Every finding on record at Ridgewood Health Services, Inc.

Based on interviews, resident record review, review of the facility's Investigation, review of the policy titled Disposal of Medication and Medication -Related Supplies, review of the policy titled Medication Storage In The Facility and review of the CONSOLIDATD DELIVERY SHEETS, the facility failed to safeguards and have a systems in place to control, account for and periodically reconcile controlled medication in order to prevent diversion. On 06/24/2021, Assistant Director of Nursing (ADON), notified the Administrator of Resident Identifier (RI) #1's missing Oxycodone- APAP 10-325 card (20 pills). This affected one of four medication carts that maintained controlled medications. Findings include: Review of Policy titled Disposal of Medications and Medication-Related Supplies with a revised date of January 2018 documented, IE1: Controlled Substance Disposal .Procedures .C. All controlled substances remaining in the facility after a resident has been discharged , or the order is discontinued, are disposed of:1) In the facility by the director of nursing and/or consultant pharmacist (or others allowed by state law). D. Disposition is documented on the [individual controlled substance accountability record/book] .E. The nurse and/or Pharmacist witnessing the destruction ensures that the following information is entered on the [individual controlled substance accountability record/book]: 1) date of destruction. 2) Resident's name. 3) Name and strength of medication. 4) Prescription number. 5) Amount of medication destroyed. 6) Signatures of witnesses. F. Accountability records for controlled substances that are disposed of or destroyed are maintained with the unused supply until it is destroyed or disposed of . Review of Policy titled Medication Storage In The Facility with a revised date of January 2018, documented, . ID2: Controlled Substance Storage Policy Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations. Procedures . I. Controlled substances remaining in the facility after .the resident has been discharged are retained in the facility in a securely locked area with restricted access until destroyed . Accountability records for discontinued controlled substances are maintained with the unused supply until it is destroyed or disposed of . A review of the Pharmacy Care Associates CONSOLIDATD DELIVERY SHEETS, identified that Oxycodone -APAP 10-325, Quanity 21 TAB was received for RI #1on 06/03/2021 at 10:36 PM by the facility. RI # 1 was admitted to the facility on [DATE]. The facility's untitled investigation report, completed by Director of Nursing Documented On 06/24/2021, around 2:00 pm, ADON (name of Assistant Director of Nursing) notified Administrator (name of Administrator) of possible medication discrepancy. Upon investigation concern, it was noted Resident (# ) had one card of [MEDICATION(S)] missing (31 tablets) . Facility was unable to locate controlled substance sheet and card, containing [MEDICATION(S)] (10-325mg) . (name of local Police Department) was notified of discrepancy .Further investigation was initiated, with complete match-backs in facility of all med carts. Drug screens were also obtained of nursing staff . with no information collected that was contributory to the investigation. An interview was conducted with EI #3, Licensed Practical Nurse (LPN) on 10/20/2021 at 1:50 PM. EI #3 stated, the RI #1's medication was removed off the medication cart the day after he/she was discharged from the facility. EI #3 stated, she and EI # 4, Registered Nurse (RN) went through the cart and pulled discontinued controlled medication, signed controlled medication log and took to EI #1's office to be destroyed. EI #3 stated, after we took medication up there; I don't know what happened to it. EI #3 was asked about policy for destruction of medication. EI #3 stated, before this incident of missing medication the nurse on cart and another nurse would remove medication (Controlled) both would sign, and supervisor would take to EI #1's office and EI #1 lock up waiting for destruction. An interview was conducted with EI #4, Registered Nurse on 10/20/2021 at 2:25 PM. EI #4 state, she remembers getting controlled medication off medication cart. EI #4 stated, they pulled a lot of medication that day. She couldn't remember the specific date, but stated, RI #1's medication was not pulled off the cart the next day. She stated that she gives the family time to come and get medication before taking off cart for destruction. EI #4 states the family never received the medication. EI #4 stated, she didn't look at the medication to verify all medication being pulled off the cart. EI #4, stated, she probably should have but she didn't. EI #4 was asked if she should have reconciled all medication being pulled off cart for destruction with nurse on med cart before signing controlled drug log that it was removed; EI #4 stated, yes. EI #4 admitted the facility's policy was not followed when she did not reconcile all medication being pulled off medication cart for medication destruction. An interview was conducted with EI #1, Director of Nursing on 10/21/2021 at 10:34 AM. EI #1 stated, EI #4 would check each medication cart and pull all controlled medications for medication destruction. EI #4 would bring medications for destruction to EI #1's office. EI #1 stated, then she would pull labels off medications cards and place on the record of medication destruction sheet. Medication is then locked in file cabinet and that's located in a locked closet until pharmacy comes to destroy medication which is monthly. EI #1 was asked should EI #4 have reconciled all medication pulled off carts for destruction with controlled drug log; EI #1 stated, yes. EI #1 admitted that EI #4 did not follow policy when she did not reconcile controlled medications pulled off the medication cart for medication destruction. EI #1 was showed controlled drug log that showed RI #1's oxycodone-APAP 10-325 was removed from the medication cart on 06/14/2021 by EI #4. EI #1 stated that medication should have been destroyed on 06/18/2021 when the pharmacist came to the facility for medication destruction that month. EI #1 was not able to locate RI #1's oxycodone -APAP 10-325 on the record for medication of destruction. EI #1 admitted the facility's medication of destruction policy was not followed. ********* The surveyor determined current compliance of this deficient practice by reviewing and verifying the following actions taken by the facility: *In-service all nursing staff on Medication Protocol for Medication Destruction 06/25/2021-06/30/2021. *Drug screen on all staff that had access to medication carts. *Implementation of new process of pulling medication for destruction. Two nurses will pull off cart now instead of one. *QA nurse to monitor medication destruction, along with DON/ADON. *Administrator to monitor weekly of medication destruction accuracy for 1 month. ****** This deficient practice was cited as a result of the investigation of complaint/report # AL 457. Cited as PNC with a completion date of 07/30/2021.

Based on observations, interview, review of facility policies titled, Refrigerators and Freezers, Food Receiving and Storage, and review of the (YEAR) U.S. (United States) Public Health Service Food Code, the facility failed to ensure: 1. open food items were labeled with a use by date or preparation date prior to storage in the walk-in cooler; and 2. flour and meal were labeled and dated. These failures had the potential to affect all residents who received meals from the kitchen. Findings Include: The facility policy titled, Refrigerators and Freezers, with a last revised date of 12/2008, included, . This facility will ensure . Use by dates will be completed with expiration dates on all prepared food in refrigerators . A review of the (YEAR) U.S. Public Health Service Food Code revealed: . 3-5 LIMITATION OF GROWTH OF ORGANISMS OF PUBLIC HEALTH CONCERN . 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . (B) . FOOD prepared and PACKAGED by a FOOD PR[NAME]ESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES . The facility policy titled, Food Receiving and Storage, with a last revised date of 12/2008, included, . Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date) . On 1/06/2020 at 12:47 p.m., the surveyor and Employee Identifier (EI) #1, Dietary Manager (DM), observed four large prepared salads on a glass plate consisting of spring salad mix, cheese and tomatoes covered with clear plastic wrap, not labeled with a preparation date or use by date in the walk- in cooler. On 1/08/2020 at 11:03 a.m., the surveyor and EI #1 observed the flour and meal container bin not labeled and not dated with a use by date. On 1/08/2020 at 5:00 p.m., an interview was conducted with EI #1, the DM. EI #1 was asked if the four salads with spring mix lettuce, cheese and tomatoes were labeled with a preparation date and use by date. EI #1 stated no they were not dated. EI #1 was then asked if the salads should be dated with a preparation date and a use by date. EI #1 stated yes the salads should have been dated. EI #1 was asked what was the potential harm in having salads in the refrigerator not labeled with a use by date. EI #1 stated that it could have made the patients sick if given to a resident, as well as have Listeria and Salmonella. EI #1 was then asked should the flour and meal be labeled and dated. EI #1 stated yes. EI #1 was asked why should the flour be labeled and dated. EI #1 stated it could be outdated and we don't know when it came. EI #1 was asked what is the potential harm in the flour and meal not being labeled and dated. EI#1 stated the resident could get sick. EI #1 was then asked what was their policy on dating refrigerated items. EI # 1 stated the item should be dated with the date it goes into the refrigerator and with the discard date. EI# 1 was asked what is their policy on dating the flour and meal. EI #1 stated it should be dated when you open it and put it in the container.

Based on observations, interviews, record review, and review of a facility policy titled, CONTROLLED MEDICATIONS, the facility failed to ensure licensed nurses implemented the facility's system of accounting for narcotic medications when Resident Identifier (RI) #s 53, 70, and 8's narcotics were removed from the medication carts for administration. This affected three of 13 residents whose narcotic medication counts were verified and was observed on two of seven total medication carts in the facility. Findings Include: A review of a facility policy CONTROLLED MEDICATIONS, with an effective date of 7/1/09, revealed: . CONTROLLED MEDICATIONS . Policy . Medications included in the . classification as controlled substances are subject to special handling, storage, disposal and record keeping in the facility . D. When a controlled medication is administered, the licensed nurse . immediately enters . on the accountability record . On 1/08/2020 at 9:52 a.m., the surveyor and Employee Identifier (EI) #2, Registered Nurse (RN), checked narcotic counts on the A2 Cart 2 (medication cart). RI #70's [MEDICATION NAME] medication card contained 53 tablets; however, the INDIVIDUAL RESIDENTS CONTROLLED SUBSTANCE RECORD for [MEDICATION NAME] to be given twice a day indicated there should have been 54. The last tablet signed out was dated 1/7 at 9:00 PM. RI #8's [MEDICATION NAME] medication card contained no capsules; however the INDIVIDUAL RESIDENTS CONTROLLED SUBSTANCE RECORD for [MEDICATION NAME] to be given every twelve hours indicated there should have been one. The last capsule signed out was dated 1/7 at 9:00 PM. On 1/08/2020 at 10:03 a.m., the surveyor and EI #2 checked narcotic counts on the A2 Cart 1. RI #53's [MEDICATION NAME] medication card contained 36 tablets; however, the INDIVIDUAL RESIDENTS CONTROLLED SUBSTANCE RECORD for [MEDICATION NAME] to be given three times a day indicated there should have been 37. The last tablet signed out was dated 1/7 at 9:00 PM. RI #53's [MEDICATION NAME] medication count was also off by one. The medication card contained 56, but the INDIVIDUAL RESIDENTS CONTROLLED SUBSTANCE RECORD for [MEDICATION NAME] to be given every twelve hours indicated there should have been 57. On 1/08/2020 at 12:14 p.m., RI #70 confirmed he/she had received [MEDICATION NAME] earlier that morning. On 1/08/2020 at 12:17 p.m., RI #8 confirmed receiving his/her [MEDICATION NAME] earlier that morning. On 1/08/2020 at 12:22 p.m., RI #53 confirmed receiving his/her morning medications. On 01/08/20 at 10:08 a.m., the surveyor conducted an interview with EI #2, RN. EI #2 was asked if she gave RI #70, 8, and 53 his/her medications. EI #2 stated yes. EI #2 was asked to describe the process for administering narcotic medications. EI #2 stated when you pop the medications out of the medication card, they should be signed off on the narcotic log sheet. EI #2 was then asked after she pulled the narcotic medications for RI #70, 8, and 53 earlier that morning, if she signed the narcotic log sheets before administering the medications to the residents. EI #2 stated no. EI #2 said she had not followed the the facility's policy for when a dose of controlled narcotics was removed. EI #2 was asked what is the potential concern of not having a corrected narcotic control count in the narcotic log records. EI #2 stated someone could have taken the medication. On 01/08/20 at 05:33 p.m., the surveyor conducted an interview with EI #4, RN/DON (Director of Nursing). EI #4 was asked what the facility policy stated regarding removing a controlled substance from a medication cart. EI #4 stated when a controlled medication is administered, the nurse administering the medication immediately signs the narcotic log accountability record when the medication is pulled. The surveyor asked EI #4 if EI #2 followed the facility's policy on removing a controlled substance from the medication carts on 01/08/2020. EI #4 stated no, she did not sign the narcotic accountability log after pulling narcotic medication from medication cart.

Based on record review, interview and review of a facility policy titled, Residents Rights, the facility failed to ensure notification of a room change was made to RI (Resident Identifier) #10 prior to moving the resident to another room inside of the facility. Findings include: An undated facility policy titled, Resident Rights Policy indicated: Notification of changes. The facility will immediately inform the resident .and interested family member . Notifications of changes shall include: .5. A change in room or roommate assignment . RI #10 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A Quarterly MDS (Minimum Data Set) with an Assessment Reference Date (ARD) of 12/8/2016 revealed, RI #10 was cognitively intact and also revealed that during 7-11 days of the assessment RI #10 indicated feeling down, depressed. RI #10's Care Plan with a problem onset date of 4/5/2016 revealed: . 2. Potential for behavior problems due to Anxiety . Depression . Approaches .Explain procedures .thoroughly to ease paranoia . Offer conversation . Clarify situations as needed . Allow resident opportunity to make choices and participate in cares . On 2/1/2017 at 2:00 PM, RI #10 requested to talk with the surveyor. RI #10 stated a room change was made without his/her notification. He/she was moved from the C hall to the A hall. He/she was told of the room change when housekeeping came into the room and began removing items and placing the resident's items in boxes. The resident asked them what they were doing and that was when he/she was told that he/she was being moved to another room. On 2/1/2017 at 4:56 PM, an interview was conducted with EI (Employee Identifier) #2, Social Worker. EI #2 was asked how were residents notified of a room change. EI #2 said she personally notified the residents by talking with them. EI #2 was asked when was the downstairs unit (C Hall) closed. EI #2 said 1/12/2017. EI #2 was asked how much notice were the residents given before the move began. EI #2 said four residents were moved that same day (1/12/2017). EI #2 was asked why was RI #10 not notified of the room change prior to housekeeping moving his/her things. EI #2 said RI #10 was the exception because he/she was not in the room when notifications were made and she thought she would be able to let RI #10 know before the move began and that RI #10 was not on the top of the list to be moved. EI #2 was asked what was the facility policy regarding notification of room change. EI #2 said the facility was to notify the resident and the resident's representative. EI #2 was asked if RI #10 was notified of a room change. EI #2 said, not by social services, he/she was told by housekeeping when they went to move RI #10. When asked if it was housekeeping's responsibility to notify the residents of a room change, EI #2 said no. EI #2 was asked what was the potential harm to a resident when a notification of room change was not given. EI #2 said, his/her rights were not met. On 2/2/2017 at 7:53 AM, an interview was conducted with EI #1, Administrator. EI #1 was asked when was the decision made to close the downstairs unit (C-Hall). EI #1 said mid January after looking at the numbers (census), she felt the need to consolidate and felt it would help staffing. EI #1 was asked when was the unit to be closed. EI #1 said that same week with the last of the moves being the following week. EI #1 was asked was RI #10 notified of the room change prior to being moved. EI #1 said social services was going to make the notice, however she was aware housekeeping told RI #10 of the move. EI #1 was asked should RI #10 have been notified by staff other than housekeeping. EI #1 said yes.

Based on observation, interviews, record reviews and a review of Potter and Perry's Fundamentals of Nursing along with a review of a facility policy titled, Perineal Care for .Residents, the facility failed to ensure a Certified Nursing Assistant (CNA) separated and cleaned Resident Identifier (RI) #4's genitalia during the provision of incontinent care on 2/2/2017. This affected one of one resident observed for incontinent care. Findings Include: A review of Potter and Perry, Fundamentals of Nursing, ninth edition, copyright 2017 Chapter 40, Hygiene, page 858 revealed .p. Provide perineal hygiene .2.patient .(d). Gently separate (genitalia) with nondominant hand to expose urethral meatus and (genital) orifice . A review of an undated and untitled facility document revealed: Perineal Care for . Residents .4 .Separate the (genitalia) and wash downward on each side of the (genital area) .Wash downward in the middle over the the urethra and (genital) openings . RI #4 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. RI #4's most recent Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/30/2016 documented RI #4 as requiring extensive assistance with toileting, with two person physical assist; and frequently incontinent of bowel and bladder. Incontinent care for RI #4 was observed on 2/2/2017 at 9:55 AM, with Employee Identifier (EI) #4, a CNA. EI #4 wiped across the top of RI #4's pubic area, changed wipe, wiped down the right groin area, changed wipe, wiped down the left groin area, changed wipe, and then wiped down the middle of the pubic area without separating the genitalia to expose and clean the urethra. An interview was conducted with EI #4, the CNA that performed incontinent care on RI #4, on 2/2/2017 at 10:08 AM, EI #4 was asked if she separated RI #4's genitalia when she wiped down the center of the pubic area. EI #4 replied, No, I just wiped down the center. EI #4 further explained the potential harm in not separating the genitalia when cleaning could result in a urinary tract infection [MEDICAL CONDITION] or a yeast infection. An interview was conducted on 2/2/2017 at 11:09 AM, with EI #3, the Registered Nurse (RN) Supervisor. EI #3 was asked to explain the facility policy on providing incontinent care to residents, specifically the cleaning of the pubic area. EI #3 explained, You wipe down each side front to back, changing wipes each time, then you separate the (genitalia) and wipe down front to back. EI #3 was asked if this was how staff was trained to perform incontinent care. EI #3 responded, Yes. EI #3 further explained that the genitalia should be separated and cleaned and if that did not occur then the resident was not getting clean and that could result in bacteria, which could cause an infection.

Based on interview and record review, the facility failed to ensure their policy and procedure was followed for investigation and reporting of allegations of abuse. This affected one of two allegations of abuse reviewed. Findings include: A review of the facility policy titled Abuse Prevention Policy with an effective date of 10/1/2013, revealed the following: .Policy .INVESTIGATION INTERPRETATION: The facility will promptly investigate all reported or suspected allegations of abuse. Identify the staff member responsible for the initial reporting, investigation of alleged violation and reporting of results to the proper authorities.THE INVESTIGATION PROCESS SHALL CONSIST OF: 1. Review of the written statement of alleged abuse .IMPLEMENTATION: 1. The nursing supervisor will promptly start the investigation and immediately notify the Director of Nursing. 2. The facility Director of Nursing shall notify the Division of Health Care Facilities .of the suspected occurrence within twenty-four hours. On 1/6/2016 at 12:00 PM EI (Employee Identifier) #4, Housekeeper, talked with the surveyor on the phone. EI #4 said she had written a report about RI #17 being mistreated by EI #5, CNA (Certified Nursing Assistant) in November. EI #4 said EI #5 would not take RI #17 to the bathroom, put his hands over his ears, and made circles around his head with his hand to indicate the resident was crazy. EI #4 stated, EI #6 RN (Registered Nurse), had her write a report about the allegation on a piece of paper. On 1/7/2016 at 8:40 AM, EI #6 was asked if she remembered an employee making a complaint about EI #5 in November and a statement being written. EI #6 stated, EI #4 had said, EI #5 was talking ugly to RI #17 in the dining room. When asked about details she remembered, EI #6 stated, someone in housekeeping said, RI #17 was in the dining room and asked why EI #5 always talked so mean to the residents. When asked what she did with the statement, EI #6 said she gave it to the DON (Director of Nursing), EI #7, Abuse Coordinator. On 1/7/2016 at 8:45 AM, EI #7 was asked about the statement written by EI #4. EI #7 stated she did not have a statement about EI #5 and did not remember that incident. On 1/7/2016 at 8:50 AM, EI #6 was again asked what she did with the statement that EI #4 had written. EI #6 said she had told EI #4 to put the statement under EI #7's door. EI #6 did not remember anything else about the incident. On 1/7/2016 at 1:55 PM, EI #4 was again asked who was given the statement. EI #4 said she gave the statement to EI #6. When asked if EI #6 acknowledged that she received the statement, EI #4 said, yes. On review of the facility abuse allegations, this allegation of abuse was not reported to the State Agency nor investigated by the facility. On 1/7/2016 at 3:00 PM, EI #7 was asked what the facility policy was regarding allegations of abuse. EI #7 said, start an investigation, remove the resident from the situation, and during the investigation the employee should be removed from contact with the resident. When asked if all allegations of abuse should be reported to the State Agency, EI #7 replied, yes. When asked why this allegation of abuse was not reported to the State Agency, EI #7 said she was not aware of it. When asked what EI #6 should have done once she was made aware of the allegation, EI #7 said, she should have reported it to the DON or abuse coordinator immediately. When asked if the facility abuse policy was followed, EI #7 said, no.

Based on interview and record review the facility failed to ensure the State Agency was notified of an allegation of abuse that occurred in November 2015. The allegation was not reported to the State Agency nor investigated by the facility. This affected one of two allegations of abuse reviewed. Findings include: A review of the facility policy titled Abuse Prevention Policy with an effective date of 10/1/2013, revealed the following: .Policy .INVESTIGATION INTERPRETATION: The facility will promptly investigate all reported or suspected allegations of abuse . and reporting results to the proper authorities.THE INVESTIGATION PROCESS SHALL CONSIST OF: 1. Review of the written statement of alleged abuse .IMPLEMENTATION: 1. The nursing supervisor will promptly start the investigation and immediately notify the Director of Nursing. 2. The facility Director of Nursing shall notify the Division of Health Care Facilities .of the suspected occurrence within twenty-four hours. On 1/6/2016 at 12:00 PM EI (Employee Identifier) #4, Housekeeper, talked with the surveyor on the phone. EI #4 said she had written a report about RI #17 being mistreated by EI #5, CNA (Certified Nursing Assistant) in November. EI #4 said EI #5 would not take RI #17 to the bathroom and put his hands over his ears and made circles around his head with his hand to indicate the resident was crazy. EI #4 stated, EI #6 RN (Registered Nurse), had her write a report about the allegation on a piece of paper. On 1/7/2016 at 8:40 AM, EI #6 was asked if she remembered an employee making a complaint about EI #5 in November and a statement being written. EI #6 stated, EI #4 had said, EI #5 was talking ugly to RI #17 in the dining room. When asked about details she remembered, EI #6 stated, someone in housekeeping said, RI #17 was in the dining room and asked why EI #5 always talked so mean to the residents. When asked what she did with the statement, EI #6 said she gave it to the DON (Director of Nursing), EI #7. On 1/7/2016 at 8:45 AM, EI #7 was asked about the statement written by EI #4. EI #7 stated she did not have a statement about EI #5 and did not remember that incident. On 1/7/2016 at 8:50 AM, EI #6 was again asked what she did with the statement that EI #4 had written. EI #6 said she had told EI #4 to put the statement under EI #7's door. EI #6 did not remember anything else about the incident. On 1/7/2016 at 1:55 PM, EI #4 was again asked who was given the statement. EI #4 said she gave the statement to EI #6. When asked if EI #6 acknowledged that she received the statement, EI #4 said, yes. On review of the facility abuse allegations reported to the State Agency, this allegation of abuse was not included in those allegations reported. On 1/7/2016 at 3:00 PM, EI #7 was asked what the facility policy was regarding allegations of abuse. EI #7 said, start an investigation, remove the resident from the situation, and during the investigation the employee should be removed from contact with the resident. When asked if all allegations of abuse should be reported to the State Agency, EI #7 replied, yes. When asked why this allegation of abuse was not reported to the State Agency, EI #7 said she was not made aware of the allegation. When asked what EI #6 should have done once she was made aware of the allegation, EI #7 said, she should have reported it to the DON or abuse coordinator immediately. When asked if the facility abuse policy was followed, EI #7 said, no.

The facility failed to ensure licensed staff did not place her fingers inside of a medication cup when picking the cup up during medication pass on 1/6/16. This affected RI (Resident Identifier) #1, one of seven residents observed during medication pass. Findings include: On 1/6/16 at 8:48 AM, medication preparation and administration was observed on EI (Employee Identifier) #1, RN (Registered Nurse). During the preparation of medication for RI #1, EI #1 was observed picking up individual medication cups by placing her index finger inside the cup with her thumb on the outside of the cup. This occurred during six of ten medications being prepared. RI #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of EI #1's physician orders [REDACTED].#1's medications were to be given per [DEVICE] (Gastrostomy tube) (due to medical conditions). Medications included: [MEDICATION NAME] 20 mg (milligrams), Magnesium Oxide 400 mg, [MEDICATION NAME] 10 Gm (grams)/15 ml (milliliters), [MEDICATION NAME] 100 mg, Labetelol HCL 200 mg, Potassium Chloride CL 10% 20 mEq (milliequivalent)/15 ml, [MEDICATION NAME] 220 mg/7.5 ml, Vitamin C 500 mg, Liquid [MEDICATION NAME] 50 mg/5 ml. On 1/6/16 at 9:10 AM, an interview was conducted with EI #1, RN. EI #1 was asked how a medication cup should be picked up for medication preparation. EI #1 picked the medication cup up from the bottom of the cup. EI #1 was asked how she picked up the medication cups when preparing for RI #1. EI #1 said and demonstrated by picking the cup up from the bottom. EI #1 was told of surveyor's observation of picking the cups up with the index finger inside the cup. EI #1 was asked if it was an appropriate practice to pick up a medication cup by placing a finger inside the cup. EI #1 said No. EI #1 was asked what was the potential harm for the resident when picking up a cup by placing a finger inside of the cup. EI #1 said contamination. On 1/7/16 at 9:28 AM, an interview was conducted with EI #2, RN/Infection Control. EI #2 was asked what was the facility's policy on picking up medication cups for medication preparation. EI #2 said Never touch anything going into a resident's mouth. EI #2 was asked if it was an appropriate practice of the facility for a medication nurse to place her finger inside of a cup to pick it up. EI #2 said no. EI #2 was asked what was the potential harm to a resident for a nurse to place her finger inside a medication cup when preparing medications to be administered. EI #2 said infection.

Based on observation, record review, and interview the facility failed to ensure signage was posted in the facility in areas accessible to residents stating where the survey results were located. This was observed on 1 of 3 days of the survey and had the potential to affect all 75 residents in the facility. Findings Include: A review of a facility document titled RESIDENT RIGHTS with a review date of 8/2013 revealed the following: .Page 4 .(g) Examination of survey results. A resident has the right to - .(1) Examine the results of the most recent survey . and any plan of correction . The facility must make the results available for examination in a place readily accessible to residents and must post a notice of their availability, . A Resident Council meeting was held on 1/6/2016 at 10:30 AM. Ten residents attended the meeting. Residents were asked if they knew where the survey results were posted in the facility. All residents in attendance reported they did not know where the survey results were located. All residents in attendance reported they were not aware of their right to read or review the survey results. On 1/6/2016 at 3:00 PM the Surveyor observed the survey results posted in the lobby, on a desk, around the corner from the front entrance. On 1/6/2016 at 3:05 PM the Surveyor walked through the facility. There were no signs posted informing residents where the survey results were located. On 1/7/2016 at 10:25 AM, an interview was conducted with EI (Employee Identifier) #3, Social Services Director. EI #3 was asked when residents were last informed of where the survey results were posted. EI #3 stated she did not know the exact date, and it would have been after the last survey. EI #3 was asked where was the location of the survey results posted in the facility. EI #3 pointed out the survey results in the lobby. When asked why it would be important for residents to know the location of survey results and know they have access to them, EI #3 said, so if they had questions about care they could look and know if there were issues in the facility.

Based on observation and record review the facility failed to ensure that a STAT or Emergency box was in the facility. This has the potential to effect all 82 in house residents. Findings Include: A review of the facility's policy and procedure titled, EMERGENCY PHARMACY SERVICE AND EMERGENCY KITS with an effective date of 07/01/2009 revealed the following: "Procedures... B. When an emergency or "stat" order is received, the charge nurse:...3) Ascertains whether the ordered medication is contained in the emergency kit by referring to the list of contents posted at the nursing station and on the box....C....Emergency drugs, antibiotics, infusion products and controlled substances are stored together...F... The emergency supply is maintained at a designated area, along with a list of supply contents as follows: ...1) Emergency non-parental medications are kept with other emergency medications, in a sealed, portable container.... 2) Antibiotic starter doses are kept with other emergency medications, in a sealed, portable container... On 12/05/2014 at 9:05 AM the following was observed during the medication room check : a green plastic box with no list of the contents on the outside of the box and no list of the contents inside the box. Medications inside the box was as follows : Nitroglycerin, Narcan, Vitamin K, Phenytoin, Benadryl, epinephrine, Dextrose 50%, Glucagon, Sodium Polystyrene and three oral airways. There was no Emergency box/kit to check. On 12/05/2014 at 11:30 AM, an interview was conducted with EI (Employee Identifier ) #1 RN (Registered Nurse) Unit Manager. EI #1 was asked the facilities policy on the Emergency and STAT box. EI #1 said Emergency and STAT box were to be two separate boxes. EI #1 was asked was it acceptable to not have an Emergency box and to not have a STAT box. EI #1 said no it was not. EI #1 was asked was there a list of contents for the box that was in the medication room . EI #1 said yes but it was in the back of a binder in the medication room. EI #1 was asked was it acceptable to not have a list for the medications . EI #1 said no. EI #1 was asked what was the potential harm in not having a Emergency box and not having a STAT box. EI #1 said could not render the services needed in an emergency to the residents. EI #1 was asked what was the potential harm in not having a list for the contents listed in the green box in the medication room. EI #1 said could not render the services needed in an emergency to the residents. On 12/05/2014 at 11:45 AM, EI #2 DON ( Director of Nursing ) was asked the facilities policy on the Emergency and STAT box. EI #2 said the Emergency and STAT box should be in a portable container. EI #2 was asked was it acceptable to not have a Emergency and STAT box. EI #2 said no. EI #2 was asked why was there not a Emergency box. EI #2 said she was not aware that there was not one in the medication room. EI #2 was asked was it acceptable to not have a medication list available. EI #2 said no. EI #2 was asked what was the potential harm in not having an Emergency and a STAT box. EI #2 said not having the accessible medication in the event of a emergency situation. EI #2 was asked what was the potential harm in not having a list for the contents in the green box in the medication room. EI #2 said not knowing what was available to you.

Based on interviews and record reviews the facility failed to ensure a CNA treated a resident with dignity and respect by placing a brief on top of a resident's head while the resident was agitated and needed to go to the bathroom. This affected RI (Resident Identifier) #18, one of one sampled residents. Findings include: A review of a facility document titled, " Policy: RESIDENTS RIGHTS..." with an effective date of October 1, 2013. Policy : Employees shall treat residents with kindness, respect and dignity. Procedure... 2. Our facility must make every effort to assist the resident in exercising his/her rights to assure that the resident is always treated with respect, kindness and dignity... RI #18 was admitted to the facility 06/19/13, with a [DIAGNOSES REDACTED]. RI #18's most recent Minimal Data Set (MDS) with an Assessment Reference Date (ARD) of 11/18/2014 documented a Brief Interview of Mental Status (BIMS) score of 7 out of 15 indicating RI #18 was severely impaired in cognition. A review of facility's abuse investigation revealed an incident on 06/23/2014 in which a CNA placed a brief on top of an agitated resident's head. The facility's investigation revealed on 6/23/2014 a Certified Nursing Assistant ( CNA) EI #3 placed a brief on RI #18's head while RI #18 was agitated and yelling to go to the bathroom. On 12/04/2014 at 3:00 pm, an interview was conducted with EI (Employee Identifier) #2, DON (Director of Nursing). EI #2 was asked if she remembered an incident on 06/23/2014 between EI #3 and RI #18. EI #2 said yes. EI #2 said EI#3 placed a brief on top of RI #18's head. On 12/04/2014 at 4:30 PM, an interview was conducted with EI #3, the CNA involved in the incident with RI #18. EI #3 was asked to tell about the incident on 06/23/2014 that happened between she and RI #18. EI #3 said she placed a pull-up on top of RI #18's head. EI #3 said she did this to try to change his mood. EI #3 was asked if she thought it was appropriate to place a brief on a resident's head. EI #3 replied no. On 12/05/2014 2:30 PM an interview was conducted with EI #3. EI #3 was asked about the incident on 06/23/2014 with RI #18. EI #3 said RI #18 was in the hallway hollering for EI #3 to take RI #18 to the restroom.EI #3 said RI #18 continued to holler to go to the restroom. EI #3 said at the time she was in another resident's room. EI #3 said she came out of the room and said let me get you a pullup and I will take you to the bathroom. EI #3 said RI #18 continued to holler to go to the bathroom. EI #3 said she walked to the end of the hallway and got a pullup and went back with the pullup. EI #3 said she opened up the pullup and placed it on top of RI #18's head. EI #3 said the pullup fell over on RI #18's shoulder and RI #18 picked it up and threw it on the floor. EI #3 said to pick it up. RI #18 said no. EI #3 said she was picking it up at the same time RI #18 said no. EI #3 said she then took RI #18 to the room and placed RI #18 on the bedside commode. EI #3 said RI #18 continued hollering after taken off of the commode. EI #3 said RI #18 was agitated for at least an hour. EI #3 was asked what is the approach when RI #18 becomes agitated. EI #3 said, walk away and come back later. The surveyor asked EI #3 was that a good time to walk away from RI #18. EI #3 said yes.

Based on interview and record review it was determined a CNA placed a brief on RI (Resident Identifier) #18's head to discourage or eliminate RI #18's behaviors of agitation and yelling out without attempting the interventions he was careplaned for. RI #18 was on a Behavior Maintenance program and was care planned for behaviors related to his [DIAGNOSES REDACTED]. RI #18 was admitted to the facility 06/19/13, with a [DIAGNOSES REDACTED]. RI #18's most recent Minimal Data Set (MDS) with an Assessment Reference Date (ARD) of 11/18/2014 documented a Brief Interview of Mental Status (BIMS) score of 7 out of 15, indicating severely impaired in cognition. The MDS also documented in section E- Behavior, RI #18 was checked for psychosis and verbal symptoms directed towards others. A review of facility's abuse investigation documented in a warning notice for (EI #3) revealed the following: "... It was noted on 06/23/2014 that (EI #3) failed to follow the Resident Rights policy as evidenced by placing a diaper on (RI #18's) head ..." A review of RI #18's care plan with a problem onset date of 05/29/2014 revealed "... Problem and Need... Potential for mood and behavior problems due to dx (diagnoses) of schizoaffective type and anxiety R/T ( related to) h/o (history of) traumatic brain injury and pain. RI #18 has behaviors such as yelling out and h/o hallucinations, becoming agitated, refusing care, cursing and threatening others. He is on Behavior Maintenance program... Approaches...Explain procedures, care efforts thoroughly to ease paranoia... If combative and resistive to care leave room and allow time to calm down then reapproach at a later time. Explain steps of care, notify charge nurse of any behaviors exhibited,..." On 12/05/2014 at 11:15 AM, an interview was conducted with EI #4, SSD (Social Service Director). EI #4 was asked what type of behaviors did RI #18 exhibit. EI #4 said yelling out, curses a lot , fixated on having to go to the restroom and delusional thoughts. RI #18 also runs up on people with his wheelchair and has periods of agitation. EI #4 was asked what types of interventions were offered when RI #18 is having these behaviors. EI #4 said offer him conversation, distract or redirect him, offer him snacks... On 12/05/2014 2:30 PM an interview was conducted with EI #3. EI #3 was asked about the incident on 06/23/2014 with RI #18. EI #3 said RI #18 was in the hallway hollering for EI #3 to take RI #18 to the restroom. EI #3 said RI #18 continued to holler to go to the restroom. EI #3 said at the time she was in another resident's room. EI #3 said she came out of the room and said let me get you a pullup and I will take you to the bathroom. EI #3 said RI #18 continued to holler to go to the bathroom. EI #3 said she walked to the end of the hallway and got a pullup and went back with the pullup. EI #3 said she opened up the pullup and placed it on top of RI #18's head. EI #3 said the pullup fell over on RI #18's shoulder and RI #18 picked it up and threw it on the floor. EI #3 said to pick it up. RI #18 said no. EI #3 said she was picking it up at the same time RI #18 said no. EI #3 said she then took RI #18 to the room and placed RI #18 on the bedside commode. EI #3 said RI #18 continued hollering after taken off of the commode. EI #3 said RI #18 was agitated for at least an hour. EI #3 was asked what is the approach when RI #18 becomes agitated. EI #3 said, walk away and come back later. The surveyor asked EI #3 was that a good time to walk away from RI #18. EI #3 said yes. On 12/04/2014 at 3:00 PM, an interview was conducted with EI #2 DON (Director of Nursing). EI #2 was asked if she remembered an incident between EI #3 and RI #18. EI #2 answered yes. EI #2 said EI #3 placed a brief on top of EI # 18's head. On 12/04/2014 at 4:30 PM, an interview was conducted with EI #3. EI #3 was asked to tell about the incident on 06/23/2014 that happened between she and RI #18. EI #3 said she placed a pull-up on top of RI #18's head. EI #3 said she did this to try to change his mood. EI #3 was asked if she thought it was appropriate to place a brief on a resident's head. EI #3 replied no.

Based on observation interview and record review the facility failed to ensure Resident Identifier (RI) #2 received a "Boost" at the 12/18/13 breakfast meal and RI #8 received a "Magic Cup" and the 12/18/13 breakfast meal and the 12/18/13 lunch meal. This affected two residents identified by the facility for weight loss and 2 of 3 sampled residents for weight loss/gain. Findings include: A policy titled"...Weight-Loss A Change in Condition," dated October 1, 2013, documented: "Policy: Weight-Loss A Change in Condition Policy Significant unplanned weight loss is considered a change in condition when intervention is tried and fails. Procedure 1. Weights are monitored monthly. ...7. Continue every nutritional intervention possible and continue weekly weights until the weight loss stabilizes over at least a 30 day period..." A policy titled "Nourishments," no date, documented: Policy Nourishments will be provided to offer therapeutic nutritional support. A physician's orders [REDACTED]. Procedure 1. Residents receiving nourishments may include those who are underweight, who are on therapeutic diets, and those with poor intake, weight loss... 2. A "Nourishment and Supplement Feeding List" is maintained for residents receiving physician-ordered supplements... 3. The list is posted in Dietary and at each nursing station. 4. These nourishments are delivered by Dietary in individual portions that are labeled with the resident's name, date and time..." 1) RI #2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #2's current Annual Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status score of 3 out of 15 which indicated RI #2 was severely cognitively impaired. She required extensive to total assistance from staff for all Activities of Daily Living Skills. RI #2's care plan with a Problem Onset date of 12/13/13 documented: "...Potential for alteration in nutrition ..." An approach listed was "...Set up tray for resident...Feed resident meals as needed..." RI #2's meal tray ticket for breakfast on 12/18/13 documented: "...Beverages: ...Boost..." On 12/18/13 at 7:45 AM, RI #2 was observed feeding herself breakfast in her room. There was not a "Boost" on her tray at this breakfast meal. On 12/18/13 at 4:30 PM, EI #6, Dietary Manager, was asked what was RI #2 suppose to get on her meal tray according to the meal tray ticket. EI #6 replied, RI #2 should be getting large portions of meat at every meal and two large oatmeal at breakfast. EI #6 further commented RI #2 loved to drink the Boost, and sometimes she would drink 2 or three of them. 2) RI #8 was readmitted to the facility with [DIAGNOSES REDACTED]. A Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented RI #8 with long and short term memory loss and severely impaired in cognitive skills for daily decision making. RI #8 required total assistance from staff for all Activities of Daily Living which included dressing, eating, bathing and personal hygiene. RI #8's care plan with a Problem Onset date of 10/30/13 documented: "...Potential for alteration in nutrition ..." An approach listed was "...Feed resident meals as needed..." RI #8's cardex, (not dated), documented: "... Magic cup." RI #8's "Dietary Assessment," dated 12/13/13, documented on page 3, "...Specification of Nutrition Concern Statement: Significant weight loss with expected further due to progression of cognitive... Mechanically altered diet due to inability to chew foods. ...Plan of Care: ...Provide Puree diet with Med pass supplement 90 cc tid and Magic cup with meals..." RI #8's care plan with a Problem Onset date of 10/30/13 documented: "...Potential for alteration in nutrition ..." An approach listed was "...Feed resident meals as needed..." RI #8's meal tray ticket documented for her to receive a "Magic cup" at each breakfast, lunch and dinner meal. On 12/18/13 at 8:00 AM, RI #8 was observed for the breakfast meal. She did not receive a Magic cup on her tray. On 12/18/13 at 12:30 PM, RI #8 was observed for the lunch meal. She did not receive a Magic cup on her tray. On 12/19/13 at 11:15 AM, EI #6, Dietary Manager, was asked why RI #8 was getting a Magic cup at all meals. EI #6 replied it had more calories and was not to much for her to consume. EI #6 was asked why RI #8 needed more calories. EI #6 replied she does not eat well and had lost weight. EI #6 was asked who was responsible to put the Magic cup on the tray. EI #6 said the aide that sets up the tray line was responsible. EI #6 further commented she was not aware RI #8 did not get a Magic cup for breakfast or lunch on 12/18/13. On 12/19/13 at 2:30 PM, EI #4, RN/Unit Manager was asked when and why was the Magic cup ordered for RI #8. EI #4 replied on 12/13/13 because she was losing weight.

Based on interview, observation and record review, the facility failed to ensure Resident Identifier (RI ) #12 was assessed for safe smoking protection prior to being allowed to smoke. RI #12 was observed with holes in his shirt on 12/18/13 and 12/19/13. This affected one of one residents sampled for smoking. Findings Include: RI #12 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #12's most recent Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD), date of 11/27/13 revealed RI #12 scored a 14 out of possible 15 on the Brief Interview for Mental Status (BIMS), indicating RI #12 was cognitively intact. A review of the Facility's policy titled, "Smoking Regulations" with an effective date of 10/1/13 documented, "...5. The attending physician and the Director of Nursing and or designee shall make the determination as to which residents are classified as "responsible", or "not responsible," and the restrictions placed on their smoking...Safety precautions are of primary concern..." On 12/18/13 at 3:00 PM, RI #12 was observed standing at the Nursing station. RI #12 was wearing a sweatshirt that had several small holes on the front of it. On 12/19/13 at 9:25 AM, RI #12 was standing at the Nursing station near his room. RI #12 was wearing a jacket and had a sweatshirt on. The sweatshirt was observed to have two round holes (with black around the edges of the holes) on the front of it near the stomach area. RI #12 wanted the surveyor to see his room. After entering RI #12's room, the surveyor asked RI #12 what happened to his shirt. RI #12 said he burned it while he was smoking. EI #12 was asked if he wore a vest (for protection) while smoking. RI #12 said he did not. RI #12 said he had seen them, but they didn't ask him about one. RI #12 was asked if he would wear a vest. He said it didn't matter to him, because he wore one in the past when he welded. RI #12 further stated no one had asked him about it. RI #12 was asked if he burned his shirt at the facility and he said he did. RI #12 showed the surveyor another shirt in his closet that he had burned. On 12/19/13 at 10:05 AM, RI #12 was observed sitting outside smoking. RI #12 was sitting on the front of the porch which was behind the side wall. RI #12 was sitting alone with no staff in sight. RI #12 said he knew the code to the door and he goes outside every two hours and smokes one cigarette. At 10:15 AM, RI #12 (along with the surveyor) went back inside the building. RI #12 entered the code on the pad for the door to open. On 12/19/13 at 10:20 AM, an interview was conducted with Employee Identifier (EI) #2 (ADON/Assistant Director of Nursing). EI #2 was asked if RI #12 had been assessed for smoking. EI #2 said they had talked about it and it should be done by the end of the day. EI #2 was asked if RI #12 had been assessed to smoke independently. EI #2 said, "No, we are working on that." EI #2 was asked how long had RI #12 been at the facility, EI #2 said she was not sure, but he had always gone outside and smoked on his own. EI #2 was asked if RI #12 had been assessed for smoking safely. EI #2 said he had not. EI #2 was asked if RI #12's physician had ever written an order so that he could smoke independetly. EI #2 replied, "Not that I am aware of." EI #2 was asked how did the facility determine who could smoke safely without supervision. EI #2 replied, "I don't know what is in place for making that determination." EI #2 was asked what could be the potential harm to the resident if they were not assessed for smoking. EI #2 said, "They could drop it on them and burn themselves." EI #2 was asked if RI #12 had been assessed for a smoking apron and EI #2 said not that she was aware of. EI #2 was asked how did the facility determine who needed an apron for smoking. EI #2 said she was not aware that was needed. EI #2 was asked if they had a resident that had burn holes in his shirt, would it warrant an assessment for a smoking apron. EI #2 said, "I would think so." EI #2 was asked if she was aware that RI #12 had a shirt on with holes in it and he said he burned his shirt smoking. EI #2 said, "No, I was not aware of it." On 12/19/13 at 10:45 AM, EI #1 (Social Service Designee), was asked had RI #12 been assessed for safe smoking. EI #1 said she did an assessment today (12/19/13). EI #1 was asked had RI #12 always gone outside and smoked on his own. EI #1 said staff may go outside to smoke when it is time for their break. EI #1 further replied, "I have not directly observed anyone with him." EI #1 was asked if the facility had a policy regarding smoking assessments for residents. EI #1 looked at the facility policy and said, "No, it says residents and families will be notified upon admission of smoking policies." EI #1 was asked what would be the potential harm to the resident if they were not assessed for smoking. EI #1 replied, "They could get burned." EI #1 was asked if RI #12 had ever gotten burned or burned his clothing. EI #1 said RI #12 had burned his clothes in the past. EI #1 was asked if she was aware that RI #12 had burned his clothes, shouldn't he have been assessed for a smoking apron. EI #1 said, "Yes." EI #1 was asked if RI #12 had ever been assessed for a smoking apron. EI #1 said not that she knew of. EI #1 was asked if she was aware that RI #12 had on a shirt with holes in it and he stated he burned it while smoking. EI #2 said she was not aware of it.

Based on observation, interview and record review the facility failed to follow a physician's order for Resident Identifier (RI) #8 for aspiration precautions during the 12/18/13 breakfast meal and the 12/18/13 lunch meal. RI #8 was observed at these two meals positioned at a 45 degree angle not at 90 degrees per the physician's order. This affected 1 of 15 sampled resident's whose physician's orders were reviewed. Findings include: Potter and Perry, "FUNDAMENTALS OF NURSING", Eighth Edition, copyright 2013, Chapter 23, Legal Implications in Nursing Practice, page 305, documented: " The health care provider (physician or advanced practice nurse) is responsible for directing medical treatment. Nurses follow health care providers' orders unless they believe the orders are in error or harm patients. ... The health care provider should write all orders. The nurse is responsible for transcribing written orders correctly..." A physician's order for RI #8 for the month of December 2013, documented an order for [REDACTED]. "...ASPIRATION PRECAUTIONS SIT UP @ (AT) 90 FOR FEEDING, DRINKING, & (AND) MEDS (medications)..." RI #8 was readmitted to the facility with [DIAGNOSES REDACTED]. A Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented RI #8 with long and short term memory loss and severely impaired in cognitive skills for daily decision making. RI #8 required total assistance from staff for all Activities of Daily Living which included dressing, eating, bathing and personal hygiene. RI #8's "Dietary Assessment," dated 12/13/13, documented on page 2, "...Physical/Mental Functioning: ...HIGH RISK: Bed bound, Inactive , Total dependence, Extensive or total assist with eating, Aspirates..." RI #8's cardex, no date, documented: "... *Aspiration Precautions..." The degree angel for feeding listed in the physician's order was not documented on the cardex. RI #8's care plan with a Problem Onset date of 10/30/13 documented: "...Potential for alteration in nutrition ..." An approach listed was "...Feed resident meals as needed..." On 12/17/13 at 8:00 AM, RI #8 was observed in her room in a recliner being fed breakfast. Her feet were raised up and she was sitting at a 45 degree angle. On 12/17/13 at 12:30 PM, RI #8 was observed in her room in a recliner being fed the lunch meal. Her feet were raised up and she was sitting at a 45 degree angle. On 12/17/13 at 12:30 PM, Employee Identifier (EI) #3, Certified Nursing Assistant, was asked how did she know how to feed RI #8. EI #3 replied as long as RI #8 was sitting in her recliner she could feed her good. EI #8 was asked if RI #8 was to be at a certain position while being fed. EI #3 replied she was never really told for RI #8 to be in any certain position. On 12/18/13 at 4:00 PM, EI #4, Registered Nurse/Unit Manager, was asked to make an observation with the surveyor of RI #8. EI #4 and the surveyor entered the room. RI #8 was in the same position she was at during her lunch meal. EI #4 was asked what degree angle did she observe RI #8 to be positioned at. EI #4 replied, 45 degrees. EI #4 was asked how did staff know which angle RI #8 is to be positioned at for meals. EI #4 pulled the cardex from the footboard and read "Aspiration Precautions." The surveyor noted there was no degree angle documented on the cardex. On 12/19/13 at 2:10 PM, EI #5, Speech Therapist, was asked why RI #8 had physician's orders for Aspiration Precautions. EI #5 replied she did not know. EI #5 was asked who would inservice the staff about proper positioning. EI #5 replied she was not sure and that was still being worked on.

Based on observations, interviews and record reviews the facility failed to ensure the social service: 1) Assisted the residents with registering in the county, and with the voting process. This affected all ten residents in resident council group meeting. 2) Assess the psychosocial needs for Resident Identifier (RI) #1, a resident whose spouse had become incapacitated at home. 3) Another task of the Social Service department was to conduct assessments for the Cognition, Mood, Behaviors and Participation Levels of the MDS. One of the sampled residents, RI #2's MDS was completed. The Significant Change MDS dated [DATE], identified RI #2 with the cognition of "01 out of a possible 15". The former MDS assessment had RI #2 with a cognitive/decision-making skills as 11/15 (dated 11/26/11 and 2/23/12). 4) Assist residents and families with the grievance process. This had the potential to affect all residents in the facility. Findings include: The facility's "Social Service Designee" Job Description dated 2003 (and Revised November 2010) documented: "...Participate in community planning related to the interests of the facility and the services and needs of the resident and family. Participate in discharge planning, development and implementation of social care plans and resident assessments. Interview residents/families as necessary and in a private setting. ... Obtain information concerning the resident's personal and family problems, past illnesses, etc.., by developing a Social Service Data Record. .... Compile and maintain a social service director listing available community resources. ...Make routine visits to residents and perform services as necessary. Maintain contact with the resident's family, involving them with non-medical progress reports as necessary. ...Work with emotional problems including assisting resident/family with anxieties and stress caused by illness and admission to the facility, difficulties in coping with residual physical disabilities, fears related to helplessness and death, and the need for institutional and specialized care. ..." The Resident Handbook given to each resident and family upon admission documented: "Your Rights as a Resident" The facility will strive to ensure that your rights as a resident of the facility are preserved. You have a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside of the Facility. ... You have the right to continue to make choices and independent personal decisions. You have the right to continue to exercise all of your rights as a citizen of the United States and a resident of the State of Alabama, including your right to vote in elections." 1) A resident group meeting was held on November 15, 2012 at 10:00 AM. During the meeting the group was asked if they had the opportunity to vote in the recent elections. All ten residents said they did not get to vote in the presidential election or any elections. The residents said no one asked them if they wanted to vote, or told them anything about absentee ballots. One resident said when he asked if he could vote, the social service designee said, she had forgotten to get the absentee ballots. In an interview with the social service designee, Employee Identifier (EI) #1 on 11/16/12 at 8:55 AM, she was asked, "Did you know that you were to assist residents to vote and/or register to vote. EI #1 replied, "Yes, I did." She further stated, she had asked people to vote (8 to 10 residents) and no one expressed they wanted to vote. However, she had no documentation that she had tried to assist the residents in any way to vote. EI #1 was asked, what was the importance of residents being afforded the opportunity to vote. EI #1 said, "It was their right, and this was their chance to have a voice." In an interview with the Administrator, EI #2 on 11/16/12 at 3:09 PM, a list of unreviewable residents were requested. EI #2 voiced the facility had discovered that no residents were given the opportunity to vote in the primaries, the local voting or in the presidential election. 2) RI #1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment for 10/15/12 revealed RI #1 was a 10 out of 15 on her BIMS (Brief Interview of Mental Status) which places her in the 'Moderately Impaired' range of cognitive skills for daily decision-making. RI #1 was assessed for bed mobility, transfers and hygiene, and was identified as requiring "extensive assistance with one to two staff assistance." In a personal interview on 11/15/12 at 11:04 AM and 2:49 PM, RI #1 revealed she was doing well with her therapy until her husband had a heart attack at home and had to have a 6 by-pass operation. She said, before she had entered the nursing home, she had taken care of him. She stated she really did not have the family to assist her. The surveyor asked RI #1 if she had talked to anyone at the nursing home about her concerns. EI #1 said she had, but she had not talked to anyone who could assist her. The surveyor asked the resident, how does this make you feel? With a worried look on her face, RI #1 said, " I feel so helpless, hopeless, I don't really know what I can do, all I can do is worry about him." When reviewing RI #1's chart, there was a brief one page "Social History & Assessment" dated 10/02/12. The social history was done by the Activity Director, and no other social notes were documented in her medical file. There were three Activity Assessments notes done, in the same amount of time. An interview with the social service designee, Employee Identifier (EI) #1 on 11/16/12 at 9:50 AM, questioned, her obligation to residents that had come into the facility and then have a major problem at home and can not go home and take care of the problem. She stated, she was not sure. She was asked if she knew about RI #1's problem. EI #1 said she did not know. After hearing about the incident, EI #1 was asked, would you have any resources to offer her. EI #1 said, "I don't know." She was asked if the facility had any sitter services and if she could check with the hospital discharge social service to see what they had set up to help ease the wife's mind. EI #1 said she could call. A surveyor asked if she had arranged any counseling for RI #1. EI #1 said, "I could ask her if she wanted that." The surveyor asked if she could just go in and talk with RI #1. 3. The CMS's RAI (Resident Assessment Instrument) Version 3.0 Manual, page C-15 documented under "Coding Instructions ... If the resident chooses not to answer a specific question(s), that question is coded as incorrect and the item(s) counts in the total score. If, however, the resident chooses not to answer four or more items, the the interview is coded as incomplete and a staff assessment is completed. Code "99", unable to complete interview: if (a) the resident chooses not to participate in the BIMS, (b) if four or more items were coded "0" because the resident chose not to answer or gave a nonsensical response, or (c) if any of the BIMS items is coded with a dash. ... This would be considered an incomplete interview; enter "99" for Summary Score, and complete the staff assessment of mental status. ...." ) Ensure residents and family members were aware of the grievance process and had the grievance resolved in a timely manner. The facility's "Grievance Policy" documented," (NH) believes that a sound, responsive Grievance Program can only improve the quality of the services offered by our facility. One of the keys to having a successful Grievance Program is the willingness to see the organization as a system of process, each of which h is in a state of constant change, and hopefully, improvement. Grievances should be viewed as one of the feedback systems available to management tot assess the level of performance of the facility. Another key to ensuring the success of the Grievance Program is to respond in writing to all grievances with managements response to the conditions grieved. 4) A resident group meeting was held on November 15, 2012 at 10 o'clock AM. During the meeting the group was asked if they or their families had ever filed a grievance. No one at the group meeting stated they had filed a grievance or knew how. When asked how the group as a whole ever voiced a grievance to the facility. The group said, we tell the social worker or the administrator, or someone and that's the last of it. The surveyor explained that any complaint/problem, verbal or written down was official, and should be acted upon. When the group was asked who do you tell when something goes missing, they said, the laundry. The surveyor inquired of the "Grievance Log" from the social service department on 11/17/12. On 11/18/12 the 'Grievance Log" was provided with 6 complaints written in, and all of these were from the Resident Council group meeting, and some did not provide a resolution to the problem. All three days of the survey (11/14/12 - 11/16/12), there were no grievance forms discovered in any accessible areas, or at nurses' stations. When the surveyor asked a Registered Nurse and a Licensed Practical Nurse on 11/16/12 at 10:00 AM, for a grievance form, they did not know where the forms were kept, and directed me to the Administrator. In a family interview on 11/15/12 at 1:15 PM, the daughter of RI # 11 was asked about the security and personal property of her mother's property. She stated that the nurses had requested the family buy gowns that open in the back. She stated she bought two gowns and her sister-in-law bought two gowns. She stated they were quite expensive of at least $20.00 + each. She said she had told the Administrator (EI #2) when they went missing, which was almost immediately after they were brought into the facility. Also her mother had crochet a white blanket and it was on her bed, and it went missing months ago. The daughter stated she also told the Certified Nursing Assistants (CNAs) that worked with her mother. There was no complaint form written up, and the daughter stated she has never heard anything back about the gowns and crochet blanket. This occurred almost five months prior. When discussing the Grievance Policy with EI #1 on 11/16/12 at 3:10 PM, she was asked where the grievance forms were kept. EI #1 said, in her office, but anyone could write a grievance. She was asked does she have a place (like a box) where grievances/suggestions could be put in. EI #1 said she did not. EI #1 explained the process that when she had a complaint she would tell the person in charge of that discipline, and they would follow through. EI #1 said, she would usually go right to EI #2, because EI #2 used to be the DON (Director of Nursing). However, EI #1 said, we so seldom have any problems. A review of August, Sept, and October 2012 resident council group meeting minutes, verified there were no problems of any sort brought up, and were almost a duplicate of the month before. In an interview with the EI #2, the Administrator on 11/16/12 at 2:00 PM; she was asked what the duties of the social service department were. EI #2 said, we meet the needs of the residents including emotional, and assist with counseling for life stresses and finding resources for them. EI #2 was asked about the grievance process; and why the grievance forms were not easily assessable to residents and their families. EI #2 said, she needed to look at the system/s more closely.

Based on observation, record review and interview the facility failed to assure the cognitive status for Resident Identifier (RI) #5, an aphasic resident and RI #2 to accurately reflected their cognition status. This affected 2 of 15 active sampled residents. Findings include: The RAI (Resident Assessment Instrument) Version 3.0 Manual C0600: Should the staff Assessment for Mental Status be conducted: Coding Instructions: "... if four or more items were coded 0 because the resident chose not to answer or gave a nonsensical response. Continue to C0700c1000 and perform the Staff Assessment for Mental Status.. . C0700-C1000: Staff assessment of Mental Status Item on page c-18, Item Rational, Health related Quality of Life...Residents may appear to be cognitively impaired because of communication challenges or lack of interaction but may be cognitively intact. When cognitive impairment is incorrectly diagnosed or missed, appropriate communication, worthwhile activities and therapies may not be offered." The facility Policy and Procedure for Care Plans- Comprehensive, documented "... 4. Areas of concern that are triggered during the resident assessment are evaluated using specific assessment tools (including Care Area Assessments..." RI # 5 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) with an assessment reference date of 7/20/12 revealed RI #5 was dependant for transfer, hygiene, dressing and eating. The MDS revealed the Cognition/ Decision making was not fully assessed. The Brief Interview of Mental Status (BIMS) was coded as a 0 and no further review or assessment done to determine the residents' cognitive status. On 11/15/12 at 8:30 AM, RI #5 was sitting up in bed being fed breakfast by a staff member. At that time RI #5 was noted to babble and mumble words but was not understandable to the surveyor. She did appear to be engaged with the staff that was feeding breakfast. On 11/15/12 during the lunch meal, RI #5 was observed in her room. At that time her husband was visiting. RI #5 appeared to be animated and smiling. When asked how she was today by the surveyor, she looked at the surveyor and "clapped" the table. The MDS Coordinator, Employee Identifier (EI) #3 was interviewed on 11/16/12 at 10:50 AM, and she stated Social Services was responsible for the assessing the cognition of the residents by interview with the resident. If the resident is unable to answer the question for a BIMS the next step is to interview the staff for their assessment and input, as outlined in the MDS. When asked what a BIMS score of "0" meant to the plan of care, EI #3 stated she would anticipate all their needs and wants, to be bed bound and a total assist. The Social Service Designee, EI #1, was asked when the BIMS for RI #5 was completed and she stated it was done during the1st three days of the assessment period. EI #1 was then asked what should be done if the resident was unable to complete the BIMS and she replied, RI #5 should have been assessed for memory and cognition by the nurses. EI #1 further stated she did not write anything like if she is understood or if you could understand her. When asked why that was important she replied."It (the cognition on the MDS) helps to describe them and tells you how to communicate with the resident. That doesn't tell you anything about them. It would help shifts to communicate." 2. A task of the Social Service department was to conduct assessments for the Cognition, Mood, Behaviors and Participation Levels of the MDS. One of the sampled residents, RI #2's MDS was completed. The Significant Change MDS dated [DATE], identified RI #2 with the cognition of "01 out of a possible 15". The former MDS assessment had RI #2 with a cognitive/decision-making skills as 11/15 (dated 11/26/11 and 2/23/12). RI #2 had a cognitive loss care plan dated 09/04/2009. The careplan stipulates that she had [DIAGNOSES REDACTED]. There were no further assessments or changes in the assessment. On 11/16/12 at 10:50 AM, EI # 3 was asked to explain how a cognition score of 1 of 15 was obtained for RI #2. She stated she was not sure she just signs the MDS as being completed, not that it is correct. Usually a zero or 1 up to a 4 means they should do the next cognition/skills for memory loss. The Social Service would usually send a note when the score is that low.

Based on observation, interviews, record review and review of an untitled facility policy, the facility failed to ensure a CNA (Certified Nursing Assistant), removed/ changed gloves and wash her hands after her gloves were contaminated with bowel movement. On 2/01/2012, during an observation of pericare on RI #2, Employee Identifier (EI) #1, and in the presence of the Director of Nursing (EI #3), failed to remove her gloves and wash her hands after becoming coming in contact with bowel. This deficient practice affected RI #2, one of two residents observed for peri-care. Findings include: The untitled and undated facility document identified by the facility's Director of Nursing (DON) as the pericare policy, documents, "FEMALE ... 19. ... remove gloves and dispose of them in the trash container and wash your hands. ..." RI #2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #2's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/27/2011, documents that RI #2 had a BIMS Brief Interview of Mental Status was zero, which indicates that RI #2 is severely impaired in cognitive skills for daily decision making. RI #2 is assessed as requiring total assist of one with bed mobility, transfers, hygiene, bathing and toileting. RI #2 is further assessed as being incontinent of bowel and bladder. On 2/01/2012 at 4:21 PM, the surveyor and DON (EI #3), entered RI #2's room. EI #1 stated she was about to provide care to RI #2. EI #1 gather supplies to provide care. RI #2 was lying in bed with a catheter bag covered by a pillowcase. The catheter bag was hanging on the bed frame. As EI #1 gathered supply EI #2 entered the room and state she would be assisting EI #1. EI #1 washed her hands and applied four (4) pair of gloves. While providing peri-care RI #2 was observed to have a bowel movement. Without changing gloves EI #1 began to wash RI #2's buttocks. EI #1 was observed to have bowel movement on her gloves and without changing her gloves continued to rinse the resident with another washcloth. On 2/2/2012 at 3:07 PM, EI #1 was interviewed regarding the pericare observation on 2/1/2012 with RI #2. EI #1 was asked what the facility ' s policy on changing gloves. EI #1 stated when going into a room wash your hands and you can put on two pair of gloves. When you are done remove your gloves and wash your hands. EI #1 was asked what she could touch wearing gloves. EI #1 stated that if the gloves are clean she could touch the resident until the gloves were dirty then she would have to remove them and wash her hands. This deficiency was cited as a result of AL 998.

Based on observations, interviews, record review and facility policies titled "CATHETER: INDWELLING URETHRAL CARE OF" and "CATHETER: FOLEY PROTOCOL," the facility failed to ensure a Certified Nurse Assistant (CNA), Employee Identifier (EI) number (#)1 performed perineal (peri) care in a manner that would not place Resident Identifier (RI) #2 at risk for developing a Urinary Tract Infection [MEDICAL CONDITION]. On 2/01/2012, RI #2, a resident with a history of UTI's, was observed during catheter care. EI #1 failed to change gloves after the gloves became contaminated with bowel movement; rinse soap off of the resident's perineal area; dry the resident during care, and change the washcloth after it was soiled with bowel movement. EI #1 also failed to position RI #2's catheter tubing and catheter bag correctly catheter care. These deficient practices affected RI #2, one of two residents observed for pericare. Findings include: The facility's policy titled "... CATHETER: INDWELLING URETHRAL CARE OF," with an effective date of April 2005 documents: "OBJECTIVE: To prevent infection within the urinary system. ... PROCEDURE: G. Gently wash gential areas per peri-care policy. Dry thoroughly... I. Check position of catheter tubing and drainage bag. ..." The facility's policy titled "... CATHETER: FOLEY PROTOCOL," with an effective date of April 2005 documents: "OBJECTIVE: E. Maintain proper positioning of the tubing and collection bag to ensure a free, downhill, continuous flow of urine. The bag is kept below the level of the bladder to prevent reflux of stale urine back into the bladder. ... CONSIDERATIONS: A. Pericare and catheter care every shift. ..." An untitled and undated facility document identified by the facility's Director of Nursing (DON) as the pericare policy, documents, "FEMALE ... B. Use a new washcloth when the first one is soiled. C. Separate the inner labias and wash with soap and water from front to back with clean section of wash cloth until area is clear. D. Rinse outer and inner thigh and then inner labias in the same manner as you washed them. E. Dry the outer labias and inner thigh and inner labias by patting with a towel. .... 17. Dry rectal area and buttocks with a towel using a patting motion. ... 19. ... remove gloves and dispose of them in the trash container and wash your hands. ..." RI #2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #2's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/27/2011 documents that RI #2 had a BIMS Brief Interview of Mental Status was zero, which indicates that RI #2 is severely impaired in cognitive skills for daily decision making. RI #2 is assessed as requiring total assist of one with bed mobility, transfers, hygiene, bathing and toileting. RI #2 is further assessed as being incontinent of bowel and bladder. RI #2's Care Plan, dated 1/26/2012, documents as a problem "Potential for urinary tract infection related to presence of indwelling catheter, history of UTI, [MEDICAL CONDITION] mass in kidney and dx (diagnosis) of [MEDICAL CONDITION]." This Care Plan has listed as approaches, "Position catheter tubing below level of bladder," and "Position resident so urine will drian from bladder." RI #2's Care Plan for skin breakdown dated 1/26/2012, has documented as an intervention, "Cleanse perineal area with soap and water following each bowel movement." On 2/01/2012 at 4:21 PM, during the initial tour, the surveyor and DON (Director of Nursing) (EI #3), entered RI #2's room. EI #1 stated she was about to provide care to RI #2. RI #2 was observed lying in bed with a catheter bag covered by a pillowcase hanging on bed frame. As EI #1 gathered supplies, EI #2 entered the room and stated she would be assisting EI #1. EI #1 washed her hands and applied four (4) pair of gloves. EI #1 poured soap onto the wash cloth and washed RI #2's groin area. EI #1 rinsed RI #2's groin area. EI #1 did not part the labias, nor did EI #1 dry RI #2's groin area. EI #1 removed the top pair of gloves. EI #1 placed another pair of gloves over these gloves and stated she needed to cleanse RI #2's bottom. EI #1 began to turn RI #2 towards EI #2, pulling the catheter tubing. EI #2 told EI #1 to give her the catheter bag and EI #1 did not change her gloves after handling the catheter bag. During the care, RI #2 was observed to have a bowel movement. Without changing gloves EI #1 began to wash RI #2's buttocks. EI #1 did not change the washcloth after it was soiled with a large amount of bowel movement. EI #1 wipe RI #2's buttocks three times, folding the washcloth between each wipe. Even though bowel movements was visible on EI #1's gloves, EI #1 continued to rinse the resident with another washcloth without changing her gloves. EI #1 did not dry the resident ' s buttocks. EI #1 stated she forgot to wash the catheter and rolled RI #2 onto her back. Wearing the same contaminated gloves, EI #1 placed soap onto a washcloth and began to wash the catheter, pulling it away from the body of RI #2. EI #2 then held the catheter close to the meatus and washed the tubing. EI #2, wearing the same contaminated gloves, wet a towel and rinsed the catheter tubing. EI #1 did not rinse the soap from he perineal area or dry the resident or tubing. EI #1 removed the top pair of contaminated gloves and placed them in the garbage, went to the dresser and removed a large jar of Vaseline. EI #1 removed the lid of the Vaseline and stuck her gloved fingers into the Vaseline container. A large amount of Vaseline was applied to RI #2's buttocks and the Vaseline top was placed back onto the Vaseline container. EI #1and EI #2 positioned RI #2 on her right side. EI #1 placed pillows to RI #2's back, under her left arm, between her legs and placed the catheter tubing over RI #2's left leg but left the catheter drainage bag on the left side of the bed frame. On 2/2/2012 at 3:07 PM, EI #1 was interviewed regarding the pericare observation on 2/1/2012 with RI #2. EI #1 was given the policy on pericare that was given to the surveyor by the DON to read. EI #1 affirmed she did not dry RI #2 or rinse the catheter. EI #1 stated she had bm (bowel movement) on the wash cloth and instead of changing the cloth she changed the corners of the washcloth instead of what the policy states to, "...get rid of that one and get a new one." EI #1 was asked about the facility's policy on placement of the catheter bag and tubing. EI #1 stated the bag and tubing is placed on the same side the resident was facing and it should not touch the floor. EI #1 was asked where she had placed it after pericare on yesterday (2/1/2012). EI #1 stated she placed it on the back side. EI #1 stated if the catheter bag and tubing are not properly placed, " ..."It can pull out. At a higher elevation that the (urine) can flow back and cause infections" On 2/3/2012 at 1:10 PM, the surveyor interviewed EI #3, the facility's DON. EI #3 was asked what the expectations of her staff were. EI #3 stated she expected her staff to meet the needs of the residents and to follow the practices that they had been shown. EI #3 was asked how often staff is trained. EI #3 stated the facility has in-services monthly and as needed. EI #3 was asked what she could tell me about the observation of pericare on 2/1/2011. EI #3 stated the pericare that was provided by EI #1 for RI #2 was not performed according to the facility's policy. This deficiency was cited as a result of AL 998.