Every finding on record at Prattville Health and Rehabilitation, LLC

Based on observations, interviews, and review of the facility's policy for Cycle Menus, the facility's Week 4 Week-At-A-Glance menu for June 5-11, 2022, the facility's Diet Guide Sheet for Day 24 (Week 4 - Tuesday), the facility's Diet Guide Sheet for Day 25 (Week 4 - Wednesday), and the facility's posted conversion information for portion control Dishers, the facility failed to ensure the menu was followed when: 1.) pears were not served at dinner on Tuesday, 6/7/2022, 2.) the specified 1/2 cup (4-ounce) serving of pudding for lunch on Wednesday, 6/8/2022, was being portioned with a #10 disher (3.25 ounces), and 3.) the Chicken and Dumpling alternate for dinner on Wednesday, 6/8/2022, had a 4-ounce (oz.) spoodle for trayline service, although the menu specified a 6 oz. portion was to be served. This had the potential to affect all residents receiving meals from the facility's kitchen, 136 of 138 residents. Findings Include: The facility's policy for Cycle Menus, dated 10/1/2005, included the following: . Purpose: To meet the nutritional needs of resident/guest(s), in accordance with the recommended dietary allowances (RDA) of the Food and Nutrition Board of the National Research Council, standard menus are utilized. Standard: The facility should use a minimum of a three-week cycle menu written and planned at least one week in advance. Process: . c. Menus should have portions stated in ounces, and/or measurements. d. Menus are revised by the Registered Dietitian and Dietary Manager based on resident/guest food preferences. Reasons for change should be noted and kept on file. f. Menus should be approved and signed by the Registered Dietitian. 1.) The facility's Diet Guide Sheet for dinner on Day 24 (Week 4 - Tuesday) included a 4-ounce serving of pears for each of the four diet menus listed: Regular, Mechanical Soft, Pureed, and Consistent Carbohydrate (Diabetic Meal Plan). On 6/7/2022 at 5:18 PM, the surveyor observed the residents' supper trayline in progress and being operated by the evening cook and two aides. The evening cook was Employee Identifier (EI) #19. The evening aides were EI #21 and a new employee, EI #20. At 5:24 PM, an observation revealed no pears on the trayline and no fruit substitute was being served. At 5:42 PM, the surveyor looked at a printed menu on one of the trays being prepared and saw pears listed as one of the printed menu items to be served. The surveyor asked EI #21 and EI #19 if they were putting pears on the trays. Both said no. On 6/7/2022 at 6:11 PM, the surveyor observed ten #10 cans of Pear Halves in the Dry Storeroom. The posted menu sheet listed pears, but no pears were dished up for service. EI #16, the Dietary Manager, was asked about the pears missing on the resident trays. EI #16 asked the staff on the dinner trayline why the pears were not prepared. EI #19, the cook, said they were not on her sheet. EI #16 was able to show EI #19 that Pears was the last item listed (after Iced Tea) on the Supper Menu for Tuesday, June 7th on the Week 4 Week-At-A-Glance menu and that it had been overlooked/missed. The Registered Dietitian (RD), EI #17, was interviewed on 6/9/2022 at 4:23 PM. When asked why it was important for the menu to be followed, EI #17 said, so the residents get the nourishment they need during the day. We have guidelines for all the essential nutrients needed for our residents. 2.) On 6/8/2022 at 9:27 AM, EI #22, a morning dietary aide, was observed dipping up Vanilla Pudding for Lunch. The facility's Diet Guide Sheet for lunch on Day 25 (Week 4 - Wednesday) documented a serving size of 1/2 cup (4 oz.) for Pudding at Lunch for each of the four diet menus listed: Regular, Mechanical Soft, Pureed, and Consistent Carbohydrate (Diabetic Meal Plan). EI #22 was using a #10 scoop/disher (3.25 oz.) instead of a #8 scoop/disher (4 oz.). When EI #22 was asked why she was using this size scoop, EI #16, the Dietary Manager, had EI #22 increase the serving amount. The surveyor observed that the document titled Dishers (the conversion sheet for scoop/disher numbers and portion sizes) posted on the kitchen wall did not include the conversion for a 1/2 cup serving. The RD, EI #17, was interviewed on 6/9/2022 at 4:23 PM. When asked what was the potential concern if correct portion sizes were not used, EI #17 said the residents will not get the nourishment that they needed. 3.)The facility's Diet Guide Sheet for dinner on Day 25 (Week 4 - Wednesday) documented a 6 oz. serving size for Chicken & (and) Dumplings, which was the alternate menu item. During a lull in serving at on 6/8/2022 at 5:15 PM, the surveyor asked EI #19 what size spoodle she was using for the Chicken & Dumplings. EI #19 looked at the spoodle and said it was a 4 oz. The RD, EI #17, was interviewed on 6/9/2022 at 4:23 PM. When asked what was the potential concern if correct portion sizes were not used, EI #17 said the residents will not get the nourishment that they needed.

Based on observations, interviews, and review of the 2017 Food Code of the United States (U.S.) Public Health Service and the U.S. Food and Drug Administration (FDA), the facility's [DATE] refrigeration temperature logs for Unit 1, Unit 2, and the Dementia Unit, and the facility's policies for Dish Machine Sanitization, the policy for Foods from Families and Friends, and the policy titled, Nursing Pantry Foods, the facility failed to ensure 1.) the dishwashing machine consistently reached the minimum sanitizing temperature of 180 degrees Fahrenheit (F) on Wednesday, [DATE], and Thursday, [DATE]; 2.) the air dryer used for drying clean dishes did not have a dirty filter on Tuesday, [DATE], and Wednesday, [DATE]; 3.) the veneer of the door in the dishroom was not peeling away from the door surface in large pointed sections on Tuesday, [DATE]; 4.) the kitchen ceiling paint was not peeling away from the ceiling in the dishroom and over the three-compartment sink on Wednesday, [DATE]; 5.) there were lens covers over three fluorescent light fixtures in the kitchen, one in the dishroom and two over the trayline, to protect against shattering fluorescent light tubes on Wednesday, [DATE]; and 6.) nourishment refrigerators on Unit 1, Unit 2, and the Dementia Unit were being monitored for safe food-holding temperatures of 41 degrees F or below and did not contain unlabeled or expired items on Wednesday, [DATE], and Thursday, [DATE]. This had the potential to affect 136 residents receiving meals from the kitchen, 136 of 138 residents. Findings Include: 1.) The 2017 Food Code of the U.S. Public Health Service and the FDA included the following: . ,d+[DATE].112 Mechanical Warewashing Equipment, Hot Water Sanitation Temperatures. (A) . in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90 [degrees] C [Centigrade] (194 [degrees] F), or less than: . (2) . 82 [degrees] C (180 [degrees] F). Th facility's policy Dish Machine Sanitization, dated [DATE], included the following: . Purpose: To prevent the spread of bacteria that may cause food borne illnesses. . Process: . c. Dish machine . rinse . temperatures should be recorded at the beginning of each dishwashing period and observed periodically during the dishwashing process. On [DATE] at 9:43 AM, the machine dishwashing of breakfast dishes was observed. Employee Identifier (EI) #23, a dietary aide, was on the dirty side of the dishroom and EI #24, a dietary aide, was on the clean side. At 09:48 AM the Final Rinse dial on the dishwashing machine was observed. The temperature was not reaching 180 degrees F, instead it was holding at 162 degrees F. At 9:57 AM the Final Rinse temperature was still holding steady at 162 degrees F. Seven racks of dishes had gone through the dishwashing machine. The surveyor asked each aide what the Final Rinse temperature should be. EI #23 and EI #24 each said the Final Rinse temperature should be 180 degrees F. The surveyor asked EI #23 to watch Final Rinse dial. EI #23 saw it was not rising to 180 F. The surveyor asked EI #23 when was the Final Rinse checked for this wash period. EI #23 asked EI #24 if he checked it that morning. EI #24 said yes and pointed to the temperature log hanging on the dishroom wall. Surveyor asked EI #23 what was she supposed to do if the Final Rinse was not working. EI #23 said tell EI #16, the Dietary Manager. At 9:58 AM the Dietary Manager, EI #16, watched the Final rinse Dial with the surveyor. The Final Rinse temperature reached 180 degrees F once when an empty rack was sent through and there was no back-up of racks coming through the machine. At 10:05 AM the Registered Dietitian (RD), EI #17, and the surveyor watched the final rinse dial. As two racks of dishes were going through, the Final Rinse temperature was holding between 164 to 166 degrees F. The Final Rinse did not reach 180 degrees F. At 11:40 AM the dishwashing machine repair person arrived at the facility. At 12:30 PM the dishwashing machine repair person said hot water from the kitchen hot water tank was not hot enough and the booster heater was not able to compensate. On [DATE] at 9:12 AM, EI #24 and EI #20, a dietary aide, began to start the machine dishwashing of breakfast dishes. The surveyor was observing with the RD, EI #17. At 9:15 AM the first rack of dirty dishes was sent through. The Final Rinse temperature was 178 degrees F. The rack was resent through the machine with the Final Rinse temperature reaching 186 F. Additional racks were sent through with the Final Rinse temperatures reaching 190 degrees F and 188 degrees F. At 9:22 AM the Final Rinse temperature reached 186 degrees F. At 9:32 AM EI #17, the RD, was no longer present in the dishroom. Two racks had gone through and were sitting at end of the dishmachine counter. EI #20 was putting up clean dishes. A third rack was sent through by EI #24. The Final Rinse temperature only reached 176 degrees F. Surveyor called EI #24's attention to this. The rack was sent through again after EI #20 removed the two racks blocking the dishwashing counter exit. The Final Rinse was 188 degrees F. The Dietary Manager, EI #16, was interviewed on [DATE] at 3:25 PM. During the interview, EI #16 said the dishwashing machine repair person told her that the racks backing up could cause the machine to shut off. In addition, EI #16 said the plumber told her that the hot water tank for the kitchen needed to be set at 140 degrees F so the booster heater could boost the temperature up another 40 degrees. The RD, EI #17, was interviewed on [DATE] at 4:23 PM. EI #17 was asked what was the problem with the Final Rinse of the dishwashing machine not reaching a minimum of 180 degrees F. EI #17 said the dishes would not be properly sanitized for our residents and through contamination it could potentially harm our residents. 2.) The 2017 Food Code of the U.S. Public Health Service and the FDA included the following: ,,, ,d+[DATE].13 Heating, Ventilating, Air Conditioning System Vents. . shall be installed so that . exhaust vents do not cause contamination of . FOOD-CONTACT SURFACES, EQUIPMENT, or UTENSILS. On [DATE] at 5:40 PM the filter of the forced-air drying mechanism (SanAire) in the dishwashing area was observed to be blocked with debris. The mechanism was blowing air onto clean dishes at the exit of the dishwashing machine. On [DATE] at 9:43 AM, the machine dishwashing of breakfast dishes was observed. A rack of cleaned plates and bowls were seen under the forced-air drying mechanism. Air was blowing over dishes. The filter of the forced air-drying mechanism was still partially clogged with debris. At 10:05 AM, the RD, EI #17, and the surveyor observed dishwashing and the air blowing on cleaned dishes from the forced-air drying mechanism was pointed out . When asked if the filter for this forced-air drying mechanism was clean, EI #7 said no. The Dietary Manager, EI #16, was interviewed on [DATE] at 3:25 PM. During the interview, EI #16 said the forced-air drying mechanism's filter being clogged with debris was her fault because she had not trained the employees on how to clean it. EI #16 said the filter needed to be cleaned at least once weekly, but preferably daily. EI #16 further said she needed to work with Maintenance on getting a new filter. The RD, EI #17, was interviewed on [DATE] at 4:23 PM. EI #17 was asked what was the problem with the forced-air drying mechanism's filter being clogged with debris and the unit being operated to blow air over washed dishes to dry them. EI #17 said we don't want dust particles or any foreign debris being blown onto clean dishes because of the potential for cross-contamination. 3.) The 2017 Food Code of the U.S. Public Health Service and the FDA included the following: . ,d+[DATE].11 Surface Characteristics. (A) . materials for indoor . wall . surfaces under conditions of normal use shall be: (1) Smooth, durable, and EASILY CLEANABLE for areas where FOOD ESTABLISHMENT operations are conducted; . On [DATE] at 5:40 PM, the veneer of the door to the dishroom was observed to be peeling away from the surface in large pointed sections. The RD, EI #17, was interviewed on [DATE] at 4:23 PM. When asked if the splintered veneer on the door in the dishwashing area would this be a problem, EI #17 said yes, because it cannot be cleaned properly. 4.) The 2017 Food Code of the U.S. Public Health Service and the FDA included the following: . ,d+[DATE].11 Surface Characteristics. (A) . materials for indoor . ceiling surfaces under conditions of normal use shall be: (1) Smooth, durable, and EASILY CLEANABLE for areas where FOOD ESTABLISHMENT operations are conducted; . On [DATE] at 10:11 AM, paint was observed peeling from the ceiling in the dishroom. Some of the peeling ceiling paint was over the clean dish storage area. On [DATE] at 12:34 PM, the Director of Maintenance, EI #18, was interviewed in the kitchen area. At 12:41 PM EI #18 was asked about the peeling ceiling paint in the dishwashing room and over the three-compartment sink. EI #18 said it was due to humidity and that he was ordering a new exhaust fan to deal with it. The RD, EI #17, was interviewed on [DATE] at 4:23 PM. During the interview, EI #17 was asked what was the potential problem of peeling ceiling paint in the dishroom and over the three-compartment sink. EI #17 said potential contamination. 5.) The 2017 Food Code of the U.S. Public Health Service and the FDA included the following: . ,d+[DATE].11 Light Bulbs, Protective Shielding. (A) . light bulbs shall be shielded, coated, or otherwise shatter-resistant in areas where there is exposed FOOD; clean EQUIPMENT; UTENSILS, . On [DATE] at 10:11 AM, one of four light fixtures in the dishroom was missing a lens cover. The fluorescent tube did not appear to have a sleeve cover. On [DATE] at 12:34 PM, the Director of Maintenance, EI #18, was interviewed in the kitchen area. EI #18 was asked what means did the facility have to protect against shattered fluorescent bulbs/tubes. EI #18 said they just had the lens covers to protect from shattered fluorescent bulbs/tubes. He further said there were no sleeves for the bulbs/tubes. When asked to explain what was the problem with no protection from shatter, EI #18 said physical contamination and someone could be critically injured. the surveyor pointed out the three light fixtures in the kitchen without lens covers. EI #18 said he had no replacement lens covers. The RD, EI #17, was interviewed on [DATE] at 4:23 PM. During the interview, EI #17 was asked what was the potential problem of having no lens cover for the fluorescent light fixtures in the dishwashing area and over the resident trayline. EI #17 said if a light burst there would be contamination. 6.) The facility's policy Foods from Families and Friends, dated [DATE], included the following: . 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. Process: . 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 . and discarded after 72 hours. The 2017 Food Code of the U.S. Public Health Service and the FDA included the following: . ,d+[DATE].16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) . TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: . (2) At 5 [degrees] C (41 [degrees] F) or less. ,d+[DATE].17 Ready-To-Eat, Time/Temperature Control for Safety Food, Date Marking. . (B) . (2) . the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. ,d+[DATE].18 Ready-To-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD . shall be discarded if it: . (2) Is in a container or PACKAGE that does not bear a date or day . The facility's policy Nursing Pantry Foods, dated [DATE], included the following: Purpose: Foods are made available at each nursing station for resident/guest(s) who may feel hungry between meals. Process: . b. Food items should be rotated (First In, First Out Method) to preserve freshness. c. Any temperature dependent foods should be stored properly on the nursing units; . During the initial kitchen tour on [DATE] at 3:25 PM, the Milk Cooler in the Dry Storage Room was found to have five individual 8-ounce (oz.) Skim Milks with an expiration date of 6 [DATE] ([DATE]). The Dietary Manager, EI #16, said the Milk delivery person removed expired product and she expected him to come tomorrow [DATE] (Wednesday). EI 16 said they marked items to be removed if items expired before Milk delivery person came. EI #16 said she was going to identify the five Skim Milks with a sign to alert dietary staff not to use it. On [DATE] at 5:33 PM, an observation was made of the nourishment refrigerator on the Dementia Unit. The refrigerator contained bottled water, 4-oz. [NAME], and 8-oz. milk. Printed at the top of the temperature log posted on the refrigerator was the following: RECORD OF REFRIGERATION TEMPERATURES, RANGE IS ,d+[DATE] DEG. (degrees) F. The temperature log included a temperature of 42 degrees F noted on [DATE]. On [DATE] at 5:39 PM, an observation was made of the nourishment refrigerator on Unit 2. At 05:42 PM the thermometer in the refrigerator read 41 degrees F. The refrigerator contents included the following items: one 8-oz. Skim Milk, expiration date: 6 [DATE], three 8-oz. Whole Milk, expiration date: 4 [DATE], two 8-oz. Whole Milk, expiration date: 5 [DATE], an unmarked styrofoam food container in a black plastic bag, and an unmarked covered styrofoam cup with a straw. The temperature log did not have a printed temperature range. The last temperature recorded on the log was for [DATE] at 0500 (5:00 AM) for 42 degrees F. On [DATE] at 5:54 PM, an observation was made of the nourishment refrigerator on Unit 1. The refrigerator contents included the following items: one 8-oz. Skim Milk, expiration date: 06 Jun 22 and one 8-oz. Whole Milk, expiration date: 04 Jun 22 that had an AM (morning) nourishment label for a resident, dated Wednesday ,d+[DATE] ([DATE]). The [DATE] temperature log on the front of the refrigerator had the following printed at the top: RECORD OF REFRIGERATION TEMPERATURES, RANGE IS ,d+[DATE] DEG. F. On [DATE] at 11:25 AM, a Licensed Practical Nurse (LPN), EI #13, was interviewed on Unit 2. EI #13 worked on both the night and day shifts. When asked who recorded the temperature of the Nourishment Refrigerator, EI #13 said the night nurse. EI #13 said she had recorded the temperature when she worked night shift. Upon being asked how she knew what a safe refrigerator temperature was for storing food, EI #13 said it had a range on the temperature log. When asked who checks for and disposes of expired/outdated items, EI #13 said the night nurse or anybody who sees the outdated item. When asked what was allowed in the nourishment refrigerator, EI #13 said snacks brought from the Cafeteria for residents to eat, juices, drinks, Ensure, and ice cream. EI #13 was asked if a friend or family member brings in food that needs to be refrigerated for a resident, what is the procedure. EI #13 said the resident's name and the date is written on a sticky paper and put on the item. EI #13 further said the date and the time are included so they know when to discard it. Upon being asked when the item should be discarded, EI #13 said to let her check, it was on the paper. EI #13 referred to a memo posted on the front of the Unit 2 nourishment refrigerator and said three days. The temperature log posted on the Unit 2 nourishment refrigerator was observed to have the following printed across the top: ENTERAL STORAGE TEMPERATURE LOG. EI #13 was then asked why there was no temperature range on the Unit 2 nourishment refrigerator temperature log. EI #13 said the others have it, I don't know why it is not on there. When asked if she knew what temperature range was used for the refrigerator, EI #13 got a blank form titled Record of Refrigeration Temperatures and pointed to the documented temperature range listed, ,d+[DATE] degrees F. On [DATE] at 11:53 AM, a LPN, EI #14, was interviewed on the Dementia Unit. The surveyor looked into the Dementia Unit nourishment refrigerator with EI #14 and found an opened bottle of Ionized Water without a name or date. EI #14 said the Night Shift Nurse usually records the refrigerator temperature around 2 or 3 AM and removes any unmarked items. EI #14 was asked how did she know what was a safe temperature for storing food. EI #14 said I know at home it should be 38 to 40 degrees Fahrenheit. EI #14 further said they do have it on the top of the Temperature Log, it says 36 to 46 degrees Fahrenheit on the June temperature log. When asked who would check for and dispose of expired/outdated items, EI #14 said in the refrigerator, the Night Shift Nurse did. EI #14 said the only things allowed in the nourishment refrigerator were snacks, milk, juice, and items belonging to a resident. EI #14 further said if an item was opened, it should be dated and covered. When asked what was the procedure if a friend or family member brought in food that needed to be refrigerated for a resident, EI #14 said it is covered and the name of the resident and date are placed on the item. When asked how long the brought in item can be kept, EI #14 said I think 2 days or 48 hours. On [DATE] at 12:10 PM, a LPN, EI #15, was interviewed on Unit 1. When asked who recorded the temperature of the nourishment refrigerator, EI #15 said she believed it is the third shift (night) nurse. Upon being asked how she knew what a safe refrigerator temperature was for storing food, EI #15 said it should have a guideline on the top of the temperature log. When asked who checks for and disposes of expired/outdated items, EI #15 said Dietary staff would do that. EI #15 said the only items allowed in the nourishment refrigerator were the snacks for the residents and any food for a resident. When asked what was the procedure if a friend or family member brought in food that needed to be refrigerated for a resident, EI #15 said we date it, put the resident's name on it, put it in the refrigerator, and let the resident know it is in there. EI #15 further said the staff can get it for the resident when they want it. Upon being asked how long the item can be kept, EI #15 said it could not be kept past 3 days. EI #15 read from the temperature log that 36 to 46 degrees F was the acceptable refrigeration temperature. The surveyor observed the following in the Unit 1 nourishment refrigerator: one 8-oz. Skim Milk, expiration date: 06 Jun 22 and one 8-oz. Whole Milk, expiration date: 04 Jun 22. The Dietary Manager, EI #16, was interviewed on [DATE] at 3:25 PM. EI #16 did not know who was responsible for recording the temperatures for the nourishment refrigerators on the Nursing Units. When asked if she provided any training or temperature logs for the nourishment refrigerators, EI #16 said no. When asked how would the the individuals recording the temperatures for the nourishment refrigerators know what the safe temperature range was for refrigerated food storage, EI #16 said she did not know because she did not know who trained them. Upon being asked who was responsible for checking for expired or out-dated items in the nourishment refrigerators, EI #16 said she do not know who was responsible, but when she restocked them, if she saw anything outdated, she throws it out. EI #16 was asked what was the potential problem with temperature sensitive foods, such as milk, being held in a refrigerator above 41 degrees F. EI #16 said it could cause sickness, especially if the milk gets hot or if it was way outdated. Upon being asked what was the potential problem with expired milk or other out-dated foods being served to a nursing home resident, EI #16 said we do not serve out-dated milk because it could cause illness. When asked if a temperature range of 36 to 46 degrees F was acceptable for refrigerated food storage, EI #16 said no, because it should be 41 degrees Fahrenheit or below. The RD, EI #17, was interviewed on [DATE] at 4:23 PM. When asked who was responsible for recording the temperatures for the nourishment refrigerators on the nursing units, EI #17 said she did not know. She assumed it is Nursing. When asked how do staff know what the safe temperature range is for refrigerated food storage for the nourishment refrigerators, EI #17 said she would assume it is on the paper on which they document the temperatures. She had not seen it though. Upon being asked what was the potential problem with temperature sensitive foods, such as milk, being held in a refrigerator above 41 degrees F, EI #17 said it could get spoiled and potentially cause food borne illness. When asked what was the potential problem with expired milk or other out-dated foods being served to a nursing home resident, EI #17 said food borne illness.

Based on observations, interviews, and review of the facility's policy for Garbage and Refuse, and the 2017 Food Code of the United States (U.S.) Public Health Service and the U.S. Food and Drug Administration (FDA), the facility failed to ensure the oil/grease waste receptacle and the four by eight foot area around it did not have a buildup of oil/grease during June 7-9, 2022. This had the potential to affect all the residents in the facility, 138 of 138 residents. Findings Include: The facility's policy for Garbage and Refuse, dated 2/1/2002, included the following: . 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 . The 2017 Food Code of the U.S. Public Health Service and the FDA included the following: . 5-501.13 Receptacles. (A) . receptacles and waste handling units for REFUSE . and for use with materials containing FOOD residue shall be durable, cleanable, insect- and rodent-resistant, leakproof . 5.501.111 Areas, Enclosures, and Receptacles, Good Repair. Storage areas, enclosures, and receptacles for REFUSE . shall be maintained in good repair. 5.501.116 Cleaning Receptacles. (B) Soiled receptacles and waste handling units for REFUSE . shall be cleaned at a frequency necessary to prevent them from developing a buildup of soil or becoming attractants for insects and rodents. During the initial kitchen tour with Employee Identifier (EI) #16, the Dietary Manager, on 6/7/2022 at 3:43 PM, the outside oil/grease waste receptacle was inspected. There was one oil/grease waste receptacle. It was half full. The receptacle was leaking from one of two pipes near the base, the one on the left. There was a buildup of oil/grease on the receptacle, curb, ground, and pavement. The Dietary Manager said EI #17, the consulting Registered Dietitian (RD), had previously told her that it needed to be pressure washed. EI #16 said Maintenance did the pressure washing and sometimes Housekeeping helped her with cleaning it. EI #16 further said she called the company when the oil container needed to be emptied. On 6/7/2022 at 3:45 PM, the surveyor asked EI #16 what was the problem with the container having a buildup of oil/grease and the approximate 7 to 8 foot length area having a buildup of oil/grease on the ground, pavement, and curb. EI #16 said it could cause slips and falls, it did not look appealing, and it could attract rodents. On 6/8/2022 at 12:44 PM, EI #18, the Director of Maintenance, inspected the oil/grease waste receptacle with the surveyor. The receptacle was still dripping oil/grease slowly. The oil/grease spill area was measured by EI #18 and found to be 4 feet by 8 feet. On 6/8/2022 at 12:49 PM, EI #18 was asked what was the potential problem with the oil/grease buildup and the receptacle leaking. EI #18 said it could attract rodents. On 6/9/2022 at 9:58 AM, the oil/grease waste receptacle was observed to be empty. It was the same container, but it not dripping oil/grease, as it was empty. The oil/grease buildup around the container was still present as seen on the two previous days. EI #17, the RD, was interviewed on 6/9/2022 at 4:23 PM. When asked what was the potential problem for a buildup of oil/grease around the outside oil/grease waste receptacle, EI #17 said to attract bugs and rodents.

Based on observation, interviews and review of a facility policy titled, Feeding the Impaired Resident, the facility failed to ensure Resident Identifier (RI) #25 was treated by staff in a manner to maintain dignity when Employee Identifier (EI) #11 Nursing Assistant (NA) stood up to feed RI #25, who was in bed during the breakfast meal on 6/8/2022. This affected one of 28 sampled residents. Findings Include: The facility policy titled Feeding the Impaired Resident with an effective date of 10/1/2010 documented: . Residents should eat in the location of their preference, and should be provided with a pleasant dining environment, regardless of the location. RI #25 was admitted to the facility on [DATE]. 6/8/2022 at 8:19 AM EI #11 NA was observed to enter RI #25's room and set up the breakfast meal tray for RI #25 who was in bed. EI #11 started to feed RI #25 while standing up on the left side of the bed. EI #11 fed the resident from the breakfast tray and provided sips from a cup with a straw all while standing up at RI #25's bedside. Four minutes later at 8:23 AM EI #11 removed the tray from RI #25. On 6/8/2022 at 8:23 AM EI #11 was asked how she fed RI #25. EI #11 stated, she stood up while she fed RI #25. EI #11 was asked what the correct way to feed a resident was. EI #11 replied, sitting. EI #11 was asked why should she sit while feeding a resident. EI #11 replied, for eye contact and dignity. EI #11 was asked should she have been sitting down while she fed RI #25. EI #11 replied, yes. On 6/10/2022 at 8:16 AM RI #25 was feeding him/herself breakfast and was asked about being fed by staff standing next to the bed. RI #25 said, it did bother him/her and the NA should have been sitting next to the bed in a chair. On 6/10/2022 at 10:21 AM the surveyor conducted an interview with EI #2, the Director of Nursing. EI #2 was asked, what was the procedure for feeding a resident. EI #2 replied, sitting down and very engaged with the residents, only touching utensils. EI #2 was asked, when should staff stand next to the bed and feed a resident. EI #2 replied, never. EI #2 was asked, what was the harm in staff standing next to the bed while feeding a resident. EI #2 replied, choking and dignity.

Based on record review, interviews and review of facility policy Pressure Ulcers, the facility failed to ensure weekly wound assessments were accurately completed for Resident Identifier (RI) #114's sacral wound that was documented as a stage three on 5/2/2022. This had the potential to affect RI #114, one of six residents reviewed for pressure ulcers. Findings Include: A review of a facility policy titled Pressure Ulcers with an effective date of October 1, 2010 revealed . Stage III (three) . Full thickness tissue loss. Subcutaneous fat may be visible . Slough may be present . May include undermining and tunneling. Documentation . c) The status of ulcers should be recorded on the Wound Flow Record weekly. RI #114 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #114's Wound Assessment Report dated 5/2/2022 documented as sacral wound that had progressed to a stage three. There was not any documentation or description on the wound assessment to support progression of the wound to a stage three. On 6/10/2022 at 5:14 PM Employee Identifier (EI) #26 Treatment Nurse was asked what prompted RI #114's wound to be stage three. EI #26 replied, the wound had slough in it at that time. EI #26 was asked if she documented slough. EI #26 replied, she did not think she did, but she should have. EI #26 was asked if RI #114's wound assessment would be correct if slough that was observed was not documented. EI #26 replied, no, she guessed not. EI #26 was asked, what would potential harm be in the wound assessment not being accurate. EI #26 replied, if it was not staged correctly it could be worse than initially identified and if all the necessary areas were not completed accurately the information may misrepresent its stage. EI #26 was asked, who monitored her for accuracy in wound assessments and staging. EI #26 replied, they had a new wound care manager but she had only been there a month. On 6/10/22 at 5:51 PM EI #27, Wound Care Manager, RN was interviewed. She was asked how long she had been at the facility; she replied, since April. EI #27 was asked what were her duties. She replied, wound care supervisor. EI #27 was asked what did that entail; she replied, lead wound care meetings, look at the nurses' skin audits, talk to staff and assess residents. EI #27 was asked if she was familiar with RI #114; she replied yes, to the resident but not to the wounds. EI #27 was asked, when had she monitored treatment nurses. EI #27 replied, she had just started a week or so ago going with them. EI #27 was asked, if there was slough in a wound and was not indicated on the assessment sheet would that be an accurate assessment. EI #27 replied, no. EI #27 was asked what would the harm be in inaccurate assessments; she replied incorrect assessments. On 6/10/22 at 6:19 PM, an interview was conducted with the Director of Nursing EI #2. EI #2 was asked, how often treatment nurses were trained on wound assessments. EI #2 replied, nurse consultant comes randomly and does skills check off monthly. EI #2 was asked, how nurses were trained to assess wounds. EI #2 replied, by the nurse consultant, by the flow sheets, and were to enter information on flow sheet, size color and appearance. EI #2 was asked, how did the facility determine treatment nurses were assessing wounds accurately. EI #2 replied, by the nurse consultant training them and monitoring. EI #2 was asked, for RI #114's wound documented as a stage two then as a stage three, what indicated a change. EI #2 replied, she did not know, to go from a stage two to a stage three there would have needed to be slough. EI #2 was asked, if slough was present in a wound should that be indicated on the weekly assessment; she replied, yes. EI #2 was asked, if slough was not recorded, would that assessment be accurate; she replied, no. EI #2 was asked what was the harm in not having accurate weekly wound assessments. EI #2 replied, skin breakdowns and not an accurate assessment.

Based on observations, interviews, resident record review and review of a facility policy titled Hand Hygiene the facility failed to ensure Employee Identifier (EI) #10, Certified Nursing Assistant (CNA), washed and sanitized her hands after delivering and setting up Resident Identifier (RI) #25's meal tray prior to delivering and setting up RI #94's meal tray. This had the potential to affect RI #94, one of 61 total residents on unit one who received meal trays. Findings include: The facility policy titled Hand Hygiene with an effective date of 6/11/2020 documented the following: . PURPOSE: To provide guidelines to employees for proper and appropriate hand washing techniques that will aide in the prevention of the transmission of infections. STANDARD: Hand washing should be performed between procedures with resident/guest(s) based upon the principle that all blood, body fluids, secretions, . may contain transmissible infectious agents. II. Hand Sanitizer If hands are not visibly soiled, use an alcohol-based sanitizer for routinely decontaminating hands . RI #25 was admitted to the facility on [DATE]. RI #94 was readmitted to the facility on [DATE]. On 6/08/2022 at 7:49 AM, EI #10 CNA was observed to take a tray off of the meal cart and enter RI #25's room. EI #10 set RI #25's head of the bed up, turned on a light and pulled the bedside tray over RI #25's bed, patting the bed with her bare hands. EI #10 then, without washing or sanitizing her hands, took a meal tray from the meal cart, to RI #94's room, set up the meal tray and opened milk for RI #94. EI #10 was then asked when she sanitized her hands as she came out of RI #25's room, before picking up another tray and going into RI #94's room. EI #10 said she did not sanitize her hands. When asked why she did not sanitize her hands before going into RI #94's room, EI #10 said, she knew she was supposed to but was busy and forgot. When asked what the risk was of not washing or sanitizing her hands after setting up a resident's meal and before picking up another resident's tray for delivery, EI #10 said, exposure of germs. On 6/10/2022 at 10:11 AM EI #12, Infection Control Nurse, was asked what the procedure was for resident tray delivery and set up. EI #12 said, hand hygiene, take the tray into the room, set up the tray, opening items, cutting meat, and hand hygiene. When asked what the risk was of not washing hands after assisting a resident up in bed without gloves and leaving the room, EI #12 said, there was a risk for the spread of infection. On 6/10/2022 at 10:21 AM EI #2, Director of Nursing (DON), was asked what the procedure was for meal tray delivery and set up. EI #2 said, the CNA should wash or sanitize her hands before and after. When asked what the risk was of not washing your hands after assisting a resident up in bed and leaving the room, EI #2 said, a spread of infection.

Based on interviews, review of the Online Incident Reporting System Reports, and review of the facility policy titled, Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, the facility failed to ensure allegations of abuse were reported to the state agency within two hours. This affected six of twenty reports of abuse reviewed. Findings Include: Review of policy titled, Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation with an effective date of February 8, 2018, documented, .VI. Investigations and Facility Response to Incidents or Accidents . b) Investigations and Reporting Steps .The Administrator/Designee will report to the State Agency .All allegations of abuse .within 2 hours . 1) Review of the Online Incident Reporting System Report regarding, revealed an allegation of physical abuse occurred on 03/24/2021 at 8:48 AM. The allegation of physical abuse was not reported to the State Agency until 04/21/2021 at 5:49 PM. An interview was conducted with Employee Identifier (EI) #1, Administrator/Abuse Coordinator on 10/01/2021 at 9:45 AM. EI #1 stated the facility became aware of the allegation of physical abuse on 03/24/2021 at 8:48 AM and the allegation of physical abuse was reported to the State Agency on 04/21/2021 at 5:49 PM. EI #1 admitted that the facility's abuse policy was not followed regarding reporting to the State Agency within the required timeframe. An interview was conducted with EI #2/Regional Administrator on 10/01/2021 at 12:21 PM. EI #2 admitted the facility's abuse policy was not followed when the allegation of abuse was not report to the State Agency within 2 hours. 2) Review of the Online Incident Reporting System Report, revealed an allegation of physical abuse occurred on 07/23/2021 at 4:00 PM. The allegation of physical abuse was not reported to the State Agency until 07/24/2021 at 9:29 AM. An interview was conducted with EI #1/Administrator/Abuse Coordinator on 10/01/2021 at 9:45 AM. EI #1 stated the facility became aware of the allegation of physical abuse on 07/23/2021 at 4:00 PM and the allegation of physical abuse was reported to the State Agency on 07/24/2021 at 9:29 AM. EI #1 admitted that the facility's abuse policy was not followed regarding reporting to the State Agency within the required timeframe. An interview was conducted with EI #2/Regional Administrator on 10/01/2021 at 12:21 PM. EI #2 admitted the facility's abuse policy was not followed when the allegation of abuse was not report to the State Agency within 2 hours. 3) Review of the Online Incident Reporting System Report, revealed an allegation of verbal abuse occurred on 09/08/2021 at 9:00 AM. The allegation of verbal abuse was not reported to the State Agency until 09/08/2021 at 4:28 PM. An interview was conducted with EI #1/Administrator/Abuse Coordinator on 10/01/2021 at 9:45 AM. EI #1 stated the facility became aware of the allegation of verbal abuse on 09/08/2021 at 9:00 AM and the allegation of verbal abuse was reported to the State Agency on 09/08/2021 at 4:28 PM. EI #1 admitted that the facility's abuse policy was not followed regarding reporting to the State Agency within the required timeframe. An interview was conducted with EI #2/Regional Administrator on 10/01/2021 at 12:21 PM. EI #2 admitted the facility's abuse policy was not followed when the allegation of abuse was not report to the State Agency within 2 hours. 4) Review of the Online Incident Reporting System Report, revealed an allegation of verbal abuse occurred on 09/15/2021 at 8:25 AM. The allegation of verbal abuse was not reported to the State Agency until 09/16/2021 at 1:36 PM. An interview was conducted with EI #1/Administrator/Abuse Coordinator on 10/01/2021 at 9:45 AM. EI #1 stated the facility became aware of the allegation of verbal abuse on 09/15/2021 at 8:25 AM and the allegation of verbal abuse was reported to the State Agency on 09/16/2021 at 1:36 PM. EI #1 admitted that the facility's abuse policy was not followed regarding reporting to the State Agency within the required timeframe. An interview was conducted with EI #2/Regional Administrator on 10/01/2021 at 12:21 PM. EI #2 admitted the facility's abuse policy was not followed when the allegation of abuse was not report to the State Agency within 2 hours. 5) Review of the Online Incident Reporting System Report, revealed an allegation of physical abuse occurred on 09/18/2021 at 6:00 PM. The allegation of physical abuse was not reported to the State Agency until 09/20/2021 at 12:40 PM. An interview was conducted with EI #1/Administrator/Abuse Coordinator on 10/01/2021 at 9:45 AM. EI #1 stated the facility became aware of the allegation of physical abuse on 09/18/2021 at 6:00 PM and the allegation of physical abuse was reported to the State Agency on 09/20/2021 at 12:40 PM. EI #1 admitted that the facility's abuse policy was not followed regarding reporting to the State Agency within the required timeframe. An interview was conducted with EI #2/Regional Administrator on 10/01/2021 at 12:21 PM. EI #2 admitted the facility's abuse policy was not followed when the allegation of abuse was not report to the State Agency within 2 hours. 6) Review of the Online Incident Reporting System Report, revealed an allegation of physical abuse occurred on 07/20/2021 at 12:00 PM. The allegation of physical abuse was not reported to the State Agency until 09/23/2021 at 10:37 AM. An interview was conducted with EI #1/Administrator/Abuse Coordinator on 10/01/2021 at 9:45 AM. EI #1 stated the facility became aware of the allegation of physical abuse on 09/22/2021 at 4:00 PM and the allegation of physical abuse was reported to the State Agency on 09/23/2021 at 10:37 AM. EI #1 admitted that the facility's abuse policy was not followed regarding reporting to the State Agency within the required timeframe. An interview was conducted with EI #2/Regional Administrator on 10/01/2021 at 12:21 PM. EI #2 admitted the facility's abuse policy was not followed when the allegation of abuse was not report to the State Agency within 2 hours. This deficient practice was cited as a result of the investigation of complaint/report # AL 465.

Based on observations, interviews, review of medical records, and a document titled, Wounds, the facility failed to ensure: 1) RI # 5's wound interventions were implemented to reduce the risk of pressure ulcer development; and 2) RI # 6's pressure ulcer dressing was changed daily as ordered. These deficient practices affected RI # 5 and RI # 6, two of four sampled residents reviewed for pressure ulcers. Finding include: 1) Review of the document titled, Wounds with a reference number of NM.I-6exh-3 and a revised date of 10-1-10 revealed, Activity of Mobility Deficit . For bed-bound individuals: . Place at-risk individuals on a pressure-reducing mattress. RI #5 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED].#5 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #5's Resident Risk Review for Pressure Ulcers 10/19, with a date of 5/25/2020 indicated that resident was at risk of developing Pressure Ulcer (P/U)/injuries. RI #5's Wound Assessment Note, dated 10/6/2020 with a time of 2:35 PM revealed, Resident is a re admit. Unstageable wound to sacrum. Yellow slough to wound bed, edges well defined, color pink. scant amount (amt) of serosanguineous drainage noted on dressing with no foul smell. Measurement is 3.0 CM X 3.0 CM. Preventive measures in place. On 1/13/2021 at 9:25 AM, an observation was made of RI #5 laying in the bed in a supine position with the head of bed (HOB) elevated about 30 degrees. No low air mattress was on the bed. On 1/14/2021 at 10:43 AM, an interview was conducted with Employee Identifier (EI) #2, Licensed Practical Nurse, Wound Care Nurse. EI #2 was asked if RI #5 was at risk for pressure ulcers. EI #2 replied, yes. EI #2 was asked what interventions for pressure ulcer prevention were in place. EI #2 replied, wedge for turning, ordered him/her an air mattress that, supplement, he/she was on hospice. EI #2 was asked, where was the low air mattress. EI #2 replied, they ordered one that day. EI #2 was asked if RI #5 had a low air mattress on his/her bed. EI #2 replied, no. EI#2 was asked who ensured that pressure ulcer interventions were implemented. EI#2 replied, wound care nurses. EI #2 was asked why RI #5 did not have a low air mattress on his/her bed. EI #2 replied, not sure, he/she had one at one time, but he/she went out to the hospital, did not get one upon return. EI#2 was asked when a low air mattress should be considered for a resident with a stage 4 pressure ulcer. EI #2 replied, anyone with a stage 4 pressure ulcer should have an air mattress. On 1/14/2021 at 9:00 AM, an interview was conducted with EI #1, Registered Nurse (RN), Director of Nursing (DON). EI #1 was asked what pressure ulcer interventions were used for a resident who developed a stage 4 pressure ulcer or had one present on admission. EI #1 replied, the treatment nurses made decisions on what interventions were appropriate for that resident. EI #1 was asked who was responsible for ensuring those interventions were implemented and followed. EI #1 replied, all nurses. EI #1 was asked where could Licensed Practical Nurses (LPN) and Certified Nursing Assistants (CNA) find interventions. EI#1 replied, various places such as the Medication Administration Record [REDACTED]. 2) RI #6 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED].#6 developed a pressure ulcer on the right buttock. A review of RI #6's Wound and Skin Status Report revealed on 9/16/2020 a pressure ulcer measuring 3.0 CM x 3.0 CM was identified to his/her right buttock. On 12/28/2020 the right buttock wound was a stage 4 pressure ulcer and measured 0.40 x 0.40 x 0.10, on 1/4/2021 the stage 4 pressure ulcer measurements were 1.20 x 0.70 x 0.10, and on 1/11/2021 measured 1.50 x 1.00 x 0.10. A review of RI #6's Physicians Orders for the month of January 2021 revealed, Order Date of 12/1/2020 Start Date 12/1/2020 WOUND STAGE 4 RIGHT BUTTOCK. CHANGE DRESSING (DSG) EVERY DAY (QD). A review of RI #6's Treatment Administration Record (TAR) revealed, Wound stage 4 right buttock. Change dsg QD. Further review of RI #6's TAR revealed EI #2 had signed off the treatment for [REDACTED]. On 1/12/2021 at 10:36 AM, the surveyor performed a skin audit on RI #6 prior to her shower, in the shower room. An observation was made of a small dressing dated 1/8 to the right buttocks of RI #6. On 1/13/2021 at 10:43 AM, an interview was conducted with EI #2. EI #2 was asked if RI #6 had a pressure ulcer. EI #2 replied, yes. EI #2 was asked where the pressure ulcer was located. EI#2 replied, the right lower buttock. EI #2 was asked what pressure ulcer interventions were being used. RI #2 replied, air mattress, pillows for positioning, supplements, and wound care. RI #2 was asked how often wound care was performed to the right buttocks. EI #2 replied, daily. EI #2 was asked who was responsible for dressing changes. EI #2 replied, she was Monday through Friday. EI #2 added, the weekend cart nurse was responsible on the weekends. EI #2 was asked if the wound was better or worse. EI #2 replied, the wound was getting better but had declined some. EI #2 was asked when the decline started. EI #2 replied, it had been a couple of weeks. EI #2 was asked what caused the decline. EI #2 replied, she was not sure, that RI #6 had recently been sick with a cold. EI #2 was asked how the wound progress was monitored. EI #2 replied, measurements every Monday. EI #2 was asked who measured the wounds. EI #2 replied, she did. EI #2 was asked who measured RI #6's wound on Monday (1/11/2021). EI #2 replied, she did. EI #2 was asked what type of dressing was applied to RI #6's right buttock. EI #2 replied, silicone foam dressing. EI #2 was asked if she worked the weekends. EI #2 replied, no. EI #2 was asked to review the TAR for RI #6, EI #2 was asked to verify that her initials were on the TAR for January 9-10, a Saturday and Sunday. EI #2 replied, yes, she was clearing out the TAR. EI #2 was asked if she changed RI #6 dressing on January 9 and 10. EI #2 replied, no. EI #2 was asked who changed RI #6 dressing on January 9 and 10. EI #2 replied, no one because the dressing she placed on RI #6 on Friday January 8, was still in place. EI #2 was asked why was it important to change the pressure ulcer dressing daily and follow physician's orders [REDACTED].#2 replied, continuity of care and consistency of care. EI #2 was asked what the potential negative affect on RI #6 could be when not receiving wound care as ordered. EI #2 replied, decline in wound and infection. On 1/13/2021 at 4:50 PM, an interview was conducted with EI #4, LPN who worked 6 AM-2 PM shift on 1/10/2021. EI #4 was asked how she knew what wound care was due on her shift. EI #4 replied, she did not work at the facility all the time, so she would usually ask. EI #4 was asked if there was a list to go by. EI #4 replied, she did not look. EI #4 was asked when she changed the dressing on RI #6's pressure ulcer on 1/10/2021. EI #4 replied, she did not change a dressing. EI #4 was asked why she did not change RI #6's dressing. EI #4 replied, she did not know she was supposed to, and she did not see a list. On 1/14/2021 at 9:00AM, an interview was conducted with EI #1, RN, DON. EI #1 was asked who was responsible for wound care and dressing changes. EI #1 replied, the nurses, treatment nurse, and medication cart nurse. EI #1 was asked what schedule EI #2 worked. EI #1 replied, day shift, none of us have set schedules and that schedules are adjusted to meet the needs of the facility. EI #1 was asked who was responsible for wound care when EI #2 was not there. EI #1 replied, that dressing changes were divided up between shifts on weekends. EI #1 was asked how she knew that wound care was being done on the weekend. EI #1 replied, no one had told him/her that it was not being done.

Based on observations, interviews, review of Resident Identifier (RI) # 5's medical records, and documents titled, Admission/Re-admission Resident Risk Review for Pressure Ulcers & Initial Plan of Care Protocol and Wounds, the facility failed to ensure: RI # 5's care plan interventions were implemented to reduce the risk of pressure ulcer development. This deficient practice had the potential to affect RI # 5, one of three sampled residents whose care plans were reviewed for pressure ulcers. Finding include: Review of the document titled, Admission/Re-admission Resident Risk Assessment Review for Pressure Ulcers & Initial Plan of Care Protocol with revised date of 10-1-10 revealed, . Intent: To evaluate resident's status to determine risk factors for skin breakdown and provide guidance for appropriate interventions. Timeframes: Actual skin breakdown should have an individualized care plan when pressure identified. Procedure: . Usual facility prevention measures should be reviewed for individual needs. The above should be reviewed at least weekly during the first month. Review of the document titled, Wounds with a reference number of NM.I-6exh-3 and a revised date of 10-1-10 revealed, Activity of Mobility Deficit . For bed-bound individuals: . Place at-risk individuals on a pressure-reducing mattress. RI #5 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #5's care plan titled, Potential for Skin Breakdown Related To (R/T) Fragile Skin . Intervention low air mattress with a start date of 7/14/2020. RI #5's Wound Assessment Note, dated 10/6/2020 with a time of 2:35 PM revealed, Resident is a re admit. Unstageable wound to sacrum. Yellow slough to wound bed, edges well defined, color pink. scant amount (amt) of serosanguineous drainage noted on dressing with no foul smell. Measurement is 3.0 CM X 3.0 CM. Preventive measures in place. On 1/14/2021 at 10:43 AM, an interview was conducted with Employee Identifier (EI) #2, Licensed Practical Nurse (LPN), Wound Care Nurse. EI #2 was asked if RI #5 was at risk for pressure ulcers. EI #2 replied, yes. EI #2 was asked what interventions for pressure ulcer prevention were in place. EI #2 replied, wedge for turning, ordered him/her an air mattress that day, supplement, and he/she was on hospice. EI #2 was asked, where was the low air mattress the care plan indicated was to be used. EI #2 replied, they ordered one that day. EI #2 was asked if RI #5 had a low air mattress, as indicated in the care plan, on his/her bed. EI #2 replied, no. EI#2 was asked who ensured that pressure ulcer interventions on care plan were being implemented. EI#2 replied, wound care nurses. EI #2 was asked why RI #5 did not have a low air mattress on his/her bed per his/her care plan. EI #2 replied, not sure, he/she had one at one time but he/she went out to the hospital, did not get one upon return. EI#2 was asked when should a low air mattress be considered for a resident with a stage 4 pressure ulcer. EI #2 replied, anyone with a stage 4 pressure ulcer should have an air mattress. On 1/14/2021 at 2:10 PM, a second interview was conducted with EI #2. EI #2 was asked when the air mattress was restarted. EI #2 replied, that day. EI #2 was asked why was the air mattress not restarted sooner. EI #2 replied, the facility had requested an air mattress from hospice, but was supplied with an eggcrate mattress. RI #2 was asked when did the facility order the air mattress. EI #2 replied, yesterday. EI #2 was asked when did she become RI #5's primary wound care nurse. EI #2 replied, about 2 months ago. EI #2 was asked after she took over wound care for RI #5 when did she review the care plan and ensure all interventions were in place. EI #2 replied, she did not. EI #2 was asked why did she not review the care plan interventions for pressure. EI#2 replied, she was the only wound care nurse in the building. On 1/14/2021 at 9:00 AM, an interview was conducted with EI #1, Registered Nurse, Director of Nursing. EI #1 was asked what pressure ulcer interventions were used for a resident who developed a stage 4 pressure ulcer or had one present on admission. EI #1 replied, the treatment nurses made the decisions on what interventions were appropriate for that particular resident. EI #1 was asked who was responsible for ensuring those interventions were implemented and followed. EI #1 replied, all nurses. EI #1 was asked where could LPNs and Certified Nursing Assistants (CNA) find interventions that had been implemented on a care plan. EI #1 replied, various places such as the Medication Administration Record [REDACTED].

Based on interviews, medical record review, and review of the facility's policy titled, Change in Medical Condition of Resident/ Guest(s), the facility failed to ensure Resident Identifier (RI) #1's sponsor and physician for were immediately notified upon identification of a significant weight loss of 19 pounds from 5/10/2020 to 6/10/2020. This affected one of seven sampled residents reviewed for notifications. Findings Include: On 8/5/2020 the State Agency received an anonymous complaint alleging RI #1's sponsor had not been immediately notified of a 20 pound weight loss from May 2020 to June 2020. The complainant alleged the weight loss was noted on 6/10/2020, but the sponsor had not been notified until 6/21/2020, 11 days later. Review of the facility's policy titled, Change in Medical Condition of Resident/ Guest(s), with an effective date of 11/28/2016, revealed: PURPOSE: To keep the physician, who is in charge of medical care, and family members/ legal representatives, responsible for health care decisions and other resident / guest representatives informed of the resident / guest(s) medical condition so they may direct the plan of care as needed. STANDARD: Notification of the physician, legal representative, or interested family member, should occur promptly, according to federal regulations, when there is a change in the resident / guest(s) condition. Change in condition is defined as: . A significant change in the resident/guest(s) physical, mental or psychosocial status (i.e., a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications) . Examples of a change in condition may include: . Loss of appetite / unplanned weight loss / gain . RI #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's weight records revealed RI #1 weighed 126 pounds on 5/10/2020 and 107 pounds on 6/10/2020. This was a significant weight loss of 19 pounds or 15 percent in one month. Review of RI #1's Nurses Notes revealed RI #1's sponsor was not notified of the weight loss until 6/21/2020 when Employee Identifier (EI) #1, a Licensed Practical Nurse (LPN) contacted her. There was no documentation in the medical record of the physician being notified of RI #1's weight loss. RI #1's sponsor was interviewed on 9/15/2020 at 2:20 PM. The sponsor stated EI #1 had contacted her sometime in June about RI #1's weight loss, but could not recall the exact date. However, the sponsor said no one had notified her about RI #1 losing weight until EI #1 called her. An interview was conducted on 9/15/2020 at 3:10 p.m. with EI #1, LPN. EI #1 was asked when she notified the sponsor of RI #1's 19 pound weight loss. EI #1 stated, It was on the 21st (of June). EI #1 was asked, what was the facility policy for contacting the sponsor about significant changes. EI #1 stated, ASAP (as soon as possible). EI #1 was asked, was 11 days ASAP. EI #1 stated, No ma'am. EI #1 was asked when she should have notified the sponsor about RI #1's significant weight loss. EI #1 stated when she found out on June 10th. During a follow-up interview on 9/18/2020 at 7:55 a.m., EI #1 was asked if she had documented evidence of Physician or CRNP (Certified Registered Nurse Practitioner) notification of RI #1's weight loss. EI #1 replied, no. A phone interview was conducted on 9/16/2020 at 6:55 p.m. with EI #4, the Medical Director. EI #4 was asked when the facility notified him of a 19 pound weight loss on RI #1 that occurred between 5/10/2020 and 6/10/2020. EI #4 replied, the Nurse Practitioner (EI #3) made him aware one morning, but he did not remember when. During a phone interview with EI #3, the CRNP, on 9/17/2020 at 2:35 p.m., EI #3 stated she was not made aware of RI #1's significant weight loss until July 28th, 2020. A phone interview was conducted on 9/16/2020 at 4:56 p.m. with EI #2, Registered Nurse/ Director of Nursing. EI #2 stated when RI #1 lost 19 pounds in one month, the physician and family should have been notified. When asked how soon the family and physician should be notified of a significant weight loss, EI #2 replied, ASAP. EI #2 further stated 11 days would not be considered ASAP, and the family and physician should be notified as soon as staff is aware of a weight loss. This deficiency was cited as a result of the investigation of complaint/report #AL 730.

Based on interview, resident record review, and review of a facility policy titled Admission Physician's Orders, the facility failed to ensure Resident Identifier (RI) #6, who was admitted to the facility on [DATE], had physician orders in place for immediate care and treatment of [REDACTED]. This affected one of one closed records reviewed for central venous catheter care. Findings include: Review of a facility policy titled Admission Physician's Orders, with an effective date of 7/21/2011, revealed the following: . STANDARD: The Physician's Plan of Care on admission may include the following: . Treatments . Specialized Therapies . RI #6 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of RI #6's radiology report and hospital notes revealed RI #6 had a tunneled central line/catheter placed on 8/4/2020. Review of RI #6's plan of care for Potential for Complication r/t (related to) Central Line, with a start date of 8/5/2020, revealed interventions to clean the central line site and flush the central line as ordered. However, review of RI #6's physician's orders for the duration of his/her stay at the facility revealed no orders for cleaning, providing a dressing, or flushing RI #6's central line. On 9/18/2020 at 11:30 a.m., Employee Identifier (EI) #2, the Director of Nursing, was asked what orders for care and treatment should be in place for a resident admitted to the facility with a central line. EI #2 replied, dressing changes and flushes. EI #2 verified there were not any orders for RI #6 for dressing changes and flushes. When asked why there were not any physician orders for the care and treatment of [REDACTED].#2 stated, whoever admitted RI #6 should have ensured orders were in place. EI #2 was asked why it would be important to have orders for care and treatment of [REDACTED]. EI #2 said, to make sure the staff provides appropriate care, avoid complications, and maintain the central line. This deficiency was cited as a result of the investigation of complaint/report #AL 018.

Based on observation, interviews, a review of facility policies including Sanitation Principles, Use of Gloves and Hairnets, Food Reheating, Calibrating and Sanitizing Thermometers and Foods from Families and Friends, as well as the (YEAR) FOOD CODE regulations, the facility failed to ensure: 1) Food preparation equipment and dishes were maintained in a clean condition; 2) Dietary staff covered hair while handling food and working in food distribution areas; 3) Foods served from the 11/06/19 supper tray line were re-heated to recommended temperatures prior to service, and the thermometer used to check each item was sanitized prior to use; 4) Nursing staff handled ready-to-eat (RTE) food for Resident Identifier (RI) #16 during the 11/06/19 lunch meal without directly contacting the item with bare hands and 5) Resident food was dated and labeled in one of three nursing pantry refrigerators. This had the potential to affect all 132 residents for whom meals were prepared and served at the time of this survey. Findings include: 1) CLEAN EQUIPMENT The (YEAR) Food Code, Regulation 4-601.11 Equipment, Food-Contact Surfaces, Non Food-Contact Surfaces, and Utensils specifies; (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NONFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. During the initial kitchen tour, on 11/05/19 at 8:58 AM, the following were observed: a) The drip heads over the coffee maker contained a significant accumulation of residue, evidence of the lack of recent cleaning. b) The grill grease drawer of the gas stove was filled nearly to the top with grease and debris. c) The drip pan beneath the range was in need of cleaning, containing more than one week's accumulation of burnt debris. On 11/06/2019 at 3:45 PM, the surveyor asked the Dietary Aide, EI #15 when the last time the drip pan under the burner had been cleaned. EI #15 stated it had been three weeks ago. When the Dietary Manager (EI #14) was questioned how often the drip pan was cleaned, she stated, They will come in once a month and spray it. On 11/06/19 at 4:03 PM, the Surveyor questioned the Dietary Manager (EI #14) about the heavy residue on the drip heads of the coffee maker. EI #14 explained staff clean them every day. On 11/06/19 at 4:22 PM, five of eight 4-ounce bowls containing the remains of dried food debris were observed stacked on a push cart by the tray line with other clean dishes. One bowl contained approximately 1/2 teaspoon of water inside. When questioned, the Dietary Manager, EI #14 confirmed the bowls had food debris which might be residue from the black eyed peas served earlier that day. EI #14 confirmed also the water in one of the bowls. 2) HAIR RESTRAINTS The facility policy titled, Use of Gloves and Hairnets dated 08/15/09 specified the purpose as; To prevent the spread of bacteria that may cause food borne illnesses. The process included; . i. Wear hair restraints (bonnets, caps, nets to cover hair) when preparing or handling food. On 11/06/2019 at 6:09 PM, two male Dietary Aides were observed handling resident trays and food on the supper tray line. Neither man's mustache was covered. When one of the men (EI #19) was questioned, he explained his mustache was not covered on the tray line because his facial hair restraint was too tight and gave him a headache. He stated it had been covered, but he pulled it down momentarily to get a release of pressure from his face. Following the interview with the dietary staff, the surveyor questioned the Dietary Manager who stated the men's mustaches were covered earlier. When asked if the aides usually wore facial hair restraints while in the kitchen, EI #14 replied yes and stated one of the men usually shaved all his facial hair. When asked what potential hazard could result from not covering mustache hair in the kitchen, EI #14 replied hair may fall into the food. 3) TRAY LINE FOOD TEMPERATURES a) The facility policy titled, Calibrating and Sanitizing Thermometers dated 02/01/02, cited a purpose as: Accurate, clean thermometers should be used for the measurement of food storage, cooking and serving temperatures. The standard specified: Thermometers should be sanitized before being used to test food and beverage temperatures. On 11/06/19 at 4:39 PM, the Dietary Aide wiped the probe of the thermometer used to check tray line food temperatures, with a paper towel. No alcohol wipe or other means of sanitization was used to sanitize the probe of the thermometer prior to a check of food temperatures on the tray line. The Surveyor alerted the staff, who then sanitized the thermometer, after five pans of food had been checked. On 11/06/19 at 4:46 PM, the Dietary Aide who checked the food temperatures (EI #20) was asked how she sanitized the thermometer. EI #20 stated she used an alcohol swab. EI #20 then got a box of swabs and started swabbing the thermometer after use of the remaining foods items on the tray line. When asked why she hadn't used a sanitizer on the thermometer probe to start with, EI #20 stated they had been told last year to just use a paper towel. b) The facility policy titled, Food Reheating dated 08/15/09, specified: . Process: a. Foods should be reheated rapidly to an internal temperature of 165 degrees F, within 2 hours. The (YEAR) Food Code, regulation 3-403.11 Reheating for Hot Holding. specified: (A) TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the FOOD reach a temperature of at least 165 degrees F (Fahrenheit) for 15 seconds. On 11/06/19 at 4:49 PM, tray line staff checked the temperature of each pan of food on the tray line. Concerns were noted with the following foods: a) Pureed Steak Fingers were found to be 102 degrees F. Staff reheated this food to 140 degrees F at 5:05 PM. b) Chopped Steak Fingers were found to be 102 degrees F. Staff reheated the chopped meat to 140 degrees F at 5:08 PM. c) Pureed Scalloped Potatoes were found to be 125 degrees F, and reheated to 145 degrees F at 5:06 PM. Each of these items were subsequently served at temperatures below 165 degrees F. 4) BARE HAND CONTACT WITH READY-TO-EAT (RTE) FOOD The Dietary policy titled, Use of Gloves and Hairnets dated 08/15/19,, specifies: . b. Wear gloves when direct contact between the hands and food occurs. No bare hand contact with food is allowed. The (YEAR) Food Code regulation, 3-301.11 Preventing Contamination from Hands specifies: (B) EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing EQUIPMENT. On 11/06/19, residents were observed in the main dining room during the lunch meal. At 12:17 PM, a Certified Nursing Assistant, EI #21 was assisting Resident Identifier/RI #16 with a sandwich. EI #21 removed a ham sandwich from a plastic bag with her bare hands and handed it to RI #16. The resident then ate the sandwich. At the completion of the meal observation (at 12:44 PM), the surveyor asked EI #21 how she had been trained to handle resident food, specifically sandwiches. EI #21 stated she cut the sandwich in half, or smaller portions. When asked why it was important to handle RTE food with utensils, napkins or gloves, rather than using bare hands, EI #21 explained the goal was not to contaminate with hands. EI #21 stated she was trained to remove a sandwich with a napkin, not to handle with bare hands. 5) DATING AND LABELING OF STORED RESIDENT FOOD The facility policy titled, Foods from Families and Friends, dated 11/28/16, directs staff as follows: . Process: . 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 11/07/19 at 11:22 AM, the Charge Nurse, EI #22 accompanied the surveyor to the Rehab Unit refrigerator, identified by EI #22 as the one in which residents on that unit could store food brought into the facility by their family and friends. EI #22 withdrew a bag of food from the refrigerator, labeled with a resident's name and room number, but with no date. The bag included containers of Chili, Dip, and a home-made casserole (as described by EI #22). EI #22 stated the bag of food was placed in the refrigerator by one of the CNAs, but she did not recall who it was. EI #22 stated she did not know why the bag was undated. When asked what potential harm could result from the lack of dating, EI #22 explained the food could stay in the refrigerator more than three days.

Based on interview, and a review of the facility's financial records titled, Resident Statement Landscape and Resident Fund Management Service, the facility failed to ensure Resident Identifier (RI) #103 was provided his/her thirty dollars from the trust fund account when requested. This affected one of 73 residents with money in their trust fund. Findings Include: A review of the facility's financial records revealed: The document tiltled, Resident Fund Management Sevice, dated 6/26/19 and signed by RI #103's sponsor and Employee Identifier (EI) #2, a Financial Specialist Assistant, authorized the facility to handle the residents' funds with a $30 monthly allowance. A review of the document titled, Resident Statement Landscape revealed a balance of $994.00 in RI #103's Trust Fund Account. RI #103 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE]. RI #103 had [DIAGNOSES REDACTED]. On 11/05/19 at 09:45 a. m. RI #103's sponsor told the surveyor that she had gone to the business office to obtain RI #103's thirty dollars from his/her trust fund. RI #103's sponsor stated, (EI) #2 would not give the thirty dollars from his/her trust fund saying she passed the money out on the third of the month. An interview was conducted on 11/06/19 at 3:57 p.m,.with EI #2. EI #2 was asked, when could residents get their thirty dollars from the trust fund. EI #2 stated, Anytime. EI #2 was asked, why RI #103's sponsor was unable to collect his/her thirty dollars when she came to obtain it. EI #2 explained, when the money comes in the first of the month, Corporate gave her $250.00. EI #2 explained that she keyed it into the system, waited to get transaction report the next day, then faxed it to Corporate. EI #2 explained she got the petty cash check the next day and would then go to the bank and cash the check. EI #2 stated she would then pass out the money. EI #2 was asked, did that mean residents/sponsors were able to get the thirty dollars 24/7, holidays, evenings, and weekends? EI #2 stated, yes, it was kept on Unit Two. EI #2 was asked, why RI #103 was unable to get the money when he/she asked for it. EI #2 stated, Didn't have the money in the petty cash. EI #2 was asked, how many residents have a trust fund account. EI #2 replied, 73. EI #2 was asked, if RI #103's sponsor was able to get his/her thirty dollars last Monday. EI #2 stated, No. EI #2 was asked, should RI #103 have been able to get this money. EI #2 stated, Yes. EI #2 was asked, do you have enough petty cash to honor all the residents' requests. EI #2 stated, No.

Based on record review and interviews the facility failed to ensure Resident Identifier (RI) #17's care plan meetings were held quarterly. This had the potential to affect RI #17, one of 28 sampled residents. Findings include: RI #17 was admitted to the facility on [DATE]. On 11/05/19 at 4:16 p.m., an interview was conducted with RI #17. RI #17 was asked if he/she had been invited to attend the care plan meetings. RI #17 replied, he/she had not been to a care plan meeting in a long time. RI #17 also stated no one had talked with him/her about care. A record review was conducted on 11/06/19 at 08:59 a.m. The last care meeting documented in the chart was dated 3/5/19. On 11/06/19 at 4:28 p.m., an interview was conducted with Employee Identifier (EI) #3, Social Services Assistant. The surveyor asked EI #3 who was responsible for setting up the care plan meetings. EI #3 replied she was; she did long term care and her supervisor did short term. EI #3 was asked, when was the last care meeting for RI #17 held. EI #3 replied, 5/21/19. On 11/06/19 at 4:28 p.m. EI #3 provided documentation of the 5/21/19 care plan meeting. EI #3 was asked, how often were care plan meetings supposed to be held. EI #3 replied every quarter and yearly. EI #3 was asked, why had RI #17 not had one since 5/21/19. EI #3 replied she may have over-looked it; it was skipped. RI #17 should have had one on 09/02/19. EI #2 said she did not know why she did not get it on the schedule. EI #3 was asked, what was the purpose of a care plan meeting. EI #17 replied, to go over the plan of care, code status, activities, dietary, therapy, the medication review and any issues the residents may have. EI #3 was asked, how were care plans updated. EI #3 replied, they were done in the care plan meetings. EI #3 was asked, what was the potential harm of not having a care plan meeting quarterly. EI 3 replied, not knowing any changes or updates on the care plan. EI #3 was asked, how could that affect the resident. EI #3 replied, the resident's care.

Based on record review, interviews and a facility policy titled, Bowel and Bladder Program, the facility failed to ensure Resident Identifier (RI) #17 had a bowel and bladder review after a change in physical ability. This affected RI #17, one of two residents sampled for bowel and bladder concerns. Findings include: A facility policy titled, Bowel and Bladder Program, with an effective date of (MONTH) 1, 2010 revealed, PURPOSE: A resident who is incontinent of bowel and bladder receives appropriate treatment & services . to restore as much normal bowel/bladder function as possible.PR[NAME]ESS: 1. A Bowel and Bladder Review should be conducted at admission, with a change in cognition, physical ability . RI #17 was admitted to the facility on [DATE]. A yearly Minimum Data Set (MDS) with an Assessment Reference Date of 8/21/19 revealed, . Section H- Bladder and Bowel . Urinary toileting program has been attempted 0. No . Urinary continence 3. Always incontinent . Bowel continence 3. Always incontinent . An interview was conducted with RI #17 on 11/05/19 at 4:26 p.m. RI #17 was asked about bladder and bowel incontinence. RI #17 replied he/she had worn briefs since he/she had a stroke. RI #17 stated he/she was not on a toileting program. RI #17 stated that he/she would rather use the restroom, that he/she was able to feel the urge to use the restroom and thought he/she would be able to use the toilet. On 11/07/19 at 9:17 a.m., an interview was conducted with EI #4, Certified Nursing Assistant (CNA). EI #4 was asked, how many person assist, was RI #17. EI #4 replied, with transfer, the resident only needed supervision. EI #4 was asked if RI #17 could stand. EI #4 replied yes, but not too long; enough to transfer. EI #4 was asked if RI #17 could move both legs. EI #4 replied he/she could. EI #4 was asked, had RI #17 ever asked her to take him/her to the toilet. EI #4 replied, no. EI #4 was asked if RI #17 had ever been on a toileting program. EI #4 replied. no. EI #4 was asked why. EI #4 replied she did not think he/she wanted to. EI #4 was asked did she think RI #17 was capable of using the toilet. EI #4 replied she thought so. On 11/07/19 at 10:11 a.m., an interview was conducted with EI #5 Registered Nurse (RN), MDS. EI #5 was asked, how long had she been doing MDS at the facility. EI #5 replied 3 years. EI #5 was asked, what could she tell the surveyor about RI #17, regarding activities of daily living (ADLs). RI #5 replied on the last assessment RI #17 needed limited assistance with transfers, was independent with rolling in the wheelchair on the unit and off the unit, RI #17 required set up with eating, was limited assist with toileting, needed assistance with personal hygiene and bathing. EI #5 was asked, how many people did it take to transfer RI #17. EI #5 replied, two people. EI #5 was asked why RI #17 was incontinent. EI #5 replied when she assessed RI #17, the nurses and CNAs said RI #17 was incontinent, but they did not say why. EI #5 was asked if RI #17 could transfer. EI #5 replied yes, with assistance. EI #5 was asked if RI #17 couldstand. EI #5 replied yes, with assistance. EI #5 was asked if RI #17 had been on a toileting program. EI #5 replied, not to her knowledge. On 11/07/19 at 10:21 a.m., an interview was conducted with EI #6, the Rehab Director regarding RI #17. EI #6 was asked, when did RI #17 have therapy. EI #6 replied (MONTH) (YEAR) the resident had Physical Therapy (PT) through (MONTH) (YEAR). EI #6 was asked, what was RI #17's functional status before the PT. EI #6 replied to sit and get to and from the edge of the bed was maximum assist; rolling side to side was partial assist; sit to stand, toilet transfer, chair and bed transfer was max assist. The resident was dependent for walking, and independent with the wheel chair. EI #6 was asked what was RI #17's functional status after PT. EI #6 explained RI #17 was moderate assistance with bed mobility and getting to and from the edge of the bed; sit to stand, chair and bed transfers, and toilet transfers was moderate assist; walking 50 feet required supervision; and independent with wheelchair. EI #6 was asked was the resident continent. EI #6 replied, she did not know. EI #6 was asked how was toilet transferring evaluated. EI #6 replied they had to transfer the resident to the toilet; now they could not use the MDS, they had to actually do it. EI #6 stated when this note was written, she was not sure if it was actually done. On 11/07/19 at 1:37 p.m., an interview was conducted with EI #7, Director of Nursing (DON). EI #7 was asked, who initiated toileting programs. EI #7 replied usually on admission they did a bowel and bladder (evaluation) and their restorative nurse initiated it. EI #7 was asked, what was the criteria. EI #7 replied it depended on what the bowel and bladder patterns were; that would determine what kind of program they would be on. EI #7 was asked, who assessed the residents for bowel and bladder functioning and toileting programs. EI #7 replied, restorative. EI #7 was asked if a resident was incontinent when they were admitted to the facility, at what point should they be re-evaluated. EI #7 replied usually it depended on what the care plan was, if there was a change in condition. EI #7 was asked, was RI #17 incontinent. EI #7 replied yes. EI #7 was asked why RI #17 was incontinent. EI #7 replied she would have to get her care plan team together to find out. EI #7 was asked was RI #17 able to transfer. EI #7 replied yes, requiring two people. EI #7 was asked could RI #17 stand. EI #7 replied yes. EI #7 was asked, had RI #17 been evaluated for a toileting program. EI #7 replied she did not see where RI #17 was ever reassessed to figure out whether or not he/she would be a candidate for a toileting program or not. EI #7 was asked what the potential concern was of not reassessing a resident for a toileting program. EI #7 replied that they could miss a decline. On 11/07/19 at 2:31 p.m., an interview was conducted with EI #8, Restorative Nurse. EI #8 was asked how long she had worked there. EI #8 replied she had been there eight years, but she had been restorative for one year. EI #8 was asked who was responsible for initiating a toileting program. EI #8 replied she was. EI #8 was asked why RI #17 was incontinent. EI #8 replied, RI #17 had come in as incontinent. EI #8 was asked when were residents assessed for being on a toileting program. EI #8 replied if they had a change of condition. EI #8 was asked, when was RI #17 assessed for a toileting program. EI #8 replied on 08/31/17. EI #8 was asked, had RI #17 ever been reassessed. EI #8 replied no. EI #8 was asked how she determined RI #17 was appropriate for a disposable brief program. EI #8 replied when residents came in and they were incontinent, they used briefs for everyone incontinent. EI #8 was asked why RI #17 had not been on a toileting program. EI #8 replied she could not answer that question. EI #8 was asked if RI # 17 went into therapy in (MONTH) (YEAR) as a maximum assist for toileting transfer and was discharged in (MONTH) (YEAR) from therapy as a moderate assist for toileting transfer, should RI #17 have been reassessed for a toileting program. EI #8 replied yes. EI #8 was asked what the potential concern was of not having a resident on a toileting program who may be capable of being on one. EI #8 replied, lowering their ability to be able to do for themselves.

Based on a review of the facility policy titled Psychoactive Drug Monitoring, the pharmacist's recommendation for the consideration of antipsychotic dose reduction, and and an interview with the Certified Registered Nurse Practitioner (CRNP), the facility failed to provide justification for the continued use of an antipsychotic medication ([MEDICATION NAME]) for Resident Identifier (RI) #23. This affected one of 5 sampled residents reviewed for the potential use of unnecessary medications. Findings include: The facility policy titled, Psychoactive Drug Monitoring, dated 03/2011, included the following: . Procedure . 1. Residents receive a psychoactive medication only if supporting documentation is provided in the medical record. 2. If continuation is deemed necessary, this is indicated in the medical record. Unless medically contraindicated, periodic dosage reductions are attempted and the results documented. 3. Non-pharmacological interventions are documented as a part of the medical record. RI #23 has resided in this facility since 8/31/18 with [DIAGNOSES REDACTED]. RI #23's medication orders, dated 10/26/18, included an antipscychotic medication, [MEDICATION NAME], 5 milligrams daily, for the resident's Major [MEDICAL CONDITION]. The most recent completed (annual) Minimum Data Set assessment, completed on 08/28/19, RI #23 as having no impairments in cognition and no evidence of depression or behavior symptoms. A review of a pharmacist's, Note to Attending Physician/Prescriber, dated 06/17/19, identified the daily use of [MEDICATION NAME] 5 mg, for mood disorder. Per CMS (Centers for Medicare/Medicaid Services) guidelines, gradual dose reductions must be attempted towards the minimum effective dose in LTC (Long Term Care) residents receiving psychoactive medications. Please consider reducing the dose or frequency of this mediation order as well as provide rationale for risk/benefit of continued use of this medication. The CRNP's written response, was Disagree. Con't (continue) dose. No evidence of a prior attempt to reduce this dose, nor justification for the continued use at this dosage was noted on the review form. On 11/07/19 at 2:54 PM, the surveyor interviewed Employee Identifier (EI)#13 and asked what precipitated the initial order of [MEDICATION NAME] for RI #23. EI #13 explained the resident had transferred from a psychiatric center with the order on 08/31/18. EI #13 stated the resident was then sent out and re-admitted on [DATE]. EI #13 stated the resident was stable, with no depression, thus the physician liked to keep his residents on the same dosage. When reviewing the resident's record, EI #13 stated the resident had no evidence of documented behavior problems; judgement and insight were intact, with no mood/behavior concerns. EI #14 explained the resident had disruptive behavior at the previous facility, and was stable at the current dose. When asked if she had attempted any dose reductions, EI #13 stated she had not; her rationale was to continue the dose as it had been. EI #13 affirmed she did not provide a rationale for the continued use of [MEDICATION NAME] at the current 5 mg dosage. When asked what non-pharmacological measures had been attempted before the medication was ordered, EI #13 did not know. EI #13 stated the resident had exhibited no behavior or mood symptoms since admission to the facility on [DATE].

Based on observation, interview, and a review of the facility's policy titled, Medication Storage, the facility failed to ensure the medication refrigerator on Unit 1 had a temperature that was maintained between 36 and 46 degrees Fahrenheit. This affected one of two medication refrigerators inspected. Findings Include: A review of the facility's policy titled, Medication Storage dated 03/011, revealed: . STORAGE OF MEDICATIONS AND BIOLOGICAL'S Policy Medications and Biological's are stored safely, securely and properly, following manufacturer's recommendations or those of the supplier. Procedures . 9. Medications requiring 'refrigeration' or temperatures between .36 degrees F {Fahrenheit} .and 46 degrees F are kept in a refrigerator with a thermometer to allow temperature monitoring. On 11/06/19 at 2:33 PM in the Unit 1, medication refrigerator was found to have an internal temperature of 30 degrees. Insulin was noted to be stored inside this refrigerator. An interview was conducted with Employee Identifier (EI) #1, a Licensed Practical Nurse on 11/06/19 at 02:41 PM. EI #1 was asked, what temperature was the medication refrigerator supposed to be. EI #1 stated, I'm not sure. EI #1 was asked, had the facility given her an in-service on the medication refrigerator. EI #1 stated, Not really; I've only been here a month. EI #1 was asked, what temperature was freezing. EI #1 stated, 32 degrees. EI #1 was asked, what happens to insulin when it freezes. EI #1 stated, I'm not really sure.

Based on interviews, record review and a facility policy titled, Medication Administration-General Guidelines, the facility failed to ensure a Licensed Practice Nurse (LPN) documented Resident Identifier (RI) #64's administration of eye drops on 11/04/19 and 11/05/19. This deficient practice affected one of 28 residents reviewed for documentation on the Medication Administration Record. Findings Include: A review of a facility's policy titled, Medication Administration - General Guidelines, with a date of 03/11, included the following: .Procedures . 22. After administration, . document administration on the Medication Administration Record [REDACTED] RI# 64 was admitted to the facility on [DATE]. RI #64 had [DIAGNOSES REDACTED]. RI #64's Physician orders [REDACTED]. RI #64's Admission Minimum Data Set Assessment (MDS) with an Assessment Reference Date of 09/25/19 revealed a Brief Interview for Mental Status score of 15, indicating intact cognition. On 11/06/19, a Resident Council meeting was conducted from 2:30 to 3:40 PM. At this meeting, RI #64 reported he/she had not received prescribed eye drops on (MONTH) 4th. On 11/06/19 at 6:13 PM, the surveyor interviewed RI #64, who remembered receiving eye drops the night of 11/05/19, but not the night before on 11/04/19. The MAR for RI #64 dated 11/04/19 and 11/05/19 were blank at the 8:00pm administration time for the Latanoprost 0.005% eye drop. The MAR for RI #64, dated 11/05/19, was blank at the 4:00 PM administration time for [MEDICATION NAME] 0.2%-0.5% eye drops. On 11/07/19 at 02:29 PM, Licensed Practical Nurse, Employee Identifier (EI) #17 confirmed he had worked on Monday, 11/04/19 and Tuesday, 11/05/19 from 2 PM until 10 PM. EI #17 was asked if he administered medication those nights and he responded that he had. When EI #17 was asked if he was responsible for giving RI #64 [MEDICATION NAME] at 4 PM on 11/05/19, EI #17 responded, Yes. EI #17 was asked if [MEDICATION NAME] was administered to RI #64 on 11/05/19 at 4 PM. EI #17 said, Yes. When asked if the MAR indicated [REDACTED]. When asked why it was not listed on the MAR, EI #17 stated that he guessed he did not sign it out; he stated that he gave RI #64 medication twice-once between 3-5 PM and once between 7-9 PM. EI #17 was asked if he gave RI #64 the Latanoprost eye drops at 8 PM on 11/04/19 and 11/05/19. EI #17 said, Yes. When asked if the administrations were listed on the MAR, EI #17 said the medications were not listed. When asked why the administrations were not listed, EI #17 said he guessed he missed signing them out. When asked about the procedure for administering and documenting medication administration, EI #17 stated that the medication was to be given and then signed out right after. When asked why the Latanoprost was not signed out, EI #17 stated because he missed it. RI #64 was interviewed again on 11/07/19 at 04:09 PM. RI #64 remembered getting a large pill on 11/05/19 at 4 PM, but did not get the eye drops. When asked if RI #64 remembered getting a pill at bedtime with the eye drops on 11/4/19 and 11/05/19, RI #64 replied No.

Based on interview, and document review of Employee Identifier (EI), #16's certification, the facility failed to ensure the Activity Program was directed by a qualified licensed or registered professional from [DATE] (date of hire) through the current survey. This deficient practice had the potential to affect 137 of 137 residents in the facility. Findings Include: A review of the Activity Director, Employee Identifier (EI) #16's certification document titled, National Certification Council for Activity Professionals (NCCAP), revealed the certification had expired [DATE]. The certification also indicated renewal was required bi-annually. On [DATE] at 1:31 p.m., the surveyor asked EI #16 how long she had been the Activity Director with the facility. EI #16 stated that she previously worked ,[DATE] but was re-hired at the facility two weeks prior, on [DATE]. When asked if she was qualified as an activities professional, EI #16 responded that she was qualified at the Federal level but it expired in 2014. When asked if she currently met with an Activity Consultant, EI #16 stated that she did not. When asked if she was licensed or registered with the State of Alabama as an activities professional, EI #16 said, No. EI #16 was asked if she was a recreational therapist and she responded, No. When asked if EI #16 had a certificate as an activities professional from an accredited body, EI #16 said, No. EI #16 stated that she has not completed a training course approved by the State. When asked if she was told to apply prior to her hire date, EI #16 responded that she was not instructed prior to her hire date as EI #12 was under the impression that the national certification did not expire.

Based on observations, interview and a review of the facility policy titled, Sanitation Principles, the facility failed to ensure the side door of one dumpster was closed. Facility staff also failed to ensure the interior garbage was securely contained in each bag prior to disposal to prevent the potential attraction of flies, ants and possible rodents. This affected two of two dumpster's on two of three days of the survey. Findings include: The facility policy titled, Sanitation Principles, with an effective date of 08/10/18, revealed the purpose as: To prevent the spread of bacteria that may cause food borne illnesses. The process specified: . d. Refuse containers and dumpster's outside the nursing facility should have tight fitting lids, and should be kept covered when not actually being loaded. The areas around the dumpster should be kept free of debris. The (YEAR) Food Code, regulation: 5-501.15 Outside Receptacles specified: (A) Receptacles and waste handling units for REFUSE, recyclables, and returnable's used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers. (B) Receptacles and waste handling units for REFUSE and recyclables such as an on-site compactor shall be installed so that accumulation of debris and insect and rodent attraction and harborage are minimized . During the initial tour of the facility on 11/05/19 at 9:00 AM, the facility's two garbage dumpster's were observed outside, in the back area of the facility. The side door of one dumpster was partially open, with a white, untied plastic bag of refuse partially hanging out of the open side. The second dumpster contained open white bags of garbage, including an orthotic carrot box and wadded paper towels. Ants were evident on the trash. Multiple plastic bags of debris were open (with nursing items debris) inside the receptacle. At least four flies were observed inside the dumpster. On 11/06/19 at 3:47 PM, the two dumpster's were again observed. At least three bags were identified by the Dietary Manager, Employee Identifier (EI) #14, as from the Certified Nursing Assistants, (white plastic bags), each untied. On 11/06/19 at 6:00 PM, the Dietary Manager (EI #14) was asked how staff had been trained to bag and dispose of the garbage in the dumpster's. EI #14 explained the staff were to tie the bags up. EI #14 explained the Dietary staff used black bags, none of the white/clear bags were theirs. When asked what concern untied bags would pose, EI #14 stated, that would attract flies, maggots and worms.

Based on interviews, review of Resident Identifier (RI) #1's medical record, and the facility's investigation file, the facility failed to honor the wishes of RI #1 on [DATE] when the staff did not continue to perform CPR on RI #1 until emergency medical services (EMS) providers arrived on-scene and took over the care of RI #1. During the morning hours of [DATE], RI #1, a resident with Full Code status was found without a pulse. The nursing staff started chest compressions; however, at some point, the licensed nursing staff, without physician or EMS notification, stopped CPR and left RI #1's room to call the physician, Director of Nursing and 911 (EMS). After speaking on the telephone with Employee Identifier (EI) #2, the Director of Nursing (DON) at 8:16 AM, the licensed nurses were instructed to return to RI #1's room and resume CPR until EMS arrives and takes over the code. This deficient practice placed RI #1, one of three sampled residents identified by the facility as having Full Code status, in immediate jeopardy because it was likely to cause serious injury, harm or death. On [DATE] at 1:35 PM, EI #1, the facility's Administrator; EI #2, the DON; EI #13, the Regional Administrator; EI #14, the Regional Nurse; and EI #15, an administrator employed with the corporation, were notified of the findings of immediate jeopardy in the area of Resident Rights, F 155. Findings include: Refer to F 309 RI #1 was readmitted to the facility on [DATE]. On [DATE] at 3:23 PM, the facility submitted an online report of neglect to the State Agency which indicated . at approximately 8:15a resident (RI #1) coded and CPR was begun. RN (Registered Nurse) (EI #3) allegedly told the staff to stop CPR due to the absence of a pulse. CPR was stopped for approximately ,[DATE] minutes and was resumed . The online report further indicated the actions taken by the facility in response to the incident were: 1. All staff that were involved in working the code were suspended pending an immediate investigation. 2. All licensed staff were reeducated on the policy and procedure for working a code and CPR before their next shift. 3. Code drills will be run every shift beginning [DATE]. 4. An immediate investigation was begun. On [DATE], the State Agency received an anonymous complaint which alleged, the facility failed to provide CPR to a full code resident, RI #1. Contained within the facility's investigative file was an undated typed document by EI #1, the facility's Administrator, which documented On [DATE] at approximately 8:30am I received a call at home from (EI #2), DON, that a resident, (RI #1), had coded in the facility and CPR was suspended for a short time before being restarted. (EI #2, DON) immediately came to facility and started an investigation . Based on interviews with staff present in the room, either (EI #3), RN (Registered Nurse), or (EI #4), LPN (Licensed Practical Nurse), made the statement, '(He's/She's) gone', or something to that effect. At this point, the staff member performing compressions, (EI #5) quit performing compressions and staff began to exit the room . Following the ending of CPR, . (EI #4) then called the DON. The DON stated (RI #1) is a full code. She (the DON, EI #2) instructed (EI #4) to immediately continue CPR. (EI #4) hung up the phone and told (EI #3) that we needed to continue CPR. (EI #3) stated that she did not see the point of continuing, (he/she) was dead. (EI #5) placed a call to 911 at 8:22 am . EMS was dispatched at 8:25 am and arrived at 8:30 am . CPR was re-initiated . In an interview on [DATE] at 6:20 PM, EI #7, a Certified Nursing Assistant (CNA) acknowledged that staff did perform CPR on RI #1; however, at some point during the CPR, someone said CPR could be stopped. When that was said, EI #7 stated she and the other CNA (EI #8) performed post-mortem care on RI #1. According to EI #7, she and EI #8 gave RI #1 a bed bath. After the bed bath was completed, EI #7 stated the licensed nursing staff (EI #3, EI #4, EI #5 and EI #6) came back in RI #1's room and started CPR again, because RI #1 was a full code. In an interview on [DATE] beginning at 4:35 PM, EI #4, the Licensed Practical Nurse (LPN) assigned to care for RI #1 was asked, why CPR was stopped on [DATE]. EI #4 replied, she could not recall. When asked, what time was CPR stopped, EI #4 stated she was not sure. According to EI #4, she left RI #1's room to make some phone calls. EI #4 stated she contacted the physician, the Director of Nursing (EI #2) and 911. It was during the phone call with EI #2 (DON), that EI #4 was told that RI #1 was a full code and CPR should be started back and continued until EMS arrived. EI #4 stated after she hung up the telephone with EI #2, she then called 911. After the phone call with 911, EI #4 stated she went back to RI #1's room to restart CPR. During an interview on [DATE] at 7:50 PM, EI #3, the Registered Nurse (RN) Supervisor stated she became aware of the code via the facility's intercom. EI #3 stated when she entered RI #1's room, a staff member was performing chest compressions. EI #3 stated she asked EI #4 (the LPN Charge Nurse) if 911 (EMS) had been called and was told no. EI #3 stated as she checked RI #1's carotid and radial pulse, she noticed the resident had none and the resident was cold. According to EI #3, EI #4 then left the resident's room to call the doctor. EI #3 stated she followed and overheard the conversation EI #4 had with the doctor, DON (EI #2) and 911. EI #3 stated that when EI #4 hung up from the DON (EI #2), she stated RI #1 was a full code and CPR should not have been stopped. EI #3 acknowledged that she was in RI #1's room when the staff stopped CPR. When asked when should CPR be stopped once it was started, EI #3 replied, when emergency personnel arrives. When asked why CPR for RI #1 was stopped, EI #3 stated because the nurse in charge, EI #4, left RI #1's room. EI #3 stated as the supervisor, she should have made sure that CPR continued until EMS arrived. In an interview on [DATE] at 10:50 AM, EI #2, the DON stated she had received a telephone call at 8:16 AM on [DATE] from EI #4 stating that RI #1 had passed. After questioning EI #4 about whether or not, the staff had performed a code/CPR, EI #2 stated she instructed EI #4 to go back to RI #1's room, code the resident and call 911 because RI #1 was a full code. In an interview with the room-mate of RI #1 (RI #4) on [DATE] at 5:30 PM, this resident stated on [DATE] CPR was started, then it stopped for a while and it was re-started when the nursing supervisor (EI #2) said to. RI #4 has been in the facility since [DATE]. RI #4's quarterly Minimum Data Set with an assessment reference date of [DATE], indicated the resident was cognitively intact, with a Brief Interview for Mental Status (BIMS) of 15. During an interview on [DATE] at 7:05 PM, EI #8, a CNA acknowledged that she was present in the facility on [DATE] when the staff started and stopped CPR on RI #1. When asked, what occurred during the time CPR was stopped, EI #8 stated she and EI #7 cleaned RI #1 up, gave the resident a bed bath, washed the resident's face, moisturized his/her hands, placed a clean gown on the resident and changed the bed linens. In an interview on [DATE] at 1:30 PM, EI #1, the facility's administrator was asked, what were his findings as to the failure of the nurses during the coding of RI #1 on [DATE]. EI #1 replied, the resident was a full code and CPR was stopped. The EMS run report indicated on [DATE] at 8:25 AM, dispatch was notified and arrived on scene at 8:30 AM. RI #1's time of death was listed as 8:35 AM. The facility immediately implemented corrective action to prevent recurrence of the identified deficient practice on [DATE]. These corrective actions included: On [DATE], the CPR Policy and Protocol in-services were initiated starting with the 6am-2pm shift. In-services were inclusive of the meaning of code status, DNR and Full Code. In-services were also inclusive of resident's preference of being a DNR or a Full code and the importance to comply with their code status preference. Nurses were not allowed to work until education was conducted. On [DATE], code drills were run every shift. These drills will be done every shift for 14 days. Any failure to perform code drill steps successfully will result in staff member re-education with successful return demonstration prior to returning to duty. After 14 days, the code drills will continue monthly on each shift to ensure the facility's policy is followed. The facility's Administrator and Director of Nursing are monitoring the implementation of education and code drills daily. All staff involved in RI #1's code in the facility on [DATE] have been suspended pending investigation. Termination proceeding for the licensed nurses, EI #3, EI #4, EI #5 and EI #6, was initiated by Human Resources. These licensed nurses will be reported to the Alabama Board of Nursing. On [DATE], the facility held a Quality Assessment (QA) and Assurance meeting. During this meeting, the facility discussed the unexpected death and the code status that occurred in the facility on [DATE]. The QA team reviewed the plan that was put in place related to the unexpected passing of RI #1. The plan included the education of all staff, every shift code drills and ensuring each resident's code status was honored. After review of the facility's investigation file, in-service/education records, code drills, and QA plan, the facility immediately implemented corrective actions beginning [DATE]. The above mentioned corrective actions were completed on [DATE]. The facility will continue to monitor and/or revise their corrective action plan to prevent recurrence and maintain compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 779.

Based on interviews, review of Resident Identifier (RI) #1's medical record, the facility's policy titled Cardio [MEDICAL CONDITION] Resuscitation (CPR) (NP.VII-4) and the 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC), the facility failed to ensure the licensed nursing staff continued CPR until emergency medical services (EMS) providers arrived on-scene and took over the care of RI #1. During the morning hours of [DATE], RI #1, a resident with Full Code status was found without a pulse. The nursing staff started chest compressions; however, at some point, the licensed nursing staff, without physician or EMS notification, stopped CPR and left RI #1's room to call the physician, Director of Nursing and 911 (EMS). After speaking on the telephone with Employee Identifier (EI) #2, the Director of Nursing (DON) at 8:16 AM, the licensed nurses were instructed to return to RI #1's room and resume CPR until EMS arrives and takes over the code. Even after being given these instructions from the DON (EI #2), the licensed nurses waited around in RI #1's room until EMS arrived before they resumed CPR on RI #1. EMS arrived in the nursing facility at 8:30 AM, 14 minutes later. While the licensed nursing staff waited, they agreed EMS would be told that CPR had been in progress for 30 minutes uninterrupted. This deficient practice placed RI #1, one of three sampled residents reviewed for emergency response, in immediate jeopardy because it was likely to cause serious injury, harm or death. On [DATE] at 1:35 PM, EI #1, the facility's Administrator; EI #2, the DON; EI #13, the Regional Administrator; EI #14, the Regional Nurse; and EI #15, an administrator employed with the corporation, were notified of the findings of immediate jeopardy in the area of Quality of Care, F 309. Findings include: The facility's policy titled Cardio [MEDICAL CONDITION] Resuscitation (CPR) (NP.VII-4) with an effective date of [DATE], documented . PURPOSE: To circulate blood containing oxygen to vital organs pending the arrival of emergency medical services (EMS) to a resident who experiences [MEDICAL CONDITION] (cessation of respiration and/or pulse) in accordance with the resident's advance directives or in the absence of advance directives or a Do Not Resuscitate (DNR) order . PROCESS: . 4. Follow AHA CPR guidelines . Page 6 of the HIGHLIGHTS of the 2015 American Heart Association Guidelines Update for CPR and ECC with a copyright date of 2015, documented . The rescuer should continue CPR until an AED (automated external defibrillator) arrives and is ready for use, EMS providers take over care of the victim, or the victim starts to move . RI #1 was readmitted to the facility on [DATE]. On [DATE] at 3:23 PM, the facility submitted an online report of neglect to the State Agency which indicated . at approximately 8:15a resident (RI #1) coded and CPR was begun. RN (Registered Nurse) (EI #3) allegedly told the staff to stop CPR due to the absence of a pulse. CPR was stopped for approximately ,[DATE] minutes and was resumed . The online report further indicated the actions taken by the facility in response to the incident were: 1. All staff that were involved in working the code were suspended pending an immediate investigation. 2. All licensed staff were reeducated on the policy and procedure for working a code and CPR before their next shift. 3. Code drills will be run every shift beginning [DATE]. 4. An immediate investigation was begun. On [DATE], the State Agency received an anonymous complaint which alleged, the facility failed to provide CPR to a full code resident, RI #1. Contained within the facility's investigative file was an undated typed document by EI #1, the facility's Administrator, which documented On [DATE] at approximately 8:30am I received a call at home from (EI #2), DON, that a resident, (RI #1), had coded in the facility and CPR was suspended for a short time before being restarted. (EI #2, DON) immediately came to facility and started an investigation . Based on interviews with staff present in the room, either (EI #3), RN (Registered Nurse), or (EI #4), LPN (Licensed Practical Nurse), made the statement, '(He's/She's) gone', or something to that effect. At this point, the staff member performing compressions, (EI #5) quit performing compressions and staff began to exit the room . Following the ending of CPR, . (EI #4) then called the DON. The DON stated (RI #1) is a full code. She (the DON, EI #2) instructed (EI #4) to immediately continue CPR. (EI #4) hung up the phone and told (EI #3) that we needed to continue CPR. (EI #3) stated that she did not see the point of continuing, (he/she) was dead. (EI #5) placed a call to 911 at 8:22 am . EMS was dispatched at 8:25 am and arrived at 8:30 am . CPR was re-initiated . When EMS arrived they initiated an unsuccessful code as well. The facility immediately suspended (EI #3), (EI #5), (EI #6), (EI #4), (EI #8), and (EI #7) . We have initiated termination proceedings against (EI #3), (EI #5), (EI #6) and (EI #4). We will also report these four nurses to the Board of Nursing . The facility initiated an all staff education beginning on [DATE] on CPR policy and procedure. Nurses were not allowed to work until education was conducted effective [DATE]. Code drills were run beginning [DATE] for fourteen days and have been run every shift. Any failure to perform code drill steps successfully will result in staff member re-education with successful return demonstration prior to returning to duty. A copy of the educations and code drills are reviewed by the Administrator and Director of Nursing daily. In an interview on [DATE] at 6:20 PM, EI #7, a Certified Nursing Assistant (CNA) acknowledged that staff did perform CPR on RI #1; however, at some point during the CPR, someone said CPR could be stopped. When that was said, EI #7 stated she and the other CNA (EI #8) performed post-mortem care on RI #1. According to EI #7, she and EI #8 gave RI #1 a bed bath. After the bed bath was completed, EI #7 stated the licensed nursing staff (EI #3, EI #4, EI #5 and EI #6) came back in RI #1's room and started CPR again, because RI #1 was a full code. EI #7 explained that before the licensed nursing staff began CPR again, they all stood around in RI #1's room. EI #7 stated she asked why the licensed nursing staff were just standing there. It was stated that they were standing there watching for the paramedics (EMS). According to EI #7, the licensed nursing staff stated they would resume CPR when EMS arrived as if they had been doing CPR the whole time. If the licensed nursing staff were asked by EMS, how long CPR had been going, the staff would say, 30 minutes. In an interview on [DATE] beginning at 4:35 PM, EI #4, the Licensed Practical Nurse (LPN) assigned to care for RI #1 was asked, why CPR was stopped on [DATE]. EI #4 replied, she could not recall. When asked what time was CPR stopped, EI #4 stated she was not sure. According to EI #4, she left RI #1's room to make some phone calls. EI #4 stated she contacted the physician, the Director of Nursing (EI #2) and 911. It was during the phone call with EI #2 (DON), that EI #4 was told that RI #1 was a full code and CPR should be started back and continued until EMS arrived. EI #4 stated after she hung up the telephone with EI #2, she then called 911. After the phone call with 911, EI #4 stated she went back to RI #1's room to restart CPR. EI #4 denied telling EMS or saying that CPR had been in progress for 30 minutes. During an interview on [DATE] at 7:50 PM, EI #3, the Registered Nurse (RN) Supervisor stated she became aware of the code via the facility's intercom. EI #3 stated when she entered RI #1's room, a staff member was performing chest compressions. EI #3 stated she asked EI #4 (the LPN Charge Nurse) if 911 (EMS) had been called and was told no. EI #3 stated as she checked RI #1's carotid and radial pulse, she noticed the resident had none and the resident was cold. According to EI #3, EI #4 then left the resident's room to call the doctor. EI #3 stated she followed and overheard the conversation EI #4 had with the doctor, DON (EI #2) and 911. EI #3 stated that when EI #4 hung up from the DON (EI #2), she stated RI #1 was a full code and CPR should not have been stopped. EI #3 acknowledged that she was in RI #1's room when the staff stopped CPR. When asked when should CPR be stopped once it was started, EI #3 replied, when emergency personnel arrives. When asked why CPR for RI #1 was stopped, EI #3 stated because the nurse in charge, EI #4, left RI #1's room. EI #3 stated as the supervisor, she should have made sure that CPR continued until EMS arrived. When asked if she instructed the staff to start CPR once EMS arrived, EI #3 said yes. When asked why this was said, EI #3 stated she didn't know, that she panicked because the DON (EI #2) stated that CPR should not have ever been stopped. EI #3 explained that the licensed nursing staff in RI #1's room, stood around and waited on staff to report that EMS was in the building before they began CPR for the second time. When asked why this occurred, EI #3 stated, mainly because RI #1 was cold and the resident's eyes were fixed. In an interview on [DATE] at 10:50 AM, EI #2, the DON stated she had received a telephone call at 8:16 AM on [DATE] from EI #4 stating that RI #1 had passed. After questioning EI #4 about whether or not, the staff had performed a code/CPR, EI #2 stated she instructed EI #4 to go back to RI #1's room, code the resident and call 911 because RI #1 was a full code. In an interview with the room-mate of RI #1 (RI #4) on [DATE] at 5:30 PM, this resident stated on [DATE] CPR was started, then it stopped for a while and it was re-started when the nursing supervisor (EI #2) said to. RI #4 has been in the facility since [DATE]. RI #4's quarterly Minimum Data Set with an assessment reference date of [DATE], indicated the resident was cognitively intact, with a Brief Interview for Mental Status (BIMS) of 15. During an interview on [DATE] at 7:05 PM, EI #8, a CNA acknowledged that she was present in the facility on [DATE] when the staff started and stopped CPR on RI #1. When asked, what occurred during the time CPR was stopped, EI #8 stated she and EI #7 cleaned RI #1 up, gave the resident a bed bath, washed the resident's face, moisturized his/her hands, placed a clean gown on the resident and changed the bed linens. After RI #1's was cleaned up, EI #8 stated she overheard EI #3, the RN Supervisor say, the staff would resume CPR when the paramedics (EMS) arrived. In an interview on [DATE] at 1:30 PM, EI #1, the facility's administrator was asked, what were his findings as to the failure of the nurses during the coding of RI #1 on [DATE]. EI #1 replied, the resident was a full code and CPR was stopped. EI #1 explained that during the investigation, it was revealed that staff stated they would re-start CPR once the paramedics arrived. The EMS run report indicated on [DATE] at 8:25 AM, dispatch was notified and arrived on scene at 8:30 AM. The report further indicated, . Staff advised pt. (patient) care had been going on for 30 min. (minutes) . RI #1's time of death was listed as 8:35 AM. The facility immediately implemented corrective action to prevent recurrence of the identified deficient practice on [DATE]. These corrective actions included: On [DATE], the CPR Policy and Protocol in-services were initiated starting with the 6am-2pm shift. In-services were inclusive of the meaning of code status, DNR and Full Code. In-services were also inclusive of resident's preference of being a DNR or a Full code and the importance to comply with their code status preference. Nurses were not allowed to work until education was conducted. On [DATE], code drills were run every shift. These drills will be done every shift for 14 days. Any failure to perform code drill steps successfully will result in staff member re-education with successful return demonstration prior to returning to duty. After 14 days, the code drills will continue monthly on each shift to ensure the facility's policy is followed. The facility's Administrator and Director of Nursing are monitoring the implementation of education and code drills daily. All staff involved in RI #1's code in the facility on [DATE] have been suspended pending investigation. Termination proceedings for the licensed nurses, EI #3, EI #4, EI #5 and EI #6, were initiated by Human Resources. These licensed nurses will be reported to the Alabama Board of Nursing. On [DATE], the facility held a Quality Assessment (QA) and Assurance meeting. During this meeting, the facility discussed the unexpected death and the code status that occurred in the facility on [DATE]. The QA team reviewed the plan that was put in place related to the unexpected passing of RI #1. The plan included the education of all staff, every shift code drills and ensuring each resident's code status was honored. After review of the facility's investigation file, in-service/education records, code drills, and QA plan, the facility implemented corrective actions from [DATE] to [DATE]. The facility will continue to monitor and/or revise their corrective action plan to prevent recurrence and maintain compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 779.

Based on record reviews and interviews the facility failed to follow care plan approaches for Resident Identifier (RI) #1 to "avoid situations that trigger the behavior of being inappropriate with female resident" by allowing the resident to be unsupervised while with female residents during a facility outing. This affected 1 of 4 sampled residents whose care plans were reviewed. Findings include: The facility policy titled, "Care Plans," dated effective date: October 1, 2012, documented the following: "Purpose: Plans of Care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals for the resident. ..." RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1's Psychiatric Evaluation, dated 5/08/2013, from the psychiatric facility prior to the resident's placement to the nursing facility was reviewed. One of the chief complaints listed on the document was " Inappropriate sexual touching of other residents. " A progress note written by a nurse, dated 5/8/13, read " ... ALF (Assisted Living Facility) reports that pt (patient) is trying to kiss females and touch inappropriately. ..." On 5/15/2013 the facility developed a care plan for the problem of "Exhibiting behaviors R/T (Related to) urinating outside, picking up/smoking cigarette butts, inappropriate behavior with female residents." Approaches listed included, "Observe for episodes of behaviors and response to interventions, ...Avoid situations that trigger behaviors -- do not over-stimulate -- provide supportive environment" and "...Provide safety for resident and others during episodes of behaviors. ..." RI #1's Admission MDS, with a reference date of 5/22/2013, indicated the resident was moderately impaired of cognition, with a score on the BIMS (Brief Interview of Mental Status) of 9 out of a possible 15. Review of the medical record revealed Nurses Notes, dated 6/7/13, the resident was seen urinating outside and digging through ashtrays and getting cigarette butts and smoking them. On 6/8/13, Nurses Notes documented "resident was outside and seen kissing another resident...". The Charge Nurse documented in a note dated 6/10/13, the resident was observed pushing another resident to her room. During an interview of 7/2/13 at 2:55PM, EI # 8, the Social Worker stated RI #1 did not exhibit any behaviors the first couple of weeks, but then was having behaviors in the smoking area and was placed on behavior monitoring. EI #8 went on to say on Monday, 6/10/13, she heard about the weekend RI #1 was pushing a resident in her wheelchair to her room and a kiss was exchanged and (she) requested the Psychiatrist to look at him. The facility progress note of a "MD/Psychiatric Evaluation", dated 6/17/13 documented the resident was seen for the reported chief complaint of "inappropriate behavior and recent behavioral management with minimal reported behaviors." The plan/recommendations were "Continue current medications and continue behavioral management." One of the facility's planned activity for 6/20/13 included an outing to the movie theater utilizing community bus service. A bus seating layout diagram was provided by the facility listing each resident that attended the outing on 06/20/13. Bus #1 had the names of nine residents(eight female and one male) and no staff members. The diagram for Bus #1 also showed that RI #1 sat in the aisle seat beside RI #2 on that outing. The diagram for Bus #2 indicated three empty seats and the names of two residents, and two staff members on that bus. Review of RI #1's Departmental Notes, dated 6/20/2013, the Director of Nursing (DON) documented, "Female resident stated that while out on the activity outing this resident (RI #1) reached over and touched her on the side of her breast near rib cage. When questioned about what happened resident stated "I tried to hold her hand but she said stop and I did. Then I tried to give her a hug and she told me not to so I didn't. On 7/02/13 at 8:35 AM, EI #3, Activity Director, was asked if there were any staff on each bus on the 6/20/13 outing. EI #3 replied there was not. EI #3 said she was in her personal truck carrying the wheelchairs. EI #3 said both CNAs were on the same bus, but she did not know it at the time. On 7/03/13 at 4:58 PM, EI #3, Activity Director, was asked what was the facility policy regarding staff responsibilities for residents on a facility outing. EI #3 replied, there was nothing in writing but they had predetermined responsibilities such as assisting with transfers on the bus to the seats. EI #3 was asked again about the policy regarding supervision of the residents. EI #3 replied while en-route, the workers would watch, but there is really nothing in place. EI #3 further explained there was one activity assistant (EI #4) on bus #1 and when RI #1 boarded the bus the activity assistant let him sit in her seat beside RI #2 and then she went and boarded bus #2. EI #3 stated she was not aware of this at the time. EI #3 stated she did not ask EI #4 why she got off bus # 1. EI #3 was asked who was suppose to supervise the residents. EI #3 replied she was. On 07/03/13 at 9:00 AM, EI #1, Administrator, acknowledged in an interview that RI #1's medical record clearly referenced a history of inappropriate touching. EI #1 further commented the goal is to put into place a care plan to monitor that resident. EI #1 was asked about the lack of supervision on the bus. EI #1 replied there was supervision by the bus driver. (The driver of the bus was not an employee of the facility).

Based on interviews and record reviews, the facility failed to provide staff supervision for residents on one of two buses utilized for a facility outing on 06/20/13. This lack of supervision provided Resident Identifier (RI) #1, a male resident with a history of inappropriate behaviors toward females, the opportunity to make unwanted sexual advances and inappropriate touching to RI #2. As a result of these behaviors exhibited by RI #1 toward RI #2, RI #2 became fearful of RI #1, causing her to isolate herself in her room and preventing her to participate in her daily normal routine. This affected 1 of 8 female residents on a bus on 06/20/13. Findings include: The facility policy titled "Conducting Activities," effective date: March 1, 2008, documented the following: Purpose: To provide a well organized and safe activity program for all residents. Standard: The Activity Director is responsible for the scheduling, planning, preparation, and execution of all activities... Process: ...II. Conducting the Activity: ...e) A representative of the nursing department should accompany residents on trips outside the facility. ..." In the facility "Resident Handbook," dated June 1, 2008, documented on page 7: "...III. YOUR RIGHTS AS A RESIDENT ...The Facility strives to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect, in full recognition of his or her individuality..." The facility job description for "Activities Director," review date: 06/30/03, documented the following: "General Purpose To plan, develop, organize, implement, evaluate and direct the Activity Programs in accordance with current Federal, State and local standards governing the facility, and as may be directed by the Administrator, to ensure that the emotional, recreational and social needs of the residents are met and maintained on an individual basis.... Standard Requirements ...2. Knowledgeable of residents rights and ensures an atmosphere, which allows for the privacy, dignity, and well-being of all residents in a safe, secure environment... B. Quality Assurance Functions ...8. Monitor activities to ensure resident's emotional, recreational and social needs are met..." RI #1, a male resident, was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. RI #1's Psychiatric Evaluation, dated 05/08/2013, from the psychiatric facility prior to the resident's placement to the nursing facility was reviewed. One of the chief complaints listed on the document was "Inappropriate sexual touching of other residents." A progress note written by a nurse, dated 5/8/13, read "... ALF (Assisted Living Facility) reports that pt (patient) is trying to kiss females and touch inappropriately. ..." On 05/15/2013 the facility developed a care plan for RI #1 for the problem of "Exhibiting behaviors ... urinating outside, picking up/smoking cigarette butts, inappropriate behaviors with female residents." The approaches included, "Observe for episodes of behaviors..., Avoid situations that trigger behaviors -- do not over-stimulate -- provide supportive environment..." and "Provide safety for resident and others during episodes of behaviors. ... " RI #1's Admission MDS(Minimum Data Set), with a reference date of 05/22/2013, indicated the resident was moderately impaired of cognition, with a score on the BIMS (Brief Interview of Mental Status) of 9 out of a possible 15. Review of RI #1's medical record revealed Nurses Notes, dated 6/7/13, the resident was seen urinating outside and digging through ashtrays and getting cigarette butts and smoking them. On 6/8/13, Nurses Notes documented "resident was outside and seen kissing another resident...". The Charge Nurse documented in a note dated 6/10/13, the resident was observed pushing another resident to her room. During an interview of 7/2/13 at 2:55PM, EI # 8, the Social Worker stated RI #1 did not exhibit any behaviors the first couple of weeks, but then was having behaviors in the smoking area and was placed on behavior monitoring. EI #8 went on to say on Monday, 6/10/13, she heard about the weekend RI #1 was pushing a resident in her wheelchair to her room and a kiss was exchanged and requested the Psychiatrist to look at him. The facility progress note of a "MD/Psychiatric Evaluation", dated 06/17/13 documented RI #1 was seen for the reported chief complaint of inappropriate behavior and recent behavioral management with minimal reported behaviors with the plan/recommendations to, "Continue current medications and continue behavioral management." Review of the Departmental Notes for RI #1, dated 06/20/2013 at 6:03 PM, the DON documented, "Female resident stated that while out on the activity outing this resident (RI #1) reached over and touched her (RI #2) on the side of her breast near rib cage. When questioned about what happened resident (RI #1) stated "I tried to hold her hand but she said stop and I did. Then I tried to give her a hug and she told me not to so I didn't. ..." RI #2, the female resident, was admitted to the facility on [DATE]. Admission [DIAGNOSES REDACTED]. Review of RI #2's Quarterly Minimum Data Set (MDS) assessment, reference date 04/01/13, revealed a BIMS score of 13 out of a possible 15, indicating her cognition was intact. The MDS also revealed a mood severity score of "0" indicating no depressive symptoms. The MDS also revealed RI #2 exhibited no behaviors. The MAR (Medication Administration Record) did reveal RI #2 was being monitored for delirium, in which no episodes were documented as exhibited. Review of the Department Notes for RI #2, provided by the facility revealed a note, dated 06/20/13, by the Director of Nurses (DON). "Resident (RI #2) stated that while out on activity, a male resident (RI #1) who was sitting beside her on the bus, reached over and touched her on the side of her breast near rib cage. Resident stated she immediately told him to stop and not do that and the resident immediately stopped. Body audit was performed and no bruising, redness or irritation noted. Resident stated no pain or discomfort. Resident also stated that the resident was holding her hand and placed his hand on his leg... ." On 06/21/13 a late entry Nurse Note was documented by the Unit Supervisor / Registered Nurse. " LATE ENTRY FOR 0830 RESIDENT APPROACHED WRITER STATING THAT SHE FORGOT TO REPORT THAT RESIDENT ATTEMPTED TO KISS HER WHEN THERE WAS NO ONE AROUND. INFORMATION REPORTED TO _____ ADMIN." On 06/21/13, RI #2's facility's physician (EI #18) visited the resident. According to the physician's progress note RI #2 recounted the incident to him that occurred on the bus on 06/20/13. The physician documented RI #2 was of sound mind at that time and wanted to avoid the other resident. On 06/24/13 the Licensed Bachelor Social Worker (LBSW) conducted BIMS assessment for RI #2. RI #2 was coded with a "15" indicating her cognition was intact. RI #2 was also coded for presently having little interest or pleasure in doing things; feeling down and trouble concentrating on things, such as reading ... RI #2's total mood score was "4" which indicated minimal depressive symptoms. On 07/01/13 at 2:25 PM, the facility Ombudsman reported to the surveyor, she received a call from the Administrator, EI #1 on 06/26/13, about the incident with RI #1 and RI #2, that RI #1 had touched RI #2 on her breast, tried to kiss her and hold her hand. The Ombudsman stated that she had received a call from an employee where RI #1 resided prior to coming to this facility. She was told by this employee that while RI #1 resided at the other facility he was seen kissing a demented resident. The Ombudsman stated that when she found out that RI #1 had exhibited this same behavior at the facility he was at now, she informed EI #1 of RI #1's past behaviors. At this time EI #1 replied to her he knew he had those behaviors in the past. The Ombudsman further commented that she was made aware that there was not any staff supervision on the bus that RI #1 and RI #2 rode on for the outing on 06/20/13. On 07/01/13 at 3:55 PM, RI #2 was asked to explain in her own words what occurred between herself and RI #1. RI #2 said they were on the bus waiting to go to the movies. She said RI #1 came and sat down beside her. She did not know who RI #1 was and she introduced herself. RI #2 said they were conversing back and forth. She said RI #1 was sitting on her right side, the aisle side. RI #2 was asked what RI #1 did. She said RI #1 was sitting on her right side and he reached his right hand over and touched the right side of her breast area. RI #2 said she slapped RI #1 on the right side of his cheek and said "no" to him. RI #2 said RI #1 then moved his hand away. RI #2 was asked what RI #1 said. She said he did not say anything. RI #2 said nothing was done the rest of the ride to the theater. RI #2 said when they arrived back at the facility and the bus was unloaded of the other residents, she and RI #1 were alone on the bus and RI #1 said, "Oh, we're alone." Then RI#1 kissed her on the lips. RI #2 said she slapped RI #1 on the left cheek. RI #2 said at that point a staff came back on the bus and noticed the residents on the bus and told them they could get off. RI #2 said she got up, got her walker and needed help off the bus. RI #1 attempted to assist her and the staff told him that RI #2 needed to do it by herself. RI #2 said she was relieved the staff said that. RI #2 said she did not know why she did not tell the Certified Nursing Assistant (CNA) at the theater. RI #2 said RI #1 kept telling her he was coming to see her that night. RI #2 said she knew she just had to tell the Administrator because just the day before in the Resident Council Meeting he had discussed reporting complaints. RI #2 said she went and told the Administrator after she got off the bus. RI #2 said she saw RI #1 the next day while he was in the smokers line and he waved and smiled at her. RI #2 said she had no other encounters with RI #1. RI #2 said she did change her seating in the dining room to avoid any contact with RI #1. RI #2 said she also stayed in her room to avoid RI #1 for 2 to 3 days, then she started coming back out. RI #2 said she only reported the incident to the Administrator. RI #2 was asked what she told the Administrator. She said she told him about RI #1 hugging her and touching the side of her breast. She said she did not remember about the kissing until the next day and she then told the unit manager. She said she then told the Administrator and the DON about the kissing. RI #2 was asked if RI #1 kissed her or attempted to kiss her. She answered he attempted to kiss her. On 07/02/13 at 8:35 AM, EI #3, Activity Director, was asked if there were any staff on each bus on the 06/20/13 outing. EI #3 replied there was not. EI #3 said she was in her personal truck carrying the wheelchairs. EI #3 said both CNAs were on the same bus but she did not know it at the time. EI #3 was asked if the CNAs were instructed to ride one on each bus. EI #3 replied they were not. She said the CNAs, activity assistants, were not given instructions on the supervision of the residents while on the buses. EI #3 was asked if she was aware of any behaviors of RI #1. EI #3 replied she was not aware. EI #3 was asked before the trip how was RI #2. EI #3 replied RI #2 was pleasant and outgoing. She interacted around the facility and attended at least 95% of activities. EI #3 was asked how did RI #2 act after the incident. EI #3 replied she was more apprehensive before RI #1 was discharged from the facility. EI #3 commented that she would escort RI #2 to and from the activities, and since RI #1 was gone from the facility RI #2 is back to her pleasant outgoing self. On 7/2/13 at 9:05 AM, activity assistant EI #4 said she was on bus #1 until RI #1 got on the bus and then she got up to give RI #1 her seat. She then got on the second bus because the first bus was full. EI #4 was asked what her pre delegated responsibilities were for outings. EI #4 said, loading the residents on the bus. On 7/2/13 at 9:25 AM, activity assistant EI #5 was also interviewed. She was asked what her pre delegated responsibilities were for outings. EI #5 said, loading the residents on the bus and in bus seats and make sure they are buckled. On 07/02/13 at 9:30 AM, during a resident group meeting, six interviewable residents who resided on the same hall as RI #1 were asked if any of them had witnessed RI #1 being inappropriate with anyone in the facility at any time. None of the six expressed any concern about any similar occurrences from RI #1. One female resident did comment that a CNA had told her about 1-2 months ago to stay away from RI #1. When this resident was asked why did the CNA tell her that, she replied she did not know, nor did she ask why herself. The group was asked did they noticed anything different about RI #2 after the incident. Another female resident replied that RI #2 did not come play dominoes as much. On 07/02/13 at 1:30 PM, EI #6, Unit Manager/ RN was interviewed. She was asked when she became aware of the incident between RI #1 and #2. She said she could not recall the day, but it was the day when the resident went to the movies. EI #6 said RI #2 came to her the next day and told her RI #1 tried to kiss her. She said she documented it in the nurses notes. She said RI #1 tried to hold her hand and said he tried to hug her and she said no don't do that and he stopped. When asked how was RI #2 after the incident. EI #6 said she noticed RI #2 did not want to come out of her room. She said since RI #1 is gone, RI #2 is out and about again. On 07/02/13 at 1:50 PM, EI #7, Licensed Practical Nurse (LPN) was interviewed. She was asked if RI #2 told her about the incident with RI #1. EI #7 said RI #2 told her of the incident the next day. She was asked what RI #2 told her. She said she asked RI #2 how she was doing and EI #7 said the resident was nervous and she was scared. She said RI #2 asked for a nerve pill and she told EI #7 what RI #1 had done. RI #2 told EI #7 she forgot to tell RI #1 had tried to kiss her. EI #7 then told RI #2 she needed to tell EI #6 the Unit Manager. EI #7 was asked how RI #2 was before and after the incident. EI #7 said RI #2 use to go to activities and since the incident she has been afraid to come out of her room. EI #7 said RI #2 told her she did not want to be here anymore and she is afraid RI #1 will come back. EI #7 was asked since RI #1 has left the facility, has RI #2 has been better. EI #7 said yes. On 07/02/13 at 5:10 PM, EI # 20, LPN, was asked about any interaction she had with RI #2 after the incident. EI #20 replied she had talked to her this past Sunday and RI #2 stated she felt better since RI #1 was gone. EI #20 stated she asked RI #2 if she knew if RI #1 was coming back to the facility. RI #2 replied to her, that no one had told her that was a possibility and she had a scared look on her face that could happen. On 07/02/13 at 5:50 PM, EI #10, an LPN, was interviewed. EI #10 was asked if she was aware of any behaviors of sexual nature regarding RI #1. EI #10 said she was aware of sexual inappropriate behaviors through the resident's History and Physical. EI #10 was asked if RI #2 told her about the incident on the bus. EI #10 said it was during her 4:00 (PM) med pass after they came back from the movies. EI #10 said RI #2 came up to her and said RI #1 was holding her hands, that when she tried to pull away he would not let her go of her hand. RI #2 told her RI #1 was putting her hand on his thigh. EI #10 also said RI #2 told her RI #1 reached around and put his hand on her right rib cage at her breast area. EI #10 said RI #2 said she was nervous because RI #1 told her several times he was coming to her room that night. EI #10 said she asked RI #2 if she had told anyone and she said she had told the Administrator. EI #10 said RI #2 was upset and would not go to the dining room. She said RI #2 stayed in her room that night and she had heard RI #2 had breakfast and lunch in her room the next day. On 07/03/13 at 9:00 AM, EI #1, Administrator, was asked who was involved in the preadmission process. EI #1 replied the Administrator and the Director of Nurses (DON) and confirmed when he reviewed RI #1's Medical Record, it clearly referenced the inappropriate touching. EI #1 was asked about the lack of supervision on the bus. EI #1 replied there was supervision by the bus driver. (The driver of the bus was not an employee of the facility.) On 07/03/13 at 2:35 PM, EI #8, Social Worker, was asked if she was aware if RI #2 isolated herself in her room after the 06/20/13 incident. EI #8 replied RI #2 told her she stayed in her room for a couple of days because she did not want to run into RI #1. On 07/03/13 at 3:00 PM, EI #12, CNA, was asked was there any change in RI #2's behavior or daily routine after the 6/20/13 incident. EI #12 replied that after the incident on the next day RI #2 did not come out of her room on the 2-10 PM shift. On 07/03/13 at 3:00 PM, RI #2 was interviewed again. She was asked how she felt about the incident that occurred on the bus. RI #2 said she was angry and did not want to see RI #1 because she was scared because he was a big man. RI #2 said she did not exactly know what he was going to do, did not know if it was a bluff or he was going to do what he said. RI #2 was asked what was it RI #1 said he was going to do. RI #2 said RI #1 said he was going to come into her room that night, that he said that several times on the ride back to the facility. She said RI #1 kissed her, hugged her and he was holding her hand and would not let go. RI #2 said when she tried to let go, RI #1 grabbed her hand again. RI #2 was asked were there any staff riding on the bus. She said no. On 07/03/13 at 3:52 PM, during a family interview for RI #2, the family member was asked when did he talk to RI #2 after the incident on 06/20/13. He replied the facility had called him the same day and he was told that another male resident had tried to hold RI #2's hand and this was the same information RI #2 had told him when he talked to her that day. The family member then commented that the second time he talked with RI #2 she told him RI #1 tried to kiss her and grabbed her breast. The family member was asked did he know how RI #2 would feel if RI #1 was returned to the facility. He replied RI #2 told him she would leave the facility. On 07/03/13 at 4:30 PM, EI #18, the Medical Director, was asked when did he become aware of the incident that occurred on 06/20/13 with RI #1 and RI #2. EI #18 commented on 06/21/13 during his regular rounds. EI #18 was asked what was his assessment of RI #2 when he saw her. EI #18 replied he gave her a tranquilizer to calm her down and that her behavior was appropriate. On 07/03/13 at 4:58 PM, RI #3, Activity Director, was asked what was the facility policy regarding supervision for residents on a facility outing. EI #3 replied, there was nothing in writing but they had predetermined responsibilities such as assisting with transfers on the bus to the seats. EI #3 was asked again about the policy regarding supervision of the residents. EI #3 replied while en-route, the workers would watch, but there is really nothing in place. EI #3 was asked who was the staff person in charge on the 06/20/13 outing. EI #3 replied, she was. EI #3 was asked how many residents were on bus #1 on the 06/20/13 outing. EI #3 replied, there were nine residents. EI #3 was asked how may staff were on bus #1 on the 06/20/13 outing. EI # 3 replied none. EI #3 was asked how many residents were on bus #2 on the 06/20/13 outing. EI #3 replied, there were two. EI #3 was asked how may staff were on bus #2 on the 06/20/13 outing. EI # 3 replied two activity assistants. EI #3 further explained there was one activity assistant on bus #1 and when RI #1 boarded the bus the activity assistant let him sit in her seat beside RI #2 and then she went and boarded bus #2. EI #3 stated she was not aware of this at the time. EI #3 stated she did not ask EI #4 why she got off bus # 1. EI #3 was asked who was suppose to supervise the residents. EI #3 replied she was. In review of the bus seating layout diagram provided by the facility, each resident that attended the outing on 06/20/13 was listed. Bus #1 had the names of nine residents and no staff. The diagram also showed that RI #1 sat beside RI #2 on that outing. Bus #2 had the names of two residents, two staff listed and three empty seats. On 07/03/13 at 5:50 PM, EI #11, Registered Nurse (RN) was interviewed. EI #11 was asked when he became aware of the incident that occurred on 6/20/13. He said he became aware when he came on duty that day. EI #11 was asked what he did at that time. EI #11 said he went into RI #2's room to talk to her about it and to assure her, she and RI #1 would be watched closely. He said he told RI #2 she was going to be kept safe. EI #11 was asked how RI #2 was after the incident. He said RI #2 ate in her room that night. EI #11 said RI #2 went to the dining room the next evening, but she was upset that RI #1 was allowed to eat in the dining hall. EI #11 said RI #2 was still upset the following week that RI #1 remained in the building. On 07/03/13 at 6:05 PM, EI #6, Licensed Practical Nurse, LPN, was asked did she noticed any thing different with RI #2 after the 06/20/13 incident. EI #6 replied that RI #2 ate supper in her room the evening of the incident, but she did not tell her why. On 07/03/13 at 6:20 PM, EI # 12, CNA was interviewed. EI #12 was asked how RI #2's behavior was that night after the incident on 06/20/13. EI #12 said the resident was nervous and shaking. EI #12 said she had to put her hand on RI #2's back, when she was talking to EI #10, because she looked like she was going to fall backwards. EI #12 said RI #2 looked pretty shaken. EI #12 said the resident did not go to the dining room that night. She said the resident moved her seating away from RI #1 in the dining room. On 07/04/13 at 8:10 AM, EI #19, CNA, was asked did she noticed any change in RI #2's behavior that was different since the incident on 06/20/13. EI #19 replied the day after the incident RI #2 did not go to the dining room to eat. EI #19 further explained that on Saturday after the incident RI #2 stayed in her room. EI#19 stated she told RI #2 she did not have to stay in her room. EI #19 then stated that RI #2 asked her if she heard what happened. RI #2 commented to EI #19 that RI #1 touched her breast and tried to kiss her. RI #2 then commented that she was just going to stay in her room. On 07/04/13 at 8:40 AM, EI #14, CNA, was asked how was RI #2 the day after the incident. EI #14 replied, she stayed in her room on the Friday after the incident and that RI #2 had told her on Saturday she was afraid to come out of her room because of what happened on the bus.