Every finding on record at Park Manor Health and Rehabilitation, LLC

Based on observation, interviews, review of the (YEAR) Food Code regulations and the facility policies related to Leftover Food Storage and Foods from Families and Friends the facility failed to ensure: 1) Food was consistently labeled with open and use-by date (UBD) and used within seven days after opening; 2) Food below recommended temperatures on the 6/19/19 lunch tray line were reheated to at least 165 degrees Fahrenheit (F); and 3) Residents' refrigerators in three of three nursing station pantries were clean and residents' food was labeled with name and date, and discarded within three days as directed by facility policy. These failures had the potential to affect all 130 residents for whom meals were prepared and served at the time of this survey. Findings Included: 1) FOOD LABELING The facility policy: Leftover Food Storage and Use, with an effective date of 8/15/09, specifies the purpose, To assure that food borne illnesses are avoided. The processes by which this is achieved included: .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 be monitored for proper cooling, with times and temperature recorded on a cooling log. The (YEAR) Food Code regulation 3-501.17, Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. regulation specifies the following: . (B) .refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PR[NAME]ESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations . During the initial kitchen tour on 6/18/19 at 8:00 AM, the Surveyor observed two 5-pound containers of commercially prepared Pimento Cheese salad. Neither container had a facility label to indicate to staff, a use-by date. One container (nearly empty) was labeled as opened on 06/06/19, 12 days prior. At this point, the Surveyor asked the Certified Dietary Manager (CDM), Employee Identifier (EI) #10, what the facility's policy was regarding the labeling of opened foods and UBDs. EI #10 stated staff were to put the open date on the items and count down three days for the UBD, if the product lasted that long. 2) TRAY LINE FOOD TEMPERATURES The (YEAR) Food Code, 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. specifies the following: . (A) Except during preparation, cooking, or cooling . TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 135 degrees F or above . The facility policy, Leftover Food Storage and Use dated 8/15/09, mandates staff to . e. Reheat foods to 165 degrees for at least 15 seconds. On 6/19/19 at 4:35 PM, the Surveyor observed staff check the temperatures of the food placed on the steam table prior to the supper meal. Three pans of food were not at the recommended serving temperature of 135 degrees F or greater, including: a) Steak Fingers: 122 degrees F b) Mashed Potatoes: 132 degrees F c) Ground Steak Fingers: 130 degrees F. At the direction of the CDM, the tray line staff returned the above food to the convection oven for reheating. At 5:30 PM the reheated items were placed back onto the tray line. When the above food was removed from the oven, the Steak Fingers registered a temperature of 145 degrees F. The Mashed Potatoes were found by staff to be 147 degrees F, and the Ground Steak Fingers were 144 degrees F. None of these food items had been reheated to the required temperature of 165 degrees F prior to service. On 6/19/19 at 5:50 PM, the CDM affirmed the above reheated temperatures. When the Surveyor asked to what temperature the food should have been reheated, EI #10 stated 165 degrees F. 3) RESIDENT FOOD STORAGE The facility policy, Foods from Families and Friends, dated 11/28/16, has a purpose: To preserve the resident/guest(s) right to receive gifts of food from family and friends, while reducing the potential for food borne illnesses. The processes by which staff may achieve this purpose include: .b. If food is to be stored, it should be labeled with resident/guest(s) name, dated and stored in airtight container. c. If refrigeration is necessary, food items should be stored in the nursing unit refrigerator or resident/guest(s) room refrigerator, and discarded after 72 hours. On 6/20/19 the Nursing Unit refrigerators identified by staff as used for the storage of residents' food were checked on three of the three nursing stations. The findings for each were as follows: a) Station One On 6/20/19 at 10:10 AM, the small refrigerator located in the Station One pantry was labeled with a sign on the front of the refrigerator door: Resident's Food Only!!! All food placed in refrigerator should have resident's name and date on it.food can only be stored for three days and must be discarded after three days . Stored inside the refrigerator was: 1. an unlabeled, undated bag of Bojangles Chicken and a napkin-wrapped biscuit; 2. a Dinex mug of thickened liquid (grey in color) with no name/date; and 3. a Styrofoam bowl with napkin covering two plastic wrapped slices of cheese, with no date. A Licensed Practical Nurse (LPN) at Station One was questioned at this time (10:10 AM). The LPN, EI #9 verified the refrigerator was used for the storage of residents' food, but could not tell the Surveyor to whom the above unlabeled items belonged. EI #9 verified the food should have a name and date on each. The Station One Registered Nurse/Unit Manager, EI #12, stated on 6/20/19 at 11:00 AM whomever received the food was responsible for the dating and labeling. b) Station Three On 6/20/19 at 10:30 AM, the Station Three Charge Nurse/LPN, EI #8, identified the pantry refrigerator (with a sign indicating it as the residents' refrigerator) as the storage site for residents' food, explaining the residents or family could give their food to a Certified Nursing Assistant (CNA) or an LPN, who would then label the item with the resident's name and date. When asked about the undated food or items without a name, EI #8 stated the food was supposed to be thrown away. Inside the Station Three residents' refrigerator were stored: 1. an opened 8.4-oz aluminum can of Red Bull with no name, date; 2. a zip-lock bag of 10 sliced pepperonis with no name, date; 3. a partially used, wrapped 8 oz bar of cream cheese, with no name or date; 4. a container of fresh broccoli, wrapped in a plastic bag, with no name/date; 5. a Chick-fil-A sack containing waffle fries, with no date; 6. a Krystal sack with one Krystal burger/bun and a container of fries, with no date; 7. a Chick-fil-A sack with a chicken pattie/bun and a container of fries, with no name/date; 8. a 750 milliliter (ml) bottle of Evian water with less than 8 oz remaining, with no name/date; 9. a 16 oz bottle of 1000 Island salad dressing with no name/date, and no legible expiration date. A dried red spill was noted in the bottom of the refrigerator, with bits of damp paper on the lower shelf. On 6/20/19 at 10:45 AM, a Housekeeping staff member was cleaning elsewhere in the pantry. When questioned, the Housekeeper, EI #7, explained the refrigerator was supposed to be cleaned on the 3:00 to 11:00 PM shift, and affirmed the inside of the refrigerator needed cleaning. On 6/20/19 at 10:50 AM, the Station Three Charge Nurse, EI #8, could not tell the Surveyor when the residents' refrigerator had last been cleaned, but affirmed it needed cleaning. c) Station Two On 06/20/19 at 11:05 AM, the Rehabilitation Coordinator, EI #6, identified a small refrigerator in the nursing station pantry as that in which residents' food was stored. The refrigerator contained: 1. a large paper cup of Wakey Wakey beverage, warm to the touch on the outside, with a lid over the contents and a tea bag label hanging out. The cup was not labeled with name or date; 2. a 20 oz bottle of Lymonade, partially consumed, with no name/date; and 3. an opened can of Pepsi with a paper napkin stuffed into the drinking hole, with no name or date. On 6/20/19 at 11:08 AM, the Charge LPN for this nursing station, EI #5, confirmed she did not know to whom the above items belonged.

Based on interviews, review of pest control treatment logs, review of a facility policy titled Quality Assurance/Quality Assurance Performance Improvement, review of facility documents titled Quality Assurance Committee Action and Emergency Q.A.P.I. (Quality Assurance Performance Improvement) Meeting Minutes and review of the Administrator's job description, Employee Identifier (EI) #1, the facility's administrator, failed to provide necessary oversight to ensure a Quality Assurance Performance Improvement plan was implemented after the identification of bed bugs on 5/09/19 in Resident Identifier (RI) #41 and RI #105's room, Room Locator (RL) #1, which resulted in the spread of bed bugs. This affected RI #s 41, 42, 46, and 105, four of 11 residents sampled for bed bugs. Bed bugs were identified in 6 of 81 total resident rooms in the facility, as well as in common areas, including the day room and dining room. Findings Include: Cross reference F867 and F925. Review of the job description, last reviewed 6/30/03, for EI #1, the Administrator, revealed: . General Purpose To direct the day-to-day functions of the facility in accordance with current Federal, State and local standards governing long-term care facilities to ensure that the highest practicable level of care is provided to the residents. Qualifications .Must possess ability to efficiently .implement and interpret programs, goals, objectives, policies, and procedures necessary for providing quality care .Standard Requirements .Knowledgeable of resident rights and ensures an atmosphere, which allows for .dignity, and well-being of all residents in a safe, secure environment .Essential Job Functions .2. Ensure that each resident receives the necessary nursing, medical and psychological services to attain and maintain the highest possible mental and physical functional status. 3. Plan, develop, organize, implement, evaluate, maintain, monitor and supervise and direct all facility departments and overall operations .7. Plan, develop and maintain an ongoing quality assurance program. 8. Identify problems and deficiencies and develop and implement appropriate plans of action . A review of a facility policy titled, Quality Assurance/Quality Assurance Performance Improvement, effective 11/1/17, documented: .Governance and Leadership Administration is responsible for developing, leading and closely monitoring of QAPI program. . c. The administrator will be the Quality Management Coordinator and responsible for . QAPI Process . Systematic Analysis and Systematic Action . On 5/14/19 the State Agency received a complaint alleging the resident residing in RL #1 was ate up with bed bugs. The complainant alleged the facility was not treating for the bed bugs as they should have. On 6/07/19 the State Agency received a second complaint alleging the facility was infested with bed bugs, and the facility was not properly treating the problem. Review of pest control treatment logs from 5/2019 through present revealed positive bed bug activity in the facility as follows: - 5/10/19 bed bugs noted during treatment on bed by door in RL #1 - 5/16/19 bed bugs noted during treatment; bed bugs crawling on wall in RL #1 - 5/22/19 bed bugs noted during treatment on curtains in RL #1 - 5/23-5/24/19 bed bugs noted during treatment in RL #s 1, 2, 4 and 5; day room and dining room also treated - 6/16/19 bed bugs noted during treatment; bed bugs on bed by door in RL #1 Review of an undated facility document titled Emergency Q.A.P.I. Meeting Minutes revealed bed bugs were noted in one resident room (RL #1) on 5/09/19. These minutes outlined the following Safety plan for resident(s) identified: . clothes secured per protocol, showered, . moved to another room . Review of the facility's Quality Assurance Committee Action plan, dated 5/09/19, revealed the following: .Quality Issue/Problem Bed bugs noted in one resident room (RL #1) . Action 1. both residents received shower and clothing change, clothes/linens secured/washed per protocol . residents moved to another room . rooms secured per policy . On 06/20/19 at 2:54 p.m., Employee Identifier (EI) #13, a Certified Nursing Assistant (CNA), said she saw the bed bugs in RL #1 and reported it to the nurse. EI #13 further stated they were told to take the residents in RL #1 (RI #s 41 and 105) to their room and strip them down and put them in a hospital gown and take them to the shower. She stated she stripped RI #41 and dressed him/her in a hospital gown, but another CNA came and got the resident and took him/her to a room on Station 2 before she could give the resident a shower. She said she then stripped down RI #105 in the room and placed him/her in a gown and another CNA took him/her to Station 2 to be showered. On 06/21/19 at 11:54 a.m., EI #3, Maintenance Supervisor, said he believed the staff needed more training on procedures because the residents from RL #1 were moved into another room before receiving a shower, which he thinks caused them to be spread to another room. EI #3 was asked if the rooms were vacuumed per policy in all the rooms where bed bugs were identified. EI #3 said he could not say that he vacuumed RL #5 because he believed that someone just walked in there with a bed bug on them. He further stated it could have been on him because he had been in there working. EI #3 was asked what was done in RL #5. EI #3 explained that he got the bed bug and flushed it and pest control sprayed, but did not fog or dust in that room. EI #3 was asked how were the mattresses in the rooms cleaned. EI #4 stated the one in RL #1 was thrown away, but in the other rooms, the covers were taken off and run through the washer and dryer. On 06/21/19 at 12:53 p.m., an interview was conducted with EI #4, Housekeeping/Laundry Director. EI #4 was asked what policy did you follow when laundering resident's clothing and cleaning the rooms where bed bugs were identified. EI #4 said the Bed Bugs Policy. EI #4 was asked what did he instruct his housekeeping staff to do in the rooms identified with bed bugs. EI #4 replied all furniture was moved to the center of the room, the rooms were cleaned top to bottom, thoroughly wiped down beds, nightstands and TVs with bleach or pine sol and let the room set for a few days to make sure everything was dead and nothing else had come out and then move the residents back into the room. EI #4 was asked what about the curtains on the windows. EI #4 stated maintenance was supposed to take down the curtains and either he or the floor technicians take down the privacy curtains. EI #4 was asked were all the privacy curtains in the rooms identified with bed bugs taken down. EI #4 said he did not know about RL #5. EI #4 was asked if the clothing was taken out of RL #5 and laundered, the furniture moved to the center of the room, and the room walls and furniture cleaned per protocol and the facility's QAPI plan. EI #4 replied no. EI #4 was asked what was the concern with the protocol for bed bugs not being followed. EI #4 answered spread more bugs. On 06/21/19 at 7:20 p.m., an interview was conducted with EI #1, Administrator. EI #1 was asked to show evidence that the QAPI plan was followed. EI #1 said the plan was to take portions of the Bed Bugs Policy and implement them and for the residents to be showered per protocol. EI #1 was asked how she ensured those things were implemented. EI #1 stated she talked through the entire QAPI plan with each department head, even while she was not in the facility, and gave encouragement and follow-up. EI #1 was asked if she was aware that RI #41 and RI #105's clothing was removed and they were dressed in a gown, but they were placed in another room without first being showered. EI #1 said no. EI #1 was asked if the residents were not showered prior to being placed in another room, was the QAPI plan followed. EI #1 replied if they were not showered first, no. EI #1 was asked if she was aware when a bed bug was found in RL #5, the clothing and privacy curtains were not removed and the bed, floor and crevices were not vacuumed as stated in the QAPI plan. EI #1 said no, she was not aware. EI #1 further stated, as the Administrator, she should have been aware of those things, and that she was ultimately responsible for ensuring the QAPI plan was implemented in the facility.

Based on interviews, review of pest control treatment logs, review of a facility policy titled Quality Assurance/Quality Assurance Performance Improvement, and review of facility documents titled Quality Assurance Committee Action and Emergency Q.A.P.I. (Quality Assurance Performance Improvement) Meeting Minutes, the facility failed to ensure their QAPI plan was implemented to prevent the spread of bed bugs after they were identified on 5/09/19 in Resident Identifier (RI) #41 and RI #105's room, Room Locator (RL) #1. This affected RI #s 41, 42, 46, and 105, four of 11 residents sampled for bed bugs. Bed bugs were identified in 6 of 81 total resident rooms in the facility, as well as in common areas, including the day room and dining room. Findings Include: Cross reference F925. On 5/14/19 the State Agency received a complaint alleging the resident residing in RL #1 was ate up with bed bugs. The complainant alleged the facility was not treating for the bed bugs as they should have. On 6/07/19 the State Agency received a second complaint alleging the facility was infested with bed bugs, and the facility was not properly treating the problem. Review of pest control treatment logs from 5/2019 through present revealed positive bed bug activity in the facility as follows: - 5/10/19 bed bugs noted during treatment on bed by door in RL #1 - 5/16/19 bed bugs noted during treatment; bed bugs crawling on wall in RL #1 - 5/22/19 bed bugs noted during treatment on curtains in RL #1 - 5/23-5/24/19 bed bugs noted during treatment in RL #s 1, 2, 4 and 5; day room and dining room also treated - 6/16/19 bed bugs noted during treatment; bed bugs on bed by door in RL #1 Review of a facility policy titled, Quality Assurance/Quality Assurance Performance Improvement, effective 11/1/17, documented: . c. The QAPI Committee monitors progress to ensure that interventions or actions are implemented and effective . Review of an undated facility document titled Emergency Q.A.P.I. Meeting Minutes revealed bed bugs were noted in one resident room (RL #1) on 5/09/19. These minutes outlined the following Safety plan for resident(s) identified: . clothes secured per protocol, showered, . moved to another room . Review of the facility's Quality Assurance Committee Action plan, dated 5/09/19, revealed the following: .Quality Issue/Problem Bed bugs noted in one resident room (RL #1) . Action 1. both residents received shower and clothing change, clothes/linens secured/washed per protocol . residents moved to another room . rooms secured per policy . On 06/20/19 at 2:54 p.m., Employee Identifier (EI) #13, a Certified Nursing Assistant (CNA), said she saw the bed bugs in RL #1 and reported it to the nurse. EI #13 further stated they were told to take the residents in RL #1 (RI #s 41 and 105) to their room and strip them down and put them in a hospital gown and take them to the shower. She stated she stripped RI #41 and dressed him/her in a hospital gown, but another CNA came and got the resident and took him/her to a room on Station 2 before she could give the resident a shower. She said she then stripped down RI #105 in the room and placed him/her in a gown and another CNA took him/her to Station 2 to be showered. On 06/21/19 at 11:54 a.m., EI #3, Maintenance Supervisor, said he believed the staff needed more training on procedures because the residents from RL #1 were moved into another room before receiving a shower, which he thinks caused them to be spread to another room. EI #3 was asked if the rooms were vacuumed per policy in all the rooms where bed bugs were identified. EI #3 said he could not say that he vacuumed RL #5 because he believed that someone just walked in there with a bed bug on them. He further stated it could have been on him because he had been in there working. EI #3 was asked what was done in RL #5. EI #3 explained that he got the bed bug and flushed it and pest control sprayed, but did not fog or dust in that room. EI #3 was asked how were the mattresses in the rooms cleaned. EI #4 stated the one in RL #1 was thrown away, but in the other rooms, the covers were taken off and run through the washer and dryer. On 06/21/19 at 12:53 p.m., an interview was conducted with EI #4, Housekeeping/Laundry Director. EI #4 was asked what policy did you follow when laundering identified resident's clothing and cleaning the rooms where bed bugs were identified. EI #4 said Bed Bugs Policy. EI #4 was asked what did he instruct his housekeeping staff to do in the rooms identified with bed bugs. EI #4 replied all furniture was moved to the center of the room, the rooms were cleaned top to bottom, thoroughly wiped down beds, nightstands and TVs with bleach or pine sol and let the room set for a few days to make sure everything was dead and nothing else had come out and then move the residents back into the room. EI #4 was asked what about the curtains on the windows. EI #4 stated maintenance was supposed to take down the curtains and either he or the floor techs take down the privacy curtains. EI #4 was asked were all the privacy curtains in the rooms identified with bed bugs taken down. EI #4 said he did not know about RL #5. EI #4 was asked if the clothing was taken out of RL #5 and laundered, the furniture moved to the center of the room, and the room walls and furniture cleaned per protocol and the facility's QAPI plan. EI #4 replied no. EI #4 was asked what was the concern with the protocol for bed bugs not being followed. EI #4 answered spread more bugs. On 06/21/19 at 6:48 p.m. an interview was conducted with EI #2, Registered Nurse (RN)/Director of Nursing. EI #2 was asked if she was aware RI #41 and RI #105 were taken out of RL #1 and taken to another room before being showered (after the identification of bed bugs in their room, RL #1). EI #2 replied no, she was not aware of that. EI #2 was asked did they determine why bed bugs were in the new room. EI #2 stated she did not know, but if the residents did not get showered before they were moved, that was probably why it happened. EI #2 was asked if the Bed Bug policy and QAPI plan were followed if the residents were not showered prior to leaving RL #1. EI #2 said if they did not get showered before they went into another room, no, it was not followed and that was a mistake. EI #2 was asked what was the concern with not following the policy and/or QAPI plan concerning bed bugs. EI #2 said there would be a risk for spreading them. On 06/21/19 at 7:20 p.m. an interview was conducted with EI #1, Administrator. EI #1 was asked to show evidence that the QAPI plan was followed. EI #1 said the plan was to take portions of the Bed Bugs Policy and implement them and for the residents to be showered per protocol. EI #1 was asked how she ensured those things were implemented. EI #1 stated she talked through the entire QAPI plan with each department head, even while she was not in the facility, and gave encouragement and follow-up. EI #1 was asked if she was aware that RI #41 and RI #105's clothing was removed and they were dressed in a gown, but they were placed in another room without first being showered. EI #1 said no. EI #1 was asked if the residents were not showered prior to being placed in another room, was the QAPI plan followed. EI #1 replied if they were not showered first, no. EI #1 was asked if she was aware when a bed bug was found in RL #5, the clothing and privacy curtains were not removed and the bed, floor and crevices were not vacuumed as stated in the QAPI plan. EI #1 said no, she was not aware. EI #1 was asked how staff were trained on the QAPI plan and Bed Bug Policy. EI #1 said she went over the Bed Bug Policy in a staff meeting (verbally), but not the QAPI plan. EI #1 was asked what was the concern with the QAPI plan not being followed. EI #1 said it could contribute to the spread of bed bugs and lack of containment.

Based on interviews, record review, review of a facility document titled Emergency Q.A.P.I. (Quality Assurance Process Improvement) Meeting Minutes, review of the facility's Quality Assurance Committee Action, review of the facility's pest control contract, and review of the facility's policies titled Bed Bugs and Insect and Rodent Control, the facility failed to ensure measures were implemented to provide effective pest control and prevent the spread to other rooms after the identification of bed bugs in Room Locator (RL) #1 on 5/9/19. Resident Identifier (RI) #s 41 and 105, who resided in RL #1, were taken to another room on Station 2 prior to receiving a shower on 5/9/19. Further, RI #s 46 and 42's clothing and other items were not removed from RL #5 after bed bugs were also discovered in that room. Further, RL #5 was not cleaned and vacuumed as outlined in the facility's Quality Assurance Committee Action and Bed Bugs policy. This affected RI #s 41, 42, 46, and 105, four of 11 residents sampled for bed bugs. Bed bugs were identified in 6 of 81 total resident rooms in the facility, as well as in common areas, including the day room and dining room. Findings include: On 5/14/19 the State Agency received a complaint alleging the resident residing in RL #1 was ate up with bed bugs. The complainant alleged the facility was not treating for the bed bugs as they should have. On 6/07/19 the State Agency received a second complaint alleging the facility was infested with bed bugs, and the facility was not properly treating the problem. Review of the facility's pest control contract, revised 9/2013, revealed the following: . CUSTOMER PARTNERSHIP Customer entitled to (Name of Pest Control company) service guarantees only if . Customer has complied with all of the following: . Performs proper post-service cleaning as directed . Review of the facility's policy titles Insect and Rodent Control, effective 3/01/10, revealed: .The facility should have a pest control program to minimize the presence of . insects on the premises . Review of the facility's policy titled Bed Bugs, effective 6/02/14, revealed: PURPOSE: To prevent the spread of bed bugs STANDARD: The facility will make every effort to promptly identify and treat bed bugs . steps will be taken to remove the environmental source or sources of bed bug infestation and to prevent the spread to other resident/guest(s). PR[NAME]ESS: . II. LAUNDRY DEPARTMENT a. Provide plastic bags (may include dissolvable plastic bags for washing clothes) for laundering and for storing clothes. b. Wash laundry items in hot water with detergent and dry in dryer on high heat for 20 minutes to kill all stages of bed bugs . III. ENVIRONMENTAL SERVICES a. Vacuum all cracks and crevices of room and furniture where bedbugs were discovered. b. Post vacuuming, furniture should be moved to center of room and dresser drawers opened to assist the PMP (Pest Management Professional) c. Mattress should be vacuumed and put into encasements, then cracks and crevices of bed frames vacuumed . Review of an undated facility document titled Emergency Q.A.P.I. Meeting Minutes revealed bed bugs were noted in one resident room (RL #1) on 5/09/19. These minutes outlined the following Safety plan for resident(s) identified: . clothes secured per protocol, showered, . moved to another room . Review of the facility's Quality Assurance Committee Action plan, dated 5/09/19, revealed the following: .Quality Issue/Problem Bed bugs noted in one resident room (RL #1) . Action 1. both residents received shower and clothing change, clothes/linens secured/washed per protocol . residents moved to another room . rooms secured per policy . Review of pest control treatment logs from 5/2019 through present revealed positive bed bug activity in the facility as follows: - 5/10/19 bed bugs noted during treatment on bed by door in RL #1 - 5/16/19 bed bugs noted during treatment; bed bugs crawling on wall in RL #1 - 5/22/19 bed bugs noted during treatment on curtains in RL #1 - 5/23-5/24/19 bed bugs noted during treatment in RL #s 1, 2, 4 and 5; day room and dining room also treated - 6/16/19 bed bugs noted during treatment; bed bugs on bed by door in RL #1 On 6/19/19 at 5:45 p.m., an interview was conducted with Employee Identifier (EI) #14, a Certified Nursing Assistant (CNA). EI #14 was asked if she had ever seen any pests in the facility. EI #14 said yes, bed bugs. EI #14 reported she had seen bed bugs in RL #1, 4, and 6, and indicated RI #41 (who resided in RL #1) had been bitten. EI #14 said pest control had been in and identified the bugs as bed bugs. EI #14 further stated pest control had told them it was the worst bed bug infestation he had ever seen. EI #14 said on 6/5/19, pest control had also identified bed bugs on a couch in the facility lobby. On 6/20/19 at 12:03 p.m., an interview was conducted with EI #17, a CNA. When asked if she was aware of any pest problems in the facility, EI #17 said yes, she had seen bed bugs in RL #4 on 6/03/19. On 6/20/19 at 2:54 p.m., an interview was conducted with EI #13, a CNA. When asked if she had seen bed bugs in the facility, EI #13 said yes, she had seen them in RL #1. EI #13 said they were instructed to to take the residents in RL #1, RI #41 and RI #105, to their room, strip them down, put a hospital gown on them, and take them to the shower. However, EI #13 indicated another CNA came and got RI #41 and took him/her to another room on Station 2 before she could give the resident a shower. EI #13 said she then stripped RI #105 down, put him/her in a gown, and another CNA came and took the resident to a different room on Station 2 to be showered. On 6/21/19 at 10:39 a.m., an interview was conducted with the facility's pest control company. The pest control technician stated he had started treating for bed bugs approximately one month prior. The pest control technician also confirmed he had told staff it was the worst infestation of bed bugs he had ever seen. On 6/21/19 at 11:54 a.m., an interview was conducted with EI # 3, the Director of Maintenance. EI #3 said one of the CNAs reported to the nurse that the resident in RL #1 (RI #41) was putting toilet paper in his/her ears because there were bugs in his/her room. EI #3 then stated he felt staff needed more training on proper bed bug procedures because staff moved RI #41 and RI #105 from RL #1 into another room prior to showering them. EI #3 said he felt this caused the bed bugs to spread to other rooms. When asked if all of the rooms had been vacuumed per the facility policy, EI #3 said he could not say RL #5 had been vacuumed because he thought someone had just walked into that room with a bug on them. When asked what was done to treat RL #5 after the bed bugs were identified, EI #3 said he picked up the bug and flushed it, and had pest control spray the room. When questioned as to how the mattresses were handled in the rooms with bed bugs, EI #3 said the one in RL #1 was thrown away, but the ones in the other rooms only had the mattress covers taken off and run through the washer and dryer. On 6/21/19 at 12:53 p.m., an interview was conducted with EI #4, Housekeeping/Laundry Director. When asked what policy was followed when handling resident's clothing and cleaning rooms identified with bed bugs, EI #4 said the Bed Bug policy. EI #4 said staff were instructed to move the furniture to the center of the rooms, clean top to bottom, thoroughly wipe down beds, night stands and TVs with bleach or pinesol and let everything sit for a few days to be sure the bugs were dead. EI #4 said maintenance was supposed to take down the curtains and privacy curtains in the rooms identified with bed bugs. EI #4 said he was not sure this was done in RL #5. When asked if the clothing was removed from RL #5 and laundered per the Bed Bug policy, EI #4 said no. When asked what the concern was in not following the policy in a room identified as having bed bugs, EI #4 said spreading more bugs. On 06/21/19 at 6:48 p.m. an interview was conducted with EI #2, Registered Nurse (RN)/Director of Nursing. EI #2 was asked if she was aware RI #41 and RI #105 were taken out of RL #1 and taken to another room before being showered (after the identification of bed bugs in their room, RL #1). EI #2 replied no, she was not aware of that. EI #2 was asked did they determine why bed bugs were in the new room. EI #2 stated she did not know, but if the residents did not get showered before they were moved, that was probably why it happened. EI #2 was asked if the Bed Bug policy and QAPI plan were followed if the residents were not showered prior to leaving RL #1. EI #2 said if they did not get showered before they went into another room, no, it was not followed and that was a mistake. EI #2 was asked what was the concern with not following the policy and/or QAPI plan concerning bed bugs. EI #2 said there would be a risk for spreading them.

Based on observation and interview the facility failed to ensure the controlled box containing narcotics, in the Station 1 medication storage room, was permanently affixed to the inside of the refrigerator. This was observed on 6/20/19 at 10:30 AM during the medication storage observation and affected one of two medication storage rooms observed. Findings include: On 6/20/19 at 10:30 AM the surveyor and Employee Identifier (EI) #12, a Registered Nurse (RN)/Unit Manager, observed the medication storage room on Station 1. EI # 12 was asked if there was a secured box for controlled refrigerated medications. EI #12 replied, yes it is the locked box. EI # 12 was then asked if the locked box was permanently affixed to the refrigerator. EI #12 said the locked box was affixed to the shelf in the refrigerator. EI #12 was asked if the shelf was permanently affixed to the refrigerator, and EI #12 proceeded to pull on the shelf, removing the shelf along with the locked controlled medication box. On 6/20/19 at 10:40 AM, EI #12 was asked if the controlled medication lock box, in the Station 1 medication storage refrigerator, was securely affixed to the refrigerator. EI #12 stated it was not secure. On 6/21/19 at 6:48 PM, EI #2, Director of Nursing (DON), was asked how the narcotic storage box should be in the refrigerator in the medication storage room. EI #2 stated, It should be firmly affixed to the refrigerator and behind two locks. EI #2 was then asked if the shelf that the box was attached to was able to be removed was the box firmly affixed. EI #2 replied, No.

Based on observation, interview, and review of a facility policy titled, Medication Administration Procedures, Eye Drops , the facility failed to ensure that a Licensed Nurse did not take multi-use items into a resident's room and place them on an unclean surface during medication administration of eye drops, then return and place items in the medication cart without first cleaning the items. This deficient practice affected Resident Identifier (RI) # 93, one of one resident observed receiving eye drops, and one of six total residents observed during medication administration observations. Findings include: Review of the facility policy titled, Medication Administration Procedures, Eye Drops, dated 03/11, revealed the following: . Procedures 1. Leave the . outside box on the medication cart. Only take the actual eye drops container into the resident's room. 2. Obtain a clean barrier and place on over-bed table . On 6/19/19 at 4:31 PM, Employee Identifier (EI) #11, a Licensed Practical Nurse (LPN), was observed administering medications to RI #93. EI #11 obtained sani cloths, a tissue box, and RI #93's eye drops, then placed them on the bedside table, without first laying down a barrier. After administering medications, she then returned to the medication cart and placed these items on top of the cart, without first cleaning them. On 6/19/19 at 04:45 PM, EI # 11 was asked why she took the container of sani cloths, the box of tissues, and the box with the eye drops, into the resident's room. EI # 11 said because she was going to clean the bedside table, but her hands were full so she just set it all down. EI #11 explained she should have taken one sani cloth and one tissue into the room. EI #11 was asked what would be the potential harm in placing a multi-use container, such as the sani cloth container, the box of tissues, and the box with eye drops, on the resident's bedside table with no barrier, then returning those items to the medication cart without cleaning them. EI #11 replied that germs could spread, causing cross contamination. On 6/21/19 at 6:48 PM, EI #2, the Director of Nursing, was asked if a nurse should take a box of tissues, a container of sani cloths and a box of eye drops into the resident's room and place them on the bedside table without a barrier, then return them to the cart without cleaning them. EI #2 said no, because that was definitely an infection control issue.

Based on observations, interviews and review of a job description for the Director of Maintenance, the facility failed to ensure Room Locator (RL) #s 19-26 were free of chipped paint and splintered plywood on walls, broken chair rail moulding, scuffed and chipped paint on door facings, misaligned furniture drawers, soap dispenser off wall, broken toilet tissue holder, dangling TV cable and wheelchairs with tape on armrests. This was observed on three of four days of the survey and affected RL #s 19-26, eight of 81 rooms in the facility. Findings Include: A facility document titled, JOB DESCRIPTION . JOB TITLE: Director of Maintenance, with a review date of 6/30/03, documented: . B. DEPARTMENTAL FUNCTIONS . 9. Maintain appearance of building and provide necessary repairs and painting as needed. 23. Paint interiror/exterior surfaces. 26. Repair departmental equipment . On 6/18/19 at 8:51 a.m., the surveyor observed the dresser in RL #19 with the top 2 drawers misaligned, and the 4th drawer difficult to open. On 6/18/19 at 9:17 a.m., the surveyor observed RL #20 with the bathroom soap dispenser and toilet paper holder off the wall. The resident in RL #20 reported that he/she had reported these items to maintenance, who did repair them, but they were now off the wall again. The handle to the bottom drawer of the dresser was half-way detached. On 6/18/19 at 10:50 a.m. the following observations were made: RL #22- the wall at the head of the bed was noted with gouges in the painted plywood applied to the wall. The plywood was splintered. RL #23- the left arm rest of the wheelchair had nursing tape wrapped around it. RL #25- the chair rail moulding around the room was broken at the head of the bed, leaving rough edges. On 6/19/19 at 8:20 a.m. RL #26's door was observed to not completely close and the door facings and wall at the head of the bed had scratched paint. The resident in this room also stated his/her wheelchair was missing a handle (on the brake). On 6/20/19 at 5:13 p.m., the surveyor and Employee Identifier (EI) #3, Director of Maintenance, observed the following: RL #19- the first and second drawers on the dresser were misaligned and the fourth drawer was hard to open. When asked what the concern with the drawers was, EI #3 stated they could be too hard for the resident to open and the drawer could fall out on the resident. RL #20- bottom drawer of the dresser was missing a screw on the handle, causing the handle to dangle. The soap dispenser was off the wall, and the toilet tissue holder was missing half of its mechanism. EI #3 stated this was a problem. RL #21- the TV cable was dangling beside the door over the light switch plate RL #22- the wall at the head of the bed was noted with gouges in the painted plywood applied to the wall. EI #3 was asked what was the concern. EI #3 replied they could get splinters, and it just did not look good. RL #23- the wheelchair armrest was taped with nursing tape. EI #3 agreed it was an issue. RL #25- the chair rail moulding was broken, with sharp, jagged edges. EI #3 observed and agreed it was a hazard. On 6/20/19 at 5:36 p.m. an interview was conducted with EI #3, Maintenance Director, upon conclusion of the observations above. EI #3 was asked what was the concern with the issues that were identified during the rounds. EI #3 answered, someone could get hurt and it just did not look good.

Based on observations and interviews the facility failed to ensure that dietary staff washed their hands after picking up an item from the floor and returning to their assigned task during lunch tray-line on 7/18/18, prevent dietary staff from entering the kitchen with a cloth apron on during the lunch tray-line on 7/18/18 and prevent the use of bowls with water in them . This had the potential to affect 119 residents receiving meals from the kitchen. On 07/18/18 at 11:45 AM EI#6, a dietary employee, was observed to drop a lid on the floor. EI# 6 picked the lid up off the floor with her gloved hands and placed the lid in dishwashing area. EI# 6 was observed to not remove her gloves, wash her hands or put on new clean gloves and she continued to adjust plates and touch items on resident lunch trays. On 07/18/18 at 2:58 PM an interview was conducted with EI# 6. EI# 6 was asked what she is to do if she drops an item on the floor during her duties in the kitchen? EI# 6 stated she should dispose of the item, take her gloves off, wash her hands and put on new gloves. When asked why that would be important EI # 6 stated to keep from spreading germs. When asked why she did not do that when she dropped the lid on the floor, she stated that she knew she should have but it just didn't click to do it because she had so much on her mind. On 07/18/18 at 11:37 AM EI#5, a dietary employee entered into the kitchen with her apron already on placed her purse down, washed her hands and began to assist with the food on the carts. EI#5 did not change her apron before she began placing ice cream on the resident's trays. On 7/18/18 at 3:20 PM EI #5 was asked if she should have had her apron already on when she entered the kitchen. EI# 5 stated no. EI #5 was asked why she did and she stated because she was running behind so she put it on before entering the kitchen. On 07/17/18 at 11:32 AM during tray-line a bowl was observed with droplets of water inside of it. A dietary employee was observed to put pureed lima beans in the bowl on a resident's tray. At 11:41 AM eight additional bowls and one divided plate were also observed with droplets of water on them. During an interview with EI # 7, the Dietary Manager on 07/18/18 at 5:55 PM, EI# 7 stated that staff should remove gloves and wash their hands after picking up an item from the floor and not come in to the kitchen with aprons already on because of cross contamination and it could cause the transfer of germs. EI# 7 also stated that dinner ware should be free of water because it could make residents sick.

Based on observation and interviews the facility failed to ensure: the grease receptacle was free of an accumulation of a grease like substance. This was observed two of three days of the survey. This had the potential to affect all residents receiving meals from the kitchen. On 07/17/18 at 8:58 AM and on 7/18/18 at 5:49 PM the grease bin located outside in the back of the kitchen was observed with a brown thick grease-like substance on the top of the bin behind the lid. On 7/18/18 at 5:49 PM an interview with EI # 7, the Dietary Manager, was conducted. EI# 7 was asked why the grease receptacle whould be free of an accumulation of a grease like substance on the outside of the receptacle. EI # 7 stated because flies and bugs could get stuck on it. anytime your contaminate your gloves Why should the grease bin be free of an accumulation of a grease like substance on the outside of the bin? A. Flies and bugs could get stuck up on it What is the potential harm of a staff member entering into the kitchen with an apron on and performing their assigned duties such as placing ice cream on residents's meal trays? A. Cross Contamination Why should dinner ware be free of droplets of water when food items are placed on them for resident consumption A. Infection Control What is the potential harm of placing food items on dinner ware with droplets of water which were served for resident consumption? A. Infection control can harm them What is wet nesting? A. When dishes are not air dried and are stacked What is the potential harm for a dietary staff member to pick up an item from the floor and to continue their assigned task without washing their hands.? A. Infection control and cross contamination Reviewed by Ms. (NAME REDACTED)

Based on a review of a facility policy titled, Pre-Admission Screening for Mental [MEDICAL CONDITION] and Mental Illness, record reviews and interviews, the facility failed to ensure a level II PASARR was completed for RI (Resident Identifier) # 118 transitioning from rehabilitation short term care to long term care. This affected one of 32 residents whose PASARRs were reviewed. RI #118's PASARR (Preadmission Screening for Mental [MEDICAL CONDITION] and Mental Illness) Level I dated 11/07/17, documented the resident has a [DIAGNOSES REDACTED]. The Level II dated 11/20/17, documented the resident was receiving restorative nursing such as Physical Therapy five times a week for four weeks for gait training and therapeutic exercise for short term care. Section VII of the level II documented that if the status changed to long term and or rehab stopped a significant change Level I screening was required within 14 days. Another Level II should have been completed when the resident transitioned from short term care to long term care. On 07/18/18 at 4:23 PM the surveyor conducted an interview with a representative of the Alabama Omnibus Budget Reconciliation Act (OBRA) Office by phone and inquired if the resident was to receive a Level II due to transitioning from short term care for PT to Long Term Care. The representative reviewed the resident's information and confirmed that the resident was to receive another Level II due to transitioning from short term for therapy care to long term care. On 7/19/18 at 7:43 AM EI#4, the facility social worker was interviewed. EI#4 stated that another Level II screening should have been completed when the resident transitioned from short term care for rehabilitation services to long term care because it was considered as a significant change. EI# 4 stated it was missed.

Based on observation, interview and review of a facility policy Hand Hygiene, the facility failed to ensure: 1) licensed staff did not check tube placement without gloves for Resident Identifier (RI) #12 then without washing her hands return to the medication cart to prepare RI #12's medication; 2) a licensed staff did not drop a tablet on the medication cart then pick up the tablet with her bare hands and place it on the pill splitter. She further failed to wash her hands when leaving RI #26s room and returned to the medication cart. Findings Include: A review of a facility policy Hand Hygiene with an effective date of 9/1/17 revealed: PURPOSE: To provide guidelines to employees for proper and appropriate hand washing techniques that will aide in the prevention of transmission of infections. STANDARD: Hand washing should be performed between procedures with resident .based upon the principle that all blood, body fluids .may contain transmissible infectious agents III. Hand Hygiene .Upon and after coming in contact with a resident . 1) RI #12 was admitted to the facility 8/4/15 and readmitted [DATE] with a [DIAGNOSES REDACTED]. A review of RI #12's (MONTH) (YEAR) Physician order [REDACTED]. TABLET GIVE 1 TAB TID (three times a day) PER GTUBE (by gastrostomy tube) . On 7/17/18 at 12:02 PM Employee Identifier (EI) #3 Licensed Practical Nurse, cleaned the over bed table in RI #12's room then removed her gloves and washed her hands. EI #3 checked gastrostomy placement for RI #12 without gloves and flushed the gastrostomy tube. EI #3 then left RI #12's room and returned to the medication cart and prepared RI #12's [MEDICATION NAME] medication. EI #3 took the medication from the medication cart without washing her hands crushed the medication, clicked the computer screen and returned to RI #12's room to administer the medication On 7/17/18 at 12:35 PM an interview was conducted with EI #3, LPN. EI #3 was asked when should you wash your hands. EI #3 replied, before going in and if you go out and reenter the room you should wash your hands. EI #3 was asked if she washed her hands before returning to the medication cart. EI #3 replied, no. EI #3 was asked if she washed her hands after checking the placement of RI #12's tube before leaving the room. EI #3 replied, no. EI #3 was asked what was the harm in not washing your hands when leaving a resident's room before returning to the medication cart. EI #3 replied, spreading germs from the resident's tube then to the medication cart. 2) RI #26 was admitted to the facility 12/1/95 and readmitted [DATE] with a [DIAGNOSES REDACTED]. A review of RI #26's (MONTH) (YEAR) Physician order [REDACTED]. [MEDICATION NAME] 20 mg .[MEDICATION NAME] FORTE 2 mg give 1/2 tab . On 7/17/18 at 4:17 PM EI #2, Registered Nurse was observed giving medication to RI #26. EI #2 removed [MEDICATION NAME] from the medication card and placed in a medication cup. EI #2 removed a [MEDICATION NAME] tablet and placed it in a medication cup, she then took the pill splitter from the cart and poured the [MEDICATION NAME] tablet on the splitter. The tablet dropped on top of the medication cart. EI #2 picked up the tablet with her bare hands and placed it on the pill splitter and cut the tablet in half then placed it in a medication cup. EI #2 removed the [MEDICATION NAME] tablet and placed it in a medication cup. EI #2 poured the Valporic acid in a medication cup. EI #2 took all the medications and a cup of water and entered RI #26's room. EI #2 pulled gloves from her uniform pocket and put them on, then proceeded to check tube placement and administered the medications. EI #2 used all the water she carried in to RI #26's room and required more. EI #2 removed her gloves left RI #26's room and returned to the medication cart and poured more water without washing her hands. EI #2 returned to RI #26's room with the water and placed it on the over bed table. EI #3 took gloves from her uniform pocket, put them on and continued with the water flush. On 7/17/18 at 4:36 PM an interview was conducted with EI#2. EI #2 was asked where did she get the gloves from. EI #2 replied, from my pocket. EI #2 was asked if her uniform pocket was clean. EI #2 replied, no. EI #2 was asked why was her uniform pocket not considered clean. EI #2 replied, because it had been against her body. EI #2 was asked what was the harm in using gloves from her pocket that was not clean. EI #2 replied, spreading germs. EI #2 was asked what was the policy when a medication dropped on the medication cart. EI #2 replied, you should discard it. EI #2 was asked if she discarded the tablet and got another. EI #2 replied, no. EI #2 was asked why she did not get another tablet; she replied, she did not know. EI #2 was asked when she left RI #26's room to get more water, what should she have done. EI #2 replied, washed her hands. EI #2 was asked if she washed her hands. EI #2 replied, no. EI #2 was asked why not. EI #2 replied, she was not thinking. On 7/18/18 at 5:30 PM an interview was conducted with EI #1, Director Nursing, Infection Control Nurse. EI #1 was asked what was the policy on what staff should do when leaving a resident's room. EI #1 replied, wash their hands. EI #1 was asked if it would be an acceptable practice for a nurse to check gastrostomy tube placement without gloves and without washing her hands then return to the medication cart to prepare resident medication. EI # 1 replied, no. EI #1 was asked what would the harm be in a nurse not washing her hands when completing tube placement verification then returning to the medication cart to prepare medication. EI #1 replied, the spreading of germs and infection control issues. EI #1 was asked what the policy was when a nurse dropped a tablet on the medication cart while preparing a resident medication. EI #1 replied, they should discard it and get another one. EI #1 was asked what was the policy on where to get gloves from if needed during medication administration. EI #1 replied, they should get them from a glove box on the medication cart or in the resident rooms. EI #1 was asked when should a nurse remove gloves from her uniform pocket to use during medication administration. EI #1 replied, never. EI #1 was asked if a nurse's uniform pocket would be considered clean or dirty. EI #1 replied, dirty. EI #1 was asked what was the harm in a nurse using gloves she pulled from her uniform pocket to administer medications. EI #1 replied, spread germs and infection control. EI #1 was asked when should staff wash their hands during the medication pass. EI #1 replied, before starting, after completing and in between medications if needed, definitely before returning to the medication cart. EI #1 was asked what was the harm in a nurse not washing her hands when leaving a resident room and returning to the medication cart. EI #1 replied, spreading germs and cross contamination.

Based on observations, staff interviews, review of medical records, Potter & Perry FUNDAMENTALS of NURSING Ninth Edition and a facility policy titled Nebulizer, the facility failed to ensure: 1) Resident Identifier (RI) #7's nebulizer mask was stored covered on two of two days of the survey, and 2) laundry staff applied Personal Protective Equipment (PPE) prior to handling dirty linen on 06/01/17. These deficient practices affected RI #7, one of one resident observed with a nebulizer machine, and had the potential to affect all 133 residents utilizing linen at the facility. Findings Include: 1) A facility policy titled Nebulizer with an effective date of May 1, 2004 documented: . PROCESS: . V. e) Store in a plastic bag . RI #7 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. RI #7's May 2017 Physician order [REDACTED].> . IPRAT-ALBUT ([MEDICATION NAME]) 0.5-3(2.5) MG (milligrams)/3 ML (milliliters) GIVE 1 VIAL PER UPDRAFT BID (twice a day) FOR COPD (Chronic Obstructive Pulmonary Disease) . On 05/31/17 at 3:02 p.m., the surveyor observed that RI #7's nebulizer mask was not stored in a covering. On 06/01/17 at 7:33 a.m., RI #7's nebulizer mask remained uncovered. On 06/01/17 at 9:29 a.m., the surveyor observed the medication nurse, Employee Identifier (EI) #4, administer a scheduled nebulizer treatment to RI #7. The surveyor asked EI #4, how should the nebulizer mask be stored. EI #4 said the mask should be stored in a plastic bag. When asked what the rational was for ensuring the mask was stored covered. EI #4 said the mask was to be stored in a covering to keep it clean and keep dust from collecting on the mask. On 06/01/17 at 12:33 p.m., the surveyor conducted an interview with EI #2, a Registered Nurse Unit Manager. The surveyor asked EI #2, how did the facility store the nebulizer masks. EI #2 said in a Ziploc bag. The surveyor asked EI #2 why should the nebulizer mask be stored in a covering. EI #2 replied, To protect it from extra germs or dust particles that may be in the room, just to keep it clean. On 06/01/17 at 2:05 p.m., the surveyor conducted an interview with EI #1, the Director of Nursing/Infection Control Nurse. The surveyor asked EI #1, how did the facility store the nebulizer mask. EI #1 said the mask should be covered in a bag. The surveyor asked EI #1 what was the reason for having the mask covered. EI #1 replied, To keep it clean. 2) On June 1 2017 at 9 a.m., the surveyor observed the laundry department and process used to handle the residents' laundry and facility linen. During this observation, one staff member was processing all of the laundry. Soiled laundry coming in was sorted and placed into the washing machines, then clean laundry was removed and placed into a dryer by the same laundry assistant. After the laundry was dry, the same laundry assistant folded the laundry and placed it on the shelf, ready for use. No use of Personal Protective Equipment (PPE), gown or apron and gloves was observed. A review of Potter and Perry's, FUNDAMENTALS of NURSING (Ninth Edition, copyright date of 2017) by Elsevier Inc. revealed in chapter 29, page 458: Infection Prevention and Control . UNIT V Foundations for Nursing Practice .To prevent transmission of microorganisms through individual contact do not allow soiled items .to touch your clothing. A common error is to carry dirty linen in the arms against your uniform .Page 461 details .Personal Protective Equipment. The PPE, specialized clothing or equipment (e.g., gowns, masks, or respirators, protective eyewear and gloves) that you wear for protection against exposure to infectious materials, should be readily available . (CDC/Centers for Disease Control, 2007). You choose the equipment to use depending on the task to be performed . On 6/01/2017 at 9:15 a.m., the surveyor asked the laundry assistant, EI #5, if she wore PPE when separating dirty linen for washing. EI #5 explained, if it was something viral, she could get PPE, but on a daily routine, she did not use PPE. EI #5 was asked if she wore the same uniform to move the washed (clean) laundry to the dryer. EI #5 replied that she did. EI #5 was then asked if she wore the same uniform to fold the clean laundry. EI #5 replied yes. EI #5 was asked what potential harm could occur to the residents if not wearing PPE when sorting dirty linen, transferring clean washed linen to the dryer, then folding the clean linen all while wearing the same uniform. EI #5 replied it was harmful to the residents because she had contaminated the clean clothes with the germs from her contaminated uniform. On 06/01/1717 at 11:30 a.m., an interview was held with EI #6, the Housekeeping Supervisor. EI #6 was asked if she was the manager of the laundry. EI #6 replied that she was. EI #6 was asked why the laundry assistants did not wear PPE when sorting soiled laundry for the halls. EI #6 stated they were supposed to wear an apron and gloves when sorting soiled laundry. EI #6 was asked why there was no PPE available in the laundry. EI #6 replied that it had been an oversight and as soon as she had been made aware of this, she had provided PPE for the laundry assistant. EI #6 was asked what was the potential harm to the residents of not wearing PPE when sorting soiled laundry, then handling clean linens with the same uniform. EI #6 replied, cross contamination. On 06/06/17 at 2:05 p.m., the surveyor conducted an interview with EI #1, the Director of Nursing/Infection Control Nurse. The surveyor asked EI #1 what type PPE should the laundry staff use when working with soiled linen. EI #1 replied, Gowns and gloves. The surveyor asked EI #1 what was the rationale for using PPE. EI #1 replied, To not contaminate the clean linen or clothes.

Based on observation, medical record review and interviews with staff, the facility failed to ensure the wire rack to which the locked narcotic box was secured, was permanently affixed to the interior of a medication room refrigerator. Two medication cards of Marinol 2.5 mg (milligrams), belonging to Resident Identifier (RI) #25, were observed inside the locked narcotic box. This deficient practice affected RI #25, one of one residents with medications in the locked narcotic box, and involved one of the facility's three medication rooms. Findings Include: RI #25 was admitted to the facility on [DATE], and readmitted on [DATE], with a [DIAGNOSES REDACTED]. RI #25's May Physician order [REDACTED].> . MARINOL 2.5 MG CAPSULES GIVE 1 CAP (capsule) PO (by mouth) BID (twice daily) . On 06/01/17 at 1:32 p.m., the surveyor conducted an observation of the medication room with a Licensed Practical Nurse, Employee Identifier (EI) #3. The surveyor observed a locked narcotic box, secured to the wire rack inside the medication refrigerator. The box contained two medication cards of Marinol 2.5 mg capsules belonging to RI #25. The surveyor observed, as EI #3 pulled the wire rack, that the rack was not permanently affixed to the interior of the refrigerator. The surveyor asked EI #3 if the wire rack was permanently affixed to the refrigerator. EI #3 said no. On 06/01/17 at 2:05 p.m., the surveyor conducted an interview with the Director of Nursing, EI #1. The surveyor asked EI #1 how should the rack in the refrigerator be when there were narcotics in the locked box. EI #1 replied, Should be affixed to the refrigerator so you can't pull the rack out.

Based on observation, interviews and record review, the facility failed to ensure the final rinse temperatures of the dish machine were maintained between 180 and 194 degrees Fahrenheit (F) as recommended. This affected all 127 residents for whom meals were prepared and served at the time of this survey. Findings Included: The 2013 Food and Drug Administration Food Code mandates the hot water sanitization temperatures for the dishmachine under regulation 4-501.112(A)(2) as follows: .in a mechanical operation, the temperature of the fresh hot water sanitizing rinse as it enters the manifold may not be more than 194 degrees F or less than: .180 degrees F. During the initial tour of the Dietary Department on 05/10/16 at 2:15 PM, the Dish Machine Temperature Log included 8 of 29 rinse temperatures (28%) during the month of May, in excess of the 194 degree F recommendation (between 195 and 198 degrees F). The Dish Machine Temperature Log for the month of April 2016 included 28 of 90 total rinse temperatures (31%) in excess of 194 degrees F. These temperatures ranged between 195 and 199 degrees F. The Dish Machine Temperature Log for the month of March 2016 listed 26 of 93 final rinse temperatures greater than 194 degrees F (28%), ranging between 195 and 198 degrees F. On 05/11/16 at 11:40 AM, the dish machine repair technician was in the department. The Certified Dietary Manager (Employee Identifier) EI #3 explained the water temperatures on the dishmachine were not reaching the required temperatures. The surveyor asked the technician what he determined to be the problem. The technician explained he discovered the contacter had two of eight burned-out contacts, and he had replaced the contacter unit. When the surveyor asked if the water temperature could be too hot, the technician stated the recommended temperatures were 150 degrees F (wash) and 180 degrees F (rinse). The technician stated, I suppose it could be too hot but provided no recommendation for an upper temperature limit. On 05/11/16 at 6:27 PM, the surveyor observed the staff as they processed the supper dishes through the dish machine. The final rinse temperature of the dish machine rose to 240 degrees F, then dropped back down to 195 degrees F. The surveyor asked the staff member EI #4, dietary aide, operating the dish machine what she observed as the final rinse temperature. EI #4 responded she had seen 196 degrees F. On 05/11/16 at 6:40 PM, the surveyor asked the Dietary Manager, EI #3, if she was aware of the Food Code regulation regarding recommendations for the final rinse temperatures of a hot water dish machine. EI #3 was not aware of the recommendation. At this point, the surveyor and EI #3 checked the final rinse temperature of the dish machine (in progress). The thermostat registered 250 degrees F.

Based on observations, interview and record review, the facility failed to ensure Room Locator (RL)#s 1-22's dresser drawers were in good working condition, chair armrests were intact, skid strips on bathroom flooring were intact, walls were free of holes and scrapes and sinks were free of rust stains. This affected 22 of 79 resident rooms on three of three nursing units. Findings Include: A review of a facility policy titled,Scheduling and Record Keeping with an effective date of 03/01/2010 revealed the following: .STANDARD: The Maintenance Supervisor is responsible for the .completion .of all preventive maintenance and repairs . During the initial tour on 05/10/2016 the following observations were made: 1) RL #1: Side B chair armrest torn 2) RL #2: Side A's mattress with rips and bathroom floor with skid strips coming up 3) RL #3: Side B's chair armrest torn and wall with scrape marks 4) RL #4: Side A with middle drawer missing a handle and bathroom skid strips coming up 5) RL #5: Side A second drawer with missing handle 6) RL #6: Side A first drawer with missing handle 7) RL #7: Wood trim missing on wall at head of bed and head of bed scratched 8) RL #8: Screw holes in wall as well as scraped paint on the walls 9) RL #9: Side A with scraped paint on wall and inside bathroom sink an orange rust like substance 10) RL #10: Side B with scraped paint on wall at the head of the bed and inside bathroom sink a orange rust like substance 11) RL #11: Bathroom tile wall with holes and side A wall with holes and scraped paint 12) RL #12: Inside of bathroom sink a orange rust like substance as well as around the base of the faucet; side A's wall with scraped paint and hole in wall above baseboard 13) RL #13: Scraped paint above light switch; black substance behind base of commode 14) RL #14: Side A's wall scraped paint; Side B's wood trim on wall at head of bed cracked and wall scraped 15) RL #15: Inside bathroom sink with an orange rust like substance 16) RL #16: Side A's wall with scraped paint; side B's wall at head of bed with scraped paint 17) RL #17: Side A behind head of bed with large scraped area on wall; side B hole in wall next to A/C (Air Conditioning) unit; inside bathroom sink with orange rust like substance 18) RL #18: Side B's wall behind head of bed with scraped paint 19) RL #19: Inside bathroom sink with orange rust like substance 20) RL #20: Room sink with orange rust like substance on inside; side B's tile window seal with chipped tile and wall area under window seal with scraped paint 21) RL #21: Bathroom wall tile with crack 22) RL #22: Room sink with wood behind it not painted On 05/12/2016 between 8:45 AM and 2:23 PM, the above concerns were shown to the Maintenance Director. On 05/12/2016 at 2:28 PM, an interview was conducted with EI (Employee Identifier) # 2, Maintenance Director. EI #2 was asked who was responsible for ensuring needed repairs were fixed. EI #2 said he was. EI #2 was asked how rooms were assessed for needed repair. EI #2 explained he walked around every day in the morning and evening. EI #2 further explained they depended on CNA (Certified Nursing Assistant) to report things to maintenance. EI #2 was asked who was responsible for monitoring resident rooms. EI #2 explained maintenance depended on the CNA's to report items in need of repair. EI #2 was asked how often rooms were monitored for good repair and condition. EI #2 explained every month. EI #2 was asked why rooms should be monitored for ensuring furniture was in good condition as well as bathroom sinks, walls and flooring. EI #2 explained for the safety of the residents. EI #2 was asked why rooms should be in good repair such as walls, bathroom sinks, floors and mattresses. EI #2 explained the appearance of walls were important, sinks should be in good working condition for residents and mattresses should be in good condition. EI #2 was asked why walls should be free of holes and scraped paint. EI #2 explained rooms should be in good condition. EI #2 was asked why drawers to resident bedside tables should be in good repair. EI #2 explained so residents would not have a hard time getting into them. EI #2 was asked why should chairs in residents rooms be in good repair. EI #2 replied, You don't want a torn chair in the room. EI #2 further explained family may visit and they would not want them to see holes in chairs or walls. EI #2 further replied, The appearance is important.

Based on record review, observation and interview, the facility failed to ensure a CNA (Certified Nursing Assistant) separated RI (Resident Identifier) #14's labia and cleaned and used a disposable wipe only once before discarding it during incontinent care on 5/11/2016. The facility also failed to ensure a CNA wiped front to back and did not use a wash cloth more than once without changing corners during the incontinent care of RI #12 on 5/12/2016. This affected two of two sampled residents with a history of UTI (Urinary Tract Infection) who were observed during incontinent care. Findings Include: A review of a facility policy titled, Perineal Care with an effective date of October 1, 2010 revealed: .PROCESS: . II.a) .Separate the labia and wash downward on each side of the labia using different corners of the wash cloth. 1) RI #14 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #14's most recent Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 03/07/2016 revealed the resident had severely impaired cognition for daily decision making. The MDS also revealed the resident was totally dependent on staff for toilet use and personal hygiene. The MDS further revealed the resident was always incontinent of bowel and bladder. A review of RI #14's DISCHARGE SUMMARY dated 04/23/2014 revealed: .Urine culture was positive for mixed bacteria species. A review of RI #14's HISTORY AND PHYSICAL dated 04/23/2014 revealed: .Urinalysis shows .leukocytes 3+, protein 1+, blood 2+. On 5/11/2016 at 4:14 PM, EI (Employee Identifier) #5, CNA, was observed performing incontinent care for RI #14. EI #5 washed her hands and donned gloves. EI #5 then performed perineal care for the resident. EI #5 did not separate the labia and clean. EI #5 cleaned bm from the resident, wiping the resident's buttocks twice with the same wipe. On 5/12/2016 at 12:45 PM, an interview was conducted with EI #5. EI #5 was asked how many times a disposable wipe should be used before discarding it. EI #5 said one wipe per swipe then toss it. EI #5 was asked how many times she wiped RI #14's buttocks with the disposable wipe before she discarded it. EI #5 said two times. EI #5 was asked what the potential harm was if she wiped the same area more than once with a disposable wipe. EI #5 said the spread of infection. EI #5 was asked if the labia should be separated and cleaned during perineal care. EI #5 said yes. EI #5 was asked if she separated RI #14's labia and cleaned. EI #5 said no ma'am. EI #5 was asked why she did not separate RI #14's labia and clean. EI #5 said she was nervous and confused. EI #5 was asked what the potential harm was if she did not separate the labia and clean. EI #5 said risk of infection. 2) RI #12 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #12's most recent Quarterly MDS with an ARD of 4/11/2016 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 8, which indicated the resident was moderately impaired for daily decision making. The MDS also revealed the resident was totally dependent on staff for toilet use and required extensive assistance for personal hygiene. The MDS further revealed the resident was always incontinent of bowel. A review of RI #12's urinalysis dated 02/03/2016 revealed: .URINALYSIS . LEUKOCYTES 3+ (500) . PROTEIN 2+ (100) . WBC (WHITE BLOOD CELLS) >182 . A review of RI #14's urine culture dated 04/14/2016 revealed: .URINE CULTURE Final >100, 000 organisms/ml (milliliter) MIXED BACTERIAL SPECIES . On 5/12/2016 at 9:24 AM, EI #6, CNA, was observed performing incontinent care for RI #12. EI #6 wiped up the resident's buttocks with a washcloth in several places without changing the corner of the washcloth. EI #6 wiped up and down on the resident's buttocks with the same washcloth. On 5/12/2016 at 9:52 AM, an interview was conducted with EI #6. EI #6 was asked in what direction she wiped RI #12's buttocks. EI #6 said she did wipe down, she was so nervous. EI #6 was asked in what direction were buttocks supposed to be wiped. EI #6 said up. EI #6 was asked why she wiped down on the resident's buttocks. EI #6 said she was nervous. EI #6 was asked what the potential harm was if she wiped in the wrong direction when cleaning the buttocks. EI #6 said she could cause a urinary tract infection. EI #6 was asked if she cleaned RI #12's buttocks without turning the washcloth. EI #6 said she thought she did turn the washcloth. EI #6 was asked what the potential harm was if she wiped with the washcloth without changing the corners. EI #6 said the same germs were put back on the resident.

Based on record review, observation and interview, the facility failed to ensure a CNA (Certified Nursing Assistant) washed her hands after cleaning bm (bowel movement) and performing perineal care for RI (Resident Identifier) #14 and before she touched and applied a clean brief to the resident during incontinent care on 5/11/2016. The facility also failed to ensure a CNA changed gloves and washed her hands after cleaning bm and before she performed perineal care and catheter care and before she touched and applied a clean brief to RI #12 on 5/12/2016. This affected two of two sampled residents observed during incontinent care. Findings Include: A review of a facility policy titled, Hand Hygiene with an effective date of December 1, 2009 revealed: .STANDARD: Hand washing should be performed between procedures with residents based upon the principle that all .body fluids, secretions, excretions .may contain transmissible infectious agents. A review of a facility policy titled, Contact Precautions with an effective date of December 1, 2009 revealed: .II. GLOVES AND HAND HYGIENE Hand hygiene should be completed prior to donning gloves. B. Gloves should be changed after having contact with infective material (e.g., (for example) fecal material . 1)RI #14 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #14's most recent Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 03/07/2016 revealed the resident had severely impaired cognition for daily decision making. The MDS also revealed the resident was totally dependent on staff for toilet use and personal hygiene. The MDS further revealed the resident was always incontinent of bowel and bladder. On 5/11/2016 at 4:14 PM, EI (Employee Identifier) #5, CNA, was observed performing incontinent care for RI #14. EI #5 washed her hands and donned gloves. EI #5 then performed perineal care for the resident. EI #5 changed gloves and placed the clean brief underneath the resident. EI #5 cleaned bm from the resident, changed gloves and pushed the brief further underneath the resident. EI #5 wiped the resident's buttocks, placed the brief on the resident, positioned the resident for comfort and then removed gloves and washed her hands. EI #5 did not wash her hands before donning new gloves. On 5/12/2016 at 12:42 PM, an interview was conducted with EI #5. EI #5 was asked when hands should be washed/sanitized during incontinent care. EI #5 said after changing gloves at least twice and after touching the soiled brief. EI #5 was asked when did she wash/sanitize her hands during RI #14's perineal care. EI#5 said she washed before she began and after she finished. EI #5 was asked what she should have done after cleaning RI #14's perineal area and before she touched the clean brief. EI #5 said wash her hands and change gloves. EI #5 was asked what she should have done after cleaning bm from RI #14 and before touching the clean brief. EI #5 said wash her hands and change gloves. EI #5 was asked why she did not wash her hands after cleaning the perineal area and wiping bm before touching the clean brief. EI #5 said she was nervous and was trying to do everything perfect and she forgot. EI #5 was asked what the potential harm was if she did not wash her hands after cleaning the perineal area and wiping bm before touching and placing the clean brief on the resident. EI #5 said risk of infection. 2) RI #12 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #12's most recent Quarterly MDS with an ARD of 4/11/2016 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 8, which indicated the resident was moderately impaired for daily decision making. The MDS also revealed the resident was totally dependent on staff for toilet use and required extensive assistance for personal hygiene. The MDS further revealed the resident was always incontinent of bowel. On 5/12/2016 at 9:24 AM, EI #6, CNA, was observed performing incontinent care for RI #12. EI #6 washed her hands and donned gloves. EI #6 cleaned the resident's buttocks with a washcloth after the resident had a large incontinent bm. EI #6 cleaned the resident's perineal area and catheter with a washcloth. EI #6 removed her gloves and touched the clean brief without washing her hands. EI #6 did not wash her hands or change her gloves in between cleaning bm and cleaning the perineal area and catheter. On 5/12/2016 at 9:52 AM, an interview was conducted with EI #6. EI #6 was asked what should have been done after cleaning bm from RI #12 and before cleaning the resident's front perineal area and catheter. EI #6 said wash her hands and change her gloves. EI #6 was asked if she washed her hands and changed her gloves at that time. EI #6 said no. EI #6 was asked what the potential harm was in not washing her hands when she went from cleaning bm to cleaning the perineal area and catheter tubing. EI #6 said infection control. EI #6 was asked what she should have done after cleaning bm and the resident's perineal area before she touched the clean brief. EI #6 said remove her gloves, wash her hands, put on clean gloves and then get the brief out. EI #6 was asked what the potential harm was in not changing gloves and washing hands after cleaning bm and cleaning the perineal area and catheter tubing before touching the clean brief. EI #6 said infection control. On 5/12/2016 at 1:42 PM, an interview was conducted with EI #1, DON (Director of Nursing)/Infection Control Nurse. EI #1 was asked how infections were prevented in the facility. EI #1 said they had weekly infection control meetings and she pulled the infection log for that week. EI #1 said she tried to determine if it was a pattern and they would do education with that CNA. She said they also did check-offs. EI #1 was asked how infections were controlled in the facility. EI #1 said through education, check-offs and training. EI #1 was asked if direct care staff were washing their hands and changing gloves according to facility protocol. EI #1 said she trained them to and they were supposed to. EI #1 was asked how she monitored direct care staff to ensure they were washing their hands and changing gloves according to facility protocol. EI #1 said they had pass offs every month. EI#1 was asked when should hands be washed and gloves changed during incontinent care. EI #1 said gloves should be changed when contaminated and hands should be washed every time gloves were changed. EI #1 was asked what the potential harm was in not washing hands or changing gloves when going from a dirty area to a clean area during incontinent care. EI#1 said infection.

Based on observations, interviews and record reviews, the facility failed to ensure a Certified Nursing Assistant (CNA) knocked on Resident Identifier (RI) #25's room door prior to entering on 5/11/16. This affected one out of 27 resident rooms located on Station III. The facility further failed to ensure a CNA knocked on RI #4's room door prior to entering on 5/12/16. This affected one out of 27 rooms located on Station I. Findings Include: A review of a facility policy titled, Privacy Upon Entering Resident's Room with an effective date of November 6, 2014 revealed: .PROCESS: 1. Prior to entering Resident's room, knock on door and ask permission to enter. 1)RI #25 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #25's most recent Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 04/15/2016 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15, which indicated the resident was cognitively intact. On 5/11/2016 at 3:34 PM, EI (Employee Identifier) #7, CNA was observed to walk into RI #25's room without knocking. On 5/11/2016 at 6:05 PM, an interview was conducted with RI #25. RI #25 was asked how it made her/him feel when staff walked into their room without knocking and asking permission. RI #25 said, Vulnerable, I have a fear of being away from home. I don't like anybody just walking in. They do it all the time. On 5/12/2016 at 12:55 PM, a telephone interview was conducted with EI #7. EI #7 was asked what should be done before entering a resident's room. EI #7 said knock. EI #7 was asked if she could tell the surveyor why she was observed walking into RI #25's room without knocking. EI #7 said she might get side tracked sometimes, but she did try to knock. EI #7 was asked what the potential harm was when she entered a resident's room without knocking. EI #7 said it would make them feel like it was not their home and they did not have any privacy. 2) On 5/12/16 at 8:15 AM, a CNA entered room [ROOM NUMBER] while the surveyor was talking with a resident. The CNA informed RI #4 that she was going to give him/her a shower that morning. The surveyor asked the CNA, what she was trained to do when entering a resident's room. The CNA, EI #8, replied, I knock on the door and see about the residents. EI #8 was asked, did she do that. EI # 8 said she did not remember. The surveyor told her that she had forgotten to knock on the door. EI #8 said she had knocked earlier when she came in but she must have forgotten to knock this time. RI #4 had a BIMS score of 14 out of 15, which meant she/he was cognitively intact. RI #4 was asked how it made her/him feel when someone entered the room without knocking. RI #4 said sometimes it was embarrassing if they (the visitor) caught the resident undressed.

Based on observations, interviews, and record reviews, the facility failed to ensure dietary staff contained their hair in a manner to prevent potential contamination. This occurred on one of three survey days and had the potential to affect 140 residents that receive a meal from the kitchen. Findings include: A review of the facility's document titled, "DIETARY SERVICE MANUAL Section: Sanitation, Safety and Infection Control Policy Title: Use of Gloves and Hairnets ... Effective Date: August 15, 2009," revealed, "PROCESS: ... i. Wear hair restraints (bonnets, caps, nets, to cover hair) when preparing or handling food." A review of the Food Code Manual dated 2013, revealed, "Hair Restraints, 2-402.11 Effectiveness (A) ... FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE AND SINGLE-USE ARTICLES." An observation was made during dishwashing on 04/02/2015 at 9:00 AM of EI (Employee Identifier) #1, a Dietary Aide, removing clean dishes from the dishwasher. EI #1 had several strands of hair hanging out from the the back of the hair net. An observation was made on 04/02/2015 at 9:15 AM of EI #2, a Dietary Manager, walking into the kitchen with hair hanging out of the hair net from the front, both sides, and from the nape of her neck. An observation was made on 04/02/2015 at 9:20 AM of EI #3, a Dietician, walking through the kitchen with no hair net on. An interview was conducted on 04/02/2015 at 10:45 AM with EI #1. EI #1 was asked when should hair be contained in a hair net. EI #1 stated, "In the kitchen, preparing snacks or doing something in the kitchen." EI #1 was asked what does the facility's policy state about containing hair in a hair net. EI #1 stated, "Wear hair restraints, (bonnets, caps, nets, to cover hair) when preparing or handling food." EI #1 was asked what was the concern with hair not being contained in a hair net while working in the kitchen. EI #1 stated, "It can get all in the food and utensils and dishes." An interview was conducted on 04/02/2015 at 10:55 AM with EI #2. EI #2 was asked when should hair be contained in a hair net. EI #2 stated, "When you're handling food and around food." EI #2 was asked what does the facility's policy state about containing hair in a hair net. EI #2 stated, "Wear hair restraints (bonnets, caps, nets to cover hair) when preparing or handling food." EI #2 was asked what was the concern with hair not being contained in a hair net while working in the kitchen. EI #2 stated, "Contamination, hair in the food, hair flies-when you stand under the ventilation." An interview was conducted on 04/02/2015 at 10:58 AM with EI #3. EI #3 was asked when should hair be contained in a hair net. EI #3 stated, "Upon entry and at all times in the kitchen." EI #3 was asked what does the facility's policy state about containing hair in a hair net. EI #3 stated, "Wear hair restraints (bonnets, caps, nets, to cover hair) when preparing or handling food." EI #3 was asked what was the concern with hair not being contained in a hair net while working in the kitchen. EI #3 stated, "The concern would be that any hair that would fall could bring unwanted debris (hair)."

Based on observations, interviews, and record reviews, the facility failed to ensure: 1) Walls were not found with the paint surface loose or splitting 2) Holes were left unfilled and painted over 3) A ceiling was not found with two different colors 4) A chair rail was not gouged and splintered 5) A bathroom door was not found heavily scuffed and splintered. This affected AL (Area Locator) #s 1 through 17, 17 of 152 resident rooms. Findings include: A review of a facility policy titled, "MAINTENANCE POLICY AND PROCEDURES ... Resident Environmental Quality ...," with an effective date of March 1, 2010, revealed, "... PURPOSE: The facility should be designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel, and the public. ..." A review of the facility document titled, "Job Description," assigned to EI (Employee Identifier) #7, the Maintenance Director, with a review date of 06/30/03, revealed, "... Standard Requirements ... 4. Support, cooperate with, and implement specific procedures and programs for: a. ... equipment repair and maintenance needs." During the tour of the facility on 3/31/2015 at 5:34 PM, the bathroom door (inside) of AL #2 was observed to be scuffed and splintered. The door was a golden/brown color and the scuffed area was pale white on the inside of the door at the bottom. The scuffed area measured approximately 12 inches at the highest point and approximately 10 inches long. The splintered area was on the bottom of the door closest to the hinges. On 4/2/2015 an observation was made at 10:21 AM of the same bathroom door of AL #2 with no changes observed from the 3/31/2015 findings. An observation was made on 4/1/2015 at 8:40 AM of AL #3. The wall and chair rail were found chipped, gouged and splintered. An observation was made on 04/02/2015 at 3:04 PM of AL #3. A square shaped area on the wall, behind the resident's bed was painted blue, while the rest of the wall and room was painted white. Scratches were noted on the chair rail and the wall near the window was scratched. On 4/1/15 at 12:37 PM, AL #11 was observed with the painted wall covering torn in 3 places and separating from the wall. On 4/1/15 at 5:59 PM, an observation was made of AL #10. The walls were observed to have the blue wall covering splitting over the head of the bed and at 2 places in the bathroom. The ceiling was noted to be painted with a beige colored paint over approximately 1/4 of the ceiling while the remaining portion of the ceiling was white. An observation was made on 4/2/15 at 8:27 AM of AL #16. The wall covering was loose. The area was also noted to have multiple scuff marks behind the head of the bed painted over. The surface had not been smoothed before being painted. An observation was made on 4/2/15 at 8:28 AM of AL #17. The wall covering was loose from the wall. An observation was made on 4/2/15 at 8:29 AM of AL #15. The wall covering was loose and split over the closet doors. An observation was made on 4/2/15 at 8:31 AM of AL #14. The wall covering was loose and split in the bathroom. An observation was made on 4/2/15 at 8:34 AM of AL #13. The wall was scuffed heavily at the head of the bed and there were 2 holes in the wall that were unfilled and painted over. An observation was made on 4/2/15 at 8:36 AM of AL #12. The wall covering was loose and splitting. There were two large screws in the wall that were painted over. Observations were made on 4/2/2015 at 1:07 PM on the following AL #s: AL #1- There were areas where the paint was chipped, paint scraped on the board, peeling wall paper in the bathroom, and tiles chipped and missing. AL #4- There was a dark brown stain on the ceiling. AL #5- There were areas behind the bed with paint missing and the wall paper was peeling behind the bed on the right side of the bed. AL #6- There was chipped paint on the wall above the bed and there were stains on the ceiling. AL #7- There were rust-like stains around the base of the toilet. AL #8- There was chipped paint on the wall where the door was located. In addition, there were stains and holes in the ceiling. AL #9- There were stains on the ceiling. A tour was conducted with EI #6, the Administrator, and EI #7, on 4/2/15 at 9:56 AM. After touring the ALs listed above, both were asked if these conditions would be considered clean, comfortable and homelike. They both responded no. An interview was conducted with EI #7 on 4/2/15 at 2:01 PM. EI #7 was asked what he observed on the ceiling of AL #10. He answered, "Spots up there, needs to be painted." EI #7 was asked what he observed on the walls in AL #s 10 and 11. He answered, "Cracks and bubbles." He was asked if this was considered clean, comfortable and homelike. EI #7 answered, "No." EI #7 was asked if paint should be over uneven walls, chips in the walls, and holes that were unfilled in the walls. He answered, "No." EI #7 was asked if he had observed these during the tour with EI #6. He answered, "We did." An interview was conducted with EI #6 on 4/2/15 at 2:10 PM. EI #6 was asked what did she observe on the ceiling of AL #10. She answered, "Two different colors of paint." EI #6 was asked what did she observe with the wall coverings in AL #s 10 and 11. She answered, "It's coming away from the wall." EI #6 was asked if these findings were considered clean, comfortable and homelike. She answered, "It's not real home-like."