Every finding on record at Sumter Health and Rehabilitation, L L C

Based on observations, record review, and interviews, the facility failed to ensure residents receiving tube feedings, feeding pumps were kept clean and free of a tube-like feeding substance. This deficient practice affected Resident Identifier (RI) #'s 3, 41 and 96, three of four residents sampled for tube feedings, and was observed on three of four days of the survey. Findings Include: RI #3 was admitted to the facility on [DATE], with diagnoses to include Dysphagia and Encounter for Attention to Gastrostomy. RI #3's April 2022 Physician Orders revealed RI #3 had an order for tube feeding of Glucerna 1.5 CAL (calorie) to infuse at 60 cc (centimeters) an hour. On 04/19/2022 at 2:20 PM, RI #3 was observed lying in bed with the head of the bed elevated at a 30-degree angle. RI #3's continuous tube feeding of Glucerna 1.5 cal (Calorie) was observed infusing by way of a pump at 60 cc's hours. There was a dried feeding tube like substance observed on the feeding pump On 04/20/22 at 9:38 AM, RI #3 was observed up in a wheelchair and the tube feeding of Glucerna 1.5 cal continued to infuse by way of pump at 60 cc's hours. The dried feeding tube like substance remained on the feeding pump. On 04/21/2022 at 8:32 AM, RI #3 was again observed up in the wheelchair with the tube feeding of Glucerna 1.5 cal observed infusing by way of pump at 60 cc's an hour. The dried feeding tube like substance remained on the feeding pump. RI #41 was admitted to the facility on [DATE], with a diagnosis of Gastrostomy Status. RI #41's April 2022 Physician Orders revealed RI #4 had an order for Tube feeding of [MEDICATION(S)] 1.5 to infuse at 50 cc's an hour. On 04/19/2022 at 2:30 PM, RI #41 was observed lying in bed with the continuous tube feeding of Jevity1.5 infusing at 50 cc's hour. The screen of the feeding tube pump has dried tube feeding looking substance on it. On 04/20/2022 at 9:40 AM, RI #41 was again observed lying in bed with the continuous tube feeding of Jevity1.5 infusing at 50 cc's hour. The screen of the feeding tube pump was again observed to have a dried tube feeding looking substance on it. On 04/21/2022 at 8:34 AM, the screen of RI #41's feeding tube pump remained with a dried tube feeding looking substance on the screen. RI #96 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Dysphagia and Encounter for Attention to Gastrostomy. RI #96's April 2022 Physician Orders revealed RI #96 was receiving the continuous tube feeding of Glucerna 1.5 to infuse at 42 cc's an hour. On 04/19/2022 at 2:01 PM, the surveyor observed RI #96's continuous tube feeding of Glucerna 1.5 cal infusing by way of a feeding pump at 42 cc's hour. There was a dried tube feeding like substance observed on the feeding tube pump. On 04/20/2022 at 9:32 AM, RI #96's feeding tube pump remained with the dried feeding tube like substance on it. On 04/21/2022 at 8:28 AM, RI #96's tube feeding of Glucerna 1.5 cal continued to infuse at 42 cc's hour with the dried feeding tube like substance remaining on the feeding tube pump. On 04/21/2022 at 8:45 AM, the surveyor conducted an interview with Employee Identifier (EI) #2, the LPN (Licensed Practical Nurse) caring for RI #'s 3, 41 and 96. The surveyor asked EI #2 how often were the resident's feeding tube pumps cleaned. EI #3 said every shift. When asked who would be responsible for ensuring the feeding tube pumps were kept clean, EI #2 said the individual caring for the residents. The surveyor asked EI #2 what could there be a potential for when feeding tube pumps are not kept clean. EI #2 said infection and the feeding tube pumps should be kept clean. EI #2 said not cleaning them would mean they are dirty. On 04/21/2022 at 8: 54 AM. EI #2 accompanied the surveyor to RI #96's room. When asked what did it look like was on the feeding tube pump, EI #2 said she was not sure but it looked dirty. On 04/21/2022 at 8: 55 AM, EI #2 accompanied the surveyor to RI #3 and RI #41's room. When asked what did it look like was on the feeding tube pumps, EI #2 stated it looked like it was dried feeding on RI #3's and 41's feeding pumps. On 04/21/22 at 9:06 AM, the surveyor conducted an interview with EI #4, the Registered Nurse Unit Manager. The surveyor asked EI #4 how often were the residents feeding pumps cleaned. EI #4 said she did not know the policy on that. When asked who would be responsible for ensuring the feeding pumps are kept clean, EI #4 said probably the nurses. EI #4 said there could be a potential for an infection control concern if the feeding pumps were not kept clean. On 04/21/2022 at 1:44 PM, the surveyor conducted an interview with EI #1, the Interim Director of Nursing. The surveyor asked EI #1 who would be responsible for ensuring the residents feeding pumps were kept clean. EI #1 said the nurses. When asked why should the feeding pumps be kept clean, EI #1 said because the feeding pump is a part of the resident's feeding.

Based on record review, interview and review of a facility policy titled Nursing Assessments, the facility failed to ensure a Quarterly Minimum Data Set (MDS) assessment was completed timely for Resident Identifier (RI) #4. This deficient practice affected RI #4, one of 20 residents reviewed for MDS assessments. Findings Include: A review of a facility policy Nursing Assessments with an effective date of August 15, 2018 revealed: . STANDARD: Comprehensive assessments should be completed on admission, quarterly and with a significant change in the resident/guest(s) condition. PROCESS: . III. Quarterly Nursing Assessments include: (once every 3 months). RI #4 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #4's Quarterly MDS assessment, with an Assessment Reference Date (ARD) of 11/07/2021 indicated the assessment was complete. A review of a most recent Quarterly MDS assessment, with an ARD of 04/4/2022, was in progress and had not been completed. On 04/21/2022 at 8:09 AM, an interview was conducted with Employee Identifier (EI) #3, the Registered Nurse (RN)/MDS Coordinator. EI #3 was asked, how she knew when an MDS assessment was due. EI #3 replied she would run a report which indicated which MDS assessments were due. EI #3 was asked, when an MDS assessment was completed, how would it indicate completed. EI #3 replied she transmits, and it would be on a transmittal page. EI #3 was asked when was RI #4 admitted to the facility. EI #3 replied, 01/15/2021. EI #3 was asked when were RI #4's MDS assessments due; and what type MDS assessments would be due. EI #3 replied, on 11/07/2021 a Quarterly MDS assessment was done, and before then a Significant change MDS assessment was completed on 08/08/2021. EI #3 was asked, when was a MDS assessment due after the one dated 11/07/2021. EI #3 replied, one should have been done in February, and she realized it was not done on 04/04/2021. EI #3 was asked, if the MDS assessment dated [DATE], had been completed and submitted. EI #3 replied, not yet but it would be submitted today, 04/21/2022. EI #3 was asked why was the next MDS assessment due after 11/07/2021 not completed until April. EI #3 replied, it was an oversight not intentional. EI #3 was asked, if the MDS was submitted timely. EI #3 replied, no. EI #3 was asked, what was the concern with an MDS assessment not being submitted timely. EI #3 replied there could be missed information. EI #3 was asked who was responsible for ensuring timely submissions of the MDS assessments. EI #3 replied, it was hers.

Based on observations, interviews, and review of the Food and Drug Administration (FDA) (YEAR) Food Code, the facility failed to ensure the 3-compartment sink drain pipes did not extend into the wall and have a direct connection with sewage system to create potential for backflow. This had the potential to affect 87 of 87 residents receiving meals from kitchen. Findings Include: 1. A review of the FDA (YEAR) Food Code revealed: . 5-402.11 Backflow Prevention. (A) . a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. On 9/3/19 at 3:38 PM, an observation was made of the 3-compartment sink. The drain extended below the 3-compartment sink and made a direct connection into the wall. At that time Employee Identifier (EI) #4, Dietary Supervisor, was asked if the 3-compartment sink had backflow prevention device. EI #4 replied that she did not know, but would ask maintenance. On 9/4/19 at 11:04 AM, an interview was conducted with EI #3, Registered Dietitian Nutritionists, Licensed Dietitian. EI #3 was asked if the 3-compartment sink had an air gap. EI #3 replied that she did not see an air gap in the plumbing of the 3-compartment sink. On 9/5/19 at 8:53 AM, a second interview was conducted with EI #4. EI #4 was asked, what was washed or placed in the 3-compartment sink. EI #4 replied, pots, pans, plates, bowls, glasses, anything they used was washed in the 3-compartment sink. EI #4 was asked, did the drain pipe from the 3- compartment sink have a direct connection to the sewage pipe. EI #4 replied, it looked like it did. On 9/5/19 at 10:12 AM, an interview was with EI #5, Maintenance. EI #5 was asked, if the drain pipe, which drained the 3-compartment sink, had a direct connection with the main sewage pipe. EI #5 replied, I am going to be honest and I think it does. It goes from the sink into the wall. EI #5 was asked, what was the potential harm for residents that existed because of the direct connection between the 3-compartment sink and sewage pipe. EI #5 replied, germs, food particles, anything that was in the sewage line could backflow into the sink and contaminant the sink and its' contents. On 9/5/19 at 10:24 AM, an interview was conducted with the Plumber. The Plumber was asked, did the drain pipe that drains the 3-compartment sink have a direct connection with the main sewage pipe. EI #6 replied, Yes, the issue is the sewage could back-up into the sink when the plumbing is tight, like this.

Based on observation, interview, record review, and review of a facility policy titled, Hand Hygiene, the facility failed to ensure Employee Identifier (EI) #2 washed hands after removing gloves before placing a clean 4x4 over Resident Identifier (RI) #87 's wound during wound care. This was observed on 9/4/19, and affected one of two residents observed for wound care. Findings Include: A review of a facility policy titled, Hand Hygiene, with an effective date of (MONTH) 1, (YEAR), revealed . III. Hand Hygiene Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene. After removing gloves . RI #87 was admitted to the facility on [DATE] and readmitted on [DATE]. A [DIAGNOSES REDACTED]. A review of RI #87's Physician order [REDACTED]. Order date 8/20/19 Start date 8/20/19 Stage 2 Wound to Right Medial Ankle, Change Dressing PRN (as needed), Cleanse With Wound Cleanser, Apply Medi Honey, Cover with [MEDICATION NAME] Foam Boarder Dressing . On 9/04/19 at10:55 AM, the surveyor observed EI #2, (RN) Registered Nurse and EI #7, Licensed Practical Nurse (LPN) perform wound care to RI #87's right ankle. EI #2 cleaned the top of the over the bed table. EI #2 and EI #7 washed and dried their hands. EI #7 put on gloves and entered the resident's room. EI #2 placed the needed supplies in zip lock bags. EI #2 dated and initialed the [MEDICATION NAME]. EI #2 then removed the old [MEDICATION NAME] dressing and discarded it into the garbage. EI #2 removed her soiled gloves and washed her hands. EI #2 put on gloves and measured the wound. EI #2 removed her gloves and washed her hands. EI #2 put on clean gloves, took a gauze pre-moistened with wound cleanser from the zip-lock bag and cleaned the wound. EI #2 removed her soiled gloves. EI #2 removed a clean dry 4x4 from the zip-lock bag and placed it on the wound using her bare hand. EI #2 did not wash her hands or put on clean gloves before getting the clean 4 x 4 from the zip lock bag and placing it on the wound. On 9/4/19 at 12:00 PM, an interview was conducted with EI #2. EI #2 was asked if she followed the facility policy to prevent causing contamination to the wound. EI #2 replied, I thought I did, but after thinking about it, I should have left the wound uncovered and after taking my gloves off, went and washed my hands, put gloves on, then got a clean, dry gauze out of the zip lock bag and laid it on top of the wound. On 9/05/19 at 8:00 AM, an interview was conducted with EI #1, RN, Director of Nursing, (DON). EI #1 was asked, what could not washing one's hands and putting on gloves during wound care, according to policy, result in. EI #1 replied, it could cause a wound to get infected. We don't know what's on our hands when we touch a clean gauze with our bare hands. We could be introducing germs. We could be putting a wound in harms way.

Based on observation, interview and review of the facility's policy titled, Garbage and Refuse the facility failed to ensure the outside garbage dumpster doors were closed and soiled items and other refuse were not lying on the concrete around the dumpster area. Findings include: The facility policy titled, Garbage and Refuse with an effective date of (MONTH) 1, 2002, documented the purpose, To prevent the spread of bacteria that may cause food borne illnesses. Process: a. Garbage should be disposed of in refuse containers, . e. Refuse containers and dumpsters kept outside the facility should . be kept covered when not being loaded. 08/16/18 01:38 PM an observation was made of the six outside dumpster's and the surrounding area. One dumpster was noted with the door open, odor noted and gnats flying around the door. Around the dumpster's were noted a pair of soiled gloves, 13 cup lids, 3 plastic cups, 1 Ensure Plus box, 1 newspaper and 1 paper towel, all lying on the concrete outside the open dumpster. On 08/16/18 12:51 PM, and interview was conducted with Employee Identifier (EI) #4, the Dietary Manager. She was asked what was the facility policy regarding garbage and refuse. EI #4 replied, the dumpster lid should have been tightly fitted/ closed. She was asked was the door open on one of the dumpster's and she replied, yes ma'am. EI #4 was asked was there an odor noted, gnats flying around the door, and trash lying on the concrete. The dietary manager answered, yes ma'am. EI #4 was asked what was the concern with the dumpster door being open, smell of odor, gnats flying around the door of the dumpster, and trash lying on the concrete beside the open dumpster. EI #4 replied, it can cause more insects and rodents, which can be harmful to the food and residents.

Based on observation, interview and a review of the facility's policy titled, Food Receipt and Storage, the facility failed to ensure mighty shakes were labeled and properly dated with use by dates. This had the potential to affect 93 of 95 residents receiving meals from the kitchen. Findings Include: A review of the facility's policy titled, Food Receipt and Storage' with an effective date (MONTH) 23, (YEAR), revealed: . PURPOSE: Foods should be received and stored properly to prevent food borne illnesses. PR[NAME]ESS: . II. Storage of Foods: . j. Label the case or tray of frozen supplements(without expiration dates) with the date they are thawed, or with a used by date which is 14 days from thaw date. On 08/13/18 at 4:15 p.m., during the initial kitchen tour, the surveyor observed three Vanilla Sugar Free Mighty Shakes with a use by date of 7/27/18, four Vanilla Sugar Free Mighty Shakes with a use by date of 8/8/18, and one Vanilla Sugar Free Mighty Shake with no use by date. An interview was conducted on 8/16/18 at 1:16 p.m., with Employee Identifier (EI) #4, Dietary Manager. EI #4 was asked what was the policy and procedure for dating and labeling mighty shakes. She replied, when thawed out in the cooler the date is 14 days from the thawed date. EI #4 was asked were the 8 mighty shakes within the 14 day time limit. She responded, no ma'am. EI #4 was asked what was the concern with the mighty shakes being out of date and having no date. She stated that the mighty shakes were not safe to be consumed by the residents. EI #4 was asked if the mighty shakes were not safe to be consumed by the residents, what potential harm was it to the residents. The dietary manager answered, the residents could become sick, nausea, and vomiting. EI #4 was asked who had the ultimate responsibility to ensure the food/ mighty shakes were properly labeled. She answered, she was,as dietary manager.

Based on observation, interviews, medical record review and review of a facility document titled, RESIDENTS: These are YOUR Rights, the facility failed to ensure Employee Identifier (EI) #5, Activity Director, allowed Resident Identifier (RI) #12 to attend the Resident Council Meeting on 08/15/18. This affected RI #12, one of 94 residents residing in the facility. Findings Include: A review of a document titled, RESIDENTS: These are YOUR Rights, with no date, documented: .YOU have the right to choose the groups and activities in which you choose to participate. RI #12 was readmitted to the facility on [DATE]. A review of RI #12's Annual Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact and that it was very important to the resident to attend group activities. A review of RI #12's Activity Care Plan dated 11/15/2017, revealed: .ENJOYS ATTENDING GROUP ACTIVITIES . On 08/15/18 at 10:00 a.m., a Resident Council Meeting was conducted. During the meeting, two residents stated that one of the residents that normally attended the meeting was not present because he/she was told by Employee Identifier (EI) #5, Activity Director, to leave the meeting. Both residents stated they were also told to leave the meeting, but they refused. On 08/15/18 at 10:26 a.m., when leaving the Resident Council Meeting, RI #12 was observed sitting in a wheelchair in the hallway outside the room. RI #32 asked RI #12 why he/she did not come to the meeting. RI #12 said he/she was told not to come. RI #32 asked who told you that. EI #5, stepped up to the resident and told her/him that she/he did no need to attend because RI #12 had already talked to the surveyors and she wanted to give other residents the chance to talk. On 08/15/18 at 10:46 a.m., an interview was conducted with RI #12. RI #12 was asked if he/she would like to talk in the conference room since he/she was not permitted to attend the Resident Council Meeting. RI #12 said yes. RI #12 then stated that he/she had been told by EI #5 not to come into the Resident Council Meeting because he/she had already talked to two surveyors. RI #12 said EI #5 instructed him/her to go play dominos after the morning devotional. RI #12 further stated that he/she regularly attended the Resident Council Meetings and had wanted to attend the meeting today as well. On 08/16/18 at 1:50 p.m., an interview was conducted with EI #1, Administrator. EI #1 was asked had she been made aware of the situation regarding RI #12 not being allowed to attend the Resident Council Meeting on 08/15/18. EI #1 said yes. She stated that EI #5 had told her that RI #12 had already talked to the surveyors and she was giving someone else the opportunity to speak with them. EI #1 then stated that she told EI #5 that she could not refuse any resident access to participate in a Resident Council Meeting. The surveyor asked EI #1 was preventing a resident from attending the meeting a violation of a resident's rights. EI #1 said, yes it was. EI #1 was asked was RI #12 prevented from attending the meeting yesterday. EI #1 stated she did not feel EI #5 did it on purpose, but it did happen.

Based on observation, interviews and review of a facility policy titled, Hand Hygiene, the facility failed to ensure a licensed staff washed her hands when removing gloves during wound care observation of Resident Identifier (RI) #72. This affected RI #72, one of three residents observed during wound care. Findings Include: A review of a facility policy titled, Hand Hygiene, with an effective date of (MONTH) 1, (YEAR), revealed: .Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some of the situations that require hand hygiene .After handling soiled equipment or utensils .After removing gloves or aprons . RI #72 was readmitted to the facility on [DATE]. A current [DIAGNOSES REDACTED]. On 08/16/18 at 10:36 a.m., an observation was made during the wound care of RI # 72. Registered Nurse (RN) Employee Identifier (EI) #3, entered RI #72's room. She washed her hands and donned gloves. EI #3 pulled the privacy curtain, then removed the gloves and put on clean gloves, without washing her hands. She then removed the wound dressing and cleaned the area. After providing additional care to the wound area, EI #3 removed her gloves and donned clean gloves, again without washing her hands. She initialed and dated the dressing, took her gloves off and washed her hands. On 08/16/18 at 11:01 a.m., an interview was conducted with EI #3. She was asked when should she wash her hands when using gloves. EI #3 answered, before and after putting them on and when taking them off. EI #3 was asked did she wash her hands after pulling the privacy curtain wearing gloves and before applying a clean pair. The RN replied, no ma'am. The surveyor asked EI #3 if she washed her hands when removing her gloves after applying the collagen matrix. She answered, no ma'am. EI #3 was asked what was the concern with not washing her hands when removing gloves and before applying clean gloves. EI #3 replied, you may touch something on the outside of the gloves when removing the dirty ones and expose your skin to something dirty that you put in the new gloves, making them dirty. EI #3 was asked what was the concern with that. She responded with, infection control.

Based on observations, an interview, and a review of the Job Description for the Director of Maintenance, the facility failed to ensure: 1) toilet bolts were not observed protruding, rusted, and uncapped on residential toilets. This was observed on RL (Room Locator) #s 1-11 and 14-16, on four of five units of the facility and 2) the facility failed to ensure the doors for RL#s 12 and 16-18 were not found splintered, with rough edges. This was observed on one of five units of the facility. Findings Include: A review of the Job Description for the Director of Maintenance for the facility with a revision date of 06/03 revealed: . Essential Job Functions A. ADMINISTRATIVE FUNCTIONS 1. Assume administrative authority, responsibility and accountability for supervising and directing the Maintenance Department. 2. Assist in planning, developing, organizing, implementing, evaluating and maintaining maintenance services. 3. Coordinate maintenance services and activities with other related departments. B. DEPARTMENTAL FUNCTIONS . 9. Maintain appearance of building and provide necessary repairs and painting as needed. 13. Inspect all lavatories, commodes and faucets and repair as necessary. E. SAFETY AND EQUIPMENT FUNCTIONS 1. Ensure that facility and department are maintained in a safe manner . 1) Observations were made during the initial tour on 7/18/17 beginning at 12:18 p.m. RL #7 was found with approximately 1 inch rusted uncapped toilet bolts. RL #6 was found with approximately 2 inch rusted uncapped toilet bolts. RL #8 was found with approximately 1/2 inch rusted uncapped toilet bolts. RL #9 was found with approximately 1 inch rusted uncapped toilet bolts. RL #5 was found with approximately 1/2 to 1 inch rusted uncapped toilet bolts. RL #2 was found with approximately 1 inch rusted uncapped toilet bolts. An observation was made on 7/20/17 at 8:15 a.m. of RL #10 with toilet bolts uncapped. An observation was made on 7/20/17 beginning at 8:25 a.m. RL #3 was found with approximately 3/4 inch rusted uncapped toilet bolts. RL #4 was found with approximately 1 inch rusted uncapped toilet bolts. RL #14 was found with approximately 2 inch rusted uncapped toilet bolts. RL #11 was found with approximately 1 inch rusted uncapped toilet bolts. RL #15 was found with approximately 1/2 inch rusted uncapped toilet bolts. RL #16 was found with approximately 1 inch rusted uncapped toilet bolts. An observation tour/interview was conducted with EI (Employee Identifier) #1, the Director of Maintenance, on 7/20/17 at 9:06 a.m EI #1 was asked what he observed at the following RL #s related to toilet base bolts: RL #3 - EI #1 answered the bolts were lacking caps and had some rust on them. RL #4 - EI #1 answered the bolts were uncapped and rust was on them. RL #14 - EI #1 answered the bolts were rusty with no caps. RL #11 - EI #1 answered the bolts were rusty and uncapped. RL #15 - EI #1 answered the bolts were rusty with no caps. RL #16 - EI #1 answered the bolts were uncapped. RL #5 - EI #1 answered the bolts were uncapped and rusty. RL #2 - EI #1 answered the bolts were rusty and uncovered. RL #6 - EI #1 answered the bolts were rusty and uncapped. RL #9 - EI #1 answered the bolts were uncapped and rusty. RL #10 - EI #1 answered the bolts were rusty and uncapped. An observation was made on 7/20/17 at 9:30 a.m. of RL #1 with approximately 2 inch rusted uncapped toilet bolts. An interview was conducted with EI #1 on 7/20/17 at 9:26 a.m. EI #1 was asked who was responsible for checking/monitoring resident areas for safety. EI #1 answered, Everybody. Staff should notify us if they see something. They can issue a work order. EI #1 was asked who checked the bolts on the toilet base for safety/concerns. EI #1 answered, Me. EI #1 was asked how often the bolts on the toilet bases should be checked. EI #1 answered, Every month we are supposed to look at 1/3 of the rooms. EI #1 was asked if toilet bolts should be capped. EI #1 answered, Yes ma'am. EI #1 was asked what was the concern with toilet bolts being rusted, long, and uncapped. EI #1 answered, Now I'm concerned that somebody could stub their toe on it. 2) An observation was made on 7/20/17 beginning at 8:25 a.m.: RL #18's room door was found with an approximate 2 inch splintered area approximately 2-3 inches below the interior door knob. RL #12's bathroom door was found with an approximate 4 inch splintered area approximately 1 inch above the exterior door knob. RL #16's bathroom door was found with an approximate 4 inch splintered area approximately 1 inch above the exterior door knob. RL #17's bathroom door was found with an approximate 2 1/2 inch splintered area at the level of the exterior door knob. The area was splintered deep enough to expose the lock inside the door. An observation tour/interview was conducted with EI #1 on 7/20/17 at 9:06 a.m EI #1 was asked what he observed at the following RL #s related splintered doors. RL #18 - EI #1 answered the room door had a rough edge. RL #12 - EI #1 answered the bathroom door was rough approximately 3-4 inches. RL #16 - EI #1 answered the bathroom door had a 3 inch rough area. RL #17 - EI #1 answered the room door had a deep gash in the door by the latch approximately 2 inches long. An interview was conducted with EI #1 on 7/20/17 at 9:29 a.m. EI #1 was asked what was observed on the doors viewed with the surveyor. EI #1 answered, The ones we looked at had wood missing. EI #1 was asked what was the concern of splintered doors in resident areas. EI #1 answered, They could get a skin tear. EI #1 was asked what was the facility policy regarding upkeep and condition of doors and toilet bolts. EI #1 answered, When we see it, we are supposed to repair it. EI #1 was asked who was responsible for monitoring the conditions of doors and he answered, Me.

Based on observations, interview and a facility policy titled, Tube Feeding-Preventing Contamination, the facility failed to ensure a resident's tube feeding bottle was labeled to include the date the feeding was initiated. This deficient practice affected RI (Resident Identifier) #6, one of two residents sampled for tube feeding. Findings Include: A review of a facility policy dated December 1, 2012, titled, Tube Feeding-Preventing Contamination, revealed: . PURPOSE: To prevent contamination of formula. STANDARD: The physician's orders [REDACTED]. feeding. PROCESS: .7. Record date and time the container is hung on the container and discard unused formula per manufacturer's guidelines . A review of the medical record revealed RI #6 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a Significant Change Minimum (MDS) data set [DATE], revealed RI #6 required extensive assistance of one person with eating. RI #6 had a Brief Interview of Mental Status score of 0 out of a possible 15 which indicated RI #6 was severely impaired for daily decision making. During an initial tour of the facility on 7/18/2017 at 12:32 p.m., RI #6's tube feeding bottle was viewed and there was no date written on the labeling of the tube feeding bottle. An observation was made of RI #6's tube feeding on 7/18/2017 at 3:32 p.m. The labeling of the tube feeding bottle was reviewed and there was no date listed on the label. On 7/20/2017 at 10:45 a.m., an interview was conducted with EI (Employee Identifier) #2, a LPN (Licensed Practical Nurse). EI #2 was asked who labeled tube feeding bottles. EI #2 stated, (The) Nurse that hangs them. EI #2 was asked what should be labeled on a tube feeding bottle. EI #2 stated, Name, date, rate, time, and initials. EI #2 was asked why should the tube feeding bottle be labeled. EI #2 responded, To show (the) time hung and the rate they go at. EI #2 was asked what was the facility policy on labeling tube feeding bottles. EI #2 stated, Name, date, and rate. EI #2 was asked what was the concern of not labeling tube feeding bottles. EI #2 stated, Not knowing the time they were hung and accurate rate.

Based on observation, record review, and interview the facility failed to ensure that dietary staff did not touch the rims of drinking glasses and provale cups with their bare hands prior to placing them on resident trays during tray line preparation. The facility further failed to ensure that a dietary aid did not touch her face then continue to touch rims of drinking glasses without washing her hands. This deficient practice had the potential to affect all 96 residents receiving meals from the kitchen. Findings Include: The facility's policy titled: Tray Assembly with an effective date of 2/1/2002 revealed the following: . Process: .d. During tray assembly, staff should avoid: . Placing thumbs or fingers inside a plate, bowl or glass/cup . The 2013 Food Code Section 2-301.14 revealed the following: When to Wash FOOD EMPLOYEES shall clean their hands . (A) After touching bare human body parts other than clean hands . The 2013 Food Code Section 3-304.11 revealed the following: Food Contact with Equipment and Utensils. Food shall only contact surfaces of : (A) EQUIPMENT and UTENSILS that are cleaned .and SANITIZED . On 6/29/2016 at 11:02 AM while observing tray line preparation, the surveyor observed Employee Identifier (EI) #2 a dietary aid transferring prepared glasses of water from a prep cart to residents trays. EI #2 held the drinking glasses from the top with all ungloved fingers and thumb touching the drinking rim/lip of the glass. The surveyor observed EI #2 repeat this six times prior to EI #2 moving the loaded tray line cart to the next part of the tray line process. On 6/29/2016 at 11:04 AM on the same tray line the surveyor observed EI #3 dietary aid, prepare trays for residents with special diets. EI #3 was observed transferring prepared glasses of iced tea from a tray to residents trays. EI #3 held the drinking glasses from the top with ungloved fingers and thumb touching the drinking rim/lip of the glass. This action was repeated for three glasses of iced tea and then for two glasses of orange drink. EI #3 was also observed to touch her face then continue to touch the rims/lip area of the drinking glasses without washing her hands. EI #3 was observed placing lids on three provale cups by placing her bare hands on the surface of the cup lids instead of the sides contaminating the drinking slots from which the residents drink. On 6/29/2016 at 2:25 PM an interview was held with EI #2. EI #2 was asked when transferring glasses of water or juice from the preparation cart to the residents trays where should the drinking glass be held. EI #2 replied, at the bottom. EI #2 was asked if she did it that way today. EI #2 responded, no. EI #2 was asked to explain why. EI #2 stated that she had been nervous and that working under pressure, she forgot. The surveyor then asked what was the potential harm of holding the drinking glasses at the rim or lip. EI #2 replied that bacteria could come off the hand onto the rim or lip of the glass. On 6/29/16 at 2:40 PM an interview was held with EI #3. EI #3 was asked when transferring glasses containing water or iced tea from a cart to residents trays how should you hold the drinking glass. EI #3 replied, at the bottom. EI #3 was then asked had she done that during the lunch tray line. EI #3 stated, not entirely. The surveyor asked EI #3 what she should do if she touched her face before going back to transferring items to the residents trays. EI #3 stated that she would wash her hands. EI #3 was asked if she did that. EI #3 said, if she did touch her face she would have washed her hands, as it was part of the guidelines. EI #3 was asked what was the potential harm of holding the drinking glass at the top by the rim/lip. EI #3 stated, that germs spread to the residents possibly making residents ill. EI #3 was then asked what was the potential harm of not washing her hands after touching the face before completing the next tray. EI #3 replied, spreading of germs. EI #3 was asked to explain the correct way to apply the top of the provale cup to the bottom. EI #3 replied, push the side until the top clicks on. EI #3 was asked if that was the method she used when placing the lids on during tray line earlier. EI #3 said, obviously not. EI #3 was asked how she fixed the top of the cups. EI #3 replied, I pushed on the flat top. When asked what the potential harm to the resident would be, EI #3 replied, transmission of germs. On 6/29/2016 at 3:00 PM an interview was held with EI #1 the Dietary Manager who was asked what was the correct way to hold a glass containing water/iced tea from the prep cart to the residents tray. EI #1 replied, all should be handled from the bottom or lower sides, never where the resident will be drinking from. EI #1 was then asked what should a kitchen employee do if they touch their face during tray line prep and prior to continuing with their next action. EI #1 stated, they need to stop and wash their hands. EI #1 was then asked what was the correct way to apply the lid to the provale cups. EI #1 replied, hold the lid by it's sides, push down on the cup until it clicks. EI #1 was asked what was the potential harm of mishandling drinking glasses and touching the tops of the provale cups instead of the sides when attaching the lids. EI #1 stated that it could lead to possible infections. EI #1 was then asked what the potential harm could be if hands were not washed after touching the face and continuing to touch residents drinking glasses and provale cups. EI #1 stated that it would spread germs and infection.

Based on interview and record review the facility failed to ensure the abuse policy was implemented when an allegation of sexual abuse was not investigated, not reported to the state agency, and not reported to law enforcement. This affected RI (Resident Identifier) #1, one of three residents reviewed for abuse. Findings include: A review of the facility policy titled: Abuse . with an effective date of 8/1/2016 revealed: PURPOSE: This policy .is concerned with all incidents and accidents involving residents. The facility will investigate and document all incidents . involving residents. Certain incidents . involving residents must also be reported to the appropriate state agencies. Reportable incidents . are those involving allegations of resident abuse, . Alleged violations that would constitute violations of criminal statutes, such as ., rapes, and assaults must be reported to the appropriate local law enforcement agency. This Policy against abuse, .includes abuse by any other person, . The facility's Policy requires that it report all instances of abuse, .as required by state and federal law. IV. Identification of Residents Incidents . a.The facility will investigate all . allegations regardless of how the facility became aware of the incident or the source of the allegation.VI. b) Investigation and Reporting . The Administrator will report to state agency per regulations .The Administrator is responsible for conducting a thorough investigation and obtaining witness statements . RI #1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1's 14 day MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/6/2015 revealed a BIMS (Brief Interview for Mental Status) score of 13, which indicated intact cognition. RI #1's nurse's note dated 8/12/2015 at 3:39 PM, revealed the following: .resident stated that .(RI #1) wanted to tell me something .one day there was a man standing at (RI #1's) .door .(RI #1) told him not to come into . room, but he did anyway . the man told (RI #1) to come to his room at 3am and wake him up and he would show ( RI #1) something. that night (RI #1) felt someone tugging at (RI #1's) foot at 3o'clock in the morning . and .could see someone standing at the foot of the bed . he told (RI #1) to say that (RI #1) used a banana. RI #1's nurse's note dated 8/15/2015 at 11:01 AM, revealed the following: .Resident reported to this nurse .was attached (attacked) in room .one week ago, resident appeared to be upset and very hesitant to explain situation . A review of allegations and investigations the facility reported to the State Agency did not include any allegations made by RI #1. On 6/30/2016 at 1:30 PM, an interview was conducted with EI (Employee Identifier) #5 Assistant Administrator, in the presence of EI #4 Administrator. EI #5 was asked how RI #1's allegations documented in the nurse's notes were investigated. EI #5 said, the facility spoke with RI #1's brother who said, RI #1 had done that before. When asked what the facility did to ensure the resident had not been attacked, EI #5 said, they talked to the family and the family did not believe RI #1 had been attacked. When asked what investigation was documented, EI #5 said, the nurse's notes contained what the resident said. When asked what type of abuse RI #1 had alleged, EI #5 said, she did not believe RI #1 had been taken advantage of. When asked what types of allegations of abuse the facility reported to the state agency with investigations, EI #5 said, We report all types. EI #5 was asked why RI #1's allegation was not reported. EI #5 said, the facility did not feel it was an allegation. On 6/30/2016 at 4:00 PM, EI #4 Administrator was asked what allegations of abuse were reported to law enforcement by the facility. EI #4 said, Any allegation of abuse is reported to police chief. When asked why the allegations made by RI #1 were not reported to law enforcement, EI #4 said, We did not see that as an allegation of abuse.

Based on interview and record review the facility failed to ensure an allegation of sexual abuse was investigated, reported to the State Agency, and reported to Law Enforcement. This affected RI (Resident Identifier) #1, one of three residents reviewed for abuse. Findings include: A facility policy with an effective date of 8/1/2015, titled: Abuse . revealed: PURPOSE: This policy .is concerned with all incidents and accidents involving residents. The facility will investigate and document all incidents . involving residents. Certain incidents . involving residents must also be reported to the appropriate state agencies. Reportable incidents . are those involving allegations of resident abuse . Alleged violations that would constitute violations of criminal statutes, such as ., rapes, and assaults must be reported to the appropriate local law enforcement agency. IV. Identification of Residents Incidents . a.The facility will investigate all . allegations regardless of how the facility became aware of the incident or the source of the allegation. RI #1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1's 14 day MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/6/2015 revealed a BIMS (Brief Interview for Mental Status) score of 13, which indicated intact cognition. RI #1's nurse's note dated 8/12/2015 at 3:39 PM, revealed the following: .resident stated that .(RI #1) wanted to tell me something .one day there was a man standing at (RI #1's) .door .(RI #1) told him not to come into . room, but he did anyway . the man told (RI #1) to come to his room at 3am and wake him up and he would show ( RI #1) something. that night (RI #1) felt someone tugging at (RI #1's) foot at 3o'clock in the morning . and .could see someone standing at the foot of the bed . he told (RI #1) to say that (RI #1) used a banana. RI #1's nurse's note dated 8/15/2015 at 11:01 AM, revealed the following: .Resident reported to this nurse .was attached (attacked) in room one week ago, resident appeared to be upset and very hesitant to explain situation . A review of allegations and investigations the facility reported to the State Agency did not include any allegations made by RI #1. On 6/30/2016 at 1:30 PM, an interview was conducted with EI (Employee Identifier) #5 Assistant Administrator, in the presence of EI #4 Administrator. EI #5 was asked how RI #1's allegations documented in the nurse's notes were investigated. EI #5 said, the facility spoke with RI #1's brother who said, RI #1 had done that before. When asked what the facility did to ensure the resident had not been attacked, EI #5 said, they talked to the family and the family did not believe RI #1 had been attacked. When asked what investigation was documented, EI #5 said, the nurse's notes contained what the resident said. When asked what type of abuse RI #1 had alleged, EI #5 said, she did not believe RI #1 had been taken advantage of. When asked what types of allegations of abuse the facility reported to the state agency with investigations, EI #5 said, We report all types. EI #5 was asked why RI #1's allegation was not reported. EI #5 said, the facility did not feel it was an allegation. On 6/30/2016 at 4:00 PM, EI #4 was asked what allegations of abuse were reported to law enforcement by the facility. EI #4 said, Any allegation of abuse is reported to police chief. When asked why the allegations made by RI #1 were not reported to law enforcement, EI #4 said, We did not see that as an allegation of abuse.

Based on observation, interviews and record reviews the facility failed to ensure food items in the walk-in cooler were labeled with a use by date. This included a six pound roll of ground beef, a large bowl of chocolate pudding, four boxes of shakes, 16 individual cups of peaches and more than 20 individual servings of pear slices with no use by date. This had the potential to affect 101 residents who received meals from the kitchen. Findings Include: The Food Code 2013 documented on page 92, "...3-501.17 Ready-to-Eat, Time/Temperature Control for Food Safety, Date Marking. (A)" ..., READY-TO-EAT,TIME/TEMPERATURE CONTROL FOR FOOD SAFETY prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded.. The day of preparation shall be counted as Day 1." The facility policy titled," Leftover Food Storage and Use," effective date August 15, 2009, documented: "...PURPOSE: To assure that food borne illnesses are avoided. STANDARD: Leftover foods should be stored under the same conditions as other foods. PROCESS: ...b. Leftover foods should be covered, labeled and dated." The facility policy titled," Food Receipt and Storage," effective date August 21, 2013, documented: "... PURPOSE: Foods should be received and stored properly to prevent food borne illnesses. ...PROCESS: ...II. Storage of Foods: ...j. Label the case or tray or tray of frozen supplements (without expiration dates) with the date they are thawed, or with a use by date which is 10 days from the thaw date. k. Open foods items should be covered, labeled and dated; ..." On 05/12/15 at 10:55 AM, during the initial tour of the kitchen the following items were observed in the walk in cooler, that were not labeled with a use by date; 1) Identified by the Dietary Manager, Employee Identifier, (EI) # 2, there was a six pound roll of uncooked hamburger meat on a tray on the bottom shelf that was wrapped in cellophane. The meat was not labeled at all with neither an open date or a use by date. 2) A large bowl of chocolate pudding was not labeled with a use by date. 3) One box of shakes dated 05/03, had no use by date. 4) Three boxes of supplements dated 05/11 had no use by date. 5) 16 individual cups of sliced peaches had no use by date and they were not covered. 6) There were more than 20 individual servings of pear slices with no use by date. On 05/13/15 at 3:30 PM, EI #2, Dietary Manager, was asked what was the facility's process for labeling items in the walk in cooler. EI #2 replied the date it was opened and the use by date. EI # 2 was asked who was responsible to label items when put in the cooler. EI #2 replied who ever handled the item. EI #2 was asked what should be documented on the label. EI #2 replied the date opened, employee initials and the use by date. EI #2 was asked why was it important to label food with a use by date. EI #2 replied so the food would not be used beyond the use by date. EI #2 was asked what would be the potential harm if items were not marked with a use by date. EI #2 replied it could make somebody sick. On 05/13/15 at 3:40 PM, EI #3, Registered Dietician, what was the facility's process for labeling items in the walk in cooler. EI #3 replied with a date it was put in and a use by date, which was three days later. EI #3 was asked who is responsible for labeling items when put in the cooler. EI #3 replied anybody who puts items in there. EI #3 was asked what should be documented on the label. EI #3 replied the date put in, what the item was and the use by date. EI #3 was asked why it was important to label with a use by date. EI #3 replied so we would know when to get rid of it. EI #3 was asked what could be the potential harm if items were not labeled with a use by date. EI #3 replied food safety, someone could get sick.

Based on observation, interviews and record review the facility failed to ensure Social Services maintained contact with Resident Identifier (RI) #14's family and made referrals for outside services. RI #14 was identified by the facility with a history of dental concerns. This affected 1 of 1 sampled residents for dental concerns. Findings Include: In the facility job description titled "Social Services Director," review date 06/30/03, documented the following: "General Purpose To act as a liaison and representative of the residents' social interests and plan, organize, develop and direct the overall operation of the Social Services Department ...to ensure that the medically-related emotional and social needs of the resident are met and maintained on an individual basis... Essential Job Functions ...3. Implement social service interventions that achieve treatment goals, address resident needs, link social supports...to enhance quality of life. 8. Provide information to residents and their families concerning available support agencies and financial assistance programs to meet the needs of the residents. 9. Provide assistance and support in the absence of family/responsible party, in assuring residents' needs are met... 11. Maintain effective relationships and open communication with residents, families, staff, community and outside healthcare resources." In the facility policy titled, "Delegation of Social Services Duties," effective date March 1, 2008, documented the following: "...Standard: According to federal regulations, the facility must provide medically-related social services to attain or maintain the highest practical physical, mental, and psychosocial well-being of each resident... Process: I. Medically-Related Social Services Medically-related Social Services is defined, ..., as the services provide by the facility's staff to assist residents in maintaining or improving their ability to manage their everyday physical, mental, and psychosocial needs. ... When services are not covered by the Medicaid state plan, or the Medicare program, facilities are still required to attempt to obtain these services, ..." In the facility policy titled," Hearing, Vision and Dental Services, effective date March 1, 2008 documented: "...Standard: ...the facility, if necessary, should assist the resident in making appointments and arranging transportation to and from the office of a practitioner specializing in the treatment of [REDACTED]. The Social Service Designee is responsible to assist resident, and their families, in locating available resources... for the provision of the services the resident needs. ...Assistive devices to maintain oral health may include bridges or dentures." On 05/12/15 at 11:15 AM, during the initial tour RI #14 was observed in her room waiting for the lunch meal. RI #14 had a noticeable brown and black colored teeth and the front two teeth on top were missing. RI #14 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Dental Care Plan for RI #14 with a problem onset date of 05/13/2011 documented "Potential for dental concerns r/t cognitive deficit... and hx of dental cavities" Approaches listed included: "Observe for mouth abscesses, ...irritation, inflammation, bleeding gums; Observe for difficulty chewing; ...Observe for changes in gums/teeth; Oral hygiene per schedule... observe for c/o complaints mouth pain..." RI #14 Quarterly Minimum (MDS) data set [DATE] documented RI #14 was rarely understood at making self understood and sometimes could understand others. RI #14 was impaired in long and short term memory loss and severely impaired with cognitive skills for daily decision making. RI #14 required limited to extensive assistance with Activities of Daily Living such as walking in the room and the hallway; dressing and toilet use. RI #14 was independent with eating after tray set up. RI #14 was documented with mouth or facial pain, discomfort or difficulty chewing. In a "Nursing Review " form dated 03/03/15, RI #14 was documented under Dental with cavity or broken natural teeth. On 05/13/15 at 5:30 PM, RI #14 was observed eating the evening meal with the Speech Therapist watching the chewing and swallowing. RI #14 consumed all of the sweet potato, squash casserole and was able to chew the chopped meat without any difficulty. When RI #14 was given a bite of cake with ice cream he/she hollered and spit out the ice cream. A Certified Nursing Assistant (CNA) that was standing near the table asked RI #14 if the ice cream hurt inside the mouth. RI #14 pointed inside the mouth and stated, "yeah, yeah, yeah." RI #14 's "Speech Therapy Plan of Care" dated 05/13/15 documented the following: "Reason for referral...decreased by mouth intake is caused by decreased attention and difficulties chewing due to dental abnormalities... "... Initial Assessment... Current Level Modified Independence (requires excess time for eating, or requires assistive device or multiple swallows to clear food. Diet may be modified due to medical and/or dental status..." In the Underlying Impairments Other section documented :"... SLP (Speech, Language, Pathologist) completed the initial clinical evaluation on this date secondary to reports from nursing of the patient presenting with a decreased appetite and weight loss. ...The SLP also noted the patient demonstrated s/s (signs and symptoms) of pain while chewing food. ..." On 05/13/15 at 3:55 PM, Employee Identifier (EI ) #4, Social Services Designee, was asked when was RI #14's last dental consult or visit. EI #4 replied Medicaid will not pay for dental unless it's medically related. EI #4 was asked when was the last time she had been in contact with RI #14's family about going to the dentist. EI #4 replied it had been a couple of years ago, back in November 2012. EI #4 was asked if she was aware RI #14's teeth were in bad shape. EI #4 replied no she was not aware. On 05/14/15 at 10:40 AM, EI #5, CNA was asked when did she brush RI #14's mouth and how often. EI #5 replied during bathtime around 6:00 AM and after breakfast everyday that she had RI #14. EI #5 was asked did RI #14 cooperate when getting the teeth brushed. EI #5 replied sometimes RI #14 would bite down on the toothbrush. EI #5 was asked how long had RI #14's teeth looked like they looked now. EI #5 replied ever since she had been there for [AGE] years. EI #5 was asked what did she do if RI #14 refused to let the teeth be brushed. EI #5 replied she would tell the Charge Nurse. EI #5 further commented that she thought RI #14 teeth did hurt because sometimes RI #14 would not cooperate and she had told the Charge Nurse in the past three months she thought RI #14 was having mouth problems. On 05/14/15 at 10 :50 AM, EI #6, Licensed Practical Nurse, was asked how often did she check to see if oral care was being done on the residents. EI #6 replied, everyday and she made sure there was nothing on or in between the teeth and smelled for odor. EI #6 was asked how long had RI #14's teeth been like they were now. EI #6 replied when she first came to work there in 1987, the teeth were like that. EI #6 was asked when was the last time she had done an oral assessment on RI #14. EI #6 replied yesterday. EI #6 was asked what could be the potential harm with cavities and possible gum disease. EI #6 replied it could cause heart problems or disease and be septic. On 05/14/15 at 1:50 PM, EI #4 was interviewed again. EI #4 was asked before 05/13/15 had she gotten a dental referral for RI #14. EI #4 replied sometimes she would get a note for a dental consult. EI #4 was asked again about contact with RI #14's sponsor. EI #4 replied it was about three years ago and the sponsor stated she would take care of it, but she never heard back from her. EI #4 was asked did she do any follow up after that phone call. EI #4 replied she did not. EI #4 was asked if she was familiar with the State Operational Manual for Long Term Care, and the responsibilities of Social Services. EI #4 replied she had read some of it. EI #4 was asked did she understand that the facility was responsible to assist residents with dental care. EI #4 stated she thought she understood that. EI #4 was asked how often did she visit RI #14. EI #4 replied not very often. EI #4 commented that she became aware on this day that RI #14 had money in her account to pay to go to the dentist. EI #4 was asked was she aware that RI #14's teeth were in bad shape. EI #4 replied yes. EI #4 was asked who would be responsible to make sure resident's had follow up concerning dental concerns. EI #4 replied it was probably me. On 5/14/15 at 2:40 PM an interview was conducted with EI #7 the Administrator. EI #7 was asked if he was aware that Social Services was not involved in getting RI #14 a dental consult or arranging transportation. EI #7 replied no he was not aware. EI #7 was asked was he aware EI #4 did not know RI #14 had personal funds to go to the dentist. EI #7 replied no however all EI #4 had to do was ask the financial person. EI #7 was asked if EI #4 was aware of the Medicaid Dental Program. EI #7 replied we have a Licensed Bachelor Social Worker who was on staff. EI#4 could have asked her for any help. EI #7 was asked who was responsible for assisting in RI #14 with dental issues. EI #7 replied the Social Worker.

Based on observation, interview and record review the facility failed to ensure Room Locator (RL) #'s 1 thru 5's windows were maintained to prevent a fog like appearance. This was observed on 3 days of the survey and affected 1 of 5 halls in the facility. Findings Include: A review of a facility policy titled "MAINTENANCE POLICY AND PROCEDURES; Policy Title: Resident Environment Quality... PURPOSE: The facility should be...maintained..." On 5/12/15 during the initial tour of the facility the windows in RL #1, 2, 3, 4, & 5 were noted with a fog like appearance. On 5/13/15 at 10:00 AM the windows in RL #'s 1, 2, 3, 4, & 5 were noted with a fog like appearance. On 5/14/15 at 9:00 AM the windows in RL #'s 1, 2, 3, 4, & 5 were noted with a fog like appearance. On 5/14/15 at 9:00 AM a tour was conducted with Employee Identifier #1, Maintenance Supervisor, each Room Locator was viewed then an interview was conducted. EI # 1 was asked why did the windows appear to have a fog like appearance. EI #1 replied it looked like condensation, but it is between the double panes. EI #1 was asked how long had a fog like appearance been noted on RL #'s 1 thru 5. EI #1 replied, he did not know they were that way. EI #1 was asked why was a sheet in the window seal of RL #2, EI #1 replied he did not know. The sheet was dry, the condensation was between the panes and there was no leaking. EI #1 was asked what was the harm to the resident. EI #1 replied there was no harm, it just looks bad and they can not see out of their windows.

Based on observation, interviews and record review the facility failed to ensure that RI (Resident Identifier) # 5, a resident with weight loss, received ice-cream as planned on 2 of 4 days during the survey. This affected one of five sampled residents with weight concerns. Findings Include: RI #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of RI #5's most recent quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 03/10/13 revealed RI #5 had both short and long term memory problems and was severely impaired for daily decision making. Section G - Functional Status revealed RI #5 was totally dependent upon staff for eating. Section K - Swallowing/Nutritional Status revealed RI #5 weighed 132 pounds and had weight loss that was not physician prescribed. RI #5 had a care plan, reviewed 4/19/13 with an onset date of 12/14/12, with a problem of "Potential for weight loss r/t (related to) new admit, PEG (Percutaneous Endoscopy Gastrostomy) tube feeding." One approach documented with this care plan was "...03/07/13 ice cream 10/2 p (p.m.)..." A facility policy with a title of "Snack" with an effective date of November 1, 2006 documented "...PURPOSE: Residents may want, or require supplementation of their meal plan, in order to attain, or maintain, acceptable parameters of nutrition...PROCESS:...b. The dietary department should provide snacks, and nursing personnel should distribute snacks to the residents. c. Residents should be offered appropriate snacks by nursing personnel..." A review of a document titled "THERAPEUTIC SUPPLEMENT LIST" dated 04/23/13 revealed RI #5 was to receive ice cream at 10:00 AM and 2:00 PM. A review of Departmental Notes dated 03/07/13 at 5:44 PM documented "Reviewed RD (Registered Dietitian) recommendation, update snack preferences. Will add icecream for 10a (A.M.) & (and) 2p (P.M.). Will con't (continue) to monitor." The note was prepared by EI (Employee Identifier) #2, CDM (Certified Dietary Manager). On 04/24/13 at 10:10 AM RI #5 was observed seated in a geri-chair in her room. The over bed table was next to her. No ice cream was noted in the room. On 4/24/13 the surveyor noted the snack cart arrived on the hall at 10:50 AM. At 10:55 AM the CNA (Certified Nursing Assistant) passing the snacks stopped at RI #5's room. The CNA, EI #4, took RI #5 an 8 ounce cup of what looked to be orange kool-aid or punch. No ice cream was taken to RI #5. The surveyor observed the snacks on the snack cart and no ice cream was noted to be on the cart. At 10:57 EI #4 left hall with the snack cart. On 04/24/13 at 2:55 PM the surveyor observed the snack cart arrive on the hall. At 3:00 PM EI #4 arrived at RI #5's room. EI #4 took RI #5 an 8 ounce cup of water. No ice cream was given to RI #5. The surveyor observed the snacks on the snack cart and no ice cream was noted to be on the cart. On 04/25/13 at 10:05 AM RI #5 was observed to be seated in a geri-chair in her room. Two CNAs were in her room. No ice cream was noted to be in the room. On 4/25/13 At 10:20 AM the snack cart arrived on the hall. EI #4 was passing snacks. EI #4 took RI #5 an 8 ounce cup of water. No ice cream was given to RI #5. The surveyor observed the snacks on the snack cart and no ice cream was noted to be on the cart. On 4/25/13 At 10:35 AM EI #4 finished passing snacks and left the hall. On 04/25/13 at 2:35 PM RI #5 was observed in her bed asleep. Her over bed table was across the room. No ice cream noted in room. On 4/25/13 At 2:50 PM EI #4 arrived with the snack cart. The surveyor observed the snacks on the snack cart and no ice cream was observed to be on the cart. On 4/25/13 At 2:55 PM the surveyor observed no ice cream in RI #5's room. On 4/25/13 At 3:00 PM EI #4 finished passing snacks and left the hall. On 04/25/13 at 3:45 PM, EI #2 was interviewed. EI #2 was asked if RI #5 was supposed to get ice cream. EI #2 stated yes that RI #5 really liked ice cream. EI #2 was asked how were RD or dietary recommendations communicated to the nursing staff. EI #2 stated RD recommendations go to the DON (Director of Nursing) and the RN (Registered Nurse) Unit Managers and they also have a snack sheet. EI #2 was asked where did the ice cream come from. EI #2 stated it came directly from dietary and was sent out at 10 AM and 2 PM as well as at night. EI #2 was asked who was responsible for passing snacks. EI #2 stated a CNA. On 04/25/13 at 4:00 PM, EI #3 RN Unit Manager was interviewed. EI #3 was asked how often RI #5 was supposed to get ice cream. EI #3 stated at 10 AM and 2 PM. EI #3 was asked why was RI #5 supposed to get the ice cream. EI #3 stated it was an intervention put in place due to weight loss. EI #3 was asked where did the ice cream come from. EI #3 stated from dietary. EI #3 was asked who was responsible for making sure RI #5 got her snack. EI #3 stated EI #4 passes the snacks or she will give them to the assigned CNA. EI #3 was asked what was the potential harm if RI #5 didn't get what dietary or the RD recommended. EI #3 stated she could have more weight loss. On 04/26/13 at 10:30 AM EI #4 was interviewed. EI #4 was asked how she knew which residents got snacks and when they were supposed to get them. EI #4 stated she had a list that she goes by and they get snacks at 10 AM and 2 PM. She also stated that every resident is supposed to get a snack or be offered one. EI #4 was asked what snack did RI #5 receive. EI #4 stated she was to get ice cream at 10 AM and 2 PM. EI #4 was asked who was responsible for making sure RI #5 got her snack. EI #4 stated the CNA. EI #4 was asked what was the potential harm if RI #5 did not receive her snack. EI #4 stated RI #5 was diabetic and needed her snack. EI #4 was asked why RI #5 received ice cream. EI #4 stated because RI #5 is a diabetic and weight loss. EI #4 was asked why RI #5 did not receive her snack at 10 AM and 2 PM on 04/24/13 and 04/25/13. EI #4 stated she offered the snack to RI #5. Later EI #4 stated she went to dietary to get the ice cream and they did not have any. EI #4 was asked how were the snacks prepared. EI #4 stated by dietary. EI #4 further explained that if something was missing from the cart she would call dietary and they would bring it or she would go get it. EI #4 further stated "it does happen sometimes."

Based on observation, record review and interviews the facility failed to ensure Resident Identifier (RI) #s 17's and 19's chairs were maintained in good repair and RI # 22's elevated toilet seat was free of rust and chipped paint and bathroom wall was free of holes. The facility further failed to provide an un-institutionalized environment for RI #s 12, 18 and 19. This affected 5 of 23 sampled residents on 1 of 5 halls. These problems were observed 3 of 4 days of the survey. Findings include: 1.) On 4/23/13 during the initial tour at 3:10 PM, the surveyor observed a chair with a tear in the cushion in RI # 19's room. At 3:15 PM, the surveyor observed a chair with a tear in the cushion in RI #17's room. At 3:40 PM the surveyor observed RI # 22's bathroom. The bathroom wall had a toilet paper dispenser missing which resulted in a hole in the wall. The metal elevated toilet seat had chipped paint on the front legs and on the bar across the front. On 4/24/13 from 10:20 AM until 10:27AM the surveyor observed the same items in RI #s 17, 19, and 22's room. No repairs had been made in the rooms. An observation of RI #17's room on 4/25/2013 at 2:45 PM revealed a chair with two tears on the green cushion exposing the foam. An observation of RI # 19's room on 4/25/13 at 2:49 PM revealed a chair with a torn green cushion exposing foam On 4/25/2013 at 3:33 PM, the surveyor interviewed Employee Identifer # 5, Maintenance Supervisor, regarding RI # 22's bathroom. When EI #5 observed the elevated toilet seat, EI #5 stated, "Oh that is terrible. We will fix it." The surveyor asked EI #5 how long the toilet paper dispenser had been missing. EI #5 explained he was not aware of it missing. The surveyor asked EI #5 if any one had reported torn chairs in residents' rooms. EI #5 explained no one had reported any and further explained the facility was in need of chairs. During the interview with EI #5, the surveyor showed him the chairs in RI # 17's and 19's room. EI #5 said they could be replaced. On 4/25/2013 at 3:53 PM, the surveyor accompanied by EI # 1 (Director of Nursing) observed the elevated toilet seat in RI #22's bathroom. The surveyor questioned EI #1 regarding the appearance of the elevated toilet seat, EI #1 explained it was rusty. On 4/25/2013 at 4:10 PM, the surveyor accompanied by EI #1 observed RI #s 17's and 19's room. RI #17's chair was observed with two tears on the green cushion exposing foam. RI #19's chair was observed with a torn green cushion exposing foam 2.) On 4/23/13 during the initial tour the surveyor observed RI #s 12, 18, and 19's rooms to be not homelike. At 3:05 PM, the surveyor observed RI #12's room there were no personalized items observed. There were no family pictures or other items to be identified with the resident. Between 3:10 PM and 3:33 PM, the surveyor observed RI # 18's and 19's rooms. There were no personal items on the walls. Neither room had items to identify the residents. On 04/24/2013 between 10:20 AM and 10:27 AM, observations were made of RI #s 12's, 18's and 19's rooms. These rooms continued to have no personalized items in the rooms. On 4/25/2013 observations were made of RI #'s 12's, 18's and 19's rooms at 12:40 PM, 2:49 PM and 2:50 PM. These three rooms contained to have no personalized items in the rooms. On 4/25/2013 at 2:55 PM, the surveyor interviewed EI # 6, Certified Nursing Assistant, regarding the lack of personal items in the residents rooms. EI # 6 explained that she thought it would help to personalize the residents rooms. She further explained if the residents' rooms had their names or family pictures in the rooms it would help them remember their family and past. On 4/25/2013 at 4:40 PM, the surveyor interviewed EI #1 regarding the lack of personal items in RI # 12's 18's and 19's rooms. The surveyor asked if the rooms appeared homelike. EI # 1 relied no. The surveyor then asked EI # 1 how RI # 12's, 18's, 19's, rooms not being personalized could affect them. EI #1 replied it could make the resident a little more confused.

Based on interview and record review the facility failed to ensure residents received mail on Saturdays. This affected 8 residents RI (Resident Identifier) #'s 2, 8, 14, 15, 23, 24, 25 and 26 who attended the resident council meeting on 4/23/2013 and had the potential to affect all residents receiving mail in the facility. Findings Include: A review of the Resident Handbook provided by the facility documented "...mail you have the right...including the right to send and promptly receive mail..." A resident council meeting was held on 4/24/2013 at 10:15AM. The surveyor instructed the staff on 4/23/2013 to invite alert and oriented residents to the meeting on 4/24/13. RI #'s 2, 8, 14, 15, 23, 24, 25 and 26 attended the meeting on 4/24/13 at 10:15AM. During the meeting the residents were asked if mail was delivered on Saturdays. All residents in attendance indicated no mail was delivered on Saturdays. RI #8 was interviewed on 4/24/13 at 1:05PM. RI #8 was asked if she received mail on Saturdays and she stated "no". RI #14 was interviewed on 4/25/13 at 2:40PM. RI #14 was asked if he received mail on Saturdays and he stated "I don't think so" people don't work up front on Saturdays. RI #15 was interviewed on 4/26/13 at 11:15AM. RI #15 was asked if she received mail on Saturdays and she responded she did not receive mail on Saturdays. RI #15 was asked if mail was available for delivery on Saturday would she like to receive it and she stated yes if its available. EI (employee identifier) #7, Activity Director was interviewed on 4/25/13 at 11:00AM. EI #7 was asked if mail was delivered to the facility on Saturdays. EI #7 stated no it has to be picked up at the post office and its only open from 9:00AM until 10:30AM. EI #7 was asked if the facility had a process to pick up mail on Saturdays and she stated no not at this time. EI #7 was asked if it was possible to have mail delivered on Saturday by the post office or by a mail carrier and she stated she did not know. EI #7 was asked if a resident could miss getting mail if they are not receiving mail on Saturday and she stated yes.

Based on interviews, record review and review of a facility policy titled "Change in Medical Condition of Residents", the facility failed to notify Resident Identifier (RI) #1's sponsor on 10/27/12 at 6:50 a.m., that RI #1 was observed by a Certified Occupational Therapist Assistant (COTA), Employee Identifier (EI) #1, with a naked male resident (RI #2) laying in bed with her. RI #2 had smeared feces on the bed linens and himself. EI #1, the COTA, said (RI #1) was fully clothed at the time of the incident and she (RI #1) had her adult brief (diaper) on during the observation. RI #1, one (1) of three (3) sampled residents for notification was affected by this deficient practice. Findings Include: Review of a facility Policy and Procedure titled "Change in Medical Condition of Residents" effective date November 1, 2001, documented: "Purpose: To keep the physician, who is in charge of medical care, and family members/legal representatives, responsible for health care decisions, informed of the resident's medical condition so they may direct the plan of care as needed. Standard: Notification of the physician, legal representative, or interested family member, should occur promptly, according to federal regulations, when there is a change in the resident's condition. Change in condition is defined as (notify parties immediately in the event of death) An accident involving the resident which results injury and has the potential for requiring physician intervention. A change in the resident's physical, mental or psychosocial status (i.e., a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications) A need to alter treatment(i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) ... " RI #1 was originally admitted to the facility on [DATE], and readmitted [DATE], with [DIAGNOSES REDACTED]. RI #1's Annual MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 09/30/12, identified RI #1 had short and long term memory problems and cognitive skills for daily decision making was severely impaired. RI #1 was assessed as needing extensive assistance with transfers, bed mobility, locomotion on the unit, toilet use and personal hygiene. RI #1 was assessed as being frequent incontinent of urine and always continent of bowel. A review of RI #1's nurses notes dated 10/27/12 at 8:57 AM documented, "At 6:50 am LPN was notified that a male resident was in resident's bed, upon entering resident's room nurse noted male resident in bed with female resident with his knees against her back, female resident was noted to be holding onto bed rails and her torso and hips were in bed and her legs were hanging out of the bed, no signs of distress noted, skin w/d (warm /dry) to touch, resp (respirations) even and unlabored, noted to be fully dressed in her sleep clothes and "pullup" was completely on, upon complete body assessment no signs of injury were noted, resident was assisted out of her bed until male resident was assisted out of her bed, no s/s (signs/symptoms) of acute distress note (noted) at this time. Resident quiet and cooperative with staff, s/s of discomfort noted at this time. BP (Blood Pressure) 120/68, Resp. - 18, Temp (Temperature) 96.0, Pulse 72." RI #1's Nurses Note Nurses Notes dated 10/27/12 at 9:29 AM documented, "7:18 am Dr ( ___ ) notified of incident and he said "I am out of town, resident got confused, he went in the wrong room no injuries noted." RI #1's Nurses Note Nurses Notes dated 10/27/12 at 9:35 AM, documented, "(Name of Sponsor) notified of incident and sponsor was very thankful of being notified." There were no evidence or documentation in these nurses notes that charge nurse, EI #4 had informed RI #1's sponsor of the pertinent details pertaining to this incident and events that had occurred with his mother on 10/27/12. RI #1's sponsor said he was upset and very dissatisfied with the communication efforts on behalf the the facility staff. The sponsor said he was not notified that a male resident was naked and soiled with feces had been found in bed with his mother and the bed linens had feces on them. RI #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #2's Annual MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 09/28/12, identified RI #2 had short and long term memory problems and cognitive skills for daily decision making was severely impaired. RI #2 was assessed as needing extensive assistance with transfers, bed mobility, locomotion on the unit, toilet use and personal hygiene. RI #2 was assessed to have a behavior of wandering significantly intrude on the privacy or activities of others. RI #2 was assessed as always being continent of urine and bowel. RI #2's nurses note Nurses Notes dated 10/27/12 at 7:58 AM, documented, "LPN notified that resident (RI #2) was in bed with a female resident (RI #1) in her room upon entering resident's room nurse noted resident in lying on back with knees up against female (RI #1's) back, he (RI #2) was naked and shivering, trying to keep spread on him he (RI #2) was reluctant to getting out of bed with female resident (RI #1) x 3 attempts by staff. he (RI #2) said "I am in my room, you are not going to to take me any where", he (RI #2) did not use profanity during conversation with staff, but when LPN told him (RI #2) that (name of wife) had breakfast ready he soon got up from bed ... female resident and allowed staff to put him on a "pullup" and wrapped him in a spread and led him to to his room without any further resistance. Resident was not noted holding onto female resident at the time when he was in bed with female resident." RI #2's nurses note "Addendum 10/27/12 at 8:21 AM, Resident's Pajamas and pull up noted in female's bathroom, pull up noted to be soiled with feces no signs of injury note to resident at this time upon complete body audit. one on one monitoring done." RI #2's nurses note "10/27/12 at 9:25 AM, Late Entry for 10/27/12 at 6:50am (6:50 a.m.) some BM (bowel movement) was noted on male resident while he was in bed with female resident, some smears of BM noted on sheet of female resident's bed assist given with cleaning resident of BM." On 11/14/12 at 10:20 a.m., the surveyor conducted an interview with the charge nurse, EI #4, who contacted the sponsor. The LPN(EI #4), who was assigned to care for RI #1 and 2 on 10/27/12. The surveyor asked EI #4 if she explained to RI #1's sponsor and documented the details what had occurred on 10/27/12. EI #4 said she did explained in details what occurred but she did not document what she told RI #1's sponsor. On 11/14/12 at 3:00 p.m., the surveyor conducted an interview with EI #1, the COTA staff member who found RI #2 in RI #1's bed on 10/27/12. EI #1 said she is new here in the facility. EI #1 said she had came in early to work this Saturday. EI #1 said she observed RI #2's soiled pants, under wear, diaper or pull up in RI #1's bathroom. EI #1 said RI #2 was in bed with RI #1, they both were facing to the right toward the door. RI #1's legs were out of the bed and her feet may have been on the floor. EI #1 said RI #1 was holding on to the side rail and the covers were off of her and she had a brief on. EI #1 said she reported this to a CNA (Certified Nursing Assistant). EI #1 said both residents were asleep at the time. On 11/15/12 at 3:10 p.m., the surveyor asked RI #1's sponsor what did the nurse tell him when he was contacted. The sponsor said the nurse told him a male resident was found in his mother's bed. She was all right and they got him out of the bed, that was all. The surveyor asked the sponsor if the nurse told him the resident was naked and soiled with feces, and the bed linens had feces on them. RI #1's sponsor said no, this was his first time hearing of this. Why wouldn't they tell him the truth when they called. This deficiency was cited as a result of the investigation of complaint/report #AL 807.