Every finding on record at Tallassee Health and Rehabilitation, LLC

Based on record reviews, interviews, review of the facility's investigation file, review of the facility's report to Alabama Department of Public Health (ADPH) Online Incident Reporting System, and a review of the facility's policy titled, Abuse, Neglect, Misappropriation of Resident/Guest Property, and Exploitation, the facility failed to ensure a Certified Nursing Assistant (CNA)/Employee Identifier (EI) #3, did not verbally abuse Resident Identifier (RI) #1 on 12/29/2022. This deficient practice affected RI #1, one of three residents sampled for abuse, and substantiated complaint/report number AL00042834. Findings Include: On 12/29/2022, the facility submitted a Facility Reported Incident through the ADPH Online Incident Reporting System. The report's summary of the incident documented that the incident was reported to a charge nurse that EI #3, CNA on the night shift yelled at RI #1 telling him/her to get up and not have accidents in the bed. A review of the facility policy Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown sources, Exploitation with an effective date of October 15, 2022, revealed PURPOSE: .All of our resident/guest(s) have the right to be free from abuse . A. Abuse . 1. Verbal-Verbal abuse is the use of oral, written or gestured communication or sounds that includes disparaging and derogatory terms to resident/guest(s) . Examples of verbal abuse could include, but are not limited to . Using profanity ., blaming the resident/guest, blaming a resident/guest for their condition . RI #1 was admitted to the facility on [DATE] with a diagnosis of Anxiety. A witness statement provided to the facility from EI #4, CNA, documented . on 12/29/2022 on the night shift during one of the rounds she witnessed EI #3 talking loudly and making several negative remarks that were derogatory in nature to RI #1. EI #3 said RI #1 needed to quit being lazy and sorry and to get up to the restroom instead of laying there Shitting in the bed, EI #3 then stated that she would be glad when RI #1 was off her hall. The facility's phone witness statement taken from EI #3 on 12/30/22 documented I don't know what to do or say because I have not done anything to RI #1 . A review of RI #1's Admission Minimum Data Set with an Assessment Reference date of 12/30/22 indicated a Brief Interview for Mental Status of 15, indicating capable of decision making, also limited assistance with toileting needs. On 6/6/23 at 5:30 PM a phone interview with RI #1 revealed it was on the night shift he/she mashed the call light for help. RI #1 said he/she needs help because he/she had soiled him/herself. RI #1 said he/she generally did not do that and unsure why it happened. RI #1 said EI #3 yelled get up and don't crap on the bed, you can walk to the bathroom. RI #1 said he/she did not report it until the next evening because he/she just had not thought about it again until later. RI #1 did validate EI #4 CNA, coming to the door and felt she heard what EI #3 had said. RI #1 said he/she talked to EI #1 the Abuse Coordinator that afternoon and told her he/she hated for people to have to have help him/her and did not mean to soil on him/herself. RI #1 said this occurred somewhere around 2 to 3 o'clock in the morning. RI #1 said this made him/her mad, EI #3 does not need to be working in a place like this where we all need care and her help, and she is rude and yelling. RI #1 said EI #3 did not come back into him/her room that night and never has seen her again. On 6/7/23 at 2:30 PM during an interview with Licensed Practical Nurse (LPN), EI #5 said during the medication pass RI #1 told her EI #3 was yelling at him/her on the night shift. EI #5 said she told RI #1 she would report this. EI #5 said RI #1 gave a description that described EI #3, CNA. EI #5 said RI #1 did say there was no cursing just talked bad and yelling. EI #5said what RI #1 told her as verbal abuse. EI #5 said once she was told by RI #1 what happen, she asked EI #4 who else worked and was told EI #3, then she reported it to the Administrator, EI #1. LPN, EI #5 said EI #4 did not follow the policy if she heard EI #3 talking unkindly to RI #1 and did not report it. EI #5 said this was disrespectful on EI #3's part. An interview on 6/7/23 at 2:00 PM with EI #4, CNA identified, when she finished her rounds on 12/29/2022, she found EI #3 in RI #1's room. EI #4 said when she open the door, she heard EI #3 saying to RI #1 you don't need to lay there shitting in the bed, she then said, I will be glad when you off my hall. EI #4 said first she did not think of this as abuse but was concerned with the tone of EI #3's voice. EI #4 said she witnessed the incident when she opened the room door to RI #1's room. EI #4 said what she witnessed was verbal abuse. EI #4 said EI #3 was suspended immediately and never returned to the facility; she was told she was terminated. EI #4 said the incident occurred about 4:00 AM, she was about to get off shift. EI #4 said she should have reported it to EI #1 at the time she heard it. EI #4 said RI #1 was not harmed RI #1 had a right to be treated respectfully, and EI #3 was not respectful by yelling and talking in a rude tone to RI #1. EI #4 said the facility's policy for witnessed abuse was not followed. During the survey on 6/7/2023 at 10:30 AM and 6/8/2023 at 10:30 AM attempts were made to reach EI #3 for interview. All the attempts were unsuccessful. On 6/8/23 at 11:30 AM EI #1, the Administrator/Abuse Coordinator was interviewed. EI #1 said she recalled EI #5, LPN coming to the office and said RI #1 said the night shift CNA, EI #3 yelled at him/her. EI #1 said during the investigation, EI #4 said she recalled EI #3 talking loudly and rude, but at the time did not think about it being verbal abuse. EI #1 said he talked to RI #1, and he/she said EI #3 said RI #1 should not be shit in the bed. RI #1 said the way she talked was rude, and EI #3 said she would be glad when RI #1 was off that hall. EI #1 said he did get statement from EI #3 by phone on 12/30/22 because we could not reach her. EI #3 denied any comments made to RI #1 and we suspended her. EI #1 said RI #1 said it made him/her feel like the aide did not want to care for him/her. EI #1 said he substantiated verbal abuse based on what RI #1 said that EI #3 was yelling and EI #4's statement saying she heard EI #3 talking loudly and making negative remarks that were derogatory in nature. EI #1 said the facility policy identifies abuse has occurred when derogatory terms are used and blaming resident for not being able to provide care for themselves. The Administrator/Abuse Coordinator, EI #1 said EI #4 said at first, she did not feel it was abuse and it was just rude, then she said later she should have reported it because EI #3 was loud and making negative remarks. EI #1 said, he told all staff, if you hear it report it and let us investigate to determine if abuse has occurred. EI #1 said the facility's abuse policy was not followed and it was EI #4's responsibility to report what was heard, then the facility would investigate to determine if abuse has occurred. This citation was cited as a result of the investigation of complaint/report number AL00042834

Based on record reviews, interviews, review of facility policy Abuse and a facility online reporting form, the facility failed to ensure a Certified Nursing Assistant (CNA) EI #4 that witnessed Resident Identifier (RI) #1 being verbally abused by another CNA (EI #3) was reported to the supervisor immediately. The not reporting of abuse occurred on 12/29/22 and affected RI #1, one of three sampled residents for abuse. Cross reference F600. Findings Include: A review of the facility Abuse policy with an effective date of October 15, 2022, revealed . IV Identification of Resident/Guest(s) Incidents and Accidents . d) Each employee has an obligation to immediately report any incident or allegation that could constitute an instance of abuse or neglect . to the Administrator. Immediately means as soon as possible . Any staff members that witnessed, suspect or is reported to, are personally obligated to . report to supervisor immediately. The state agency Online Reporting Form dated 12/29/2022 at 5:10 PM identified, . Resident reported to charge nurse that CNA last night on night shift had yelled at him/her telling him/her to get up and not have accidents in the bed. The facility's investigation identified, On 12/29/22 LPN charge nurse notified the Administrator that one of her residents had made an allegation of verbal abuse . Resident told the LPN that CNA Employee Identifier (EI) #3 was yelling at RI #1 for ringing the call light and was using derogatory language . CNA EI #4 reported to the Administrator she heard the CNA EI #3 talking loudly and making negative derogatory remarks to the resident. On the 3rd shift night of 12/29/22 during one of her rounds and witnessed EI #3 talking loudly and making several negative remarks that were derogatory in nature to RI #1. but did not report it to licensed staff. On 6/6/23 at 5:30 PM a phone interview with RI #1 revealed it was on the night shift he/she mashed the call light for help. RI #1 said he/she needs help because he/she had soiled him/herself. RI #1 said he/she generally did not do that and unsure why it happened. RI #1 said EI #3 yelled get up and don't crap on the bed, you can walk to the bathroom RI #1 did validate EI #4 CNA, coming to the door and felt she heard what EI #3 had said. RI #1 said this occurred somewhere around 2 to 3 o'clock in the morning. RI #1 said this made him/her mad, EI #3 does not need to be working in a place like this where we all need care and her help, and she is rude and yelling. On 6/7/23 at 2:30 PM during an interview with Licensed Practical Nurse, EI #5 said during the medication pass RI #1 told her EI #3 was yelling at him/her on the night shift. EI #5 said she told RI #1 she would report this. EI #5 said RI #1 did say there was no cursing just talked bad and yelling. EI #5 said described what RI #1 told her as verbal abuse. EI #5 said once she was told by RI #1, she asked EI #4 who else worked and was told EI #3, then she reported it to the Administrator, EI #1. EI #5 said she did not know why it was not reported at the time it occurred. EI #5 said the policy states if witnessing abuse the employees are to separate the persons and report it. EI #5 said EI #4 did not follow the policy if she heard EI #3 talking unkindly to RI #1 and did not report it. An interview on 6/7/23 at 2:00 PM with EI #4, CNA identified, when she finished her rounds on 12/29/2022, she found EI #3 in RI #1's room. EI #4 said when she open the door, she heard EI #3 saying to RI #1 you don't need to lay there shitting in the bed, she then said, I will be glad when you off my hall. EI #4 said first she did not think of this as abuse but was concerned with the tone of EI #3 voice. EI #4 said she witnessed the incident when she opened the room door to RI #1's room. EI #4 said what she witnessed was verbal abuse. EI #4 said the incident occurred about 4:00 AM, she was about to get off shift. EI #4 said she should have called the abuse coordinator or told the nurse on shift when she heard EI #3 talking rudely to RI #1. EI #4 said the facility's policy for witnessed abuse was to report it. EI #4 said a concern of not reporting witnessed abuse is that it could escalate. On 6/8/23 at 11:30 AM EI #1, the Administrator/Abuse Coordinator was interviewed. EI #1 said she recalled EI #5, LPN coming to the office and said RI #1 said the night shift CNA, EI #3 yelled at him/her. EI #1 said that doing the investigation EI #4 said she recalled EI #3 talking loudly and rude, but at the time did not think about it being verbal abuse. EI #1 said she talked to RI #1, and he/she said EI #3 said RI #1 should not be shit in the bed. RI #1 said the way she talked was rude, and EI #3 said she would be glad when RI #1 was off that hall. EI #1 said RI #1 said it made him/her feel like the aide did not want to care for him/her. EI #1 said EI #4 witnessed the incident that occurred between EI #3 and RI #1 and should have reported it. EI #1 said, he told all staff, if you hear it report it and let us investigate to determine if abuse has occurred. EI #1 said in the facility's abuse policy related to reporting abuse, identifies in the verbal abuse section Verbal abuse is use of oral written or gestured communication that includes disparaging and derogatory terms . written or gestures or derogatory against resident .should be reported and it was not. EI #1 said the facility's abuse policy was not followed and it was EI #4's responsibility to report what was heard. This citation was cited as a result of the investigation of complaint/report number AL00042834.

Based on observation, interview, the Resident Council Meeting on 11/2/22, a Test Tray on 11/3/22, and the facility's Week 3 S/S (Spring/Summer) menu for Thursday (11/3/22); the facility failed to ensure hot food was served hot. This had the potential to affect 87 of 87 residents receiving meals from the kitchen. Findings Include: A Resident Council Meeting was held on 11/02/22 at 2:56 PM with eleven residents attending. During this meeting, all of the residents attending complained that hot foods were being served cold. The facility's Week 3 S/S menu for Lunch on Thursday (11/03/22) included the following items for the Regular Diet: Salisbury Steak, Rice, Seasoned Greens, Cornbread, and Frosted Cake. A tray line observation on 11/03/22 revealed the following: 10:58 AM Preparations for setting up lunch tray line starting. Steamtable water was already steaming, and steamtable holes were covered with empty pans. The plates in the plate warmer were hot. 11:04 AM Tray line temperatures taken by Employee Identifier (EI) #5, the PM Cook, included Seasoned Greens at 200 degrees Fahrenheit (F), Salisbury Steak at 180 degrees F, and Rice at 180 degrees F. 11:33 AM Tray assembly started with three staff on the tray line. 12:07 PM The first of two carts began to be loaded with trays for the last hall to be served, Back Hall. A Regular Diet test tray was requested for this hall. 12:20 PM Twelve plates on the first cart were observed to not be fully covered as insulated bases were being used instead of insulated lids. EI #2, the Registered Dietitian (RD), said there was a shortage of lids due to supply problems. Some dirty lids were washed in the dishwasher for use. It was observed the test tray was properly covered with an insulated lid. 12:25 PM The second of two carts were sent to Back Hall. The test tray was on this cart. 12:26 PM The carts on Back Hall were being served by two staff members. 12:43 PM Four staff members were present to serve trays. 12:47 PM The last resident tray was served. It took at least 22 minutes to serve the trays on Back Hall. At 12:48 PM, the test tray was tasted with EI #2, the RD, in the Back Hall nourishment room. The rice was not hot. EI #2 agreed. Margarine had been added to the rice, but it did not melt. The Salisbury Steak was not hot. EI #2 agreed. EI #3, the Dietary Manager, was interviewed on 11/03/22 at 4:40 PM. When asked what could be the problem if residents receive cold food items that should be served hot, EI #3 said they would get upset because it is cold. EI #2, the RD, was interviewed on 11/03/22 at 5:00 PM. When asked what could be the problem if residents receive cold food items that should be served hot, EI #2 said the palatability would be affected and the residents might not want to eat it; which, if a chronic problem, could roll into other issues such as weight loss.

Based on observation, interview, and the 2017 Food Code of the United States (U.S.) Public Health Service and U.S. Food and Drug Administration (FDA); the facility failed to ensure: 1.) expired milk and sour cream were not served to residents on [DATE] and [DATE], 2.) cross-contamination did not occur when forced air passed through dirty grids/grates and then onto cleaned dishes on [DATE], and 3.) food was not stored on the floor on [DATE]. This had the potential to affect 87 of 87 residents receiving meals from the kitchen. Findings Include: 1.) The 2017 Food Code of the U.S. Public Health Service and the FDA included the following: . ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (B) . refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, . (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. During the initial kitchen tour on [DATE] at 12:30 PM, the refrigerated Milk Box contained the following: a.) one-half of a case (56 cartons per case) of 8 oz. skim milk cartons with the manufacturer's expiration date of [DATE] and b.) two 8 oz. cartons of 1% low fat milk with the manufacturer's expiration date of [DATE]. Also, during the initial kitchen tour on [DATE] at 12:38 PM, the Walk-in Cooler contained a five-pound tub of sour cream with the following manufacturer's stamp: Expires [DATE]. In addition, a milk crate was observed to be filled with individual 8 oz. cartons of skim milk that were labeled with the manufacturer's expiration date of [DATE]. On [DATE] at 12:59 PM, an observation was made of a dirty tray cart returned to the kitchen after lunch service. There were two empty cartons of 1% low fat milk, one was dated [DATE] and the other was dated [DATE]. In addition, there was one unopened carton of 1% low fat milk dated [DATE]. On [DATE] at 4:15 PM, the Walk-in Cooler was still found to contain the five-pound tub of sour cream, but with a sticker added to the top lid labeled, Opened [DATE]. This sticker was placed alongside the commercial label documentation, Expires [DATE]. Employee Identifier (EI) #3, the Dietary Manager, was interviewed on [DATE] at 4:40 PM. When asked what was the problem with serving expired milk or using expired sour cream when serving nursing home residents, EI #3 said we cannot use expired milk or expired sour cream because then we would have everybody sick. Upon being asked what was the problem with an Opened [DATE] sticker being placed onto a container of sour cream that expired [DATE]; EI #3 said it should have been thrown in the garbage. EI #2, the Registered Dietitian (RD), was interviewed on [DATE] at 5:00 PM. When asked what was the problem with serving expired milk or using expired sour cream when serving nursing home residents, EI #2 said foodborne illness. Upon being asked what was the problem with an Opened [DATE] sticker being placed onto a container of sour cream that expired [DATE]; EI #2 said we would be serving out-of-date food, which could cause a foodborne illness. 2.) The 2017 Food Code of the U.S. Public Health Service and the FDA included the following: . ,d+[DATE].12 Heating, Ventilating, Air Conditioning System Vents. . shall be . installed so that make-up air intake and exhaust vents do not cause contamination of . FOOD-CONTACT SURFACES, EQUIPMENT, or UTENSILS. On [DATE] at 12:50 PM, the Dish room was observed. The San-Aire Power Dry, a forced-air drying mechanism on the clean side of the dishwashing machine, had no intake filter. In addition, dirty grime was observed around the air intake and exhaust openings of the mechanism and there was also dirty grime on the wire grates over the openings. Washing of lunch dishes was ongoing at this time. This mechanism was blowing air onto clean dishes exiting the dishwashing machine. EI #3, the Dietary Manager, was interviewed on [DATE] at 4:40 PM. When asked what was the problem with air flowing through a dirty intake opening on the San-Aire Power Dry and then flowing out a dirty exhaust vent onto cleaned dishes, EI #3 said the dust and whatever was being blown onto the clean plates. EI #2, the RD, was interviewed on [DATE] at 5:00 PM. When asked what was the problem with air flowing through a dirty intake opening on the San-Aire Power Dry and then flowing out a dirty exhaust vent onto cleaned dishes, EI #2 said foreign debris on the clean dishes causing contamination. 3.) The 2017 Food Code of the U.S. Public Health Service and the FDA included the following: . ,d+[DATE].11 Food Storage. (A) . FOOD shall be protected from contamination by storing the FOOD: . (3) At least 15 cm [centimeters] (6 inches) above the floor. During the initial kitchen tour on [DATE] at 12:38 PM, the Walk-in Cooler contained two full cases of 8 oz. 1% skim milk cartons that were each stored directly on the floor. One case flat on the floor and the other case standing on its end. On [DATE] at 3:45 PM, there was still one case of milk standing on its end on the floor in the Walk-in Cooler. EI #3, the Dietary Manager, was interviewed on [DATE] at 4:40 PM. When asked what was the problem in storing food items on the floor, EI #3 said food should not be stored on the floor because of germs. EI #2, the RD, was interviewed on [DATE] at 5:00 PM. When asked what was the problem in storing food items on the floor, EI #2 said we elevate things so we can clean properly.

Based on an observation, interviews and review of facility policies titled, Medication Administration Procedures Oral Inhalation and Medication Administration procedures Self -Administration of Medications, the facility failed to ensure the licensed nurse remained with (Resident Identifier) RI #5, a resident not assessed to self-administer his/her nebulizer breathing treatment, when RI #5 received a nebulizer treatment on 11/01/22. This deficient practice affected RI #5; one of two sampled residents observed receiving a nebulizer breathing treatment. Findings Include: Review of facility policy titled, Medication Administration Procedures Oral Inhalation, dated 04/20, revealed the following: . Policy: To allow for safe, accurate, and effective administration of medication using . nebulizer. Nebulizer- . 11. Instruct the resident to take a deep breath, pause briefly and then exhale normally. Repeat pattern throughout treatment. 12. Remain with the resident for the treatment unless the resident has been assessed and authorized to self-administer. A second policy titled Medication Administration Procedures Self-Administration of Medications dated reviewed 04/20, revealed, . Policy . An order to self- administer must be given by the physician. Procedures . 2. Facility staff will administer the resident's medications until the interdisciplinary team completes an assessment and a physicians order is obtained . RI # 5 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] RI #5's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . DOUNEB 0.5 MG-3 MG/3ML SOLN- GIVE 1 VIAL VIA NEBULIZER Q4H PRN . On 11/01/22 at 03:24 PM, RI #5 was observed sitting in a wheelchair with a nebulizer treatment mask on machine was not on. RI #5 turned on machine and began treatment. At, 3:34 PM, RI #5 turned off nebulizer machine. RI #5 stated the nurse had given him/her medication to put into the nebulizer. An interview was conducted with Employee Identifier (EI) # 6, Licensed Practical Nurse, (LPN) on 11/03/22 at 11:19 AM. EI #6 stated she provided care for RI #5 on 11/01/22 and administered the nebulizer treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #6 stated she had not seen an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #6 stated the concern of leaving the room while administering a nebulizer treatment was something could happen with the machine or resident. An interview was conducted with EI #1, Director of nursing on 11/03/2022 at 6:38 PM. EI #1 stated the procedure for administering a nebulizer treatment was to check the order to make sure it was the right patient, right route, right medication, check respirations, o2 stats, stay with resident while administering the nebulizer treatment, assess respiration rates o2 stats after treatment and document. EI #1 stated RI #5 does not have an order to self -administer nebulizer treatment. EI #1 stated the concern with leaving the room while administering the nebulizer treatment was the resident could have complications, the machine could not be working properly, knowing if the resident actually got the medication, and making sure the resident was not in distress.

Based on interview, record review, and review of Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User ' s Manual, the facility failed to ensure Resident Identifier (RI) 5's Minimum Quarterly Data Set (MDS), with an Assessment Reference Date (ARD) of 09/06/22 was accurately coded to reflect RI #5 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] This deficient practice affected RI #5, one of six sampled resident's 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: . SECTION I: ACTIVE diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Intent: The items in this section are intended to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status . I: Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .) Item Rationale Health-related Quality of Life * Disease processes can have a significant adverse effect on an individual's health status and quality of life. Planning for Care * This section identifies active diseases and infections that drive the current plan of care . RI # 5 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a quarterly MDS with an Assessment Reference Date of 09/06/22, Section I .Pulmonary I6200. Asthma, Chronic Obstructive Pulmonary Disease ([CONDITION(S)]), or Chronic Lung Disease . was unchecked and Asthma was not listed in I8000. Additional active diagnosis An interview was conducted with Employee Identifier (EI) #7, Licensed Practical Nurse (LPN), MDS Coordinator on11/03/22 at 6:18 PM. EI #7 stated RI #5 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #7 admitted the MDS for RI #5 was not coded accurately.

Based on observation, interviews, record review and review of a facility policy titled Wheelchairs and Rock-N-Go Wheelchairs, the facility failed to ensure a CNA (Certified Nursing Assistant), Employee Identifier (EI) #9, safely pushed Resident Identifier (RI) #32 in his/her wheelchair in the hallway on 11/01/2022. This deficient practice affected RI #32; one of 12 sampled residents observed in wheelchairs during the survey. Findings include: Review of a facility policy titled Wheelchairs and Rock-N-Go Wheelchairs, with an effective date of 11/01/2001, revealed the following: . PURPOSE: To provide safe and comfortable transportation for non-ambulatory residents. RI #32 was admitted to the facility on [DATE] with diagnoses to include [CONDITION(S)] following Cerebral Infarct affecting the Right Dominant Side, Unsteadiness on Feet and Muscle Weakness. RI #32's Annual Minimum Data Set (MDS) assessment dated [DATE], identified RI #32 as scoring an 11 on the Brief Interview for Mental Status indicating moderately impaired cognition. RI #32 was coded on the MDS section G Functional Status as having impairment on both sides of the lower extremities and under Mobility Devices; was coded as using a wheelchair. On 11/01/2022 at 3:37 PM, the surveyor observed RI #32 being pulled backwards in the hallway in his/her wheelchair by EI #9. On 11/01/2022 at 3:57 PM, the surveyor conducted an interview with EI #9. When asked what was the proper way to push a resident in a wheelchair, EI #9 said forward. EI #9 said she was pulling RI #32 backwards instead of pushing RI #32 forward because RI#32 had a missing foot rest. The surveyor asked EI #9 what type of issue would it be considered when you pull a resident backwards instead of pushing them from behind. EI #9 said it could be a fall hazard. On 11/03/2022 at 3:17 PM, RI #32 was observed propelling him/herself in his/her wheelchair in the hallway. A foot rest was observed on the right side of the wheelchair and RI #32 was using his/her left foot to propel him/herself in the wheelchair. When asked why the CNA was pulling him/her backward in his/her wheelchair on 11/01/2022, RI #32 said that was the way staff pulled him/her when he/she was in his/her wheelchair. When asked could he/she get around in his/her wheelchair without staff pushing him/her, RI #32 said yes. On 11/03/22 at 6:10 PM an interview was conducted with EI #10, an RN (Registered Nurse)/Unit Manager. The surveyor asked EI #10 how did RI #32 move about the facility. EI #10 said RI #32 self-propelled with his/her non affected leg. When asked, when RI #32 was in his/her wheelchair and staff were pushing RI #32, how should RI #32 be pushed, EI #10 said the correct way would be pushing someone forward using the handles on the back of the wheelchair with attachments in place.

Based on observation, interview, medical record review and a facility policy titled, Weight Change and Malnutrition, the facility failed to ensure Resident Identifier (RI) #74, a resident at risk for weight loss, received an ordered supplement. This affected RI #74, one of two residents who were sampled for weight loss concerns and who was observed during two meal observations. Findings Include: A review of a facility policy titled, Weight Change and Malnutrition with an effective date of 03/17/2016, documented: .PURPOSE: Maintenance of adequate nutrition and hydration is necessary for the Resident/Guest to maintain health, and prevent complications such as malnutrition . RI #74 was admitted to the facility 06/03/2021 and readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #74's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .FORTIFIED HEALTH SHAKES WITH EVERY MEAL . The Surveyor reviewed RI #74's weights since 04/10/2022. RI #74 weighed 138 pounds (lbs) on 04/10/2022 and 113 lbs on 10/10/2022 which was a 18.12% loss. On 09/14/2022 RI #74 weighed 124 lbs and on 10/10/2022 the resident weighed 113 lbs which was an 8.87% loss. The Surveyor observed RI #74's midday meal on 11/02/2022 at 12:29PM. The tray consisted of double portion of four pureed items, two cranberry thickened juices, and sherbet. The house shake was not observed. The Surveyor observed RI #74's midday meal on 11/03/2022 at 12:24PM. The tray consisted of double portions of four pureed items, a pureed dessert, thickened apple juice and thickened cranberry juice. The house shake was not observed. In an interview on 11/03/2022 at 12:50PM, Employee Identifier (EI) #8, Certified Medication Technician (CMT), stated the resident's meal ticket had house shake listed but it was not on his/her tray. In an interview on 11/03/2022 at 04:30PM, EI #3, Dietary Manager, stated house shakes should have been on RI #74's lunch tray on 11/02/2022 and 11/03/2022. EI #3 stated house shakes are given when a resident loses weight. EI #3 stated the resident could continue to lose weight if not given the house shakes. In an interview on 11/03/2022 at 04:38PM, EI #2, Registered Dietitian (RD), stated RI #74 should have received house shakes on his/her lunch tray on 11/02/2022 and 11/03/2022. EI #2 did not know why RI #74 was not given house shakes because house shakes were available and there was no reason for the resident not to receive them. EI #2 stated the concern with RI #74 not getting the house shakes was the resident was not getting the increased nutrition recommended by her and approved by the physician.

Based on observation, interview, a Test Tray on 11/03/22, and the facility's Week 3 S/S (Spring/Summer) menu for Thursday (11/03/22); the facility failed to ensure the approved menu serving sizes were served for roast turkey, which was the alternate meat for lunch, and for fruit cocktail, which was used as a dessert substitute at lunch. This had the potential to affect 3 of 87 residents receiving meals from the kitchen. Findings Include: The facility's Week 3 S/S menu for Lunch on Thursday (11/03/22) included the following items for the Regular Diet: Salisbury Steak, Rice, Seasoned Greens, Cornbread, and Frosted Cake. In addition, the menu specified 3 oz (ounces) Turkey Roasted to be served at Lunch for the alternate meat choice. On the same menu at Supper, a fruit service portion for Peaches was identified as 4 oz. During a tray line observation on 11/03/22 at 11:55 AM, six slices of turkey meat, were being served for an alternate choice meal by Employee Identifier (EI) #5, the PM Cook. The surveyor asked EI #2, the Registered Dietitian (RD), to have a portion of turkey weighed. Upon weighing six slices, it was found that two additional slices needed to be added, for a total of eight slices, to achieve a 3 oz. serving. Only one alternate choice meal had so far been served. At 12:07 PM, the carts for the last hall were started and a Regular Diet test tray was requested for this hall. At 12:17 PM, a second alternate choice meal was served for lunch. At 12:48 PM, the Test Tray was checked with EI #2, the RD. Instead of frosted cake, an extremely small serving of fruit cocktail in a 6-oz. insulated soup bowl was served as a substitute dessert. At 12:58 PM, the tray line staff was asked about the dessert substitute. EI #4, a Diet Aide, said they ran out of cake, so fruit cocktail was used. The small serving of fruit cocktail was shown to the tray line staff. EI #4 said she did that. EI #4 said she needed to open a new can, but didn't really want to and then they got called to a meeting and she just put a lid on the bowl. EI #4 was asked how she would feel if she got a serving of fruit cocktail similar to this. EI #4 said she would be upset. EI #2, the RD, then measured the fruit cocktail using a tablespoon. There were two tablespoons in the bowl. EI #2 said two tablespoons was 1/4 of the correct serving size. EI #2 said 4 ounces would be the proper serving size. EI #3, the Dietary Manager, was interviewed on 11/03/22 at 4:40 PM. When asked what could be the problem if foods are served in portion sizes smaller than documented on the approved menu, EI #3 said they would get complaints. EI #2, the RD, was interviewed on 11/03/22 at 5:00 PM. When asked what could be the problem if foods are served in portion sizes smaller than documented on the approved menu, EI #2 said they would not be getting the proper nutrition for the day.

Based on observations, record reviews, interviews and a facility policy titled, Use of Gloves and Hairnets, the facility failed to ensure staff did not touch food with bare hands. This was observed during Resident Identifier (RI) #3's lunch meal and RI #7's supper meal on 07/26/2022. This had the potential to affect RI #3 and RI #7, two of seven residents sampled for infection control. Findings include: A facility policy titled, Use of Gloves and Hairnets with an effective date of 08/15/2009, documented, . No bare hand contact with food is allowed. 1) RI #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 07/26/2022 at 11:45 AM, Employee Identifier (EI) #4, Nursing Assistant (NA) was observed in the room with RI #3. EI #4 encouraged RI #3 to eat and EI #4 picked up a piece of pork chop with her bare hand and offered it to RI #3. On 07/26/2022 at 11:50 AM EI #4 was asked what the facility policy was for handling food. EI #4 said, she was not sure. When asked what the concern would be for handling food with bare hands, EI #4 said, germs. When asked if she picked up the pork chop with her bare hands, EI #4 said, yes, she did. EI #4 said she could have picked up the food using a spoon or fork. 2.) RI #7 was admitted to the facility on [DATE]. Review of RI #7's Baseline Care Plan Summary revealed RI #7 required eating assistance of one person. On 07/26/2022 at 5:12 PM EI #5 Restorative Certified Nursing Assistant (CNA), was observed assisting RI #7 with the supper meal without wearing any gloves. EI #5 picked up a roll from RI #7's supper tray with her bare hand. EI #5 offered the roll to RI #7, who took a bite of the roll from EI #5's bare hand. In an interview on 07/26/2022 at 5:51 PM, EI #5 was asked if she picked up RI #7's roll with her bare hand and fed it to RI #7. EI #5 stated, yes. When asked about the concern with touching residents' food, EI #5 responded, contamination. On 07/27/2022 at 3:08 PM, an interview was conducted with EI #3, Assistant Director of Nursing. EI #3 stated staff were not supposed to pick up residents' food with their bare hands. When asked how should staff feed the resident bread and pork chop, EI #3 stated they should wash hands before they start and put on gloves or use utensils. When asked what would the harm would be in handling food with bare hands, EI #3 said, infectious disease could be transmitted. In an interview on 07/28/2022 at 9:44 AM, EI #2, Director of Nursing (DON), reported staff assisting a resident with eating a pork chop or a roll should never touch the food with their bare hands. EI #2 stated staff should use utensils instead. When asked about the concern with touching residents' food with bare hands, EI #2 stated it was unsanitary. This was cited as a result of the investigation of complaint/report number AL 523.

Based on interviews, record review, facility's investigation, police report and a review of facility's policy titled, Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, and Exploitation, the facility failed to protect resident's funds from a staff member who used resident's funds for personal use. This deficient practice affected RI (Resident Identifier) #1, #2, #3, #4, #9 and #11; six of the eighteen sampled residents reviewed for misappropriation of resident property. Findings include: The facility's policy titled, Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation with effective date of February 8, 2018, revealed PURPOSE: .The Policy also prohibits the misappropriation of resident/guest(s) property. This policy against abuse, neglect, exploitation and misappropriation of resident/guest property includes abuse by any other person, including, but not limited to: any member of the facility staff .Definitions: . D. Misappropriation of Resident/Guest Property. Misappropriation of resident/guest property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident/guest(s) belongings or money without the resident/guest(s)consent. Acts that may constitute the misappropriation of resident/guest property include but are not limited to: the theft or attempted theft of a resident/guest (s) money or personal property of any value or type, theft of a resident/guest(s) medication or use of resident/guest(s) funds including credit cards or checks and identify theft. 1) RI #1 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #1 's Admission Minimum Data Set (MDS) Assessment, dated [DATE], indicated he/she had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated the resident was cognitively intact. The police report dated [DATE] identified, Upon arrival contact was made with the victim W/F (white/female) RI #1 (Name), RI #1 stated he/she gave the offender two signed blank checks to go and get his/her some merchandise. The victim stated he/she did not receive his/her merchandise and that the checks were cashed The facility's Verification of Investigation identified, on [DATE], the Detective (Det.) allowed (Employee Identifier) EI #2 and E#8 to watch the interview that he conducted so he could re-interview EI# 1 regarding any discrepancies. Det. (Name) then went back into the interrogation room and gave EI #1 numerous opportunities to confess. After some time had passed, he asked if EI #2 wanted to ask any questions ourselves. EI#8 went into the interrogation room and asked questions about the checks that were written out to EI#1 and what happened with the money. EI#1 stated that she had taken RI#1's watches to Tallassee Jewelers, but they had to send the watches off to be fixed. She said she paid (Name) Jewelers for the watch repairs and they were around $40. EI#1 stated that she cashed the checks because RI#1 had requested items from several different places. EI#1 said that she did not have any receipts for items/services purchased but that she gave RI #1 his/her change and that it would be in his/her room. After almost three hours of interviews by Detective (Name) and EI#8, EI#1 did admit to keeping some of RI#1's money and depositing it into her personal bank account. The Alabama Uniform Arrest Report documented on [DATE], EI #1 was taken into custody at the listed location (Elmore County) for the listed offense Theft of Property Fourth Degree. On [DATE] at 1:26 PM, an interview was conducted with RI #1 (resident). RI #1 was asked about the incident and he/she stated his/her daughter asked him/her why he/she was withdrawing large amounts of money from his/her banking account. RI #1 informed his/her daughter that he/she was not withdrawing large amounts of money from his/her banking account. RI #1 stated shortly after him/her being admitted into the facility, he/she signed a blank check and gave it to EI#1. When asked why RI #1 signed a blank check and gave it to EI #1, RI #1 stated because EI #1 stated it was for his/her stay at the facility. RI #1 stated he/she also signed two additional blank checks and gave them to EI #1. When RI #1 was asked if he/she gave EI #1 permission to use his/her checks for personal use, RI #1 replied, no. When RI #1 was asked how it made him/her feel; RI #1 replied, it made me feel rotten because I really liked EI #1 and I really cared for her. I felt terrible. If my daughter had never found out, I would have never known. On [DATE] at 4:52 PM, an interview was conducted with the daughter of RI #1, who stated she asked RI#1 why he/she wrote checks in the amount of $100.00, $150.00, and $650.00. RI #1 replied to his/her daughter that he/she did not write any checks for those amounts. RI #1 had an appointment with EI #7 (Beautician) on [DATE] and he/she informed her about his/her daughter's phone call regarding the fraudulent activity on his/her bank statements. EI#7 reported this information to E1 #4 (Business Office Manager). On [DATE] at 11:00 AM, an interview was conducted with E1#2 (Administrator), who stated she went to speak with RI #1 regarding a statement he/she had made about his/her daughter asking he/she about suspicious activity on his/her bank statements including three checks for $100.00, $150.00 and $650.00. EI #2 stated, RI #1 told her he/she had signed 3 blank checks and given them to EI #1. The Administrator (EI #2) went to EI #1's office and conducted a search in which she located carbon copies of RI #1's checks. The checks were dated [DATE] for $650.00, [DATE] for $150.00, and [DATE] for $100.00 written to EI #1. On [DATE] at 11:54 AM, an interview was conducted with EI #3 (Director of Nursing), who stated E1 #1 had informed her of the incident with RI #1 stating that suspicious activity was on his/her bank statements. EI #3 stated the facility began to investigate the incident in which she and EI #2 went to EI #1's office and located carbon copies of RI #1's checks written to herself. When EI #3 was asked if facility policy was followed, she replied, no. When EI #3 was asked if this incident was considered abuse, she replied, yes. On [DATE] at 2:48 PM, an interview was conducted with EI #5 (Internal Auditor), who stated she conducted an internal audit on resident's trust account at the facility and determined that RI#1 was missing money from his/her account in the amount of $1,692.24. EI #5 stated she was reimbursing residents who had missing money from resident trust funds accounts. On [DATE] at 10:35 AM, a phone interview was conducted with EI #7 (Beautician). EI #7 was asked how she became aware of this incident. EI #7 stated that RI #1 was upset with EI #1 because more money was missing out of his/her bank account than what he/she had given EI #1 checks for purchases. RI #1 stated he/she had given EI #1 two blank checks, for a balance owe to the facility. The two checks were for the repair of a Rolex watch and balance owed. EI # 7 stated that she knew that sounded fishy, so she spoke with the finance office. 2) RI #2 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #2's MDS Assessment, dated [DATE], indicated he/she had a BIMS score of 12 out of 15 which indicated the resident was cognitively intact. The facility's Verification of Investigation identified, on [DATE], stated EI # 2 was notified on [DATE] by Detective (Name) with Tallassee Police Department that he had received a letter from Attorney (Name). Attorney (Name) is representing, sponsor/nephew for RI#2. The letter states that there were several suspicious charges out of resident's account totaling approximately $900. Nephew suspects; EI #1, former Social Services Designee, to have been involved in these suspicious transactions. On [DATE] at 2:48 PM, an interview was conducted with EI #5 (Internal Auditor), who stated she conducted an internal audit on resident's trust account at the facility and determined that RI#1 was missing money from his/her account in the amount of $810.00. EI #5 stated she was reimbursing residents who had missing money from resident trust funds accounts. On [DATE] at 09:35 AM, an interview was conducted with RI #2's nephew, who stated he obtained a lawyer because RI #2's stimulus check had been sent to the facility when it was supposed to be sent to him, which is when he was informed by the facility RI #2 had suspicious activity on his/her resident trust fund account. 3) RI #3 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #3's Minimum Data Set (MDS), dated [DATE], revealed he/she had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The police report dated [DATE] identified RI #3 (Name) had been admitted to TH&R (Tallassee Health and Rehabilitation) since [DATE] and shortly after his admittance gave Social Services Designee, EI #1 his/her debit card in order for EI #1 to make purchase on his behalf. The purchases mostly consisted of drinks and snacks and were not for EI #1 to make large purchases or withdraw money. In order to use the card, EI #1 was provided the PIN from RI #3. EI #3 also advised that it is a violation of company policy for any employee to exhibit control over patients' belongings or finances. While checking his/her account balance at Regions Bank, RI #3 determined that approximately $200-$250 was missing unexplainably from his/her account, through small purchases here and there. RI #3 stated he/she is the only name on his/her account and the only person who had access to his/her debit card during that time was EI #1. RI #3 was asked if he/she ever requested that EI #1 purchase any big-ticket items on his/her behalf, to which he/she stated, she used my stimulus check to buy my tv, mini fridge and scooter. When asked if RI #3 was given a receipt for the scooter, he/she stated E1 #1 had a copy in her office, yet he/she had not seen it. The facility's Verification of Investigation identified, on [DATE], EI #2 stated during an interview, she witnessed EI #1 confess to cashing the money order RI #3 had asked her to use to purchase a motorized wheelchair. EI #1 said she deposited the money into her personal bank account. The Alabama Uniform Arrest Report documented on [DATE], EI #1 was taken into custody at the listed location (Elmore County) for the listed offense Charge Theft by Deception 3rd Degree and Fraudulent use of Credit/Debit Card. RI #3 stated he/she gave EI #1 his/her debit card to purchase him/her a television, a refrigerator, and a motorized wheelchair. RI #3 stated he/she gave EI #1 his/her debit card. RI #3 stated he/she received the television and refrigerator, but the wheelchair never came so he/she assumed the money order must have gotten lost in the mail or stolen by the wheelchair company because it had been cashed. An interview was conducted with EI #2 (Administrator) on [DATE] at 11:00 AM, stated RI #3 had a Regions debit card he was suspicious of charges on his account, so he had went to Regions bank when he was out for a doctor's appointment with his brother and had the card cancelled; he/she got a new one. He/she never gave anyone the pin number to the second one. He asked EI #1 to purchase him a refrigerator, tv and motorized wheelchair with his stimulus. He/she gave her the card. EI #1 gave him/her the tv and refrigerator. He/she found a wheelchair online and gave him/her the money, but the wheelchair never came. He/she assumed the money order must have gotten lost or stolen by the wheelchair company because it was cashed. EI #1 found him/her a donated wheelchair and told him/her they wanted $300.00 for it. He/she never expected EI #1. When the police did a search of EI #1's home they found RI #3's food stamp card. EI #2 stated EI #1 did not follow facility policy and she considered this misappropriation of property. On [DATE] at 2:48 PM, an interview was conducted with EI #5 (Internal Auditor), who stated she conducted an internal audit on resident's trust account at the facility and determined that RI#1 was missing money from his/her account in the amount of $3756.91. EI #5 stated she was reimbursing residents who had missing money from resident trust funds accounts. On [DATE] at 1:32 PM, a phone interview was conducted with EI # 8, (Regional Administrator). EI # 8 was asked what did EI #1 state about taking money from residents. EI #8 stated, it was after a good bit of interrogation and EI #1 admitted to taking resident's debit card. EI #1 also confessed to taking the resident's money order, checks and debit cards. EI # 1 admitted to the allegations before her and stated that was not facility abuse policy and knew she had done wrong. When asked did EI # 1 say why she took the debit card and money; EI #8 stated, no. EI # 8 was asked is it normal practice for Social Service to handle resident's money, checks, and debit card. EI #8 stated, no, she knew what she was supposed to do, she knew this was not permitted. EI # 8 was asked did EI #1 follow the abuse policy. EI #8 stated, no. When asked if using resident's money order and debit card without resident's permission would be classified as abuse; EI#8, stated misappropriation of residents funds and that falls under abuse. 4) RI #4 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #4's Minimum Data Set (MDS), dated [DATE], revealed he/she had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The police report dated [DATE] RI #4 has been admitted to TH&R (Tallassee Health and Rehabilitation) since [DATE] and shortly after his/her admittance gave Social Services Designee, EI #1 (suspect), his/her debit card in order for EI #1 to make purchases on her behalf. The purchases mostly consisted of drinks and snacks and were not for EI #1 to make any large purchases or withdraw money. In order to use the card, EI #1 was provided the PIN from RI #4. Over the course of time, RI #4 learned that someone had been making fraudulent purchases/cash withdrawals from his/her account without his/her permission. The debit card was only accessed during this time by EI #1 and was cancelled while RI #4 was in EI #1's office. A second debit card was received and again, given to EI #1 along with the PIN. When checking his/her account balance, RI #4 was informed her account balance was $5 and change, when in fact, he/she should have had a balance over $2,000 due to her retirement income and stimulus money. The only person who has access to RI #4's account is himself/herself and EI #1, who is still in possession of RI #4's debit card. The facility's Verification of Investigation identified, on [DATE], stated Det. (Name) notified EI#2 when he had completed his initial interview with EI#1. EI #2, EI #5 and EI#8 went to the police station to interview EI#1(Social Service Designee). EI #2 (Administrator), EI#5 (Internal Auditor), and EI#8 (Regional Administrator) were allowed to watch the initial interview that EI#1 had with Det. (Name) prior to arrival. Det. (Name) then went back into the interrogation room and allowed EI#2, EI#5, and EI#8 to watch the live feed of the interview. After he had questioned EI#1 for a while, he asked did EI#2, EI#5 and EI#8 want to send someone in to ask questions more about company policies and procedures that he would not be familiar with. EI#8 went into the interrogation room with Det. (Name) and EI#1(Social Service Designee). EI#5 and EI#2 were watching the live feed from another room. During the interview, EI#2 witnessed EI#1 admit to swiping RI#4's debit card for additional cash and depositing it into her personal bank account. The Alabama Uniform Arrest Report documented on [DATE], EI #1 was taken into custody at the listed location (Elmore County) for the listed offense Theft by Deception, and Financial Abuse of the Elderly. On [DATE] at 7:05 PM, an interview was conducted with RI #4. He/she was asked about concerns regarding his/her money. RI #4 stated that his/her money disappeared. RI #4 stated that he/she is not sure how much money was missing, however it was his/her entire check except for $5. RI #4 stated he/she has not gotten his/her money back yet and is supposed to talk with someone in finance office this week. RI #4 was asked did he/she give someone his/her debit card. RI #4 stated yes, EI #1 for her to put up for me. When asked did he/she give EI # 1 his/her pin number, RI #4 stated yes, because EI # 1 went shopping for him/her. RI #4 was asked if anyone else had access to his/her debit card and pin number. RI #4 stated no. RI #4 was asked if he/she authorized EI #1 to make purchases on his/her card. RI #4 stated I did for my snacks, but nothing else or not to get money out of my account. When asked how this made him/her feel; RI #4 stated I felt so low. I don't know how my money went missing. I feel helpless. On [DATE] at 11:00 AM, the Administrator said, RI #4 also stated to her that he/she had given EI #1 his/her debit card to hold on to, however, RI #4 stated he/she began to notice suspicious activity on his/her card. So, the resident and EI #1 called the bank and cancelled the card and received a new one. RI #4 stated he/she did not give the pin number to anyone else other than EI #1 however, fraudulent activity was still ongoing on his/her account. When asked if EI #1 followed facility policy, EI #2 (Administrator) replied, no. When EI #2 was asked if this incident is considered resident abuse she replied, yes. When EI #2 was asked what type of abuse this is considered she replied, misappropriation of resident property. On [DATE] at 2:48 PM, an interview was conducted with EI #5 (Internal Auditor), who stated she conducted an internal audit on resident's trust account at the facility and determined that RI#1 was missing money from his/her account in the amount of $6932.79. EI #5 stated she was reimbursing residents who had missing money from resident trust funds accounts. On [DATE] at 1:32 PM, a phone interview was conducted with EI # 8, (Regional Administrator). EI # 8 was asked what did EI #1 state about taking money from residents. EI #8 stated, it was after a good bit of interrogation and EI #1 admitted to taking resident's debit card. EI # 1 admitted to the allegations before her and stated that was not the facility's policy and knew she had done wrong. When asked did EI #1 say why she took the debit card; EI #8 stated, no. EI # 8 was asked was it normal practice for Social Service to handle resident's money, checks, and debit card. EI #8 stated, no, she knew what she was supposed to do, she knew this was not permitted. EI # 8 was asked did EI #1 follow abuse policy. EI #8 stated, no. When asked if using a resident's debit card without the resident's permission would be classified as abuse; EI#8, stated misappropriation of residents funds and that falls under abuse. 5) RI #9 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #9's Minimum Data Set (MDS), dated [DATE], revealed he/she had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The facility's Verification of Investigation dated [DATE], revealed (RI #9), BIMS of 13, stated he/she asked (EI #1) to hold his/her food stamps card and debit card for him/her when he/she was first admitted here. Resident states (EI #1) worked out an agreement with his/her son regarding purchasing items Resident's son stated he had never discussed any of the above with (EI #1). (RI #9) gets over $100/month on his/her food stamps card. (RI #9) said that he/she used it until it ran out. Resident's son said he has debit card in his possession . On [DATE] at 8:07 AM, a phone interview was conducted with RI #9's son. RI #9's son informed that he had RI #9's debit card, but food stamp card was left at facility with him/her. RI #9's son was asked if someone went to store for RI #9 to purchase items. He stated that he did not know. He stated that he/she asked for items but is not sure if items were purchased. On [DATE] at 11:30 AM, an interview was conducted with EI #2, Administrator. EI #2 informed that she had spoken with local Department of Human Resources (DHR) worker and was informed that there were charges on RI #9's food stamp card from [DATE] through [DATE]. EI #2 noted that in [DATE] there were balance inquires every couple of days. In an additional interview conducted with EI #2 on [DATE] at 3:55 PM. EI #2 stated that she had spoken with RI #9 and he/she informed that he/she had given EI #1 his/her food stamp card when he/she first arrived at facility. RI #9 stated that he/she asked EI #1 to purchase items for him/her twice and then asked for card back. EI #2 stated that RI #9 had card in his/her possession but stated that it took EI #1 a while to get card back to him/her. RI #9 states that EI #1 was the only person that had access to his/her card. 6) RI #11 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #11's Minimum Data Set (MDS), dated [DATE], revealed he/she had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The facility's Verification of Investigation dated [DATE](RI #11), BIMS of 15, stated he/she had given his/her food stamp card and debit card with PIN number, to (EI #1) to lock up in her office for (RI #11). Resident states he/she had asked multiple times for it back and (EI #1) never would give it back. Resident states he/she is unable to recall the timeframe of events. (local police department) did recover the resident's Direct Express debit card during their search of (EI #1)'s residence, but the EBT card is still missing. The Direct Express card is being held in evidence, but it will be returned to (RI #11) as soon as available . On [DATE] at 5:01 PM, an interview was conducted with EI #2, administrator. EI #2 was asked if allegation involving RI #11 was substantiated. EI #2 stated, yes. RI #11's Direct express card was recovered during the search of EI #1's home. RI #11 alleged his/her food stamp card was also used and the facility has the history of it and it was used from the time RI #11 was admitted to the facility. EI #2 stated there were numerous purchases and balance inquires on account. EI #2 stated that she spoke with RI #11's son and he was aware that EI #1 purchased snacks and drinks for RI #11 but that she did not have permission to spend the amounts that were showing on the transaction history from DHR. EI #2 stated, that RI #11's family is being reimbursed for $969.21 for purchases made from the food stamp card. EI #2 stated, the facility was unable to obtain statements from Direct Express Card. On [DATE] at 9:36 AM, a phone interview was conducted with local Detective. Detective informed surveyor a search warrant was issued to search EI #1's residence and vehicle. Detective stated, during the execution of the search RI #11's Direct Express Card was found. Detective was asked why wasn't EI #1 charged in connection with RI #11's debit card. Detective stated, in the eyes of the law we don't have a case because we don't have a victim because RI #11 is deceased , that's not to say that the Attorney General's office won't prosecute on RI #11's behalf. Detective stated that his office was not able to obtain RI #11's Direct Express Statements.

Based on interview, review of the facility's Non-Controlled Drugs Record of Medication Destruction forms and review of a facility policy titled, Non-Controlled Medication Destruction, the facility failed to ensure the Non-Controlled Drugs Record of Medication Destruction forms had the required signatures. This was noted on two of eight months (February 2019 and (MONTH) 2019) of Non-Controlled Medication Destruction forms reviewed. Findings include: A facility policy titled, 4.3: Non-Controlled Medication Destruction, dated 3/2011, documented: Policy: Discontinued medications, expired medications, and medications left in the facility after a resident has expired or has been discharged are destroyed or disposed of per federal/state regulations. Procedures . 3. The registered nurse and/or pharmacist witnessing the destruction . ensures that the following information is entered on the Record of Medication Destruction form . [NAME] Signature of witnesses, two witnesses required for non-controlled substances . in the designated areas on the destruction form . On 10/17/19 at 10:41 AM, the surveyor reviewed the drug destruction records for Non-Controlled Drugs for eight months during 2019. Two of the eight months (February and June) did not have the required two signatures. On 10/17/19 at 11:28 AM, an interview was conducted with Employee Identifier (EI) #1, Director of Nursing. EI #1 was asked, according to the policy titled Non-Narcotic Drug Destruction, how many signatures should be documented on the Record of Medication Destruction forms for non-narcotic drugs. EI #1 replied, for non-narcotics, you need a pharmacist and a nurse. EI #1 was asked how many signatures were located on the (MONTH) 2019 Medication Destruction form for non-narcotic drugs. EI #1 replied, one, the pharmacist signature. EI #1 was asked how many signatures were located on the (MONTH) 2019 Medication Destruction form for non-narcotic drugs. EI #1 replied, one. EI #1 was asked why there was only one signature on the (MONTH) and (MONTH) Medication Destruction forms for non-narcotic medications. EI #1 stated, forgot to sign it, I don't know what to tell you. EI #1 was asked, what is the potential negative outcome of having only one signature on the Medication Destruction forms for non-narcotic medications. EI #1 stated, if only one person signed, they could possibly take the medications; the policy and procedure is to have two signatures.

Based on observations, interview, and review of the facility policy titled Privacy Upon Entering Resident's Room, the facility failed to ensure staff utilized privacy curtains while providing incontinent care to Resident #s 64. This deficient practice affected one of four incontinence care observations. Findings include: The facility's policy titled Privacy Upon Entering Resident's Room, with an effective date of 11/06/2014, revealed the following: . Purpose: The resident has the right to privacy and confidentially. Standard: Resident right to privacy will be honored. Process: 1 Prior to entering resident's room knock on door and ask permission to enter 2. If resident able to respond, await permission to enter. 3. If resident unable to respond announce entrance. Resident #64 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #64's Minimum Data Se assessment, with an Assessment Reference Date of 12/04/17, revealed the resident had severely impaired decision making skills and was always incontinent of bowel and bladder. On 1/08/18 at 4:06 PM, the surveyor entered Resident #64's room and observed two Certified Nursing Assistants (CNAs) providing incontinent care for Resident #64. When the surveyor entered the room the privacy curtain was not pulled to block the resident from view of his/her roommate or the hallway when the door was opened. The CNA's were observed removing a brief soiled with bowel movement from the resident's buttock. On 01/08/18 at 4:21 PM, Employee Identifier (EI) #8, CNA , was asked why Resident #64's privacy curtain was not pulled during the incontinence care. EI #8 replied she had tried to pull it but it was hung on the other resident's foot board. EI #8 said the privacy curtain should have been pulled to provide privacy to the resident. On 1/08/18 at 4:38 PM, EI #9, the other CNA, was also asked why Resident #64's privacy curtain was not pulled when care was being provided. EI #9 replied that EI #8 tried to pull it but it was hung. On 01/08/18 at 4:45 PM, EI #9, CNA, and the surveyor went to Resident #64's room to check the privacy curtain. EI #9 demonstrated and was able to pull the curtain without any difficulty.

Based on observations, record review, and interviews, the facility failed to ensure Resident # 39's windowsill did not have four nail heads protruding from the wood, which created the potential for injury. This deficient practice affected one of 19 sampled residents for whom room observations were made. Findings include: A review of the facility policy titled Repair Requisition with an effective date of 3/1/2010 documented the following: . PURPOSE: to assist in the prompt repair of . facility physical plant features, that may be broken or have failed. STANDARD: Requests for repairs to . the building, should be communicated in writing to the maintenance department . Resident #39 was readmitted to the facility on [DATE]. On 1/09/18 at 9:20 AM, the windowsill beside Resident #39's bed was observed with four nail heads protruding and a gap under the window in the wall. On 01/10/18 at 9:09 AM, Employee Identifier (EI) #2, Maintenance Director, observed Resident #39's window next to the bed with the surveyor and four nails were protruding in the windowsill and there was a gap underneath the window next to the bed. On 01/10/18 at 9:12 AM, EI #2 was asked what he saw wrong with the window. EI #2 said, the bed was too close to the wall and had been let up too close to the wooden windowsill. EI #2 was asked what was sticking up from the wood. EI #2 said, finishing nails that were used to install the windowsill. When asked why there was a gap underneath, EI #2 said it was not reinstalled after they pulled it up (when raising the bed). EI #2 was asked why should the window be maintained without nails exposed. EI #2 replied, to keep the resident, visitors, or anyone else from getting hurt on the nails. When asked how long it had been that way, EI #2 stated, he did not know. EI #2 said CNAs (Certified Nursing Assistants) were told to report anything in rooms that needed repair and nothing about these things has been reported. On 1/10/18 at 10:05 AM, EI #3, CNA, was asked how often she took care of Resident # 39. EI #3 replied, pretty much every time she worked. When asked if she knew how long the windowsill had nails protruding, EI #3 said, she saw them yesterday the day before when she lifted Resident #39's bed. EI #3 was asked what she usually did when there was a concern for maintenance. EI #3 said fill out a form for maintenance. When asked why she did not tell Maintenance about it, EI #3 said, it slipped her mind. EI #3 was asked what could happen with the nails sticking up. EI #3 stated, the resident could stick themselves.

Based on observations, interviews, and review of facility QA (Quality Assurance) documents, the facility failed to ensure floor tiles were maintained in an orderly manner to provide a homelike environment for residents. Floor tiles throughout the facility were observed with a thick accumulation of dark build-up along the edges of the halls where the floor meets the wall, in cracks, corners, and crevices, and in the entryways of resident rooms. This was observed on all halls of the facility, as well as common areas and had the potential to affect all 94 residents residing in the facility. Findings include: On 12/19/2017 the state agency received an anonymous complaint that the floors in the facility were not clean. Review of the facility's Quality Assurance Committee Action log, revealed in 06/2016 the facility identified a Quality Issue/Problem of a leaking roof and concerns with floor tiles. This log indicated the facility contacted corporate staff to make a site visit, which was completed in 07/2016. After the site visit, the facility was awaiting quotes in August and September 2016. In 10/2016 quotes were received addressing the facility's roof, but not the floor tiles. The log further documented the facility's roof repairs were initiated in 03/2017 and completed in 07/2017, but the facility was still awaiting quotes for floor tiles. In 11/2017 the log documented an Action of the following: to Review at Budget . Review for Floor Tiles. However, there was no documentation as to the facility's plan to address the known problem with the floor tiles, 17 months after first listing the floor tiles as an identified concern. During the Resident Council meeting on 1/8/2018 at 9:03 AM, one of eight residents reported a black build up of wax at the door to their room. He/she reported it made them feel bad it looked that way, and said is had been about five months since the facility waxed the floors. On 1/9/2018 at 6:06 PM, Resident #83 said the facility did not clean the floors in his/her room too often, only if something got on the floor. Resident #83 said he/she would prefer the floors be kept clean, and said it would feel more homelike if they did. On 1/9/2018 at 6:15 PM, Resident #62 said they mopped his/her floors in the room daily, but only did the halls when they felt like it. Resident #62 had noticed the build-up on in the halls, and said he/she would prefer the floors to be clean. On 1/9/2018 at 6:34 PM, Resident # 65 said the facility mopped his/her floors every day, but it did not do much good. He/she said the facility even did a deep clean not long ago, but it did not do any good either. Resident #65 said he/she thought the floors looked bad and would rather them look clean. On 1/07/18 at 10:56 AM, a dark, thick build-up was noted along the sides of hallways under baseboards, in cracks, crevices, and corners, and was observed to be worst within corners of resident doorframes. This was observed throughout the facility. On 1/07/18 at 3:37 PM, an observation was made of the room Resident #244 resided in. Dark build-up was noted along the corners of the doorframe and along the baseboards within the room. A brown substance was observed on the baseboard on the far side of room, across from the entry door. Also, a shoe print was visible on the floor, as well as several black streaks. The discoloration appeared to be within the finish of the floor. On 1/08/18 at 7:15 AM, a facility Floor Technician, Employee Identifier (EI) #4, was observed with a floor buffer machine on the front hall, cleaning floors. When asked how often they buffed the floors, he stated they tried to buff the floors every day, and were working on baseboards; however, he explained they had a new employee and sometimes they got behind. On 1/08/18 at 9:24 AM, EI #4 was again observed using the buffer on the front hall. He was also observed using a mop and made one pass along one side of the hallway about a one foot section, then returned the mop bucket to the closet. EI #4 indicated he saw something on the floor and did not want to buff over it. However, he then unplugged the buffer and left the unit without buffing the area. After putting the buffer away, EI #4 was not observed to address darkened build-up or dark areas on floor finish. EI #7, another Floor Technician, was also noted on the hall with a mop bucket, mopping along the baseboards. He stated they mop along the baseboards, sweep, and mop everyday. During a follow-up with EI #4, Floor Technician, on 1/08/18 at 4:20 PM, EI #4 said he had to put the buffer away during breakfast and again after their delivery truck came. EI #4 verified he had not completed the floors for that day. On 1/08/18 at 4:26 PM, EI #1, the Administrator, stated Floor Technicians come in overnight or really early in the morning. She said EI #5, the Director of Environmental Services, oversaw the floor technicians and maintained a schedule for how frequently the floors were done. EI #1 stated the floors were really old, and she was not sure when the last time they had been stripped and waxed was. On 1/09/18 at 7:15 AM, a housekeeping cart was noted on the front hallway and three wet floor signs were observed in the doorways of resident rooms. However, a dark, thick build-up was still noted in the corners of the doorframes to these rooms. Grey streaks were noted going down the length of the hall, and build-up (grey) was noted along the sides of the hall, where the floor meets the wall. The common area/TV area across from the nurses station was observed with a grey, dark build-up on the floor surrounding the area. Also the baseboards in this area had dark discoloration. The surveyor walked the distance of all halls and noticed grey streak marks running the distance of the hallways. Every resident entry way was noted with dirt-like substance built up in the corners of the doorways and along the floors at the entry ways. On 1/9/2018 beginning at 8:25 AM, EI #5, the Director of Environmental Services, and the surveyor made walking rounds of the entire facility. On the Front Left, as described by EI #5, EI #5 agreed she saw the build up along the sides of the hall along the baseboards. EI #5 stated their stripper machine was round like the buffer, so it would not get in the corners. She said for the areas not in corners, the stripper machine would lighten the areas, but when they applied the finish, because it was scratched and stained into the tiles, it would come right back. EI #5 attempted to remove areas of discoloration and build-up on all halls of the facility and the common area across from nurses station without success. EI #5 agreed the floors building-wide were old and look dirty because they were stained. EI #5 said the facility had discussed the problem and she was told they were going to remodel, but they had not done that yet. EI #5 explained the only way the floors could be fixed was to put down new tile. When asked how she thought it may make the residents feel to have tile in the condition it was, she said it does look bad. On 1/09/18 beginning at 2:37 PM, the surveyor walked the halls of the facility with EI #1, with Administrator. EI #1 indicated she did see the areas that appeared dirty. EI #1 said it was glue that had seeped out and would not come up. She said it was just old build up. EI #1 also explained some of the grey areas in the floor were from where, over the years, the build up had been sealed into the tiles. EI #1 said the facility did need some cosmetic work and indicated, cosmetically, the facility did not look like residents and/or their families would want. EI #1 said the facility had not yet gotten any quotes on replacing the floor tiles, and was unsure if corporate had. EI #1 explained it was a long process, and the facility would discuss the things they needed and anything they wanted, but corporate had to approve it. EI #1 said the only way to address the build-up and discoloration of the tiles was to replace them. On 1/9/2017 at 3:07 PM, EI #6, Senior Vice President of Operations, said he was part of the capital budget committee. EI #6 said he did not know that any quotes had been obtained for the facility's floor tiles, because they first had to get a capital budget approved. EI #6 said the facility's roof was their first priority before doing any sort of work on the floors. EI #6 said he believed the facility's roof was completed in the fall. He explained there was just not an overwhelming amount of money to do everything in every building and they had to prioritize based on issues in all of the company's buildings. When asked who ultimately made the decision as to what would take precedence and be repaired and approved on the budget, EI #6 said he was on committee, but the owner ultimately decided. EI #6 said he was in the facility four or five times a year, and said the floors were part of the reason they were going to build a whole new building at one point, but those plans changed. He said, instead they would be completing a series of projects to improve the building. EI #6 said there was a whole lot that had to be done in the building, but it would have to be done as resources were available. He explained in January of last year, the budget was adjusted to allow for the facility to get a new roof, but there was no master plan to address all of the known issues and needed repairs. When asked what should be done to address the tiles while awaiting budget approval to ensure the residents' environment is maintained and homelike, EI #6 said it was hard to say, and indicated the only thing to correct the issue was to replace the tiles, but that would have to be approved as part of the budget first.

Based on observations and interview, the facility failed to ensure the 10/05/2016 breakfast meal was served at palatable temperatures. This had the potential to affect all 98 residents receiving meals from the dietary department. Findings include: During the initial tour of the facility on 10/04/2016 beginning at 8:15 a.m., Resident Identifier (RI) #15 and two Unsampled Residents (USRs) voiced concerns regarding the food served at the facility. RI #15 stated all meals served were cold. USR #1 said he/she had been at the facility for approximately five months and at all meals, the food was cold. USR #2 said the breakfast was cold. A Group Meeting was conducted on 10/04/2016 at 3:00 p.m. with 12 residents in attendance. During the meeting, the residents voiced complaints that the food was served cold. On 10/05/2016 beginning at 7:25 a.m., observations were made of the breakfast meal service. Staff began plating trays for the dining room at 7:30 a.m The staff were not utilizing insulated bases or lids for these trays. They remained on the cart uncovered before being sent to the dining room at 7:38 a.m Staff in the dining room did not begin passing the trays until 7:45 a.m The surveyor asked Employee Identifier (EI) #8, the Dietary Manager, if the facility utilized the plate warmer observed not in use. EI #8 said they could use it but it makes the plates really hot so they just use the bases and lids. On 10/05/2016 at 9:11 a.m., staff began plating the last cart of trays for the breakfast meal and a test tray was requested. The test tray was plated and placed on the cart at 8:28 a.m. and arrived on the hall at 8:30 a.m The last resident was served at 8:45 a.m. and the test tray was tested at 8:47 a.m The eggs measured 88 degrees Fahrenheit. EI #8, the Dietary Manager, and the surveyor both tasted the eggs and agreed they were cold. EI #8 said she did not think the residents would be happy with the temperature.

Based on observations, interview, and review of facility policies, the facility failed to ensure the Robot-coupe (food processor) and stacked cups were allowed to air dry instead of stored wet. This had the potential to affect all 98 residents receiving meals from the dietary department. Findings include: A review of the facility policy titled, . Section: Sanitation, Safety and Infection Control . Policy Title: Cleaning of Miscellaneous Equipment and Utensils, dated 03/17/2016, revealed the following: . 8. Dishes . allow dishes to air dry . During the initial tour of the kitchen on 10/04/2016 beginning at 8:37 a.m., the Robot-coupe was noted stored (not in use) with the lid on it with water inside. Employee Identifier (EI) #8, the Dietary Manager, was asked to remove the lid. She agreed the equipment was wet. During trayline observations on 10/05/2016 beginning at 7:25 a.m., clean cups and bowls were noted stacked on a cart while wet. EI #8 stated she saw it and agreed the items were wet nested (stacked together without allowing to air dry). During an interview on 10/05/2016 at 3:40 p.m., EI #8 said items should be allowed to air dry before storing them. EI #8 said the Robot-coupe with water in it could lead to contamination. She also stated the wet nested cups could potentially allow bacteria to grow.

Based on interviews and record review, the facility failed to ensure residents were provided the opportunity to vote in the 10/04/2016 Run-off Mayoral Election. This affected Resident Identifier (RI ) #5, #15, and #16 and had the potential to affect all eleven registered voters in the facility. Findings Include: On 10/04/2016 at 3:00 p.m., a Resident Council Meeting was conducted with twelve residents in attendance. RI #s 5, 15, and 16, all present for the meeting, stated they would have liked to vote in the run-off election for Mayor. In one on one follow-up conversations with each of these residents, all three stated they were unable to vote in the election. On 10/06/2016 at 11:30 a.m., an interview was conducted with Employee Identifier (EI) #9, Social Services Designee, regarding resident voting. EI #9 explained the residents that have chosen to vote, are registered and have voted in previous elections. EI #9 said she was out of work from 6/2016-9/2016 and during her absence residents were unable to vote via absentee ballot for the run-off election. On 10/06/2016 at 2:44 p.m., EI #9 provided documentation on eleven registered voters in the facility. EI #9 said the facility did not have a policy addressing resident voting. EI #9 also said after she returned from her absence, she was unable to process absentee ballots for the residents because they require three to four weeks for submission.

Based on observation, interview and record review, the facility failed to ensure: 1) left-over foods were consistently labeled with use-by dates; 2) expired food was discarded; and 3) commercially prepared milkshakes were labeled with use-by dates after thawed. This had the potential to affect all 92 residents for whom meals were prepared and served at the time of this survey. Findings included: A facility policy related to Leftover Food Storage and Use (policy number: DS.IV-12) with an effective date of 08/15/09 described the following process to assure that food borne illnesses are avoided: .b. Leftover foods should be covered, labeled and dated. c. Refrigerated leftover foods should be used within 72 hours (three days). If not used within 72 hours, refrigerated foods should be discarded . 1) During the initial kitchen tour on 11/16/15 at 4:45 PM, the following was stored in the walk-in refrigerator with no labels to indicate a preparation or use-by date: a) a one gallon-sized zip-lock bag containing cooked sausage patties and ground meat (with a similar appearance), and b) a one gallon-sized zip-lock bag of cooked bacon. 2) The following foods were also stored in the walk-in refrigerator: a) a plastic container containing steak and gravy, labeled with a preparation date of 11/12/15, and a use-by date of 11/15/15 (one day prior); and b) a commercially-prepared five-pound container of egg salad with a stamped expiration date of 11/03/15 (nearly two weeks prior). The container was less than 50% full. On 11/17/15 at 9:40 AM, the surveyor asked the Dietary Manager, Employee Identifier (EI) #6 who was responsible for the labeling of left-over food. EI #6 explained it was every dietary staff member's responsibility for dating the food, and everyone's responsibility to check the dated labels. When asked what was done with the expired food, EI #6 stated she and the cooks would throw it out. EI #6 explained contamination could result when food was not disposed of in a timely manner. 3) The facility policy related to Therapeutic Supplements (policy number DS.III-44) dated 08/13/13, describes the following process for use: .b. Shakes/supplements should be removed from the freezer, as needed, and placed in the refrigerator to thaw, at least one day ahead. Shakes/ supplements should be labeled with the date removed from the freezer or with a used-by date which is 10 days from thaw date. Any product remaining after ten days should be discarded. a) On 11/16/15 at 4:50 PM, seven of seven thawed 4-oz cartons of (Ready Care) commercially prepared milkshakes were stored in the walk-in refrigerator with no dated labels to indicate the use-by date. b) During the 11/16/15 supper trayline, a small push cart was positioned at one end of the trayline. Eleven of 11 Ready Care thawed milkshakes were stored on the cart for distribution on the supper trays. None of the shakes contained a label to indicate the use-by date. On 11/18/15 at 9:25 AM, the surveyor asked the Dietary Manager, Employee Identifier (EI) #6 to explain the facility's procedure for the labeling of commercially-prepared milkshakes. EI #6 explained the staff label all the milkshakes (each carton) when they are removed from the freezer and placed in the walk-in cooler to thaw. When asked what hazard could result without the dating of unused, dispensed milkshakes, EI #6 stated the product could go bad.

Based on observation, interviews and record review, the facility failed to ensure one of four medication nurses closed the Electronic Medication Administration Record [REDACTED]. This affected Resident Identifier (RI) #20, one of twelve residents observed during the medication administration pass on 11/17/15. Findings Include: A facility policy titled, Workstation Use and Security dated 04/21/05, documented: .Policy 1. The policies and procedures stated herein apply to all electronic protected health information created, maintained or transmitted by the facility . Procedures .4. Workstation users will abide by the following: (a) Log off or lock the computer prior to leaving the workstation unattended . (c) Close files not in use . RI #20 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #20's Physician order [REDACTED]. . [MEDICATION NAME] SODIUM 100 MG (milligram) CAPSULE- 1 CAP (capsule) PO (by mouth) BID (twice a day) . [MEDICATION NAME] HCL ([MEDICATION NAME]) 200 MG TABLET- GIVE 2 TABS TO = 400 MG BID . [MEDICATION NAME] 325 MG TABLET GIVE 2 TABS PO BID . On 11/17/15 at 9:05 AM, the surveyor observed a licensed nurse, Employee Identifier (EI) #4, prepare the above medications for RI #20. After preparing the medications, EI #4 took the medications into the resident's room. EI #4 left the screen of the e-MAR open, exposing a listing of RI #20's medications. The surveyor asked EI #4 what was it called when you leave the e-MAR screen opened? EI #4 said it was a HIPPA (Health Information Privacy Portability Act) violation and a resident privacy issue. The surveyor asked EI #4 what she should have done with the e-MAR before leaving the medication cart? EI #4 said she should have clicked the privacy screen button before she left the cart, and closed the computer so no information about the resident was showing. On 11/19/15 at 4:37 PM, the surveyor conducted an interview with the Director of Nursing, EI #1. The surveyor asked EI #1, when a nurse prepares medications for the resident and leaves the medication cart, how should the e-MAR be left? EI #1 said the e-MAR should be logged out of. The surveyor asked EI #1 when this is not done, what is that considered? EI #1 replied, That's considered to be wrong because their (the resident's) information is on the screen. The surveyor asked EI #1 when information is left on the e-MAR screen what is that considered? EI #1 replied, HIPPA violation.