Every finding on record at Signature Healthcare of Monroe County Rehab and We

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure that two (Resident (R) 29 and R35) of four residents reviewed for respiratory services, out of 27 sampled residents, received respiratory care in a manner to prevent discomfort. R29 and R35, who received continuous oxygen therapy, did not consistently receive water/humidification services designed to prevent discomfort, including drying out of nasal passages. The findings included: Review of the facility's policy, titled Oxygen Administration Policy, revised 05/04/2024, revealed the facility staff would change the humidification bottle when changing the oxygen tubing monthly and as needed (PRN). 1. Review of R35's Face Sheet revealed the resident was admitted to the facility on [DATE] with admitting diagnoses including chronic obstructive pulmonary disease (COPD), other seasonal allergic trinities, shortness of breath, unspecified chronic bronchitis, and emphysema. Review of R35's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated intact cognition. Per the MDS, the resident received continuous oxygen. Review of R35's comprehensive care plan (CCP), dated 01/20/2020, revealed R35 was at risk for respiratory distress related to shortness of breath, increase in carbon dioxide levels above his normal limits, and a diagnosis of end stage COPD, with a goal to not exhibit signs of respiratory distress through the next review. Continued review of the CCP revealed R35 had interventions for administration of oxygen as ordered by the physician. The CCP did not include interventions related to humidification bottle changes. Review of R35's physician orders, dated April 2024, revealed R35 was on oxygen at 2 liters per minute (L/M) per nasal cannula (NC) continuous with titration up to 3L/M while walking. Continued review of physician orders revealed no information about the use of water/humidification during oxygen administration or the need for humidification bottle changes. Observation of R35 on 05/07/2024 at 9:18 AM revealed the resident was receiving oxygen at 3L per minute via NC while walking from his bathroom to his wheelchair. The humidification bottle on the resident's oxygen concentrator, which was dated 04/26/2024, was empty. Additional observation on 05/07/2024 at 11:35 AM revealed the resident was receiving oxygen at 3L per minute via NC while walking in his room. The humidification bottle, dated 04/26/2024 and attached to the oxygen concentrator, was still empty. Interview with R35 on 05/07/2024 at 9:20 AM, revealed the humidification bottle had been empty since this past Sunday. R35 stated he had requested the empty bottle to be changed on Sunday, but the nurses were really busy and didn't get to it. R35 stated he had asked again this morning, but it still had not been changed. R35 stated when the humidification bottle was empty, it causes my nose to dry out, which led to nasal irritation, such as a nosebleed. 2. Review of R29's Face Sheet revealed the resident was admitted to the facility on [DATE] with admitting diagnoses including COPD with acute exacerbation, sleep apnea, and generalized anxiety disorder. Review of R29's Quarterly MDS, dated [DATE], revealed R29 had a BIMS score of 14/15, which indicated the resident was cognitively intact. Per the MDS, the resident was on continuous oxygen therapy. Review of R29's CCP, dated 10/03/2023, revealed the resident was at risk for complications related to COPD with a goal to not exhibit signs of respiratory distress through the next review. Per the CCP, R29 had interventions for administration of oxygen as ordered by the physician. Further review of the care plan revealed that it did not address the use of water/humidification during oxygen administration or the need for humidification bottle changes. Review of R29's physician orders, dated April 2024, revealed R29 had an order for oxygen at 3L/M via NC continuously. Continued review of R29's physician orders revealed no information about the use of water/humidification during oxygen administration or the need for humidification bottle changes. Observation on 05/07/2024 at 9:07 AM revealed R29 was receiving oxygen via NC at 3L/M. A humidification bottle, which was dated 04/26/2024 and was part of the oxygen therapy setup, was empty. An additional observation of R29 on 05/07/2024 at 11:45 AM revealed R29 was receiving oxygen at 3L via NC. The humidification bottle, dated 04/26/2024, was still empty. Interview with R29 on 05/07/2024 at 09:07 AM revealed the resident was aware the humidification bottle was empty as it dries my nose out. R29 stated that when her nose dried out, she would get some irritation and it made her uncomfortable. Interview with a family member of R29 (FM 29-1), on 05/07/2024 at 09:10 AM, revealed she had found the resident's humidification bottle empty on a couple of occasions in the past and her mother would tell her it irritated her nose. Interview with FM 29-2, on 05/07/2024 at 9:13 AM, revealed that she had noticed some blood on the oxygen tubing in the past, which she contributed to the dryness of her mother's nose from an empty humidification bottle on the oxygen concentrator. During interview with Registered Nurse (RN) 2 on 05/07/2024 at 11:50 AM, she stated the humidification bottles were to be changed out monthly. In addition, RN 2 stated the nursing staff should change the humidification bottles PRN whenever the bottle was empty, or the resident requested the bottle to be changed. RN2 stated all of her residents on continuous oxygen received oxygen with a humidification bottle, whose purpose was to ensure the resident's nares did not dry out, which would cause irritation. RN2 stated all nursing staff should be checking the humidification bottles to ensure they were not empty during their routine rounds. During interview with MDS Nurse 1 on 05/10/2024 at 2:35 PM, she stated physician's orders for each resident should be placed on the CCP during the clinical meeting when the orders were reviewed. Continued interview revealed ancillary oxygen care orders, which included changing of the humidification bottle, should also be on the CCP. Further interview revealed that she was a regional nurse filling in for the facility's regular MDS Nurse and was unaware as to why this information was not on the care plan. During interview with the Director of Nursing (DON) on 05/10/2024 at 3:07 PM, he stated humidification bottles should be changed monthly, as well as PRN whenever needed before the next scheduled change. The DON stated his expectation was the nursing staff would change the humidification bottles whenever the bottles were empty. The DON stated the purpose of the humidification bottles was to keep resident's nasal passages from drying out, which could cause irritation for the residents. During interview with the Administrator on 05/10/2024 at 3:27 PM she stated her clinical team handled all the oxygen concerns and would update her as necessary. The Administrator would not state what her expectations were in this regard and repeated that her clinical team handled all clinical issues in the building.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to maintain an effective infection prevention and control program to provide a safe and sanitary environment to prevent the transmission and development of infection for two (2) of three (3) residents with wounds (Resident #30 and Resident #76). Observation of wound care for Resident #30 and Resident #76 on 04/17/19 revealed the residents were in Contact Isolation due to wound infections. However, the Wound Care Nurse was observed to take containers of wound care supplies into both residents' rooms, and then return the containers to the treatment cart which contained treatment supplies for other residents. Review of the facility policy, Policies and Practices - Infection Control, revised (MONTH) (YEAR), revealed the facility infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Review of the facility policy, Isolation-Categories of Transmission-Based Precautions, revised (MONTH) (YEAR), revealed when transmission-based precautions are in effect, non-critical resident-care equipment items such as a stethoscope, sphygmomanometer, or digital thermometers should be dedicated to a single resident when possible. If re-use of items was necessary, then the items would be cleaned and disinfected according to current guidelines. Review of the Centers for Disease Control and Prevention's (CDC) Management of Multidrug-Resistance Organisms (MDRO) In the Healthcare Setting guidelines revealed facilities should implement patient dedicated or single-use disposable noncritical equipment for patients/residents who have been diagnosed with [REDACTED]. 1. Review of Resident #30's medical record revealed the facility readmitted the resident on 03/29/19, with [DIAGNOSES REDACTED]. Review of Resident #30's annual MDS (Minimum Data Set) assessment dated [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS also revealed the resident had one (1) Stage 3 pressure ulcer and two (2) unstageable pressure ulcers. Further review of Resident #30's Medical Record revealed the resident had a culture obtained on the left lower coccyx wound that showed a heavy growth of Pseudomonas Aeruginosa (a MDRO) on 04/03/19. New orders were obtained to clean the wound with Dakin's Solution, pack with [MEDICATION NAME], and cover with a Foam Dressing twice daily. Observation of the wound care nurse performing wound care for Resident #30 on 04/17/19 at 10:00 AM, revealed the nurse placed a bottle of Dakin's solution, a tape measure, gauze pads, a bottle of [MEDICATION NAME] packing strips, disposable plastic cups, biohazard bags, and other items to perform wound care into a plastic basket. The nurse took the supplies into the resident's room and performed wound care on the resident. During the wound care the nurse was observed to pour Dakin's solution into a disposable cup and put the bottle of Dakin's solution back into the basket. The nurse also opened the bottle of [MEDICATION NAME], removed some of the packing strips, and then placed the bottle of [MEDICATION NAME] back into the basket. After performing wound care the nurse wiped the external portion of the basket with bleach wipes and took the basket and its contents out of the room. The nurse was then observed to wipe the containers of the Dakin's solution and [MEDICATION NAME] with bleach wipes and placed both containers back into the treatment cart among other residents' treatment supplies. 2. Review of Resident #76's medical record revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the medical record revealed the resident's left great toe nail came off on 04/10/19 leaving an open wound. The physician evaluated the wound on 04/10/19 and ordered a culture and x-ray of the left great toe. Results of the x-ray on 4/10/19 revealed [DIAGNOSES REDACTED] of the left great toe and the culture results on 04/13/19 revealed the wound contained [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA). Review of physician orders for Resident #76 dated 04/10/19 revealed an order for [REDACTED]. Observation of wound care for Resident #76 on 04/17/19 at 2:04 PM, revealed the Wound Care Nurse donned personal protective equipment and entered the resident's room with a bottle of wound cleanser, gauze pads, a tube of [MEDICATION NAME] ointment, bleach wipes, a treatment supply tray, and a barrier pad. The Wound Care Nurse was observed to clean the overbed table with bleach wipes, place the barrier pad on the table, and then place the other supplies on top of the barrier pad. The Wound Care Nurse then proceeded to perform the wound care for Resident #76. Further observation revealed after performing the wound care the nurse cleaned the bottle of wound cleanser and tube of [MEDICATION NAME] with bleach wipes, and placed them both in the treatment cart among supplies utilized for other residents. Interview on 04/18/19 at 3:17 PM with the Wound Care Nurse revealed she had been taught to take the wound care supplies into the room and take them back out and place in the cart with other resident supplies as long as the container was wiped off with bleach wipes before return to the cart. Interview on 04/18/19 at 3:32 PM with the Infection Control Nurse revealed the Wound Care Nurse should have placed enough of the Dakin's solution, [MEDICATION NAME] packing strips, wound cleanser, and [MEDICATION NAME] Ointment to complete the wound care for each resident into separate containers while at the treatment cart and taken those containers into the residents' rooms and performed the wound care. The Infection Control Nurse stated that the nurse should not have taken the bottles of the cleansers and medications into the rooms of Resident #30 and Resident #76. Interview on 04/18/19 at 4:08 PM with the DON (Director of Nursing) revealed that she did not see a problem with the technique utilized by the Wound Care Nurse, because the containers had been cleaned with bleach wipes.

Based on observation, interview, record review and review of the facility policy and procedures, the facility failed to implement a comprehensive person-centered care plan for two (2) of twenty-two (22) sampled residents (Residents #10 and #247) related to not following interventions to provide catheter care per facility policy. The findings include: Review of facility policy titled, Care Plans - Comprehensive , dated 06/01/15, revealed each resident's care plan is designed to aid in preventing or reducing declines in the resident's functional status and/or functional levels. It further states, care plan interventions are implemented after consideration of the resident's problem areas and their causes. Review of facility policy titled Catheterization Care, not dated, revealed the guideline steps are as follows: Explain procedure to resident and provide privacy for procedure; Raise bed to appropriate working height and lower side rail if needed; Organize equipment for perineal care; Position males in supine position and expose only genital area and catheter; Wash and dry hands thoroughly and put on gloves; Female: Use non-dominant hand to gently separate labia to fully expose urethral meatus and catheter and maintain position of hand throughout procedure; Male: use non-dominant hand to retract foreskin if not circumcised and hold penis at shaft just below glans and maintain hand position throughout procedure; Grasp catheter with two fingers to stabilize it and assess urethral meatus and surrounding tissue for inflammation, swelling, discharge, or tissue trauma and ask resident if burning or discomfort is present; Provide perineal hygiene using mild soap and warm water; Using a clean washcloth, clean catheter starting close to urinary meatus and clean catheter in circular motion along its length for about four inches moving away from the body; and, Male: reduce or reposition foreskin after care. Record review revealed the facility admitted Resident #247 to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed no Minimum Data Set (MDS) assessment had been completed due to the resident being a new admission. Review of Resident #247's Baseline Admission Care Plan, dated 03/04/18, revealed an intervention that stated staff are to provide catheter care per facility policy. However, observation of catheter care on 03/07/18 at 9:32 AM revealed Certified Nurse Aide (CNA) #1, failed to wash his hands and place clean gloves on prior to starting catheter care per facility policy/care plan. CNA #1 also failed to use non-dominant hand to hold penis at shaft just below glans and to grasp catheter with two (2) fingers to stabilize it. CNA #1 then failed to clean catheter in circular motion along its length for about four inches moving away from the body as he cleaned the head of penis per facility policy/care plan. CNA #1 was observed to hold/anchor the catheter with left hand which was approximately one (1) inch above the urinary meatus/opening and as CNA #1 continued to anchor catheter in same spot, he washed around the anchor point by dabbing wash cloth to clean catheter directly above and below the anchor point and then placed soiled wash rag on resident's bed next to resident's leg. CNA #1 then grabbed a towel from the bedside table, dried the head of penis, dabbing dry the catheter, and then placed the towel on resident's bed. No further care was provided. Interview with CNA #1 on 03/07/18 at 9:54 AM, revealed he knew what he did wrong and stated sometimes when in a hurry things are forgotten. He stated he is expected to follow the facility care plans. 2. Record review revealed the facility readmitted Resident #10 on 10/04/16 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 12/17/17, revealed the facility assessed Resident #10's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fourteen (14), which indicated the resident was interviewable. Review of Resident #10's Comprehensive Care Plan, last revised 03/03/18, revealed an intervention for staff to provide urinary catheter care per facility policy. However, observation of urinary catheter care for Resident #10, on 03/08/18 at 9:40 AM, revealed CNA #4 failed to use her non-dominant hand to gently separate labia fully exposing the meatus to check for inflammation, swelling, discharge, or tissue trauma, ask the resident if burning or discomfort is present, and clean the catheter in circular motion along its length approximately four (4) inches moving away from the body. CNA #4 was observed to pull down the resident's pajama pants with cleansing washcloth in hand, wipe the vaginal area, put the washcloth back in soap and water, cleanse the vaginal area again using the same washcloth; change water, and with same gloves on, rinse soap off vaginal area, and cleanse catheter tubing. Interview with CNA #4, on 03/08/18 at 10:03 AM, revealed CNA #4 stated, I should not have put the washcloth back in water and should have changed my gloves when I changed water to rinse soap. CNA #4 stated she failed to follow Resident #4's Comprehensive Care Plan related to urinary catheter care. Interviews on 03/08/18 with Licensed Practical Nurse (LPN) #1 at at 8:40 AM, CNA #5 at 8:48 AM, CNA #2 at 8:56 AM, and CNA #6 at 9:11 AM revealed staff are expected to follow the facility care plans. Interview with Assistant Director of Nursing (ADON) on 03/08/18 at 11:17 AM, revealed staff are expected to follow each resident's care plans. Interview with facility Staff Development Coordinator on 03/08/18 at 11:28 AM, revealed she expects staff to follow all the resident care plans. Interview with facility Director of Nursing (DON) on 03/04/18 at 3:15 PM, revealed she expects staff to follow all the resident care plans.

Based on observation, interview, record review and review of the facility policy and procedure, it was determined the facility failed to ensure a resident, who requires a urinary catheter, receives the appropriate treatment and services related to urinary catheter care for two (2) of twenty-two (22) sampled residents (Residents #10 and #247). The findings include: Review of facility policy titled Catheterization Care, not dated, revealed the guideline steps are as follows: 1. Explain procedure to resident and provide privacy for procedure. 2. Raise bed to appropriate working height and lower side rail if needed. 3. Organize equipment for perineal care. 4. Position males in supine position and expose only genital area and catheter. 5. Wash and dry hands thoroughly and put on gloves. 6. Female: Use non-dominant hand to gently separate labia to fully expose urethral meatus and catheter and maintain position of hand throughout procedure. 7. Male: use non-dominant hand to retract foreskin if not circumcised and hold penis at shaft just below glans and maintain hand position throughout procedure, 8. Grasp catheter with two fingers to stabilize it and assess urethral meatus and surrounding tissue for inflammation, swelling, discharge, or tissue trauma and ask resident if burning or discomfort is present. 9. Provide perineal hygiene using mild soap and warm water. 10. Using a clean washcloth, clean catheter starting close to urinary meatus and clean catheter in circular motion along its length for about four inches moving away from the body. 11. Male: reduce or reposition foreskin after care. Record review revealed the facility admitted Resident #247 to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed there was no Minimum Data Set assessment completed thus far due to the resident being newly admitted . Review of Resident #247's Baseline Admission Care Plan, dated 03/04/18, revealed an intervention for staff to provide catheter care per facility policy. Observation of catheter care for Resident #247 on 03/07/18 at 9:32 AM by Certified Nurse Aide (CNA) #1, revealed CNA #1 had gloved hands and gathered a bath basin and removed residents covers. CNA #1 did not wash his hands and place clean gloves on prior to starting catheter care. CNA #1 started catheter care by anchoring Resident #247's indwelling urinary catheter with his left hand approximately one (1) inch above Resident #247's urinary meatus/opening. CNA #1 then cleaned head of penis, continued to hold/anchor catheter with left hand which was approximately one (1) inch above the urinary meatus/opening and as CNA #1 continued to anchor catheter in same spot, he washed around the anchor point by dabbing wash cloth to clean catheter directly above and below the anchor point and then placed soiled wash rag on resident's bed next to resident's leg. CNA #1 then grabbed a towel from the bedside table and dried this resident's head of penis along with dabbing dry the catheter and then placed the towel on resident's bed also. No further care was provided. Interview with CNA #1 on 03/07/18 at 09:54 AM, revealed he knew what he did wrong and stated sometimes when in a hurry, things are forgotten of what to do. He stated he is expected to follow the resident care plans and facility policies. 2. Record review revealed the facility readmitted Resident #10 on 10/04/16 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 12/17/17, revealed the facility assessed Resident #10's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fourteen (14), which indicated the resident was interviewable. Further review of the MDS revealed Resident #10 had an indwelling urinary catheter. Observation of urinary catheter care to Resident #10, on 03/08/18 at 09:40 AM, performed by CNA #4, revealed catheter tubing and drainage bag was positioned above bladder level. Further observation revealed CNA #4 pulled down the resident's pajama pants with washcloth in hand, wiped at vaginal area, put the washcloth back in water, and cleansed resident again, CNA #4 then changed the water, with same gloves on and with same gloves on, rinsed soap off resident, cleansed catheter tubing, put washcloth back in water, and using same washcloth rinsed catheter tubing again. CNA #4 failed to use non-dominant hand to gently separate labia fully exposing the meatus to check for inflammation, swelling, discharge, or tissue trauma, ask the resident if burning or discomfort is present, and to clean the catheter in a circular motion along its length approximately four inches moving away from the body. Review of the Physicians Orders, dated 2/24/18, revealed Resident #10 was treated for [REDACTED]. In addition, further review of the Physician Orders revealed Resident #10 was placed on Contact Precautions on 02/24/18 through 03/06/18 because urine culture was positive for Extended Spectrum Beta-Lactamases (ESBL). Interview with CNA #4, on 03/08/18 at 10:03 AM, revealed the CNA stated, I should not have put the washcloth back in water after touching the resident; also, I should have changed gloves when I changed the water to rinse soap, I increased the chances for the resident to get a UTI. Interviews on 03/08/18 with Licensed Practical Nurse (LPN) #1 at at 8:40 AM, CNA #5 at 8:48 AM, CNA #2 at 8:56 AM, and CNA #6 at 9:11 AM revealed staff are expected to follow the resident care plans and facility policies. Interview with Assistant Director of Nursing (ADON) on 03/08/18 at 11:17 AM, Staff Development Coordinator on 03/08/18 at 11:28 AM; and the Director of Nursing (DON) on 03/04/18 at 3:15 PM, revealed staff are expected to follow each resident care plans and facility policies.

Based on observation, interviews, record review and review of the facility policy, it was determined the facility failed to ensure drugs and biologicals were stored properly related a review of one (1) of six (6) medication carts that contained an expired medication and applesauce that should have been discarded. The findings include: Review of the facility policy titled, Medication Storage, dated (MONTH) 2010, revealed outdated, contaminated, discontinued, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal and reordered from the pharmacy if a current order exists. Observation of the Medication Cart for C wing, on 03/06/18 at 3:26 PM, revealed a bottle of [MEDICATION NAME] 6.25 milligrams (mg)/5 milliliters (ml) suspension with an expiration date of (MONTH) (YEAR). Interview with Licensed Practical Nurse (LPN) #2 on 03/06/18 at 3:28 PM, revealed she did not know the syrup was expired. She stated the medication should have been removed by the night shift staff on Wednesdays. She further stated each nurse is responsible for removing outdated medications on carts daily. Observation of the Medication Cart for rooms 9-16, on 03/06/18 at 4:07 PM, revealed an opened 3.9-ounce plastic container of applesauce dated 03/05/18 at 1:00 PM with a black marker. Interview with Registered Nurse (RN) #1, on 03/06/18 at 4:10 PM, revealed the applesauce should not have been left on the cart and should have been discarded during the 7-3 PM shift the day before. She stated a policy doesn't exist on discarding the applesauce but they were trained to discard it after each shift. Interview with the Director of Nursing (DON), on 03/07/18 at 5:01 PM, revealed night shift nurses were responsible for cleaning and checking the medication carts for expired medications and proper storage of drugs and biologicals every Wednesday. She stated the nurses on every shift were responsible for cleaning and removing expired medications daily. She further revealed the facility policy stated expired medications are removed from the cart and not used.

2. Based on observation, interview, record review and review of the facility policy, it was determined the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for two (2) Residents, (#10, #247), related to improper urinary catheter care, improper hand washing, and glove changing. Review of facility policy titled Catheterization Care, no date, revealed the guideline steps are as follows: Explain procedure to resident and provide privacy for procedure; Raise bed to appropriate working height and lower side rail if needed; Organize equipment for perineal care; Wash and dry hands thoroughly and put on gloves; Female: Use non-dominant hand to gently separate labia to fully expose urethral meatus, catheter, and maintain position of hand throughout procedure, grasp catheter with two fingers to stabilize, assess urethral meatus and surrounding tissue for inflammation, swelling, discharge, or tissue trauma and ask resident if burning or discomfort is present; Provide perineal hygiene using mild soap and warm water; Using a clean washcloth, clean catheter starting close to urinary meatus, clean catheter in circular motion along its length for about four inches moving away from the body. Review of the medical record revealed the facility readmitted Resident #10 on 10/04/16 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set, dated dated [DATE], revealed the facility assessed the Resident #10's cognition as intact with a BIMS score of fourteen (14), which indicates the resident was capable of making his/her own decisions. Observation of urinary catheter care to Resident #10, on 03/08/18 at 09:40 AM, performed by CNA #4, revealed catheter tubing and drainage bag was positioned above bladder level (per resident). Procedure revealed CNA #4 pulled down the resident's pajama pants with washcloth in hand, wiped at vaginal area, put the washcloth back in water, cleansed resident again, Further observation revealed CNA #4 changed water after resident cleansed with soap and water; with same gloves on, CNA #4 rinsed soap off resident, cleansed catheter tubing, put washcloth back in water, and using same washcloth rinsed catheter tubing again. Interview with CNA #4, on 03/08/18 at 10:03 AM, revealed the CNA stated, I should not have put the washcloth back in water after touching the resident; also, I should have changed gloves when I changed the water to rinse soap, I increased the chances for the resident to get a UTI. Interview with the DON, on 03/08/18 at 03:15 PM, revealed her expectation is for staff to follow the facility's policy when providing catheter care related to infection control and maintain the urinary catheter drainage system according to policy to minimize infection control. Interview with the Staff Development Coordinator, on 03/08/18 at 03:30 PM, revealed she expect the staff to follow the facility's policy, competency of the Company's policy used in educating related to catheter care and performing task. Based on observation, interview, record review and review of the facility policy, it was determined the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of twenty-two (22) sampled residents (Resident #247) related to improper handling of soiled linen. The findings include: Review of facility policy titled Linen Handling, not dated, revealed staff are to deposit soiled linen directly into the covered linen receptacle or plastic bag. Record review revealed the facility admitted Resident #247 to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of catheter care completed for Resident #247 on 03/07/18 at 9:32 AM by Certified Nurse Aide (CNA) #1, revealed CNA #1 cleansed the resident's catheter tubing then placed the soiled washcloth on the resident's bed next to the resident's leg. He also grabbed a towel from the bedside table and dried the resident perineal area and catheter tubing then placed the towel on resident's bed. Interview with CNA #1 on 03/07/18 at 9:54 AM, revealed he understand what he did wrong and forgot his bag to put the soiled wash rag and towel in. He stated he was not supposed to place soiled wash rags or towels on a resident's bed. Interviews on 03/08/18 with CNA #5 at 8:48 AM, CNA #2 at 8:56 AM, and CNA #6 at 9:11 AM, revealed staff are supposed to have their supplies ready and in place when they start catheter care. The CNA's stated the dirty rags and towels should be placed in a bag and It was not appropriate to place dirty wash rags and towels on a resident's bed. Interview with Licensed Practical Nurse (LPN) #1 on 03/08/18 at 8:40 AM, revealed It is not acceptable to place dirty linen on resident's bed and it needs to be disposed of properly and placed in a bag. She stated she expects staff to ensure they have their supplies present at the beginning of the procedure. Interview with Assistant Director of Nursing (ADON) on 03/08/18 at 11:17 AM, revealed she expects staff to have the supplies available and present at the beginning of catheter care. She stated soiled wash rags and towels are to be placed in a bag and not on the resident's bed and that would be a infection control issue. Interview with facility Director of Nursing (DON) on 03/04/18 at 3:15 PM, revealed she expected staff to ensure they dispose of soiled linens, wash rags and towels appropriately and per facility policy. She stated staff should have a bag available to put soiled linens in when providing catheter care to residents.

Based on observation, interview, and record review, it was determined the facility failed to post the nurse staffing data daily at the beginning of each shift. Observation on 03/06/18, and review of staffing data that was posted from 09/05/16 through 03/05/18, revealed the facility failed to post the actual hours that licensed and unlicensed nursing staff worked each shift. In addition, the facility failed to maintain seven (7) daily staffing schedules for the previous eighteen (18) months. The findings include: Interview with the Director of Nursing (DON) on 03/06/18 at 12:20 PM revealed the facility did not have a policy that addressed posting of licensed and unlicensed nursing staff at the facility. Observation on 03/06/18 at 12:18 PM revealed the facility posted the number of nursing staff that were present for the day shift from 7 AM to 3 PM on 03/06/18; however, the 3-7 PM shift and 7 PM to 7 AM shift were not posted and the total number of actual hours worked were not completed for each shift. Review of the eighteen (18) months of staffing posted revealed the nurse staffing data that was posted from 09/05/16 through 03/06/18 did not show the actual hours worked for licensed and unlicensed staff. Staffing schedules were missing for seven (7) dates as follows: 10/23/17, 12/08/17, 02/07/18, 02/08/18, 02/11/18, 02/12/18, and 02/26/18. Interview with the Director of Nursing (DON), on 03/06/18 at 12:20 PM revealed it was the 7 AM to 3 PM shift charge nurse's responsibility to post the 24-hour nurse staffing report. The DON stated that it was her responsibility to check the posting of staffing daily for accuracy, but she was not aware that the posting was required to show the actual hours worked. She stated the posting should be accurate and posted daily to show family members, staff and residents the staff that are caring for the residents in the facility. Interview with the Administrator on 03/07/18 at 10:51 AM revealed it was important to post staffing daily to ensure there is enough staff to meet the necessary care of the residents in the facility.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to ensure a resident who received enteral feedings receives the appropriate treatment and services to prevent complications of enteral feeding one (1) of nineteen (19) sampled residents (Resident #7). Observation revealed Resident #7's Enteral feeding was not changed within forty-eight (48) hours per facility policy and manufacturer's recommendations. The findings include: Review of the facility policy titled, Medication Administration-Enteral Tubes, dated December 2012, revealed the manufacturer's written recommendations regarding suggested time period for hanging of the product are considered when determining the schedule for enteral feeding administration. Review of the Manufactures Instructions, not dated, revealed to hang the product up to forty-eight (48) hours after initial connection when clean technique and only one new feeding set are used; otherwise, hang no longer than twenty-four (24) hours. Record review revealed the facility admitted Resident #7 on 01/22/16 with diagnoses, which included Acute [MEDICAL CONDITION], Acute [MEDICAL CONDITION] with [MEDICAL CONDITIONS], Dysphagia, Hypertension, Diabetes Mellitus Type 2, Dementia, [MEDICAL CONDITION], and Heart Failure. Review of the Admission Minimum Data Set (MDS) assessment, dated 11/01/16, revealed the facility assessed Resident #7's cognition to be intact with a Brief Interview for Mental Status (BIM) of twelve (12), which indicated the resident was interviewable. Review of the Physician's Orders, dated 11/22/16, revealed [MEDICATION NAME] 1.5 Cal liquid -hang 8:00 PM through 6:00 AM per gastrostomy tube at 25 cubic centimeters per hour (cc/hr) due to ntritional deficiency. Observations on 12/19/16 at 10:30 AM and 2:30 PM, revealed Resident #7 to have a enteral feeding pump at bedside with a bottle of [MEDICATION NAME] 1.5 Cal formula hanging with instructions to be infused at twenty-five (25) cubic-centimeters per hour (cc/hr). Further observation revealed the bottle of formula was hung on 12/16/16 (over seventy-two (72) hours prior). A new bag was not hung after fourty-eight hours (12/18/16) per facility policy. Interview with the Unit Manager, on 12/21/16 at 1:55 PM, revealed it was the nurses ' responsibility to change the enteral feeding and she expected it to be done every morning. Interview with the Director of Nursing (DON) on 12/21/16 at 2:00 PM revealed she expected the enteral feeding to be changed by the nursing staff every morning at 6:00 AM.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure the medical record for two (2) of nineteen (19) sampled residents was complete related to not documenting the daily assessment of their [MEDICAL TREATMENT] shunt (Resident #12 and Resident #13). The findings include: Review of the facility policy titled, [MEDICAL TREATMENT] Monitoring, not dated, revealed to check the access site and document the findings each day and upon return from their [MEDICAL TREATMENT] center to see if, the access site is functioning. Use your fingers to feel for a buzzing sensation, (this is called a thrill) or if you use your stethoscope you can listen over the access for a bruit. The bruit is the sound of blood rushing through the access. Notify the physician if a thrill or bruit is absent. 1. Record review revealed the facility admitted Resident #12 on 12/05/15 with diagnoses, which included End Stage [MEDICAL CONDITION]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/07/16, revealed the facility assessed Resident #12's cognition as intact with a Brief Interview for Mental Status (BIM's) score of fourteen (14), which indicated the resident was interviewable. Review of the Treatment Administration Record (TAR) for October, November, and December 2016 revealed no documented evidence Resident #12's [MEDICAL TREATMENT] shunt was being assessed. Review of the Nurses Notes for the months of October, November, and December 2016, revealed no documented evidence Resident #12's [MEDICAL TREATMENT] shunt was being assessed. Interview with Resident #12, on 12/21/16 at 9:30 AM, revealed the nurses keep a good check on his/her [MEDICAL TREATMENT] shunt every day, especially when he/she returns back from [MEDICAL TREATMENT]. Interview with Licensed Practical Nurse (LPN) #1, on 12/21/16 at 11:19 AM, revealed when Resident #12 comes back from [MEDICAL TREATMENT] she always assesses the shunt for the thrill and the bruit, and looks for any signs of bleeding at the wound sight; however; she was unable to provide any documented evidence. 2. Record review revealed the facility admitted Resident #13 on 12/06/16 with diagnoses, which included [MEDICAL CONDITION], Diabetics, Pancreatic Necrosis, and [MEDICAL CONDITION]. Review of the Admission MDS assessment, dated 12/13/16, revealed the facility assessed Resident #13's cognition as moderately impaired with a BIMS score of ten (10) which indicated the resident was interviewable. No interview was obtained with the resident because the resident was out to [MEDICAL TREATMENT]. Review of the December 2016 TAR revealed no documented evidence Resident #13's [MEDICAL TREATMENT] Shunt was assessed. Review of the Nursing Progress Notes for December 2016 revealed there was no documented evidence of an assessment of the [MEDICAL TREATMENT] shunt. Interview with the Unit Manger on 12/21/16 at 1:50 PM and 1:55 PM, revealed staff were not following the [MEDICAL TREATMENT] Monitoring policy and documenting the assessment on a daily bases. She stated somehow the order fell off the TAR for the shunt to be assessed. She revealed the nurses generally chart by exception-only if something is wrong but the policy states to chart every shift and that is what should have been done. Interview with the Director of Nursing (DON), on 12/21/16 at 1:56 PM, revealed she felt very confident the nurses were assessing the shunt. She stated the order must have fell off the TAR when the facility went from paper to an electronic system a few months back. She revealed she expected the assessment to be completed and documented every shift, every day. Interview with the facility Administrator, on 12/21/16 at 1:57 PM, revealed she expected the staff to follow the policy/procedure and provide quality of care for the residents.

Based on observation and interview it was determined the facility failed to ensure the resident environment remained as free of accident hazards as possible for fourteen (14) residents who were assessed to wander of ninety-four (94) total residents. Doors to medical supply rooms on the A/B Hallway and the C/D Hall had the door latch taped to prevent the door from locking. In addition, an oxygen supply room door latch had been set to prevent the door from locking. The findings include: Interview with the Facility Administrator on 11/05/15 at 6:10 PM, revealed the facility did not have an accident hazard policy nor a policy regarding the locking of medical supply rooms or the oxygen supply room. According to the Administrator, the corporation that owned the facility may have a policy but the Administrator could not find a policy related to accident hazards of unlocked supply rooms, oxygen storage rooms, or electrical panels. Review of a list of residents who had been assessed by the facility to be at risk for wandering, revealed fourteen (14) residents were on the list. Residents were observed in the hallway throughout the survey wandering near the A/B Hall and the C/D Hall medical supply rooms. Observation of the A/B Hall medical supply room on 11/05/15 at 3:05 PM revealed tape had been placed on the door latch to prevent locking. Observations of shelves and cabinets in the room revealed one (1) bottle of lice shampoo, thirty-six (36) bottles of shampoo/body wash, and eight (8) safety razors. Observation of a medical supply room on the C/D Hall on 11/05/15 at 3:15 PM revealed the door latch had been covered with tape and cardboard to prevent locking. Observation of the medical supply room revealed two (2) high-voltage electrical panels that controlled the facility alarm system were open with exposed electrical connections. Further observations revealed shelves, cabinets, and lockers that contained employee personal items and thirty-nine (39) bottles of enteral feeding for use with feeding tubes. Observation of an oxygen storage room on the C/D Hall revealed the door latch had been set to prevent the door from locking when closed. Observation of the room revealed twenty-three (23) oxygen tanks stored in racks in the room. An interview conducted with Licensed Practical Nurse (LPN) #1 on 11/05/15 at 3:07 PM, revealed the LPN had placed tape on the A/B medical supply room door because the lock would malfunction and was difficult to open. An interview conducted with LPN #2 on 11/05/15 at 3:08 PM, revealed she was aware the door was taped and that tape was placed on the door by the nurses because the door lock malfunctioned. An interview conducted with LPN #3 on 11/05/15 at 3:15 PM, revealed the LPN was aware of the tape and cardboard on the C/D Hall supply room and thought that maintenance had placed the tape on the door because the lock was not working. An interview conducted with the Maintenance Director on 11/05/15 at 5:00 PM revealed the medical supply room door on the A/B Hall had been replaced in May 2015 and no one had notified Maintenance of any concerns related to the doors not opening. Further interview revealed a contract company had worked on the facility alarm system in October 2015 and may have left the electrical panel open. According to the Maintenance Director, he checked the other facility electrical panels weekly for temperature concerns but did not check the alarm system panels and was not aware the panels were not locked. An interview with the Director of Nursing (DON) on 11/05/15 at 4:25 PM revealed she was not aware the nurses were taping the medical supply room doors to prevent locking and according to the DON, the doors should have been locked. Further interview with the DON revealed she checked the doors at random when she goes in and checks the room but did not have a formal system for checking the rooms or the doors.

Based on observation, interviews, review of facility policies, and review of manufacturer's guidelines it was determined the facility failed to store, prepare, distribute, and serve food under sanitary conditions. Observations on 11/03/15, 11/04/15, and 11/05/15 revealed the following: facility Kitchen staff failed to follow the manufacturer's guidelines for testing the three-compartment sink to ensure proper sanitation of dishes, staff allowed cross-contamination of raw meat with a raw vegetable, the utensil drawers had dried food and grease buildup on the trays and utensils, utensils had cracked handles, the dishwashing machine did not reach appropriate temperatures to assure sanitation of dishes, and there was excessive grease buildup on and behind the gas grill. The findings include: 1. Review of the facility's policy, Environmental Sanitation/Infection Control Policy 9.53 Manual Washing in a Three Compartment Sink, dated August 2004, revealed a stainless steel three-compartment sink with two drain boards was used to manually wash pots, pans, and other production utensils. Production equipment and utensils were cleaned as needed during meal preparation and remaining items were cleaned at the completion of meal service. The policy stated the washing procedure was to wash items in a hot clean detergent solution at a temperature of at least 110 degrees Fahrenheit (F) in one sink, rinse items in clean hot water in a second sink, and sanitize items in an appropriate amount of sanitizing solution as specified by the manufacturer at 75 degrees F for at least one minute in a third sink. Review of the directions for use of the sanitizer revealed that the required water temperature should be from 65 degrees to 75 degrees (room temperature) and there should be from 150 parts per million (ppm) to 400 ppm of sanitizer present in the water to ensure sanitation. Observation on 11/04/15 at 11:20 AM revealed Dietary Aide #2 set up the three-compartment sink. Dietary Aide #2 ran hot water, added sanitizer, and filled the sink. Dietary Aide #2 then took a sanitizer reading that indicated the sanitizer level was above 400 ppm. Interview with Dietary Aide #2 on 11/04/15 at 11:23 AM revealed in order to sanitize pots in the three-compartment sink, the pots were to be left in the sanitizer for 30 seconds, and the water temperature must be at least 100 degrees F with a sanitizer level of more than 400 ppm. On 11/04/15 at 11:25 AM an interview with Cook #1, who had worked at the facility for approximately [AGE] years, revealed she thought the procedure for sanitation was to get the sanitizer water really really hot and just stick the pots in and out of the sanitizer water. Interview with the Assistant Dietary Manager (ADM) on 11/05/15 at 1:49 PM revealed that she had worked at the facility for [AGE] years and was unaware that the sanitizer should not be above 400 ppm and that hot water should not be used with the sanitizer. 2. Review of the facility's policy, Environmental Sanitation/Infection Control Policy 9.54, revealed a commercial dish machine certified by the National Sanitation Foundation was used following manufacturer's guidelines for proper washing and sanitizing of dishes and utensils. The policy stated that the dish machine should be operated following standards for temperatures and sanitizing agents and the rinse cycle should reach 180 degrees F. However, a review of the Dish Machine Temperature Chart for November 2015 revealed rinse temperatures that were below the required 180 degrees F. On 11/01/15, the rinse temperatures were 137 degrees F in the morning, 167 degrees F at noon, and 132 degrees F in the evening. The rinse temperatures on 11/02/15 were 152 degrees F in the morning, 124 degrees F at noon, and 181 degrees F in the evening. The rinse temperatures on 11/03/15 were 172 degrees F in the morning, 171 degrees F at noon and 181 degrees F in the evening. Observation on 11/04/15 at 11:10 AM revealed two dietary staff members in the dish room running dishes through the dish machine and observing the rinse temperature on the dish machine. Observations during five rinse cycles revealed that the rinse temperature did not reach the required 180 degrees F. The temperatures were 153 degrees F, 164 degrees F, 170 degrees F, 179 degrees F, and 164 degrees F. Interview with Dietary Aide # 1 on 11/04/15 at 11:14 AM revealed the highest temperature she had seen that morning was 178 degrees F. Dietary Aide #1 further stated they had been washing dishes without a chemical sanitizing agent or utilizing the three-compartment sink. Interview with the Plant Operations Manager on 11/05/15 at 4:45 PM revealed that the dish washing machine booster heater had a heating element that went out and had been replaced several times in the past; however, he had not received a work order recently. Interview with the Assistant Dietary Manager (ADM) on 11/05/15 at 1:49 PM revealed she was unaware that the dish machine was not reaching 180 degrees as necessary, and that staff should have let her know and notified Maintenance immediately. 3. Review of the facility's policy, Environmental Sanitation/Infection Control Policy 9.14, revealed kitchen area employees follow routine cleaning schedules that indicate frequency for cleaning equipment and kitchen areas. Surfaces of grills, griddles, and similar cooking equipment were cleaned at least daily or at intervals throughout the day. The cleaning schedule was based on the amount of soil accumulation and interruptions in production. The policy further stated work surfaces were cleaned and sanitized at the start of each day, after each production period, and after using potentially hazardous products such as raw meats. Observation on 11/03/15 at 5:53 PM revealed a utensil drawer that had food particles and a grease-like substance built up on the drawer trays and a serving ladle that was cracked with a grease-like substance built up in the cracked areas. Further observation in the kitchen revealed a heavy grease-like substance built up on the back, bottom, and behind the grill, and behind the stove on the gas lines and floor. Interview with the Assistant Dietary Manager (ADM) on 11/05/15 at 1:49 PM revealed the grease buildup on the grill and the pipes, and the food particles and grease buildup in the utensil drawers and on the utensils should not have been there. She stated staff had been signing off that they were cleaning the items, but stated it appeared it was not being done. 4. Interview with the Registered Dietitian on 11/05/15 at 10:49 AM revealed the facility did not have a policy regarding transporting foods. Observation on 11/03/15 at 6:10 PM revealed Dietary Aide #3 placed raw bacon on a countertop, fried the bacon, and placed the bacon on a paper plate. Dietary Aide #3 then placed a tomato on the same area of the countertop where the raw bacon was placed before preparation. The aide sliced the tomato and placed it on the bacon to be served. The aide did not sanitize or clean the countertop after laying raw meat on the area. Interview with Dietary Aide #3 on 11/03/15 at 6:10 PM revealed Dietary Aide #3 was a new employee, but she should have wiped the counter after placing raw meat on the countertop.

Based on observation, interview, record review, and review of equipment manuals, it was determined the facility failed to assure that a Vulcan Gas Range and a Hobart Dish Machine were in safe operating condition. The findings include: 1. Review of the facility's policy, 9.56 Meal Service Repair of Dish machine, revised August 2014, revealed in the event the dish machine was scheduled for repairs or was not operating properly, meals were served using disposable dishes and flatware. Interview with the Plant Operations Manager on 11/05/15 at 4:45 PM revealed the facility did not have other policies for the repair or replacement of kitchen equipment. Review of the facility's policy, Environmental Sanitation/Infection Control Policy 9.54, revealed the facility's dish machine rinse cycle should reach 180 degrees Fahrenheit (F) to ensure proper washing and sanitizing of dishes and utensils. Review of the Installation and Operation Manual for the facility's dishwasher revealed the booster water heater was designed to maintain a minimum final rinse temperature of 180 degrees F. Review of the Dish Machine Temperature Chart for November 2015 revealed the rinse temperatures did not reach 180 degrees on 11/01/15 or on 11/02/15 and 11/03/15 after breakfast and noon meals. Observation on 11/04/15 at 11:10 AM revealed two (2) dietary staff members were running dishes through the dish machine and observing the rinse temperature on the dish machine. Observations during five (5) rinse cycles revealed that the rinse temperature did not reach 180 degrees F. Interview with Dietary Aide # 1 on 11/04/15 at 11:14 AM revealed the highest temperature she had seen that morning was 178 degrees F. Dietary Aide #1 further stated they had been washing dishes without a chemical sanitizing agent or utilizing the three-compartment sink. Interview with the Plant Operations Manager on 11/05/15 at 4:45 PM revealed the dishwashing machine booster heater had a heating element that went out and had been replaced in the past, but he had not received a work order recently. Interview with the Assistant Dietary Manager (ADM) on 11/05/15 at 1:49 PM revealed she was not aware that the dish machine was not reaching 180 degrees as necessary. She stated staff should have notified her and Maintenance immediately. 2. Review of the Installation & Operation Manual Vulcan Endurance Gas Restaurant Range, revised July 2008, revealed in the event a gas odor was detected, staff was required to shut down the units at the main shutoff valve and contact the local gas supplier for service. The manual stated that if the range had a pilot outage, staff should call for service. Observation on 11/03/15 at 4:47 PM and at 6:05 PM revealed a strong odor of what appeared to be natural gas in the kitchen area; however, staff said they did not smell anything. Observation on 11/04/15 at 11:21 AM revealed a strong natural gas odor in the kitchen. Observation on 11/04/15 at 11:34 AM revealed there were four pilot lights out on the facility's Vulcan brand six-burner range, and a strong odor of natural gas near the gas range. Interview with Dietary Aide #2 on 11/04/15 at 11:40 AM revealed she could not smell gas, but stated that the pilot light on the range went out all the time. Interview with the Plant Operations Manager on 11/05/15 at 4:45 PM revealed the gas range pilot lights kept going out. He stated he believed an air vent was blowing them out. The Plant Operations Manager further stated he believed staff turned on the gas burner and when the pilot light did not light the burner, staff left the gas burner running, causing the gas smell. Interview with the Assistant Dietary Manager (ADM) on 11/05/15 at 1:49 PM revealed she was aware that the gas range had four pilot lights that kept going out. She stated she thought an air vent was blowing them out. She further stated she did not know if a work order to check/repair the range had been completed.

Based on observation, interview, and record review it was determined the facility failed to develop a comprehensive care plan for one (1) of nineteen (19) sampled residents (Resident #8) related to the use of an indwelling urinary catheter. Resident #8 was observed to have an indwelling urinary catheter. However, review of Resident #8's comprehensive care plan revealed the facility failed to develop a comprehensive care plan to address the resident's needs and the risks related to the indwelling urinary catheter. The findings include: Review of the facility's policy titled Assessment/Care Planning Policy and Procedure, with a revision date of 06/06/11, revealed a care plan would be developed to promote a more independent state or maintain the resident at his/her current level of functioning. A review of the medical record revealed the facility admitted Resident #8 on 04/17/13, with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was assessed by the facility to have moderately impaired cognition. The MDS also revealed the resident was always incontinent of bowel and bladder and required the extensive assistance of staff for toileting. Review of the physician's orders [REDACTED]. Review of Resident #8's care plan dated 08/18/15, revealed Resident #8's care plan did not address the use of an indwelling catheter or provide interventions to address the risks related the use of an indwelling catheter. Interview with the Rehabilitation Nurse on 11/05/15 at 4:00 PM, revealed she was responsible for developing the care plan for Resident #8 to address his/her indwelling urinary catheter. The Rehabilitation Nurse stated she should have developed interventions related to Resident #8's indwelling urinary catheter and had just missed it. Interview with the Director of Nursing (DON) on 011/05/15 at 4:25 PM revealed a care plan should have been developed to address Resident #8's indwelling urinary catheter. The DON stated she reviewed care plan meeting minutes and reviewed care plans at that time. The DON stated the Rehabilitation Nurse was responsible for developing the care plans related to all residents' bladder and bowel requirements. The DON stated she had not identified any concerns with care plans for indwelling urinary catheters not being developed.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of nineteen (19) sampled residents (Resident #8) received appropriate treatment and services for an indwelling urinary catheter to prevent trauma. Observation of a skin assessment and catheter care for Resident #8 on 11/04/15, revealed Resident #8's indwelling urinary catheter was observed to be draped over the resident's left leg and not secured to the resident (to prevent trauma). The findings include: Interview conducted with the Director of Nursing (DON) on 11/05/15 at 4:25 PM revealed the facility did not have a policy related to indwelling urinary catheter care, but referred to Mosby's Textbook for Long Term Care Nursing Assistants, Seventh Edition as the reference utilized by the facility. A review of the reference revealed when performing indwelling urinary catheter care, staff was required to secure the catheter to the resident's thigh (to prevent trauma). Review of the medical record revealed the facility admitted Resident #8 on 04/17/13, with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 was assessed by the facility to have moderately impaired cognition. The MDS also revealed the resident required the extensive assistance of staff for toileting and was always incontinent of bowel and bladder. Review of Resident #8's care plan dated 08/18/15, revealed Resident #8's care plan did not address the use of an indwelling catheter or provide interventions to address the risks related the use of an indwelling catheter. Review of the physician's orders [REDACTED]. Observation of catheter care for Resident #8 by State Registered Nurse Aide (SRNA) #4 and Licensed Practical Nurse (LPN) #3 on 11/04/15 at 3:30 PM revealed SRNA #4 draped the catheter over Resident #8's left leg. The SRNA and the LPN left the room and failed to secure the urinary catheter to the resident's thigh. Interview conducted with SRNA #4 on 11/05/15 at 3:15 PM revealed he had not been trained to secure an indwelling urinary catheter to the resident's body. The SRNA stated he secured the catheter by coiling the catheter. Interview conducted with LPN #3 on 11/05/15 at 3:20 PM revealed the catheter should have been attached to the resident's thigh with a Velcro strap. The LPN stated she had just been nervous and had not identified the SRNA had not secured the resident's catheter. Interview conducted with the DON on 11/05/15 at 4:25 PM revealed she made rounds throughout the facility several times a day to ensure residents were being provided the care and treatment they required. The DON stated all indwelling urinary catheters were required to be secured to the resident with a Velcro strap. The DON stated she monitored to ensure indwelling urinary catheters were being secured and had not identified any concerns.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to serve food at a palatable temperature and of palatable flavor. Observation of the noon meal on 10/07/14 revealed a meal cart was observed to sit on the "C" and "D" units for 37 minutes before the last tray was removed to be served. In addition, a test tray on 10/08/14 (noon meal) revealed the broccoli did not contain enough seasoning. The broccoli tasted bland and needed salt. The findings include: 1. A review of the "Meal Delivery" policy (dated 08/2014) revealed meals are delivered promptly to ensure Maximum temperature retention and to preserve quality of food. Observation of the noon meal on 10/07/14 at 12:15 PM revealed a food cart with resident meal trays was sitting on the "C" unit. Staff moved the food cart to the "D" unit at 12:20 PM on 10/07/14 and five resident meal trays remained on the food cart. Further observation revealed staff removed the last resident tray from the food cart at 12:52 PM on 10/07/14. Temperatures were obtained of the last tray removed from the cart and the temperatures were as follows: meatloaf - 107.9 degrees Fahrenheit, mashed potatoes - 112.6 degrees Fahrenheit, and mixed vegetables - 107.2 degrees Fahrenheit. A palatability test was conducted by the surveyor and the Dietary Manager. The meat loaf, mashed potatoes, and the mixed vegetables did not taste warm, and the food was not palatable due to the temperature and lack of salt. The Dietary Manager agreed the food temperature was not warm. Interview with the Dietary Manager at 12:55 PM on 10/07/14 revealed the food was not warm enough, and the food did not taste palatable. The Dietary Manager stated the trays had sat on the unit too long before being served. A review of the "Resident Council Meeting" minutes dated 10/01/14 revealed the Council voiced a complaint regarding cold food. Six residents in the group interview stated the food was served cold at times. 2. A review of the "Food Preparation and Tasks" policy (dated 08/2014) revealed food would be prepared using proper methods to enhance flavor and increase digestibility. The resident group interview was conducted at 9:45 AM on 10/08/14 with six alert residents. The residents stated that the food was not seasoned with enough salt. Therefore, a test tray was requested for the noon meal on 10/08/14. Observation revealed the last food cart arrived on the "A" unit at 12:57 PM on 10/08/14 containing ten resident trays, and two test trays. The last resident tray and test tray were removed from the food cart at 1:15 PM on 10/08/14. A palatability test revealed the broccoli tasted bland and did not have enough seasoning, especially salt. The Director of Nursing was present during the palatability test. The Director of Nursing stated if the broccoli did not have enough salt, there was a salt packet on the tray. A review of the broccoli recipe revealed 1 tablespoon, and 1 3/4 teaspoon of salt was specified to be cooked in the broccoli. The Dietary Manager stated, "That's not much salt for 20 pounds of broccoli." Interview with the Dietary Manager at 1:25 PM on 10/08/14 revealed salt was supposed to be added during the cooking process. The Dietary Manager further stated the lunch cook was already gone for the day, and the cook would not be back for the week. Therefore, an interview with the cook was not possible.

Based on interview, personnel record review, and review of facility policy, it was determined the facility failed to ensure the Nurse Aide Abuse Registry and Criminal Background checks were requested/obtained upon hire for one (1) of five (5) employees (Employee #4). Record review and interview revealed no evidence a Criminal Background Check or a status check of the Nurse Aide Abuse Registry was obtained for Employee #4. The findings include: Review of the facility's policy, "Abuse Prohibition," dated 02/12/13 with a revision date of 09/08/14, revealed all potential employees would be screened as part of the application process to determine the individual's status on the Kentucky Abuse Registry. The policy also stated a Criminal Background Check will be performed on all new hires. Review of the personnel record on 10/09/14 at 1:15 PM for Employee #4 revealed the employee's hire date was 08/01/14; however, no documentation of a Criminal Background Check or status check of the Nurse Aide Abuse Registry was found. Interview with the Human Resources Manager on 10/09/14 at 1:55 PM revealed she was responsible for checking the Nurse Aide Abuse Registry and performing Criminal Background Checks on all potential new hires. Further interview revealed she had no documentation that a Nurse Aide Abuse Registry and Criminal Background Check had been completed for Employee #4.

Based on observation, interview, record review, and review of the facility policies, it was determined the facility failed to implement care plan interventions for two (2) of twenty-one (21) sampled residents (Residents #4 and #15). Facility staff failed to provide care plan interventions for oral care for Resident #4 and Foley catheter care for Resident #15. The findings include: Review of the facility policy, "Assessment/Care Planning," with a revision date of 06/06/11, revealed a care plan will be developed (by each discipline) to guide staff to provide optimal/individualized care for each resident. 1. Review of the medical record revealed the facility admitted Resident #4 on 10/28/11 with [DIAGNOSES REDACTED]. Review of the annual Comprehensive assessment dated [DATE] revealed the facility assessed Resident #4 to not be interviewable. The resident was also assessed to require total staff assistance with personal hygiene and bathing. Review of the comprehensive care plan with a revision date of 08/13/14, revealed the facility addressed a self-care deficit problem for Resident #4. The interventions revealed Resident #4 to be in the Restorative Nursing Program for grooming. Review of the Certified Nurse Aide (CNA) care plan revealed grooming and oral care would be provided daily by facility staff. Resident #4 was observed on 10/08/14, at 9:30 AM with dry crusty lips and a dark brown substance on the lower teeth. On 10/08/14 at 10:55 AM, during a skin assessment with Licensed Practical Nurse (LPN) #1, the resident was again observed with a dark brown substance on the lower teeth and a buildup of a dark brown substance between the resident's toes. A phone interview with CNA #3 on 10/08/14 at 1:25 PM revealed she gave Resident #4 a bed bath the day before, on 10/07/14, and provided oral care. She stated she washed between the resident's toes and used a toothette to swab Resident #4's mouth because the resident refused to allow her to use a toothbrush. Interview with LPN #2 on 10/08/14 at 11:35 PM revealed the CNAs were scheduled to give the residents a shower two times a week and a bed bath on the other days. She further stated that the interventions were on the CNA care plans for each resident. Interview with the Director of Nursing (DON) on 10/08/14 at 1:40 PM revealed the nurses were responsible to ensure residents were clean and that care plan interventions were being followed. The DON said she had not identified a problem with Resident #4. The DON stated LPN #1 came to her after the skin assessment on 10/08/14 and told her that Resident #4 had a problem with dirt between her toes and dirty teeth. 2. Review of the medical record revealed the facility admitted Resident #15 on 02/28/14 with [DIAGNOSES REDACTED]. Review of the quarterly comprehensive assessment dated [DATE] revealed the facility assessed Resident #15 to require the use of an indwelling catheter and to require extensive assistance with toileting needs. Review of the comprehensive care plan for Resident #15 revealed the facility identified the use of the indwelling catheter for elimination. Interventions included providing care to reduce signs/symptoms of urinary tract infection. However, observation conducted of catheter care on 10/09/14, at 11:35 AM, revealed facility staff cleaned the catheter tubing and the groin area, but failed to retract the foreskin and clean the area with soap and water. Interview conducted with CNA #2 on 10/09/14, at 2:35 PM, revealed she had been trained to retract the foreskin and clean around the area thoroughly when performing catheter care. The CNA stated she did not clean the resident's foreskin because she was afraid of pulling too much on the catheter tubing. Interview with the DON on 10/09/14, at 2:50 PM, revealed different nursing staff members were assigned to monitor specific care areas of the residents' care plans to make sure the care plan interventions were followed. The DON stated this was done randomly and no problems related to catheter care had been identified.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide the necessary services to maintain grooming and personal hygiene for one (1) of twenty-one (21) residents (Resident #4). Resident #4 was observed to have a buildup of a dark brown substance between the resident's toes and a dark brown substance on the resident's teeth. The findings include: Review of the facility policies, "Providing Nail and Foot Care," (not dated) and "Oral Hygiene for the Unconscious or Dependent Resident," (not dated) revealed residents' feet would be washed with soap and water, including washing between their toes. Oral care would be provided by using a toothbrush and toothpaste. Review of the medical record revealed the facility admitted Resident #4 on 10/28/11 with [DIAGNOSES REDACTED]. Review of the annual Comprehensive assessment dated [DATE] revealed the facility assessed Resident #4 to not be interviewable. The resident was also assessed to require total staff assistance with personal hygiene and bathing. Review of the Comprehensive Care Plan with a revision date of 08/13/14, revealed the facility addressed a self-care deficit problem for Resident #4. Review of the Certified Nurse Aide (CNA) care plan revealed the CNA was responsible to provide grooming and oral care for Resident #4 daily. Resident #4 was observed on 10/08/14, at 9:30 AM with dry crusty lips and a dark brown substance on the lower teeth. On 10/08/14 at 10:55 AM, during a skin assessment with Licensed Practical Nurse (LPN) #1, the resident was observed with a dark brown substance on the lower teeth and a buildup of a dark brown substance was observed between the resident's toes. A telephone interview with CNA #3 on 10/08/14 at 1:25 PM revealed she gave Resident #4 a bed bath the day before, on 10/07/14, and provided oral care. She revealed she washed between the resident's toes and used a toothette to swab the mouth because the resident refused to allow her to use a toothbrush. Interview with LPN #3 on 10/08/14 at 11:55 AM revealed Resident #4's toothbrush was kept in the resident's room. LPN #3 was observed to search Resident #4's room but was unable to locate the resident's toothbrush. Interview with the Director of Nursing (DON) on 10/08/14 at 1:40 PM revealed the nurses were responsible to ensure residents were clean. The DON said she had not identified a problem with Resident #4. The DON stated LPN #1 came to her after the skin assessment on 10/08/14 and told her that Resident #4 had a problem with dirt between her toes and dirty teeth.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure appropriate treatment and services were provided to prevent urinary tract infections for one (1) of twenty-one (21) sampled residents (Resident #15). Observations revealed catheter care was not provided in a manner to prevent urinary tract infection for Resident #15. The findings include: Review of the Catheter Care policy (no date) revealed the foreskin would be retracted when perineal care was provided to male residents. The policy noted the perineal area should be cleaned with a clean washcloth, soap, and water. In addition, the policy further noted while holding the catheter near the meatus, the tubing should be cleaned downward about four inches. The policy further noted after rinsing and drying the catheter tubing and perineal area, the foreskin should be returned to a natural position. Review of the medical record revealed the facility admitted Resident #15 on 02/28/14 with [DIAGNOSES REDACTED]. Review of the quarterly Comprehensive assessment dated [DATE] revealed Resident #15 was assessed to require the use of an indwelling catheter. Review of the Comprehensive Care Plan for Resident #15 revealed the facility identified the use of the indwelling catheter for elimination. Interventions included providing care to reduce signs/symptoms of urinary tract infection. Observation conducted of catheter care on 10/09/14, at 11:35 AM, revealed facility staff cleaned the catheter tubing and the groin area, but failed to retract the foreskin and clean the area with soap and water. Interview conducted with CNA #2 on 10/09/14, at 2:35 PM, revealed she had been trained to retract the foreskin and clean around the area thoroughly when performing catheter care. The CNA stated she did not clean the resident's foreskin because she was afraid of pulling too much on the catheter tubing. Interview with the DON on 10/09/14, at 2:50 PM, revealed a skills competency evaluation is completed for the CNAs within 60 days of employment and annually to review the various skills/tasks required for the CNAs. The DON stated the CNAs should be retracting and cleaning the foreskin area as part of catheter care for the male residents.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure the medication error rate was less than five (5) percent. During medication observation pass conducted on 10/07/14 and 10/08/14, twenty-nine (29) medication opportunities were observed and two (2) errors were observed, resulting in a six (6) percent medication error rate. The findings include: Review of the facility's policy titled "Medication Administration-General Guidelines," with a revision date of 12/18/12, revealed medications would be administered in accordance with written orders of the attending physician. A medication observation conducted for Resident A on 10/08/14, at 9:15 AM, revealed Registered Nurse (RN) #2 prepared 11 different medications to be administered per gastrostomy tube ([DEVICE]) to Resident A. Two of the medications included [MEDICATION NAME] 17 grams (medication used to treat constipation) and [MEDICATION NAME] (iron supplement) 325 milligrams. RN #2 was observed to pour each medication separately into a plastic medication cup for administration. After verifying placement of the gastrostomy tube, RN #2 administered each of the 11 medications, including the [MEDICATION NAME] and [MEDICATION NAME], and then gave at least 30 cc of water after each medication. Review of the current physician's orders [REDACTED]. In addition, the physician ordered the [MEDICATION NAME] to be administered twice a day at 1:00 PM and at 9:00 PM. Interview with RN #2 on 10/08/14, at 10:10 AM, revealed she had been trained to read and follow the directions on the Medication Administration Record [REDACTED]. RN #2 stated she had not given enough fluids with the [MEDICATION NAME] and had given the [MEDICATION NAME] at the wrong time because she read the MAR indicated [REDACTED] Interview conducted with the Director of Nursing (DON) on 10/09/14, at 2:50 PM, revealed the pharmacist conducted monthly random medication pass audits with the nurses responsible for administering medications to the residents. The DON stated annual in-services were also conducted to review medication administration guidelines for the nurses.

Based on observation, interview, and record review it was determined the facility failed to provide five (5) of twenty (20) sampled residents (Residents #7, #9, #10, #11, and #12) with services in accordance with each resident's written plan of care. The facility assessed Residents #7, #9, #10, #11, and #12 to require specialized swallowing/feeding precautions during meals and indicated this intervention on the residents' plan of care. However, observations on 09/14/11, during the evening meal and on 09/15/11, during the noon meal revealed the facility failed to ensure the swallowing precautions were implemented for each resident in accordance with the resident's written plan of care. The facility's failure to ensure each resident was provided with swallowing precautions as directed by their written plan of care caused, or is likely to cause serious injury, harm, impairment, or death to Residents #7, #9, #10, #11, and #12, and other residents in the facility assessed to have feeding precautions. Immediate Jeopardy and Substandard Quality of Care (SQC) were determined to exist on 09/14/11. An acceptable Allegation of Compliance (AOC) was received from the facility on 09/21/11, and alleged removal of Immediate Jeopardy on 09/21/11. The State Agency determined the Immediate Jeopardy was removed on 09/21/11, prior to exit, which lowered the scope and severity to "E" while the facility monitors the effectiveness of the systemic changes and quality assurance activities. The findings include: 1. Review of Resident #7's medical record revealed the facility admitted the resident on 11/17/09. Resident #7 had [DIAGNOSES REDACTED]. A review of a Speech Therapy Dysphagia Medical Work Up, dated 02/07/11, for Resident #7 revealed the resident experienced oral motor retention, had difficulty in biting, chewing, sucking, or shaping food into a [MEDICATION NAME], and had a negative reaction to food texture/consistency. A review of the swallowing Strategies for Resident #7, dated 02/11/11, revealed staff was to ensure the resident alternated bites of solids/sips of liquids at a one to one (1:1) ratio, be checked for "pocketing" of food during/after meals, and be provided decreased distractions with increased time allotted for meals. Review of Resident #7's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident's cognition to be severely impaired and to require extensive assistance for eating. A review of Resident #7's comprehensive plan of care, dated 07/30/11, and the resident's Nurse Aide Care Plan, dated 08/21/11, revealed staff was to "see swallowing strategies" related to the provision of assistance to the resident with each meal. An observation on 09/14/11, at 6:35 PM, of the evening meal service in the dining room revealed Resident #7 feeding himself/herself without staff cueing or interaction, the resident was observed taking large bites in repeated succession, without fluid intake, and coughed throughout the meal. A review of Resident #7's tray card revealed staff was to "check for pocketing, down distraction" during the meal. Paid feeding assistant #2 was observed on 09/14/11, at 6:35 PM, to assist residents at the same table that Resident #7 had been seated during the meal. An interview conducted on 09/15/11, at 5:30 PM, with paid feeding assistant #2 revealed if a resident required anything such as "a special spoon or cup" it would be on the tray card that comes out of the kitchen on each resident tray. Paid feeding assistant #2 stated Resident #7 "most times feeds (himself/herself) and don't get anything special because if (he/she) did it would be on the tray card." Paid feeding assistant #2 was unable to explain what the "check for pocketing, down distraction" referenced on Resident #7's tray card meant and stated, "I don't know." 2. Review of Resident #11's medical record revealed the facility admitted the resident on 09/11/09. Resident #11 had [DIAGNOSES REDACTED]. A review of the Swallowing Precautions dated 09/30/10, revealed staff was to ensure the resident took small bites/sips, to alternate bites of solids to sips of liquid at a two to one (2:1) ratio, to allow two swallows per bite of food/sip of liquid, and to ensure straws were not utilized. According to Resident #11's Quarterly Minimum Data Set (MDS) assessment dated [DATE], the facility assessed the resident's cognition as severely impaired and the resident as totally dependent on staff for eating. A review of Resident #11's comprehensive care plan dated 08/30/11, revealed the resident was to be fed per staff and straws were not to be utilized. A review of the resident's Nurse Aide Care plan dated 08/31/11, revealed an entry under dietary listing "see swallow precaution" and "no straws." An observation of Resident #11 on 09/14/11, at 6:36 PM, during the evening meal service revealed paid feeding assistant #1 provided Resident #11 with large bites in rapid succession of each other without offering the resident fluids. During approximately 14 minutes of observation of the meal on 09/14/11, paid feeding assistant #1 provided no verbal communication or cueing to Resident #11. A review of Resident #11's tray card revealed feeding instructions that included "at least two swallows per bite of food and sip of liquid." 3. Review of Resident #12's medical record revealed the facility admitted the resident on 02/27/03. Resident #12 had [DIAGNOSES REDACTED]. According to the Quarterly Minimum Data Set (MDS) assessment dated [DATE], for Resident #12 the facility assessed the resident's cognition as severely impaired and the resident required supervision for eating. A review of Resident #12's swallowing strategies dated 08/18/11, revealed staff was to ensure the resident maintained a slow intake, took small bites, alternated solids and liquids at a two to one (2:1) ratio, cue the resident to chew food before swallowing, and assess the resident for "pocketing" of food. A review of Resident #12's Comprehensive Care Plan and Nurse Aide Care Plan dated 08/31/11, revealed staff was to "see swallowing strategies" when assisting the resident with a meal. An observation of Resident #12 on 09/15/11, at 6:30 PM, during the evening meal, revealed Resident #12 eating a whole hamburger on a bun very rapidly and was observed to continually bite, chew, and swallow the hamburger until it was completely consumed; eating a bowl of coleslaw and a bowl of dessert by holding the bowls under his/her chin and continually eating spoonful after spoonful until the food was gone; and completely filling his/her oral cavity with a whole tomato slice, which the resident then swallowed with very minimal chewing observed. A review of Resident #12's tray card revealed the only instruction listed on the card was "unsweet tea." An interview was conducted on 09/15/11, at 7:40 PM, with LPN #5 who was present in the dining room while Resident #12 ate dinner. LPN #5 stated although the resident's care plan directed staff to cue the resident to slow down and eat slowly, she had not "noticed" staff was not providing the interventions as directed by the resident's plan of care. 4. Review of Resident #9's medical record revealed the facility admitted the resident on 10/20/08. Resident #9 had [DIAGNOSES REDACTED]. A review of Swallowing Strategies developed on 04/06/11, for Resident #9 revealed staff was to provide the resident with small, one-half teaspoon bites, to alternate bites of solids/sips of liquid at a ratio of one to one (1:1), and to feed the resident at a slow rate to ensure the resident swallowed before another bite was offered. According to Resident #9's Quarterly Minimum Data Set (MDS) assessment dated [DATE], the facility assessed the resident's cognition to be severely impaired and the resident was assessed to require extensive assistance for eating. A review of Resident #9's comprehensive care plan, dated 04/04/11, and Nurse Aide Care plan, dated 08/31/11, revealed staff was to "see swallowing strategies" when providing the resident with assistance during meals. An observation on 09/14/11, at 6:40 PM, during the evening meal in the dining room revealed Resident #9 being fed by paid feeding assistant #4. Paid feeding assistant #4 was observed to give the resident large, full bites of food with a regular spoon and to provide several bites in succession before fluids were offered. Based on observation, the paid feeding assistant failed to provide verbal or tactile cues to Resident #9 during the meal. A review of Resident #9's tray card listed feeding instructions as "fed per staff, no straws." An interview was conducted with paid feeding assistant #4 on 09/15/11, at 3:00 PM. The paid feeding assistant stated if a resident required special precautions during meals, it would be listed on the resident's tray card. The paid feeding assistant stated Resident #9 required "nothing special" during meals. 5. Review of Resident #10's medical record revealed the facility admitted the resident on 11/16/01. Resident #10 had [DIAGNOSES REDACTED]. A review of Resident #10's Swallowing Strategies, dated 02/21/11, revealed staff was required to ensure the resident's head/neck was in an upright position when sitting, that he/she took one-half teaspoon bites, to alternate bites of solids/sips of liquids at a one to one (1:1) ratio, to ensure the resident ate at a slow rate, to allow the resident to swallow before presenting another bite/sip, and to wait for the resident to open his/her mouth for a bite. According to Resident #10's Quarterly Minimum Data Set (MDS) assessment dated [DATE], the facility assessed the resident's cognition to be severely impaired and noted the resident required extensive assistance for eating. A review of Resident #10's comprehensive care plan, dated 09/13/11, revealed Resident #10 was "a total feed" and the Nurse Aide Care plan, dated 08/31/11, revealed an entry under dietary to "see swallowing precautions/strategies." An interview with Certified Nursing Assistant (CNA) #12 on 09/15/11, at 6:40 PM, revealed Resident #10 required no special feeding precautions and none had been provided for the resident during the evening meal on 09/15/11. CNA #12 stated if the resident required any specialized precautions or devices for meals, it would be detailed on the resident's tray card for staff awareness. An interview with the Dietary Director on 09/16/11, at 9:30 AM, revealed she was responsible for updating the dietary tray cards. The Dietary Director stated she thought all the swallowing precautions were listed on the tray cards for each resident and was unaware that the cards were not accurate. An interview with the Administrator and Director of Nursing (DON) on 09/15/11, at 8:51 PM, revealed the facility utilized dietary tray cards to ensure swallowing interventions were implemented as directed by each resident's individualized comprehensive care plan. The Administrator and DON stated facility staff had been informed in a training provided by the facility that all equipment/instructions the resident had been assessed to require would be listed on the tray card, and should be provided to each resident accordingly. --A review of the Allegation of Compliance revealed the following: On 09/16/11, the Speech Therapist screened all residents on swallowing precautions. Any new or revised recommendations were made. On 09/16/11, the Director of Nursing (DON) and Administrator audited the personal care plans and tray cards for the residents on swallowing precautions to ensure accuracy. A Swallowing Precaution Communication Procedure was established. The Speech Therapist will give a copy of each resident's swallowing precautions to the Dietary Manager, the Assistant Director of Nursing (ADON), the Infection Control Nurse, and the Director of Nursing (DON). The DON will monitor the communication procedure. The DON will also ensure the swallowing precautions have been added by the Dietary Manager to the tray cards. The DON will ensure the ADON has put a copy of swallowing precaution strategies in each resident's personal care record books. Each week the DON will review the swallowing precaution sheets that she received from the Speech Therapist. After the DON sees the swallowing precautions on the tray card are correct and the swallowing strategies are in the personal care record she will sign her copy of the swallowing strategies. She will keep a copy of this sheet in a binder in her office. Swallowing precaution books were created to include a master list of residents with swallowing precautions, a copy of the book, a copy of the emergency care for choking poster, and a copy of the signs and symptoms of aspirations. The Dietary Manager will be responsible for keeping the book up to date. The Administrator will audit the swallowing precaution book at least weekly to ensure that they are up to date. On 09/16/11, the Administrator educated the Dietary Manager, Speech Therapist, DON, Infection Control Nurse, and the ADON on the swallowing precaution communication procedure and on the swallowing precaution book. On 09/20/11, a copy of the emergency care for choking poster was posted in the dining room. On 09/16/11, the DON, MDS Coordinator, and the Infection Control Nurse educated all nursing personnel on swallowing precautions and how they are effective. The Speech Therapist form used to inform staff of what swallowing interventions each resident required was explained. On 09/16/11, nursing assistants were educated on where the swallowing precautions master list and the swallowing precaution strategies could be found. They were told the locations included: the personal care records, the tray cards, and in binders located in the dining room on the snack cart, and at both nurses' stations. Beginning 09/19/11, all nursing personnel will be reeducated on the choking section of the nurse aide training curriculum. Beginning 09/20/11, all nursing personnel were reeducated on the signs and symptoms of aspiration. Nursing assistants were trained on what to do when a resident showed signs and symptoms of aspiration. No nursing personnel will work until trained. Beginning 09/20/11, nurses were reeducated on what to do when a nurse aide reports signs and symptoms of aspiration. No nursing personnel will work until trained. Upon hire all employees will be educated on the facility swallowing procedures and the signs and symptoms of aspiration. On 09/16/11, administrative nurses observed nurse aides feeding residents on swallowing precautions to ensure that nursing assistants were aware of swallowing precautions. Beginning 09/17/11, the licensed nurse assigned to the resident halls and the licensed nurse assigned to the dining room were to monitor each resident on swallowing precautions to ensure the nursing assistants were aware of the swallowing precautions, the swallowing precautions were being followed, and the swallowing precautions were on the tray card. This quality assurance is to be done at every meal. During the lunch meal the licensed nurse assigned to the resident halls and the licensed nurse assigned to the dining room were to monitor all residents for signs and symptoms of aspiration to ensure that nursing assistants were aware of the signs and symptoms of swallowing issues. All nurses on duty on 09/20/11, were educated on the monitoring procedure, and no nurse will be allowed to work before being educated. The Medical Director was informed of the immediate jeopardy. Weekly the Administrator will observe meal service and will audit the plan of correction. The Administrator will report the audit to the quality assurance committee quarterly. --The surveyors validated the corrective actions taken by the facility as follows: Observation of the noon meal on 09/21/11, revealed RN #4 in the dining room supervising CNAs feeding residents. Interview at this same time revealed she was responsible for observing residents in the dining room to assure they have received the correct diet, that the diet and swallowing precautions were printed on the tray card, to assure the nursing aides were following swallowing precautions and observing for signs and symptoms of aspiration and choking. Interview further revealed there was a poster on the wall with interventions for choking, and there was a book with each resident on swallowing precautions, what the precautions were, what to do in the event of choking, and signs and symptoms of aspiration. RN #4 further stated she was in-serviced on 09/19/11, regarding the need to supervise nursing aides while feeding residents, what swallowing precautions were, the swallowing precaution book, that all swallowing precautions were required to be on the tray card, choking, and aspiration. Further observation of the noon meal on 09/21/11, revealed Residents #7, #11, and #10, in the dining room at a table assisted by a nursing assistant. Review of their tray cards revealed their swallowing precautions were listed on the card. Observation of the dining room on 09/21/11, revealed an emergency care for choking sign posted on the wall. Observation on 09/21/11, revealed a swallowing precaution book in the dining room, at each nurses' station, and on each snack cart. Interview with the Speech Therapist (ST) on 09/21/11, at 3:30 PM, revealed she had conducted a current screening for all residents on swallowing precautions and had made any revisions or new recommendations for each resident. The ST went on to say she was responsible for providing a copy of the current swallowing precautions for each resident to the Dietary Manager (DM), ADON, Infection Control Nurse, and the DON. Interview further revealed she had been educated by the Administrator related to the need to provide a current copy of each resident's swallowing precautions to the DM, ADON, Infection Control Nurse, and the DON; and the swallowing precaution book. Interview with the Administrator on 09/21/11, at 3:45 PM, revealed she is responsible for auditing the swallowing precaution book weekly to ensure it is up to date. She further stated she had educated the Dietary Manager, Speech Therapist, DON, Infection Control Nurse, and the ADON on the swallowing precaution communication procedure and the swallowing precaution book. Further interview revealed she would be observing meal service weekly and would perform an audit during that time to ensure the plan of correction was being followed. The Administrator stated she would report this audit at the quality assurance meeting quarterly. Interview with the DON on 09/21/11, at 3:15 PM, revealed she along with the Administrator had audited all personal care plans and tray cards and found no problems. Interview further revealed she is responsible for assuring the Dietary Manager puts all swallowing precautions on each resident's tray card. Further interview revealed she had assured the ADON had put a copy of the swallowing precautions strategies in each resident's personal care book. The DON further stated she was in-serviced on 09/16/11, related to the swallowing precaution communication procedure and the swallowing precaution book. Interview further revealed each week the DON would verify the swallowing precautions were on the tray cards and in each resident's personal care book. She further stated after verifying the swallowing precautions were on the tray cards and in the personal care books, she would then sign her copy of the swallowing strategy for each resident and it would be kept in a binder in her office. Interview further revealed the DON had been in-serviced by the Administrator regarding the swallowing precaution communication procedure and the swallowing precaution book. Interview on 09/21/11, at 2:03 PM, with the Dietary Manager revealed it was her responsibility to ensure all swallowing strategies were on each resident's tray card. Further interview revealed the Dietary Manager is responsible for ensuring the swallowing precaution books are current and up to date for each resident on special feeding precautions. Interview further revealed she had been educated by the Administrator regarding the swallowing precaution communication procedure and the swallowing precaution book. Interview on 09/21/11, at 3:38 PM, with CNA #9, at 3:42 PM, with Nurse Aide #1, at 4:00 PM, with CNA #11, and at 4:10 PM, with CNA #4 revealed they had been in-serviced on swallowing precautions, where each resident's swallowing precautions were located, what to do when a resident chokes, and signs and symptoms of aspiration. Interview further revealed a nurse has to be in the dining room before they can begin feeding the residents, and they are required to look at each resident's tray card and ensure any precautions are followed. Interview with LPN #5 on 09/21/11, at 3:47 PM, and RN #2 at 4:15 PM, revealed they had been in-serviced on resident swallowing precautions, and that all precautions have to be on the tray card and in the swallowing strategy book. They further stated they had also been in-serviced on signs and symptoms of aspiration, and what to do when a resident chokes. Interview further revealed they were instructed when they were in the dining room or on the floor with residents they were to monitor to ensure nurse aides were following swallowing precautions, and observe for aspiration/choking. Interview on 09/21/11, at 2:00 PM, with the Medical Director revealed she had been informed of the immediate jeopardy identified at the facility. Review of the personal care records audit revealed the DON and Administrator had audited all personal care plans and tray cards for each resident on swallowing precautions on 09/16/11, and found no discrepancies. A review of the new swallowing precaution communication procedure revealed it was implemented on 09/16/11. A review of the facility's training records revealed evidence employees of the facility, except for those on vacation or on medical leave, had received training on swallowing precautions and how they are effective on 09/16/11. Any employee who did not attend training was informed they are not allowed to work until trained. Further review revealed nursing assistants had received training on 09/16/11, on where the swallowing precautions master list and the swallowing precaution strategies could be found. Review further revealed on 09/19/11, nursing personnel were educated on the choking section of the nurse aide training curriculum. Facility training records further revealed on 09/20/11, nursing personnel were educated on signs and symptoms of aspiration. A review of "Swallowing Precaution Education," to be given to employees upon hire, revealed the facility would ensure any new hires would be educated on each resident's swallowing precautions, signs and symptoms of aspiration, and emergency preparedness for choking. A review of facility tray cards for the nine residents, assessed by the facility to require swallowing strategies, revealed each card had the resident's required strategies on them. A review of the facility's swallowing precaution quality assurance log revealed from 09/16/11-09/21/11, staff had observed to ensure each resident with a swallowing strategy had the strategy on their tray card, that the nurse aide was adhering to the swallowing precautions, and if education had to occur. Based on the above findings, the State Agency determined Immediate Jeopardy was removed on 09/21/11, prior to exit, which lowered the scope and severity to "E" while the facility monitors the effectiveness of systemic changes and quality assurance actions.

Based on observation, interview, record review, and review of the Fundamental Procedures instruction text book, it was determined the facility failed to ensure that nine (9) of twenty (20) sampled residents received the necessary care and services to attain or maintain their highest practicable physical well being. The facility failed to ensure the system in place to identify residents requiring specific care with feeding needs and supervision during meal service was implemented, and failed to ensure that staff providing feeding services to residents with complicated feeding problems had received appropriate training to ensure each resident's safety during meals. Five (5) sampled residents (Residents #7, #9, #10, #11, and #12) required specialized swallowing/feeding precautions to be implemented during meals. However, observations and interviews on 09/14/11 and 09/15/11, revealed the residents were not provided the required supervision/assistance to ensure their safety. In addition, facility staff failed to implement the facility's bowel protocol, for seven (7) sampled residents (Residents #3, #6, #7, #9, #11, #15, and #17). Facility staff documented no bowel movement for at least three (3) days for each resident; however, no interventions were put in place as per the bowel protocol. The facility's failure to ensure residents received specialized feeding/swallowing precautions and supervision/assistance the facility assessed them to require has caused, or is likely to cause serious injury, harm, impairment, or death to Residents #7, #9, #10, #11, and #12, and other residents in the facility assessed to have feeding precautions. Immediate Jeopardy and Substandard Quality of Care (SQC) were determined to exist on 09/14/11. An acceptable Allegation of Compliance (AOC) was received from the facility on 09/21/11, and alleged removal of Immediate Jeopardy on 09/21/11. The State Agency determined the Immediate Jeopardy was removed on 09/21/11, prior to exit, which lowered the scope and severity to "E" while the facility monitors the effectiveness of the systemic changes and quality assurance activities. The findings include: Upon requesting the facility's feeding/swallowing precautions policy and procedures, the facility stated they did not have a specific policy, but utilized the Fundamental Procedures instruction text book as a guide. A review of the "Feeding" and "Impaired Swallowing and Aspiration Precautions" sections in the textbook revealed if a resident had swallowing difficulties a consultation with Speech Therapy should be obtained. According to the text, choking and aspiration of food could occur if the patient was fed too quickly or was given excessively large mouthfuls of food. Additionally, the text indicated caregivers should develop a management plan that included common swallowing strategies, nutritional status, and supervision. The text went on to instruct caregivers to monitor residents for signs and symptoms of swallowing problems and aspiration. 1. Review of Resident #7's medical record revealed the facility admitted the resident on 11/17/09. Resident #7 had [DIAGNOSES REDACTED]. According to Resident #7's Quarterly Minimum Data Set (MDS) assessment dated [DATE], the facility assessed the resident's cognition to be severely impaired and noted the resident required extensive assistance for eating. Additionally, the facility obtained a chest x-ray for Resident #7 on 08/21/11, due to Resident #7 experiencing a cough and congestion, which revealed "small lower lung field infiltrates." Review of the comprehensive plan of care dated 07/30/11, and the resident's Nurse Aide Care Plan dated 08/21/11, revealed staff was instructed to "see swallowing strategies." A review of a Speech Therapy Dysphagia Medical Work Up dated 02/07/11, for Resident #7 revealed the resident had been referred for evaluation due to having experienced a decrease in oral intake with weight loss. The therapist's report revealed Resident #7 experienced oral motor retention, had difficulty in biting, chewing, sucking, or shaping food into a [MEDICATION NAME], and had a negative reaction to food texture/consistency. A review of the Speech Therapy Discharge Summary for Resident #7 dated 02/18/11, revealed the resident would be placed on a functional maintenance program for eating/swallowing. The maintenance program required staff to provide strategies and compensatory techniques to increase safety and reduce Resident #7's risk for injury. A review of the Swallowing Strategies for Resident #7 dated 02/11/11, revealed staff was to ensure the resident alternated bites of solids/sips of liquids at a one to one (1:1) ratio, be checked for "pocketing" of food during/after meals, and be provided decreased distractions with increased time allotted for meals. The Discharge Summary further revealed staff and Resident #7 were educated regarding the swallowing strategies and feeding techniques to be utilized during meals. Observations on 09/14/11, at 6:35 PM, of the evening meal service in the dining room revealed Resident #7 was seated at a table with five peers, feeding him/herself without staff cueing or interaction. Although two paid feeding assistants were feeding/supervising residents at the table, Resident #7 was observed taking large bites in repeated succession, without fluid intake, and coughed throughout the meal. A review of Resident #7's tray card revealed feeding instructions included "check for pocketing, down distraction." An interview conducted on 09/15/11, at 5:30 PM, with paid feeding assistant #2 who was assisting at Resident #7's table on 09/14/11, revealed he was unaware that Resident #7 required swallowing strategies to be implemented for safety and was unaware of what a swallowing strategy was, answering, "I don't think I know what that is," when asked. Paid feeding assistant #2 stated he had completed a paid feeding assistants class at the facility in July 2011 but had never received training in feeding residents with swallowing precautions or had instruction from a Speech Therapist regarding proper feeding techniques. Paid feeding assistant #2 explained that if a resident required anything such as "a special spoon or cup" it would be on the tray card that comes out of the kitchen on each resident tray. Paid feeding assistant #2 stated Resident #7 "most times feeds (himself/herself) and don't get anything special because if (he/she) did it would be on the tray card." Paid feeding assistant #2 was unable to explain the "check for pocketing, down distraction" referenced on Resident #7's tray card, stating, "I don't know." 2. Review of Resident #11's medical record revealed the facility admitted the resident on 09/11/09. Resident #11 had [DIAGNOSES REDACTED]. According to Resident #11's Quarterly Minimum Data Set (MDS) assessment dated [DATE], the facility assessed the resident's cognition as severely impaired and noted the resident was totally dependent on staff for eating. A review of Resident #11's comprehensive care plan dated 08/30/11, revealed the resident was to be fed per staff and utilize no straws, and review of the resident's Nurse Aide Care plan dated 08/31/11, revealed an entry under dietary listing, "see swallow precaution" and "no straws." A review of the Speech Therapy Discharge Summary for Resident #11 dated 10/16/10, revealed the resident had received therapy services from 08/13/10 until 10/16/10. The Discharge Summary revealed Resident #11 had received Therapy Services related to oropharyngeal dysphagia and would be placed on a functional maintenance program with staff utilizing compensatory swallowing strategies. A review of the Swallowing Precautions dated 09/30/10, and the Speech Therapy Discharge Summary dated 10/16/10, revealed staff was to ensure Resident #11 was supervised during all oral intake by a swallowing therapist or trained staff. In addition, staff was directed to ensure the resident took small bites/sips, to alternate bites of solids to sips of liquid at a two to one (2:1) ratio, to allow two swallows per bite of food/sip of liquid, and to ensure straws were not utilized. An observation of Resident #11 on 09/14/11, at 6:36 PM, during the evening meal service revealed the resident was seated at a table being fed by paid feeding assistant #1. The paid feeding assistant was observed to provide Resident #11 with large bites in rapid succession of each other without offering the resident fluids. During approximately 14 minutes of observation, paid feeding assistant #1 provided no verbal communication or cueing to Resident #11. The resident was observed at a minimum of four times to cough loudly and forcibly, and audible wheezes were heard. The paid feeding assistant appeared to be concerned regarding Resident #11's continued coughing and wheezing and stated to paid feeding assistant #2 who was in close proximity, "What do I do, (he/she) is coughing." Feeding assistant #2 replied, "Give (him/her) a minute it will be all right," but failed to alert the nurse or provide Resident #11 with further assistance. A review of Resident #11's tray card revealed listed feeding instructions that included "at least two swallows per bite of food and sip of liquid." 3. Review of Resident #12's medical record revealed the facility admitted the resident on 02/27/03. Resident #12 had [DIAGNOSES REDACTED]. According to the facility's Quarterly Minimum Data Set (MDS) assessment dated [DATE], for Resident #12, the facility assessed the resident's cognition as severely impaired and the resident required supervision for eating. A review of Resident #12's comprehensive care plan and Nurse Aide Care plans dated 08/31/11, revealed an entry under dietary to "see swallowing strategies." A review of the Speech Therapy Discharge Summary for Resident #12 dated 08/04/11, revealed the resident had received a dysphagia evaluation, and was being placed on a restorative program to increase safety and decrease the resident's risk for injury. The Discharge Summary and a Restorative Swallowing Program, dated 08/18/11, for Resident #12 indicated compensatory swallowing strategies were to be utilized for the resident that included to ensure the resident's rate of intake was slow, the resident took small bites, to alternate solids and liquids at a two to one (2:1) ratio, to cue the resident to chew food before swallowing, and to assess the resident for "pocketing" of food. The summary further indicated Resident #12 and staff had been trained regarding the swallowing strategies. An observation of Resident #12 on 09/15/11, at 6:30 PM, during the evening meal, revealed the resident was seated at a table with three peers and was eating independently with no staff supervision present at the table. Resident #12 was observed eating very rapidly, consuming a whole hamburger on a bun in one act by continually biting, chewing, and swallowing the hamburger until it was completely consumed; eating a bowl of coleslaw and a bowl of dessert by holding the bowls under his/her chin and continually eating spoonful after spoonful until the food was gone; and completely filling his/her oral cavity with a whole tomato slice, which the resident then swallowed with very minimal chewing observed. A review of Resident #12's tray card revealed the only instruction listed on the card was "unsweet tea." Licensed Practical Nurse (LPN) #5 was observed to be in the Dining Room on 09/15/11. An interview conducted on 09/15/11, at 7:40 PM, with LPN #5 revealed she was aware of how fast Resident #12 eats and stated, "I've told him ain't nobody going to take it." However, LPN #5 stated she had not realized that Resident #12 was not being provided with the required supervision during the meal. 4. Review of Resident #9's medical record revealed the facility admitted the resident on 10/20/08. Resident #9 had [DIAGNOSES REDACTED]. According to Resident #9's Quarterly Minimum Data Set (MDS) assessment dated [DATE], the facility assessed the resident to be severely cognitively impaired and require extensive assistance for eating. A review of Resident #9's comprehensive care plan dated 04/04/11, revealed interventions of "total feed" and "see swallowing strategies;" the Nurse Aide Care plan dated 08/31/11, revealed an entry under dietary to "see swallowing strategies." A review of the Speech Therapy Plan of Care dated 04/05/11, revealed a dysphagia evaluation for Resident #9 indicated the resident had severe dysphagia with a high risk of aspiration. The evaluation further revealed the resident required maximum verbal and tactile cues to swallow solids and liquids. A review of Swallowing Strategies, dated 04/06/11, for Resident #9 revealed staff was to provide the resident with small, one-half teaspoon bites, to alternate bites of solids/sips of liquid at a ratio of one to one (1:1), to feed the resident at a slow rate to ensure the resident swallowed before another bite was offered, and based on the assessment the resident was not to utilize straws. An observation on 09/14/11, at 6:40 PM, in the dining room during the evening meal revealed Resident #9 was being fed by paid feeding assistant #4. Paid feeding assistant #4 was observed to give the resident large full bites with a regular spoon, and to provide several bites in succession before fluids were offered. The paid feeding assistant was observed to provide no verbal or tactile cues to Resident #9 during the observation. A review of Resident #9's tray card listed feeding instructions as "fed per staff, no straws." Observation of Resident #9's room on 09/14/11, at 7:45 PM, revealed the resident had a full water pitcher containing a straw on his/her bedside table. An interview was conducted with paid feeding assistant #4 on 09/15/11, at 3:00 PM. The paid feeding assistant stated she had not been trained to feed residents with specialized feeding/swallowing precautions and was not aware of any resident in the facility who required special precautions when eating. The paid feeding assistant went on to state if a resident required special precautions during meals, it would be listed on the resident's tray card. The paid feeding assistant stated Resident #9 required "nothing special" during meals. 5. Review of Resident #10's medical record revealed the facility admitted the resident on 11/16/01. Resident #10 had [DIAGNOSES REDACTED]. According to Resident #10's Quarterly Minimum Data Set (MDS) assessment dated [DATE], the facility assessed the resident to be severely cognitively impaired and require extensive assistance for eating. A review of Resident #10's comprehensive care plan dated 09/13/11, revealed the resident was to be a "total feed" and the Nurse Aide Care plan dated 08/31/11, revealed an entry under dietary to "see swallowing precautions/strategies." Review of the Speech Therapy Discharge Summary for Resident #10 dated 03/15/11, revealed the resident had been evaluated for feeding difficulties and holding solids in his/her mouth. The summary revealed Resident #10 would be placed on a functional maintenance plan and staff was to utilize strategies to increase safety and reduce the risk of injury. According to the discharge summary and a review of Swallowing Strategies, dated 02/21/11, for Resident #10, staff was to ensure the resident sat with head/neck upright, that he/she took one-half teaspoon bites, and to alternate bites of solids/sips of liquids at a one to one (1:1) ratio, eat at a slow rate and allow resident to swallow before presenting another bite/sip, and wait for the resident to open mouth for a bite. The Speech Therapy Discharge Summary indicated staff had been trained on the swallowing strategies to be utilized by Resident #10. An interview with Certified Nursing Assistant (CNA) #12 on 09/15/11, at 6:40 PM, revealed she had fed Resident #10 at around 4:30 PM. CNA #12 stated Resident #10 took a long time to feed so the resident was fed each meal early. Interview with CNA #12 further revealed Resident #10 required no special feeding precautions and none had been provided for the resident during the evening meal on 09/15/11. CNA #12 stated if the resident required any specialized precautions or devices for meals, it would be detailed on the resident's tray card so the staff would know to provide it for the resident. A review of Resident #10's tray card listed feeding instructions as "fed per staff." Additional interviews were conducted on 09/15/11, at 3:37 PM, with Nursing Assistant (NA) #1; at 4:03 PM, with CNA #9; at 4:30 PM, with CNA #5; at 4:53 PM, with CNA #6, and at 5:08 PM, with LPN #4. All the staff interviewed stated they relied on the resident's tray cards to know what, if any, specialized interventions or equipment was to be provided to residents during meals. An interview with the Dietary Director on 09/16/11, at 9:30 AM, revealed she was responsible for updating the dietary tray cards. The Dietary Director stated she thought all the swallowing precautions were listed on the tray cards for each resident, and was unaware that the cards were not accurate. The Dietary Director stated a former Speech Therapist (ST) had verbally told her the instructions that were to be provided on "some" of the tray cards. Per interview the facility did not have a system in place for ensuring the Dietary Director was aware of all the precautions for each resident to ensure the precautions were listed on the resident's tray cards. An interview conducted on 09/21/11, at 9:15 AM, with ST #2, the current Speech Therapist, revealed the nine residents who were on swallowing precautions were not currently receiving Speech Therapy services and had been "discharged to a restorative program." The ST stated the swallowing precautions/strategies were to be utilized by the staff who assisted the residents with meals. The ST stated that each of the nine residents had been placed on the restorative program prior to her employment at the facility and she had not trained residents or staff responsible on implementation of the feeding strategies. The ST went on to state that since none of the residents had been actively receiving Therapy services, she had not been responsible to ensure any of the swallowing precautions/strategies were followed. An interview conducted on 09/15/11, at 7:43 PM, with LPN #5, who was responsible for training the CNAs, revealed any specialized swallowing/feeding precautions the residents required were listed on the resident's individualized tray card by the kitchen staff. LPN #5 stated the CNAs were trained to rely on the tray cards to know what each resident required. LPN #5 stated to her knowledge there "was no one person" responsible to ensure the tray cards were accurate or that residents were receiving the supervision/assistance they had been assessed to require in regards to the swallowing precautions/strategies. An interview with the Administrator and Director of Nursing (DON) on 09/15/11, at 8:51 PM, confirmed the facility staff was trained to rely on the tray cards for any specialized instructions, including feeding precautions to be provided for residents. However, the Administrator and DON explained they had not realized the feeding precautions were not on the tray cards until informed on 09/15/11. In addition, facility staff failed to implement the facility's bowel protocol, for seven of twenty sampled residents (Residents #3, #6, #7, #9, #11, #15, and #17). Facility staff documented no bowel movement for at least three days for each resident; however, no interventions were put in place as per the bowel protocol. Review of the facility's undated "Bowel Management Program" revealed residents were assessed upon admission, quarterly, and with any significant change in condition for risk of constipation. The review revealed staff was required to document all bowel movements on the "Care Tracker." The program stated the 7 PM-7 AM shift nurse was responsible to review each resident's Care Tracker, and place the name of each resident that had not had a bowel movement for three days on the Communication Flow sheet. In addition, the program revealed the charge nurse was responsible to administer medications as appropriate. 6. A review of the medical record revealed the facility admitted Resident #11 on 09/11/09. Resident #11 had [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set, dated dated [DATE], revealed the facility assessed Resident #11 to be incontinent of bowel and bladder. A review of the "Resident Bowel and Bladder by Shift Chart" revealed no evidence Resident #11 had a bowel movement on 06/22/11, 06/23/11, 06/24/11, and 06/25/11, a total of four days; on 07/18/11, 07/19/11, 07/20/11, and 07/22/11, a total of four days; and on 08/20/11, 08/21/11, and 08/22/11; a total of three days. Review of the facility Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the nursing notes for June, July, and August 2011, revealed no documentation of any bowel intervention provided for Resident #11. 7. A review of the medical record revealed the facility admitted Resident #6 on 07/15/11, with [DIAGNOSES REDACTED]. A review of the admitting MDS, dated [DATE], revealed the facility assessed Resident #6 to be continent of bowel. A review of the "Resident Bowel and Bladder by Shift Chart" revealed no evidence Resident #6 had a bowel movement on 07/17/11, 07/18/11, 07/19/11, 07/20/11 (four days); 07/24/11, 07/25/11, 07/26/11, 07/27/11 (four days); 07/30/11, 07/31/11, 08/01/11 (three days); 08/08/11, 08/09/11, 08/10/11 (three days); 08/17/11, 08/18/11, 08/19/11 (three days); or on 09/13/11, 09/14/11, 09/15/11, or 09/16/11 (four days). A review of Resident #6's MAR for July, August, and September 2011, revealed no evidence medications were administered to the resident related to the absence of a bowel movement. A review of nursing notes for July, August, and September 2011 also revealed no documentation that any medication was administered related to the resident's lack of a bowel movement. 8. Review of Resident #7's medical record revealed the facility admitted the resident on 11/17/09. Resident #7 had [DIAGNOSES REDACTED]. Review of the resident's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to be severely cognitively impaired, and always incontinent of bowel and bladder. Review of Resident #7's "Resident Bowel and Bladder by Shift Chart" sheet revealed the resident had not experienced a bowel movement on 08/14/11, 08/15/11, 08/16/11 (three days); 08/31/11, 09/01/11, 09/02/11 (three days); or on 09/11/11, 09/12/11, or 09/13/11 (three days). Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further review of Resident #7's nurse's notes for August 2011 and September 2011 revealed no documentation of bowel interventions implemented by staff for the resident's absence of bowel movement for three days as per facility policy. 9. Review of Resident #9's medical record revealed the facility admitted the resident on 10/20/08, with [DIAGNOSES REDACTED]. Review of the resident's Quarterly MDS assessment dated [DATE], revealed the facility had assessed the resident to be severely cognitively impaired, occasionally incontinent of bowel, and frequently incontinent of bladder. Review of Resident #9's "Resident Bowel and Bladder by Shift Chart" sheet revealed the resident had not experienced a bowel movement on 08/05/11, 08/06/11, 08/07/11 (three days); 08/18/11, 08/19/11, 08/20/11 (three days); or on 08/28/11, 08/29/11,08/30/11, or 08/31/11 (four days). Review of the resident's MARs and TARs for August 2011 revealed no evidence bowel interventions were implemented related to the absence of a bowel movement for three days as per facility policy. Further review of Resident #9's nurse's notes for August 2011 revealed no documentation of bowel interventions implemented by staff for the resident's absence of bowel movements for three days as per facility policy. 10. Review of the medical record revealed the facility admitted Resident #3 on 01/07/09, with [DIAGNOSES REDACTED]. Review of the Bowel and Bladder flow sheet for the month of August 2011 revealed no documented evidence of a bowel movement from 08/05/11 through 08/10/11 (six days). Review of the MAR for the same period revealed no evidence medication was administered to Resident #3 per facility bowel protocol. 11. Medical record review revealed Resident #15 was admitted by the facility on 10/20/09, with [DIAGNOSES REDACTED]. Review of the Bowel and Bladder flow sheet for the month of August 2011 revealed no documented evidence of a bowel movement between 08/03/11 and 08/07/11 (five days) for Resident #15. Review of the MAR indicated [REDACTED]. 12. Review of the medical record revealed the facility admitted Resident #17 on 05/31/07. Review of the Bowel and Bladder flow sheets for the months of July, August, and September 2011 revealed no documented evidence of a bowel movement for the following dates: 07/11 through 07/15 (five days); 07/19 through 07/24 (six days); 07/25 through 7/30 (six days); 08/05 through 08/17 (thirteen days); 08/22 through 08/27 (six days); 09/05 through 09/08 (four days); and 09/12 through 09/20 (nine days). Continued review of the MAR indicated [REDACTED]. Interview with LPN #1 on 09/21/11, at 8:57 AM, revealed she had reviewed each resident's medical record of the above mentioned timeframe and was unable to find where the resident had been assessed for use of possible interventions including prune juice, contacting physician for stool softener, or consulting the dietitian as per the bowel protocol. Interview on 09/21/11, at 10:32 AM, with LPN #2 revealed the night shift nurse was responsible for printing a bowel list to provide for the day shift nurse and then to place a copy in the bowel log book. The day shift nurse was then responsible for providing bowel care for residents who had not had a bowel movement for two days. LPN #2 stated she thought bowel care used to be provided after three days with no bowel movement, however, now it was provided after two days. Interview with LPN #2 further revealed when an intervention had been provided for a resident related to bowel care, the intervention would be documented either in the nurse's notes on or the MAR. Interview with LPN #4, the bowel and bladder nurse, revealed she was not aware that there was a bowel book that tracked residents who had not had a bowel movement for three days. LPN #4 went on to state she had just assumed the responsibility as bowel and bladder nurse in May 2011. Therefore, LPN #4 stated staff had not tracked each resident's bowel movement to assure interventions were provided. --A review of the Allegation of Compliance revealed the following: On 09/16/11, the Speech Therapist screened all residents on swallowing precautions. Any new or revised recommendations were made. On 09/16/11, the Director of Nursing (DON) and Administrator audited the personal care plans and tray cards for the residents on swallowing precautions to ensure accuracy. A Swallowing Precaution Communication Procedure was established. The Speech Therapist will give a copy of each resident's swallowing precautions to the Dietary Manager, the Assistant Director of Nursing (ADON), the Infection Control Nurse, and the Director of Nursing (DON). The DON will monitor the communication procedure. The DON will also ensure the swallowing precautions have been added by the Dietary Manager to the tray cards. The DON will ensure the ADON has put a copy of swallowing precaution strategies in each resident's personal care record books. Each week the DON will review the swallowing precaution sheets that she received from the Speech Therapist. After the DON sees the swallowing precautions on the tray card are correct and the swallowing strategies are in the personal care record she will sign her copy of the swallowing strategies. She will keep a copy of this sheet in a binder in her office. Swallowing precaution books were created to include a master list of residents with swallowing precautions, a copy of the book, a copy of the emergency care for choking poster, and a copy of the signs and symptoms of aspirations. The Dietary Manager will be responsible for keeping the book up to date. The Administrator will audit the swallowing precaution book at least weekly to ensure that they are up to date. On 09/16/11, the Administrator educated the Dietary Manager, Speech Therapist, DON, Infection Control Nurse, and the ADON on the swallowing precaution communication procedure and on the swallowing precaution book. On 09/20/11, a copy of the emergency care for choking poster was posted in the dining room. On 09/16/11, the DON, MDS Coordinator, and the Infection Control Nurse educated all nursing personnel on swallowing precautions and how they are effective. The Speech Therapist form used to inform staff of what swallowing interventions each resident required was explained. On 09/16/11, nursing assistants were educated on where the swallowing precautions master list and the swallowing precaution strategies could be found. They were told the locations included: the personal care records, the tray cards, and in binders located in the dining room on the snack cart, and at both nurses' stations. Beginning 09/19/11, all nursing personnel will be reeducated on the choking section of the nurse aide training curriculum. Beginning 09/20/11, all nursing personnel were reeducated on the signs and symptoms of aspiration. Nursing assistants were trained on what to do when a resident showed signs and symptoms of aspiration. No nursing personnel will work until trained. Beginning 09/20/11, nurses were re-educated on what to do when a nurse aide reports signs and symptoms of aspiration. No nursing personnel will work until trained. Upon hire all employees will be educated on the facility swallowing procedures and the signs and symptoms of aspiration. On 09/16/11, administrative nurses observed nurse aides feeding residents on swallowing precautions to ensure that nursing assistants were aware of swallowing precautions. Beginning 09/17/11, the licensed nurse assigned to the resident halls and the licensed nurse assigned to the dining room were to monitor each resident on swallowing precautions to ensure the nursing assistants were aware of the swallowing precautions, the swallowing precautions were being followed, and the swallowing precautions were on the tray card. This quality assurance is to be done at every meal. During the lunch meal the licensed nurse assigned to the resident halls and the licensed nurse assigned to the dining room were to monitor all residents for signs and symptoms of aspiration to ensure that nursing assistants were aware of the signs and symptoms of swallowing issues. All nurses on duty on 09/20/11, were educated on the monitoring procedure, and no nurse will be allowed to work before being educated. The Medical Director was informed of the immediate jeopardy. Weekly the Administrator will observe meal service and will audit the plan of correction. The Administrator will report the audit to the quality assurance committee quarterly. --The surveyors validated the corrective actions taken by the facility

Based on observation, interview, and record review the facility failed to ensure paid feeding assistants did not assist residents assessed to have complicated feeding precautions with their meals. A review of twenty (20) residents revealed six (6) of the residents had complicated feeding precautions. Observation revealed paid feeding assistants assisted three (3) of the six (6) residents (Residents #7, #9, and #11) assessed to have complicated feeding precautions with their meals on 09/14/11, during the evening meal. Residents #7, #9, and #11 were assessed by the facility to require specialized swallowing precautions during oral intake. (Refer to F309.) The facility's failure to ensure paid feeding assistants did not assist/feed residents assessed to have complicated feeding precautions has caused, or is likely to cause serious injury, harm, impairment, or death to Residents #7, #9, and #11 and other residents in the facility assessed to have feeding precautions. Immediate Jeopardy and Substandard Quality of Care (SQC) were determined to exist on 09/14/11. An acceptable Allegation of Compliance (AOC) was received from the facility on 09/21/11, and alleged removal of Immediate Jeopardy on 09/21/11. The State Agency determined the Immediate Jeopardy was removed on 09/21/11, prior to exit, which lowered the scope and severity to "E" while the facility monitors the effectiveness of the systemic changes and quality assurance activities. The findings include: Observations on 09/14/11, from 6:35 PM until 7:30 PM, (of the evening meal in the facility's dining room) revealed four paid feeding assistants were observed to feed/assist Residents #7, #9, and #11 with their meal. 1. A review of Resident #7's medical record revealed the facility admitted the resident on 11/17/09. Resident #7 had [DIAGNOSES REDACTED]. as severely impaired and the resident required extensive assistance with eating. A review of Resident #7's Speech Therapy Plan of Care dated 02/07/11, revealed Resident #7 required staff to utilize compensatory swallowing strategies (to help with swallowing) while feeding/assisting the resident during meals to increase the resident's safety and decrease the resident's risk for injury. An observation on 09/14/11, at 6:35 PM, revealed Resident #7 was seated at the table with five peers, all of which were being fed/assisted by paid feeding assistant #1 and paid feeding assistant #2. 2. A review of Resident #9's medical record revealed the facility admitted the resident on 10/20/08, and the resident's [DIAGNOSES REDACTED]. to be severely impaired and he/she required extensive assistance with eating. A review of Resident #9's Speech Therapy Plan of Care dated 04/11/11, revealed staff was required to utilize compensatory swallowing strategies while feeding the resident to increase the resident's safety and decrease the resident's risk for aspiration. An observation on 09/14/11, at 6:40 PM, revealed paid feeding assistant #4 was feeding Resident #9 in the dining room. 3. A review of Resident #11's medical record revealed the facility admitted the resident on 09/11/09. Resident #11 had [DIAGNOSES REDACTED]. A review of Resident #11's Minimum Data Set (MDS) assessment dated [DATE], revealed the facility had assessed the resident's cognition to be severely impaired and totally dependent on staff for eating. A review of Resident #11's Speech Therapy Plan of Care dated 11/24/10, revealed the resident had impaired pharyngeal function and required compensatory swallowing strategies to be provided by staff to reduce the likelihood of aspiration. An observation on 09/14/11, at 6:36 PM, revealed Resident #11 was seated in a wheelchair at a table and paid feeding assistant #1 was feeding the resident. Interviews conducted on 09/15/11, at 3:00 PM, with paid feeding assistant #4; at 5:32 PM, with paid feeding assistant #2; and at 5:49 PM, with paid feeding assistant #3 revealed they had completed the Paid Feeding Assistants Program at the facility and functioned as paid feeding assistants. A review of the Paid Feeding Assistants Program exam results revealed paid feeding assistant #4 successfully completed the training on 03/08/11; paid feeding assistants #2 and #3 successfully completed the training on 07/04/11; and paid feeding assistant #1 successfully completed the training on 09/05/11. The paid feeding assistants all stated they were permitted to feed/assist any resident that ate in the dining room and had never been instructed they could not feed certain residents. According to the paid feeding assistants, feeding assignments were not made. They stated staff fed/assisted "the first resident you come to" that required assistance. The paid feeding assistants stated they had not been trained to feed residents with specialized feeding precautions and, in addition, stated they were not aware of any resident in the facility that required special feeding precautions. An interview with Licensed Practical Nurse (LPN) #5 on 09/15/11, at 7:43 PM, revealed she had the responsibility to facilitate the Paid Feeding Assistants Program in the facility. A review of the Paid Feeding Assistants Manual and Paid Feeding Assistant Exam utilized by the facility revealed it was a state approved training course, which indicated residents with complicated feeding problems could not be fed by a paid feeding assistant. LPN #5 stated the facility implemented the Paid Feeding Assistant Program on 03/08/11, and utilized four paid feeding assistants. According to LPN #5, the facility had not developed a formal written policy/procedure that governed the Paid Feeding Assistant Program, and stated the paid feeding assistants were only utilized in the dining room and could feed/assist any resident who required assistance when they ate in the dining room. LPN #5 stated she, the Administrator, and the Director of Nursing (DON) discussed the Paid Feeding Assistant Program and decided the paid feeding assistants would only be utilized in the dining room and that "if a resident was well enough to eat in the dining room, they could be fed by a paid feeding assistant." LPN #5 stated she was not aware paid feeding assistants were not permitted to feed/assist residents who had complicated feeding problems. In an interview on 09/15/11, at 8:50 PM, the Administrator and DON confirmed the facility had utilized paid feeding assistants since 03/08/11, and stated they were not aware that paid feeding assistants could not feed residents with complicated feeding problems. The DON stated, "I thought it was just state to state, I didn't realize there was a Federal Regulation about it." Both the Administrator and DON confirmed the facility had never implemented restrictions on which residents could be fed by a paid feeding assistant as long as the resident was fed/assisted in the dining room. --A review of the Allegation of Compliance revealed the following: As of 09/15/11, the facility will no longer utilize paid feeding assistants to feed residents. On 09/15/11, the Administrator and Director of Nursing (DON) informed nursing and dietary staff that paid feeding assistants would no longer be utilized to feed residents at the facility. On 09/15/11, a sign was posted at the employee time clock and in the dining room notifying staff that paid feeding assistants would no longer be utilized to feed residents at the facility. This information was also reported to staff on the 24-hour nursing report. On 09/15/11, all paid feeding assistants were informed they would no longer be utilized to feed residents at the facility. --The surveyors validated the corrective actions taken by the facility as follows: Interview on 09/16/11, at 10:10 AM, with the DON and Administrator revealed as of 09/15/11, the facility would no longer utilize paid feeding assistants to feed residents. The interview also revealed a sign had been posted at each time clock to inform employees paid feeding assistants would no longer be utilized to feed residents. Further interview revealed facility staff had been informed that paid feeding assistants would no longer be used, and this information had been placed on the 24-hour report for staff to see. Interview revealed all four paid feeding assistants were notified on 09/15/11, they would no longer be utilized at the facility to feed residents. Interview on 09/16/11, with paid feeding assistant #3 at 9:45 AM, and paid feeding assistant #1 at 9:53 AM, revealed they had been notified by the DON and Administrator that they would no longer be utilized at the facility as paid feeding assistants and would no longer be permitted to feed residents at the facility. Interview on 09/16/11, at 9:15 AM, with Licensed Practical Nurse (LPN) #4 revealed she had been informed by the DON and Administrator the facility would no longer employ and use paid feeding assistants to feed residents. Interview on 09/16/11, at 9:22 AM, with Registered Nurse (RN) #4 revealed she had been informed by the DON and Administrator the facility would no longer employ and use paid feeding assistants to feed residents. Interview on 09/16/11, at 9:27 AM, with Certified Nursing Assistant (CNA) #4 revealed she had been informed by the DON and Administrator the facility would no longer use paid feeding assistants to feed residents. Interview on 09/16/11, at 10:17 AM, with a dietary aide revealed she had been informed the facility would no longer use paid feeding assistants as of 09/15/11. Observation on 09/16/11, at 9:00 AM, of the facility time clocks revealed signs were posted on the time clocks to inform employees the facility would no longer utilize paid feeding assistants effective 09/15/11. A review of the 24-hour nursing report on 09/16/11, revealed the facility would no longer use paid feeding assistants to feed residents. Based on the above findings, the State Agency determined Immediate Jeopardy was removed on 09/21/11, prior to exit, which lowered the scope and severity to "E" while the facility monitors the effectiveness of systemic changes and quality assurance actions.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to be administered in an effective/efficient manner to maintain the highest physical well-being for five (5) of twenty (20) sampled residents (Residents #7, #9, #10, #11, and #12). The facility failed to have an effective system in place to ensure paid feeding assistants did not assist residents assessed to have complicated feeding precautions with their meals, and also failed to ensure policies/procedures related to impaired swallowing precautions/aspiration precautions were implemented. Record review and interview revealed from 03/08/11, until 09/14/11, the facility permitted paid feeding assistants to feed/assist residents identified to have swallowing precautions. The facility failed to ensure the system in place to aid staff in identifying residents that required specific care with feeding needs and supervision during meal service was implemented. Additionally, the facility failed to ensure that staff providing feeding services to residents with complicated feeding problems had received appropriate training to ensure each resident's safety during assistance with feedings. (Refer to F282, F309, and F373.) The Administrator's failure to ensure paid feeding assistants did not feed residents assessed to have complicated feeding precautions, and to ensure facility policies/procedures related to residents with impaired swallowing and aspiration precautions were implemented caused, or is likely to cause, serious injury, harm, impairment, or death to residents in the facility, to include Residents #7, #9, #10, #11, and #12. Immediate Jeopardy and Substandard Quality of Care (SQC) were determined to exist on 09/14/11. An acceptable Allegation of Compliance (AOC) was received on 09/21/11, which alleged removal of Immediate Jeopardy on 09/21/11. The State Agency determined the Immediate Jeopardy was removed on 09/21/11, prior to exit, which lowered the scope and severity to "E" while the facility monitors the effectiveness of the systemic changes and quality assurance activities. The findings include: Upon request to view the facility's feeding/swallowing precautions policy/procedure, the Director of Nursing stated they did not have a specific policy/procedure, but utilized the Fundamental Procedures instruction textbook as a guide. A review of the "Feeding" and "Impaired Swallowing and Aspiration Precautions" sections revealed if a resident had swallowing difficulties a consultation with Speech Therapy should be obtained prior to feeding the resident. Choking and aspiration of food could occur if the patient is fed too quickly or is given excessively large mouthfuls. Additionally, the text indicated caregivers should develop a management plan that included common swallowing strategies, nutritional status, and supervision. The text went on to instruct caregivers to monitor residents for signs and symptoms of swallowing problems and aspiration. 1. Observation of the evening meal on 09/14/11, revealed paid feeding assistants feeding/supervising Residents #7, #9, and #11 during the meal. The facility's assessments revealed the residents required swallowing strategies for [DIAGNOSES REDACTED]. Interviews were conducted on 09/15/11, at 3:00 PM, with paid feeding assistant #4; at 5:32 PM, with paid feeding assistant #2; and at 5:49 PM, with paid feeding assistant #3. The paid feeding assistants stated they had completed the Paid Feeding Assistants Program at the facility and functioned as paid feeding assistants. The paid feeding assistants all stated they were permitted to feed/assist any resident that ate in the dining room and had never been instructed they could not feed any particular residents. The paid feeding assistants stated they had not been trained to feed residents with specialized feeding precautions and, they were not aware of any resident in the facility that required special feeding precautions. An interview with Licensed Practical Nurse (LPN) #5 on 09/15/11, at 7:43 PM revealed she was responsible to facilitate the Paid Feeding Assistants Program in the facility. LPN #5 stated the facility implemented the Paid Feeding Assistant Program on 03/08/11, and utilized four paid feeding assistants. According to LPN #5, the facility had not developed a formal written policy/procedure that governed the Paid Feeding Assistant Program and stated the paid feeding assistants were only utilized in the dining room and could feed/assist any resident who required assistance when they ate in the dining room. LPN #5 stated she, the Administrator, and the Director of Nursing (DON) discussed the Paid Assistant Feeding Program and decided the paid feeding assistants would only be utilized in the dining room and that "if a resident was well enough to eat in the dining room, they could be fed by a paid feeding assistant." LPN #5 stated she was not aware paid feeding assistants were not permitted to feed/assist residents who had complicated feeding problems. In an interview on 09/15/11, at 8:50 PM, the Administrator and the Director of Nursing (DON) revealed the facility had utilized paid feeding assistants since 03/08/11. She stated she was not aware paid feeding assistants could not feed residents with complicated feeding problems. The DON stated, "I thought it was just state to state, I didn't realize there was a Federal Regulation about it." Per interview, the Administrator revealed the facility had never implemented restrictions on which residents could be fed by a paid feeding assistant as long as the resident was fed/assisted in the dining room. 2. Observation and interviews from 09/14-16/11, revealed Residents #7, #9, #10, #11, and #12, required swallowing strategies for feeding and were not provided the required assistance with feeding. Furthermore, facility staff was not knowledgeable of the resident's swallowing strategies. Interviews conducted on 09/15/11, with four staff persons that had been observed feeding residents, and with four CNAs and a Licensed Practical Nurse revealed if a resident required any special feeding assistance it would be on the resident's tray card that was placed on each resident's food tray by dietary personnel. The staff interviewed stated if the tray card did not contain any special instructions related to feeding/assisting residents with meals assistance was not required and/or provided. However, a review of Residents #7, #9, #10, #11, and #12's tray cards revealed specialized instructions related to feeding were not documented on the cards and only portions of the feeding instructions were documented on the meal cards of Residents #7, #10, and #12. The Administrator stated in interview on 09/15/11, that facility staff had been trained to rely on the tray cards for any specialized instructions which included feeding precautions for each resident that had been assessed to require the precautions. However, the Administrator explained that she had not realized the feeding precautions were not on the tray cards until 09/15/11. --A review of the Allegation of Compliance revealed the following: On 09/16/11, the speech therapist screened all residents on swallowing precautions. Any new or revised recommendations were made. On 09/16/11, the Director of Nursing (DON) and Administrator audited the personal care plans and tray cards for the residents on swallowing precautions to ensure accuracy. A Swallowing Precaution Communication Procedure was established. The Speech Therapist will give a copy of each resident's swallowing precautions to the Dietary Manager, the Assistant Director of Nursing (ADON), the Infection Control Nurse, and the Director of Nursing (DON). The DON will monitor the communication procedure. The DON will also ensure the swallowing precautions have been added by the Dietary Manager to the tray cards. The DON will ensure the ADON has put a copy of swallowing precaution strategies in each resident's personal care record books. Each week the DON will review the swallowing precaution sheets received from the Speech Therapist. After the DON ensures swallowing precautions on the tray card are correct and swallowing strategies have been included in the personal care record, she will sign her copy of the swallowing strategies to acknowledge receipt/approval. The DON will also keep a copy of this sheet in a binder in her office. Swallowing precaution books were created to include a master list of residents with swallowing precautions and also included a copy of the emergency care for choking poster and a copy of the signs and symptoms of aspirations. The Dietary Manager will be responsible to keep the book up to date. In addition, the Administrator will audit the swallowing precaution book at least weekly to ensure the books are kept up to date. On 09/16/11, the Administrator educated the Dietary Manager, Speech Therapist, DON, Infection Control Nurse, and the ADON on the swallowing precaution communication procedure and on the swallowing precaution book. On 09/20/11, a copy of the emergency care for choking poster was posted in the dining room. On 09/16/11, the DON, MDS Coordinator, and the Infection Control Nurse educated all nursing personnel on swallowing precautions and how they are effective. The form used by the Speech Therapist to inform staff of what swallowing interventions each resident required was explained to staff. On 09/16/11, nursing assistants were educated on where to locate the swallowing precautions master list where the residents' swallowing precaution strategies could be found. Staff was instructed on the locations of the master list: the personal care records, the tray cards, in binders located in the dining room on the snack cart, and at both nurses' stations. Beginning 09/19/11, all nursing personnel will be reeducated on the choking section of the nurse aide training curriculum. Beginning 09/20/11, all nursing personnel were reeducated on the signs and symptoms of aspiration. Nursing assistants were trained on what to do when a resident showed signs and symptoms of aspiration. No nursing personnel will work until trained. Beginning 09/20/11, nurses were reeducated on what to do if a nurse aide reports a resident has exhibited signs and symptoms of aspiration. No nursing personnel will work until trained. Upon hire, all employees will be educated on the facility swallowing procedures and the signs and symptoms of aspiration. On 09/16/11, administrative nurses observed nurse aides feeding residents on swallowing precautions to ensure that nursing assistants were aware of swallowing precautions. Beginning 09/17/11, the licensed nurse assigned to the resident halls and the licensed nurse assigned to the dining room were to monitor each resident on swallowing precautions to ensure the nursing assistants were aware of the swallowing precautions, the swallowing precautions were being followed and the swallowing precautions were on the tray card. This quality assurance is to be done at every meal. During the lunch meal the licensed nurse assigned to the resident halls and the licensed nurse assigned to the dining room were to monitor all residents for signs and symptoms of aspiration to ensure that nursing assistants were aware of the signs and symptoms of swallowing issues. All nurses on duty on 09/20/11, were educated on the monitoring procedure, and nurses will be not allowed to work before being educated on the signs and symptoms of swallowing issues. The Medical Director was informed of the immediate jeopardy. Weekly the Administrator will observe meal service and will conduct audits to ensure compliance with the plan of correction. The Administrator will report the audit to the quality assurance committee on a quarterly basis. --The surveyors validated the corrective actions taken by the facility as follows: Observation of the noon meal on 09/21/11, revealed RN #4 in the dining room supervising CNAs feeding residents. Interview at this same time revealed the nurse was responsible for observing residents in the dining room to assure they have received the correct diet, that the diet and swallowing precautions were printed on the tray card, to assure the nursing aides were following swallowing precautions and observing for signs and symptoms of aspiration and choking. Interview further revealed there was a poster on the wall with interventions for choking, and there was a book with each resident on swallowing precautions, what the precautions were, what to do in the event of choking, and signs and symptoms of aspiration. RN #4 further stated she received in-service training on 09/19/11, regarding the need to supervise nursing aides while the aides fed residents, what swallowing precautions were, the swallowing precaution book, that all swallowing precautions were required to be on the tray card, and on choking and aspiration. Further observation of the noon meal on 09/21/11, revealed Residents #7, #11, and #10, in the dining room at a table assisted by a nursing assistant. Review of their tray cards revealed swallowing precautions were listed on the cards. Observation of the dining room on 09/21/11, revealed an emergency care for choking sign posted on the wall. Observation on 09/21/11, revealed a swallowing precaution book in the dining room, each nurses' station, and on each snack cart. Interview with the Speech Therapist (ST) on 09/21/11, at 3:30 PM, revealed she had conducted a current screening for all residents on swallowing precautions and had made any revisions or new recommendations for each resident. The ST went on to say she was responsible for providing a copy of the current swallowing precautions for each resident to the Dietary Manager (DM), ADON, Infection Control Nurse, and the DON. Interview further revealed the therapist had been educated by the Administrator on the need to provide a current copy of each resident's swallowing precautions to the DM, ADON, Infection Control Nurse, and the DON, and in the swallowing precaution book. Interview with the Administrator on 09/21/11, at 3:45 PM, revealed she is responsible for auditing the swallowing precaution book weekly to ensure it is up to date. She further stated she had educated the Dietary Manager, Speech Therapist, DON, Infection Control Nurse, and the ADON on the swallowing precaution communication procedure and the swallowing precaution book. Further interview revealed she would be observing meal service weekly and would perform an audit during that time to ensure the plan of correction was being followed. The Administrator stated she would report this audit at the quality assurance meeting quarterly. Interview with the DON on 09/21/11, at 3:15 PM, revealed she, along with the Administrator, had audited all personal care plans and tray cards and found no problems. Interview further revealed she is responsible to ensure the Dietary Manager puts all swallowing precautions on each resident's tray card. Further interview revealed she had assured the ADON had put a copy of the swallowing precautions strategies in each resident's personal care book. The DON further stated she received in-service training on 09/16/11, on swallowing precaution communication procedures and the swallowing precaution book. Interview further revealed each week the DON would verify the swallowing precautions were on the tray cards and in each resident's personal care book. She further stated that after verifying the swallowing precautions were on the tray cards and in the personal care books, she would then sign her copy of the swallowing strategy for each resident and it would be kept in a binder in her office. Interview further revealed the DON had been in-serviced by the Administrator on the swallowing precaution communication procedures and the swallowing precaution book. Interview on 09/21/11, at 2:03 PM, with the Dietary Manager revealed it was her responsibility to ensure all swallowing strategies were on each resident's tray card. Further interview revealed the Dietary Manager is responsible for ensuring the swallowing precaution books are current and up to date for each resident on special feeding precautions. Interview further revealed she had been educated by the Administrator regarding the swallowing precaution communication procedure and the swallowing precaution book. Interview on 09/21/11, at 3:38 PM, with CNA #9, at 3:42 PM, with Nurse Aide #1, at 4:00 PM, with CNA #11, and at 4:10 PM, with CNA #4 revealed they had been in-serviced on swallowing precautions, where each resident's swallowing precautions were located, what to do when a resident chokes, and signs and symptoms of aspiration. Interview further revealed a nurse has to be in the dining room before they can begin feeding the residents, and they are required to look at each resident's tray card and ensure precautions are followed. Interview with LPN #5 on 09/21/11, at 3:47 PM, and RN #2 at 4:15 PM, revealed they had been in-serviced on resident swallowing precautions and all precautions have to be on the tray card and in the swallowing strategy book. They further stated they had also been in-serviced on signs and symptoms of aspiration and what to do if a resident chokes. Interview further revealed they were instructed to monitor the dining room and/or the resident floors to ensure nurse aides were following swallowing precautions, and to observe for aspiration/choking. Interview on 09/21/11, at 2:00 PM, with the Medical Director revealed she had been informed of the immediate jeopardy identified at the facility. Review of the personal care records audit revealed the DON and Administrator had audited all personal care plans and tray cards for each resident on swallowing precautions on 09/16/11, and found no discrepancies. A review of the new swallowing precaution communication procedure revealed the procedure was implemented on 09/16/11. A review of the facility's training records revealed evidence that employees of the facility, except for those on vacation or on medical leave, had received training on swallowing precautions and how they are effective on 09/16/11. Any employee who did not attend training was informed they will not be allowed to work until trained. Further review revealed nursing assistants had received training on 09/16/11, on the location of the swallowing precautions master list, and the swallowing precaution strategies. Review further revealed on 09/19/11, nursing personnel were educated on the choking section of the nurse aide training curriculum. Facility training records further revealed on 09/20/11, nursing personnel were educated on signs and symptoms of aspiration. A review of "Swallowing Precaution Education" to be given to employees upon hire revealed the facility would ensure newly hired employees were educated on each resident's swallowing precautions, signs and symptoms of aspiration, and emergency preparedness for choking. A review of facility tray cards for the nine residents assessed by the facility to require swallowing strategies revealed each card contained the resident's required strategies. A review of the facility's swallowing precaution quality assurance log revealed from 09/16/11-09/21/11, staff had monitored tray cards to ensure each resident with a swallowing strategy had the strategy on their tray card, that the nurse aide was adhering to the swallowing precautions, and if further staff education was needed. Based on the above findings, the State Agency determined Immediate Jeopardy was removed on 09/21/11, prior to exit, which lowered the scope and severity to "E" while the facility monitors the effectiveness of systemic changes and quality assurance actions.