Every finding on record at Talladega Healthcare Center, Inc

Based on observations, interview and a facility policy titled Environmental Conditions the facility failed to provide necessary housekeeping services to maintain a clean and sanitary environment and maintenance services necessary to maintain good repair of equipment. This deficient practice was observed on 2 of 4 days of the survey and affected two of eight shower rooms within the facility. Findings include: An undated facility policy titled Environmental Conditions documented: .The facility will provide a safe, functional, sanitary and comfortable environment for residents . On 9/13/22 the State agency received an anonymous complaint that the facility had shower rooms with what appeared to be black mold on the floors and walls and poor drainage that caused standing water. On 10/3/22 at 6:00 PM, an interview with Employee Identifier (EI) #4 floor administrator was conducted with an observation of an East View shower room. EI #4 was asked to identify the black substance on the floor and walls in the East View shower room. EI #4 stated it looked like dirt. EI #4 was asked if the shower room/Bath room on East View was clean. EI #4 stated no, it was not clean and needed a deep cleaning. EI #4 was asked why the shower room should be clean. EI #4 stated so the residents can have a sanitary bathroom and shower. During an observation of the shower room on Past Times on 10/3/22 at 5:40 PM, water was noted on the floor throughout the shower room. Water was dripping from shower head in the shower area of the room. A black substance was noted on the floor and walls throughout the room. On 10/3/22 at 5:49 PM, an interview with EI #3, Licensed Practical Nurse (LPN) was conducted. EI #3 was asked how long the shower head had been leaking in Past Times shower room. EI #3 stated she was not sure. EI #3 was asked what was the black substance on the floor and walls of the shower room on Past Times. EI #3 responded dirt. EI #3 was asked why the shower room should be clean. EI #3 stated she would want to take a bath in a clean shower room and possible infection control concerns. A follow up interview was conducted with EI #3 on 10/4/22 at 9:48 AM. EI #3 was asked if water was still on the floor in the Past Times shower room. EI #3 stated yes and the shower head was still dripping water. During a follow up observation on 10/4/22 at 9:51 AM of the shower room on Past Times hall, the floor was wet with water standing in the shower area. The floor and walls were dirty with a black substance noted throughout the room. An interview was conducted with EI # 5, Maintenance on 10/4/22 at 10:10 AM. EI #5 was asked what was being done to correct the water drainage issue in Past Times shower room. EI #5 stated the tile in the shower area was replaced two months ago and a drain was added near the door. He further stated it corrected the flooding in the hallway but water was still standing in the shower area. EI #5 was asked why water was standing in the shower area. EI #5 stated the shower head was leaking and it appeared to not be draining properly. An interview was conducted with EI #6, Environmental Services on 10/4/22 at 12:00 PM. EI #6 was asked if the shower room on Eastview and Past times were clean when he observed them on 10/3/22 with the surveyor. EI #6 stated they both needed attention. EI #6 was asked about the black substance on the walls and floor in the shower rooms on Eastview and Past times. EI #6 stated he did not know what the black substance was. This was cited as a result of the investigation of complaint/report number AL 046.

Based on observations, interviews and review of facility policies, titled Sanitation: Food Handling, Nourishment Room Refrigerators and Personal Cleanliness and Standards for Sanitation, the facility failed to ensure: 1. food in the kitchen cooler/freezer was labeled with an open and use by date; 2. kitchen in staff wore head coverings This had the potential to affect 184 of 184 residents who received meals from the kitchen. Findings include: 1. A review of the facility's policy titled Sanitation: Food Handling with an updated date of [DATE] revealed Policy Statement Foods are prepared and served in a sanitary manner, in order to prevent bacterial, biological and physical contamination and the possible spread of infection. Policy Interpretation and Implementation .11. Leftover foods are labeled and dated. These are used within 72 hours . On [DATE] at 5:00 PM an initial kitchen tour was conducted with Employer Identifier (EI) #6, Cook. The walk-in cooler was observed to have an aluminum pan covered with foil labeled cheese sauce with a date [DATE] with no other date. An aluminum pan covered with foil labeled baked chicken was observed with a date of [DATE]. The walk-in freezer was observed to have a large aluminum pan covered with foil that was not labeled, an opened bag of chicken tenders without a label, an open bag of chicken nuggets without a label and an open bag of Brussel sprouts without a label. EI #6 was interviewed during the initial tour on [DATE] at 5:00 PM. EI #6 stated food should be labeled when it's opened with the name of the item, the date it was opened and a use by date. EI #6 admitted that items observed without a label should have a label. EI #6 stated, labeling leftover food is important so staff will know when to use it by. EI #6 stated, the harm of not labeling items was that food could be expired and make residents sick. On [DATE] at 3:06 PM an interview was conducted with EI #9, Dietary Manager. EI #9 stated the cooks that put the food up are responsible for labeling leftovers and open containers. EI #9 stated leftovers and open containers should be labeled with date open and use by date. EI #9 was asked how the aluminum pan of cheese sauce with date of [DATE], should have been labeled. She stated, it should have been labeled with the date it was opened and 3 days after then (use by date). When asked what the date of [DATE] represented, EI #9 guessed it was the date item was put in cooler. EI #9 admitted that all items in walk-in freezer should have been labeled with an open date and use by date. EI #9 admitted the facility's policy was not followed which could possibly lead to sick residents. 2. A review of an undated facility policy titled Personal Cleanliness and Standards for Sanitation revealed Policy statement many pathogens are due to poor hygiene of food handlers. Dietary personnel shall follow sanitary standards. Policy Interpretation and Implementation . Hair restraints should be worn at all times . During the initial kitchen tour on [DATE] at 5:00PM, two kitchen staff members were observed to not be wearing hair coverings. On [DATE] at 5:35 PM an interview was conducted with EI #7, Kitchen Aide. EI #7 admitted she should have had on a hair net but stated that she forgot it. When EI #7 was asked why hair nets should be worn in the kitchen, she stated for the safety of the food. On [DATE] at 5:41 PM an interview was conducted with EI #8, Kitchen Aide. EI #8 admitted that he did not have on a hair net when the surveyor began the initial kitchen tour. EI #8 stated, hair nets should be worn in the kitchen to prevent hair from going into resident's food. On [DATE] at 3:06 PM an interview was conducted with EI #9, Dietary Manager. EI #9 stated, the facility's policy was kitchen staff must put on a hair net before coming in the door of the kitchen. She admitted the policy was not followed when two kitchen staff were observed with no hair net. EI #9 stated the potential harm was hair in food and residents becoming sick.

Based on interview, review of the facility's online reports to the State Agency and a facility policy titled, ABUSE PREVENTION, the facility failed to ensure allegations of abuse were reported to the state agency within two hours. This affected six out of 91 reports of abuse reviewed. Findings include: Review of the facility's policy titled, ABUSE PREVENTION, revised 12/20/2018, revealed, .POLICY AND PROCEDURE . Procedures: . VII. REPORTING/RESPONSE . The Administrator will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including suspicious injuries and misappropriations of resident property are reported immediately but no later than 2 hours after the allegation is made. The report will be sent to the State Survey Agency, . 1) Review of the facility's online report to the state agency revealed complaint # 2, an allegation of sexual abuse occurred on 02/23/2021 at 11:00 PM. The allegation of sexual abuse was not reported to the State Agency until 02/23/2021 at 11:05 AM. In an interview on 03/10/2022 at 03:45 PM, Employee Identifier (EI) #1, Administrator/Abuse Coordinator stated the facility became aware of the allegation of sexual abuse on 02/22/2021, based on the facility's investigation addendum. EI #1 stated the allegation was reported to State Agency on 02/23/2021 at 11:05 AM. EI #1 stated the facility's policy of reporting to the State Agency within two hours was not followed. 2) Review of the facility's online report to the state agency revealed complaint # 2, an allegation of verbal abuse occurred on 06/20/2021 at 01:00 PM. The allegation of verbal abuse was not reported to the State Agency until 06/21/2021 at 10:39 AM. In an interview on 03/10/2022 at 03:45 PM, EI #1, Administrator/Abuse Coordinator stated the facility became aware of the allegation of verbal abuse on 06/20/2021 at 01:00 PM. EI #1 stated the allegation was reported to State Agency on 06/21/2021 at 10:39 AM. EI #1 stated the facility's policy of reporting to the State Agency within two hours was not followed. 3) Review of the facility's online report to the state agency revealed complaint # 2, an allegation of physical abuse occurred on 07/29/2021 at 06:34 AM. The allegation of physical abuse was not reported to the State Agency until 07/29/2021 at 02:56 PM. In an interview on 03/10/2022 at 03:45 PM, EI #1, Administrator/Abuse Coordinator stated the facility became aware of the allegation of physical abuse on 07/29/2021 at 06:34 AM. EI #1 stated the allegation was reported to State Agency on 07/29/2021 at 02:56 PM. EI #1 stated the facility's policy of reporting to the State Agency within two hours was not followed. 4) Review of the facility's online report to the state agency revealed complaint # 3, an allegation of verbal abuse occurred on 08/25/2021 at 10:30 AM. The allegation of verbal abuse was not reported to the State Agency until 08/25/2021 at 01:25 PM. In an interview on 03/10/2022 at 03:45 PM, EI #1, Administrator/Abuse Coordinator stated the facility became aware of the allegation of verbal abuse on 08/25/2021 at 10:00 AM. EI #1 stated the allegation was reported to State Agency on 08/25/2021 at 01:25 PM. EI #1 stated the facility's policy of reporting to the State Agency within two hours was not followed. 5) Review of the facility's online report to the state agency revealed complaint # 4, an allegation of physical abuse occurred on 09/28/2021 at 08:20 PM. The allegation of physical abuse was not reported to the State Agency until 09/28/2021 at 10:47 AM. In an interview on 03/10/2022 at 03:45 PM, EI #1, Administrator/Abuse Coordinator stated the facility became aware of the allegation of physical abuse on 09/27/2021 at 08:45 PM, based on a statement in the facility's investigation. EI #1 stated the allegation was reported to State Agency on 09/28/2021 at 10:47 AM. EI #1 stated the facility's policy of reporting to the State Agency within two hours was not followed. 6) Review of the facility's online report to the state agency revealed complaint # 2, an allegation of verbal abuse occurred on 11/04/2021 at 04:00 PM. The allegation of verbal abuse was not reported to the State Agency until 11/04/2021 at 07:52 PM. In an interview on 03/10/2022 at 03:45 PM, EI #1, Administrator/Abuse Coordinator stated the facility became aware of the allegation of verbal abuse on 11/04/2021 at 04:15 PM. EI #1 stated the allegation was reported to State Agency on 11/04/2021 at 07:52 PM. EI #1 stated the facility's policy of reporting to the State Agency within two hours was not followed. This deficient practice was cited as a result of the investigation of complaint/report # AL 572.

Based on interviews, record review, review of facility policies titled, CONTROLLED SUBSTANCE RECONCILIATION, Abuse Prevention, and a review of Alabama Department of Public Health Online Incident Reporting System report, the facility failed to ensure RI (Resident Identifier) #220's [MEDICATION(S)] ([MEDICATION(S)]) tablets were all accounted for and further failed to ensure RI #220 controlled substance count sheet remained with the resident's blister medication card at all times. This deficient practice affected RI #220 one of three sampled residents for misappropriation of property. Finding Include: A review of the facility policy titled, CONTROLLED SUBSTANCE RECONCILIATION, dated 10/19/21 revealed: .Policy The purpose of this policy is to provide guidelines for .reconciling controlled substances Procedure .Ongoing Reconciliation . At shift change the on-coming and off-going nurse will verify each controlled substance's current count on the controlled substance record matches the actual amount substances in the lock box. The nurses will then verify using the controlled substance log that all the received controlled substances are in the lock box. After the verification is complete both nurses will sign the shift to shift reconciliation sheet . A review of the facilities' policy titled, Abuse Prevention, with a revised date of 12/20/18 revealed: .Abuse is defined as the willful infection of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish . 3. Staff are trained on actual activities that would constitute abuse and they are but not limited to: . b. Misappropriation of resident property-The deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings .without their consent. A review of the Alabama Department of Public Health Online Incident Reporting System report, revealed: .Incident Type .Misappropriation of Resident Property . Narrative summary of Incident: .On 01/27/2022 .reported that 60 [MEDICATION(S)] could not be found for (resident's name) RI #220. RI #220 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] RI #220's January 2022 physician's orders revealed: .[MEDICATION(S)] HCL-30 MG (milligrams)-ONE TAB BY MOUTH EVERY SIX HOURS . On 03/09/22 at 5:59 PM, an interview was conducted with EI (Employee Identifier) #5, LPN, License Practical Nurse. EI #5 was asked according to her statement, she gave RI #220's medications on 01/10/22. EI #5 said yes, she did and then told RI #220 that he/she would be moving to the COVID Unit. EI #5 was asked who moved RI #220 and his/her medications to the COVID unit. EI #5 said, EI #4, RN, Unit Manager moved RI #220 and his/her medications but there was one card they decided to keep on the medication cart. EI #5 was asked how many [MEDICATION(S)] was on the card that was kept on the unit. EI #5 said 60 pills was on the card and it had not been popped. EI #5 was asked how many [MEDICATION(S)] pills was on the card she used and sent to the COVID unit. EI #5 was said it was pretty full, so she was thinking that was why they kept one card. EI #5 was asked what was the facility's procedure for ensuring narcotic medication was accounted for. EI #5 said we, she and the on coming shift nurse, count the cards and the pills of narcotics. EI #5 was asked where was the count of the controlled medications kept. EI #5 said in the narcotic book, a sheet we (nurses) sign out each medication and then when you turn the sheet we have the name and every narcotic he/she take and the card number. EI #5 further said when that card was completed, where it says complete you put your initial, they left that sheet with his name and narcotic on it on the Northview unit. EI #5 was asked what should have been done with the resident's controlled medication once he/she moved to the COVID unit. EI #5 said all of his/her medication should have went with him/her. EI #5 was asked what was the concern with RI #220's controlled medications missing. EI #5 said it could be considered theft of property. On 03/10/22 at 9:54 AM an interview was conducted with EI #4, RN, Unit Manager. EI #4 was asked how did she become aware that RI #220 had 60 [MEDICATION(S)] pills missing. EI #4 said she worked the medication cart on 01/24/22 and noticed his/her card was low, he/she had 16 tablets, so she called the doctor to send in a prescription. When she worked the medication cart again on 01/26/22 she noticed it had not been refilled, he/she had 8 tablets left, so she called the pharmacy. EI #4 further said, pharmacy said they had sent 120 [MEDICATION(S)] tablets on 01/08/22 so they could not refill it, it was too soon. EI #4 was asked what did she do next. EI #4 said she notified EI #2, DON, Director of Nurses that there should be another card, the DON and other nurses looked for the medications and was unable to locate it, therefore an investigation was initialed. EI #4 was asked when RI #220 moved to the COVID unit did all his/her narcotics ([MEDICATION(S)]) go with him/her. EI #4 said she does not remember. EI #4 was asked when she moved RI #220 to the COVID Unit, did she take his/her medications (narcotics) to the unit and who did she verify them with. EI #4 said she took his/her medications (narcotics) and verified them with the nurse. EI #4 further stated, she was not sure if she took his/her 120 pills, she knows she took one card with 60 pills and another card with 10 pills. EI #4 was asked what should have been done with a resident's controlled medications when that resident moved to another unit. EI #4 said resident narcotic sheet, narcotic medications and log sheet should go with them and the person (nurse) bringing them verifies the correct count and the correct log with the receiving nurse. EI # 4 was asked if the facility found the 60 pills of [MEDICATION(S)] missing for RI #220. EI #4 said no it was never found. EI #4 was asked what type of abuse was it considered with RI #220's medication missing. EI #4 said misappropriation. On 03/10/22 at 5:31 PM an interview was conducted with EI #2, DON. EI #2 was asked when did she become aware that RI #220's narcotics 60 [MEDICATION(S)] pills were missing. EI #2 said on 01/28/22 when EI #4 notify her that she had re-ordered the medication and it had not come in. EI #2 further said, EI #4 called the pharmacy and it was not time to reorder it, because they had sent 120 pills on 01/08/22. EI #2 said, she and the nurses checked the medication carts on all units and the drug destruction, but RI #220's medications were not found. EI #2 was asked what was the facility's procedure for ensuring narcotics are accounted for. EI #2 said the nurses count the sheets with the cards and narcotic logs for each resident and those logs have information on each card that is a controlled substance with the prescription number, date and the initial of the nurse who signs it in. EI #4 was asked what was the facilities procedure for verifying the narcotic count with the nurse coming on duty and the nurse going off shift. EI #2 said the nurse counts each card with the narcotic sheets and count the log and sign the front of the book. EI #2 was asked what should be done when a resident goes to another unit with his/her medications (narcotics). EI #2 said all medications should go with them and the nurse should verify the narcotic cards with the sheets that match and the log sheet with the given nurse. EI #2 was asked should this process have been done when RI #220 was moved to the COVID Unit. EI #2 said yes, it was like you do the medication carts, you do not know if the count was right until it is verified. EI #2 was asked what it was considered when RI #220's medications (narcotics) was missing. EI #2 said misappropriation of resident's property. On 03/11/2021 at 8:47 AM an interview was conducted with EI #1, Administrator. EI #1 was asked when did she become aware that 60 of RI #220's narcotics [MEDICATION(S)] pills was missing. EI #1 said she received a phone call from EI #2 or the corporate nurse, that they had a missing card of [MEDICATION(S)] for RI #220's and they searched carts, medication rooms and the pharmacy manifest. EI #1 was asked what was the facility's procedure for ensuring narcotics are accounted for. EI #1 said the outgoing and on coming nurses count the narcotics and sign the number was correct. EI #1 was asked what should happen when a resident moves to another unit with his/her medications. EI #1 said all the resident's medication should go with them, the narcotic log and narcotic sheets. EI #1 was asked did all RI #220's narcotics, narcotic log and sheets go with him/her to the COVID Unit. EI #1 said, she did not know, but it should have went with him/her. EI #1 was asked what was the findings of the investigation. EI #1 said, the facility could not locate the [MEDICATION(S)] card of 60 pills. EI #1 was asked what was it considered when RI #220's narcotics was missing and the facility replaced them. EI #1 said it would be considered misappropriation. This deficient practice was cited as a result of compliant/report #AL 735

Based on interview, record review and a review of the, Centers for Medicare & Medicaid Services Long- Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure RI (Resident Identifier)'s #2 and #3's discharge MDS (Minimum Data Set) assessment was transmitted to CMS within 14 days of the discharge date . This deficient practice affected two out 35 sampled residents whose MDS's were reviewed. Findings Include: A review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2019 revealed: '' .09. Discharge Assessment-Return Not Anticipated .Must be submitted within 14 days after the MDS completed date . RI #2 was admitted to the facility on [DATE] and discharged on [DATE]. A review of RI #2's MDS's revealed: .10/08/21 (D) Close . There was no documentation of a discharge MDS was transmitted to CMS. RI #3 was admitted to the facility on [DATE] and discharged on [DATE]. A review of RI #3's MDS's revealed: .10/21/21- (DE) Close .there was no documentation of a discharged MDS transmitted to CMS. On 03/10/22 an interview was conducted with EI (Employee Identifier) #11, RN, MDS Coordinator. EI #1 was asked was a discharge MDS assessment completed on RI #3 when she/he discharged on [DATE]. EI #11 said yes, a discharged MDS assessment was completed on RI #3. EI #1 was asked if RI #3's discharge MDS assessment was transmitted to CMS. EI #11 said no it had an error A410 that prevented it from being transmitted. EI #11 was asked when should RI #3's discharge assessment have been transmitted to CMS. EI #11 said 14 days after the close day. EI #11 was asked was RI #2's discharge MDS assessment transmitted to CMS. EI #11 said no it had an error A410 that prevented it from being transmitted. EI #11 was asked when should RI #2's discharge MDS assessment have been transmitted to CMS. EI #3 said 14 days after it was closed.

Based on observations, interviews, record review and review of facility's policy titled SHOWER/TUB BATH, the facility failed to provide ADL care to a total Dependent resident. This deficient practice affected Resident Identifier (RI) #38, one of three residents sampled for activities of daily living. Findings include: Review of undated facility's policy titled Shower/ Tub Bath revealed Policy The purpose of this policy and procedure are to promote cleanliness and comfort, to relax the resident, to stimulate circulation, and to observe the condition of the resident's skin. RI #38 was readmitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #38's Quarterly Minimum Data Set (MDS) assessment, with an ARD (Assessment Reference Date), revealed RI #38 was totally dependent on one staff member for personal hygiene tasks. A review of the resident's Care Plan, with a start date of 06/26/2008, indicated RI #38 needs assistance with all activities of daily living (ADLs), with approaches that directed nursing assistants to Assist to extent needed with shower as scheduled and assist as needed with nail care, hair care and oral hygiene On 03/08/2022 at 9:49 AM, RI #38 was observed in sitting up in bed. Resident's skin was clean. Resident's gown was observed to have a food stain at the top of it. On 03/09/2022 at 3:25 PM, RI #38 was observed sitting up in bed with same clothing on from the day before. On 03/10/2022 at 10:40 AM RI #38 was observed sitting up in bed with same clothing on from 03/08/2022. On 03/11/2022 at 8:37 AM RI #38 was observed sitting up in bed with same clothing on from 03/08/2022. RI #38's skin was dry and scaly. RI #38's hair was greasy. An interview was conducted with RI #38 on 03/11/2022 at 8:37 AM. RI #38 stated he/she had on same clothing from 03/08/2022 because no one had come to give him/her a shower. RI #38 stated he/she wanted a shower and not getting one made him/her feel bad. An interview was conducted with Employee Identifier (EI) #10, Nursing Assistant (NA) on 03/11/2022 at 9:26 AM. EI #10 stated that she has provided care for RI #38 before. When asked how staff are notified who receives showers on certain days, EI #10 stated, staff are given a list of residents that need showers. EI #10 stated she had a list but didn't know who needed a shower on 03/10/2022. EI #10 was given a copy of the assignment sheet. EI #10 reviewed and stated, RI #38's shower days are Tuesday, Thursday and Saturdays. EI #10 stated that RI #38 should have gotten a shower on yesterday. EI #10 admitted that she did not given RI #38 a shower on yesterday and admitted the facility's policy was not followed. EI #10 stated harm on not providing ADL's to total dependent resident was their skin can become raw. An interview was conducted with EI #2, Director of Nursing (DON) on 03/11/2022 at 10:24 AM. EI #2 stated RI #38's shower days are Tuesday, Thursday and Saturdays. EI #2 stated, CNAs are responsible for showers and sometimes nurses assist. EI #2 stated when given a shower resident's bed linen and clothing should be changed. EI #2 stated, the harm in not providing ADL care was it compromised skin integrity. EI #2 stated, the importance of providing ADL care was to keep residents at an optimum level of wellbeing and it will help the way residents feel about themselves. A follow-up interview was conducted with EI #2 on 03/11/2022 at 2:53 PM. EI #2 was informed EI #10 admitted to not giving RI #38 a shower on 03/10/2022. EI #2 stated RI #38's needs were not fully met and care was not provided. This deficient practice was cited as a result of Complaint/Report # AL 638.

Based on observation, interviews and review of a facility policy, titled Food Storage, the facility failed to ensure expired canned goods were removed from the dry storage area. This had the potential to affect 168 residents receiving meals from the kitchen. Findings Include: 1. A review of a facility policy undated titled Food Storage revealed .11. All expired food and food products should be discarded . 12. Left over foods are labeled and dated. These are used within 72 hours. On [DATE] at 3:44 p.m., during the initial kitchen tour, the dry storage area was observed as having nine cans of chicken noodle soup 50 ounce(oz) size all with an expiration date [DATE]. A pan labeled dressing, with a used by date [DATE], was also observed in the freezer/cooler. On [DATE] at 9:30 a.m., the surveyor conducted an interview with Employee Identifier (EI) #4, Dietary Manager. EI #4 was asked was she present during the kitchen tour on [DATE]. EI #4 said yes. EI #4 was asked who was responsible for checking the dry storage for expired items. EI #4 said herself and the entire staff. EI #4 was asked what was the expiration date on the 50 oz size cans of chicken noodle soup. EI #4 said (MONTH) 2019. EI #4 was asked what was the total number of chicken noodle soup 50 oz cans with the expiration date (MONTH) 2019. EI #4 said nine. EI #4 was asked when should those cans have been removed from the shelf. EI #4 said immediately when they expired. EI #4 was asked when touring, was there one pan of dressing with the used by dated [DATE] written on the pan in the freezer. EI #4 said yes. EI #4 was asked when should this pan of dressing have been discarded. EI #4 said on [DATE]. EI #4 was asked what was the potential harm for consuming expired foods. EI #4 said food borne illness.

Based upon observation, interviews and review of a facility policy titled, Respiratory Therapy Equipment, the facility failed to ensure that a resident's mask for breathing treatments was contained in a plastic bag. This affected Resident Identifier (RI) # 118, one of four sampled residents receiving breathing treatments. Findings Include: A review of a facility policy titled, Respiratory Therapy Equipment with no date, revealed: . Medication Nebulizers/Continuous Aerosol: . 7. Store circuit in plastic bag, marked with date and resident's name, between uses . RI # 118 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A physician order [REDACTED]. On 07/29/19 at 4:57 PM, RI #118 was seated at the edge of his/her bed. This surveyor observed a breathing treatment mask on the bedside table, beside the nebulizer treatment machine, not covered. No plastic bag was observed to place the treatment mask between treatments. On 7/29/19 at 5:31 PM, during an interview with Employee Identifier (EI) #5, Licensed Practical Nurse (LPN), Staff Nurse, EI #5 was asked if RI #118 received breathing treatments. EI #5 replied, yes. EI #5 was asked, what were the orders for breathing treatments. EI #5 replied, routine every six or every eight hours; [MEDICATION NAME]. EI #5 was asked, where was the treatment mask. EI #5 replied, on the bedside table. EI #5 was asked, was it covered. EI #5 replied, no. EI #5 was asked, should it be covered. EI #5 replied, yes, it should be in a Zip Lock bag. EI #5 was asked, who was responsible for replacing the mask. EI #5 replied, Saturday 7pm- 7am shift replaces them. EI #5 was asked, who was responsible for storing the mask in a Zip lock bag between treatments. EI #5 replied, the nurse when he/she finishes should replace to the plastic bag. EI #5 was asked, what was the potential harm in not keeping the mask covered between treatments. EI #5 replied, infections. On 7/31/19 at 2:58 PM, an interview was conducted with EI #6, Registered Nurse (RN), Staff Development Coordinator. EI #6 was briefed on the surveyor's observation on 7/29/19 of RI #118's breathing treatment mask lying on top of the bedside table beside the nebulizer being uncovered and not in a plastic bag, nor was a plastic bag observed. EI #6 was asked what was the policy on storing the nebulizer treatment masks between treatments. EI #6 replied, they are supposed to be stored in a plastic bag. EI #6 was asked, how often were they replaced. EI #6 replied, every Saturday night; it is included on the treatment record Saturday night and as needed. EI #6 was asked, should the mask be lying on the bedside table uncovered. EI #6 replied, no. EI #6 was asked, how often were the Zip lock bags replaced. EI #6 replied, same as the masks, Saturday night. EI #6 was asked, who was responsible for returning the mask to a Zip lock bag between treatments. EI #6 replied, the nurse. EI #6 was asked, what was the potential harm in not returning the masks to the Zip lock bags between treatments, EI #6 replied, infections.

Based on observation, interviews, record review and review of a facility document titled The Medication Pass, the facility failed to ensure a nurse did not administer the wrong dose of [MEDICATION NAME] to Resident Identifier (RI) #85. This affected one out of 27 medication opportunities observed. Findings include: A review of an undated facility document titled The Medication Pass revealed Before administering any medication, check the FIVE RIGHTS: . 2. Right DOSE . Check the medication label: 1. When taking the medication from the medication cart .Check the following for correctness: . 2. MAR (Medication Administration Record) against the medication label . RI #85 was re-admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A review of RI #85's Physicians Orders for the month of (MONTH) 2019 revealed 12/13/18 . [MEDICATION NAME] HCL 500 MG (milligram) Tablet Give 1 tablet By Mouth Twice Daily . A review of the Medication card revealed . [MEDICATION NAME] HCL 1,000 mg TAB .Take 1 tablet by mouth every BID (two times a day) . A review of RI #85's MAR for the month of (MONTH) 2019 revealed, . [MEDICATION NAME] HCL 500 MG Tablet Give 1 Tablet By Mouth Twice Daily . On 7/30/19 at 4:15 pm, an observation of medication pass was conducted with EI #2 for RI #85. Among the medication EI #2 prepared and administered was [MEDICATION NAME] 1000 mg. On 7/30/19 at 4:35 pm, a reconciliation of medications by the surveyor revealed, [MEDICATION NAME] 1000 mg was given by EI #2. A review of the (MONTH) physician's orders [REDACTED]. On 7/30/19 at 4:45 pm, an interview was conducted with EI #2. EI #2 was asked, what did the MAR indicated [REDACTED]. EI #2 was asked, what did the medication card say. EI #2 replied, 1000 mg BID (twice a day). EI #2 was asked, what did she give medications by. EI #2 replied, the MAR. EI #2 was asked, what did the MAR indicated [REDACTED]. EI #2 was asked, when was the [MEDICATION NAME] 500 mg ordered. EI #2 replied, 12/13/18. EI #2 was asked, did she give the correct medication. EI #2 replied, yes, but not the correct dose. EI #2 was asked, did she verify the medication card with the MAR. EI #2 replied, she thought she did. EI #2 was asked, did she verify the medication card with the MAR, if 1000 mg was given and not 500 mg. EI #2 replied, she guessed not. EI #2 was asked, what was the harm in giving the incorrect dose of [MEDICATION NAME]. EI #2 replied, it could lower the blood sugar. On 7/31/19 at 4:20 pm, an interview was conducted with EI #1, Director of Nursing. EI #1 was asked, how did the nurses verify the correct medication and dose was being given. EI #1 replied, the nurse should read the order on the MAR indicated [REDACTED]. EI #1 was asked, when should a nurse verify the correct medication and dose was being given. EI #1 replied, prior to punching it out and prior to giving it to the resident. EI #1 was asked, what dose of [MEDICATION NAME] did the nurse administer. EI #1 replied, 1000 mg. EI #1 was asked, what dose of [MEDICATION NAME] was ordered. EI #1 replied, 500 mg. EI #1 was asked, would she consider [MEDICATION NAME] a significant medication. EI #1 replied, yes, in its use. EI #1 was asked, what was its use. EI #1 replied, to treat diabetes. EI #1 was asked, what was the harm in a nurse administering the incorrect medication dose. EI #1 replied, she was not sure.

Based on observations, interviews and a facility's policy titled, General Procedures for Medication Administration the facility failed to ensure: 1. another licensed staff did not leave medication out, unattended and out of the licensed staff view and 2. another licensed staff member did not leave the medication cart unlocked, unattended and out of the licensed staff member's view. These deficient practices affected two of the five nurses observed during medication pass. Findings included: A review of the facility's document undated titled, GENERAL PR[NAME]EDURES FOR MEDICATION ADMINISTRATION, no date, revealed . 3. Lock the medication cart when leaving unattended. 4. Medications cannot be left on top of the medication cart . On 7/31/19 at 9:46 a.m., the surveyor observed the Licensed Practical Nurse (LPN), Employee Indentifier (EI) #7 place [MEDICATION NAME]/[MEDICATION NAME] ([MEDICATION NAME]) on top of the medication cart. EI #7 then went into the resident's bathroom and washed her hands. At this time the [MEDICATION NAME]/[MEDICATION NAME] was completely out of EI #7 view while residents and staff were ambulating in the hallway. On 7/31/19 at 10:03 a.m., an interview was conducted with EI #7. The surveyor asked EI #7 did she wash her hands before giving the [MEDICATION NAME]/[MEDICATION NAME] treatment. EI #7 said yes. The surveyor asked EI #7 where was the [MEDICATION NAME]/[MEDICATION NAME] while she washed her hands. EI #7 said on top of the medication cart on a napkin. The surveyor asked EI #7 at that time was the [MEDICATION NAME]/[MEDICATION NAME] in her view. EI #7 said no. The surveyor asked EI #7 what were the issues with the medication not being in her view. EI #7 said somebody could have picked it up. On 7/31/19 at 3:50 p.m., the surveyor observed on the 300 hall a medication cart unlocked with the top draw slightly opened. The cart was positioned with the back to the nurse's station. The front of the medication cart was facing the hallway. At this time there was staff at the nurses station talking and attending to other things. The license staff was observed coming out of a resident's room. On 7/31/19 at 4:24 p.m., an interview was conducted with LPN, EI #8. The surveyor asked EI #8 how was the medication cart lock positioned while she was in the resident's room. EI #8 said unlocked. The surveyor asked was the medication cart completely out of her view. EI #8 said it was. The surveyor asked EI #8 how should the medication cart be left when not in view. EI #8 said it should be locked. The surveyor asked EI #8 what was the issue with leaving the medication cart unlocked and unattended. EI #8 said someone could get into it. On 8/01/19 8:47 a.m., and interview was conducted with Registered Nurse (RN), Director of Nursing EI #1. The surveyor asked EI #1 what should be the position be of the lock on the medication cart when unattended. EI #1 said it should be pushed in and locked. The surveyor asked EI #1 whose responsibility was it to make sure the medication was locked. EI #1 said the person holding the keys to that medication cart's lock. The surveyor asked EI #1 what were the issues with the medication cart being left unlocked and unattended. EI #1 said it increased the risk of someone that is not authority to get into the medication cart. EI #1 was then asked when should medications, pulled for administration, be out of the nurse's view. EI #1 said it should not be. The surveyor asked EI #1 what are the issues with medications being our of the nurses's view. EI #1 said a resident may pick up the medication.

Based on observation, interview and review of a facility policy titled Hand Hygiene, the facility failed to ensure a Certified Nursing Assistant (CNA) did not remove her gloves during peri-care, wash her hands and use paper towels to dry hands. This deficient practice affected Resident Identifier (RI) #25, one of one resident observed for pericare. Finding Include: A facility policy titled Hand Hygiene dated (MONTH) 28th, (YEAR) revealed, Appropriate hand hygiene must be performed under the following conditions: .15 After removing personal protective equipment. RI #25 was admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. On 7/31/19 at 9:14 a.m., peri-care was observed with Employee Identifier (EI) #3, Certified Nursing Assistant (CNA). EI #3 was observed with gloved hands unfastening and folding back RI #25 brief/diaper. EI #3 then, with the same soiled gloves, continued to obtain a wash cloth, soak it in water, apply peri-wash, and cleanse RI #25 perineum in the correct manner. EI #3 then removed the gloves, proceeded to bathroom and washed her hands with soap and water. EI #3 attempted to dry her hands after washing, however, when EI #3 reached for paper towels none were noted in the dispenser. On 7/31/19 at 2:17 p.m., the surveyor conducted an interview with EI #3. EI #3 was asked when providing peri-care for RI #25 did she unfasten and fold back RI #25 brief/diaper with gloves on. EI #3 said yes. EI #3 was asked did she change gloves before obtaining a wash cloth and placing it in water. EI #3 said she did not. EI #3 was asked should she have changed gloves. EI #3 said she should have and washed her hands. EI #3 was asked when she finished peri-care did she remove her gloves, wash hands and no paper towels were available in the bathroom. EI #3 said there were no paper towels. On 8/1/19 at 11:15 p.m., the surveyor conducted an interview with EI # 6, Registered Nurse/Staff Development Coordinator/Infection Control Nurse. EI # 6 was asked when providing peri-care should the certified nursing assistant have washed her hands when unfastening/folding brief on resident. EI #6 said yes , when they finished doing that task, yes they should remove gloves, then wash hands before another task. EI # 6 was asked what should the CNA have done when no paper towels were available to dry hands. EI #6 said she should have stopped, rewashed hands, got another staff member to bring paper towels or found a housekeeper. EI #6 was asked what was the potential harm with not washing and drying hands properly. EI #6 said infections.

Based on observations, interviews, record review, and a review of the facility's policy titled, . ADMINISTRATION OF MEDICATION VIA NASOGASTRIC OR GASTROSTOMY TUBE . the facility failed to ensure Resident Identifier (RI) #183's enteral feeding was infusing at 60 ml/hr as ordered by the physician. This affected one of three sampled residents observed for tube feeding. Findings Include: A review of the facility's policy titled, . ADMINISTRATION OF MEDICATION VIA NASOGASTRIC OR GASTROSTOMY TUBE POLICY: Medications are administered appropriately and safely when the resident has a Nasogastric tube or Gastrostomy tube. Medication is administered, as ordered by a physician, . A review of RI #183's medical record showed a physician's orders [REDACTED]. GIVE GLUCERNIA 1.5 at 60 ML/HR X22 HR PER FEEDING TUBE. RI # 183 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/19/18 at 9:18 a.m. RI #183's Glucernia 1.5 is infusing at 55 ml/hr. On 6/19/18 at 4:54 p.m. RI #183's Glucernia 1.5 is infusing at 55 ml/hr. On 6/20/18 at 4:36 p.m. RI #183's Glucernia 1.5 is infusing at 55 ml/hr. An interview was conducted on 6/20/18 at 4:38 with Employee Identifier (EI) #1, a Licensed Practical Nurse. EI #1 was asked if there was another physician's orders [REDACTED]. The order on 5/26/18 readed Glucernia 1.5 to be infused at 60 ml/hr. EI #1 stated,No, the rate is 60. This is my first time to work with him. EI #1 was asked, what was the potential for harm. EI #1 stated, His sugar would get out of whack. I just checked it and it was 311. Also his fluid intake would not be accurate.

Based on observations, interviews, medical record review, and a review of POTTER AND PERRY's, FUNDAMENTALS OF NURSING the facility failed to ensure a licensed nurse washed her hands and changed her gloves after cleaning one wound and before cleaning the second wound, and further failed to use a separate cotton tipped applicator to apply gel to each wound while performing wound care on Resident Identifier (RI) #187. This affected one of two sampled residents observed for wound care. Findings Include: A review of Potter and Perry's, FUNDAMENTALS OF NURSING, NINTH EDITION, PAGE 459, TABLE 29-6 revealed: Centers for Disease Control and Prevention Isolation Guidelines Standard Precautions . Perform hand hygiene after contact with blood, body fluids, mucous membranes, non intact skin, secretions, excretions, or wound dressings, after contact with inanimate surfaces or articles in a patient room; . On 6/20/18 at 9:40 a.m. Employee Identifier (EI) #2, a Licensed Practical Nurse/Treatment Nurse, did not wash her hands and change her gloves after cleaning the first wound and before cleaning the second wound. Further, EI #2 did not use a separate cotton tipped applicator to apply gel to each wound. An interview was conducted on 6/21/18 at 1:59 p.m. with EI #2. EI #2 was asked what should be done after cleaning the first wound and before cleaning the second wound during wound care. EI #2 stated, Wash my hands. EI #2 was asked if she had done that. EI #2 stated, I did not. EI #2 was asked if the same cotton tipped applicator should be used to apply gel to two separate wounds. EI #2 stated, No it should not. EI #2 was asked if she had done that. EI #2 stated, Yes I did. EI #2 was asked what was the potential for harm. EI #2 stated, You can transfer infection. An interview was conducted on 6/21/18 at 2:32 p.m. with EI #3, a Registered Nurse/ Infection Control. EI #3 was asked what should be done after cleaning one wound and before cleaning the second wound during wound care. EI #3 stated, Change your gloves and wash your hands. EI # 3 was asked if the same cotton tipped applicator should be used to apply gel to two separate wounds. EI #3 stated, No. EI #3 was asked what was the potential for harm. EI #3 stated, You risk spreading bacteria/ infectious disease from one wound to another, cross contamination.

Based on observation, interview and a review of a policy titled Food Storage the facility failed to ensure the following: 1. Ice Cream remained frozen in the freezer 2. A bag of hot dogs and a pan of Jello were not kept past the use by date. This was observed on 4-11-17 during the initial tour of the facility and had the potential to affect 170 residents receiving meals from the kitchen. Findings Include: A review of an undated policy titled, Food Storage revealed the following: .Frozen Foods shall be stored at 0 F (Fahrenheit) or below at all times .17. Potentially hazardous foods are dated upon delivery to include use by dates. During the initial tour of the kitchen on 4-11-17 at 7:40 a.m. the following items were observed in the kitchen: 1. A Bag of hot dogs with a use by date of 4-3-17. 2. A half pan of Jello with a use by date of 4-15-17. 3. Ice cream in the freezer was soft to touch. An interview was conducted with Employee Identifier (EI) #1, Dietary Manger on 4-11-17 at 3:15 p.m. EI #1 was asked if the bag of hot dogs should be in the cooler past the use by date. EI #1 responded they should not have been in there past the use by date. EI # 1 was asked should the ice cream be soft to touch in the freezer. EI #1 stated foods should be frozen solid. EI #1 was asked if the half of pan of jello should have been in cooler past the use by date. EI # 1 responded it should not have been in there.

Based on interview, record review, and a review of a policy titled CAREPLANS - COMPREHENSIVE the facility failed to ensure Resident Identifier (RI) # 17's care plan was followed. RI # 17 did not receive a Handy Cup on his/her meal tray on 4/12/17. This deficient practice affected RI #17, one of 26 sampled residents whose care plans were reviewed. Findings Include: A review of an undated policy titled, CAREPLANS - COMPREHENSIVE documented the following: .1. An interdisciplinary team, in coordination with the resident, his/her family or resident representative, develops and maintains a comprehensive care plan .e. Identify the professional services that are responsible for each element of care . RI # 17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].# 17's most recent Quarterly Minimum Data Set (MDS), with an Assessment Reference Date of 2/14/17, documented RI #17 required extensive assistance with eating. and was on a mechanically altered diet. A review of RI #17's Physician order [REDACTED].Start Date 12/05/16 .HANDY CUP WITH THIN LIQUIDS AND SWALLOW PRECAUTIONS TO DECREASE ASPIRATION RISK. A review of RI # 17's Nutritional /Hydration care plan, dated 5/20/14, documented the following: .Problem Onset: 5/20/2014 .Provide handy cup and thin liquids with swallow precautions . On 4/12/17 at 11:19 a.m. the Surveyor observed RI #17's lunch meal. No Handy Cup was observed on the tray. An interview was conducted with Employee Identifier (EI) # 8, Licensed Practical Nurse (LPN) on 4/13/17 at 10:33 a.m. EI #8 was asked if RI #17 was care planned to have a Handy Cup with meals. EI # 8 said yes he/she was. EI # 8 further stated that according to RI # 17's care plan he/she should have received a Handy Cup on 4/12/17 during the meal observation. EI # 8 was asked who was responsible for ensuring the care plan is followed. EI # 8 responded all staff should follow the care plan for the residents.

Based on observation, record review, interview and a review of a policy titled, Adaptive Devices the facility failed to ensure Resident Identifier (RI) # 14 and RI # 17 received their adaptive devices, handy cups, when eating. This deficient practice affected two of 16 sampled residents who received a Handy Cup with meals. The facility identified 20 residents who received handy cups with meals. Findings Include: A review of an undated policy titled, ADAPTIVE DEVICES documented the following: .This facility will provide the necessary services to any resident requiring adaptive devices to eat. Procedure 1. Facility staff will provide the resident with adaptive devices required for eating. 2. Adaptive devices may include .Handy Cup . 1) RI # 14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI # 14's most recent Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 02/28/2017 documented RI #14 was independent with set up help only when eating and had a swallowing disorder. A review of RI # 14's Physician order [REDACTED].Start Date 3/01/17 .THIN LIQUIDS AND HANDYCUP . A review of RI # 14's Departmental Notes dated 3/6/2017 documented the following .Regular Diet with a HANDY CUP . A review of RI # 14's Speech Therapy Weekly Progress/Discharge Summary dated 1/8/17 - 1/14/17 documented the following: .Mild oral/Mild-moderate pharyngeal dysphagia .Thin liquids via (by means of ) Handy Cup . On 4/11/17 at 4:35 p.m. the Surveyor observed RI #14 eating dinner in the dining room. The Surveyor did not observe a Handy Cup on the meal tray. On 4/12/17 at 11:16 a.m. the Surveyor observed RI # 14 eating lunch in the dining room. The Surveyor did not observe a Handy Cup on the meal tray. An interview was conducted with Employee Identifier (EI) #5, Licensed Practical Nurse on 4/13/17 at 7:45 a.m. EI #5 was asked if RI #14 should have received a Handy Cup with his/her meals on 4/11/17 and 4/12/17. EI # 5 replied it is documented on the chart for swallowing precautions. EI # 5 further stated dietary is responsible for ensuring the Handy Cup is placed on the cart. An interview was conducted with EI # 1, Dietary Manager on 4/13/17 at 10:15 a.m. EI #1 was asked who is responsible for ensuring Handy Cups are placed on the meal trays. EI # 1 responded the kitchen send up and the Certified Nursing Assistants places on the trays. EI # 1 was asked if RI # 14 should have received a Handy Cup with meals observed on 4/11/17 and 4/12/17. EI # 1 responded yes he/she is on the list and the kitchen sent it up. 2) RI # 17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI # 17's most recent Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 2/14/17 documented RI # 17 required extensive assistance with eating and was on a mechanically altered diet. A review of RI #17's Physician order [REDACTED].Start Date 12/05/16 .HANDY CUP WITH THIN LIQUIDS AND SWALLOW PRECAUTIONS TO DECREASE ASPIRATION RISK. A review of RI # 17's Nutritional /Hydration care plan, dated 5/20/14, documented the following: .Problem Onset: 5/20/2014 .Provide handy cup and thin liquids with swallow precautions . On 4/12/17 at 11:19 a.m. the Surveyor observed RI # 17's lunch meal. No Handy Cup was observed on the tray. An interview was completed with EI # 5/Licensed Practical Nurse on 4/13/17 at 7:45 a.m. EI # 5, was asked if RI # 17 should have received a Handy Cup on 4/11/17 during lunch observation. EI # 5 responded yes, if it was ordered. EI # 5 was asked what is the harm of not receiving a Handy Cup. EI # 5 responded she had never known RI # 17 to be a risk for aspiration. An interview was conducted with EI # 1, Dietary Manager on 4/13/17 at 10:15 a.m. EI # 1 was asked who is responsible for ensuring Handy Cups are placed on the meal trays. EI # 1 responded the kitchen sends up a list and the Certified Nursing Assistants places on the trays. EI # 1 was asked if RI # 17 should have received a Handy Cup with lunch observed on 4/11/17. EI # 1 responded yes he/she is on the list and the kitchen sent it up.

Based on observations, record review, and interview: 1. The facility failed to assure proper cleaning/sanitizing of equipment as evidence by: a. Meal tray delivery carts lacked proper cleaning/sanitizing between use for returned soiled trays and prior to delivery of food trays. b. The blender was stored with visible standing water (and not air-dried). 2. The facility failed to prevent potential cross-contamination and a potential transfer of pathogens as evidenced by: a. The plate server in the kitchen, at the steamtable wore gloves. The server picked up bacon and pancakes with gloved hand which was potentially contaminated due to touching/repositioning the food cart. b. Clean/sanitized plate dome covers were not transported stacked and braced against the body and potentially unclean apron. c. During dishmachine operation and on the clean side of the machine, the Dietary Aide failed to wash hands after potential contamination due to resting hands on the dish apron (counter) edge and standing with both hands resting on the hips (touching outer clothing and apron strings). The above practices posed the potential for food contamination and compromised food safety. This had the potential to affect all residents receiving meal trays from dining services. Findings include: 1. a. A review of an undated facility policy: Cleaning Procedures- Major Equipment under the category of Tray Carts directed staff to Wash inside and outside thoroughly using a mild detergent solution and brush .Sanitize with appropriate strength solution. On 8/03/16 at 9:18 a.m., a Dietary Aide, Employee Identifier (EI) #8, was observed to wipe soiled meal tray carts with a moist cloth. At this time the Dietary Manager, EI #6, who was also observing, was requested to describe the facility protocol for cleaning the carts. EI #6 said: Take (the) cloth from (the) bucket, wipe (the) entire surface. The Dietary Aide, EI#8 was then asked if she had washed with soap (per documented facility policy) and she responded, No, Ma'am. b. The 2013 Food Code by the United States Public Health (USP) and the Food and Drug Administration (FDA) included the following: Drying 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining . On 8/02/2016 at 6:10 a.m., a blender stored on the stand was observed. A request was made for EI #7 to remove the blender from the stand (to facilitate a better view). EI #7 removed the blender and turned it upside down. EI #7 was asked, was there water in the blender. EI #7 responded, Yes, Ma'am. EI #7 was asked if that was a problem and she replied yes, and that the blender should have been air dried. 2. a. On 8/2/2016 at 6:25 a.m., EI #10, a Cook, was observed in the kitchen at the steamtable plating food. EI #10's hands were gloved. EI #10 positioned the tiered cart with her gloved hands, then she picked up bacon and a pancake. EI #10 did not change her gloves and wash her hands prior to handling the food. b. On 8/3/2016 at 9:45 a.m., a Dietary Aide, EI #9, was observed on the clean side of the dishmachine. She stacked clean plate dome covers (almost chin high) to transport to the drying rack. The stack was braced against her body. The Dietary Manager, EI #6 was asked if the observed practice was a problem. EI #6 replied that yes there was a potential for cross-contamination. c. On 8/3/2016 at 9:15 a.m., prior to the above incident, EI #9 was noted to stand on the clean side of the dishmachine, waiting for action, with her hands resting on the ledge of the machine dish apron. Between racks of clean dishes/utensils, EI #9 stood with both hands resting on her hips. EI #9 failed to wash her hands prior to returning to the clean side of the machine to stack/store items. On 8/4/2016 at 1:10 p.m., the Registered Dietitian, EI #14, was asked about the potential risk factor or harm due to cross-contamination. EI #14 stated the risk was for a transfer of bacteria or an illness to a resident.

Based on observations, interviews, and record reviews, the facility failed to ensure the residents' doors were free of scuff and scratch marks; and handrails were free of broken areas, were firmly affixed to walls and were aligned smoothly on one of five halls. Further, the facility failed to ensure the ceiling tiles were free of water stains in the Northview dining room and Room Locators (RL) #'s 1 through 6 and RL #11. Findings Include: An undated facility policy titled, Maintenance Service, revealed: Policy Statement Maintenance service shall be provided to all areas of the building .and equipment. Policy Interpretation and Implementation 1. The maintenance department is responsible for maintaining the building .and equipment in a safe and operable manner at all times. 2. The following functions are performed by maintenance . a. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. b. Maintaining the building in good repair . A review of an undated facility policy titled, Director of Maintenance, revealed the following: .Purpose of Your Job .to plan, organize, develop, and direct the overall operation of the Maintenance Department in accordance with current federal, state and local standards, guidelines and regulations governing our facility .to assure our facility is maintained in a safe and comfortable manner . Duties and Responsibilities .Make daily rounds to assure .that appropriate maintenance procedures are being rendered to meet the needs of the facility . During the initial tour of the facility on 08/02/2016 at 6:10 a.m., the following observations were made inside residents rooms on the Westview Hall: RL #1 had a stained ceiling tile. RL #2 had stained ceiling tiles. RL #3 had a stained ceiling tile. RL #4 had a stained ceiling tile. RL #5 had stained ceiling tiles. RL #6 had a stained ceiling tile. During the initial tour on 08/02/2016 at 6:52 a.m., the surveyor toured Northview Hall and observed 3 ceiling tiles in the center of the dining room with brown water stains. The stains on 2 of the tiles were approximately 1 foot wide, with a third tile having a smaller brown water stain. On 08/03/2016 at 11:45 a.m., the surveyor noted the tiles in Northview Dining Room had been replaced and had small wet stains on 2 of the ceiling tiles. On 08/04/2016 at 07:30 a.m., the surveyor observed the 3 ceiling tiles in the Northview Dining Room to have large dark brown stains, again. On 08/02/2016 beginning at 3:00 pm, the following observations were made on the Crossroads Hall: The doors to RL #s 7, 9,11,14,15 and 16 were observed to have multiple horizontal scrapes and scratches extending across the bottom half of the door and doorframe. The doors to RL #'s 13, 21, and 22 were observed to have multiple scrapes and scratches with chunks of missing wood on door edges. The handrail outside of RL #8 was loose to the touch. The handrail outside of RL #10 had a spacing gap at the joint connection. The handrail outside of RL #12 was loose to the touch and not flushed with the wall. The handrail outside of RL #15 had a spacing gap at the joint connection. The handrail outside of RL #17 was loose to the touch and the end piece was broken and gaping open. The handrail outside of RL #19 was not fitted together properly creating a gap in the structure. The Handrail outside of RL #20 had a spacing gap at the joint connection. The handrail outside of RL #22 was not flush with the wall. RL #11 was observed to have a brown stain on the ceiling tile above the doorframe on the outside of the door, and a brown stain on the ceiling tile above the doorframe on the inside of the door. Employee Identifier (EI) #1, Maintenance Director, was interviewed on 08/04/2016 beginning at 1:10 p.m. The surveyor, along with EI #1, toured the Crossroads Hall. EI #1 described the residents' doors as having lots of scuff marks and scratches caused by wheelchairs and carts banging into them daily. He described the doors with missing wood chunks as worn wood areas caused by food carts banging into them. When asked how he would describe the appearance of the hall, EI #1 replied, I agree, there are a lot of scuffs and scratches and it looks bad. When asked to describe the appearance of the handrails, EI #1 replied, I see older handrails that need to be updated/repaired. EI #1 explained that he had installed some new handrails on another unit, but did not know if there were orders for handrails for the Crossroads Hall. EI #1's overall description of the handrails on the Crossroads Hall was that they were old and needed to be replaced or repaired. On 08/04/2016 at 1:41 p.m., EI #1 was taken to the Northview Dining Room where he, along with surveyors, observed a large water stain on a ceiling tile. EI #1 noted it was wet and removed the tile to find the source which was condensation on the air conditioning duct dripping onto the tile. On 08/04/2016 at 3:40 p.m., EI # 1 was taken to the Westview Hall to observe the stained ceiling tiles in RL #s 1 through 6. After confirming the presence of the ceiling stains, EI #1 explained he could not be sure of the cause, but they may have been caused by water line leaks, splatter, or roof leaks. EI #1 did confirm that the stained tile in RL #2 should have already been changed. He further explained the stained tile in RL #1 was fresh and still wet and he would check on it immediately since he thought it may be a leak coming from a pin hole in the roof. When asked what could be a potential negative outcome for residents having stained tiles in their rooms, he replied, Nobody likes to look at a stained tile.

Based on observation, interviews, and record review, the facility failed to ensure RI (Resident Identifier) #22 did not self administer his/her nebulizer treatment on 08/02/2016, without being assessed for safety/proficiency to perform treatment prior to self administering. This affected RI #22, one of one residents observed receiving nebulizer treatment. Findings Include: RI #22 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a document titled, POTTER PERRY FUNDAMENTALS OF NURSING EIGHTH EDITION with a copyright date of 2013, revealed the following on page 588, Unit 5: Foundations for Nursing Practice .NURSING DIAGNOSIS .Assessment provides data about the patient's condition, ability to self-administer medications . A review of a facility policy titled, Administration of Nebulizer Treatments, with a date of 01/23/2001, revealed the following: .This facility will administer nebulizer treatments . A further review of RI #22's Physician order [REDACTED]. .[MEDICAL CONDITION], unspecified IPRAT-ALBUT ([MEDICATION NAME]/[MEDICATION NAME]) 0.5-3 MG (MILLIGRAM)/3 ML (MILLILITER) ADMINISTER ONE VIAL VIA NEBULIZER TO INHALE INTO LUNGS BY MOUTH EVERY SIX HOURS . A review of a facility document titled, MEDICATION ADMINISTRATION, for the month of August 2016, revealed RI #22 received his/her nebulizer treatment on August 2, 2016 at 4:00 AM from EI (Employee Identifier) #3, LPN (Licensed Practical Nurse). On 08/02/2016 at 6:10 a.m., RI #22 was observed laying in bed with the nebulizer on and in use. RI #22 was asked why he/she was wearing the mask. RI #22 said the treatment was infusing. At 6:12 AM, RI #22 was observed turning the nebulizer machine off and taking the mask off. RI #2 stated he/she did his/her own nebulizer treatments. A review of RI #22's current quarterly MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 05/17/2016, revealed a BIMS (Brief Interview for Mental Status) score of two, which indicated the resident was severely impaired in cognition for daily decision making and cues and supervision was required. On 08/04/2016 at 10:42 a.m., an interview was conducted with EI #2, LPN. EI #2 was asked how often RI #22 received nebulizer treatments. EI #2 said every six hours. EI #2 was asked who was to administer RI #22's nebulizer treatment. EI #2 said the charge nurse. EI #2 was asked why RI #22 was receiving nebulizer treatments. EI #2 said RI #22 had [MEDICAL CONDITIONS]. EI #22 was asked what was the potential harm in a resident with [MEDICAL CONDITION] administering their own nebulizer treatment. EI #2 explained they could possibly get too much medication or may not get enough medication. On 08/04/2016 at 3:40 p.m., a telephone interview was conducted with EI #3, LPN. EI #3 was asked when did she provide nursing care to RI #22. EI #3 said the third shift on 08/02/2016. EI #3 was asked when RI #22 received his/her nebulizer treatment, if he/she self administered the treatment. EI #3 said no, she usually did it but RI #22 refused the 4:00 a.m. treatment; so she went back at 5:45 a.m. or 6:00 a.m. She further explained when she went back, RI #22 agreed to the treatment and she administered it. RI #3 further explained she put the breathing treatment on RI #22 and came back to take it off. EI #3 was asked if RI #22 was to self administer his/her nebulizer treatment. EI #3 said no. EI #3 was asked if RI #22 was assessed to self administer his/her nebulizer treatment. EI #3 said she did not know. EI #3 was asked should she have stayed in the room with RI #22 until the treatment was completed. EI #3 said usually she did. EI #3 was asked why did she leave RI #22 alone while he/she received the nebulizer treatment. EI #3 said because it had not finished. EI #3 was asked what was the facility's policy and procedure for administering a nebulizer treatment, for a resident not assessed to do so. EI #3 said staff was to remain with the resident for 15 minutes or until the treatment was completed. EI #3 was asked if that was what she had done. EI #3 said no, she did not stay the entire time. EI #3 was asked what was the potential harm in allowing a resident, who had not been assessed to self administer medication, to administer a nebulizer treatment. EI #3 said he/she could take it off and not receive all of the treatment.

Based on observation, interviews, and record reviews, the facility failed to ensure licensed staff remained with RI (Resident Identifier)#22 throughout the administration of his/her nebulizer treatment on 08/02/2016. This affected RI #22, one of one residents observed receiving nebulizer treatment. Findings Include: RI #22 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #22 current quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 05/17/2016 revealed a BIMS (Brief Interview for Mental Status) score of two, which indicated the resident was severely impaired in cognition for daily decision making; and cues and supervision were required. A review of RI #22's Care Plans, with a review date of 05/31/2016, revealed the following: .Problem Onset: .Risk for respiratory distress: [MEDICAL CONDITIONS] .Approaches .Administer nebulizer treatments . A review of RI #22's Physician order [REDACTED]. .[MEDICAL CONDITION], unspecified IPRAT-ALBUT ([MEDICATION NAME]-[MEDICATION NAME]) 0.5-3 MG (MILLIGRAM)/3 ML (MILLILITER) ADMINISTER ONE VIAL VIA NEBULIZER TO INHALE INTO LUNGS BY MOUTH EVERY SIX HOURS . A review of a RI #22's MEDICATION ADMINISTRATION record for the month of August 2016 revealed RI #22 received a nebulizer treatment on August 2, 2016 at 4:00 a.m. from EI (Employee Identifier) #3, LPN (Licensed Practical Nurse). On 08/02/2016 at 6:10 a.m., RI #22 was observed laying in bed with the nebulizer mask on and in use. RI #22 was asked why he/she was wearing the mask. RI #22 said he/she was receiving his/her treatment. At 6:12 a.m., RI #22 was observed turning the nebulizer machine off and taking the mask off. RI #2 stated he/she did his/her own nebulizer treatment. On 08/04/2016 at 10:42 a.m., an interview was conducted with EI #2, LPN. EI #2 was asked how often RI #22 received nebulizer treatments. EI #2 said every six hours. EI #2 was asked who was supposed to administer RI #22's nebulizer treatment. EI #2 said the charge nurse. EI #2 was asked why RI #22 was receiving nebulizer treatments. EI #2 said RI #22 had [MEDICAL CONDITION]. EI #22 was asked what was the potential harm in a resident with [MEDICAL CONDITION] administering their own nebulizer treatment. EI #2 explained they could possibly get too much medication or may not get enough medication. On 08/04/2016 at 3:40 p.m., a telephone interview was conducted with EI #3, LPN. EI #3 was asked if she was she familiar with RI #22. EI #3 said yes. EI #3 was asked when did she provide nursing care to RI #22. EI #3 said the third shift on 08/02/2016. EI #3 was asked when RI #22 received his/her nebulizer treatment, did he/she self administer treatment. EI #3 said no, she usually did it but RI #22 had refused the 4:00 a.m. treatment; so, she went back at 5:45 a.m. or 6:00 a.m. She further explained when she went back RI #22 agreed to the treatment and she gave it to him/her. RI #3 further explained she put the breathing treatment on RI #22 and went back later to remove it. EI #3 was asked if RI #22 was supposed to self administer his/her nebulizer treatment. EI #3 said no. EI #3 was asked if RI #22 was assessed to self administer his/her nebulizer treatment. EI #3 said she did not know. EI #3 was asked should she have stayed in the room with RI #22 until the treatment was completed. EI #3 said she usually did. EI #3 was asked why had she left RI #22 alone while he/she received the nebulizer treatment. EI #3 said because it had not finished. EI #3 was asked what was the facility's policy and procedure for administering a nebulizer treatment for [REDACTED]. EI #3 said staff was to remain with the resident for 15 minutes or until the treatment was completed. EI #3 was asked if that was what she had done. EI #3 said no, she did not stay the entire time. EI #3 was asked what was the potential harm in allowing a resident, who has not been assessed to self administer medication, to administer the nebulizer treatment. EI #3 said he/she could take it off and not receive all of the treatment.