Every finding on record at Randolph County Nursing Home

Based on observation, record review, interview, and facility policy review, the facility failed to ensure expired food items and leftovers food items were promptly removed/discarded on or before the expiration or use by date and dietary staff washed their hands between dirty and clean tasks and before handling clean equipment for 1 of 1 meal observed. The findings are: 1. On [DATE] at 5:52 PM, in the storage room, there was a box that contained four (4) cups of sweet corn with an expiration date of [DATE]. Another box of sweet corn had an expiration date of [DATE]. The Dietary Manager/Registered Dietician stated she checked all stock, and she must have missed those two cartons. 2. On [DATE] at 10: 31 AM, Dietary Aide (DA) #3 pushed a cart that held containers of supplement towards the steam table, contaminating her hands. Without washing her hands. She used her contaminated hands to pick up glasses by their rims and placed them on the counter. 3. On [DATE] at 10:35 AM, DA #1 was wearing gloves on her hands when she turned on the food preparation sink and ran water into a pitcher. She then turned off the faucet with her gloved hand, contaminating the glove. DA #1 used her contaminated gloved hands to pick up glasses by their rims and poured water in them and placed them on the trays to be served to the residents for lunch. 4. On [DATE] at 10:59 AM, DA #2 turned on the hand washing sink and washed her hands. She turned off the faucet with her bare hands, contaminating her hands. She picked up a bread bag from the bread rack and placed it on the counter. She removed gloves from the glove box and placed them on her hands, contaminating the gloves. She then untied the bread bag, and without changing gloves and washing her hands, she used her contaminated gloved hand to remove slices of bread and placed them in individual bags to be served to the residents for the lunch meal. During an interview on [DATE] at 1:07 AM, DA #2 was asked what she should have done after touching dirty objects and before handling clean equipment. DA #2 stated she should have washed her hands. 5. On [DATE] at 11:00 AM, DA #1 pushed a cart that contained boxes of sausage patties from the freezer towards the food preparation counter, contaminating her hands. DA #1 removed gloves from the glove box and placed them in her hands. After putting them on, she used a knife to cut open the box of sausage patties. Then, with her contaminated hands, she removed the sausage patties from the box and placed them on the trays. During an interview on [DATE] at 11:08 AM, DA #1 was asked what she should have done after touching dirty objects and before handling clean equipment. DA #1 stated she should have washed her hands. 6. On [DATE] at 11:05 AM, Dietary [NAME] (DC) #3, who was on the tray line assisting with the lunch meal service, used her bare hands to pick up cartons and bottles of supplements and placed them on the trays. DC #3 opened the refrigerator, removed individual bags of sandwiches and placed them on the trays, contaminating her hands. Without washing her hands, she used her contaminated hands to pick up glasses by their rims and placed them on the trays to be served to the residents for lunch. During an interview on [DATE] at 11:09 AM, DC #3 was asked what she should have done after touching dirty objects and before handling clean equipment. She stated she should have washed her hands. 7. On [DATE] at 11:14 AM, two bottles of skim milk on a shelf in the refrigerator had an expiration date of [DATE]. The Dietary Manager/Registered Dietician stated the milk was expired and she would toss it. The Dietary Manager/Registered Dietician also stated she checked the refrigerator and freezer often and knew where the 2 bottles of milk came from. 8. On [DATE] at 11:15 AM, the following observations were made on a shelf in the freezer in the kitchenette in the central area: a. Two bags of bagel bites with an expiration date of [DATE]. b. A bag of pepperoni with an expiration date of [DATE]. The Dietary Manager/Registered Dietician stated that they were all expired and she would toss them. A review of facility policy titled, Handwashing/Hand Hygiene reviewed indicated all personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare -associated infections. Hands should be washed with soap and water and the use of gloves does not replace hand washing/hand hygiene. A review of facility policy titled, First in, first out reviewed indicated for the old stock to be placed in the front and newer in the back.

Based on observation, record review and interview, the facility failed to ensure foods stored in the freezer, refrigerator and dry storage area were covered, sealed and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; expired dessert with dairy products and food items were promptly removed / discarded on or before the expiration or use by date to prevent the growth of bacteria; dietary staff washed their hands between dirty and clean tasks and before handling clean equipment or contamination and hot food items were maintained at above 135 degrees Fahrenheit on the steam table while awaiting service to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 125 residents who received meals from 1 of 1 kitchen, as provided by the Dietary Supervisor on [DATE] at 12:59 PM. The findings are: 1. On [DATE] 10:48 AM, there was a partially open bag of shredded mozzarella cheese on a shelf in the refrigerator. The bag was not completely sealed. 2. A box that contained 34 individual cartons of vanilla pudding was on a shelf in the walk-in refrigerator with an expiration date of ,d+[DATE] 2023. 3. On [DATE] at 11:03, Dietary Employee (DE) #1 had gloves on her hands when she picked up a temperature gauge and checked the food temperatures on the steam table. At 11:07 AM Dietary Employee was still wearing the gloves that she had on her hands when checking the temperatures of the food items on the steam table when she picked up plates to be used in portioning foods to be served to the residents for lunch and placed them on the plate holders with her contaminated gloves fingers inside the plates. 4. On [DATE] at 11:04 AM, the temperatures of the food items when checked on the steam table by Dietary Employee #1 were the following: a. Hamburger patties 120 degrees Fahrenheit. b. English peas was 129 degrees Fahrenheit. The above food items were not reheated before being served to the residents. 5. On [DATE] at [DATE] 11:04, the following observations were made in the walk-in freezer: a. An opened box of biscuit dough was on a shelf in the freezer. The box was not covered and the bag inside the box was not completely sealed. b. An opened box of hamburger patties was on a shelf in the freezer. The box was not covered, and the bag inside the box was not completely sealed. c. An opened box of sausage patties was on a shelf in the freezer. The box was not covered, and the bag inside the box was not completely sealed. d. An opened box of beef patties was on a shelf in the freezer. The box was not covered, and the bag inside the box was not fully sealed. e. An opened box of beef fritters was on the shelf in the freezer. The box was not covered, and the bag was not sealed. f. An opened box of beef steaks was on a shelf in the freezer. The box was not covered and the bag inside the box was not completely sealed. 6. On [DATE] at 11:10 AM, there was an open bag of bread on the bread rack. There was no date on the bag to indicate when it was received and or opened. 7. On [DATE] at 2:17 PM, Dietary Employee #2 turned on the hand washing sink faucet and washed her hands. After washing her hands, she used tissue paper to turn off the faucet. Then, used the same tissue paper to dry her hands. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in grounding meat for the residents on mechanical soft diets for supper. At 2:18 PM, when Dietary Employee #2 was ready to place meat items into the blender to ground. The Surveyor immediately asked her what should you have done after touching dirty objects and before handling clean equipment? She stated, That's how I was taught. 8. On [DATE] at 2:36 PM, Dietary Employee #2 picked up a pot of carrot from the stove and placed it on the counter. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureed foods for the residents on pureed diets for supper. The Surveyor asked Dietary Employee #2 what she should have done after touching dirty objects, before handling clean equipment? She stated, I should have washed my hands. 9. On [DATE] at 2:45 PM, Dietary Employee #3 was wearing gloves on his hands when he turned on the hand washing sink faucet and rinsed tomatoes. After rinsing tomatoes, he used his gloved hand to turn off the faucet and placed tomatoes on the cutting board. When Dietary Employee #3 was ready to slice tomatoes, The Surveyor asked him what should have done after touching dirty objects, before handling clean equipment. He stated, I should have washed my hands. 10. The facility policy titled, Hand Hygiene provided by the infection preventionist on [DATE] at 02:18 PM documented, Hand hygiene is a key feature of standard precautions and should be used by all departments and personnel working or performing duties within the facility. Wash hands with water. Apply enough soap to cover all hand surfaces. Rinse hands with water. Dry hands thoroughly with a single use rowel. Use towel to turn off faucet.

Based on observation and interview, the facility failed to ensure 19 residents ' personal information was kept confidential. The findings are: On 01/08/24 at 12:11 PM, the Surveyor observed a news and notice board outside of the Director of Nurses (DON) office and a 2nd one outside of the main dining room that showed 2 lists of Resident's with a scheduled Care Plan meeting dated January 10, 2024, and January 17, 2024, at 11 AM. The notices state, There will be a care plan meeting for the following residents .in the activity room . On 01/09/24 at 11:17 AM, the Surveyor observed 2 separate news and notice boards that showed 2 lists of Resident's with a scheduled Care Plan meeting dated January 10, 2024, and January 17, 2024, at 11 AM. On 01/10/24 at 8:42 AM, the Surveyor observed 2 separate notice boards with lists of Resident's with a scheduled Care Plan meeting. On 01/11/24 at 9:25 AM, the Surveyor asked the Director of Nursing (DON), how do you notify family and residents of care plan meetings? The DON said the Minimum Data Set (MDS) Coordinator sends a letter to the family, and post a list with date and time by the MDS office and in front of my office for the weekly meetings. The Surveyor asked, how does this provide confidentiality for the residents? The DON stated, It's not private. I thought it was a requirement that it had be posted. A document titled Privacy and Confidentiality provided by the DON on 1/10/2024 at 3:17 p.m. showed, .Personal privacy extends to .communications .and meetings of family .

Based on observation, interview, and record review, the facility failed to ensure a physician's order was followed for 1 (Resident #111) Resident of 6 (Residents #1, #5, #11, #62, #106, #111) sample mixed residents on the 200 halls. The findings are: Resident #111's diagnoses showed dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The Minimum Data Set (MDS) with and Assessment Reference Date (ARD) of 10/24/2023 showed a Brief Interview for Mental Status (BIMS) of 7 (score of 0-7 points suggests severe cognitive impairment). The resident is dependent for personal care. Review of Resident # 111 ' s Physician's Order Summary showed No order for topical mentholated rub or topical zinc oxide ointment. On 01/08/24 at 11:41 AM, the Surveyor observed a 2-ounce (oz.) tube of zinc oxide ointment and a 3.5.3 oz. jar of topical mentholated rub sitting on resident's bedside table. Resident # 111 stated, I use those when I need them. On 01/08/24 at 12:44 PM, the Surveyor observed a tube of zinc oxide ointment and a jar of topical mentholated rub sitting on nightstand. On 01/08/24 at 3:06 PM, the Surveyor observed a tube of zinc oxide ointment and a jar of topical mentholated rub sitting on nightstand. On 01/09/24 at 8:50 AM, the Surveyor observed a tube of zinc oxide and a jar of topical mentholated rub sitting on resident's nightstand. On 01/09/24 at 9:45 AM, LPN #2 confirmed there was no order for the topical mentholated rub or the zinc oxide ointment. On 01/11/24 at 9:28 AM, the Surveyor asked the (Director of Nursing) DON, who is responsible for ensuring an order is placed in a Resident's chart? The DON said,stated, whoever processes the order is responsible for putting the order in electronic health record. The Surveyor asked, should there be an order for every medication? The DON stated, yes.

Based on observations, interview and record review, the facility failed to ensure medication was not left unattended at the bedside; and topical ointments and mouthwash was stored properly for 2 f 2 Resident ' s #1 and #111. The failed practice had the potential to affect 7 ambulatory residents. The findings are: 1. Resident #1 diagnoses showed moderate intellectual cerebral palsy and dementia with mood disturbance. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/17/2023 showed a Brief Interview for Mental Status (MDS) of 12 (Score of 8-12 points: suggests moderate cognitive impairment). The resident is dependent for oral hygiene. Active diagnoses showed the need for assistance with personal care. 1 a. The Resident #1 ' s care plan showed Resident #1 needs help taking care of oral care: assist twice daily and as needed floss daily. 1 b. On 01/08/24 at 11:28 AM, the Surveyor observed a used 4-ounce (oz.) bottle of mouthwash sitting beside the Resident's sink. 1 c. On 01/08/24 at 12:47 PM, the Surveyor observed a used 4 oz. bottle of mouthwash beside the Resident's sink. 1 d. On 01/08/24 at 03:05 PM, the Surveyor observed a used 4 oz. bottle of mouthwash sitting beside the Resident's sink. 1 e. On 01/09/24 at 08:46 AM, the Surveyor observed a used 4 oz. bottle of mouthwash sitting on the resident's counter by the sink. 1 f. On 01/09/24 at 9:43 AM, the Surveyor asked LPN #2 do you see anything sitting out that shouldn't be in Residnet #1's room? LPN #2 said, the mouthwash shouldn't be out because another resident could come in the room, get it, and drink it. 2. Resident # 111's diagnoses showed unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The Minimum Data Set (MDS) with and Assessment Reference Date (ARD) of 10/24/2023 showed a Brief Interview for Mental Status (BIMS) of 7 (score of 0-7 points suggests severe cognitive impairment). The resident is dependent for personal care. 2 a. On 01/08/24 at 11:41 AM, the Surveyor observed a 2-ounce (oz.) tube of zinc oxide ointment and a 3.5.3 oz. jar of topical mentholated rub sitting on resident's bedside table. Resident #111 said, I use those when I need them. The Surveyor also observed a round white scored tablet sitting on Resident # 111's nightstand. 2 b. On 01/08/24 at 12:44 PM, the Surveyor observed a round white scored tablet sitting on the nightstand. A tube of zinc oxide ointment and a jar of topical mentholated rub sitting on nightstand. 2 d. On 01/08/24 at 3:06 PM, the Surveyor observed a tube of zinc oxide ointment, a round white scored tablet, and a jar of topical mentholated rub sitting on nightstand. 2 e. On 01/09/24 at 08:50 AM, the Surveyor observed a tube of zinc oxide and a jar of topical mentholated rub sitting on resident's nightstand. 2 f. On 01/09/24 at 9:45 AM, the Surveyor asked LPN #2, can you tell me what is sitting on the Resident #111's side table. LPN #2 said a jar of [Named] vapor rub and a tube of zinc oxide ointment. The Surveyor asked, should they be left out on the Resident's nightstand? LPN #2 said, the zinc should be in the drawer and the vapor rub shouldn't be in here. LPN #2 confirmed a round white scored tablet was sitting on the table in the room. 2 g. On 01/11/24 at 09:36 AM, the Surveyor asked the Director of Nursing (DON) how should mouthwash, zinc oxide ointment, and a jar of mentholated vapor rub be stored in a resident's room? The zinc should be in the treatment cart. The mouthwash should have been in the resident's personal drawer with all the bathing stuff. The mentholated vapor rub shouldn't have been there because the family brought it. The Surveyor asked, should medication be left at the resident's bedside? The DON confirmed no medication should be left unattended at the bedside.

Based on observation and interview, the facility failed to ensure a CPAP (Continuous Positive Airway Pressure) storage bag was changed weekly for 1 of 1 (Resident #119) sampled residents, and the facility failed to ensure oxygen tubing was dated for 1 (Resident #5) of 2 Residents (Resident #5 & #88) requiring oxygen on the 200 Hall. The findings are: 1. Resident #119 had a diagnosis of OBSTRUCTIVE SLEEP APNEA (ADULT) (PEDIATRIC). A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) on 12/14/23 documented the resident scored 14 (cognitively intact) on a Brief Interview for Mental Status (BIMS). A January 2024 physician order documented, .CPAP every evening and night shift per home settings . A care plan with a revision date of 11/15/23 documented, . Uses CPAP nightly for sleep apnea . On 1/08/24 at 12:01 PM, a CPAP mask was in a storage bag dated 12/01/23. Resident #119 was asked, Do you use your C-Pap every night? She stated, Yes I use it every night. On 1/09/24 at 9:03 AM, a CPAP mask was on the nightstand in a plastic storage bag dated 12/01/23. On 1/09/24 at 3:45 PM, a CPAP mask was on the nightstand in a plastic storage bag dated 12/01/23. On 1/09/24 at 3:49 PM, Licensed Practical Nurse (LPN) #1 was asked, How often should Resident #119 ' s CPAP storage bag be changed? She stated, weekly. She was asked, who's responsible for changing the CPAP storage bag? She stated, Night shift; the nurses. She was asked, can you tell me what date is on Resident #119 ' s CPAP storage bag? She stated, 12/01/23. On 1/10/24 at 2:43 PM, the surveyor asked the Administrator, How often should a CPAP storage bag be changed? She stated, weekly. Resident #5's diagnoses showed COVID-19; chronic obstructive pulmonary disease (COPD) with (acute) lower respiratory infection; acute and chronic respiratory failure with hypercapnia and hypoxia; atrial fibrillation; heart failure. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/18/2023 showed a Brief Interview for Mental Status (BIMS) of 15 (score of 13-15 points indicates cognitive intactness). Resident was on continuous oxygen therapy upon admission and as needed while a resident. The Physician's Order Summary showed oxygen to be administered via nasal cannula at 2 liters as needed for shortness of breath. Titrate oxygen to maintain oxygen level greater than 92%. The care plan showed the Resident has COPD (Chronic Obstructive Pulmonary Disease) and is short of breath when lying flat, sitting, and exerting self. Staff is to report an increase in shortness of breath, wheezing, difficulty breathing, and changes in respirations or mental status. The resident has heart failure and atrial fibrillation. The staff is to report shortness of breath. On 01/08/24 at 3:32 PM, the Surveyor observed oxygen tubing with no date. On 01/09/24 at 8:57 AM, the Surveyor observed no date on oxygen tubing. On 01/11/24 at 9:02 AM, Registered Nurse (RN) #1 confirmed the oxygen tubing was not dated. The Surveyor asked the DON, how often is oxygen tubing changed? The DON said, it is changed weekly on Monday nights 11-7. The Surveyor asked, should the tubing be dated? The DON said yes. The Surveyor asked, can you tell me what the date is on Resident #5 ' s oxygen tubing? The DON confirmed there was not a date on the oxygen tubing. A policy provided by the DON on 1/9/2024 at 10:30 AM titled Oxygen Administration and Storage showed tubing will be changed weekly on the 11- 7 shift.

Based on observation and interview the facility failed to ensure daily staffing schedules were posted in a public location. The findings are: On 01/08/24 at 2:44 PM, the Surveyor did not observe a daily staffing schedule posted in a public area. On 01/09/24 at 1:37 PM, the Surveyor did not observe a daily staffing schedule posted. On 01/10/24 at 10:25 AM, the Surveyor did not observe a daily staffing schedule posted. On 01/10/24 at 10:26 AM, the Director of Nursing (DON) confirmed daily staffing schedules are not posted. The DON said, we were told at the Arkansas Health Care Association (AHCA) Convention that we didn't have to post them anymore.

Based on observation, interview and policy review, the facility failed to store controlled medications were not stored properly in a permanently affixed box in 2 (100, and 300 Halls) of 4 Medication Storage Rooms in the facility. The findings are: On 01/09/2024 at 1:55 PM, the medication refrigerator in the 300 Hall Medication Room was observed to be unlocked. Licensed Practical Nurse (LPN) #3 opened the refrigerator without having to unlock it and removed from it a transparent plastic box. The plastic box was not permanently affixed. LPN #3 confirmed the box was used to store controlled medications and opened it to identify the medication inside, a 30-milliliter bottle of Lorazepam. LPN #3 was asked if storage containers for controlled medications needed to be permanently affixed. LPN #3 said they had not heard of the need to secure the narcotics box. On 01/09/2024 at 3:23 PM, the medication refrigerator in the 100 Hall Medication Room was observed to be unlocked. Inside was a transparent plastic box containing 2 opened 30 milliliter bottles and 5 single use syringes of Lorazepam. The plastic box was not permanently affixed. On 01/10/2024 at 1:24 PM, the Director of Nursing (DON) was asked if they were aware that the containers being used to store controlled medications in the facility were not permanently affixed. The DON stated, Yes, we'd been discussing that issue with our consultant, but we weren't sure of a safe solution. We were worried that drilling into the refrigerator to mount it would be dangerous. On 01/11/2024 at 9:33 AM, the Administrator confirmed that they were aware that the containers being used to store controlled medications in the facility were not permanently affixed. On 01/11/2024 at the Administrator provided a policy titled, Storage of Medications. It documented, Drugs and biologicals will be stored in a safe, secure, and orderly manner .All controlled substances are stored under double-lock and key .

Based on observation, record review and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 8 residents who received pureed meals from 1 of 1 kitchen. The findings are: 1. On 01/08/24, the menu for the supper meal documented, Residents on pureed diets were to receive 2 #8 scoops of pureed chili dog with cheese and a #8 scoop (1/2 cup) of pureed carrots. 2. On 01/08/24 at 4:36 PM, Dietary Employee(DE) #2 used a #16 scoop (1/4 cup) to serve a single portion of pureed chili dog and pureed carrots to the residents on pureed diets, instead of 2#8 scoop of the pureed chili dog (1 cup) and 1/2 cup of carrots, as specified on the menu. 3. On 01/09/2024 12:08 PM, the Surveyor asked DE #2 what scoop sizes she used to serve the supper meal to the residents and how many servings she gave to each resident. She stated, I used the blue scoop the 2-ounce scoop to serve pureed chili dog and pureed carrots. I gave one serving each.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. This failed practice had the potential to affect 8 residents who received pureed diets. The findings are: 1. On 01/08/24 at 11:04 AM, the following observations were made on the steam table. a. A pan of pureed chicken [NAME] was on the steam table. The consistency of the pureed paste was lumpy, not smooth. There were pieces of paste visible in the mixture. b. A container of pureed broccoli in a mold shape. The consistency of the pureed broccoli was dried and thick. 2. On 01/08/24 at 11:55 AM, the surveyor asked the Dietary Supervisor to describe the consistency of the pureed foods served to the residents on pureed diets. She stated, Pureed meat was dried, and thick and pureed pasta was lumpy. 3. On 01/09/24 at 11:41 AM, A pan of pureed chicken was on the steam table. The consistency of the pureed chicken was lumpy, not smooth. There were pieces of chicken visible in the mixture. The surveyor asked Dietary Supervisor to describe the consistency of the pureed chicken served to the residents on pureed diets. She stated, It has little lumps.

Based on observation, interview, and record review the facility failed to ensure staff had on appropriate Personal Protection Equipment (PPE) for 1 of 1 (Resident #62) sampled residents that were on enhanced barrier precautions on the 200 hall. The findings are: Resident # 62's diagnosis showed a urinary tract infection. The Physician's Order Summary showed an order with a start date of 1/05/2024 for Enhanced Barrier precautions three times a day for Methicillin-resistant Staphylococcus aureus (MRSA) Urinary tract infection (UTI). The Care Plan showed the Resident #62 had been placed on Enhanced Barrier Precautions on 1/5/24 for MRSA of the urine. Precautions will remain in place for as long as the resident meets the criteria for these enhanced precautions. Gowns and gloves will be worn during any close contact activities per Centers for Disease Control (CDC) guidance in addition to all standard precautions. On 01/08/24 at 1:07 PM, the Surveyor observed PPE located outside of Resident # 62's door. The Surveyor observed Certified Nursing Assistant (CNA) #1 enter Resident # 62's room without proper PPE in place and then leave the room. On 01/08/24 at 1:09 PM, the Surveyor observed a sign hanging outside of the resident's room showing enhanced barrier precautions. The Surveyor entered the room to speak with the resident and did not observe a gait belt on them at this time. On 01/08/24 at 01:20 PM, the Surveyor observed CNA #1 enter Resident # 62's room without PPE. CNA #1 closed the door with no PPE in place. The Surveyor knocked and entered the room. CNA #1 was standing in front of the resident and was in the process of putting gloves on. A gait belt was observed around the Resident's waist. The Surveyor asked CNA #1, what type of precautions is Resident #62 on? CNA #1 said,, we put the gait belt on when we assist them to the bathroom. The Surveyor asked, what type of precautions is the resident on. CNA #1 stated, I don't understand what you mean. The Surveyor stated, Resident #62 is on enhanced barrier precautions, why are they on precautions and what type of PPE should staff be wearing when caring for the resident? CNA #1 said, the resident has scratches on their legs, so we must wear gloves. Oh, and we should wear a gown. CNA #1 then went and put a gown on and continued care. On 1/11/24 at 09:29 AM, the Surveyor asked the Director of Nursing (DON), how should care be given to a resident on enhanced barrier precautions? The DON said, instructions are listed on the sheet outside the door. The enhanced barrier precautions are for high-risk activities of daily living (ADL) care. If staff are providing any high-risk care, they are required to wear PPE. The Surveyor asked, is it appropriate for a staff member to enter the room and provide care without PPE? The DON stated, It depends on what it is The Surveyor asked, if the resident has MRSA, is it appropriate for care to be provided without PPE? The DON stated, No, it is not. A Policy provided by the DON on 1/11/24 at 11:24 a.m. titled Categories of Transmission-based Precautions showed, .an approach of targeted gown and glove use during high-contact resident care activities designed to reduce transmission of Staphylococcus aureus .when performing high-contact resident care activities, a gown and gloves will need to be worn .

Based on observation and interview the facility failed to ensure 1 (Resident #16) of 6 (Resident #16, #18, #84, #101, #119, and #126) sampled residents who receive a meal tray from the kitchen on the 100 hall was not served food on a paper towel. The findings are: Resident #16 had a diagnosis of Protein Calorie Malnutrition. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) on 10/09/23 documented the resident scored 08 (moderately impaired) on a Brief Interview for Mental Status (BIMS). On 1/09/24 at 8:33 AM Resident #16 was sitting in the day area eating breakfast. Her eggs and toast were on a brown paper towel. She was asked, Did you ask the staff to put your food on a paper towel? She stated, No I didn't. She came and got my plate and put it on their herself. She was asked, Do you prefer to have your food on a plate? She stated, Yes I do. On 1/09/24 at 8:35 AM the surveyor asked Certified Nurse Aide (CNA) #2 why is Resident #16 ' s breakfast sandwich on a paper towel was? She stated, Sometimes she likes for us to put it on a napkin. I was picking up the trays and she said it was ok to put it on one. On 1/10/24 at 2:38 PM, the Surveyor asked the Administrator, Should staff put a resident's food on a paper towel if they're not finished eating in order to remove the tray? She stated, No, they can come back later and get the tray.

Based on interviews, and record review, the facility failed to ensure resident concerns from the Resident Council Meeting were acted upon promptly for 1 of 1 (Resident #3) sampled residents. This failed practice had the potential to affect 129 residents that reside in the facility. The findings included: Review of Resident #3's Order Summary Report dated 09/11/2023 showed a diagnosis of an urinary tract infection. Review of the resident council minutes dated 08/30/2023 at 2:07 PM showed Resident #3 said staff gripes at her if she used the restroom and last night aides were rude. There was no documentation of a grievance report filed. On 09/14/2023 at 10:46 AM the Surveyor asked the Social Worker (SW) what is the process if a resident reports abuse? The SW said, report what happened to the nurse, and would report to the Administrator if she witnessed abuse. The Surveyor asked the SW did you report what Resident #3 stated in the Resident Council Meeting and to whom? The SW replied, Yes, I told the nurse, but I don't remember the nurse's name. The Surveyor asked, did you file a grievance? The SW stated, No I did not. The Surveyor asked why wasn't a grievance filed? The SW said it is done at the QA (Quality Assurance) meeting once a month, and was scheduled for today. During interview on 09/14/2023 at 11:41 AM Registered Nurse #1 confirmed if a resident reports staff gripe at me for using the restroom and are rude that is a form of emotional abuse and should have been reported to the Director of Nursing (DON) or Administrator. During interview on 09/14/2023 at 11:58 AM Licensed Practical Nurse #1 confirmed if a resident reports staff gripe at me for using the restroom and are rude that is a form of verbal abuse and should be reported to the next person in the chain of command. During interview on 09/14/2023 at 1:06 PM, The Surveyor asked the DON if a resident reports staff gripe at me for using the restroom and are rude, what kind of abuse is this considered to be? The DON stated, Verbal. The Surveyor asked should this be reported, when, and to whom? The DON said, Yes, to the immediate supervisor and follow through. The Surveyor asked, did anyone report to you what Resident #3 stated in the August 2023 Resident Council Meeting that staff griped at her for using the restroom and were rude? The DON sated, I have not received anything on Resident #3. Anything that comes out of the meetings should be filed as a grievance and followed through. Review of a copy of the Resident's Guide to Your Rights and Responsibilities provided by the Administrator on 09/13/2023 at 10:24 AM showed, residents have the right to speak up about grievances and have them responded to promptly and fairly. Residents have the right to voice concerns and complaints, spoken or in writing about the treatment and care provided without fear of discrimination. Review of the facility's policy titled Grievances/Complaints-Staff Responsibility- Staff Members provided by the DON on 09/14/2023 at 9:20 AM showed, if a staff member overhears or is the recipient of a complaint voiced by a resident concerning the resident's medical care or treatment, the staff member is encouraged to assist the resident to file a written complaint with the facility.

Based on interview and record review, the facility failed to ensure the responsible party/family member was notified of changes in condition after new orders were obtained for 3 (Resident #1, Resident #2, and Resident #3) of 3 sample mix residents. This failed practice had the potential to affect 129 residents who reside in the facility. A. Review of the Order Summary Reports showed the following: 1. A physician order for Resident #1 with a start date of 06/07/2023 to administer Lamictal 25 mg (milligram) by mouth at bedtime and no documentation of the responsible party notification. 2. A physician order for Resident #2 with a start date of 09/09/2023 to administer Seroquel 12.5 mg by mouth in the morning and no documentation of the responsible party notification. 3. A physician order for Resident #3 with a start date of 06/24/2023 to administer Keflex 250 mg by mouth one time a day and no documentation of the responsible party notification. B. During interview on 09/14/2023 at 11:41 AM, Registered Nurse #1 confirmed the findings in A. C. During interview on 09/14/2023 at 11:58 AM the Surveyor asked Licensed Practical Nurse #1 if a resident has a change of condition or a new medication, who do you notify? LPN #1 replied, The POA (power of attorney). D. During interview on 09/14/2023 at 1:06 PM the Surveyor asked the Director of Nursing (DON) if a resident has a change of condition or a new medication, who do you notify? The DON said, The primary contact on the chart. E. Review of facility's policy titled Change in a Resident's Condition or Status provided by the DON on 09/14/2023 at 1:03 PM showed, the nurse supervisor will notify the resident's next of kin or representative when there is a significant change in the resident's physical, mental, or psychosocial status or there is a change in the resident's treatment.

Based on observation and interview, the facility failed to ensure that staff washed their hands before handling clean equipment or food items to prevent the potential for cross contamination, expired food items and spoiled foods were promptly removed and discarded on or before the expiration or use by dates and failed to ensure leftover food items were used by the use-by date to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen; failed to ensure opened food items in a rubber container were covered to maintain freshness and prevent potential cross contamination. These failed practices had the potential to affect 128 residents who received meals from the kitchen (total census: 129) according to the list provided by the Dietary Supervisor dated [DATE]. The findings are: a. On [DATE] at 10:23 AM, Dietary Employee #1 was wearing gloves on her hands, she picked up a pan liner and spread it inside the pan. She untied bags of hamburger buns and placed them on the utility cart. Dietary Employee #1 did not wash her hands before she removed the hamburger buns from the bag and placed them inside the pan to be served to the residents for the lunch meal. b. On [DATE] at 10:31 AM, an opened box of Cream of Wheat was in a rubber container on the counter. The box was not sealed. c. On [DATE] at 10:35 AM, The Dietary Employee united a bag that contained bowls. Without washing her hands, she picked up the bowls and placed them on the counter with her fingers inside the bowls to be used in portioning food items to be served to the residents for the lunch meal. d. On [DATE] at 10:40 AM, a box of gluten oatmeal raisins stored on a shelf had an expiration date [DATE]. e. On [DATE] at 10:55 AM, Dietary Employee #2 was wearing gloves on her hands when she picked up a bag that contained lids. She untied the bag and placed it on the counter. She removed the gloves and threw them away. She placed new gloves on her hands and contaminated the gloves. Without washing her hands, she picked up tea glasses by their rims and placed them on the trays to be served to the residents for lunch. At 11:31 AM, The Surveyor asked Dietary Employee #2, what should you had done after touching dirty objects and before handling clean equipment and or food items? She stated, I should have washed my hands. f. On [DATE] at 11:08 AM, Dietary Employee #1, who was wearing gloves on her hands, picked up tray cards and placed them on the trays and without washing her hands, she picked up the hamburger buns, opened the buns and placed them on the plates. She scooped the barbeque pork meat on them to serve to the residents for lunch. g. On [DATE] at 11:12 AM, a box of Mac and Cheese was stored in the freezer in the clean utility room on the 400 Hall with an expiration date of [DATE]. h. On [DATE] at 11:45 AM, The Surveyor asked Dietary Employee #1 what should you have done after touching dirty objects and before handling clean equipment and or food items? She stated, Washed my hands. i. On [DATE] at 1:03 PM, Dietary Employee #3 took out a marker from her pocket and used it to write the date on the cover of the bowls that contained dessert to serve to the residents for supper. At 1:08 PM Dietary Employee #3 went into the walk-in refrigerator and took out a gallon jar of bread and butter pickle slices and placed it on the counter. Next, she removed gloves from the glove box and placed them on her hands contaminating the gloves. She used her gloved hand to remove slices of pickles from the jar and placed them on top of the shredded lettuce to serve to the residents who requested salad with their supper meal. j. On [DATE] at 1:16 PM, Dietary Employee #3 picked up bags of peanut butter jelly sandwiches (from the from???) and threw them away. She picked up a bag of bread from the utility cart and placed it on the counter. She picked up grapy jelly from the refrigerator and placed it on the counter. She took out a container of peanut butter from a shelf in the storage room and placed it on the counter. Without washing her hands, she placed gloves on her hands and contaminated the gloves. She used her contaminated gloved hand to remove slices of bread from the bag and spread peanut butter and grape jelly on them to serve to the residents who requested for peanut butter and jelly with their supper meal. The Surveyor immediately stopped Dietary Employee #3 and asked, what should you done after touching dirty objects and before handling clean equipment and or food items? She stated, I should have washed my hands. k. On [DATE] at 3:39 PM, Dietary Employee #3 was wearing gloves on her hands. She picked up and opened a can of mandarin oranges and emptied them in a colander to drain them. Without changing gloves and washing her hands, she picked up the blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents who received pureed diets for the supper meal. At 3:50 PM, The Surveyor asked Dietary Employee #3, what should you have done after touching dirty objects and before handling clean equipment or food items? She stated, I should have washed my hands. At [DATE] at 12:58 PM, The facility policy on hand washing provided by Food Safety Services (FSS) documented, Wash hands when starting work, when returning from break and when contaminated.

Based on observation, record review and interview, the facility failed to ensure meals were served at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. This failed practice had the potential to affect 35 residents who received meal trays in their rooms on the 100 Hall, 32 residents who received meal trays in their room on the 200 Hall, 36 residents who received their meal trays in their rooms on the 300 Hall and 28 residents who received their meal trays in their rooms on the 400 Hall as documented on a list provided by Dietary Supervisor on 10/11/2022. The findings are: 1. Resident #70 had diagnoses of [CONDITION(S)], [CONDITION(S)] and Muscle Wasting. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/30/2022 documented a Brief Interview Mental Status (BIMS) of 15. October Physician's Orders documented .Regular diet, texture . Resident complained, The food is cold at most meals. a. On 10/11/22 at 06:55 AM, the unheated food carts that contained trays for breakfast were delivered to the 200 halls. At 07:29 AM, after the last resident received their tray in their room on the 200 Halls, the temperatures of the food items on a test tray from the cart were checked and read by the Dietary Supervisor with the following results: 1. The milk was 56.6 degrees Fahrenheit. 2. The scrambled eggs were 96.6 degrees Fahrenheit. 3. The sausage was 94 degrees Fahrenheit. 4. The ground sausage was 94.6 degrees Fahrenheit. b. On 10/11/22 at 07:03 AM, the unheated food carts that contained trays for breakfast were delivered to the 100 halls. At 07:35 AM after the last resident received their tray in their room on the 100 Halls, the temperatures of the food items on a test tray from the cart were checked and read by the Dietary Supervisor with the following results: 1. The milk was 46.7 degrees Fahrenheit. 2. The pureed sausage was 107.7 degrees Fahrenheit. 3. The pureed eggs were 108.5 degrees Fahrenheit. 4. The oatmeal was 107.4 degrees Fahrenheit. 5. The ground sausage was 110.3 degrees Fahrenheit. 6. The scrambled eggs were 107.7 degrees Fahrenheit. 7. The regular sausage was 102.2 degrees Fahrenheit. 8. The omelets were 101.4 degrees Fahrenheit. 9. The gravy was 113.7 degrees Fahrenheit. c. On 10/11/22 at 07:20 AM, the unheated food carts that contained 36 trays for breakfast were delivered to the 300 halls. At 08:08 AM after the last resident received their tray in their room on the 300 Halls, the temperatures of the food items on a test tray from the cart were checked and read by the Dietary Supervisor with the following results: 1. The milk was 50 degrees Fahrenheit. 2. The regular sausage was 107 degrees Fahrenheit. 3. The oatmeal was 103 degrees Fahrenheit. 4. The scrambled eggs were 106.7 degrees Fahrenheit. 5. The pureed sausage was 108 degrees Fahrenheit. 6. The cream of wheat was 103.6 degrees Fahrenheit. 7. The omelets was 108 degrees Fahrenheit. 8. The ground sausage was 104.3 degrees Fahrenheit. d. On 10/11/22 at 07:36 AM, the unheated food carts that contained 28 trays for breakfast were delivered to the 400 Hall. At 07:58 AM after the last resident received their tray in their room on the 400 Halls, the temperatures of the food items on a test tray from the cart were checked and read by the Dietary Supervisor with the following results: 1. The sausage was 91 degrees Fahrenheit. 2. The omelets were 95.2 degrees Fahrenheit. 3. The ground sausage was 96 degrees Fahrenheit.

Based on observation and interview, the facility failed to ensure staff washed their hands before handling clean equipment or food items to prevent potential for cross contamination, expired food items were promptly discarded to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen. These failed practices had the potential to affect 110 residents who received meals from the kitchen (total census: 110) according to a list provided by the Dietary Supervisor on [DATE]. The findings are: 1. On [DATE] at 3:41 P.M., Dietary Employee #1 took a pan of salad into the walk-in refrigerator, as he walked out of the refrigerator, he removed his gloves and threw them away. Without washing his hands, he picked up gloves from the glove box and placed on his hands. He then picked up bowls used to portion salad to be served to the residents with his fingers inside the bowls. 2. On [DATE] at 3:49 P.M., Dietary Employee #2 touched the utility cart that was by the handwashing sink. Without washing her hands, she picked up a clean blade and attached it to the base of the blender. 3. On [DATE] at 4:19 P.M., Dietary Employee #1 was on the tray line serving supper meal. He picked up tray cards and placed them on the tray. Without washing his hands, he picked up clean plates to be used to portion food items for the residents and placed on the tray. He picked up glasses by the rim that contained beverages and placed them on the trays. He picked up cans of V8 juice and placed them on the trays. On [DATE] at 4:38 P.M., Dietary Employee #1 was asked, What should you do after touching dirty objects and before handling clean objects? He stated, I should have washed my hands. 4. On [DATE] at 4:21 P.M., Dietary Employee #3 who was assisting on the tray line dropped a carton of milk and picked it up and placed it on top of another clean carton of milk in a pan of ice that was by the refrigerator. Without washing her hands, she picked up glasses by the rim that contained beverages and placed them on the trays to be served to the residents. On [DATE] at 4:22 P.M., the Dietary Supervisor was informed about the milk carton that was dropped on the floor that was placed on top of a clean carton of milk in a pan of ice. She then removed both cartons of the milk and the ice around both cartons of the milk. 5. On [DATE] at 4:23 P.M., Dietary Employee #3 opened the refrigerator and took out supplements and placed them on a tray. Without washing her hands, she proceeded to pick up glasses that contained beverages and placed them on the trays to be served to the residents. On [DATE] at 1:31 P.M., Dietary Employee #3 was asked, What should you have done after touching dirty objects and before touching clean objects? She stated, Wash my hands. 6. On [DATE] at 8:34 P.M., Dietary Employee #4 who was wearing gloves on her hands, picked up a pan and placed it into the oven. She then pushed boxes of noodle into a trash can. She used the same gloved hands to pick up ground beef to put in the blender. She was immediately stopped and asked, What should you have done after touching dirty objects and before handling food items? She stated. I should have changed my gloves and washed my hands. 7. On [DATE] at 8:47 A.M., Dietary Employee #4 had gloves on her hands, when she opened the boxes of noodle, she did not wash her hands before removing the noodles from the boxes and placing the noodles in a pan and spreading lasagna sauce over it to be cooked and served to the residents. 8. On [DATE] at 9:10 A.M., Dietary Employee #5 pulled her pants up, without washing her hands she picked up utensils and wrapped them individually with a napkin. Dietary Employee #5 was asked, What do the residents use the napkins for? She stated, To wipe their mouths. She was asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, Probably wash my hands, I didn't think about that. 9. On [DATE] at 9:23 A.M., Dietary Employee #4 used a spatula to scoop ten servings of lasagna into a blender. She then pureed the lasagna and poured it into a pan. She picked up a rag and wiped spilled sauce off the blender and the counter. Without washing her hands, she used her bare hand to adjust the blade at the base of the blender. She then poured the remaining lasagna into the pan of approximately twelve servings or more and pureed. 10. On [DATE] at 9:38 A.M., Dietary Employee #6 touched a cart that had a dirty mixer bowl, a whisk, and a pan on it. Without washing her hands, she picked up clean dishes with her fingers touching the interior surfaces of the plates. She was asked, What should you have done after touching dirty objects and before handling clean equipment or food? She stated, I am supposed to wash my hands. 11. On [DATE] at 9:44 A.M., there was a box of three 10-ounce bottles of Ocean Spray cran-grape juice on a shelf in the refrigerator in the 100 clean utility nourishment room, that had an expiration date of [DATE]. 12. The facility policy statement. Dietary personnel shall follow sanitary standards. Policy Interpretation and Implementation under H documented: Others that may become necessary or appropriate such as between task and touching dirty equipment.

Based on record review and interview, the facility failed to ensure residents were provided with the opportunity to formulate Advanced Directives to enable them to make advance decisions regarding which measures should be provided or withheld in the event of their incapacitation and the Advance Directives were documented in the clinical records for 1 (Residents #39) of 24 (Residents #85, #84, #57, #93, #82, #258, #88, #9, #73, #3, #39, #35, #19, #47, #28, #23, #21, #60, #10, #40, #83, #11, #27 and #91). The findings are: Res #39 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission Minimum Data Set (MDS) with an Assessment Reference Date of [DATE] documented the resident scored 15 (,d+[DATE] indicates cognitively intact) on a Brief Interview for Mental Status (BIMS). a. As of [DATE] at 2:23 P.M., a review of Resident #39's paper chart did not contain an Advance Directive. b. On [DATE] at 10:34 A.M., the Director of Nursing (DON) was informed that the Advance Directive wasn't in the chart for Resident #39. She looked in the chart, then stated, She's fairly new I will have to check with Social Services and Admissions. c. On [DATE] at 11:28 A.M., Social Services and Admissions was asked for Resident #39's MDS. She looked in a drawer in her office and she presented a form titled, CPR (Cardiopulmonary Resuscitation). This surveyor stated, I'm looking for the Advance Directive. She stated, This is all she has, she doesn't want anything else. d. On [DATE] at 3:17 P.M., Social Service and Admissions was asked if she admitted Resident #39 into the facility. She stated, Yes. She was asked, Why wasn't an Advance Directive completed when she was admitted ? She stated, Her family took it because they didn't want to commit to anything, and they were going to bring it back. She was asked, Is [Resident #39] able to make her own decisions? She stated, She wasn't at the time. She was asked, Did you ever follow up with the family to see when they were going to bring the Advance Directive form back? She stated, We asked them, and they just kept saying they forgot. e. An Advance Directives policy provided by the Administrator on [DATE] at 8:52 A.M. documented, .A copy of the advance directive will be included in the resident's medial record located at the nurses' station .Advance directives are defined as preferences regarding treatment options and include, but are not limited to: a. Living Will- A document that specifies a resident's preferences about measures that are used to prolong life when there is terminal prognosis .

Based on observation, record review, and interview, the facility failed to ensure used personal protective equipment (PPE) was discarded before exiting a contact isolation room, properly disinfected face shields after use and had separate designated wing to isolate COVID-19 positive residents from COVID-19 negative residents to prevent the spread of COVID-19. These failed practices resulted in Immediate Jeopardy which caused or was likely to cause serious harm injury or death by not having designated wings to separate positive COVID 19 cases from negative cases. The Administrator was informed of the Immediate Jeopardy on 7/23/2020 at 1:07 p.m. These failed practices had the potential to affect all 131 residents within the facility, according to the Census provided by the Administrator on 7/23/2020. The findings are: 1. On 7/23/2020 at 10:42 a.m., Certified Nursing Assistant (CNA) #1 was exiting an isolation room and removing his face shield. CNA #1 placed the face shield in his right scrub pocket without disinfecting it. CNA #1 was asked why the resident was on isolation. He stated, Her roommate showed symptoms for COVID, so they separated them and put her on isolation too. Just in case. CNA #1 was asked, What PPE was required to enter the room? He stated, We have to wear the N95 everywhere. So, we place a surgical mask on top before entering the room. We also wear the face shields, gloves, and isolation gowns. CNA #1 was asked how PPE equipment was prepared for reuse. CNA #1 pulled the face shield from his scrub top pocket and stated, We disinfect the shields with wipes front and back then let them air dry. I guess I should go do that. 2. On7/23/2020 from 2:00 p.m. to 4:30 p.m., there were 3 employees seen entering the facility with N95 masks on. One employee placed the N95 on the hood of their car before putting it on. On 7/24/2020 at 2:30 p.m., an 80-page scanned document was received from the Administrator related to PPE use and Infection Control. Page 75 documented, .FEMA (Federal Emergency Management Agency) Fact Sheet . At the end of the shift, all PPE is labeled, collected, and stored for reuse . 3. On 7/27/2020 at 2:39 p.m., the Director of Nursing (DON) was asked if all staff should wear N95 masks when walking on the COVID halls. She stated, If doing direct care with residents yes. If they are non-direct care staff, they don't have to wear N95 masks but surgical masks. The DON was asked if staff should disinfect face shields after use. She stated, Yes. The DON was asked if employees should take N95 masks home. She stated, We've asked them to leave them here. They have bags and containers to put them in. I don't think it is a CDC guideline, but we don't want the staff to lose them and have to keep replacing them. The DON was asked where surgical masks should be disposed of when exiting an isolation room. She stated, In the isolation trash. 4. On 7/23/2020 at 10:19 a.m., the Administrator was asked if they had any Covid-19 positive residents and where they were located within the facility. She stated that 400 Hall was the dedicated Covid-19 Hall and had it completely contained. She stated that test results came back and there was Covid all over the building. She stated that they talked to their Medical Director, who advised them to keep the COVID positive residents in their current rooms and use isolation precautions. She stated that there were 8 COVID-19 positive residents on 100 Hall, 3 on 200 Hall, and 2 on 400 Hall. She stated that there were numerous residents on precautionary isolation, and they were treating them as COVID positive. a. On 7/23/2020 at 11:01 a.m., the area before 400 hall had thick plastic rolled up and clipped near the ceiling. The plastic was located at an area between the Lounge and the Chapel before entering 400 Hall. If plastic were rolled down, it would have provided a barrier between 400 hall and 200 Hall. b. On 7/23/2020 at 11:01 a.m., Housekeeper #1 was standing in isolation room [ROOM NUMBER] with a surgical mask over an N95 mask. Housekeeper #1 stepped out of the room, removed the surgical mask, and threw it away in the trash on housekeeping cart. Housekeeper #1 was asked where the mask should have been thrown away at. She stated, I should have put it in the biohazard bin in the room before walking out. Housekeeper #1 was asked what type of training she received related to PPE use. She stated, Last month they went over how to put on and take off the PPE and when it should be done. c. On 7/23/2020 at 11:15 a.m., Dietary Employee #1 rolled a large metal cart with empty meal trays and a cup from 200 hall through 400 hall and was heading towards the kitchen. She was wearing a regular surgical mask. She was asked if she received any training related to the use of PPE and she stated no, not really. I'm supposed to wear a N95 when we walk down the hall but this just started while I was off. She was asked if she knew where to go to get a N95 mask and she replied I'm not sure. She was asked where she was going with the cart and she stated we park it outside of the kitchen, then take it into the kitchen to restock it with ice. The surveyor followed the Dietary Employee #1 who parked the cart in the dining room hallway and took the meal trays into the kitchen and without using gloves, placed them with the rest of the dirty dishes. She then walked through the kitchen. d. On 7/23/2020 at 11:37 a.m., the door to Resident room [ROOM NUMBER] had an isolation cart next to it with a red plus (+) sign to show a COVID positive resident resided in the room. There was an isolation precaution sign at the side of the door. The door to the room then opened and the resident stuck their head out of the room asking the surveyor a question. She started to step out of the room, the surveyor remained 6 feet away from the resident and took a step back. The resident repeated her question but did not fully exit the room. The surveyor then notified a staff member that the resident needed assistance. e. On 7/23/2020 at 11:42 a.m., the door to Resident room [ROOM NUMBER] had an isolation cart next to it with a red plus (+) sign to show a COVID-19 positive resident resided in the room. There was a blue and white sign that stated, PLEASE KEEP THIS DOOR CLOSED. There was an isolation precaution sign at the side of the door. The door to the room was observed to be open approximately 2-3 inches. The door to the resident's room directly across the was completely open. f. On 7/23/2020 at 11:45 a.m., the door to Resident room [ROOM NUMBER] had an isolation cart next to it with a red plus (+) sign to show a COVID-19 positive resident resided in the room. There was a blue and white sign that stated, PLEASE KEEP THIS DOOR CLOSED. There was an isolation precaution sign at the side of the door. The door to the room was observed to be open approximately 2-3 inches. The door to the Resident room [ROOM NUMBER] and 114 directly across the were completely open. g. On 7/23/2020 at 11:47 a.m., the door to Resident room [ROOM NUMBER] had an isolation cart next to it with a red plus (+) sign to show a COVID-19 positive resident resided in the room. There was a blue and white sign that stated, PLEASE KEEP THIS DOOR CLOSED. There was an isolation precaution sign at the side of the door. The door to the room was opened approximately 2-3 inches. The door to Resident room [ROOM NUMBER] directly across the was completely open as well as room [ROOM NUMBER] located adjacent to Resident room [ROOM NUMBER]. h. On 7/23/2020 at 5:38 p.m., the Immediate Jeopardy was removed and the scope and severity reduced to an F after the following Plan of Removal was implemented: 1) On 7/23/2020 Smart notice mass messaging system to employees to ensure the doors to all the resident rooms in areas of isolation for covid positive or persons under investigation for covid remain shut at all times this was sent at 14:41 p.m by Administrator. All staff will be in-serviced by delegated staff on all COVID policies and procedures this will be done by 7/27/20. Staff on vacation will be in-serviced on return to work. We will monitor daily and train all new hires to the facility. 2) Resident positive for COVID has a dementia [DIAGNOSES REDACTED]. She does have a mask in her room and has to be reminded. We will put a hook on the wall by the door for her mask so if she does open the door it will be readily available for staff to redirect and re-educate. This will be a constant reminder due to residents has dementia and doesn't remember. She met the criteria to be removed from isolation today 7/23/2020. For future residents with dementia that are COVID positive we will use the hooks for the masks by the door. 3) We do have a dedicated COVID hall on our 400 Wing. 4) We had a dedicated COVID team scheduled in place on the 400 wing Covid hall initiated on 7-16-20 until 7-20-20 when we received the results of several more positive residents. We will ensure that they remain assigned to Covid positive rooms only as dedicated staff. 5) We went through and made sure all resident's doors on wings 1, 2, and 4 are shut and will monitor on and ongoing basis that they remain closed except on entering and exiting. We will move the 2 positive residents on 200 to the 400 contained hall with the 2 positives from 400 wing already there. We are going to move the persons under investigation from 400 wing and 100 wing to different rooms opening from moving the positives. We will move two of three positive 100 wing residents to 400 contained hall and one down to the concentrated area on 100. Therefore containing our positives together in two separate contained sections. Residents that are at risk are the ones that are not COVID positive and will be protected by not housing with positive residents. We are starting all the room changes now and should have all moves completed by 7/24/2020. 6) On 7/27/2020 at 8:05 a.m., the Plan of Removal was followed and Covid positive residents had been moved with plastic barriers put into place on 100 and 400 hall.

Based on observation and interview, the facility failed to ensure opened food items in the refrigerator, freezer, and store room were sealed and dated to maintain freshness and prevent potential cross-contamination; failed to ensure dietary staff washed their hands between dirty and clean tasks to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 140 residents who received meals from the kitchen, according to the Diet List dated 12/12/19 (Total census:140). The findings are: 1. On 12/9/19 at 11:14 a.m., one box of beef patties was stored on a shelf in the walk-in freezer. The box of beef patties was not sealed. 2. On 12/9/19 at 11:18 a.m., a fan in the dish room near the 3-compartment sink had a dust accumulation on the blades. 3. On 12/11/19 at 8:22 a.m., the following observations were made in the walk-in freezer: a. One zip lock bag that contained French toast was stored on a shelf in the walk-in freezer. The zip lock bag of French toast was not sealed. b. Two boxes of cheese omelets were stored on a shelf in the walk-in freezer. The boxes of cheese omelets were not covered or sealed. c. One box of pork chops was stored on a shelf in the walk-in freezer. The box of pork chops was not covered or sealed. d. One box of pizza was stored on a shelf in the walk-in freezer. The box of pizza was not covered or sealed. 4. On 12/11/19 at 8:29 a.m., two zip lock bags that contained bologna were stored on a shelf in the walk-in refrigerator. The zip lock bags of bologna were not sealed. 5. On 12/11/19 at 8:58 a.m., two packages of hot pockets were stored on a shelf in the freezer in the Utility Room on the 100 Hall. The hot pockets had freezer burn and the packages were not dated. Dietary Employee #1 was asked to describe the appearance of the hot pockets. She stated, That looks like freezer burn. 6. On 12/11/19 at 9:03 a.m., one carton of butter pecan ice cream was stored on a shelf in the freezer in the Utility Room on the 300 Hall. The ice cream had freezer burn, and the container was not dated. Dietary Employee #1 was asked to describe the appearance of the butter pecan ice cream. She stated, The butter pecan ice cream has freezer burn. 7. On 12/11/19 at 9:14 a.m., one bag of 8 hot dog buns dated 12/5/19 was stored on the bread rack in the kitchen 8. On 12/11/19 at 11:13 a.m., Dietary Employee #2 had gloves on her hands. She pushed a cart that contained empty glasses towards the counter. She placed her gloved fingers inside the glasses and picked them up. She lifted up the ice chest lid and scooped ice cubes into each individual glass with her fingers still inside the glasses. She placed the glasses on the cart and poured beverages in the glasses which were to be served to the residents for the lunch meal. At 11:24 a.m., Dietary Employee #2 was asked, what should you have done after touching dirty objects and before handling clean equipment? She stated, I should have changed gloves and washed my hands. 9. On 12/11/19 at 2:50 p.m., Dietary Employee #5 picked up cartons of mighty shakes, ensure, prune juices, apple juice, orange juice, cranberry juice, a box of Nepro, and can of Glucerna from the storage room and placed them on the counter. Without washing her hands, she picked up clean glasses by their rims and poured beverages in the glasses which were to be served to the residents for the supper meal. Dietary Employee #5 was asked, what should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands.

Based on observation, record review and interview, the facility failed to ensure adequate supervision was provided to prevent mechanical lift-related accidents, as evidenced by failure to ensure staff utilized the correct size mechanical lift sling, as per the manufacturer's instructions, and failure to ensure staff were provided with the necessary tools and information to allow the correct sling size to be determined to minimize the potential for accidents / injuries for 3 (Residents #25, #7 and #17) of 3 case mix residents that required mechanical lift transfers. The failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #25, who fell from the mechanical lift and sustained a hematoma to the head when staff utilized the wrong sling. The failed practice also had the potential to cause more than minimal harm to 13 residents who required mechanical lift transfers, as documented on a list provided by the Director of Nursing (DON) on 8/23/16 at 1:00 p.m. The facility was notified of the Immediate Jeopardy condition on 8/18/16 at 5:38 p.m. The findings are: 1. Resident #25 had [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set with an assessment reference date of 6/13/16 documented the resident was moderately impaired in cognitive skills for daily decision making per a staff assessment for mental status, was totally dependent on the assistance of two plus people for transfers and locomotion, and had not fallen since admission/entry or reentry or the prior assessment. A MDS dated [DATE] documented the resident weighed 171 pounds. a. A Progress Note dated 8/12/16 at 9:15 a.m. documented, Nurse was in the hall when CNA (Certified Nursing Assistant) reported she needed assist, resident had fallen. (CNA #3) reported resident fell to floor while being transferred with the full body lift / 1 assist to her Geri (geriatric) chair. She was secured in transfer sling and before she could get her to the chair she slid out of the sling. When nurse entered the room sling was still secured to lift. Sling size was 'Bariatric' (persons weighing over 300 pounds or who are 100 pounds or more over their ideal body weight). Resident was lying on the floor, lift legs / bars were under her neck and legs as she landed on top of them. Resident alert, talking and yelling out at staff to 'shut up' and threatening to kick/hit staff. ROM (Range of motion) WNL (within normal limits). Noted hematoma to back of head. Neuro WNL. Noted a small bruise to Lt (left) side and skin red/blanching on her back and neck . Will change resident to 2 assist w/ (with) transfers full body lift w/lg (large) sling. This note was signed by Registered Nurse (RN) #1. b. A Physician's note dated 8/12/16 documented, [AGE] year old female being seen for a nursing home visit: Resident seen today due to fall while being transferred using mechanical lift. 4 cm (centimeter) hematoma noted to left occipital area . Reevaluated lift sling size. c. A Witnessed Fall form dated 8/12/16 prepared and electronically signed by Registered Nurse (RN) #1 documented, Lift sling in use during transfer too large for resident . Changes level of assist for transfers to 2 assist/full body lift, lg sling. d. The Plan of Care dated as revised on 8/12/16 documented, .Focus: Self-care deficit and requires staff intervention . Intervention: Transfer: 2 assist / full body lift, lg (large) sling. The Nursing Care Instructions form dated as revised 12/15/15 documented, .TRANSFER: a full lift requiring 1-2 (people needed for assistance) . The Nursing Care Instruction form did not specify the sling size to be used for transferring the resident. e. On 8/18/16 at 10:45 a.m., CNA #3 was asked what happened when (Resident #25) fell from the lift. The CNA stated she was transferring the resident by herself from the bed to the Geri chair. The CNA stated that she had the resident almost to the chair and the resident, .started to wiggle and just slid out of the sling on to the floor. The CNA also stated, .the care plan said 1 or 2 person assist. f. On 8/18/16 at 2:55 p.m., RN #1 was asked about Resident #25's fall from the mechanical lift on 8/12/16. The RN stated when she entered the room, the sling was still connected to the lift and, .I noted it was a bigger extra-large size and felt it was too large for the resident, and may have contributed to her falling. RN #1 was asked, How do you determine sling size? The RN stated, By weight and size. Don't have a guide, just what appears to fit. RN #1 was asked, How do CNAs know what lift pad to use? RN #1 stated, The size of the sling was not specified on the care plan. RN #1 also stated that the pad CNA #3 used to transfer Resident #25 was for another resident that was larger in size. g. On 8/18/16 at 3:45 p.m., CNA #3 was asked what type of sling was in use when the resident fell from the mechanical lift sling on 8/12/16. CNA #3 stated the sling was already on the mechanical lift and that she did not know the size of the sling. CNA #3 stated the care plan did not say what size to use. The CNA also stated that she really thought the sling was too large. h. On 8/18/16 at 3:45 p.m., Licensed Practical Nurse (LPN) #1 was asked how Resident #25 was assessed for 1 to 2 person transfers per mechanical lift. LPN #1 stated, Sometime in 2015, the resident came back from the hospital, and it was discussed with another shift nurse and agreed that the resident could be a 1 or 2 person assist, depending on her behaviors. LPN #1 also stated that the RN supervisors determined the size of sling to be used. i. On 8/18/16 at 3:45 p.m., a telephone call was made to the product service provider. The Product Specialist #1 stated the manufacturer of the mechanical lift recommended 2 staff assistance with mechanical lift transfers, but did not require 2 people to operate. The Product Specialist also stated that was the facility's decision. Product Specialist #1 stated that she would be emailing a sling specification chart to the facility. j. On 8/18/16 at 3:55 p.m., the Director of Nursing (DON) was asked about the mechanical lift the facility used. The DON stated the facility did not have any weight guidelines, except weight limits, from the company that manufactured the lift. The DON stated the only instruction they had was to not use the lift pads on residents over 400 pounds. The DON stated the only way the facility had to determine the size of the sling was by a visual assessment, to determine if they needed small, medium or large. The DON stated the CNAs knew, or should know, the lift pads/slings were kept in the resident's closet except when they were sent to the laundry. k. On 8/18/16 at 4:40 p.m., two surveyors entered Resident #25's room and opened the closet door. There was no lift sling in the resident's closet. l. The Safety Instructions provided by the Administrator on 8/18/16 at 10:30 a.m., documented, .Select a sling that will properly fit the patient and have the appropriate weight capacity Sling use Warning! ALWAYS ensure the sling is the correct size and capacity for the patient being transferred . Roll the patient onto one side with the assistance of another caregiver. m. The Battery Operated Patient Lift Owner's Manual, provided by the Administrator of 8/18/16 at 12:45 p.m., documented, .ALWAYS fit the sling according to the instructions provided . DO NOT lift a patient unless you are trained and competent to do so . Position the resident onto his/her side by gently rolling them towards you with the assistance of another caregiver. 2. On 8/18/16 between 5:35 p.m. and 5:55 p.m., the Plans of Care and Nursing Care Instruction sheets for 6 additional residents (Residents #7 and #17, plus 4 non-case mix residents) who required mechanical lift transfers were reviewed. Neither the Plans of Care, nor the Nursing Care Instruction sheets, documented the size of the lift pad / sling to be used. 3. The Sling Specifications Chart, emailed to the facility from Product Specialist #1 on 8/18/16 at 4:36 p.m., documented, Large Full Body Slings . Weigh the patient. Size Large 160-280 lb (pounds) . Bariatric 200-600 lb . 4. The Immediate Jeopardy was removed and the scope/severity reduced to E on 8/18/16 at 6:30 p.m., when the facility implemented the following Plan of Removal: Step 1: To remove the immediate jeopardy the nurses will assess all 13 residents that use the mechanical lift for the correct sling size. Step 2: Educate staff on how to determine the correct sling size by following (manufacturer's) guidelines. Step 3: Educate certified nursing assistants on where to obtain appropriate slings for use-size will be noted on each resident care plan on their closet door. Step 4: Director of Nursing or designee will monitor for correct sling sizes being used for mechanical lift transfers weekly for 4 weeks, then monthly for two weeks then quarterly thereafter with resident's MDS assessment.

Based on observation, record review and interview, the facility's nursing administration failed to ensure nursing staff were provided with adequate supervision and training to prevent mechanical lift-related accidents, as evidenced by failure to ensure staff were provided with the necessary information to select and utilize the correct size mechanical lift sling to minimize the potential for accidents / injuries for 3 (Residents #25, #7 and #17) of 3 case mix residents that required mechanical lift transfers. The failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #25, who fell from the mechanical lift and sustained a hematoma to the head when staff utilized the wrong sling. The failed practice also had the potential to cause more than minimal harm to 13 residents who required mechanical lift transfers, as documented on a list provided by the Director of Nursing (DON) on 8/23/16 at 1:00 p.m. The facility was notified of the Immediate Jeopardy condition on 8/18/16 at 5:38 p.m. The findings are: 1. The facility's job description for the Director of Nursing (DON), provided by the Administrator on 8/19/16 at 8:00 a.m., documented, .Summary: Works as a team member to provide direct personal care for nursing home residents according to established care procedures. Works under the supervision of the Administrator . a. Supports and demonstrates practices consistent with the mission, philosophy, standards, policies & (and) procedures of the nursing department . i. Assures nursing staff comply with facility policies and procedures . 2. The facility's job description for the Assistant Director of Nursing (ADON), provided by the Administrator on 8/19/16 at 8:00 a.m., documented, .Works as a team member to provide direct personal care for nursing home residents according to established care procedures. Works under the supervision of the DON . a. Supports and demonstrates practices consistent with the mission, philosophy, standards, policies & procedures of the nursing department . i. Assures nursing staff comply with facility policies and procedures . Education . a. Provides instruction to staff as needed. Participates in development and presentation of in-service education programs . 3. Resident #25 had [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set with an assessment reference date of 6/13/16 documented the resident was moderately impaired in cognitive skills for daily decision making per a staff assessment for mental status, was totally dependent on the assistance of two plus people for transfers and locomotion, and had not fallen since admission/entry or reentry or the prior assessment. A MDS dated [DATE] documented the resident weighed 171 pounds. a. A Progress Note dated 8/12/16 at 9:15 a.m. documented, Nurse was in the hall when CNA (Certified Nursing Assistant) reported she needed assist, resident had fallen. (CNA #3) reported resident fell to floor while being transferred with the full body lift / 1 assist to her Geri (geriatric) chair. She was secured in transfer sling and before she could get her to the chair she slid out of the sling. When nurse entered the room sling was still secured to lift. Sling size was 'Bariatric' (persons weighing over 300 pounds or who are 100 pounds or more over their ideal body weight). Resident was lying on the floor, lift legs / bars were under her neck and legs as she landed on top of them. Resident alert, talking and yelling out at staff to 'shut up' and threatening to kick/hit staff. ROM (Range of motion) WNL (within normal limits). Noted hematoma to back of head. Neuro WNL. Noted a small bruise to Lt (left) side and skin red/blanching on her back and neck . Will change resident to 2 assist w/ (with) transfers full body lift w/lg (large) sling. This note was signed by Registered Nurse (RN) #1. b. A Physician's note dated 8/12/16 documented, [AGE] year old female being seen for a nursing home visit: Resident seen today due to fall while being transferred using mechanical lift. 4 cm (centimeter) hematoma noted to left occipital area . Reevaluated lift sling size. c. A Witnessed Fall form dated 8/12/16 prepared and electronically signed by Registered Nurse (RN) #1 documented, Lift sling in use during transfer too large for resident . Changes level of assist for transfers to 2 assist/full body lift, lg sling. d. The Plan of Care dated as revised on 8/12/16 documented, .Focus: Self-care deficit and requires staff intervention . Intervention: Transfer: 2 assist / full body lift, lg (large) sling. The Nursing Care Instructions form dated as revised 12/15/15 documented, .TRANSFER: a full lift requiring 1-2 (people needed for assistance) . The Nursing Care Instruction form did not specify the sling size to be used for transferring the resident. e. On 8/18/16 at 10:45 a.m., CNA #3 was asked what happened when (Resident #25) fell from the lift. The CNA stated she was transferring the resident by herself from the bed to the Geri chair. The CNA stated that she had the resident almost to the chair and the resident, .started to wiggle and just slid out of the sling on to the floor. The CNA also stated, .the care plan said 1 or 2 person assist. f. On 8/18/16 at 2:55 p.m., RN #1 was asked about Resident #25's fall from the mechanical lift on 8/12/16. The RN stated when she entered the room, the sling was still connected to the lift and, .I noted it was a bigger extra-large size and felt it was too large for the resident, and may have contributed to her falling. RN #1 was asked, How do you determine sling size? The RN stated, By weight and size. Don't have a guide, just what appears to fit. RN #1 was asked, How do CNAs know what lift pad to use? RN #1 stated, The size of the sling was not specified on the care plan. RN #1 also stated that the pad CNA #3 used to transfer Resident #25 was for another resident that was larger in size. g. On 8/18/16 at 3:45 p.m., CNA #3 was asked what type of sling was in use when the resident fell from the mechanical lift sling on 8/12/16. CNA #3 stated the sling was already on the mechanical lift and that she did not know the size of the sling. CNA #3 stated the care plan did not say what size to use. The CNA also stated that she really thought the sling was too large. h. On 8/18/16 at 3:45 p.m., Licensed Practical Nurse (LPN) #1 was asked how Resident #25 was assessed for 1 to 2 person transfers per mechanical lift. LPN #1 stated, Sometime in 2015, the resident came back from the hospital, and it was discussed with another shift nurse and agreed that the resident could be a 1 or 2 person assist, depending on her behaviors. LPN #1 also stated that the RN supervisors determined the size of sling to be used. i. On 8/18/16 at 3:45 p.m., a telephone call was made to the product service provider. The Product Specialist #1 stated the manufacturer of the mechanical lift recommended 2 staff assistance with mechanical lift transfers, but did not require 2 people to operate. The Product Specialist also stated that was the facility's decision. Product Specialist #1 stated that she would be emailing a sling specification chart to the facility. j. On 8/18/16 at 3:55 p.m., the Director of Nursing (DON) was asked about the mechanical lift the facility used. The DON stated the facility did not have any weight guidelines, except weight limits, from the company that manufactured the lift. The DON stated the only instruction they had was to not use the lift pads on residents over 400 pounds. The DON stated the only way the facility had to determine the size of the sling was by a visual assessment, to determine if they needed small, medium or large. The DON stated the CNAs knew, or should know, the lift pads/slings were kept in the resident's closet except when they were sent to the laundry. k. On 8/18/16 at 4:40 p.m., two surveyors entered Resident #25's room and opened the closet door. There was no lift sling in the resident's closet. l. The Safety Instructions provided by the Administrator on 8/18/16 at 10:30 a.m., documented, .Select a sling that will properly fit the patient and have the appropriate weight capacity Sling use Warning! ALWAYS ensure the sling is the correct size and capacity for the patient being transferred . Roll the patient onto one side with the assistance of another caregiver. m. The Battery Operated Patient Lift Owner's Manual, provided by the Administrator of 8/18/16 at 12:45 p.m., documented, .ALWAYS fit the sling according to the instructions provided . DO NOT lift a patient unless you are trained and competent to do so . Position the resident onto his/her side by gently rolling them towards you with the assistance of another caregiver. 4. On 8/18/16 between 5:35 p.m. and 5:55 p.m., the Plans of Care and Nursing Care Instruction sheets for 6 additional residents (Residents #7 and #17, plus 4 non-case mix residents) who required mechanical lift transfers were reviewed. Neither the Plans of Care, nor the Nursing Care Instruction sheets, documented the size of the lift pad / sling to be used. 5. The Sling Specifications Chart, emailed to the facility from Product Specialist #1 on 8/18/16 at 4:36 p.m., documented, Large Full Body Slings . Weigh the patient. Size Large 160-280 lb (pounds) . Bariatric 200-600 lb . 6. The Immediate Jeopardy was removed and the scope/severity reduced to E on 8/18/16 at 6:30 p.m., when the facility implemented the following Plan of Removal: Step 1: To remove the immediate jeopardy the nurses will assess all 13 residents that use the mechanical lift for the correct sling size. Step 2: Educate staff on how to determine the correct sling size by following (manufacturer's) guidelines. Step 3: Educate certified nursing assistants on where to obtain appropriate slings for use-size will be noted on each resident care plan on their closet door. Step 4: Director of Nursing or designee will monitor for correct sling sizes being used for mechanical lift transfers weekly for 4 weeks, then monthly for two weeks then quarterly thereafter with resident's MDS assessment.

Complaint # (AR 253) was substantiated (all or in part) in these findings. Based on observation, record review, and interview, the facility failed to ensure residents were assessed for the ability to safely handle hot liquids in order to develop interventions to prevents burns and failed to ensure staff members did not reheat coffee that was not at room temperature in the microwave for 1 of 1 (Resident #1) case mix resident who routinely requested staff to reheat her coffee. The failed practices resulted in actual harm for Resident #1, who sustained a burn from spilling hot coffee which had been reheated by staff and had the potential to cause more than minimal harm for 73 residents who had not been assessed for the ability to safely handle hot liquids and who received hot liquids from the kitchen according to a list provided by the Certified Dietary Manager (CDM) on 5/29/15. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 3/23/15 documented the resident scored 5 (0 - 7 indicates severely impaired) on the Brief Interview for Mental Status; required extensive assistance of 2 + persons for bed mobility, transfers, and dressing; and was independent with eating after set up help. a. A Nurse's Note dated 5/21/15 at 8:15 documented, Late entry. Entered room to give meds. Noticed clothes soiled (with) coffee. 'I spilt my coffee. It was hot.' Notified CNA (Certified Nurse Assistant (CNA# 1)). Had her to change clothes (and) (to) let me know if there was a burn. (No) redness. Resident often has CNAs heat up coffee (due to) too cold. This entry was signed by Licensed Practical Nurse (LPN) # 1. 1) The Occurrence Report dated 5/21/15 at 8:15 a.m. documented, . Description of Incident: Subjective (Ask the resident what happened/why): Spilt coffee, it's hot. Objective: . Entered room to give a.m. meds and noted coffee spilt on clothes. Instructed CNA (name, CNA # 1) to get someone to get her up and check to see if any burnt areas and change clothes. (CNA # 1) (and) (CNA # 4) (and) (CNA # 3) assisted (with) (no) redness noted. (Clothes) changed (with) (no) further (complaint of) pain to area or anything noted when toileted (every) 2 (hours) (after). (Family Member # 1) in room (approximately) 1:45 p.m. and assisted to (bathroom) (with) (no) skin issues noted. This report was signed by LPN # 1. 2) On 5/28/15 at 1:25 p.m., LPN #1 stated she had worked in the facility for [AGE] years and was the charge nurse for the hall on which (Resident # 1) resided. LPN # 1 was asked, Was (Resident # 1) able to feed herself on 5/21/15? LPN # 1 stated, Yes, she was alert that day. LPN # 1 was asked, When did you start feeding her at meals, that's what I've seen since I've been here. LPN # 1 stated, We have done that on and off. She will start eating and if she isn't eating when we go back we sit down and feed her. That's been going on for a while. LPN # 1 was asked, Did you see the coffee spill on 5/21/15? LPN # 1 stated, Yes, when I gave her meds I saw coffee on her clothes and I asked her what have you done. She said 'I spilled coffee, it's hot'. So I got (CNA # 1), her CNA to stop what she was doing to change her. I told her to sit the resident on the pot (BSC) and to let me know if there was any redness and the aides never told me she was red. So the next day I came in and filled out the (Occurrence Report). LPN # 1 was asked, Were her clothes hot where the spill was? LPN # 1 stated, No. LPN # 1 was asked, On 5/21/15 did you see her skin? LPN # 1 stated, No, there was three people in there and they all said there was no redness or nothing else. LPN #1 was asked, On 5/22/15 did you check her skin? LPN # 1 stated, Yes and we got a treatment for [REDACTED]. We poke a hole and put a straw in the cold stuff. LPN # 1 was asked, What do you do for the hot stuff? LPN # 1 stated, We take the lid off. LPN # 1 was asked, Any spills prior to 5/21/15 of hot or cold fluids? LPN # 1 stated, No. b. A Nurse's Note dated 5/21/15 at 9:45 p.m. documented, . Blisters (with) red rash noted to (left) hip. (No) (complaint of) pain or discomfort. Placed on (communication book). This entry was signed by Registered Nurse (RN) # 1. On 5/28/15 at 3:25 p.m., RN # 1 stated she had worked in the facility for 6 years. RN # 1 was asked to review the Nurses Notes dated 5/21/15 at 9:45 p.m. RN # 1 was then asked, Is this your entry? RN # 1 stated, Yes. RN # 1 was asked, What happened? RN # 1 stated, Before supper they, (CNA # 5) came and got me and said there are some red blisters on her hip so I went down to look at them. It might have been after supper when I saw the blisters. I couldn't figure out what would have caused them so I told the CNAs to keep her off that side so the blisters did not burst and I told the CNAs to put some A & D ointment or skin repair cream on them, one or the other. At that time I thought it might be shingles starting to come up. RN # 1 was asked, Has (Resident # 1) had any spills of fluids hot or cold prior to 5/21/15? RN # 1 stated, No. RN # 1 was asked, Did the resident have any complaints of pain? RN # 1 stated, No. c. A Nurse's Note dated 5/22/15 at 8:00 a.m. documented, (At) (approximately 11:30 p.m. (resident) had burns on outside (left) thigh from coffee earlier that morning. After looking (at) (resident's) clothes previously worn (Family Member # 1) noted the coffee stain in the same location of bottoms as burn on (left) outer thigh . The Nurse's Note dated 5/22/15 at 9:20 a.m. documented, Assessment (at) approximately 8:15 a.m. per (Physician # 1), (Administrator) (and) myself revealed small area of blisters to (left) thigh. (Resident) stated, 'I spilled my coffee yesterday'. Denies pain. Stated 'I don't hurt anywhere'. Questioned resident about coffee temperature. Declined wanting cooler coffee. Stated 'I want my coffee hot'. Dietary notified to send coffee cup (with) lid. This entry was signed by the Director of Nurses (DON). A Nurse's Note dated 5/22/15 with no time documented, Red area to left hip. blistered area measures 5 (by) 2 cm (centimeters) surrounding area in total 13 (by) 12 cm. Noted 4 line red areas measured 8 - 11 cm (approximately) 2 mm (milliliters) each. This entry was signed by the Assistant Director of Nurses (ADON). d. A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, And Exploitation of Residents in Long Term Care OLTC (Office of Long Term Care) Witness Statement Form dated 5/22/15 documented, Just about 7:25 a.m. - 7:30 a.m. I took resident (Resident # 1) coffee to be warmed up. She always request this every day. So I went to the pantry and warmed up her coffee for 30 seconds. The outside of cup wasn't hot. I took it to (Resident # 1's) room and placed it on her tray and I told her I had warmed her coffee up so was probably hot so be careful. I asked her if she wanted her lid on or off and she stated 'Just leave it off. I'm fixing to drink it.' Then I left the room. This witness statement was signed by CNA # 2. On 5/28/15 at 1:10 p.m., CNA # 2 was asked, Did you serve her (Resident #1) breakfast tray on 5/21/15? CNA # 2 stated, No I took the coffee cup off the tray while it was on the cart and I took it to the microwave because she always wants it reheated. I reheated it for 30 seconds and I took it to her and put it on the tray. I asked her if she wanted the lid on or off and she said off because I'm fixing to drink it and then I left the room. I told her to be careful it was hot. CNA # 2 was asked, The lid, did it have any opening in the lid to drink out of? CNA # 2 stated No, it was a flat one without a hole. CNA # 2 was asked, Do you know of any time she spilled her coffee prior to this? CNA # 2 stated, No. CNA # 2 was asked Is it okay for you to reheat coffee or other fluids in the microwave? CNA # 2 stated, No, not now. CNA # 2 was asked, Did anyone talk with you about not reheating coffee in the microwave anymore? CNA # 2 stated, When I came back on 5/26/15, Tuesday. I was off 5/22/15, 5/23/15, 5/24/15, and 5/25/15. CNA # 2 was asked, Who told you that? CNA # 2 stated, My charge nurse, (LPN # 2), on the East hall. e. A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, And Exploitation of Residents in Long Term Care OLTC Witness Statement Form dated 5/22/15 documented, At (approximately) 7:30 a.m. on 5/21/15 I took tray into (Resident # 1's) room. (Resident #1) always request coffee to be heated up. So CNA (CNA # 2) took coffee to heat. I was still sitting up tray when (CNA # 2) brought the coffee in. Cup did not feel abnormally hot. (Resident # 1) was sitting in her recliner alert and taking to us. At (approximately) 8:15 a.m. nurse (LPN # 1) called me to room stating resident had spilled her coffee. When cleaning up resident and changing clothes (resident) stated 'I spilled my coffee'. Did not seem to be in pain. (Resident) later stated 'I think I fell asleep'. Took residents clothing off and washed skin, saw no redness. Placed (resident) back in recliner where she napped through the day. At (approximately) 2:15 p.m. (Family Member # 1) and (Family Member # 2) came to visit. (Family Member # 1) and I set her on BSC (bed side commode) and changed her clothes and brief. (Family Member # 1) wanted her changed into PJs (pajamas). I did not notice any redness. (Family member # 1) did not state anything about seeing any redness. When I came back in room to answer call light resident was back in her chair. This witness statement was signed by CNA # 1. On 5/28/15 at 12:32 p.m., CNA # 1 was asked, When did you know she was burned? CNA # 1 stated, On the day she spilled the coffee I changed her. She'd spilled it all over her. I had to completely change her and clean her body. She (had) on a tee shirt, and a tank top and pants and she was completely soaked. This surveyor drew a picture of a stick figure wearing a shirt and pants and asked CNA # 1 to color in where the coffee was on the clothes. CNA # 1 drew multiple circles on the left side of the drawing from the chest down to the knees. CNA # 1 stated, It was on the front of her, on the left side and across her lap and left hip and she had a soaked clothing protector on. CNA # 1 was asked, You did a total pan bath? CNA # 1 stated, Yes. CNA # 1 was asked, Did you see any red or pink areas? CNA # 1 stated, No and we even sat her on the commode and she was completely naked. (Family Member # 1) came and we changed her that afternoon. We changed her into PJs (pajamas). She was on the BSC. I didn't see anything and she didn't say anything. f. A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, And Exploitation of Residents in Long Term Care OLTC Witness Statement Form dated 5/22/15 documented, At (approximately) 6:40 a.m. on 5/21/15 I was getting (Resident # 1) up and put her on BSC and bathed and dressed her to get up for breakfast. I used the standup lift and put her in her recliner for breakfast . At (approximately) 7:45 a.m. on 5/21/15 I was walking up the hallway to get silverware for a resident. I saw (Resident # 1) with her coffee in her hand drinking her coffee. At (approximately) 8:15 a.m., LPN (LPN # 1) asked me and (CNA # 3) to help (CNA # 1) to change (Resident # 1) because she had spilled her coffee. Resident stated, 'I spilled my coffee. It was hot'. We put her on BSC where changed her entire clothes including her brief. We washed her off. I did not notice any red area. We transferred her back into her recliner. She did not complain of hurting even when we washed her. She was alert and talking the whole time. This witness statement was signed by CNA # 4. On 5/28/15 at 1:50 p.m., CNA # 4 stated, I was working 6:00 a.m. to 2:00 p.m. on the day (Resident # 1) spilled her coffee on 5/21/15. CNA # 4 was asked, Was (Resident # 1) feeding herself breakfast that day? CNA # 4 stated, Yes, when I walked by that a.m. she was holding her coffee cup, she was alert and she was watching TV. CNA # 4 was asked, When did you find out she'd spilled her coffee? CNA # 4 stated, The nurse (LPN # 1) came and got me and asked me if I could help change her with (CNA # 1) and (CNA # 3) that she'd spilled coffee. CNA # 4 was asked, Where was the coffee spill? CNA # 4 stated, She had it on her shirt and pants. The spill was from the waist down around her hip and around the back side. CNA # 4 was asked, When you changed her did you see any pink or red areas? CNA # 4 stated, No. g. A Nurse's Note dated 5/22/15 at 3:05 p.m. documented, . (Family Member # 1) stated (resident) wasn't able to chew very well. 'I guess it's from the coffee burning her lip'. She stated she had been putting Carmex on it since yesterday but a Vaseline chapstick since the beginning of the week. (Approximately) 3 mm (dark) flat area to bottom right side of lip. (Family Member # 1) stated though it was a fever blister previously. (No) swelling or blister noted. This entry was signed by the DON. h. The communication book documented, 5/21/15 (Resident # 1). Blisters on (left) hip. Red rash. (Family Member # 1) came in at 10:00 p.m. and said 7:00 a.m. - 3:00 p.m. aides had reported that (Resident # 1) split coffee on her. Possible burn? This entry was initialed by (Physician # 1), as reviewed, and was dated 5/22/15. i. A physician progress notes [REDACTED]. overturned yesterday. Coffee at the nursing home is served at temperatures per established guidelines. Nurses report, however, that (Resident # 1) frequently asks for her coffee to be reheated. Nurses plan to serve patient's coffee in a cup with a covered top in attempt at minimizing any potential future spills. Patient denies any pain and specifically denies any tenderness to touch in areas of [DIAGNOSES REDACTED]tous skin on the left femoral trochanteric area. O (Objective): Elderly, alert, (white female) in (no acute distress) . Skin: Patient has an area or [DIAGNOSES REDACTED]tous skin over the left femoral trochanteric area that measures approximately 7 cm in greatest diameter. There is a cluster of small, nodular areas of indurated skin in the central portion of the [DIAGNOSES REDACTED] but no vesicles or blisters at this time. Additionally, patient has several linear areas of [DIAGNOSES REDACTED]tous skin anterior to the femoral trochanteric area of the left hip. These [DIAGNOSES REDACTED]tous lines are approximately 6 - 8 mm in width and 5 - 6 cm in length. No tenderness to palpation of these areas. A (Assessment): 1) Skin burn, apparently secondary to hot coffee . Addendum: S: Nurses reported (Family Member # 1) was concerned that patient may have some blisters on her mouth or tongue. Patient denies any pain in mouth. O: Mucosal surface of the mouth and tongue were unremarkable at this time, specifically I see no blisters or ulcerations. A: Normal exam of mouth at this time. A physician order [REDACTED]. Wash area of [DIAGNOSES REDACTED]tous skin on left femoral trochanteric area once daily with soap and water, then apply Silvadine cream under gauze dressing (times) 7 days . j. On 5/27/15 at 3:50 p.m., this surveyor and the DON conducted a body audit. There were no red areas or blisters noted on the resident's chest, abdomen, axillary areas, groins, back or buttocks. There were 3 faint linear areas on the outer, upper left hip area. The DON removed one side of the dressing that was on the resident's left upper lateral thigh area. There was a red area that was covered with a white substance. This surveyor could not visualize the area clearly. There appeared to be an open area in the center of the red area. The surrounding skin was red. The dressing on the area was dated 5/27/15. This surveyor requested to be present when the treatment was done on 5/28/15 in order to fully visualize the red area. k. On 5/28/15 at 8:02 a.m., the resident was sitting upright in a recliner with the back of the recliner at approximately 90 degrees. The resident's feet were up. The foot lever control was noted on the right side of the recliner and the resident's right arm and hand was elevated on pillows. The resident was asked, Did you ever spill coffee? The resident stated, Yes, and I burnt my hip when I did it. The resident was asked, Did you notice it was hot on your hip when it happened? The resident stated, I don't guess so. The resident was asked, Did it burn your mouth or lip? The resident stated, No. The resident was asked, Did you spill anything before this? The resident stated, No. The resident was asked, Does it hurt now? The resident stated, No. This surveyor noted 2 cups with built in straws and one metal cup with a removal lid with a hole in one side for drinking. l. On 5/28/15 at 1:51 p.m., the charge nurse provided wound care. The left upper lateral thigh area was red with an open area in the center of the red area. The red area measured approximately 7 centimeters long and 5 centimeters wide. The open area in the center of the burn appeared to be the approximate size of a half dollar. The open area wound bed was red with a half moon shaped area of slough on the bottom 2/3 of the open area covering less than 1/4 of open area of the wound. The State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities page 339, Revision 127, 11/26/14, Revision 130, 12/12/14. documented, Second-degree burns involve the first two layers of skin. These may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin. Based on this description, this surveyor would classify the residents burn as a second-degree burn. m. On 5/28/15 at 2:10 p.m., Family Member # 1 presented 7 pictures allegedly taken on 5/21/15 by Family Member # 1 to this surveyor. One picture was of the resident's mouth that showed dry scabs times three to the resident's right lower lip area. Six pictures showed red areas to the resident's left hip with one large red area that had a darker red in the center of the area and four linear areas across the resident upper thigh area where the side of the pull up would have been. The linear red areas appear to have been where the elastic sides of the brief were located. Family Member # 1 showed this surveyor the clothes that the resident was allegedly wearing at the time of the coffee spill. There was one white tank top, one tee shirt and one pair of sweat pants. The white tank top had a coffee stain starting approximately at the nipple line that extended to the hem of the tank top, approximately 11 inches long. The coffee stain on the tank top started approximately in the mid sternal area and was 6 inches wide. The tee shirt had a coffee stain that started approximately at the nipple line and extended to the hem of the tee shirt. The stain was approximately 13 inches long. The stain on the tee shirt started approximately in the mid sternal area and was 8 inches wide, extending into the side and back of the tee shirt. The coffee stain on the sweat pants started at the waist and went down the legs of the pants approximately 15 inches. The width of the stain on the pants started approximately 1.5 inches from the center front seam of the pants and extended on the side and back of the pants. This stain was dark for approximately 7 inches over the hip area and was surrounded by a lighter stain that extended approximately 5 inches beyond the darker stain. The entire width was approximately 12 inches from the front to the back of the pants. n. On 5/28/15 at 4:10 p.m., the Director of Nurses (DON) was asked to find the resident's admission and quarterly assessments in the resident's medical record. The DON located a Bowel and Bladder Assessment, an Infection Risk Assessment, a Braden Scale, a Fall Risk Assessment, and an Elopement Risk Assessment. The DON was asked, Is there a hot liquid safety assessment for (Resident # 1)? The DON stated, No. The DON was asked, On 5/21/15 was (Resident # 1) having any problems feeding herself? The DON stated, No. On 5/29/15 at 8:47 a.m., the DON was asked, Are you aware of any prior spills of fluid with (Resident # 1) prior to her spilling her coffee on 5/21/15? The DON stated, No. 2. On 5/27/15 from 10:15 a.m. to 12:15 p.m. during initial rounds, this surveyor observed residents with meal trays in all three dining rooms and some residents were eating in their rooms. This surveyor noted insulated plastic cups with handles and no lids being used for hot fluids. There were no concerns noted with resident's hands shaking or noted inability to hold coffee cups in their hands. 3. On 5/28/15 at 7:45 a.m., the test coffee cup prepared for this surveyor at 6:30 a.m. was on the hall cart on the West hall. The test coffee was taken to the pantry and the coffee temperature was 117.3 degrees Fahrenheit. The coffee was warm to taste. The coffee was then heated in the 700 watt microwave oven for 30 seconds. The coffee's temperature was 150.4 degrees Fahrenheit. The coffee was hot to the mouth but not scalding. 4. The Microwave Oven Owners Manual received from the DON on 5/28/15 for the microwave oven in the west hall pantry documented the microwave was a 700 watt microwave oven. The owners manual documented, . Safety Fact. Superheated water. Microwave water and other liquids do not always bubble when they reach the boiling point. To prevent this happening and causing injury, do not heat any liquid for more than 2 minutes per cup. After heating, let the cup stand in the microwave for 30 seconds before moving it or putting anything into it. Quick Start: The controls on your microwave oven . Beverage: 1 cup (8 oz. (ounces)) or 2 cups (16 oz) beverage . Operating Instructions: . Beverage. The beverage feature works best for heating a beverage that is at room temperature. Press BEVERAGE once for 1 cup (8 oz.) or twice for 2 cups (16 oz.) The oven starts automatically. There were no instructions for reheating liquids that were above room temperature. 5. On 5/28/15 at 2:45 p.m. the Administrator was asked, Do you have lids for coffee cups with holes in them? The Administrator stated, I'll have to ask. The Administrator was asked, Do you do a hot liquid safety assessment for residents? The Administrator stated, No, I never heard of something like that. On 5/28/15 at 4:10 p.m., the Director of Nurses (DON) was asked, Does the facility do a hot liquid safety assessment? The DON stated, No. 6. On 5/28/15 at 3:05 p.m., the Certified Dietary Manager (CDM) was asked, For coffee cups, is the solid lid the only lids you have for coffee cups? The CDM stated, No, we have this lid (indicated the solid lid with no holes that was on coffee cup) and we have one with a straw slot in the middle of the lid. The CDM was asked, Do you use the lids with straw slots on coffee cups? The CDM stated, No.