hands and applied a pair of gloves. EI #17 turned on the faucet with her gloved hands and put water in both of the medication cups. With the same gloved hands, EI #17 placed the tube feeding pump for RI #8 on hold. EI #17 checked the placement of the resident's Gastrostomy tube and checked for residual. EI #17 flushed the Gastrostomy tube with water, and poured water in the medication cup containing the crushed medication. The nurse flushed the tube then stirred the medication and water with her right gloved index finger. EI #17 gave the mixture of medication to RI #8 via Gastrostomy tube, and flushed the tube with water. EI #17 put the used syringe in a plastic bag. EI #17 did not rinse or dry the syringe prior to putting it in a plastic bag. EI #17 then washed her hands. EI #17 multitasked with the same glove that she used to turn the faucet on and off. EI #17 also used the same gloves to turned off the pump, and mixed the crushed medication and water in the medication cup. An interview was conducted with EI #17 on 6/4/15 at 9:00 AM. She was asked how should she open the plastic bags to crush medication. EI #17 stated, I slid the bag open. The surveyor shared the above observation of EI #17, when she opened the crush bag with her index finger. EI #17 said she did not remember putting her finger in the crush bag. EI #17 was asked if she had on gloves when she turned on the faucet to obtain the water for the medication cups. EI #17 stated, I think I did have my gloves on because I had my gloves on to do the feeding. The surveyor asked EI #17 what she did after she put the water into the medication cups. EI #17 stated, I got the cups and put them on the table. I checked for placement, disconnected the tube and covered it up to prevent infection. After I checked for placement and residual, I then gave the medication and flushed again. After I flushed, I uncapped the tubing and reconnected. The surveyor asked EI #17 when did she wash her hands and/or change her gloves during the medication administration. EI #17 stated, I washed before, when I finished and in between. I washed my hands a lot. The surveyor shared the above medication administration observation with EI #17, and asked what was the concern. EI #17 stated, Potential for cross contamination. I should have mixed the medication with the syringe. An interview was conducted with the Director of Nursing, EI #14, on 6/5/15 at 4:15 PM. The surveyor asked EI #14 when should a nurse wash her hands during a medication pass for a resident with a Gastrostomy tube. EI #14 stated, Before and after she is done, and sometimes in between, when needed. The surveyor discussed the above observation with EI #14, and asked what was the concern. EI #14 stated, Infection. 2. On 6/4/15 at 9:40 AM, an observation was made of RI #8's feeding syringe in a plastic ziploc bag dated 6/4/15. The syringe and plastic bag were wet. A pool of a tan colored liquid was observed in the bag. On 6/4/15 at 10:35 AM, RI #8's feeding syringe remained in a plastic ziploc bag dated 6/4/15. The syringe and plastic bag remained wet. The pool of a tan colored liquid was observed in the bag. On 6/4/15 at 12:00 PM, RI #8's feeding syringe remained in a plastic ziploc bag dated 6/4/15. The syringe and plastic bag still observed wet. The pool of a tan colored liquid was observed in the bag. On 6/4/15 at 12:20 PM, an LPN, EI #20, and the surveyor observed RI #8's wet feeding syringe and plastic bag with the pool of a tan colored liquid in the bag. EI #20 was asked why was RI #8's syringe and plastic ziploc bag wet. EI #20 stated, It should not be wet. The surveyor asked why not. EI #20 stated, When it is wet it is a chance for infection. 3. A review of a facility document titled, INFECTION PREVENTION & CONTROL MANUAL, with an effective date of Dec. (December) 1, 2009 revealed: . Policy Title: Hand Hygiene . PURPOSE: To provide guidelines to employees for proper and appropriate hand washing techniques that will aide in the prevention of the transmission of infections. PROCESS: I. Handwashing 1. Pull down paper towels before washing hands. 4. Dry hands thoroughly with paper towels and then turn off faucets with those towels. A medication room observation was conducted on 6/5/15 at 4:00 PM, with an LPN, EI #18. The paper towel dispenser was empty with no paper towels observed. The surveyor asked EI #18 how he dried his hands during hand washing. EI #18 said he washed his hands prior to entering the medication room. EI #18 said it would be nice to have paper towels in the medication room. An interview was conducted with the Director of Nursing, EI #14, on 6/5/15 at 4:15 PM. The surveyor asked EI #14 if paper towels should be in the medication room. EI #14 stated, Yes ma'am it should be in there. How can you dry your hands correctly without paper towels?

Based on observation, interviews, and document reviews, the facility failed to ensure cucumber chunks were not served to a resident with a mechanical soft diet order, and the resident stated they were unable to chew the cucumbers because of having no teeth. This affected RI #5, one of eleven sampled residents observed for meals. Findings included: A review of the medical record revealed RI #5 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #5's Annual MDS (Minimum Data Set) with an Assessment Reference Date of 12/30/2014 indicated a BIMS (Brief Interview for Mental Status) score of 5 out of 15 possible points. This score indicated RI #5 was severely impaired for daily decision making skills. This MDS also indicated RI #5 required extensive staff assistance with dressing, toileting and hygiene, and limited assistance with eating. A review of the June 2015 Physician order [REDACTED]. A review of a Care Plan for RI #5 with a Problem Onset date of 02/23/2014, revealed, Actual weight loss R/T (related to) MECH. (Mechanical) SOFT DIET AND FAIR INTAKE . The Approaches on the Care Plan revealed, . * Provide diet as ordered . * Observe resident while eating meals, snacks and foods .for intolerance to the foods served. A review of the facility's Spreadsheet of Diets, dated as 6/4, revealed, . Mechanical Soft . Marinated Cucumber Salad (1/2 cup) (Chopped) . On 6/4/2015 at 12:15 PM, RI #5 was observed in bed and lunch was being served. The resident was fed by EI (Employee Identifier) #1, a CNA (Certified Nursing Assistant). The lunch tray included, Baked Beans, Shredded Pork, Soup, A Peanut Butter and Jelly Sandwich, a Dinner Roll, Cucumber Salad (which contained cucumber chunks), Strawberry Short Cake, an Apple/Cranberry Juice, and Iced Tea. On 6/4/2015 at 12:43 PM, the surveyor observed EI #1 still at the resident's bedside attempting to get RI #5 to eat. The surveyor asked EI #1 if RI #5 could eat the meat as served without any problems. EI #1 stated, Yes, she could. RI #5 stated, Yes, it's chopped up. The surveyor asked if RI #5 could eat the Cucumber Salad. RI #5 stated, No. I don't have any teeth. On 6/5/2015 at 1:40 PM, an interview was conducted with EI #14, the Director of Nursing for the facility. EI #14 was asked what RI #5's diet order was and she replied, Mechanical Soft with Chopped Meats. EI #14 was asked if RI #5 could chew Cucumber chunks/wedges. EI #14 stated, Not with that diet, I wouldn't think so. EI #14 was asked if the Cucumber Chunks were in accordance with RI #5's diet orders, and she stated, No ma'am. EI #14 was asked what the potential harm was of not providing diets as ordered. EI #14 replied, Choking, aspiration; Not following the physician's orders [REDACTED]. An interview was conducted on 6/5/2015 at 2:40 PM, with EI #6, the Dietary Manager. EI #6 was asked what services she had provided for RI #6. EI #6 stated, Updated (RI #5's) likes and dislikes. (RI #5) likes soups and nutritional juice drinks. (RI #5) requested a mechanical soft diet because of missing teeth. EI #6 was asked what the diet order was for RI #5, and she replied, Mechanical Soft. EI #6 was asked if the Cucumber Salad with chunks and/or wedges would be appropriate for RI #5's diet order of Mechanical Soft. EI #6 stated, According to our menus. (RI #5) likes the vegetable salads, (RI #5) says. EI #6 was asked what the potential harm was of not addressing a resident's complaint of not being able to chew up a food item. EI #6 replied, Lack of intake, may need a better diet, especially from the meats. For other things, weight loss. On 6/5/2015 at 2:57 PM, an interview was conducted with EI #7, the Registered Dietitian. EI #7 was asked what services she had provided for RI #5. EI #7 replied, I know I've evaluated (RI #5's) weights. (RI #5's) been here several years. EI #7 was asked what RI #5's diet order was, and she stated, Mechanical Soft. EI #7 was asked if the Cucumber Salad with chunks and/or wedges would be appropriate for RI #5's diet order of Mechanical Soft. EI #7 replied, I would think so. They are peeled. Cucumbers, if appropriately soaked in the vinegar, it softens them. EI #7 was asked what the potential harm was of not addressing a resident's complaint of not being able to chew up a food item. EI #7 stated, It might inhibit their proper intake of nutrients.

Based on observations, interviews, and document reviews, the facility failed to ensure 2 residents out of 8 in attendance to the Resident Group Meeting did not complain of bland foods, and that the Squash and Beef Stroganoff tested by the surveyor on 6/3/2015 were not observed bland. This affected RI (Resident Identifier) #'s 7 and 14, two of sixteen sampled residents. Findings included: On 6/03/2015 at 9:00 AM, a Resident Council Group interview was held by a surveyor. During the group interview, RI #'s 7 and 14 complained that the facility's food was bland. RI #7 and RI #14 stated that most meals were bland and that the food needed more flavor and seasonings. On 6/03/2015 at 12:15 PM, observations were made of a regular and a pureed diet test trays. The squash and the beef stroganoff for the regular diets were found to be bland by the surveyor. EI (Employee Identifier) #6, the Dietary Manager, and EI #7, the Registered Dietitian, agreed the the squash was bland. A review of RI #7's medical record revealed RI #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a Quarterly Minimum Data Set (MDS) with an ARD (Assessment Reference Date) of 4/20/2015 indicated RI #7 was coded as having a BIMS (Brief Interview for Mental Status) score of 5 out of 15. This score indicated the resident had severe cognitive impairment. RI #7 required set-up assistance with meals. A review of the medical record revealed RI #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of an Annual MDS, with an ARD of 03/20/2015, indicated RI #14 was coded as having a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. RI #14 required set-up assistance with meals and supervision. On 6/5/2015 at 4:05 PM, an interview was conducted with EI #6, the Dietary Manager. EI #6 was asked if any residents had complained of bland foods. EI #6 responded, I had one, and in another breath, they said they didn't have any taste buds. EI #6 was asked what was done about the complaint. EI #6 replied, I went out and got some (Name Brand flavoring) to enhance the food flavor. EI #6 was asked what the potential harm was of bland foods. EI #6 stated, Probably wouldn't want to eat it; they would want more seasoning.

Based on observations, interviews, and document reviews, the facility failed to ensure call lights were placed within reach for RI (Resident Identifier) #4 on 2 observations, on 1 of 4 survey days, and for RI #5 on 1 observation, on 1 of 4 survey days. Findings include: A review of the facility's policy dated October 1, 2010, titled, Answering the Call Light, revealed, .PURPOSE: Call lights serve as notice to the staff the resident has a need or request. Prompt answering of call lights provides a sense of security to the resident. PROCESS: . g) Place the call light within reach of the resident before leaving the room . A review of the medical record revealed RI #4 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of an MDS (Minimum Data Set) for RI #4 with an ARD (Assessment Reference Date) of 05/05/2015 revealed RI #4 had a BIMS (Brief Interview for Mental Status) score of 15 out of 15 possible points. This score indicated RI #4 was cognitively intact for daily decision making skills. This MDS also indicated RI #4 was totally dependent on staff for toileting and hygiene, and required extensive staff assistance for transfers, dressing and eating. A review of a Care Plan for RI #4, with a Problem Onset date of 05/10/2013, revealed, Impaired Cognition . has CHRONIC DEPRESSION, [MEDICAL CONDITION] DISORDER, ANXIETY AND AGITATION . Approaches . * FMP (Functional Maintenance Plan) Remind/encourage to use call button for assistance . On 6/2/2015 at 8:45 AM, RI #4 was observed in bed and the call light was not in the resident's reach. The call light was on the floor, on the right back of the head of the bed. On 6/2/2015 at 2:56 PM, RI #4 was observed in bed and the call light was again not in reach. The call light was laying across the bedside table which was on the right side of the resident's bed. On 6/5/2015 at 10:15 AM, EI (Employee Identifier) #2, the Registered Nurse/Unit Manager where RI #4 resided, was asked to accompany the surveyor to the resident's room. While in the room, RI #4 demonstrated the ability to use the call light. The surveyor placed the call light in the places and/or positions where it had been observed (behind the head of the bed on the floor, and laying across the bedside table) when out of reach. The surveyor asked EI #2 if the resident could use the call light while it was in those positions, and she stated, No. A review of the medical record revealed RI #5 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #5's Annual MDS with an ARD of 12/30/2014 indicated a BIMS score of 5 out of 15 possible points. This score indicated RI #5 was severely impaired for daily decision making skills. This MDS also indicated RI #5 required extensive staff assistance with dressing, toileting and hygiene, limited assistance with eating, and was always incontinent of bowel and bladder functions. On 6/2/2015 at 3:03 PM, RI #5 was observed asleep and laying on the right side. The call light was observed hanging from the bottom of the right bed rail, on the floor, and not in the resident's reach. On 6/4/2015 at 10:54 AM, EI #3, the Assistant Director of Nursing, and EI #15, a Licensed Practical Nurse, were at RI #5's bedside. EI #3 was asked if the resident could use the light, and she stated, Yes. The resident was then asked to demonstrate the ability to use the call light, and did. On 6/5/2015 at 10:22 AM, EI #2, RN/Unit Manager, was asked to accompany the surveyor to the resident's room. While in the room, the surveyor placed the call light in the position where the light had been observed when out of reach. EI #2 was asked if RI #5 could use the call light when the call light was in that position, and she stated, No. An interview was conducted with EI #16, RI #5's CNA (Certified Nursing Assistant), on 6/5/2015 at 11:10 AM. EI #16 was asked what was the purpose of the call lights, and she replied, So the resident can call if they need anything or assistance. EI #16 was asked where the call lights should be placed for the residents to use. EI #16 stated, I normally place them in their hands. EI #16 was asked why it was important for a resident to be able to reach their call lights. EI #16 stated, Because there might be an emergency and it might save their life. EI #16 was asked what the potential harm was of a resident's call light not being in reach. EI #16 replied, They won't be able to call for help if they needed it. On 6/5/2015 at 1:56 PM, EI #13, RI #4's CNA, was interviewed. EI #13 was asked what was the purpose of the call lights, and she stated, So the resident can call if something's needed. EI #13 was asked where call lights should be placed for the residents to use. EI #13 stated, Placed so they can get to it; most times clipped to their tops or bedspreads. EI #13 was asked why it was important for a resident to be able to reach their call lights, and she replied, If they get sick or need help, they can push it. EI #13 was asked what the potential harm was of a resident's call light not being in reach. EI #13 responded, If they were sick and couldn't let anyone know, or if they fell and couldn't get to the call light, they couldn't make their needs known. An interview was conducted on 6/5/2015 at 1:19 PM, with EI #14, the Director of Nursing for the facility. EI #14 was asked what was the purpose of the call lights. EI #14 replied, To let us know when our residents need assistance. EI #14 was asked where call lights should be placed for the residents to use, and she stated, Within the resident's reach. EI #14 was asked why it was important for a resident to be able to reach their call lights. EI #14 stated, So they can ask for assistance if needed. EI #14 was asked what the potential harm was of a resident's call light not being in reach. EI #14 stated, We not knowing that something's wrong or needed.

Based on interviews and medical record reviews, the facility failed to ensure laboratory (lab) results were reported to the Physician after a Urinalysis (UA) was collected on 11/03/14. The facility did not obtain the results of the UA until 11/06/14 when questioned by the family. The lab results were not reported to the Physician until 11/09/14. On 11/11/14 RI #1 was transferred to the hospital with a [DIAGNOSES REDACTED]. This affected RI #1, one of three sampled residents whose labs were reviewed. Findings Include: A review of the facility's policy title: "Diagnostic Testing Services" with an effective date of October 1, 2010, revealed the following: "... Standard: The physician should be notified of the results of any diagnostic testing, within one day of the results being received, by the facility. Abnormal results prompt an immediate phone call to the physician. ..." RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/07/14, revealed, RI #1 had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating RI #1 was alert and oriented. The MDS documented RI #1 required extensive assistance with Toilet Use and Personal Hygiene. This MDS also documented RI #1 was always incontinent of bowel and bladder. After a visit on 11/3/14 by the Certified Registered Nurse Practitioner (CRNP) for RI #1's complaint of dysuria, an order for [REDACTED]. A review of the facility's "TWENTY FOUR HOUR REPORT FORM" dated 11/03/14, documented a UA for RI #1 in the Urinary Concerns box. On 12/17/14 at 6:05 PM in an interview EI #8 was asked who checked for the results of RI #1's UA collected on 11/03/14. EI #8 said after a family member called inquiring about the results of the UA on 11/6/14, she called for the results. The hospital lab faxed the results of the UA/C&S to her on 11/06/14. EI #8 was asked did she check to see if the lab results were back on 11/04/14 or 11/05/14. EI #8 said she had no idea a lab had been done. EI #8 said when she found out a lab had been done, that was when she called for the results on 11/06/14. EI #8 was asked why the lab results were not on the chart on 11/04/14 and 11/05/14. EI #8 replied the facility had to call for the results, the lab does not automatically send the results to the facility. EI #8 was asked who was responsible for calling to get the UA results. EI #8 responded that she was. EI #8 was asked when did she notify the physician of the results of the UA/C&S. EI #8 said she did not notify the doctor of the results. EI #8 was asked if the facility policy for collecting a UA and obtaining the results were followed. EI #8 said no it was not followed. EI #8 further stated it was not done by her because she did not know a UA had been collected. On 12/18/14 at 10:22 AM, EI #11 (RN/Week-End Supervisor) was asked why did she call the lab for RI #1's UA results on 11/09/14. EI #11 said it was because RI #1 had a UA done (on 11/03/14) and spiked a temperature on 11/09/14. EI #11 further stated EI #7 (Licensed Practical Nurse/LPN) had collected the urine for the UA but could not find the UA results. EI #11 said she called the lab on 11/09/14 and obtained the results for the UA and the C&S. EI #11 further stated she notified the doctor on 11/09/14 with the UA results and received an order for [REDACTED]. During an interview on 12/18/14 at 5:17 PM, EI #2 (RN) Director of Nursing (DON) was asked, did any one call for the results of RI #1's UA from 11/03/14 through 11/08/14. EI #2 replied she was told by EI #8 that she had spoken to the family on 11/06/14. EI #8 called and got the results. EI #2 said EI #8 did not call the the family back, did not call the doctor and did not put the labs in the chart. On 12/18/14 at 8:35 AM, EI #1 (Administrator) stated EI #8 did not inform her that she (EI #8) had received RI #1's lab results. EI #1 further stated EI #8 did not follow nursing procedures for labs. EI #1 also stated EI #8 had both lab results on 11/06/14 and withheld that information. EI #1 further stated she suspended EI #8, pending an investigation. EI #1 also said EI #8 should have followed through, notified the doctor and called the family. On 12/18/14 at 3:30 PM, EI #1 presented to the surveyor an interview summary she conducted with EI #8 which revealed the following: "Interview with (EI #8) RN on 12/17/2014 regarding a missing lab on resident, (RI #1). (EI #8) stated she never revealed that she had received the lab results because no one ask (ed). ..."

Based on interview and medical record review, the facility failed to ensure laboratory (lab) results were reported to the Physician in a timely manner after a Urinalysis (UA) was collected on 11/03/14. On 11/06/14 the UA results were obtained by the facility, but were not reported to the Physician until 11/09/14 and an order for [REDACTED].#1 was transferred to the hospital with a [DIAGNOSES REDACTED]. This affected RI #1, one of three sampled residents whose labs were reviewed. Findings Include: A review of the facility's policy title: "Diagnostic Testing Services" with an effective date of October 1, 2010, revealed the following: "... Standard: The physician should be notified of the results of any diagnostic testing, within one day of the results being received, by the facility. Abnormal results prompt an immediate phone call to the physician. ..." RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/07/14, revealed RI #1 required extensive assistance for Toilet Use and Personal Hygiene. This MDS also documented RI #1 was always incontinent of bowel and bladder. A review of the medical record revealed a visit on 11/3/14 by the Certified registered Nurse Practitioner (CRNP) to RI #1 for a complaint of dysuria. An order was written on 11/03/14 for a UA c (with) C&S (Culture and Sensitivity) if indicated and was documented as noted on 11/03/14 at 1305 (1:05 PM) by Employee Identifier (EI) #8, Registered Nurse (RN/Clinical Coordinator). A nurses note, dated 11/3/14 at 2:56 PM, documented the UA had been collected. A review of the facility's "TWENTY FOUR HOUR REPORT FORM" dated 11/03/14 revealed documentation of the UA for RI #1 under the area for Urinary Concerns. The UA report obtained by the facility documented the specimen for the UA had been received by the lab on 11/3/14. On 12/17/14 at 6:05 PM, EI #8 was interviewed and was asked who checked for the results of RI #1's UA collected on 11/03/14. EI #8 said the hospital lab faxed the results of the UA/C&S to her on 11/06/14. EI #8 was asked did she check to see if the lab results were on the chart on 11/04/14 or 11/05/14. EI #8 said she had no idea labs had been done. EI #8 further stated when she found out a lab had been done, she called for the results on 11/06/14. EI #8 was asked who was responsible for calling to get the UA results, she stated she was. EI #8 was asked why the lab results were not on the chart on 11/04/14 and 11/05/14. EI #8 replied the facility had to call for the results because, the lab does not automatically send the results to the facility. When asked if she notified the doctor of the results of the UA and C&S, EI #8 stated that she did not notify the doctor. EI #8 was asked if the facility's policy for collecting a UA and obtaining the results were followed. EI #8 said no it was not followed. On 12/18/14 at 10:22 AM, EI #11 (RN/Week-End Supervisor) was asked why did she call the lab for RI #1's UA results on 11/09/14. EI #11 said it was because RI #1 had a UA done (on 11/03/14) and had spiked a temperature on 11/09/14. EI #11 further stated EI #7 (Licensed Practical Nurse/LPN) had collected the urine for the UA but could not find the UA results. EI #11 said she called the lab on 11/09/14 and obtained the results for the UA and the C&S. EI #11 further stated she notified the doctor on 11/09/14 with the UA results and received an order for [REDACTED]. During an interview on 12/18/14 at 5:17 PM, EI #2 (RN) Director of Nursing (DON) was asked, did any one call for the results of RI #1's UA from 11/03/14 through 11/08/14. EI #2 replied she was told by EI #8 that she had spoken to the family on 11/06/14, but did not call the doctor. On 12/18/14 at 3:30 PM, EI #1 (Administrator) presented to the surveyor an interview summary she conducted with EI #8 which revealed the following: "Interview with (EI #8) RN on 12/17/2014 regarding a missing lab on resident, (RI #1). (EI #8) stated she never revealed that she had received the lab results because no one ask.(ed) ..."

Based on interviews and medical record review, the facility failed to notify the Physician and the responsible party, of the results of a Urinalysis (UA) collected on 11/03/14. The UA and the Culture and Sensitivity (C&S) results were reported to the facility on [DATE]. However, the results were not reported to the Physician and responsible party until 11/09/14. This affected Resident Identifier (RI) #1, one of three sampled residents. Findings Include: RI #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/07/14, revealed RI #1 required extensive assistance for Toilet Use and Personal Hygiene. The MDS also documented RI #1 was always incontinent of bowel and bladder. After a visit on 11/3/14 by the Certified Registered Nurse Practitioner (CRNP) for RI #1's complaint of dysuria, an order for [REDACTED]. A review of the facility's policy title: "Diagnostic Testing Services" with an effective date of October 1, 2010 revealed the following: "... Standard: The physician should be notified of the results of any diagnostic testing, within one day of the results being received, by the facility. Abnormal results prompt an immediate phone call to the physician. ..." On 12/17/14 at 6:05 PM, EI #8 was interviewed. During the interview EI #8 was asked, who checked for the results of RI #1's UA that was obtained on 11/03/14. EI #8 stated on 11/6/14, she called about the results of the test after the family asked her about it and had the hospital lab fax the results of the UA/C&S to her. EI #8 was asked when did she notify the physician and the family of the results of the UA/C&S. EI #8 said she did not notify the doctor or the family. EI #8 was asked did she check to see if the lab results were back on 11/04/14 or 11/05/14. EI #8 said she had no idea a lab had been done. EI #8 said when she found out a lab had been done, that was when she called for the results on 11/06/14. During an interview on 12/18/14 at 5:17 PM, EI #2 (RN) Director of Nursing (DON) was asked, did any one call for the results of RI #1's UA from 11/03/14 through 11/08/14. EI #2 replied she was told by EI #8 that she had spoken to the family on 11/06/14. EI #8 called and got the results. EI #2 said EI #8 did not call the the family back, did not call the doctor and did not put the labs in the chart.