Every finding on record at Springhill Senior Residence

Based on observation, interviews, a review of manufacturer's specifications and facility standards for dish machine sanitization, staff failed to ensure the water temperatures were consistently hot enough to sanitize items processed through the dish machine on 11/07/18. This had the potential to affect all 92 residents for whom meals were prepared and served at the time of this survey. Findings include: Directives from the Felder Corporation, posted on the Dish Room wall direct staff as follows: .DISHMACHINE SANITIZING Wash Cycle=125 degrees F (Fahrenheit) or hotter Rinse Cycle=140 degrees F or hotter 50 PPM (parts per million) (Chlorine concentration) . The Data Plate affixed to the side of the Auto-Chlor Dishmachine specified the following: Water Temperature=120 degrees F Chlorine Residual=50 PPM Minimum Wash=56 seconds, Rinse=24 seconds. The facility's Dish Machine temperature log (on which staff documented daily water temperatures) included a recommended rinse water temperature of 140 degrees F or above, and a concentration of sanitizer of 50 PPM (parts per million). On 11/07/18 at 8:50 AM the surveyor observed facility staff process dishes from the breakfast meal. The first cycle of dishes, which included a rack of ceramic plates were processed at a wash temperature of 98 to 100 degrees F, and a rinse temperature of 112 degrees F. The readings on the temperature gauge were verified by Employee Identifier (EI) #1, the Dietary Aide responsible for pre-rinsing and sending the racks through the dishmachine. After the rack of plates had sat on the clean end of the dishmachine counter several minutes, the second Dietary Aide (EI #2) stacked and put the plates away. At 9:00 AM, EI #1 sent another rack of trays through the dishmachine. The wash water registered 94-95 degrees F, and the rinse water registered 110 degrees F. EI #1 then processed a rack of silverware and a rack of trays at a wash temperature of 95 degrees F and rinse temperature of 110 degrees F. The temperatures were confirmed by the Dietary Manager EI #3. At the surveyor's request, staff checked the chlorine concentration, which was found to be adequate at 50 PPM (parts per million). The same rack of trays was re-processed through the dishmachine at a wash temperature of 104 degrees F, and a rinse temperature of 110 degrees F. The trays were then stacked and put away by EI #2. Another rack of trays and a rack of silverware (separated by knives, forks, spoons into a divided caddy) were processed though the dishmachine at a wash temperature of 108 degrees F, and a rinse temperature of 122 degrees F. The water temperatures were confirmed by EI #3. The rack of trays were not re-washed, but were instead, put away by EI #2. The final items processed through the dishmachine and observed by the surveyor was a rack of trays and a rack of silverware (third time processed). The wash temperature registered 108 degrees and the rinse temperature registered 120 degrees F. On 11/07/18 at 9:20 AM, the surveyor asked EI #1 (Diet Aide) whose responsibility it was to monitor the dishmachine temperatures and chlorine concentration. EI #1 stated it was herself. EI #1 stated the goal water temperature was at least 120 to 125 degrees F. When asked what could happen if the water temperatures did not get hot enough, EI #1 stated she would run the rack through the machine again, and call the company to determine the problem. When asked if wash temperatures of 95 and rinse temperatures of 110 were hot enough, no answer was given. On 11/07/18 at 9:45 AM, the surveyor asked the Dietary Manager (EI #3) what wash temperature was recommended by the dishmachine (data plate). EI #3 responded, 140 degrees F or above. The surveyor commented the staff knew to rewash if the water temperature was not high enough, but they did not rewash the trays when the wash temps were 95 to 104 degrees, and the rinse was 110 degrees F. The surveyor asked what was the potential concern. In response, EI #3 stated the staff should rewash the dishes. EI #3 further explained if the dishes did not get adequately sanitized at the right temperature, it could potentially cause sickness.

Based on observations, interview and record review, the facility failed to ensure Resident Identifier (RI) #80, a resident identified by the facility as being at risk for falls, had the fall intervention of mats on the floor on both sides of the bed implemented. This deficient practice affected RI #80, one of one resident sampled for accidents, and who was observed on three of four days of the survey. Findings Include: RI #80 was admitted to the facility on [DATE], and readmitted on [DATE]. RI #80's Fall care plan, with a Problem Onset date of 01/23/17, documented: . (RI #80) is at risk for falls related to (his/her) fall history . Approaches . * SOFT MATS TO EACH SIDE OF BED . On 11/06/18 at 5:17 p.m., the surveyor observed RI #80 lying in bed. There was a fall mat on the floor on the left side of the bed. A second mat was observed underneath the bed. There was no mat observed on the floor on the right side of the bed. On 11/07/18 at 8:41 a.m, the mat remained on the floor on the left side of the bed with the second mat on the floor underneath the bed. There was no mat observed on the floor on the right side of the bed. On 11/08/18 at 7:45 a.m., the surveyor observed a fall mat on the floor on the left side of the bed and a second mat was observed underneath the bed. There was no mat observed on the floor on the right side of the bed. On 11/08/18 at 2:48 p.m., the surveyor conducted an an interview with Employee Identifier (EI) #4, a Registered Nurse (RN) Unit Manager. The surveyor asked EI #4 was RI #80 a fall risk. EI #4 said yes. The surveyor asked EI #4 what did she observe concerning the mats when she and the surveyor entered RI #80's room. EI #4 said there was only one mat on the floor on the left side of the bed.

Based on observations, interview and record review, the facility failed to ensure Resident Identifier (RI) #80's Fall care plan intervention to have mats on both sides of the bed was followed. This deficient practice affected RI #80, one of 24 sampled residents whose plans of care were reviewed, and who was observed on three of four days of the survey. Findings Include: RI #80 was admitted to the facility on [DATE], and readmitted on [DATE]. RI #80's Fall care plan, with a Problem Onset date of 01/23/17, revealed: . (RI #80) is at risk for falls related to (his/her) fall history . Approaches . * SOFT MATS TO EACH SIDE OF BED . On 11/06/18 at 5:17 p.m., the surveyor observed RI #80 lying in bed. There was a fall mat on the floor on the left side of the bed. A second mat was observed underneath the bed. There was no mat observed on the floor on the right side of the bed. On 11/07/18 at 8:41 a.m, the mat remained on the floor on the left side of the bed with the second mat on the floor underneath the bed. There was no mat observed on the floor on the right side of the bed. On 11/08/18 at 7:45 a.m., the surveyor observed a fall mat on the floor on the left side of the bed and a second mat was observed underneath the bed. There was no mat observed on the floor on the right side of the bed. On 11/08/18 at 2:48 p.m., the surveyor conducted an interview with Employee Identifier (EI) #4, a Registered Nurse (RN) Unit Manager. The surveyor asked EI #4 was RI #80 care planned to have mats on the floor on both sides of the bed. EI #4 said yes. The surveyor asked EI #4 what did she observe concerning the mats when she and the surveyor entered RI #80's room. EI #4 said there was only one mat on the floor on the left side of the bed. The surveyor asked EI #4 was RI #80's care plan being followed if the mats were not on the floor on both sides of the bed. EI #4 replied no.

Based on interviews and record review, the facility failed to ensure Resident Identifier (RI) #12's Significant Change (SC) Minimum Data Set (MDS) assessment, dated 08/15/18, reflected RI #12's accurate weight during this assessment period. This deficient practice affected RI #12, one of 24 sampled residents whose MDS was reviewed. Finding Include: RI #12 was admitted to the facility on [DATE]. RI #12's SC MDS assessment, with an Assessment Reference (ARD) of 08/15/18, identified RI #12's weight to be 128 pounds during this assessment period. A review of RI #12's Weight Change History form revealed RI #12's weight was 159 pounds on 08/07/18. On 11/08/18 at 2:05 p.m., the surveyor conducted an interview with Employee Identifier (EI) #5, the MDS Coordinator. The surveyor asked EI #5, according to RI #12's 08/15/18, SC MDS, what was RI #12's weight. EI #5 said 128 pounds. EI #5 said the weights on RI #12's Weight Change History form were the correct weights. EI #5 said there was a specific section each discipline signed off on the MDS. The surveyor asked EI #5 who signed off on RI #12's 08/15/18, SC MDS. EI #5 replied EI #3, the Dietary Manager. The surveyor asked EI #5 what was RI #12's weight before the SC MDS assessment. EI #5 said 159 pounds. On 11/08/18 at 2:29 p.m., the surveyor conducted an interview with EI #3. The surveyor asked EI #3 was she responsible for coding RI #12's weight on the 08/15/18, SC MDS. EI #3 said yes. The surveyor asked EI #3 what was RI #12's weight on the 08/15/18, SC MDS. EI #3 said 128 pounds. EI #3 said it looked like she made a mistake and put in the wrong weight. The surveyor asked EI #3 was this an accurate weight on the MDS assessment. EI #3 replied no.

Based on an observation, interviews, and a review of a facility policy titled, Dignity, the facility failed to ensure a resident's dignity was maintained regarding removal of facial hair for RI (Resident Identifier) #4. This affected RI #4, one of eleven sampled residents. Findings Include: A review of a facility policy titled, Dignity dated 09/2006 revealed, . POLICY: Residents are cared for in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his/her individuality. A review of the medical record revealed RI #4 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Quarterly MDS (Minimum Data Set) assessment dated [DATE], revealed RI #4 required extensive assistance of one person for personal hygiene. An observation was made during the initial tour of the facility at 8:45 a.m. on 10/11/2017 of RI #4 seated in a wheelchair with multiple long (approximately 1/4 inch) white hairs on both sides of the lips and under the chin. An interview was conducted with EI (Employee Identifier) #2, a CNA (Certified Nursing Assistant), at 3:48 p.m. on 10/12/2017. EI #2 was asked if she had provided grooming for RI #4 on 10/11/2017 and she answered yes. EI #2 was asked what care she provided for RI #4's facial hair. EI #2 answered, Shaved the hairs off. EI #2 was asked what she observed prior to shaving the resident's face. EI #2 answered a bunch of hairs, both black and gray facial hair. EI #2 was asked if the hairs were long and she answered yes and they were very noticeable. EI #2 said, It's a dignity issue for residents to have long facial hairs. An interview was conducted with EI #1, the DON (Director of Nursing), at 5:13 p.m. on 10/12/2017. EI #1 was asked if RI #4 could perform facial grooming unassisted and she answered, No. EI #1 was asked who was supposed to perform this care for RI #4 and she answered, CNAs. EI #1 said it was a dignity issue for residents to have long hairs beside their lips and under their chin. EI #1 was asked what was the facility's policy regarding dignity. EI #1 answered, Provide care with the utmost dignity.

Based on observations, interviews, and record reviews, the facility failed to ensure: 1. An expired vial of influenza vaccine dated [DATE], was not observed in the medication room on [DATE]. 2. Two vials of Tubersol/Tuberculin Purified Protein were not observed without an open date in the medication room on [DATE]. This was observed in one of one medications room reviewed. Findings include: A review of a facility policy titled, Storage of Medication, with no date revealed: Medications, such as insulin and biologicals, are stored properly, following manufacturer's recommendations or those of the supplier to maintain their integrity and to support safe administration. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medication. A review of the Manufacturer's information sheet for the influenza vaccine revealed: .Storage and Handling . Do not use after the expiration date shown on the label . A review of the Manufacturer's information sheet for Tubersol revealed: .STORAGE . A vial of Tubersol which has been entered and in use for 30 days should be discarded . On [DATE] at 4:00 PM, during a medication room check, a vial of influenza vaccine was observed with an expiration date of [DATE]. Two vials of Tubersol/ Tuberculin were observed with no open date. EI (Employee Identifier) #3, a Unit Manager was present during the observation. On [DATE] at 4:05 p.m., an interview was conducted with EI #3. The surveyor asked EI #3 what she observed, regarding the influenza vaccine in the med room. EI #3 stated, The influenza vaccine has an expiration date of [DATE]. The surveyor asked EI #3 if the vial was opened. EI #3 stated, Yes. The surveyor asked EI #3 if the vial had an open date. EI #3 stated, No ma'am. The surveyor asked what did she observe regarding the 2 Tubersol vials observed in the medication room. EI #3 stated, The expiration date is [DATE], but they have no open date. The surveyor asked EI #3 what was the concern when medication was expired. EI #3 stated, It can interfere with the potency of the medication. EI #3 was asked what was the concern when vials were opened with no open dates. EI #3 stated, We don't know how long it is open, or how long the medication has been out. On [DATE] at 5:45 p.m., an interview was conducted with EI #5, DON (Director of Nursing). EI #5 was asked whose responsibility was it to ensure medications were labeled and monitored for expiration dates. EI #5 stated, The nurses should do it. The nurse that opens the bottle should date it, with an open date. The surveyor asked EI #5 what was the potential negative outcome when medications were expired and not labeled with an open date. EI #5 stated, They are immunizations, so the concern would be they might not be as effective.

Based on an observation, interviews, and record reviews, the facility failed to ensure Employee Identifier (EI) #1, a Certified Nursing Assistant (CNA) changed the position of the wipe during incontinence care. This affected RI #6, one of one resident observed for incontinence care. Findings include: A review of a facility document titled: Incontinence/Perineal Care, with a revision date of April 2014, revealed: .POLICY: Resident will be provided with incontinence care and/or perineal care to control odor, reduce the risk of urinary tract infection and protect the integrity of the skin. PROCEDURE: - Use [MEDICAL CONDITION] from pubis to perineum (cleanse front to back) . RI #6 was readmitted to the facility on [DATE]. RI #6's Quarterly Minimum Data Set with a assessment reference date of 9/15/16, revealed RI #6 required extensive to total assistance with all activities of daily living. RI #6 was coded as always incontinent of bladder and bowel. On 11/30/16 at 2:40 p.m., an observation was made of incontinence care for RI #6. The incontinence care was performed by EI #1, a CNA. EI #1 wiped the top of RI #6's penis four times in a circular motion without changing the position of the wipe. EI #1 wiped the front of the scrotum twice without changing the position of the wipe. EI #1 then wiped around and down seven times over the penis and in and around the resident's scrotum without changing the position of the wipe. On 11/30/16 at 4:15 p.m., an interview was conducted with EI #1. The surveyor asked EI #1 how she cleaned the front of RI #6's perineal area. EI #1 stated, I started at the lining of his/her stomach and threw the wipe away. I went from corner to corner at each side. I wiped his/her private area. There was no skin to pull back. I cleaned the area and applied (the name of the perineal solution). The surveyor asked EI #1 when should the position of the perineal wipe be changed during incontinence care. EI #1 stated, I don't use the wipe to re-clean the area. I use a new wipe. The surveyor asked how did she clean the resident's penis during the incontinence care observation. EI #1 stated. I went from the tip down. The surveyor shared the above observation with EI #1 and asked what was the concern. EI #1 stated, The concern is contamination, you are putting the same germ back on the resident. On 12/1/16 at 11:00 a.m., EI #2, the Education Nurse was asked when should staff change the position of the wipe, or change wipes during incontinence care. EI #2 stated, They are to change a new wipe with each swipe. EI #2 was asked how should the front of a male's perineal area be cleaned during incontinence care. EI #2 stated, We teach them to start at the top of the penis, wiping in a circular motion. Throw the wipe away. The next step is to wipe the base of the penis and throw it away. They are also taught about the foreskin, to pull back the foreskin, and clean and pull back over after cleaning.

Based on observations, interviews and record review, the facility failed to ensure Employee Identifier (EI) #5 and EI #6, both Certified Nursing Assistants (CNAs) did not stand while they fed Resident Identifier (RI) #3. This deficient practice affected RI #3, one of two residents observed for feeding assistance. Findings include: RI #3 was admitted to the facility on [DATE]. RI #3's Quarterly Minimum Data Set with an assessment reference date of 3/3/16, identified RI #3 as being totally dependent on staff for eating. On 4/19/16 at 5:05 PM, EI #5, a CNA was observed standing while feeding RI #3, who was observed lying in bed. In an interview on 4/20/16 at 2:57 PM, EI #5, a CNA, was asked, what her body position was when she fed RI #3 on 4/19/16. EI #5 stated, she was standing. When asked, how should she have been positioned, EI #5 stated, she should have been sitting. On 4/20/16 at 8:15 AM, EI #6, a CNA, was observed standing while feeding RI #3. During an interview on 4/21/16 at 9:16 AM, EI #6, a CNA acknowledged that she was standing when she fed RI #4 on 4/20/16. EI #6 explained that she should have been in a seated position. In an interview on 4/20/16 at 3:09 PM, EI #2, the Director of Nursing was asked, how should staff member be positioned when feeding a resident. EI #2 stated, Sitting next to them. When asked, should a staff member stand to feed a resident, EI #2 stated, No ma'am. EI #2 was asked what issue could arise if a staff member stood to feed a resident. EI #2 stated, What we teach them to sit because of dignity. This deficiency was cited as a result of the investigation of complaint/report number AL 364.

Based on observations, interview and record review, the facility failed to ensure Employee Identifier (EI) #8, a Licensed Practical Nurse (LPN) did not sign off the Medication Administration Record (MAR) before preparing and before administering medications to Resident Identifier (RI) #2 and RI #3. This affected RI #2 and RI #3, two of two residents observed for medication administration. Finding include: According to Chapter 31 titled Medication Administration page 586-587 of FUNDAMENTALS OF NURSING EIGHTH EDITION with a copyright date of 2013, . Right Documentation . After administering a medication, indicate which medication was given on the patient's MAR . Never document that you have given a medication until you have actually given it . During medication administration observation on 4/20/16 beginning at 9:06 AM, EI #8, a LPN documented on RI #2's and RI #3's MAR that each resident had received the ordered medication before it was actually administered. As EI #8 prepared each medication for administration, she documented on the MAR that medications had been administered to the resident. In an interview on 4/20/16 at 11:27 AM, EI #8 was asked, when should medication administration be documented on the MAR. EI #8 replied, After administration. EI #8 acknowledged that she documented on the MARs before the medication was administered to the resident. EI #8 was asked, if she was taught to sign for a medication before administering the medication. EI #8 stated no. When asked, what was the potential harm in documenting the administration of a medication before actually administering the medication, EI #8 explained that if something happened and the resident did not get the medication, it would look as if they did. During an interview on 4/20/16 at 12:18 PM, EI #2, the Director of Nursing was asked, when should a nurse document the administration of medication on the MAR. EI #2 replied, after the medication was given. This deficiency was cited as a result of the investigation of complaint/report number AL 364.

Based on observation, interviews, and record review, the facility failed to ensure Employee Identifier (EI) #7, a Certified Nursing Assistant (CNA) transferred Resident Identifier (RI) #4, as care planned on 4/20/16. This affected RI #4, one of three sampled residents identified as being care planned for Hoyer Lift transfers. Findings include: RI #4 was readmitted to the facility on [DATE]. RI #4's medical history included a [DIAGNOSES REDACTED]. RI #4's Annual Minimum Data Set with an assessment reference date of 3/18/16, indicated RI #3 was totally dependent on two plus person physical assistance for transfers. RI #4's Care Plan titled At risk for falls . had an approach of . * Assist of 2 of more with Hoyer Lift transfer . During an observation on 4/20/16 at 8:21 AM, EI #7, a CNA transferred RI #4 with a Hoyer Lift, from the bed to a wheelchair by herself. In an interview on 4/21/16 at 11:39 AM, EI #7 was asked if she had any assistance when she transferred RI #4 on 4/20/16 with the Hoyer Lift. EI #7 stated, No. EI #7 was asked, if she followed RI #4's care plan with transfers when she transferred the resident. EI #7 stated, Well I was supposed to have two in there and I just did it by myself so I guess not. When asked, what the potential harm was for not following the care plan, EI #7 stated, the resident could fall. During an interview on 4/21/16 at 12:13 PM, EI #2, the Director of Nursing acknowledged that RI #4's care plan indicated the resident was to be transferred with the assistance of two people. This deficiency was cited as a result of the investigation of complaint/report number AL 364.

Based on observation, interviews and record review, the facility failed to ensure Employee Identifier (EI) #3 and EI #4, both Certified Nursing Assistants (CNAs) correctly placed Resident Identifier (RI) #1 in the Hoyer lift on 2/29/16. During the transfer, RI #1 was dropped from the Hoyer lift. The facility further failed to ensure EI #7, also a CNA, did not transfer RI #4 with a Hoyer lift by herself on 4/20/16. These deficient practices affected RI #1 and RI #4, two of three residents sampled who required the use of a Hoyer lift for transfer. Findings include: On 4/15/16, the State Agency received a complaint, which alleged RI #1 was dropped from a lift, as the result of sling not being applied correctly. 1) RI #1 was readmitted to the facility on [DATE]. RI #1's NURSE'S NOTES dated 2/29/16 7:00 PM, documented Resident observed on the floor next to bed. (EI #3) stated (he/she) fell backwards out of the hoyer pad onto the floor. No visible signs of injury. Resident stated my arm hurts. When asked if (he/she) hit (his/her) head resident replied yes. send to (local) ER (emergency room ) for eval (evaluation) & tx (treatment) . A review of the INCIDENT/ACCIDENT REPORT indicated on 2/29/16 at 7:00 PM, when RI #1 was being transferred from the chair to the bed via Hoyer lift, the resident slipped backwards of the lift pad and landed on the floor. The lift pad was observed to be too small for the resident's size. The staff involved during the transfer was identified as EI #3 and EI #4, both CNAs. To prevent the recurrence, the CNAs were instructed to use the proper pad size during Hoyer lift transfers. In an interview on 4/20/2016 at 2:35 PM, EI #4, a CNA was asked, what happened during the transfer of RI #1 on 2/29/16. EI #4 replied something went wrong with the Hoyer lift, one loop slipped out of the hook while RI #1 was being lifted. During an interview on 4/21/2016 at 12:42 PM, EI #3, a CNA, was asked what happened that resulted in RI #1's fall on 2/29/16. EI #3 replied, RI #1 was hooked up to the Hoyer lift and the other aide (EI #4) lifted the resident up while the chair was being moved. RI #1's head was sliding down and it was too late to stop the fall. When asked, if she made sure the Hoyer lift pad was positioned right before transfer, EI #3 replied no. EI #3 was asked when moving a resident, should she check the pad and she said yes. EI #3 was asked how was the resident positioned in the chair. EI #3 replied, the pad was half way of RI #1's body it should have been at RI #1's shoulder blades. During an interview on 4/21/2016 at 2:52 PM, EI #1, the Administrator stated, the CNAs (EI #3 and EI #4) did not cross the straps on the Hoyer lift pad when they transferred RI #1 on 2/29/16. When asked, what the potential harm could be, EI #1 replied, injury. RI #1's NURSE'S NOTES dated 3/1/16 at 12:30 AM, indicated RI #1 returned to the nursing facility, the CT (Computerized Tomography) of the head and all X-rays were negative. RI #1 received no new physician orders. SPRINGHILL SENIOR RESIDENCE Staff Development - Attendance Record held on 3/4/16 at 2:30 PM, indicated the following was discussed . CNA's (names) presented and demonstrated the proper way to use the hoyer lift. The policy was also handed out. It was emphasized to make sure the strings are criss-crossed under the legs. The hoyer is safe to use but policy of use must be followed or it can cause human error . RI #1's physician progress notes [REDACTED]. 2) RI #4 was readmitted to the facility on [DATE]. RI #4's medical history included a [DIAGNOSES REDACTED]. RI #4's Annual Minimum Data Set with an assessment reference date of 3/18/16, indicated RI #3 was totally dependent on two plus person physical assistance for transfers. RI #4's Care Plan titled At risk for falls . had an approach of . * Assist of 2 of more with Hoyer Lift transfer . During an observation on 4/20/16 at 8:21 AM, EI #7, a CNA transferred RI #4 with a Hoyer Lift, from the bed to a wheelchair by herself. In an interview on 4/21/16 at 11:39 AM, EI #7 was asked if she had any assistance when she transferred RI #4 on 4/20/16 with the Hoyer Lift. EI #7 stated, No. EI #7 was asked, if she followed RI #4's care plan with transfers when she transferred the resident. EI #7 stated, Well I was supposed to have two in there and I just did it by myself so I guess not. When asked, what the potential harm was for not following the care plan, EI #7 stated, the resident could fall. During an interview on 4/21/16 at 12:13 PM, EI #2, the Director of Nursing acknowledged that RI #4's care plan indicated the resident was to be transferred with the assistance of two people. This deficiency was cited as a result of the investigation of complaint/report number AL 364.

Based on observation, interviews and record review, the facility failed to ensure Employee Identifier (EI) #8, a Licensed Practical Nurse (LPN) disposed of a used Fentanyl (a narcotic medication) patch after it had been used. EI #8 left the Fentanyl patch on top of an unattended medication cart. This deficient practice was observed on one of three days of the survey. Findings include: The facility's Controlled Drug Record document titled, Topical Patches, with a revised date of 10/13 indicated: . USED PATCH DESTRUCTION When patch is removed, it must be immediately destroyed and witnessed with two nurse signature . During medication administration on 4/20/16 beginning at 9:37 AM, a Fentanyl patch was observed sitting on top of the medication cart. EI #8 stated she had not disposed of the patch because she needed another nurse to witness the disposal. While EI #8 administered medications to residents, the Fentanyl patch was left unattended on the medication cart. At 9:58 AM, a Registered Nurse placed the Fentanyl patch in a sharps container located on the medication cart, while EI #8 witnessed. In an interview on 4/20/16 at 11:27 AM, EI #8 was asked, if she immediately disposed of the Fentanyl patch. EI #8 replied, Not immediately after removable, but soon as I had a witness. EI #8 was asked, where else could she have stored the patch until she had a witness. EI #8 stated, she probably could have locked it in the medication cart top drawer. EI #8 was asked, should a used Fentanyl patch be left unattended on top of the medication cart. EI #8 replied, No. EI #8 was asked, when should a used Fentanyl patch be disposed of. EI #8 explained it should be immediately after removal by placing it inside the pack the new patch came in and disposed of into the sharps container. EI #8 was asked, what harm could occur if the Fentanyl patch was left unattended on top of the medication cart and not disposed of immediately after removal. EI #8 stated it could put other people at risk to get it and touch it. During an interview on 4/20/16 at 12:03 AM, EI #2, the Director of Nursing was asked should a Fentanyl patch be left on top of the medication cart unattended. EI #2 replied no. EI #2 was asked, what should be done with a Fentanyl patch once it was removed from a resident. EI #2 explained it should be discarded with another nurse present. This deficiency was cited as a result of the investigation of complaint/report number AL 364.

Based on observations, interviews, and record reviews, the facility failed to ensure 1. A licensed staff member performed wound care in a manner to prevent the potential for cross contamination. This affected RI (Resident Identifier) #s 1, 3, 4, and 10, four of four residents observed with pressure ulcers for wound care. 2. Staff floated the heels of RI #1 and RI #3 to prevent the potential for skin breakdown. This affected RI #1 and RI #3, two of seventeen sampled residents. Findings include: 1. A review of a facility document titled, (Name of facility) POLICY AND PROCEDURES TITLE/DEPARTMENT: Wound Care, with a revision date of 3/2015, revealed, PURPOSE: To provide a guideline for safe, effective wound care using evidenced based practices. STANDARD: Dressing care will be performed in accordance with The Lippincott Nursing Manual of Clinical Practice. A review of the Lippincott Nursing Center, revealed, WOUND WISE: Basic wound cleaning step by step .*Remove the soiled dressing. Roll or lift an edge of the dressing, then gently remove it while supporting the surrounding skin. When possible, remove the dressing in the direction of hair growth. *Inspect the dressing and wound. Note the color, amount, and odor of drainage and necrotic debris. *Clean the wound. Moisten gauze pads either by dipping the pads in wound cleaning solution and wringing out excess or by using a spray bottle to apply solution to the gauze. Move from the least contaminated area to the most contaminated area and use a clean gauze pad for each wipe. For an open wound, such as a pressure ulcer, gently wipe in concentric circles, starting directly over the wound and moving outward . *Dry the wound. Using the same procedure as for cleaning a wound, dry the wound using dry gauze pads. A review of the medical record indicated RI #4 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Admission MDS (Minimum Data Set), assessment dated [DATE], revealed RI #4 had a BIMS (Brief Interview for Mental Status) score of 15 out of a possible 15. This score indicated RI #4 was cognitively intact for daily decision making skills. The MDS also indicated RI #4 required the assistance of 2 persons when transferring and 1 person assistance when ambulating. A review of the Wound Assessment Report, revealed, Treatments (9/30/15) CLEAN SACRUM WOUND WITH NORMAL SALINE AND PAT DRY. APPLY A [MEDICATION NAME] BORDER. CHANGE EVERY OTHER DAY. PRN (AS NEEDED) IF NEEDED. (9/21/15) TURN RESIDENT EVERY TWO HOURS PER TURNING SCHEULDE (SCHEDULE) An observation was made on 10/7/15 at 8:45 AM of wound care performed on RI #4 by EI (Employee Identifier) #1, an LPN (Licensed Practical Nurse). After measurements were taken of RI #4's wound, EI #1 ungloved, washed her hands, re-gloved and applied Normal Saline to a Sterile 4X4 (4 inch by 4 inch gauze pad). EI #1 then used the wet gauze pad to pat the wound bed three times. EI #1 did not change the position of the gauze pad. She did not use a circular motion to go from the center and move outward. EI #1 used a dry 4X4 to dry the wound using the same patting technique. A review of the medical record revealed RI #10 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Quarterly MDS dated [DATE], revealed RI #10 had a BIMS score of 10 out of a possible 15. This score indicated RI #10 was moderately impaired for daily decision making skills. The MDS also indicated RI #10 required the assistance of 1 person when transferring and was unable to ambulate. A review of the physician's orders [REDACTED]. 9/22/15 . Cleanse area with normal saline and pat dry. Apply 2X2 (2 inch by 2 inch) [MEDICATION NAME] nonadhesive dressing and then apply [MEDICATION NAME] adhesive dressing to sacrum . An observation was made on 10/7/15 at 9:43 AM of wound care performed on RI #10 by EI #1. After measurements were taken of RI #10's wound, EI #1 ungloved, washed her hands, re-gloved and applied Normal Saline to sterile 4X4s. EI #1 then used the wet gauze pad to pat the wound bed center then around the edges. EI #1 failed to clean from inner to outer wound bed. EI #1 used a dry 4X4 to dry the wound using the same patting technique. A review of the medical record revealed RI #3 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. (Eshcherichia) Coli Infection, Hypertension, Diabetes Mellitus II and [MEDICAL CONDITION]. A review of an Annual MDS dated [DATE], revealed RI #3 had a BIMS score of nine out of a possible score of fifteen. This indicated that RI #3 was moderately impaired for daily decision making skills. RI #3 was coded as totally dependent on staff for transfers, dressing, toileting and bathing. RI #3 had an indwelling catheter and a [MEDICAL CONDITION]. A review of RI #3's October 2015 Physicians Orders revealed, . 4/03/14 . Clean Sacrum wound with normal saline and pat dry. Skin prep (preparation) peri wound and allow to dry. Pack wound with DAKINS SOLUTION dampened 4X4. Cover with ABD (Abdominal) pad and secure with paper tape. Change daily and prn if soiled. An observation was made on 10/7/15 at 11:22 AM of wound care performed on RI #3 by EI #1. After measurements were taken of RI #3's wound, EI #1 ungloved, washed her hands, re-gloved and applied Normal Saline to a Sterile 4X4. EI #1 then used the wet gauze pad to pat the wound bed three times. EI #1 did not change the position of the gauze pad. She did not use a circular motion to go from the center and move outward. A review of the medical record indicated RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a Quarterly MDS dated [DATE], revealed RI #1 had no short or long term memory problems. RI #1's cognitive skills for daily decision making was coded as Independent-decisions consistent/reasonable. RI #1 was totally dependent for transfers, dressing, eating, bathing and toileting. RI #1 was incontinent of bladder and bowel with an indwelling urinary catheter. RI #1 had range of motion impairment on one side. A review of RI #1's October 2015 Physicians Orders revealed, . CLEAN SACRUM ULCER WITH NORMAL SALINE AND PAT DRY. APPLY DAKINS DAMPENED 4x4 TO WOUND BED. COVER WITH [MEDICATION NAME] BORDER. CHANGE DAILY. An observation was made on 10/7/15 at 12:10 PM of wound care performed on RI #1 by EI #1. After measuring the wound, EI #1 ungloved, washed her hands, and re-gloved. EI #1 used Normal Saline to wet a sterile 4X4 gauze pad. EI #1 then used the wet gauze pad to pat the wound bed three times. EI #1 did not change the position of the gauze pad. She did not use a circular motion to go from the center and move outward. EI #1 used a dry 4X4 to dry the wound using the same patting technique. An interview was conducted on 10/7/15 at 4:34 PM with EI #1. EI #1 was asked how a wound bed should be cleaned regarding the technique/motion. She answered, I've always been told circular. EI #1 was asked where does she start and she answered, Start in the center and work your way out. EI #1 was asked why. She answered, To prevent infection. That way you are cleaning from clean to dirty. The germs are wiped to the outside. EI #1 was asked how she had cleaned the wound bed for RI #4. She answered, I patted it. EI #1 was asked how she had cleaned the wound bed for RI #10. She answered, I think I did (RI #10) similar. EI #1 was asked how she dried the wound bed for RI #4. She answered, Patted it dry. EI #1 was asked how she dried the wound bed for RI #10. She answered, The same. EI #1 was asked how the facility's policy indicated the wound should be cleaned and dried. She responded she had always been told circular, not sure if that is the facility's policy. EI #1 was asked if after the normal saline soaked 4X4 touched the wound the first time, was it contaminated when she provided wound care for RI #4 and RI #10. She answered, It would be. Yes ma'am. EI #1 was asked if she should have touched the wound bed 2 more times with the contaminated 4X4. She answered, No Ma'am. EI #1 was asked what was the potential harm of using a dabbing motion, not turning the 4X4, and repeating in the same spot several times. She answered, If it is contaminated you are putting the same germ back into the wound. An interview was conducted with EI #2, Wound Care/Registered Nurse, on 10/7/15 at 4:52 PM. EI #2 was asked how should a wound be cleaned. She answered, You want to start in the middle and work your way out in a circular motion. EI #2 was asked if a wound should be cleaned with a 4X4 using a patting motion without changing the position of the 4X4. She answered not with a patting motion. EI #2 was asked why not. She answered, It's been contaminated. EI #2 was asked what was the potential harm of using a dabbing/patting motion, not turning the 4X4, and repeating in the same area several times. EI #2 answered, Infection control. A subsequent interview was conducted with EI #1 on 10/8/15 at 9:12 AM regarding RI #1 and RI #3. EI #1 was asked what technique she had used when cleaning the wounds for RI #1 and RI #3. She answered, I think it was the same as the other 2 residents. EI #1 was asked what training she had received during her transition to Wound Care Nurse such as skills check offs. She answered, I have mainly followed (named EI #2), how to clean the wound bed, how to identify tissue; I also went over to wound care with a couple of our residents and met with (named wound care Doctor) and his nurse. Any time I have any question I can call his nurse and she will come over. Some skills have been checked off. (No skills check-off sheets could be provided by the facility staff when the surveyor requested copies.) An interview was conducted with EI #3, Infection Preventionist, on 10/8/15 at 10:50 AM. EI #3 was asked how a wound should be cleaned. She answered You would clean with a clean surface, never back and forth motion to prevent possibility of cross contamination. Circular, in to out. EI #3 was asked if a wound should be cleaned with a 4X4 using a patting motion without changing the position of the 4X4. She answered, No. EI #3 was asked why not. She answered, You would contaminate. You would be putting dirty over dirty. You are basically not cleaning it. EI #3 was asked what the potential harm of using a dabbing/patting motion, not turning the 4X4, and repeating several times in the same area was. She answered, Contamination. 2. A review of RI #1's physician orders [REDACTED]. Float heels while in bed. The review of a facility form titled, RESTORATIVE NURSING REFERRAL, for RI #1 dated 8/10/2015, revealed, . Strategy/Approaches: (Devices, Equipment, Material, etc {et cetera}): . Comments: . float heels . On 10/6/15 at 5:04 PM, RI #1 was observed lying on back with the heels not floated. On 10/7/15 at 7:47 AM, RI #1 was observed in bed with eyes close. RI #1's heels were not floated. On 10/7/15 at 9:40 AM, RI #1 was observed lying on back with the heels not floated. On 10/7/15 at 11:50 AM, RI #1 was observed on the left side and the heels were not floated. On 10/7/15 at 2:54 PM, RI #1 was lying on back with head of bed elevated. The heels were not floated. On 10/7/15 at 4:50 PM, RI #1 was observed with the heels not floated. On 10/8/15 at 7:32 AM, RI #1 was observed in the bed with the heels not floated. A review of RI #3's October 2015 Physician order [REDACTED]. Float heels at all times while in bed. This order was dated 4/07/14. A review of the Care Plan for RI #3, with a review date of 12/10/15, with a focus area of, .Resident is totally dependent on nursing for most aspects of care ., revealed, . Turn and reposition every two hours side to side as needed, supporting with pillows and or with wedge, float heels, heel protectors . On 10/6/15 at 11:38 AM during the initial tour, RI #3's heels were observed to not be floated. On 10/6/15 at 4:53 PM, RI #3 was lying in bed with the heels not floated. On 10/7/15 at 9:05 AM, RI #3 was lying in bed with head of bed elevated. RI #3's heels were not floated. On 10/7/15 at 5:11 PM, RI #3 was lying in bed on the back, with head of bed elevated and the heels were not floated.

Based on interviews and record reviews the facility failed to ensure that medication orders were completed to include the route for six medications. This affected RI (Resident Identifier) #'s 1, 2, 3, 4, and 11, five of twenty residents whose medications were reviewed. Findings include: A review of the facility's policy and procedure titled, Administration of Medication with a revised date of January 07, revealed, Purpose: To assure the patient of safe administration of medication and to define medication privileges. Policy: . .Prior to administering a medication ordered by a physician the five Rights shall always be practiced. 1. Right Patient 2. Right Medication 3. Right Dose 4. Right Time 5. Right Route Before administering a medication ordered by a physician, the individual administering the medication will . He/she will verify that the medication is being administered at the correct time, in the prescribed dose and by the correct route. 1) A review of the medical record indicated that RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 6/26/15, revealed, RI #1 had no short or long term memory problems. RI #1's cognitive skills for daily decision making was coded as Independent-decisions consistent/reasonable. A review of RI #1's physician's orders [REDACTED]. . [MEDICATION NAME] Tablet: 25 mg (milligram) Give one tablet twice a day . LOW SLIDING SCALE (HUMALOG) <70----------------CALL MD 251-300---------5 UNITS 301-350-----7 UNITS 351-400---------12 UNITS 401-450--------15 UNITS Repeat BG in 2 hours , if >400 give 10 units regular insulin and Call MD . There was no routes included in the orders for these two medications. A review of the MARs (Medication Administration Record) for RI #1 revealed for September 2015 and October 2015 . [MEDICATION NAME] Tablet: 25mg Give one tablet twice a day Order Date: 6/19/15 Start Date 6/19/15 . LOW SLIDING SCALE (HUMULOG) <70--------------------CALL MD 251-300---------5 UNITS 301-350-------7 UNITS 351-400-----------12 UNITS 401-450-------15 UNITS Repeat BG in 2 hours, if >400 give 10 units regular insulin and Call MD Order Date: 6/19/15 Start Date: 6/19/15 . There was no routes included on the MARs for these two medications. 2) A review of RI #2's medical record revealed, RI #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Admission MDS dated [DATE], revealed, RI #2's BIMS (Brief Interview for Mental Status) score was 14 out of a possible 15. This score indicated RI #2 was cognitively intact for daily decision making skills. The MDS also indicated RI #2 required extensive assistance of 2 persons when transferring and performing many activities of daily living. A review of RI #2's physician's orders [REDACTED]. . LOW SLIDING SCALE <70-----------------------CALL MD 251-300----------5 UNITS 301-350-----------7 UNITS 351-400------------12 UNITS 401-450-------------15 UNITS Repeat BG in 2 hours, if >400 give 10 units [MEDICATION NAME] and Call MD . There was no route included in this medication order. 3) A review of RI #3's medical record revealed, RI #3 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. (Escherichia) Coli Infection, Hypertension, Diabetes Mellitus Type II, and [MEDICAL CONDITION]. A review of an annual MDS with an ARD of 9/9/2015, revealed a BIMS score of nine out of a possible score of fifteen. This indicated that RI #3 was moderately impaired for daily decision making skills. RI #3 was totally dependent for transfers, dressing, toileting and bathing. RI #3 was totally dependent on staff for activities of daily living. A review of RI #3's physician's orders [REDACTED]. . LOW SLIDING SCALE (HUMALOG) <70----------------CALL MD 251-300---------5 UNITS 301-350-----7 UNITS 351-400---------12 UNITS 401-450--------15 UNITS Repeat BG in 2 hours , if >400 give 10 units regular insulin and Call MD . There was no route included in this medication order. A review of the MARs for RI #3 for September 2015 and October 2015 revealed: . LOW SLIDING SCALE <70--------------------CALL MD 251-300---------5 UNITS 301-350-------7 UNITS 351-400-----------12 UNITS 401-450-------15 UNITS Repeat BG in 2 hours, if >400 give 10 units regular insulin and Call MD Order Date: 8/22/15 Start Date: 8/23/15 . There was no routes included for this medication on the MARs. 4) A review of RI #4's medical record revealed, RI #4 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of an Admission MDS for RI #4, dated 9/28/15, revealed, RI #4's BIMS score was 15 out of a possible 15. This score indicated RI #4 was cognitively intact for daily decision making skills. The MDS also indicated RI #4 required the assistance of 2 persons when transferring and 1 person assistance when ambulating. A review of RI #4's physician's orders [REDACTED]. . LOW SLIDING SCALE (HUMALOG) <70-----------------CALL MD 251-300---------5 UNITS 301-350--------7 UNITS 351-400-----------12 UNITS 401-450----------15 UNITS Repeat BG in 2 hours, if >400 give 10 units regular insulin and Call MD . There was no route included in this medication order. A review of the MARs for RI #4 for September 2015 and October 2015 revealed: . LOW SLIDING SCALE (HUMULOG) <70--------------------CALL MD 251-300---------5 UNITS 301-350-------7 UNITS 351-400-----------12 UNITS 401-450-------15 UNITS Repeat BG in 2 hours, if >400 give 10 units regular insulin and Call MD Order Date: 9/21/15 Start Date: 9/21/15 . There was no route included for this medication on the MARs. 5) A review of RI #11's current medical record revealed, RI #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of an annual MDS with an ARD of 6/25/15, indicated RI #11 was coded as having a BIMS score of 15 out of a possible 15. This score indicated RI #11 was cognitively intact for daily decision making skills. A review of RI #11's physician's orders [REDACTED]. . [MEDICATION NAME] 10 MG TABLET TAKE 4 TABLETS (40 mg) ONCE A WEEK Generic: [MEDICATION NAME] . There was no route included in this medication order. A review of the MARs for RI #11 for September 2015 and October 2015 revealed: . [MEDICATION NAME] 10 MG TABLET TAKE 4 TABLETS (40 MG) ONCE A WEEK Order Date 6/18/15 Start Date 6/18/15 [MEDICATION NAME] SODIUM . There was no route included for this medication on the MARs. On 10/8/15 at 1:41 PM, an interview was conducted with EI #4, an LPN (Licensed Practical Nurse). EI #4 was asked the requirements for a complete medication order. EI #4 replied Medication Name, dose, how often, reason for medication, MD(Medical Doctor) prescribing, if voice order, and route of administration. EI #4 was asked if the requirement would also apply to sliding scale insulin. EI #4 stated, yes, you need to make sure you are giving the right dose based on BG (Blood Glucose) results and verify all of the above. EI #4 was asked what should be done if the medication had no route ordered. EI #4 said to call the MD for order clarification. EI #4 was asked if she would give the medication before calling the MD. EI #4 replied, no, because you want the correct route like P.O.(by mouth), per tube, SQ (Subcutaneous) or IM (Intramuscular). EI #4 was asked what the facility policy was related to medication orders regarding a route. EI #4 responded the five rights of the patient as stated previously and policy does not allow us to give certain medications and needs to be within my scope of practice. EI #4 was asked what the Nursing Standard of Practice on medication administration was. EI #4 stated to follow the five rights of the resident and the right time is one hour before or one hour after being scheduled and with narcotics, you can give 30 minutes before but not an hour before. On 10/8/15 at 2:30 PM, an interview was conducted with EI #7, a RN (Registered Nurse). EI#7 was asked the requirements for a complete medication order. EI #7 replied, name of the drug, dosage, route, frequency, how long to give and name of the patient. EI #7 was asked if the requirement would also apply to sliding scale insulin. EI #7 answered, yes, with a variation in dose based on BG level. EI #7 was asked what should be done if the medication had no route ordered. EI #7 replied, call the doctor. EI #7 was asked would she make that call even before she gave the medication. EI #7 stated, definitely. EI #7 was asked what the facility policy was related to orders without a route. EI #7 stated name, dose, frequency, patient name, and route. EI #7 was asked what the Nursing Standard of Practice was on medication administration. EI #7 replied name, dose, frequency, patient name, and route. EI #7 was asked if she ever gave RI #1 medications. EI #7 responded possibly at 9:00 AM. EI #7 was asked to review orders on [MEDICATION NAME] and respond to what was wrong with that order. EI #7 stated there was no route. EI #7 was asked to review sliding scale insulin orders and reply to what was seen. EI #7 stated, there was no route. EI #7 was asked who checked orders to ensure all orders were transcribed correctly to the MARS. EI #7 responded that nonclinical secretaries entered in between orders into the patient record on the computer. Sometimes the unit manager entered the order and gave us (the Nurses) a set of MD orders and the MARS. We compare the previous month and the current orders/MAR to ensure all orders were present. On 10/8/15 at 4:37 PM, an interview was conducted with EI #5, an LPN. EI #5 was asked the requirements for a complete medication order. EI #5 stated the right medication, resident, route, dose, and time. EI #5 was asked if the requirement would also apply to sliding scale insulin. EI #5 stated you were only going to give it subcutaneously, but you still have to have the route on the order. EI #5 was asked what should be done if the medication had no route ordered. EI #5 responded, get a clarification order by calling the doctor. EI #5 was asked what the facility policy was related to medication orders without a route. EI #5 stated to verify the order and have the 5 rights. EI #5 was asked what the Nursing Standard of Practice was on medication administration. EI #5 responded the five rights. On 10/8/15 at 4:44 PM, an interview was conducted with EI #6, an LPN. EI #6 was asked the requirements for a complete medication order. EI #6 stated the right patient, route, time, medication and dose. EI #6 was asked if the requirement would also apply to sliding scale insulin. EI #6 replied, yes. EI #6 was asked what should be done if the medication had no route ordered. EI #6 replied, call the doctor and clarify the order and resubmit it with the correct information. EI #6 was asked what the facility policy was related to orders not having a route. EI #6 stated that calling the doctor, clarifying the order, and resubmitting it with the correct information was the facility policy. EI #6 was asked what the Nursing Standard of Practice was on medication administration. EI #6 responded the five rights and educate the patient. On 10/8/15 at 5:05 PM, an interview was conducted with EI #9, the Director of Nursing. EI #9 was asked if medication was ordered for a resident, what information the order should include. EI #9 said route, dose, time, medication and patient name. EI #9 was asked if all information was not included what should be done. EI #9 responded that it should be corrected. The M.D. should be called to clarify the order and the medication should not be given before contacting the M.D. EI #9 was asked who put the orders into the computer on nurses MARS. EI #9 stated the unit secretary. EI #9 was asked who was responsible for verifying orders were complete and correct and how often was that done. EI #9 replied the nurses when initially entered, any new orders or changed orders, and during monthly review.

Based on observations, interviews, and record reviews, the facility failed to ensure a contracture tree leg brace for a residents' ROM (Range of Motion) deficit was used as ordered on three of three survey days. This affected RI (Resident Identifier) #1, one of seventeen sampled residents. Findings include: A review of the medical record indicated RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a Quarterly MDS (Minimum Data Set), assessment dated [DATE], revealed RI #1 had no short or long term memory problems. RI #1's cognitive skills for daily decision making was coded as, Independent-decisions consistent/reasonable. RI #1 was totally dependent for transfers, dressing, eating, bathing and toileting. RI #1 was incontinent of bladder and bowel with an indwelling urinary catheter. RI #1 had range of motion impairment on one side. A review of RI #1's Physician order [REDACTED]. Contracture tree on right leg except during hygiene/bath. A review of the facility document titled, ADL (Activities of Daily Living) sheet for the month of September 2015, for RI #1 revealed, eighteen dates the placement of the contracture tree for the right leg was not initialed on the form for the 7 PM to 3 PM shift. A review of the document titled, Assessment of Contracture Risk, for RI #1, with a revision date of 8/30/10, revealed, The higher the score, the greater the potential to develop contracture. Residents with scores above seven should be considered at risk and should be on a regular positioning schedule for both bed and chair. RI #1's total score was twelve out of a possible twenty-seven. On 10/6/15 at 5:04 PM, RI #1 was observed lying in bed on back with the contracture tree not on RI #1's right leg. On 10/7/15 at 7:47 AM, RI #1 was observed lying in bed without the contracture tree on the right leg. On 10/7/15 at 9:40 AM, RI #1 was observed in bed lying on back and no contracture tree was on the right leg. On 10/7/15 at 11:50 AM, RI #1 was observed in bed, on the left side and the contracture tree was not on the right leg. On 10/7/15 at 4:50 PM, RI #1 was observed on the back, with head of bed elevated, no contracture tree was on the right leg. On 10/8/15 at 7:32 AM, RI #1 was observed in bed and the contracture tree was not on the right leg. An interview was conducted on 10/8/15 at 1:51 PM with EI (Employee Identifier) #4, an LPN (Licensed Practical Nurse). EI #4 was asked if she had provided care for RI #1 and what care she had provided. EI #4 stated she had assessed for medications, helped reposition the resident, and pain management for RI #1. EI #4 indicated, she assessed (RI #1) every day to ensure (RI #1) was okay and full assistance was required. The CNAs (Certified Nursing Assistants) used the Hoyer lift to get RI #1 up. EI #4 was asked who supervised the CNAs' assignments and the ADLs that were required for the resident. She stated all Nurses on the hall were responsible to ensure the CNAs were doing their assignments. EI #4 was asked how the Nurses knew what the CNA was supposed to do for the residents. She answered, the assignment board and the assignment book. EI #4 was asked if she checked the assignment book every day. She stated, yes and that she looked at least once per day to see who was coming and who had each resident. EI #4 was asked if she was aware RI #1 was supposed to be wearing a contracture tree. She stated, no and usually Restorative did the application. EI #4 was asked if the contracture tree was on an order and on a Care Plan, should it be her responsibility to know RI #1 was supposed to have it on. She stated yes. An interview was conducted with EI #10, a CNA, on 10/8/15 at 2:30 PM. EI #10 was asked if she was familiar with RI #1. EI #10 stated, yes. EI #10 was asked if RI #1 had a leg brace for the right leg. She statedyes. EI #10 was asked how often RI #1 was supposed to wear the leg brace. She stated, she thought RI #1 was supposed to wear it every day. EI #10 reported that she took it off when she cleaned (RI #1) and at night. EI #10 was asked if she replaced the contracture tree back after completing care for RI #1. She stated, she thought therapy was supposed to do that. EI #10 was asked if she notified anyone if the brace needed to be replaced on the resident. She stated no. EI #10 was asked how therapy would know it was taken off. EI #10 stated, she didn't know. EI #10 was asked should therapy be notified and she stated yes, they should. An interview was conducted with EI #11, a CNA, on 10/8/15 at 2:50 PM. EI #11 was asked if she was familiar with RI #1 and she said yes. EI #11 was asked to explain the type of care she provided for RI #1. She listed bathing, changing, feeding, talking to the resident, emptying the catheter drainage bag, changing sheets, grooming, turning every 2 hours and taking RI #1's leg brace off after supper. EI #11 was asked if RI #1 had a leg brace for the right leg. She replied yes. EI #10 was asked how often RI #1 was supposed to wear the leg brace. EI #10 stated, she forgot, the therapy lady had told her. EI #11 was asked if she had ever put the contracture tree on RI #1. She stated no. EI #11 was asked why she had not placed the contracture tree on RI #1. EI #11 stated she had only taken it off. An interview was conducted with EI #12, an RPT (Registered Physical Therapist), on 10/8/15 at 2:59 PM. EI #12 was asked if she was familiar with RI #1 and she recalled performing an evaluation for RI #1. EI #12 was asked if RI #1 was wearing a leg brace during therapy and she answered she did not know. EI #12 was asked if RI #1 had the brace in use upon admit. She responded that she didn't see where the brace was on admit. EI #12 was asked if an MD (Medical Doctor) order was necessary to place a device like the Contracture Tree. EI #12 stated, she guessed it would. It would depend on the device being used. EI #12 was asked if she was going to put a Contracture Tree in use for a resident, would she be required to get an MD order. She stated, yes, because she would call the MD and include him in the Plan of Care. EI #12 was asked if she had to obtain a signed MD order. She answered she didn't think so. EI #12 was asked if she was aware RI #1 still had an MD order and was care planned to wear the leg brace. She responded, no. EI #12 was asked the purpose for the leg brace and she answered to prevent contractures. EI #12 was asked what the potential negative outcome would be by the resident not wearing the Contracture Tree. EI #12 replied, contractures. An interview was conducted with EI #13, a CNA, on 10/8/15 at 3:17 PM. EI #13 stated she was familiar with RI #1. EI #13 listed the care provided by her for RI #1 as perineal care, oral care, feeding, turning, and emptying the catheter drainage bag. EI #13 was asked if RI #1 had a leg brace for the right leg. She stated yes, she does. EI #13 was asked how often RI #1 was supposed to wear the brace. She stated, they (the staff) put it on during the 6 AM - 2 PM shift every day. EI #13 was asked if she had ever put the brace on the resident. EI #13 stated she had never put the brace on the resident. An interview was conducted with EI #9, the DON (Director of Nursing), on 10/8/15, at 4:35 PM. EI #9 was asked if she was familiar with RI #1. She stated yes. EI #9 was asked how were Restorative issues included or applied to the Nursing Care Plans and to the Restorative assignment. She stated the Restorative Supervisor puts them in the computer. EI #9 was asked who ensured the CNAs and Restorative care were following their assigned care for the resident. She stated, the Nurses were supposed to make sure the CNAs were doing what they were supposed to do. The Restorative Supervisor follows up on the Restorative orders. EI #9 was asked what did the blank spaces on the ADL form indicate. EI #9 stated, if it's not documented, it's not done. EI #9 was asked if the contracture tree was being put on every day for RI #1. She stated no. EI #9 was asked who was supposed to place the contracture tree on RI #1. She stated, the CNAs. EI #9 was asked if RI #1 had a contracture tree that was supposed to be worn daily. EI #9 stated, yes. EI #9 was asked who was supposed to ensure it was put on. EI #9 stated, the Nurses.

Based on observations, record reviews, and interviews, the facility failed to ensure the care plan was implemented for RI (Resident Identifier) #1 regarding the use of a contracture tree to the right leg. In addition, RI #3's heels were not floated while in bed. This affected RI #1 and RI #3, two of seventeen sampled residents. Findings Include: A review of a facility document titled, SPRINGHILL SENIOR RESIDENCE POLICY AND PROCEDURES TITLE/DESCRIPTION: Comprehensive Plan of Care . REVISED: March 2007, revealed, POLICY: To provide an individual plan of care for each resident, by means of a written document which includes input from all disciplines involved in the provision of care. It will be the responsibility of each interdisciplinary team member involved in the resident's care to provide input into the development, implementation, maintenance and evaluation of the residents' plan of care.The comprehensive plan must describe: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well being. A review of RI #1's medical record revealed RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The review of a Quarterly MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 6/26/2015, revealed RI #1 had no short or long term memory problems. RI #1's cognitive skills for daily decision making was coded as, .Independent-decisions consistent/reasonable RI #1 was unable to speak but usually understood most conversations. RI #1 was totally dependent for transfers, dressing, eating, bathing and toileting. RI #1 had a range of motion impairment on one side. A review of RI #1's October 2015 Physician order [REDACTED]. Contracture tree on right leg except during hygiene/bath. A review of RI #1's Care Plan, dated 8/17/15, for Problem/Need/Strength Resident is at risk for Contractures Approaches .Contracture tree on R (Right) leg except during hygiene/bath The review of a facility form for RI #1 titled, RESTORATIVE NURSING REFERRAL, and dated 8/10/2015, with an initiation date of 8/17/2015, revealed, . Strategy/Approaches: (Devices, Equipment, Material, etc. {et- cetera}): . Comments: . Contracture Tree on R (Right) leg - except during hygiene/bath . A review of RI #1's ADL check off sheet for the month of September 2015 revealed, . Contracture tree on right leg except during hygiene/bath. There were eighteen blank spaces (without initials) on different days and different shifts throughout the entire month of September. A review was done of a facility document for RI #1, titled, Assessment of Contracture Risk, with a revision date of 8/30/10. The higher a residents' score indicated a greater potential for developing contractures. A score greater than seven was considered high risk and the resident should be on a regular positioning schedule for both bed and chair. RI #1's total score was twelve out of a possible twenty seven. On 10/6/15 at 5:04 PM, RI #1 was observed lying on back with no contracture tree on the right leg. On 10/7/15 at 7:47 AM, RI #1 was observed in bed with eyes close. There was no contracture tree on the right leg. On 10/7/15 at 9:40 AM, RI #1 was observed lying on back, with no contracture tree on the right leg. On 10/7/15 at 11:50 AM, RI #1 was observed on the left side with no contracture tree on the right leg. On 10/7/15 at 4:50 PM, RI #1 was observed with no contracture tree on the right leg. On 10/8/15 at 7:32 AM, RI #1 was observed in bed with no contracture tree on the right leg. An interview was conducted with EI (Employee Identifier) #9, DON (Director of Nursing) on 10/8/2015 at 4:35 PM. EI #9 was asked if RI #1 had a contracture tree that was supposed to be worn daily. EI #9 said yes. EI #9 was asked who was supposed to put the contracture tree on. EI #9 stated the CNA. EI #9 was asked who ensured that the contracture tree was put on the resident. EI #9 stated the nurses. A review of the medical record revealed RI #3 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. (Escherichia) Coli Infection, Hypertension, Diabetes Mellitus Type II and [MEDICAL CONDITION]. The review of an Annual MDS for RI #3, with an ARD of 9/9/2015, revealed a BIMS (Brief Interview for Mental Status) score of nine out of a possible fifteen. This score indicated that RI #3 was moderately impaired for daily decision making skills. RI #3 was totally dependent on staff for transfers, dressing, toileting and bathing. A review of RI #3's physician orders [REDACTED]. Float heels at all times while in bed. A review of a check off sheet for RI #3 dated June 2015, revealed, . Float heels at all times while in bed. There were no initials in any of the columns to indicate RI #3's heels were floated. There was no reference to floating heels found on any check off sheets for July through September 2015. A review of RI #3's ADL check off sheet for the month of September 2015, revealed, . Float heels while in bed . All spaces for every shift were blank. The review of a care plan for RI #3 with Problem/Need Problem Onset: 11/30/2012, revealed, . Resident is totally dependent on nursing for most aspects of care R/T (Related To): Decreased mental capacity, weakness, obesity, decreased physical functioning, chronic disease process . review date 12/10/15 .Approaches . Turn and reposition every two hours side to side and as needed, supporting with pillows and or with wedge, float heels, heel protectors . On 10/6/15 at 11:38 AM during the initial tour, RI #3's heels were observed to not be floated. On 10/6/15 at 4:53 PM, RI #3 was lying in bed with the heels not floated. On 10/7/15 at 9:05 AM, RI #3 was lying in bed with head of bed elevated. RI #3's heels were not floated. On 10/7/15 at 5:11 PM, RI #3 was lying in bed on the back, with head of bed elevated and the heels were not floated.

Based on observations, record reviews, and interviews, the facility failed to ensure Physician orders [REDACTED].>1) Regarding floating of heels for RI (Resident Identifier) #1 and RI #3, two of seventeen sampled residents. 2) Regarding the application of a Contracture Tree for RI #1, on three of three survey days. Findings include: A review of RI #1's medical record revealed RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The review of a Quarterly MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 6/26/2015, revealed RI #1 had no short or long term memory problems. RI #1's cognitive skills for daily decision making was coded as, .Independent-decisions consistent/reasonable RI #1 was unable to speak but usually understood most conversations. RI #1 was totally dependent for transfers, dressing, eating, bathing and toileting. RI #1 had a range of motion impairment on one side. A review of RI #1's October 2015 Physician order [REDACTED]. Float heels while in bed. and . Contracture tree on right leg except during hygiene/bath . The review of a facility form for RI #1 titled, RESTORATIVE NURSING REFERRAL, and dated 8/10/2015, with an initiation date of 8/17/2015, revealed, . Strategy/Approaches: (Devices, Equipment, Material, etc. {et- cetera}): . Comments: . float heels . and . Contracture Tree on R (Right) leg - except during hygiene/bath . The review of a care plan for RI #1 dated 6/19/2015, revealed, . Problem/Need/Strengths Resident at risk for skin breakdown or pressure ulcers related to decreased mobility . Approaches . There were no interventions to float heels listed under approaches of the care plan. A review of a care plan for RI #1 dated 8/17/2015, revealed, . Problem/Need/Strength, Resident at risk for Contractures. Approaches . Contracture tree on R (Right) leg except during hygiene/bath. A review of RI #1's ADL (Activities of Daily Living) check off sheet for the month of September 2015, revealed, . Float heels while in bed . There were blank spaces (without initials) noted on each day, on different shifts through out the month of September. A review of RI #1's ADL check off sheet for the month of September 2015, revealed, . Contracture tree on right leg except during hygiene/bath. There were blank spaces (without initials) noted on multiple days of the month of September. On 10/6/15 at 5:04 PM, RI #1 was observed lying on back with heels not floated and there was no contracture tree on the right leg. On 10/7/15 at 7:47 AM, RI #1 was observed in bed with eyes close. RI #1's heels were not floated and there was no contracture tree on the right leg. On 10/7/15 at 9:40 AM, RI #1 was observed lying on back, with heels not floated and there was no contracture tree on the right leg. On 10/7/15 at 11:50 AM, RI #1 was observed on the left side, heels not floated and no contracture tree on right leg. On 10/7/15 at 2:54 PM, RI #1 was lying on back with head of bed elevated. The heels were not floated. On 10/7/15 at 4:50 PM, RI #1 was observed with heels not floated and there was no contracture tree on the right leg. On 10/8/15 at 7:32 AM, RI #1 was observed in bed, heels not floated and no contracture tree on the right leg. A review of the medical record revealed RI #3 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. (Escherichia) Coli Infection, Hypertension, Diabetes Mellitus Type II, and [MEDICAL CONDITION]. The review of an Annual MDS for RI #3, with an ARD of 9/9/2015, revealed a BIMS (Brief Interview for Mental Status) score of nine out of a possible fifteen. This score indicated that RI #3 was moderately impaired for daily decision making skills. RI #3 was totally dependent on staff for transfers, dressing, toileting and bathing. A review of RI #3's physician orders [REDACTED]. Float heels at all times while in bed. A review of RI #3's ADL check off sheet for the month of September 2015, revealed, . Float heels while in bed . All spaces for every shift were blank. On 10/6/15 at 11:38 AM during the initial tour, RI #3's heels were observed to not be floated. On 10/6/15 at 4:53 PM, RI #3 was lying in bed with the heels not floated. On 10/7/15 at 9:05 AM, RI #3 was lying in bed with head of bed elevated. RI #3's heels were not floated. On 10/7/15 at 5:11 PM, RI #3 was lying in bed on the back, with head of bed elevated and the heels were not floated. On 10/8/2015 at 4:35 PM, an interview was conducted with EI (Employee Identifier) #9, the DON (Director of Nursing). EI #9 was asked how was it ensured the therapy orders that needed to be continued by the LTC (Long Term Care) staff were obtained. EI #9 stated when a resident was discharged from therapy and transferred to LTC, but still required some therapy care, there was a referral made to Restorative. EI #9 was asked how Restorative orders got to the Nursing care plans and how the Restorative assignment was put into the computer. EI #9 stated the Restorative Supervisor was responsible. EI #9 was asked who was responsible for verifying orders were complete and correct. EI #9 stated the Nurses were responsible. EI #9 was asked how this was done. EI #9 stated when initially entered, any new orders, changed orders, and during monthly review.

Based on observations and record reviews, the facility failed to ensure the plan of care for RI (Resident Identifier) #1 was revised to include the intervention of floating heels while in bed. This affected RI #1, one of seventeen sampled residents. Findings Include: A review of a facility document titled, SPRINGHILL SENIOR RESIDENCE POLICY AND PROCEDURES TITLE/DESCRIPTION: Comprehensive Plan of Care . REVISED: March 2007, revealed, POLICY: To provide an individual plan of care for each resident, by means of a written document which includes input from all disciplines involved in the provision of care. It will be the responsibility of each interdisciplinary team member involved in the resident's care to provide input into the development, implementation, maintenance and evaluation of the residents' plan of care. The comprehensive plan must describe: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well being. The comprehensive plan of care will be updated at least every 90 days or whenever significant changes occur . PROCEDURE: . Existing needs/problems will be reviewed by the team prior to or at the target dates that were set. Care plans will be updated at the completion of the review . A review of the medical record indicated RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's Quarterly MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 6/26/2015, revealed RI #1 had no short or long term memory problems. RI #1's cognitive skills for daily decision making was coded as, .Independent-decisions consistent/reasonable . RI #1 was unable to speak but usually understood most conversations. RI #1 was totally dependent for transfers, dressing, eating, bathing and toileting. RI #1 had a range of motion impairment on one side. A review of RI #1's October 2015 physician orders [REDACTED]. Float heels while in bed. The review of a facility document for RI #1 titled, RESTORATIVE NURSING REFERRAL, dated 8/10/2015, with an initiation date of 8/17/2015, revealed, . Strategy/Approaches: (Devices, Equipment, Material, etc {et-cetera}): . Comments: . float heels . The review of a care plan for RI #1 dated 6/1/2015, revealed, . Problem/Need/Strengths Resident at risk for skin breakdown or pressure ulcers related to decreased mobility . Approaches . There were no interventions for floating heels listed under approaches in the care plan. The review of an ADL (Activities of Daily Living) check off sheet for September 2015, revealed, . Float heels while in bed . There were blank spaces noted on 18 days and on different shifts throughout the month. On 10/6/15 at 5:04 PM, RI #1 was observed in bed with eyes closed. The resident's heels were not floated. On 10/7/15 at 7:47 AM, RI #1 was observed with heels not floated. On 10/7/15 at 9:40 AM, RI #1 was observed lying on back, with heels not floated. On 10/7/15 at 11:50 AM, RI #1 was observed on the left side, with heels not floated. On 10/7/15 at 2:54 PM, RI #1 was observed lying on back with head of bed elevated and the heels were not floated. On 10/7/15 at 4:50 PM, RI #1 was observed with heels not floated. On 10/8/15 at 7:32 AM, RI #1 was observed in bed, with heels not floated.

Based on observations, interviews, and document review, the facility failed to ensure food was served in a manner to prevent the potential for food borne illness. This deficient practice was observed during the lunch tray line on 11/19/2014. Pureed meat sauce, green beans, and ground beef were observed on the tray line below 135 degrees, and were not reheated to 165 degrees, and/or was reheated more than once prior to being served to residents. These deficiencies had the potential to affect 21 residents who received Mechanical Soft Diets, and 9 residents who received Pureed Diets. This was 30 of 30 Therapeutic Diets served from the dietary department. Findings include: The 2013 Food Code by the United States Public Health Service (USPHS) and the Food and Drug Administration (FDA) included the following: "... 3-403.11 Reheating for Hot Holding. (A) ... TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the FOOD reach a temperature of at least ... (165 {degree} F) for 15 seconds ... 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) ... TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At ... (135 {degree} F) or above ... ." A review of the facility's policy entitled, "Food Temperatures," dated 2013, revealed: "Policy: The temperature of the food items will be taken and properly recorded for each meal. Procedure: 1. All hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 (degree symbol) F(Fahrenheit). Take temperatures often to monitor for safe food holding temperature ranges ... and at or above 135 (degree symbol) F for hot foods. a. Cooking temperatures must be reached and maintained according to regulations, laws, and standardized recipes while cooking. b. Hot food items may not fall below 135 (degree symbol) F after cooking ... and reheated to at least 165 (degree symbol) F prior to serving. ..." During the lunch tray line observation on 11/19/2014, staff started taking temperatures of the food items at 11:40 AM. The following observations were made: The initial temperature of the pureed meat sauce was 120 degrees. The dietary staff pulled the item off of the tray line and reheated the sauce in the steamer to 140 degrees. The meat sauce was put back on the tray line and was served to the residents. The initial temperature of the ground beef with no sauce was 120 degrees. The dietary staff pulled the item off of the tray line and reheated it to 145 degrees. At 11:48 AM, the ground beef was placed back on the tray line and served to the residents. The Dietary Manager, EI #9, was asked what the re-heated temperature of the ground beef should be. EI #9 said 135 to 140 degrees. At 12:05 PM, the ground beef was put back in the steamer for the third time, and re-heated to 165 degrees. The item was put back on the tray line and served to the residents. The initial temperature of the pureed green beans was 120 degrees. The dietary staff pulled the food item and re-heated the pureed green beans. At 11:55 AM, the pureed green beans were 120 degrees. At 12:10 PM, EI #9 put the pureed green beans back into the steamer for the third time and re-heated the item to 160 degrees. Staff then began to serve the pureed green beans to residents from the containers that were heated up in individual bowls in the microwave. At 12:12 PM, the pureed green beans were put back into the steamer for the fourth time. The reheated temperature was 136 degrees. The staff continued to reheat the individual bowls of pureed green beans in the microwave. The temperature of one of the bowls of the pureed green beans that was served to a resident was 136 degrees. At 12:15 PM, the pureed green beans were put back into the steamer for the fifth time and reheated to 136 degrees. The pureed green beans never reached the required re-heated temperature of 165 degrees after 5 attempts of re-heating the item in the steamer. An interview was conducted with EI #9 on 11/19/2014 at 4:40 PM. The surveyor discussed the above observations of the improper temperatures of the three items during the lunch tray line observation on 11/19/2014. The surveyor asked EI #9 what the concern was when pureed meat sauce, ground beef, and pureed green beans are not reheated to 165 degrees, and/or reheated more than twice on the tray line. EI #9 said typically food should not be heated more than twice. EI #9 said the steamer appeared not to be cooking properly. An interview was conducted with EI #10, the Registered Dietitian, on 11/19/2014 at 5:45 PM. The surveyor discussed the concerns regarding the above observations of the improper food temperatures. EI #10 said she had spoken with EI #9, and EI #9 stated she was aware the re-heated food items should reach 165 degrees. EI #10 said EI #9 reported the temperatures did not reach 165 degrees and that was why she continued to reheat the food items. EI #10 said EI #9 knew the reheated temperatures should have been 165 degrees and should not be reheated more than one time.

Based on observations, interviews, and document reviews, the facility failed to ensure call lights were within residents reach. This was observed on 2 of 3 survey days, and had the potential to affect RI (Resident Identifier) #s 3 and 11, two of fourteen sampled residents. Findings Include: 1) A review of the medical revealed RI #11 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #11's Admission MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 10/22/2014, revealed RI #11 had long and short term memory problems and was moderately impaired for decision making. RI #11 was assessed as requiring extensive assistance for personal hygiene, and total assistance for bed mobility, dressing, and toilet use. RI #11 was coded as having impairments in range of motion on one side of the upper and lower extremities. RI #11 was coded as continent of bowel but had an indwelling catheter for urinary output. RI 11's Activity of Daily Living Care Plan dated 10/28/14 revealed: "...Approaches Have call light within reach when in room... Instruct patient to call for assistance PRN (as needed)..." During a tour of the facility on 11/18/2014 at 9:49 AM, RI #11 was observed lying in bed with the head of the bed elevated. RI #11's call light was observed hanging on the floor on the right back side of the bed. The call light was out of RI #11's reach. On 11/19/2014 at 7:50 AM, RI #11's call light was observed hanging from the right back of the bed rail and touching the floor. The call light was out of RI #11's reach. RI #11 requested to have a leg straightened out. On 11/19/2014 at 5:00 PM, RI #11's call light was observed at the back of the elevated side rail. The call light was given to RI #11 by a CNA, EI #1. The resident was able to use the call light. An interview was conducted with EI #1 on 11/20/2014 at 8:54 AM. The surveyor asked EI #1 where RI #11's call light was, during the rounds on 11/19/14 at 5:00 PM. EI #1 said the call light was at the back of the rail. EI #1 said the call light had been twisted around. The surveyor asked EI #1 if RI #11 could have used the call light. EI #1 stated, "No Ma'am." 2) A review of the medical records revealed RI #3 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #3's Annual MDS, with an ARD (Assessment Reference Date) of 10/09/2014, revealed RI #3 had a BIMS (Brief Interview for Mental Status) score of 9 out of 15 possible points. This indicated RI #3 was moderately impaired for daily decision making skills. This MDS also indicated RI #3 was totally dependent on staff for all ADLs (Activities of Daily Living), but could feed self after meals were set up. During a tour of the facility on 11/18/2014 at 9:58 AM, RI #3 was observed in bed. The call light was observed hanging on the wall behind the bed. The call light was out of reach of the resident. RI #3 was observed yelling, "God help me." On 11/19/2014 at 7:49 AM, RI #3's call light was not in reach. The call light was observed hanging from the back of the right bed rail. On 11/19/2014 at 5:00 PM, RI #3's call light was observed under the covers on the right side of the bed. The call light was given to RI #3 by EI #1. RI #3 was able to use the call light. An interview was conducted with EI #1 on 11/20/2014 at 8:54 AM. The surveyor asked EI #1 what the purpose of the call light was. EI #1 stated, "For the patient to be able to call for help." The surveyor asked EI #1 where the call light should be positioned for resident's use. EI #1 stated, "Right across the stomach, pin it, so it's within reach." The surveyor asked EI #1 where RI #3's call light was during the rounds on 11/19/2014 at 5:00 PM. EI #1 said the call light had fallen down between the rails. The surveyor asked EI #1 if RI #3 could have used the call light. EI #1 said not at that time. The CNA stated, "If RI #3 had looked for it, RI #3 may have found it." The surveyor asked EI #1 if RI #3 was able to use the call light. EI #1 said sometimes RI #3 could and would. The CNA said RI #3 yelled out a lot and staff would go and see what the resident needed. The surveyor asked EI #1 what the potential harm was when call lights were not within resident's reach. EI #1 stated, "Anything could happen. They may be in pain or they may want something." An interview was conducted with EI #2, a CNA, on 11/20/2014 at 9:06 AM. The surveyor asked EI #2 what the purpose of the call light was. EI #2 stated, "So if the resident have an emergency or need, they can push it and we can go see what is wrong." The surveyor asked EI #2 where the call light should be positioned for resident's use. EI #2 stated, "It should be in reach, but most of the time we tie them to the bed rails." The surveyor asked EI #2 where RI #3 and RI #11's call lights were, during the rounds on 11/19/2014 at 7:49 and 7:50 AM. EI #2 said they should have been on the bed rails, but she did not remember where they were at that time. The surveyor asked EI #2 what the potential harm was when call lights were not within resident's reach. EI #2 stated, "If it's not in reach, and they have a problem, they can't call us." An interview was conducted with EI #7, the facility's Director of Nursing, on 11/20/2014 at 4:10 PM. The surveyor asked EI #7 where the call lights should be positioned for resident's use. EI #7 stated, "In their reach." The surveyor shared the positions of RI #11 and RI #3's call lights during rounds on 11/19/2014, and asked if the call lights were within the reach of the residents. EI #7 stated, "No Ma'am." EI #7 was asked if RI #11 and RI #3 were able to use their call lights. EI #7 stated, "Yes Ma'am." The surveyor asked EI #7 what the potential harm was, when call lights were not within resident's reach. EI #7 stated, "We would not provide what they needed in an adequate time."

Based on videotape / picture evidence, resident interviews, staff interviews, review of a facility form titled "Standards Authorization Form" and medical record reviews, the facility failed to: (1) Ensure Employee Identifier (EI) #1, a Certified Nursing Assistant (CNA) maintained the diginity and respect of Resident Identifier (RI) #2, a cognitively impaired resident, while rendering care. On 06/20/11, the State Agency received a compact disc (CD) from a police department which revealed a photograph that had been downloaded from a cell phone belonging to EI #1. On the CD was a picture of RI #2, taken 5/2/11 at 8:56 AM, which shows RI #2 sitting on a shower chair in a shower room completely nude. RI #2's head was in a downdard position and there was no indication that the resident knew she was having her picture taken. When the owner of the cell phone, EI #1, was questioned and shown the photograph she offered no explantion and said she was unsure how the picture got on her cell phone. On 03/31/11, EI #1 signed a "Confidentially Acknowledgement" statement in which she agreed not to disclose any confidential information concerning a patient during the course of her employment. (2) Ensure RI #1 was fed in a dignified manner. Further review of the CD revealed videos from EI #1's personal cell phone of RI #1 being fed by a facility staff member (later identified as EI #1) in a hurried manner. RI #1 could be heard and seen on the video saying she was being fed to "quick" yelling for the staff member to "quit." In an interview on 06/22/11, EI #7, the Speech Therapist said the staff member should have stopped when the resident (RI #1) requested her to. In an interview on 06/23/11, EI #5 said "even a normal human being you wouldn't fed like that." This deficient practice compromised the physical, mental and psychosocial well-being of RI #1 and RI #2, by placing their health in immediate jeopardy. On 06/23/11 at 4:25 PM, the facility's Administrator, Director of Nursing, Risk Manager and two Unit Managers were notified that immediate jeopardy had been identified in the area Quality of Life/Dignity & Individuality, F 241 at a "J" level. Findings include: A complaint "Intake Information" form for complaint #AL 532, with a received / start date of 06/20/11, documents on page 2, "...The Alabama Department of Public Health received a CD from the Trussville Police Department. The CD had been downloaded from a cell phone belonging to (Employee Identifier (EI) #1). A picture downloaded from the cell phone shows a female resident fully exposed (naked), sitting on a shower chair in a shower room. The picture was taken on 05/02/11 at 8:56 AM. There is no indication that the resident knew she was having her picture taken...." This intake information form also documents on page1, "...Videos recorded from the cell phone indicate an employee(s) mistreating and verbally abusing a female resident. The recording dated 05/29/11 at 12:58 PM, and shows the employee feeding the resident and referring to her as "Tooty, Tooty Fruity." The video further shows the resident is angered by the employee as a result of the employee not allowing her to swallow food before being given another large bite of food. The employee calls the resident a dog and tells the resident to shut up...." 1. RI #2 was originally admitted to the facility on [DATE] and readmitted [DATE], with [DIAGNOSES REDACTED]. RI #2's Minimum Data Set (MDS) with an assessment reference date of 06/11/11, identified RI #2 as being severely impaired in cognitive skills, with a BIMS (Brief Interview for Mental Status)score of 3. According to "CMS's RAI (Resident Assessment Instrument) Version 3.0 Manual, page C-14, a score of 0 - 7 indicates a resident has a severe impairment. In an interview on 06/21/11 at 5:15 PM, EI #1 stated that she works the day shift (7 AM - 3 PM) and normally cares for residents who reside in rooms on the 200 hall; she gave the specific room numbers that she is usually assigned. When the state surveyor asked EI #1 if she owns a cell phone, she answered that she did, and stated that she has owned her cell phone since February 2011. EI #1 further stated that she has not lost or misplaced her phone and then she pulled from her pocket a black HTC T-Mobile cell phone. The state surveyor showed EI #1, the picture and three of the videos that were taken from her cell phone. EI #1 was asked if she could explain why the state surveyor had pictures and videos from her phone. EI #1 replied, "...I can't offer any explanation for (RI #2) ...." Image #113, dated 05/02/11 at 8:56 AM, shows RI #2, a female resident who had undergone a [PROCEDURE] (the surgical removal of a breast), sitting in a shower room completely nude. RI #2's head was in a downward position and there was no indication that the resident knew she was having her picture taken. On 06/22/11 at 11:00 AM, an interview was conducted with RI #2. When the state surveyor questioned RI #2 about the naked photo of her taken on 05/02/11, RI #2 stated that she didn't know what the state surveyor was talking about. RI #2 then commented that she doesn't take naked photos. On 06/22/11 at 3:10 PM, the surveyor observed the shower room where the picture was allegedly taken of RI #2. The floor tiles were similar to the floor tiles in the photo taken of RI #2 on 05/02/11 at 8:56 AM, while the resident was sitting nude in a shower chair. In an interview on 06/23/11 at 1:41 PM, EI #5, the Director of Nursing (DON), was asked if she thought the residents knew that they were being photographed or videotaped. EI #5 replied, "I don't think so, no reason to think so ... ." The state surveyor then asked, is it okay for staff to photograph a resident without their permission? EI #5 answered, "No." EI #5 explained that since she was made aware of this incident, she has started inservicing the staff on resident rights and the use of a cell phone within the facility. According to EI #5, the staff has been instructed that the use of a cell phone to videotape of photograph a resident will not be accepted; its a violation of the patient's rights and a violation of privacy. On 06/23/11 at 3:26 PM, the surveyor conducted an interview with the facility's Risk Manager, EI #6. The surveyor asked EI #5 had law enforcement been notified about the incident with EI #1 photographing and video recording residents without their permission. EI #6 stated as far as he knew the facility had contacted the corporate attorney about the photo and videos. The surveyor asked EI #6 was the facility proposing criminal charges against EI #1? EI #5 stated, "Yes sir, based on the viewing of the video and federal changes from HIPAA (Health Information Portability and Accountability Act) violations and for using a Telemedia device to record a nude resident as well as video taping other residents without their knowledge." The surveyor asked EI #5 was it okay to photograph and video a resident without their permission? EI #6 stated, "No, it's not...." EI #6 explained that it was against their policy and procedures. 2. RI #1 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. RI #1 has the following Diagnoses: [REDACTED]. RI #1's speech therapy evaluation dated 11/11/10, documented that RI #1 was referred to speech therapy because she had difficulty tolerating regular thin liquids. RI #1's treatment [DIAGNOSES REDACTED]." The "Physician Medical Work-Up for Dysphagia" with an onset date of 11/10/10, documented " ... On 11/11/10, a speech and language evaluation was requested to assess severity and give recommendations for a plan of care. This resident demonstrates swallowing difficulty as evidenced by: Moderate Dysphagia when tolerating regular thin liquids. Wet vocal quality, nasal emissions, watery eyes, and coughing noted ... ." RI #1's May 2011 and June 2011 "Physician Orders" documented " ... 11/13/10 ... Mech (mechanically) Soft Diet PUREED DIET ... NECTAR THICK LIQUID ... ." The Quarterly Minimum Data Set (MDS) with an assessment reference date of 06/01/11 identified RI #1 as having severely impaired cognitive skills for daily decision making with long and short term memory problems. RI #1 is assessed as requiring extensive assistance to being totally dependent on staff for all Activities of Daily Living (ADLs). RI #1 requires one person physical assistance to complete ADLs. RI #1 is 64 inches tall and weighs 148 pounds and requires a mechanically altered diet for nutrition. RI #1's care plan titled "Weight loss ... Nectar thickened liquids" with a problem onset of 03/09/11 and last reviewed 06/06/11, has documented approaches of "... I need staff to feed me ... ." In an interview on 06/21/11 at 5:15 PM, EI #1 stated that she normally cares for residents who reside in rooms on the 200 hall; she gave the specific room numbers that she is usually assigned. When the state surveyor asked EI #1 if she owns a cell phone, she answered that she did, and stated that she has owned her cell phone since February 2011. When asked if she or any coworker had ever taken pictures of residents, EI #1 stated, "No - I'm serious. No pictures, trying to see what's going on now." EI #1 denied loosing or misplacing her phone; then, she pulled from her pocket a black HTC T-Mobile cell phone. EI #1 denied recently visiting the city of New Orleans, and said that she hadn't left the state of Alabama recently. During the interview, EI #1 said that she didn't know how her cell phone got to New Orleans. EI #1 affirmed that she knew RI #1, and commented that she had just left the resident's room. The state surveyor asked EI #1, what she calls RI #1. EI #1 answered, "I call her Ms. (last name of RI #1)." EI #1 commented that RI #1 has to be fed a pureed diet. The state surveyor showed EI #1, the picture and three of the videos that were taken from her cell phone. EI #1 was asked if she could explain why the state surveyor had pictures and videos from her phone. EI #1 replied, "I can't offer any explanation for (RI #2) but there is a video of (RI #1)." The state surveyor asked, what the video of RI #1 said. EI #1 answered that it was a video of RI #1 being called, "tootie fruitie." When asked the identity of the person who had filmed the video, EI #1 replied, "I did. I don't want to get anybody else in trouble." On 06/22/11 at 9:00 AM, the state surveyor allowed EI #4 (the facility's Administrator), EI #5 (the Director of Nursing) and EI #6 (the Risk Manager), the opportunity to review the CD that was provided to the Alabama Department of Public Health by the (name) Police Department. EI #4, EI #5 and EI #6 all verified the CD contained videos of RI #1 taken on 05/29/11 at 12:53 PM and 12:58 PM. A review of video 167 recorded 05/29/11 at 12:53 PM for one minute and eight seconds, shows an elderly white female (RI #1) in bed being fed by staff. RI #1 is seen and heard in this recording telling the staff member "that's too much" after the staff placed a large food portion in her mouth. A review of video 168 recorded 05/29/11 at 12:58 PM (five minutes after video 167) for two minutes and 33 seconds, shows an elderly white female (RI #1) in bed being fed by staff. RI #1 is seen and heard in this video telling the staff that she couldn't eat anymore; however, the staff (EI #1) continued to feed RI #1. RI #1 can be heard on the video saying, "You dog. EI #1 replied, "Your're a dog." RI #1 asked, "Why don't you wipe my mouth?" EI #1 answered, "No, cause you called me a dog." EI #1 instructed RI #1 to say that she was sorry. RI #1 responded, "...You got me too quick. I'm sorry. You messed me up; you hate my guts." EI #1 replied, "Eat mines." As EI #1 continued to hurriedly feed RI #1 large spoonfuls of food, the CNA (EI #1) stated, "Now, here, here some guts for you to eat; right here, guts, more guts.... Hurry up." RI #1 screamed, "Quit!" EI #1 replied, "Dog that!" Although RI #1 yelled that she didn't want anymore, EI #1 continued feeding the resident and said, "Yea! You gon get some more." Again, RI #1 said that she didn't want anymore; but, EI #1 continued placing large spoonfuls of food into the residents mouth and said, "Yep (yes), gain five pounds." When RI #1 screamed to be left alone, EI #1 told RI #1 to, "Shut up!...drink up!" Also, EI #1 was seen holding a cup of liquid pressed against RI #1's chest while telling the resident to "shut up!...drink up!" Once the staff member removed the cup from RI #1's upper chest area, a circular indention could be in the chest area, where the cup had been placed; but, the indentation quickly disappeared. EI #1 referred to RI #1 as "Tootie" and asked, "Was that good Tootie, Tootie?" RI #1 answered, "Fruitie my butt." EI #1 laughed and said, "Why Tootie?" EI #1's "Employee Punches By Day Report" dated 06/22/11 at 11:54 AM, indicated that EI #1 clocked in the facility on 05/29/11 at 6:34 AM and clocked out at 3:18 PM. The "Daily Assignment Sheets" indicated that EI #1 was the direct care staff assigned to care for RI #1 during the 7:00 AM to 3:00 PM shift on 05/29/11. In an interview on 06/22/11 at 4:15 PM, EI #7, the Speech Therapist stated that she hasn't treated RI #1 since early December 2010. According to EI #7, she received a referral from nursing that RI #1 was having a hard time swallowing thin liquids and she was experiencing some coughing with consumption. EI #7 began treating RI #1 on 11/11/10 and ended treatment on 12/06/10. At the conclusion of treatment, EI #7 recommended that RI #1 be fed by staff a diet that consisted of pureed solids and nectar thicken liquids. EI #7 further commented that at the end of her treatment, she educated the direct care staff on safe swallowing precautions (SSP) and compensatory swallowing strategies (CSS) to be used with RI #1. According to EI #7, the education included: offering RI #1 small sips, small bits, alternating solids and liquids, report any coughing, nasal emissions and water eyes to the nurse because that could be a sign that RI #1 is aspirating and make sure RI #1 is in an upright position during meal consumption. The state surveyor showed EI #7, video 168 which shows a staff member feeding RI #1. Before the video was started, EI #7 stated that she would already say that RI #1 was not in the correct position for consumption. EI #7 commented that RI #1's head and mouth is but her pharynx isn't because for the pressure system involved with the swallowing function, there has to be gravity on the swallowing mechanism. During the video, EI #7 explained that RI #1 was given three portions before she was allowed to swallow; RI #1 was fed way too fast and RI #1 commented that it was too quick. EI #7 further explained that RI #1's vocal quality is wet which suggests residue in the pharynx that hasn't gone down. On the video, it was noted that RI #1 yelled out quit. The state surveyor asked EI #7, what should have happened. EI #7 answered, "She (staff member) should have stopped. (RI #1) said she didn't want anymore and staff said you gonna get some more. She (RI #1) said she didn't want anymore twice, then said leave me alone. (Staff) told resident to shut up, gain five pounds. This is so disgusting." The state surveyor then asked EI #7, if the staff in this video fed RI #1 based on safe swallowing precautions and compensatory swallowing strategies. EI #7 replied, "Absolutely not" and explained that RI #1 was not in an upright positron, she was fed at a much faster rate, the portions were too large, the staff did not alternate between solids and liquids and RI #1 was only given something to drink one time. The state surveyor asked, what could have happened to RI #1. EI #7 responded that RI #1 could have choked but the worst thing that could have happened is that RI #1 could have aspirated some of the food in her lungs, which could cause aspiration pneumonia, which could have killed her. EI #7 explained that the main two dangers with being fed in this manner are pneumonia and asphyxiation (to kill or make unconscious through inadequate oxygen). According to RI #1's "Resident ADL Sheet" for May 2011, EI #1 documented that RI #1 consumed 100% of her lunch meal and 240 cc (cubic centimeter) of fluids on 05/29/11. In a follow up phone interview on 06/22/11 at 8:55 PM, EI #1 was asked, who else was present when she filmed RI #1. EI #1 replied, "Can't remember just me." When the state surveyor asked EI #1 how she could feed RI #1 and record a video all at the same time; EI #1 commented, "I did it." EI #1 gave no reason for recording RI #1. The state surveyor asked EI #1 if she thought that it was the right thing to do. EI #1 answered, "No." In an interview on 06/23/11 at 1:41 PM, EI #5 was asked if she thought RI #1 was fed in the correct manner after viewing video 168. EI #5 answered, "Absolutely doubt it. No." The state surveyor asked, why? EI #5 replied, "There is no way someone could have been educated on feeding someone like this. Even a normal human being, you wouldn't feed like that ... ." This deficiency is cited as a result of the investigation of complaint/report number AL 532. ****************************************************** On 06/24/11 at 11:20 AM, the facility submitted a credible allegation of compliance for F 241, which documented: "1.) Specific Corrective Action: EI #1 was terminated - 6-21-2011. EI #1 was reported to ADPH on 6-22-2011. EI #1 was reported to local law enforcement authorities and ADPH on 6-23-2011. RI #2's sponsor was contacted by the administrator 6-22-2011. Investigation was started 6-21-2011 and will be completed and turned into ADPH within five business days on or before 6-28-2011. Attempted body audit by RN on RI #2 on 6-22-2011, but she refused body audit. Interview was attempted on RI #2 on 6-22-2011 by social worker. 2.) Identify Similar Problems: Social worker/designee started resident interviews on 6-22-2011 and completed 6-23-2011. No resident reported any violations. Risk manager checked YouTube, Twitter, and Facebook for possible resident images and none were found - 6-23-2011. 3.) Describe System Changes: After DON in-serviced education coordinator, education coordinator/designee began in-servicing employees on abuse, neglect, cell phone use, resident rights, and HIPAA - 6-22-2011. Estimated completion 7-1-2011. Up to this point, irrespective of the two terminated employees, no employees have reported any abuse, or knowledge of unauthorized filming or images. Unit managers/designee will daily for one week do a random audit of resident rooms/showers to ensure no abuse is occurring and perform monthly audits thereafter - 6-23-2011. Documentation will be kept on a form in DON's office. 4.) Monitoring: Social worker/designee will interview a sample of residents for possible resident rights violations every day for one week and then monthly thereafter - started on 6-22-2011. Documentation will be kept on a form in DON's office. If warranted, additional in-servicing, mentoring, write-ups, terminations, or reporting may occur. Completed 7-1-2011." ******************************************************* On 06/23/11 and 06/24/11, the State Surveyors reviewed the facility's information provided in their allegation of credible compliance, in-service records, conducted staff interviews, verified notification of sponsors and local authorities, to determine if the facility had implemented their allegation of credible compliance. The immediate jeopardy was relieved on 06/24/11 at 11:20 AM, with the recommendation of the scope and severity being lowered to a "D" level, to allow the facility time to monitor/revise their corrective actions to achieve compliance.

Based on videotape / picture evidence, resident interviews, staff interviews, the facility's pamphlet titled "Customer Service Standards of Performance", and medical record reviews, the facility failed to ensure Employee Identifier (EI) #1, a Certified Nursing Assistant (CNA), maintained the privacy of Resident Identifier (RI) #1, RI #2, RI #3 and RI #4, when she knowingly recorded and / or photographed these residents without their consent. On 6/20/11, the State Agency received a compact disc (CD) from a police department which contained the following pictures or videos: (1) Video number (#)168, dated 05/29/11 at 12:58 PM, shows RI #1 being fed large spoonfuls of pureed food by a facility staff member (later identified as EI #1), in a hurried manner. The video further shows the resident is angered by the employee as a result of the employee not allowing her to swallow food before being given another large bite of food. RI #1 can be heard on the video saying, "You dog. Why don't you wipe my mouth?" EI #1 answered, "No, cause you called me a dog." EI #1 instructed RI #1 to say that she was sorry. RI #1 responded, "You messed me up; you hate my guts." EI #1 replied, "Eat mines." As EI #1 continued to hurriedly feed RI #1 large spoonfuls of food, the CNA (EI #1) stated, "Now, here, here some guts for you to eat; right here, guts, more guts.... Hurry up." RI #1 screamed, "Quit!" EI #1 replied, "Dog that!" Although RI #1 yelled that she didn't want anymore, EI #1 continued feeding the resident and said, "Yea! You gon get some more." When RI #1 screamed to be left alone, EI #1 told RI #1 to, "Shut up!...drink up!" EI #1 referred to RI #1 as "Tootie" and asked, "Was that good Tootie, Tootie?" RI #1 screamed, "Please shut up!" (2) Image #113, dated 05/02/11 at 8:56 AM, shows RI #2, a female resident who had undergone a [PROCEDURE] (the surgical removal of a breast), sitting in a shower room completely nude. RI #2's head was in a downward position and there was no indication that the resident knew she was having her picture taken. (3) Video #158, dated 05/19/11 at 10:40 AM, shows RI #3 lying in bed with no shirt on engaged in conversation with two facility staff members. A facility staff member (later identified as EI #3) could be seen in the video assisting RI #3 to put on a blue "muscle" shirt. Another staff member (later identified as EI #1) can be heard saying, "I don't know why he (RI#3) got a muscle shirt for; he aint got no muscles." While assisting RI #3 into the blue "muscle" shirt, EI #3 asked the resident to use his arm muscles to lift himself (RI #3) up to assist with getting the shirt on. Then, EI #1 can be heard saying, "He aint got no muscles." Also, a facility staff member can be heard saying, "Watch that thing." Then, the other facility staff member responded, "The camera." On 06/22/11, EI #3 denied knowing that she was being recorded. EI #3 identified EI #1 as the person who recorded the video. (4) Video #174, dated 06/04/11 at 8:51 AM, shows RI #4 lying in bed fully dressed with staff present. The video shows EI #2 in the resident's room and another staff member can be heard calling RI #4 by name and asking the resident to "look." EI #2 identified the other staff member as EI #1, the person doing the recording. EI #2 was laughing, holding her hand up to hide her face and saying, "Don't put that (referring to the camera) on me." EI #1 replied that she was "putting this on YouTube." When the owner of the cell phone, EI #1, was questioned and shown the photograph of RI #2 and three of the videos that were taken from her cell phone, she said she couldn't offer any explanation for RI #2 but that she was aware of a video of RI #1. On 02/21/11, 03/10/11, 03/31/11, EI #2, EI #3 and EI #1, respectively, all signed an "Acknowledgment Statement Confidentiality of Patient/Medical Information" form in which they agreed not to disclosed any confidential information concerning a patient during the course of their employment. This deficient practice compromised the physical, mental and psychosocial well-being of RI #1, RI #2, RI #3, and RI #4, by placing their health in immediate jeopardy. On 06/23/11 at 4:25 PM, the facility's Administrator, Director of Nursing, Risk Manager and two Unit Managers were notified that immediate jeopardy had been identified in the area of Resident Rights/Confidentiality & Privacy, F 164 at a "J" level. Findings include: The facility's pamphlet titled, "Customer Service Standards of Performance," page 17 documents, " ... Each patient, visitor, and guest in our hospital should have their basic privilege of privacy honored at all times. Our guests entrust their rights of privacy to each of us. We need to ensure our patients that we respect their privacy. Treat all information as confidential and in a professional manner. When our customers feel we respect their privacy, they will be more comfortable. They will enjoy peace of mind and the comforts of home.... Every employee is responsible for ensuring that confidentiality is not compromised ...." 1. A complaint "Intake Information" form, with a received / start date of 06/20/11, documents: "...The Alabama Department of Public Health received a CD from the Trussville Police Department. The CD had been downloaded from a cell phone belonging to (name of Employee Identifier (EI) #1). Videos recorded from the cell phone indicate an employee(s) mistreating and verbally abusing a female resident. The recording dated 05/29/11 at 12:58 PM, shows the employee feeding RI #1, referring to the resident as "tootie tootie fruitie". The video further shows the resident is angered by the employee as a result of the employee not allowing her to swallow food before being given another large bite of food. The employee calls the resident a dog and tells the resident to shut up...." RI #1 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. RI #1 has the following Diagnoses: [REDACTED]. RI #1's "Springhill Senior Residence Standard Authorization Form" signed by RI #1's sponsor and dated 02/09/11, indicates that RI #1's sponsor did not give the facility permission to release graphic images of RI #1. This authorization form documents, "...(Please initial if yes) ___I hereby authorize Springhill Senior Residence to release information provided by me or graphic images of me (including photographs and video) for publication in SSR printed materials and/or for advertising purposes and/or for general promotional uses by SSR. I understand that the media also may use these images for news coverage or promotional purposes and do hereby grant permission for such use ...." The initials of RI #1's sponsor are marked out inside the blank beside the above authorization statement with the word, "NO!" handwritten in large print followed by an exclamation punctuation mark; this indicates that RI #1's sponsor was not agreeable to any images being taken of the resident. This authorization form is signed by RI #1's sponsor and witnessed by RI #1's second listed contact. The Quarterly Minimum Data Set (MDS), with an assessment reference date of 06/01/11, identified RI #1 as having severely impaired cognitive skills for daily decision making with long and short term memory problems. RI #1 is assessed as requiring extensive assistance to being totally dependent on staff for all Activities of Daily Living (ADLs). RI #1 requires one person physical assistance to complete ADLs. RI #1 is identified as receiving a mechanically altered diet (requiring a change in the texture of food / liquid, e.g., pureed foods). RI #1 is further assessed as requiring the use of oxygen therapy during the last 14 days of this assessment period. In an interview on 06/21/11 at 5:15 PM, EI #1 stated that she normally cares for residents who reside in rooms on the 200 hall; she gave the specific room numbers that she is usually assigned. When the state surveyor asked EI #1 if she owns a cell phone, she answered that she did, and stated that she has owned her cell phone since February 2011. When asked if she or any coworker had ever taken pictures of residents, EI #1 stated, "No - I'm serious. No pictures, trying to see what's going on now." EI #1 denied loosing or misplacing her phone; then, she pulled from her pocket a black HTC T-Mobile cell phone. EI #1 denied recently visiting the city of New Orleans, and said that she hadn't left the state of Alabama recently. During the interview, EI #1 said that she didn't know how her cell phone got to New Orleans. EI #1 affirmed that she knew RI #1, and commented that she had just left the resident's room. The state surveyor asked EI #1, what she calls RI #1. EI #1 answered, "I call her Ms. (last name of RI #1)." EI #1 commented that RI #1 has to be fed a pureed diet. The state surveyor showed EI #1, the picture and three of the videos that were taken from her cell phone. EI #1 was asked if she could explain why the state surveyor had pictures and videos from her phone. EI #1 replied, "I can't offer any explanation for (RI #2) but there is a video of (RI #1)." The state surveyor asked, what the video of RI #1 said. EI #1 answered that it was a video of RI #1 being called, "tootie fruitie." When asked the identity of the person who had filmed the video, EI #1 replied, "I did. I don't want to get anybody else in trouble." On 06/22/11 at 9:00 AM, the state surveyor allowed EI #4 (the facility's Administrator), EI #5 (the Director of Nursing) and EI #6 (the Risk Manager), the opportunity to review the compact disc (CD) that was provided to the Alabama Department of Public Health by the Trussville Police Department. EI #4, EI #5 and EI #6 all verified the CD contained videos of RI #1 taken on: 05/19/11 at 1:16 PM (video #159); 05/25/11 at 1:18 PM (video #163); 05/28/11 at 1:17 PM (video #165); 05/28/11 at 1:21 PM (video #166); 05/29/11 at 12:53 PM (video #167); and, 05/29/11 at 12:58 PM (video #168). A review of video 159, recorded 05/19/11 at 1:16 PM for 40 seconds, shows an elderly white female (RI #1) lying in bed being fed by staff. EI #1's "Employee Punches By Day Report", with a run date of 06/22/11 at 11:54 AM, indicates that EI #1 clocked in the facility on 05/19/11 at 6:39 AM and clocked out at 3:16 PM. The "Daily Assignment Sheets" dated 05/19/11, indicates that EI #1 was the direct care staff assigned to care for RI #1 during the 7:00 AM to 3:00 PM shift on 05/19/11. A review of video 163, recorded 05/25/11 at 1:18 PM, for 47 seconds, shows an elderly white female (RI #1) lying in bed with oxygen on per nasal cannula. Twenty-five (25) seconds into the recording, the camera is placed on a staff member (later identified as EI #1). At this time, the recording shows EI #1's mouthing some words, with the television on in the background. When RI #1 begins to ramble in speech, there is a voice in the recording that tells RI #1 "shh" (be quiet). EI #1's "Employee Punches By Day Report", with a run date of 06/22/11 at 11:54 AM, indicates that EI #1 clocked in the facility on 05/25/11 at 6:47 AM and clocked out at 3:18 PM. The "Daily Assignment Sheets" indicates that EI #1 was the direct care staff assigned to care for RI #1 during the 7:00 AM to 3:00 PM shift on 05/25/11. A review of video 165, recorded 05/28/11 at 1:17 PM for one minute and 43 seconds, shows an elderly white female (RI #1) lying in bed with oxygen on per nasal cannula being fed by staff. The staff member (EI #1) is heard in the recording calling RI #1 "tootie fruite". During this recording, RI #1 asks for more food; however, the staff (EI #1) told the resident "no," and made the resident say, "goodie good good," before giving RI #1 some more food. Once RI #1 repeated, "goodie good good," the staff gave RI #1 more food and then laughed. A review of video 166, recorded 05/28/11 at 1:21 PM (four minutes after video 165) for two minutes and one second, shows an elderly white female (RI #1) lying in bed. RI #1 is seen and heard in this video asking the staff member for some more, but the staff (EI #1) is heard saying there isn't anymore, it's all gone. EI #1's "Employee Punches By Day Report", with a run date of 06/22/11 at 11:54 AM, indicates that EI #1 clocked in the facility on 05/28/11 at 6:49 AM and clocked out at 3:39 PM. The "Daily Assignment Sheets" for 05/28/11, indicates that EI #1 was the direct care staff assigned to care for RI #1 during the 7:00 AM to 3:00 PM shift on 05/28/11. A review of video 167 recorded 05/29/11 at 12:53 PM for one minute and eight seconds, shows an elderly white female (RI #1) in bed being fed by staff. RI #1 is seen and heard in this recording telling the staff member "that's too much" after the staff placed a large food portion in her mouth. A review of video 168 recorded 05/29/11 at 12:58 PM (five minutes after video 167) for two minutes and 33 seconds, shows an elderly white female (RI #1) in bed being fed by staff. RI #1 is seen and heard in this video telling the staff that she couldn't eat anymore; however, the staff (EI #1) continued to feed RI #1. RI #1 can be heard on the video saying, "You dog. EI #1 replied, "Your're a dog." RI #1 asked, "Why don't you wipe my mouth?" EI #1 answered, "No, cause you called me a dog." EI #1 instructed RI #1 to say that she was sorry. RI #1 responded, "...You got me too quick. I'm sorry. You messed me up; you hate my guts." EI #1 replied, "Eat mines." As EI #1 continued to hurriedly feed RI #1 large spoonfuls of food, the CNA (EI #1) stated, "Now, here, here some guts for you to eat; right here, guts, more guts.... Hurry up." RI #1 screamed, "Quit!" EI #1 replied, "Dog that!" Although RI #1 yelled that she didn't want anymore, EI #1 continued feeding the resident and said, "Yea! You gon get some more." Again, RI #1 said that she didn't want anymore; but, EI #1 continued placing large spoonfuls of food into the residents mouth and said, "Yep (yes), gain five pounds." When RI #1 screamed to be left alone, EI #1 told RI #1 to, "Shut up!...drink up!" Also, EI #1 was seen holding a cup of liquid pressed against RI #1's chest while telling the resident to "shut up!...drink up!" Once the staff member removed the cup from RI #1's upper chest area, a circular indention could be in the chest area, where the cup had been placed; but, the indentation quickly disappeared. EI #1 referred to RI #1 as "Tootie" and asked, "Was that good Tootie, Tootie?" RI #1 answered, "Fruitie my butt." EI #1 laughed and said, "Why Tootie?" EI #1's "Employee Punches By Day Report" dated 06/22/11 at 11:54 AM, indicates that EI #1 clocked in the facility on 05/29/11 at 6:34 AM and clocked out at 3:18 PM. The "Daily Assignment Sheets" indicates that EI #1 was the direct care staff assigned to care for RI #1 during the 7:00 AM to 3:00 PM shift on 05/29/11. In a follow-up phone interview on 06/22/11 at 8:55 PM, EI #1 was asked, if anyone else was present during the filming of RI #1. EI #1 replied, "Can't remember just me." When the state surveyor asked EI #1 how she could feed RI #1 and record a video all at the same time; EI #1 commented, "I did it." EI #1 gave no reason for recording RI #1. The state surveyor asked EI #1 if she thought it was the right thing to do. EI #1 answered, "No." In an interview on 06/23/11 at 1:41 PM, EI #5, the Director of Nursing (DON), was asked if she thought the residents knew they were being photographed or videotaped. EI #5 replied, "I don't think so, no reason to think so ...." The state surveyor then asked, is it okay for staff to videotape a resident without their permission? EI #5 answered, "No." EI #5 explained that since she was made aware of this incident, she has started inservicing the staff on resident rights and the use of a cell phone within the facility. According to EI #5, the staff has been instructed that the use of a cell phone to videotape or photograph a resident will not be accepted; its a violation of the patient's rights and a violation of privacy. On 03/31/11, EI #1's signed the facility's "Acknowledgement Statement Confidentiality of Patient/Medical Information". This statement documents, "As an employee of Springhill Medical Center, I understand and agree that I must hold medical and other patient information in confidence. I understand "confidential information" of a patient ... to mean any information which I have seen, heard, learned of or contributed to during the course of my employment with Springhill Medical Center, regardless of whether the information is in written or other tangible form. I agree not to discuss, reveal, copy or in any other manner disclose the contents of any medical record or information concerning a patient who has or is receiving health care services, unless I am authorized to do so through an appropriate and properly executed "authorization for release of medical information" where it has been determined and ordered by the appropriate authority that the information is to be released, or the necessary authorization and consent has been obtained from the patient.... By signing this statement, I agree not to disclose any confidential information concerning a patient which is obtained during the course of my employment with Springhill Medical Center." 2. RI #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date of 05/13/11 identified RI #4 as being moderately impaired in cognitive skills, with a BIMS (Brief Interview for Mental Status) score of 11. According to "CMS's RAI (Resident Assessment Instrument) Version 3.0 Manual", page C-14, a score of 8 - 12 indicates a resident is moderately impaired. RI #4 is assessed as requiring extensive assistance of two plus persons for bed mobility, transfers and toilet use. According to a complaint "Intake Information" form for complaint AL 532, with a received / start date of 06/20/11, the Alabama Department of Public Health received a CD from the Trussville Police Department which contained photographs and/or videos of residents that had been downloaded from a cell phone belonging to EI #1, a Certified Nursing Assistant (CNA). In an interview on 06/21/11 at 5:15 PM, EI #1 stated that she normally cares for residents who reside in rooms on the 200 hall, and identified the specific room numbers that she was usually assigned. When the state surveyor asked EI #1 if she owns a cell phone, she affirmed that she did, and said that she has owned her cell phone since February 2011. EI #1 further stated that she has not lost or misplaced her phone and then she pulled from her pocket a black HTC T-Mobile cell phone. On 06/22/11 at 9:00 AM, the state surveyor allowed EI #4 (the facility's Administrator), EI #5 (the Director of Nursing) and EI #6 (the Risk Manager), the opportunity to review the compact disc (CD) that was provided to the Alabama Department of Public Health by the Trussville Police Department. EI #4, EI #5 and EI #6 all verified the CD contained a video (video #174) of RI #4 taken on 06/04/11 at 8:51 AM. Video #174, shows RI #4 lying in bed on her right side, fully dressed with staff present. The video shows EI #2 in the resident's room and the voice of EI #1, can be heard laughing, calling RI #4 by name and asking the resident to "look." EI #2 can be seen and heard laughing, holding her hand up to hide her face and saying, "Don't put that (referring to the camera) on me." EI #1 replied that she was "putting this on YouTube." While laughing, EI #1 is heard calling RI #4 by name and asking RI #4, "who did this to you" over and over again. A staff member places their hand on RI #4 and has the resident to roll over so that the resident's face becomes visible; then, the staff member (EI #1) asked again, "(RI #4) who did this to you." A staff member hands RI #4 a red doll and says "here you go honey"; while another staff member says "you gone need him Jesus." The two staff members (EI #1 and EI #2) then began to have a discussion about repositioning RI #4, while laughing. EI #1's "Employee Punches By Day Report", with a run date of 06/22/11 at 11:54 AM, show that EI #1 clocked in the facility on 06/04/11 at 6:38 AM, and clocked out at 3:28 PM. The "Daily Assignment Sheets" indicates that EI #1 was the direct care staff assigned to care for RI #4 during the 7:00 AM to 3:00 PM shift on 06/04/11. In an interview on 06/22/11 at 12:10 PM, EI #2 was shown video 174, taken / recorded on 06/04/11 at 8:51 AM. EI #2 identified herself and RI #4 in the video. The state surveyor asked EI #2, who filmed (recorded) the video. EI #2 replied that EI #1 filmed the video. When asked the reason the video was taken, EI #2 responded, "You see me hiding. I didn't want her to film me." EI #2 explained that she was not assigned to RI #4, she was only helping EI #1 get RI #4 out of her chair and into the bed. EI #2 verified that it was her voice on the video saying, "you want some more cover (RI #4)", "I lay like that all the time" and "we going to turn you (RI #4) over." EI #2 further admitted that she was the staff member in the video who passed the doll to RI #4. EI #2 identified the doll as RI #4's Jesus doll, and explained that usually when RI #4 is up in the hall, she has this doll sitting on the arm rest of her chair. The state surveyor asked the reason that EI #1 was filming. EI #2 answered, "I do not know." EI #2 explained, "When she put the camera on me that why I did this (EI #2 demonstrated by blocking her face with her hand) that's when I realized she was filming." EI #2 stated that she had not known EI #1 to film before. The state surveyor then asked EI #2 if RI #4 knew she was being filmed. EI #2 replied, "Probably not because I didn't know until she (EI #1) put the camera in my face." EI #2 was then asked, is it okay to film a resident? She answered, "I would think not its against their rights." The state surveyor asked EI #2 if she reported this to anyone and she answered "no I didn't." When the state surveyor asked why, EI #2 commented, "Because I don't get into other people' business." The state surveyor asked EI #2 what was her responsibility to do when she witnessed abuse. She answered, "I guess report but is that abuse that would be invading her (RI #4) privacy." EI #2 was then asked why she didn't report that her co-worker was invading a resident's privacy. EI #2 explained again "Because I don't get involved with stuff like that; it didn't have anything to do with me." The state surveyor asked EI #2 if abuse was the only thing she reported. She replied, "Yes if she (EI #1) would have hit her (RI #4), cursed her, sexually abused her, hurt her but I guess that is hurting her. I just didn't think of it like that." According to EI #2, EI #1 used her camera on her cell phone to record RI #4. EI #2 said that the cell phone camera was in EI #1's hand. When the state surveyor asked EI #2 if EI #1 intentionally meant to record RI #4. EI #2 answered, "Yes since she said she was going to put something on YouTube. I would say yes she meant to film." In a follow up phone interview on 06/22/11 at 8:55 PM, EI #1 was asked, what staff knew she was recording. EI #1 replied, "Just one other person, (EI #2) and you (state surveyor) already spoke with her." The state surveyor then asked EI #1 which video was EI #2 present during the videotaping. EI #1 answered that EI #2 was present when she videotaped RI #4. EI #1 gave no reason for recording RI #4. The state surveyor asked, if EI #2 thought that it (filming) was the right thing to do. EI #1 answered, "No." In an interview on 06/23/11 at 1:41 PM, EI #5, the Director of Nursing was asked if she thought the residents knew that they were being videotaped. EI #5 replied, "I don't think so, no reason to think so ... ." EI #5 was asked if she thought EI #2 knew EI #1 was videotaping? EI #5 answered, "Yes after seeing it (CD) yesterday after seeing only once, we took her (EI #2) in and interviewed, she denied everything - think she tried real hard to not let us know. My gut says she wasn't being truthful then after second viewing - absolutely sure she was aware." The state surveyor then asked, what should EI #2 have done. EI #5 responded that EI #2 should have notified her charge nurse, supervisor or any person in authority. The state surveyor then asked, is it okay for staff to videotape a resident without their permission? EI #5 answered, "No." EI #5 explained that since she was made aware of this incident, she has started inservicing the staff on resident rights and the use of a cell phone within the facility. According to EI #5, the staff has been instructed that the use of a cell phone to videotape of photograph a resident will not be accepted; its a violation of the patient rights and a violation of privacy. On 03/10/11 and 03/31/11, EI #2 and EI #1, respectively signed the facility's "Acknowledgement Statement Confidentiality of Patient/Medical Information". This statement documented, "As an employee of Springhill Medical Center, I understand and agree that I must hold medical and other patient information in confidence. I understand "confidential information" of a patient ... to mean any information which I have seen, heard, learned of or contributed to during the course of my employment with Springhill Medical Center, regardless of whether the information is in written or other tangible form. I agree not to discuss, reveal, copy or in any other manner disclose the contents of any medical record or information concerning a patient who has or is receiving health care services, unless I am authorized to do so through an appropriate and properly executed "authorization for release of medical information" where it has been determined and ordered by the appropriate authority that the information is to be released, or the necessary authorization and consent has been obtained from the patient ... By signing this statement, I agree not to disclose any confidential information concerning a patient which is obtained during the course of my employment with Springhill Medical Center." 3. A complaint "Intake Information" form for complaint #AL 532, with a received / start date of 06/20/11, documents on page 2, "...The Alabama Department of Public Health received a CD from the Trussville Police Department. The CD had been downloaded from a cell phone belonging to (Employee Identifier (EI) #1). A picture downloaded from the cell phone shows a female resident, (later identified as RI #2), fully exposed (naked), sitting on a shower chair in a shower room. The picture was taken on 05/02/11 at 8:56 AM. There is no indication that the resident knew she was having her picture taken. RI #2 was originally admitted to the facility on [DATE] and readmitted [DATE], with [DIAGNOSES REDACTED]. RI #2's Minimum Data Set (MDS) with an assessment reference date of 06/11/11, identified RI #2 as being severely impaired in cognitive skills, with a BIMS (Brief Interview for Mental Status)score of 3. According to "CMS's RAI (Resident Assessment Instrument) Version 3.0 Manual, page C-14, a score of 0 - 7 indicates a resident has a severe impairment. In an interview on 06/21/11 at 5:15 PM, EI #1 stated that she works the day shift (7 AM - 3 PM) and normally cares for residents who reside in rooms on the 200 hall; she gave the specific room numbers that she is usually assigned. When the state surveyor asked EI #1 if she owns a cell phone, she answered that she did, and stated that she has owned her cell phone since February 2011. EI #1 further stated that she has not lost or misplaced her phone and then she pulled from her pocket a black HTC T-Mobile cell phone. The state surveyor showed EI #1, the picture and three of the videos that were taken from her cell phone. EI #1 was asked if she could explain why the state surveyor had pictures and videos from her phone. EI #1 replied, "...I can't offer any explanation for (RI #2) ... ." A review of a photograph taken on 05/02/11 at 8:56 AM, shows an elderly white female with one breast (RI #2) completely naked sitting on a shower chair in a shower room. RI #2's head was in a downward position and there was no indication that the resident knew she was having her picture taken. On 03/31/11, EI #1's signed the facility's "Acknowledgement Statement Confidentiality of Patient/Medical Information". This statement documented, "As an employee of Springhill Medical Center, I understand and agree that I must hold medical and other patient information in confidence. I understand "confidential information" of a patient to mean any information which I have seen, heard, learned of or contributed to during the course of my employment with Springhill Medical Center, regardless of whether the information is in written or other tangible form. I agree not to discuss, reveal, copy or in any other manner disclose the contents of any medical record or information concerning a patient who has or is receiving health care services, unless I am authorized to do so through an appropriate and properly executed "authorization for release of medical information" where it has been determined and ordered by the appropriate authority that the information is to be released, or the necessary authorization and consent has been obtained from the patient ... By signing this statement, I agree not to disclose any confidential information concerning a patient which is obtained during the course of my employment with Springhill Medical Center." On 6/22/11 at 11:00 AM, an interview was conducted with RI #2. When the state surveyor questioned RI #2 about the naked photo of her taken on 05/02/11, RI #2 stated that she didn't know what the state surveyor was talking about. RI #2 then commented that she doesn't take naked photos. In an interview on 06/23/11 at 1:41 PM, EI #5, the Director of Nursing (DON), was asked if she thought the residents knew that they were being photographed or videotaped. EI #5 replied, "I don't think so, no reason to think so ... ." The state surveyor then asked, is it okay for staff to photograph a resident without their permission? EI #5 answered, "No." EI #5 explained that since she was made aware of this incident, she has started inservicing the staff on resident rights and the use of a cell phone within the facility. According to EI #5, the staff has been instructed that the use of a cell phone to videotape of photograph a resident will not be accepted; its a violation of the patient's rights and a violation of privacy. 4. A complaint "Intake Information" form for complaint #AL 532, with a received / start date of 06/20/11, documents on page 2, "...The Alabama Department of Public Health received a CD from the Trussville Police Department. The CD had been downloaded from a cell phone belonging to (Employee Identifier (EI) #1). A video from the cell phone shows a male resident referred to as "Mr. (RI #3)" lying in the bed receiving ADL care. The resident (later identified as RI #3)is without a shirt, but wearing PJ bottoms. There is no indication that the resident was aware that he was being recorded...." RI #3 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #3's Annual Minimum Data Set (MDS) with an assessment reference date of 05/21/11, identified RI #3 as being cognitively intact, with a BIMS (Brief Interview for Mental Status) score of 15. According to "CMS's RAI (Resid