Every finding on record at The Pine of Camden, LLC

Based on observation, interview, record review, and the review of a facility document titled, Hand Hygiene Policy, the facility failed to ensure Employee Identifier (EI) #1, a Licensed Practical Nurse (LPN), removed her gloves and washed her hands, perform hand hygiene, before leaving a resident's room after giving an injection. This affected 1 of six residents observed during medication pass, conducted by 1 of three nurses, on 1/30/19. Finding include: The facility document titled, Hand Hygiene Policy copyright date (YEAR), included: . Staff involved in direct resident contact will perform proper hand hygiene procedure to prevent the spread of infection to other . residents, . Between resident contacts . After handling items potentially contaminated with blood, body fluids . On 01/30/19 at 3:50 PM, EI #1 was observed during a medication pass. The resident required an insulin injection. EI #1 applied gloves to her hands before giving the injection to the resident. After giving the injection EI #1 wore the gloves out of the room, went to the nurses station, reached into her front pocket for the keys to the nurses station and put the insulin pen back in the cart. She then removed the gloves and washed her hands. On 01/30/19 at 5:05 PM, an interview was conducted with EI #1. She was asked what should she do after giving an injection, when wearing gloves, and before leaving the resident's room. EI #1 said take her gloves off and wash her hands. She was asked what should she have done after she removed her gloves. EI #1 replied washed her hands. She was asked did she walk down the hall with the dirty gloves on. EI #1 replied yes. EI #1 was asked what was the potential concern for walking down the hall with dirty gloves on. She replied spreading infection, infection control. On 01/31/19 at 12:20 PM, an interview was conducted with EI #2, the infection control nurse. EI #2 was asked what should a nurse, wearing gloves, do before leaving a resident's room. She replied take the gloves off and perform hand hygiene before leaving the room. EI #2 was asked what was the potential concern for not removing gloves before leaving the residents room. EI #2 replied contamination.

This deficiency was written as a result of complaint #AL 777. Based on interviews and record reviews, the facility failed to revise RI (Resident Identifier) #1's care plan after RI #1 was found self propelling in a wheelchair into the parking lot unsupervised on 12/11/2013. No interventions were added to RI #1's careplan to address the resident's continued behavior of entering the facility's parking lot unsupervised. On 10/28/2016, RI #1 was self propelling in the parking lot unsupervised when struck by a vehicle. This incident resulted in a skull fracture and hearing loss that required hospitalized from [DATE] until 10/31/2016. On 11/11/2016 at 2:42 p.m., the Administrator, the Director of Nursing, and the Assistant Director of Nursing were notified of the findings of Immediate Jeopardy level of J in the area of Care Plans F280. This deficient practice affected RI #1, a resident with a history of self propelling in a wheelchair unsupervised in the parking lot, one of thirteen residents whose Care Plans were reviewed. The immediate jeopardy began on 10/28/2016, until the facility implemented immediate corrective actions. The Immediate Jeopardy was relieved onsite on 11/12/2016 at 11:26 a.m. Findings include: On 11/7/2016, the State Agency received a complaint alleging the facility often allowed RI #1 to be in the parking lot of the facility in a wheelchair. The complainant also alleged that on 10/28/2016, RI #1 was hit by a vehicle in the facility's parking lot. A review of the Facility's undated Policy and Procedure titled, Reviewing and Revising the Care Plan revealed, Policy: The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Procedure: . (ii) Prepared by an interdisciplinary team, that includes the attending physician, a registered nurse with responsibility for the resident, and other appropriate staff in disciplines as determined by the resident's needs, and, to the extent practicable, the participation of the resident, the resident's family or the resident's legal representative; and (iii) Periodically reviewed and revised by a team of qualified persons after each assessment. Reviewing and Revising the Care Plan 1. Upon identification of a change in status, the nurse will notify the MDS (Minimum Data Set) Coordinator, the physician, and the resident representative, if applicable. 2. The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options. 3. The team meeting discussion will be documented in the nursing progress notes. 4. The care plan will be updated with the new or modified interventions. 5. Staff involved in the care of the resident will report resident response to new or modified interventions. 6. Care plans will be modified as needed by the MDS Coordinator or other designated staff member. 7. The Unit Manager or other designated staff member will communicate care plan interventions to all staff involved in the resident's care. 8. The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs. RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's Significant Change MDS assessment dated [DATE], revealed RI #1 had a BIMS (Brief Interview for Mental Status) score of 9 out of a possible 15, indicating RI #1 was moderately impaired for daily decision making skills. RI #1 used a wheelchair for mobility. RI #1's medical record contained an entry dated and timed 12/11/2013 at 9:25 a.m. that documented the resident was located in the facility parking lot . Mr. (Name of RI #1) was backing his wheelchair across the parking lot as I was coming to work this am around 9:15 am. (He/she) was backing (his/her) w/c (wheelchair) right behind the cars. I immediately went to (him/her) and stayed with (him/her) until (he/she) came to the front entrance porch A review of RI #1's care plan, with a Problem onset date of 1/1/2013 revealed, Problem/Need Behavior Management . 6. Rolls Wheelchair out in parking lot unattended. 12-11-13 (hand written) . There were no approaches added to the care plan to guide staff on how to handle RI #1's behavior of going out into the facility's parking lot unattended. Review of the RI #1's ELOPEMENT/WANDERING REVIEW following the 12/11/2013 incident, when the resident was found in the facility parking lot, revealed RI #1 did not have a history of leaving the facility without need of supervision and leaving the facility without informing staff. This assessment concluded RI #1 was not at risk for elopement. The most recent RISK FOR ELOPEMENT/WANDERING REVIEW completed prior to the incident when RI #1 was hit by a vehicle and sustained a skull fracture, dated 10/19/2016, also documented RI #1 did not have a history of leaving the facility without need of supervision and leaving the facility without informing staff although staff reported the resident frequently left the building to go outside without supervision. An interview was conducted with EI #7, RN/MDS Co-Coordinator, on 11/10/2016 at 2:00 p.m. EI #7 reviewed RI #1's 10/19/2016 Elopement/Wandering Review and said she was aware RI #1 went in the parking lot without notifying staff in 12/2013. EI #7 said when RI #1 went from the facility porch to the parking lot without staff in 12/2013, it would be considered an elopement per facility policy. She said after reviewing the facility's Elopements and Wandering Residents policy, it would have changed the outcome of RI #1's 10/19/2016 assessment, making RI #1 at risk for elopement. EI #7 further explained had the assessment been accurate, they would have revised RI #1's care plan to include a secure care transmitter and required staff supervision when outside. EI #7 said the 10/28/2016 incident could have been avoided if someone had been with RI #1 outside. A follow-up interview was conducted with EI #7 on 11/10/2016 at 6:12 p.m. EI #7 reviewed RI #1's 12/11/2013 Nurses Notes regarding staff finding RI #1 in the parking lot unsupervised. When asked how they determined if RI #1's care plans required revisions, EI #7 said it would be reviewed by the Interdisciplinary Team (IDT). After reviewing RI #1's care plans, EI #7 said nothing had been added to the care plans, but should have been. EI #7 said RI #1's care plans should have been updated following the 12/11/2013 incident to include supervision when outside. EI #7 then said staff had not reported that RI #1 continued to go into the parking lot. She explained if staff observed RI #1 in the parking lot, they should have reported it to a nurse so the IDT could address it. When asked how RI #1's plan of care would have been affected if his/her behaviors were monitored and staff reported knowledge of RI #1 going into the parking lot, EI #7 said they would have implemented a secure care transmitter and staff supervision. EI #7 said RI #1's care plans were reviewed 10/19/2016 and were reviewed by the IDT on 10/25/2016, but no changes were made to the care plans. She said the IDT had not discussed RI #1's behavior of going to the parking lot or reviewed behavior monitoring. She said they reviewed care plans in general. On 11/10/2016 at 10:51 a.m., EI #2, the Administrator, and EI #1, the DON (Director of Nursing), met with the surveyor regarding to RI #1. EI #2 stated RI #1 was not easy to deal with and had multiple behavior issues. RI #1 also had several psychiatric admissions. EI #2 stated RI #1 loved to go outside and sit in the sun. The parking lot issue started about 3 years ago. EI #2 stated RI #1 was instructed not to go into the parking lot. EI #2 stated on 10/28/2016 RI #1 decided to change from one porch to the other porch. RI #1 was a very difficult resident to work with at times. At this point, the surveyor pointed out RI #1 had been care planned in 2013 for not going into the parking lot. EI #2 replied RI #1 liked the sun better on the other end of the facility, therefore RI #1 moved to the other porch area. Some days RI #1 was outside all day long. EI #2 stated RI #1 was monitored by the staff off and on. The surveyor asked EI #2 and EI #1 if RI #1 and other residents were allowed outside without supervision of any kind. EI #1 replied yes. The surveyor asked how long residents were outside before they were checked/supervised by staff. EI #1 replied, I guess up to a maximum of 2 hours. EI #1 stated, They talked to (RI #1) and instructed (him/her) not to go into the parking lot, it was unsafe for him. This behavior was added to the care plan, but not new interventions added. No incident report found for this date (12/11/2013) . ************************************************* AOC (Allegation of Compliance) On 11/12/16 at 11:26 a.m., the facility provided the following AOC: F-280 - Camden Nursing Facility, Inc. Allegation of Compliance November 11, 2016 Care Plans 1. Incident occurred on October 28, 2016, and resident was sent to hospital for evaluation and treatment. Upon his/her readmission on October 31, 2016, affected resident was reassessed and Care Plan for affected resident was updated, to provide that he/her would wear a wander-guard to alert staff if he/she tried to exit the facility. That if he/she wished to exit the facility that he/she could do so only with direct staff supervision at all times while he/she was outside. Resident is also receiving physical, speech and occupational therapy. On October 28, 2016, staff on duty were inserviced on safety related to this incident. Charge nurses were instructed to pass this on during pre-shift report. 2. On October 28, 2016, the DON, ADON (Assistant Director of Nursing), and MDS Coordinator met in ADON's office and reviewed all residents who did not have wander-guard bracelets and independently would sit on the porch to determine if any of those ever showed signs of wandering into the parking lot. No other residents have been identified as having a propensity to wander off of the porch. Facility has a secure unit for those residents at risk for wandering or are given wander guard bracelets. On October 28, 2016, staff on duty were inserviced on safety related to this incident. Charge nurses were instructed to pass this on during pre-shift report. On November 11,2016, all staff on duty were re-inserviced by DON, or designee, on importance of care plans, quality assurance and accident prevention. Those staff not on duty will be called and inserviced and no staff can come on duty without this inservice training. Charge nurses were instructed to ensure staff knew and were following this training. In addition, on November '11, 2016, Administrator, DON, ADON, both MDS Coordinators, and Infection Control RN took current census and identified those who could move independently and either did not have a wander guard bracelet or were not in the secure unit. Then using the Risk of Elopement/Wandering Review Tool, those independently mobile residents were re-assessed and none were identified as an elopement risk, Care plans and ADLs were updated to reflect any potential risk factors identified. On November 11, 2016, all staff on duty and those reporting to work were inserviced on any changes and a note was placed on time clock so that staff reporting to duty will be apprised to report to charge nurse for inservice training prior to taking assignment. 3. On October 28, 2016, staff on duty were inserviced on safety related to this incident. Charge nurses were instructed to pass this on during pre-shift report. On November 11, 2016, all staff on duty were re-inserviced by DON or designee on importance of care plans, quality assurance and accident prevention. Those staff not on duty will be called and inserviced and no staff can come on duty without this inservice training, Charge nurses were instructed to ensure staff knew and were following this training. In addition, the facility has ordered gates for the porches to impede residents from exiting the porches and fencing on the west side to permit the affected resident to sit in the sun in a protected area. Expect delivery and installation in two to three weeks. On November 11, 2016, DON, ADON, ADM (Administrator), and care planning nurses, were telephonically inserviced by regional nurse. (Name of Regional Nurse), RN, NHA (Nursing Home Administrator), on care plans, accident prevention, quality assurance and administration. 4. DON and administrator to monitor that the above is followed. Monitoring by Administrator and DON to begin 116 daily for I week, then 3 times a week for I month, then weekly for 4 weeks, and then random for 1 month. (Name of Regional Nurse) will make visits to the Facility every two weeks for 2-months to evaluate the effectiveness of this training and the interventions. Record of monitoring by DON & Administrator and records of the Regional Nurse's monitoring visits will be kept in business office, and monitoring results will be docwnented in QA (Quality Assurance) records and minutes and used in accordance with QA procedures. ************************************* After reviewing the facility's information provided in their Allegation of Compliance (AOC), inservice records completed as of 11/12/2016 and interviews with facility staff, it was determined the facility had implemented their AOC, the immediate jeopardy was relieved and the scope and severity was lowered to a D level on 11/12/2016 at 11:26 a.m.

This deficiency was written as a result of complaint #AL 777. Based on interviews and record reviews, the Quality Assurance and Assessment Committee failed to identify a concern and implement an action plan, regarding RI (Resident Identifier) #1's behavior of self propelling in a wheelchair into the parking lot unsupervised. On 10/28/2016, RI #1 was self propelling in the parking lot unsupervised. RI #1 was struck by a vehicle and as a result, sustained a skull fracture and hearing loss that required hospitalized from [DATE] until 10/31/2016. The resident had previously been found in the parking lot unattended and had a history of [REDACTED]. RI #1's Behavior Management care plan, with onset date of 1/1/2013, contained a hand written entry describing the following behavior 6. Rolls Wheelchair out in parking lot unattended. 12-11-13 . No approaches were added to this care plan to guide staff on how to handle and/or monitor RI #1's behavior of going out into the facility's parking lot unattended. RI #1's behavior of going out into the facility's parking lot unattended was documented in a medical record entry on 8/23/2016 as an issue discussed during his/her 8/17/2016 careplan meeting, however, this issue was not referred to the QAA Committee. On 11/11/2016 at 2:42 p.m., the Administrator, the Director of Nursing, and the Assistant Director of Nursing were notified of the findings of Immediate Jeopardy level of J in the area of Quality Assurance and Assessment Committee, F520. This deficient practice affected RI #1, a resident with a history of self propelling in a wheelchair unsupervised in the parking lot, one of two residents reviewed for Accidents/Incidents. The immediate jeopardy began on 10/28/2016, until the facility implemented immediate corrective actions. The Immediate Jeopardy was relieved onsite on 11/12/2016 at 11:26 a.m. Findings include: Cross reference F 323 and F 490. A review of the Facility's undated Policy and Procedure titled Quality Assessment and Assurance (QAA) Policy revealed, Policy: This facility will operate a Quality Assessment and Assurance Committee to identify quality issues, and develop and implement appropriate plans of action to correct identified quality deficiencies within the facility through an interdisciplinary approach. Policy Explanation and Compliance Guidelines: 2. The Committee will meet at least quarterly to identify whether issues are present that may affect the quality of care and services delivered to its residents either negatively or positively. 3. The Committee will develop plans of correction or action to correct identified quality deficiencies, including monitoring the effect of implemented changes and revising the action plans as needed. Review of RI #1's medical record revealed on 10/28/2016 RI #1, a cognitively impaired resident, was struck by a vehicle in the facility parking lot resulting in a skull fracture and hearing loss. The resident had previously been found in the parking lot unattended. According to staff, RI #1 had a history of [REDACTED]. RI #1's Behavior Management care plan, with onset date of 1/1/2013, contained a hand written entry describing the following behavior 6. Rolls Wheelchair out in parking lot unattended. 12-11-13 . On 11/10/2016 at 10:51 a.m., EI #2, the Administrator, and EI #1, the DON (Director of Nursing), met with the surveyor regarding to RI #1. EI #2 stated RI #1 was not easy to deal with and had multiple behavior issues. RI #1 also had several psychiatric admissions. EI #2 stated RI #1 loved to go outside and sit in the sun. The parking lot issue started about 3 years ago. EI #1, DON/ QAA Chair, was interviewed concerning the QAA Committee on 11/12/2016 at 6:31 p.m. The committee consisted of the Director of Nursing, Administrator, Assistant Director of Nursing, MDS (Minimum Data Set) Coordinator, Activities personnel, Dietary staff, Social Services and the Medical Director. According to EI #1, the committee met at least quarterly. EI #1 was asked what QAA activity was completed regarding the 8/17/2016 risk documented in the care plan meeting notes for RI #1 of rolling in the wheelchair into the parking lot, unattended. She replied, Nothing. EI #1 was asked should that risk have been reviewed/addressed in a QAA committee meeting. She replied, Yes ma'am. If it was written down, it should have been. RI 1's medical record contained and entry dated 8/23/2016 at 9:27 a.m. The entry documented information regarding RI #1's careplan meeting held on 8/17/2016, Care Plan meeting for (name of RI #1) was held on 8/17/10. (He/she) did not attend the meeting. (He/she) has [DIAGNOSES REDACTED]. (Name of RI #1) is care planned for cognitive impairments related to short term memory loss. (He/She) requires limited to total assistance with his ADL's. (He/She) remains on Behavior Management for cursing at staff, rolling (his/her) wheelchair into the parking lot unattended . This entry was signed by the facility Social Worker, EI #19, who is a member of the QAA Committee. A review of a statement provided by EI #1, the DON (Director of Nursing)/QAA Committee Chair, regarding QAA review of RI #1's behavior of ambulating via wheelchair in the parking lot unsupervised, documented, There has been no Quality Assurance Plan of action put into place for (RI #1) prior to 10/28/16. An interview was conducted at 7:17 p.m. on 11/12/16 with EI #2, the Administrator. EI #2 was asked if the QAA committee failed to address safety issues for RI #1 prior to the incident resulting in injury on 10/28/16. He answered, I don't know. EI #2 was asked if QAA failed to identify ongoing concerns and implement an action plan to provide prevention and protection related to safety for RI #1. He answered, No. EI #2 added the initial incident report was never done, therefore QAA was not followed. ******************************************************** AOC (Allegation of Compliance) On 11/12/16 at 11:26 a.m., the facility provided the following AOC: F-520 - Quality Assurance: On November 11, 2016, DON, ADON (Assistant Director of Nursing), ADM (Administrator), and care planning nurses, were telephonically inserviced by regional nurse (Name of Regional Nurse), RN (Registered Nurse), NHA (Nursing Home Administrator), on care plans, accident prevention, quality assurance and administration. (Name of Regional Nurse) will make visits to the Facility every two weeks for 2-months to evaluate the effectiveness of this training and the interventions. Records of the Regional Nurse's monitoring visits will be kept in business office, and monitoring results will be documented in QA (Quality Assurance) records and minutes and used in accordance with QA procedures. **************************************************** After reviewing the facility's information provided in their Allegation of Compliance (AOC), in-service records completed as of 11/12/2016 and interviews with facility staff, it was determined the facility had implemented their AOC, the immediate jeopardy was relieved and the scope and severity was lowered to a D level on 11/12/2016 at 11:26 a.m.

This deficiency was written as a result of complaint #AL 777. Based on interviews and record reviews, Administrator who is responsible for the overall management of the facility, and Director of Nursing, who is responsible for the overall management of the Nursing Department, failed to ensure the facility policies regarding Incidents/Accidents, Elopements and Wandering Residents and Reviewing and Revising the Careplan were followed. On 10/28/2016 RI #1, a cognitively impaired resident, was struck by a vehicle in the facility parking lot resulting in a skull fracture and hearing loss. The resident had previously been found in the parking lot unattended and had a history of [REDACTED]. RI #1's Behavior Management care plan, with onset date of 1/1/2013, contained a hand written entry describing the following behavior 6. Rolls Wheelchair out in parking lot unattended. 12-11-13 . No approaches were added to this care plan to guide staff on how to handle and/or monitor RI #1's behavior of going out into the facility's parking lot unattended. On 11/11/2016 at 2:42 p.m., the Administrator, the Director of Nursing, and the Assistant Director of Nursing were notified of the findings of Immediate Jeopardy level of J in the area of Administration, F490. This deficient practice affected RI #1, a resident with a history of accessing the parking area unsupervised, one of two residents reviewed for Accidents/Incidents. The Immediate Jeopardy began on 10/28/2016, until the facility implemented immediate corrective actions. The Immediate Jeopardy was relieved onsite on 11/12/2016 at 11:26 a.m. Findings include: Cross reference F 280 and F323. On 11/7/2016, the State Agency received a complaint alleging the facility often allowed RI #1 to be in the parking lot of the facility in a wheelchair. The complainant also alleged that on 10/28/2016, RI #1 was hit by a vehicle in the facility's parking lot. A review of the Facility's undated Policy and Procedure titled Elopements and Wandering Residents revealed: Policy: . Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so . 4. Documentation, a. The RN and/or charge nurse, shall document the elopement incident and interventions in the medical record. b. A plan of care should be developed or revised as indicated for the resident. A review of an undated Facility Policy and Procedure titled Incident and Accident revealed: Policy: The resident environment remains as free of accident hazards as is possible . Accidents may involve residents, employees or visitors . 2. Documentation . b. An Incident/Accident report should be completed c. Witness Information should be completed as follows: . D. Initiate an investigation. A review of the Facility's undated Policy and Procedure titled, Reviewing and Revising the Care Plan documented, Policy: The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Procedure: . Reviewing and Revising the Care Plan 1. Upon identification of a change in status, the nurse will notify the MDS (Minimum Data Set) Coordinator, the physician, and the resident representative, if applicable. 2. The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options. 3. The team meeting discussion will be documented in the nursing progress notes. 4. The care plan will be updated with the new or modified interventions. 5. Staff involved in the care of the resident will report resident response to new or modified interventions. 6. Care plans will be modified as needed by the MDS Coordinator or other designated staff member. 7. The Unit Manager or other designated staff member will communicate care plan interventions to all staff involved in the resident's care. 8. The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs. A review of the Administrator's job description revealed, . Purpose of Your Job Position The primary purpose of your job position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern long-term care facilities to assure that the highest degree of quality care can be provided to our residents at all times. Major Duties and Responsibilities Administrative Functions . Assume the administrative authority, responsibility and accountability of directing the activities and programs of the facility. Personnel Functions . Consult with department directors concerning the operation of their departments to assist in eliminating/correcting problem areas, and/or improvement of services. Review accident/incident reports and establish an effective accident prevention program. Assure that each resident receives the necessary nursing, medical and psychosocial services to attain and maintain the highest possible mental and physical functional status, as defined by the comprehensive assessment and care plan. A review of the Director of Nursing Service's job description revealed, . Purpose of Your Job Position The primary purpose of your job position is to plan, organize, develop, and direct the overall operation of our Nursing Services Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be directed by the Administrator and the Medical Director, to ensure that the highest degree of quality care is maintained at all times. Administrative Functions . Schedule daily rounds to observe residents and to determine if nursing needs are being met. RI #1's medical record contained an entry dated and timed 12/11/2013 at 9:25 a.m. that documented the resident was located in the facility parking lot backing his wheelchair across the parking lot around 9:15 am. On 11/10/16 at 6:00 p.m., the surveyor requested the DON (Director of Nursing) provide the incident/accident report for the 12/11/13 incident when RI #1 was found in the parking lot in the wheelchair, unattended. The DON stated she was unable to locate the incident/accident report regarding the 12/11/13 incident. R#1's Behavior Management care plan, with onset date of 1/1/2013, contained a hand written entry describing the following behavior 6. Rolls Wheelchair out in parking lot unattended. 12-11-13 . No approaches were added to this care plan to guide staff on how to handle and/or monitor RI #1's behavior of going out into the facility's parking lot unattended. A review of the RI #1's Resident Incident Report for 10/28/2016 at 10:30 a.m., revealed RI #1 was struck by a vehicle in the facility's parking lot while self propelling in a wheelchair unsupervised. RI #1 sustained a skull fracture and hearing loss. During an interview at 10:51 a.m. on 11/10/16, EI #1, the DON (Director of Nursing) stated prior to the injury RI #1 sustained on 10/28/16, RI #1 was monitored by staff off and on while outside. However, RI #1 was outside most of the time, unsupervised. The surveyor asked if more residents were allowed outside without supervision of any kind and for how long. She answered yes and for up to two hours. EI #1 reported that RI #1 was instructed in 2013 not to go into the parking lot because it was unsafe for him/her. An interview was conducted at 4:30 p.m. on 11/12/16 with EI #1, DON. EI #1 was asked if she was aware of the frequency RI #1 was in the parking lot unsupervised over the past 3 years. She answered no, she was not made aware of the behavior. CNAs were not coming to me. EI #1 was asked if she should have known of this safety concern/behavior issue. She answered yes. After reviewing RI #1's risk assessment form dated 10/19/16, EI #1 was asked if there were risk factors identified that safety could be an issue for RI #1. She answered yes. EI #1 was asked what should have been done regarding these findings. She answered report information to the Nurse immediately. EI #1 was asked if any of the elopement assessments indicate RI #1 was not safe to be outside, unsupervised. She replied yes. EI #1 was asked what was identified. She responded poor decision making skills and [DIAGNOSES REDACTED].#1 was asked about an approach listed on RI #1's care plan for close supervision. EI #1 reported she had not in-serviced the staff on what should be considered close supervision. When EI #1 was asked what would be considered close supervision, she responded to know where RI #1 was and pay attention to RI #1 at all times. An interview was conducted at 6:39 p.m., on 11/12/16 with EI #2, the Administrator. EI #2 was asked what were the expectations of the management staff related to RI #1 ' s safety. EI #2 stated they were to assess and care plan to meet needs and address behaviors and safety accordingly. EI #2 was asked if RI #1 exhibited behaviors or safety issues, who and how was monitoring done. He replied monitor until resolved, document, and report information to appropriate management staff. EI #2 was asked if RI #1 was going outside, who was monitoring RI #1 for safety prior to 10/28/16. He answered monitoring would not apply unless RI #1 was sitting in the middle of the parking lot, then close monitoring would apply by direct care staff. EI #2 was asked based on his knowledge of RI #1, if the resident was at risk for safety while outside unsupervised. EI #2 answered no, because the resident went outside for pleasure. He/She had a purpose. ******************************************** AOC (Allegation of Compliance) On 11/12/16 at 11:26 a.m., the facility provided the following AOC: F-490 - Administration: Administrator received telephonic inservice training regional nurse (Name of Regional Nurse), RN (Registered Nurse), NHA (Nursing Home Administrator), on care plans, accident prevention, quality assurance and administration. (Name of Regional Nurse) will make visits to the Facility every two weeks for 2-months to evaluate the effectiveness of this training and the interventions. Records of the Regional Nurse's monitoring visits will be kept in business office, and monitoring results will be documented in QA (Quality Assurance) records and minutes and used in accordance with QA procedures. *************************************** After reviewing the facility's information provided in their Allegation of Compliance (AOC), inservice records completed as of 11/12/2016 and interviews with facility staff, it was determined the facility had implemented their AOC, the immediate jeopardy was relieved and the scope and severity was lowered to a D level on 11/12/2016 at 11:26 a.m.

This deficiency was written as a result of complaint #AL 777. Based on record reviews and interviews, the facility failed to ensure RI (Resident Identifier) #1, a cognitively impaired resident with impaired decision making skills, did not enter the facility's parking lot without staff supervision. On 12/11/2013, RI #1 was found unsupervised in his/her wheelchair in the parking lot. After this incident, no approaches were added to the resident's care plan to address RI #1's behavior of entering the parking lot unsupervised nor was the behavior monitored by the facility. Facility staff stated the resident routinely went outside and into the parking lot unsupervised. On 10/28/2016, RI #1 self-propelled in a wheelchair out into the facility's parking lot behind a vehicle that backed up, hitting RI #1. As a result of the accident, RI #1 sustained a skull fracture and hearing loss. On 11/11/2016 at 2:42 p.m., the Administrator, the Director of Nursing, and the Assistant Director of Nursing were notified of the findings of Immediate Jeopardy level of J in the area of Quality of Care, F323 (Accidents). This deficient practice affected RI #1, a resident with a history of self propelling in a wheelchair unsupervised in the parking lot, one of two residents reviewed for Accidents/Incidents. The immediate jeopardy began on 10/28/2016, until the facility implemented immediate corrective actions. The Immediate Jeopardy was relieved onsite on 11/12/2016 at 11:26 a.m. Findings include: On 11/7/2016, the State Agency received a complaint alleging the facility often allowed RI #1 to be in the parking lot of the facility in a wheelchair. The complainant also alleged that on 10/28/2016, RI #1 was hit by a vehicle in the facility's parking lot. The resident's wheelchair fell over and the resident fell out. The resident bumped his/her head and was knocked unconscious. A review of the Facility's undated Policy and Procedure titled Elopements and Wandering Residents revealed: Policy: . Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so . 4. Documentation, a. The RN and/or charge nurse, shall document the elopement incident and interventions in the medical record. b. A plan of care should be developed or revised as indicated for the resident. A review of an undated Facility Policy and Procedure titled Incident and Accident revealed: Policy: The resident environment remains as free of accident hazards as is possible . Accidents may involve residents, employees or visitors . 2. Documentation . b. An Incident/Accident report should be completed c. Witness Information should be completed as follows: D. Initiate an investigation. RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's Significant Change MDS (Minimum Data Set) assessment dated [DATE], revealed RI #1's hearing was adequate - no difficulty in normal conversation, social interaction, and listening to television. RI #1 used a wheelchair device for mobility. On the BIMS (Brief Interview for Mental Status) RI #1 scored a 9 out of a possible 15, indicating moderate impairment for daily decision making skills. RI #1's medical record contained an entry dated and timed 12/11/2013 at 9:25 a.m. that documented the resident was located in the facility parking lot .(Name of RI #1) was backing his wheelchair across the parking lot as I was coming to work this am around 9:15 am. (He/she) was backing (his/her) w/c (wheelchair) right behind the cars. I immediately went to (him/her) and stayed with (him/her) until (he/she) came to the front entrance porch. A review of RI #1's care plan, with a Problem onset date of 1/1/2013 revealed, Problem/Need Behavior Management . 6. Rolls Wheelchair out in parking lot unattended. 12-11-13 (hand written) . The problem onset was dated 12/11/2013 however, there were no approaches added to the care plan to guide staff on how to handle RI #1's behavior of going out into the facility's parking lot unattended. On 11/10/16 at 6:00 p.m., the surveyor requested from EI (Employee Identifier) #1, the DON (Director of Nursing), the incident/accident report for the 12/11/13 incident when RI #1 was found in the parking lot in the wheelchair, unattended. The DON stated she was unable to locate the incident/accident report regarding the 12/11/13 incident. A review of RI #1's medical record revealed facility a document titled, MOOD/BEHAVIOR MONITORING used by the CNAs (Certified Nursing Assistants) to monitor and document resident behaviors. RI #1's MOOD/BEHAVIOR MONITORING for April 2016 through October 2016 were reviewed. RI #1's behavior of going outside into the parking lot unattended was not listed on any of these monitoring forms. A review of the facility document titled, Resident Incident Report, revealed, on 10/28/2016 at 10:30 a.m., Incident Type: Struck by vehicle Type of Injury: Abrasion, Laceration-superficial Location: Facility grounds Property Involved: Private vehicle Equipment: Wheelchair - non-motorized . Narrative of incident and description of injuries: heard paging over intercome (intercom) for nursing staff outside stat (immediately) - everyone immediately rushed outside to parking lot - noted res (resident) lying face down behind a black truck which was occupied by a visitor - several nurses safely rolled res (resident) over to (his/her) back - securing head and neck - noted large amt (amount) of bright red blood on ground and to Lt (Left) side of res (resident) head - res (resident) unresponsive for a few mins (minutes) then (he/she) slowly started to respond verbally - res (resident) trying to move and get up - staff trying to calm res (resident) by talking to (him/her) - abrasion and superficial laceration to lt (left) side of head - no other visible injuries noted. Immediate Actions Taken: several staff members rush to res (resident) aide - first aid given - res examined per (name of Medical Doctor) immediately after incident - res (resident) transport per ambulance . The ambulance transfer report detailing RI #1's transfer via ambulance on 10/28/2016 indicated the type of service requested was a 911 Response to the scene. The Patient Assessment Section of the ambulance transfer report indicated RI #1 had altered mental status with a chief complaint of the head and a secondary impression of a head bleed. The head assessment indicated a laceration. The mechanism of injury was noted as . Blunt . The patient care report documented emergency services were dispatched to the scene due to RI #1 being hit by a vehicle in the facility's parking lot. The report further noted a nurse stated RI #1 was in his/her wheel chair and was hit by a vehicle backing up. EMS (Emergency Medical Services) found RI #1 laying on the ground, with nurses holding C-spine (cervical spine); the nurses indicated RI #1 was going across the parking lot when a man backed up and did not see the patient, hit the resident, and turned the wheelchair over and (RI #1) hit his/her head. A review of the Alabama Uniform Incident/Offense Report dated 10/28/16 and timed 11:00 a.m., documented a visitor was backing out of the facility's parking lot when he backed over RI #1. It was further noted RI #1 was behind the truck in his/her wheelchair and the visitor couldn't see him/her. The visitor said he felt a bump and looked in his rearview mirror and saw RI #1 behind his truck on the ground. RI #1 was admitted to the hospital 10/28/2016 with [DIAGNOSES REDACTED]. A review of RI #1's hospital admission assessment dated [DATE], revealed, HEAD AND NECK: Deep abrasion minor laceration left forehead. the left canal was impacted and irrigated . NEURO (NEUROLOGICAL): (RI #1 was) a bit dazed, (RI #1's) sensorium is immediately clouded with some confusion but is a bit more pronounced, clouded mentation at present compared to usual. ADMISSION Diagnosis: [REDACTED]. Multiple abrasions left forehead. (He/She) did have some loss of consciousness verified by the nurse who tended (him/her) in the parking lot of (name of nursing facility) immediately after the incident. RI #1 ' s CT (Computer Tomography) scan without contrast, dated 10/28/2016 documented, . IMPRESSION: . 2. there is a linear fracture of the right occipital skull base. It's quite long extending from near the foramen magnum back along the curvature of the occiput toward the insertion of the nuchal ligaments. Close follow up is suggested. A further review of RI #1's hospital records revealed a progress note dated 10/29/2016, . claims to have some difficulty hearing. The progress note dated 10/30/2016 revealed, . Still complaining of difficulty hearing . The resident was discharged back to the facility on [DATE]. A Significant Change MDS, with an assessment reference date of 11/7/16, was completed following RI #1's hospitalization . The MDS revealed, a BIMS score of 10 out of a possible 15 which indicated moderately impaired cognitive skills for daily decision making. RI #1's hearing was assessed with [REDACTED]. Compared to the previous Significant Change MDS, dated [DATE], RI #1's hearing declined from adequate to moderate difficulty following the injury on 10/28/2016. An observation was made on 11/09/2016 at 9:01 a.m., of the two front porches and entrance ways into the facility. The main front entrance had a covered porch with a wide walkway extending towards the parking lot, this walkway was 31 feet in length and 8 feet in width. There was a small side walk that extended off the large walk way. This side walk turning left off the wide walk way extended 15 feet and was 4.5 feet wide. Adjacent to this sidewalk was the asphalt parking lot. From the sidewalk to the next front porch area was 74 feet of asphalt parking lot, with parking spaces on both sides of the parking lot. The resident had rolled their wheelchair to the first parking spot next to this sidewalk and was parked behind the truck that struck him. An interview was conducted on 11/9/2016 at 5:38 p.m., with EI #5, the facility Medical Director. EI #5 was asked to explain the incident which occurred on 10/28/2016 related to RI #1. EI #5 stated he was making rounds and a nurse summoned him and said a resident was outside in the parking lot. The nurse informed him the resident was hit by a truck and knocked out of a wheelchair. The resident was dazed with no distress, an abrasion on the forehead. The resident would follow simple commands. EI #5 was informed the resident was unconscious, but by the time he saw the resident, RI #1 was responsive, dazed, and not usual self. EI #5 was asked if RI #1 was having any hearing impairment prior to the accident. EI #5 stated he did not recall this being an issue for this resident prior to the incident. Prior to the incident the resident had confusion. EI #5 was asked what was the level of impairment for this resident at this time related to the resident's hearing loss. EI #5 replied he knew it started in the hospital after the incident. There is a very significant loss attributed to the skull fracture extending to the base of the brain. EI #5 was asked if he was aware of the RI #1 going out into the parking lot at will and unsupervised, traveling from one porch to the other porch. EI #5 replied no. EI #5 was asked if there should have been concern for the resident being unsupervised outside. EI #5 replied probably when resident showed increased confusion, like with a urinary tract infection, which the resident had frequently. If there was increased confusion the resident should not be outside unsupervised. There was an increased potential for injury or an accident. EI #5 stated if the resident did not have increased confusion, he would expect someone to check on him/her every 5 -10 minutes. EI #5 was asked if there a change in RI #1's mental alertness and confusion after the incident on 10/28/2016. EI #5 replied, yes, for about 36 hours, then the RI #1 returned to the resident's normal status. EI #5 was asked how significant was the linear fracture to the right occipital skull. EI #5 replied usually with a basil skull fracture there was a slow return to normal. EI #5 stated he did not know if the hearing loss would be resolved or permanent. EI #5 was asked if he would have expected supervision for RI #1 and what kind of supervision. EI #5 replied yes, and if confused, should have had full supervision and if not confused, then at least intermittent supervision. On 11/10/2016 at 10:51 a.m., EI #2, the Administrator, and EI #1, the DON (Director of Nursing), met with the surveyor regarding to RI #1. EI #2 stated RI #1 was not easy to deal with and had multiple behavior issues. RI #1 also had several psychiatric admissions. EI #2 stated RI #1 loved to go outside and sit in the sun. The parking lot issue started about 3 years ago. EI #2 stated RI #1 was instructed not to go into the parking lot. EI #2 stated on 10/28/2016 RI #1 decided to change from one porch to the other porch. RI #1 was a very difficult resident to work with at times. At this point, the surveyor pointed out RI #1 had been care planned in 2013 for not going into the parking lot. EI #2 replied RI #1 liked the sun better on the other end of the facility, therefore RI #1 moved to the other porch area. Some days RI #1 was outside all day long. EI #2 stated RI #1 was monitored by the staff off and on. The surveyor asked EI #2 and EI #1 if RI #1 and other residents were allowed outside without supervision of any kind. EI #1 replied yes. The surveyor asked how long residents were outside before they were checked/supervised by staff. EI #1 replied, I guess up to a maximum of 2 hours. EI #1 stated, They talked to (RI #1) and instructed (him/her) not to go into the parking lot, it was unsafe for him. This behavior was added to the care plan, but not new interventions added. No incident report found for this date (12/11/2013) Review of the RI #1's ELOPEMENT/WANDERING REVIEW following the 12/11/2013 incident, when the resident was found in the facility parking lot, revealed RI #1 did not have a history of leaving the facility without need of supervision and leaving the facility without informing staff. This assessment concluded RI #1 was not at risk for elopement. The most recent RISK FOR ELOPEMENT/WANDERING REVIEW completed prior to the incident when RI #1 was hit by a vehicle and sustained a skull fracture, dated 10/19/2016, also documented RI #1 did not have a history of leaving the facility without need of supervision and leaving the facility without informing staff although staff reported the resident frequently left the building to go outside without supervision. During an interview with EI #7, Registered Nurse (RN)/MDS Co-Coordinator, on 11/10/2016 at 2:00 p.m., EI #7 stated they completed Elopement/Wandering Risk Assessments upon admission, quarterly and if anything changes. She explained the facility determined if someone was at risk for elopement/wandering, if they were exit seeking, asking to go home, or have a history in the past. After reviewing the facility policy, EI #7 defined an elopement as a situation in which a resident leaves the premises or a safe area without authorization and/or necessary supervision. She then said when RI #1 went from the facility porch to the parking lot without staff in 12/2013, it would be considered an elopement per facility policy. She said after reviewing the facility policy, it would change the outcome of RI #1's 10/19/2016 assessment, making RI #1 at risk for elopement. She further explained had the assessment been accurate, they would have revised RI #1's care plan to include a secure care transmitter and required staff supervision when outside. EI #7 said the 10/28/2016 incident could have been avoided if someone had been with RI #1 outside. An interview was conducted with EI #9, a CNA, on 11/10/2016 at 2:35 p.m . This CNA reported she cared for RI #1 usually Monday, Wednesday, and Friday. EI #9 was asked what type of care she provided for RI #1. EI #9 answered she helped RI #1 with shower or bed bath/total care with ADLs (Activities of Daily Living) except with food, set up only. The resident gets dressed, goes to activities, or sits at the Nurse's station. EI #1 was asked how RI #1 got to those places. EI #9 replied RI #1 propel in the wheelchair and does not need any help with pushing. EI #9 was asked where does RI #1 go when outside. EI #9 replied the resident likes to sit in the sun by the columns. EI #9 was asked how often did RI #1 go outside each day. She answered about twice a day. EI #9 was asked how long did RI #1 stay outside and she answered, It varies, 10-30 minutes. EI #9 was asked when she checked on RI #1. She answered, Most of the time I take (them) out and stay with (them). EI #9 was asked why and she answered to make sure he/she didn't leave the porch. EI #9 was asked when did that start and she answered, Early this year, when the weather got warm. EI #9 was asked how were CNAs made aware of this. She answered, We were told in an in-service. EI #9 was asked where RI #1 went when outside. She responded either of the front doors. EI #9 was asked if she had ever observed the resident in the parking lot. EI #9 replied, Maybe once or twice when I had to go out there and get (him/her). EI #9 was asked if the parking lot was a safe place for the resident to be. EI #9 was asked what had she been told about RI #1's care and safety supervision. She responded to make sure staff know where the resident was at all times. EI #9 added it was kind of hard because RI #1 rolls themselves around. EI #9 was asked who she told about RI #1's safety concerns and behaviors. She replied the Nurse. EI #9 was asked what was the potential harm of RI #1 being outside unsupervised. She answered, Getting hurt. EI #1 was asked what was the potential harm of RI #1 going into the parking lot, behind vehicles. She stated, Getting hit by a vehicle. EI #9 was asked would she consider the parking lot a safe place for a resident to be unsupervised and she said, No. An interview was attempted on 11/10/2016 at 3:45 p.m., with RI #1, the resident that sustained the injury from the accident. RI #1 was unable to recall the incident. An interview was conducted on 11/10/2016 at 3:48 p.m., with EI #11, CNA. EI #11 was asked if she was familiar with RI #1. EI #11 replied yes. EI #11 was asked how often she cared for RI #1. EI #11 replied 3 - 4 times each week. EI #11 was asked how RI #1 typically spent the day. EI #11 stated RI #1 gets up and takes a shower, rolls around in the wheelchair freely. RI #1 goes inside and outside when he/she wants to. EI #11 was asked how often she monitored RI #1. EI #11 replied they monitor the resident every time the resident goes to the porch now for about 2 weeks. Before that, the RI #1 would go out whenever the resident wanted to. EI #11 was asked if she knew every time RI #1 would go outside. EI #11 replied no, but sometimes she did. EI #11 was asked how often RI #1 went outside. EI #11 replied the majority of the day. EI #11 was asked when she checked on RI #1 when the resident was outside. EI #11 replied the resident was not monitored at times before the accident. EI #11 stated she saw the resident on the porch on 10/28/2016, no other residents or staff were outside. EI #11 stated she returned into the facility and went into the resident's room and heard a noise from outside the facility. EI #11 stated she had seen the resident in the parking lot prior to 10/28/2016 several times. EI #11 stated she would tell the RI #1 the resident he/she could be on the porch, but not in the parking lot. EI #11 stated that this behavior was noticed by her about a month ago. EI #11 was asked if this information was report to anyone. EI #11 replied yes, she reported it each time to the nurses and the DON. EI #11 was asked what was RI #1's safety awareness. EI #11 replied the resident was aware of the potential danger but the resident just does it anyway. EI #11 was asked if she had observed any safety issues with the resident. EI #11 replied going into the parking lot about a month ago. EI #11 was asked if any changes in the resident's condition had been observed by her since the accident on 10/28/2016. EI #11 replied yes, the resident was very hard of hearing now. An interview was conducted with EI #12, CNA that provided care for the RI #1, on 11/10/2016 at 4:15 p.m. EI #12 was asked if there were any supervision or observations that she was required to make for RI #1 daily. EI #12 replied the resident needed monitoring, the resident likes to go to the parking lot and doesn't let the staff know before he/she goes. EI #12 was asked how often the resident goes outside. EI #12 replied a lot. EI #12 was asked how often she had seen the resident in the parking lot. EI #12 replied just about every day. EI #12 was asked where she had seen RI #1 in the parking lot. EI #12 answered usually right in the center. The resident goes from one end to the other end, not on the side walk, on asphalt behind the cars. We tell him/her not to roll behind the cars, but it does not do any good. EI #12 was asked if she reported to anyone about the resident being in the parking lot. EI #12 replied she usually stayed out there with them. EI #12 was asked when RI #1 was last in the parking lot without supervision. She responded one month ago. She further indicated she didn't report this to anyone, she just got him/her back on the sidewalk and stayed with him/her. EI #12 was asked if she should have reported this behavior to anyone. EI #12 replied the DON was aware and so were the LPN's (Licensed Practical Nurse). A phone follow up interview with EI #9, CNA was conducted on 11/10/2016 at 4:31 p.m. EI #9 was asked when she saw RI #1 in the parking lot. EI #9 replied the resident was seen in the parking lot about four months (ago) several times and mainly sits under a tree near the second porch. EI #9 was asked if she reported this to anyone when she found him in the parking lot. EI #9 replied no I did not, I just talked to the resident and moved the resident to a safe place. EI #9 was asked if she should have reported this to anyone. EI #9 replied yes. An interview was conducted on 11/10/2016 at 4:45 p.m., with EI #10, LPN. This LPN indicated she cared for RI #1 at least 3-4 days per week. EI #10 was asked if RI #1 required any monitoring or supervision. EI #10 replied now the resident does, but prior to the accident RI #1 did not require direct supervision. EI #10 was asked how RI #1 spent his /her day. EI #10 replied the resident was up in a wheelchair and sat outside in the sun on the porch. EI #10 was asked how RI #1 got outside. EI #10 replied the resident rolls self outside. EI #10 was asked if it had ever been reported to her about RI #1 being found in the parking lot. EI #10 replied no, but it should be reported to her or another nurse on duty. EI #10 was asked if a CNA observed RI #1 in the parking lot, without supervision, what should they do. She answered return the resident to the porch and report to the Nurse. EI #10 was asked if the resident had any changes in condition since the accident on 10/28/2016. EI #10 replied yes, RI #1 cannot hear as good as before. An interview was conducted on 11/11/2016 at 12:35 p.m., with EI #4, the CNA that witnessed the accident on 10/28/2016, involving RI #1 being hit by a truck in the parking lot. EI #4 stated it was common for RI #1 to be in the parking lot rolling (in a wheel chair) right behind the bumpers of the vehicles. RI #1 had been told many times not to do this. Because the ambulance enters into the facility through this parking lot, they could easily hit this resident. EI #4 further stated everyone saw him out there all the time, including Nurses. EI #4 stated everybody knows this goes on. EI #4 was asked who she reported this to. EI #4 replied it has been a while since I reported this issue, probably not since March or April. It is common every day thing and everybody knows this. EI #4 stated the staff all said the resident was going to get hit. An interview was conducted with EI #3, an LPN, on 11/11/2016 at 1:00 p.m. EI #3 was asked if the resident had orders to manage and monitor behaviors and how did this occur. EI #3 replied the CNA had a book and they documented in it every shift, a behavior occurred or did not occur. EI #3 was asked if the CNA observed a behavior what were they to do. EI #3 replied they were to notify her or another RN supervisor. EI #3 was asked if RI #1 was being monitored while the resident was outside. EI #3 replied no. EI #3 was asked should the resident have been monitored while outside. EI #3 replied yes. EI #3 was asked if the accident that occurred on 10/28/2016 was avoidable. EI #3 replied yes, it was. A review of RI #1's Departmental Notes dated 8/23/16 regarding the Care Plan meeting held on 8/17/16 revealed, . He/she remains on Behavior Management for cursing at staff, rolling (his/her) wheelchair into the parking lot unattended, . An interview was conducted on 11/12/2016 at 4:30 p.m., with the EI #1, the DON. EI #1 was asked to review the resident's care plan with a next review date of 2/15/2014. EI #1 was asked about a new identified problem related to behavior management. There was a hand written statement dated 12/11/2013, Resident rolls wheel chair into parking lot unattended. EI #1 was asked what was the approach developed for this behavior and safety issue. EI #1 replied there was a current approach that said provide close supervision was in place. EI #1 was asked how does staff know what close meant. EI #1 stated her definition of close was, staff needed to know where RI #1 was and pay attention to the resident at all times. EI #1 was asked what would the staff say close meant and had the staff been educated as to what close meant. EI #1 replied she had not reviewed with the staff what close was, but she had instructed the staff on keeping the resident safe. EI #1 added she needed to drill down with more specific information other than close. The surveyor reviewed with the DON the elopement tool used by the facility to evaluate safety issues for residents, such as safety of a resident to be outside. EI #1 was asked to review all assessments performed on RI #1 from 12/11/2013. EI #1 was asked if any of the elopement assessments for RI #1 told her RI #1 was safe to be outside by himself/herself. The surveyor showed EI #1 the assessment dated [DATE]. EI #1 replied yes, because of poor decision making skills, there are some risk factors that should be monitored for safety and dementia diagnosis. EI #1 was asked to look at the elopement assessment from 10/19/2016 prior to RI #1's accident on 10/28/2016. EI #1 was asked were there risk factors for this resident related to safety that should have been addressed. EI #1 replied yes and listed cognition, dementia, and poor decision making skills. EI #1 was asked if she was aware of the frequency RI #1 had been found in the parking lot. EI #1 replied no, the CNAs were not coming to her. EI #1 was shown the behavior monitoring tool that the CNAs used to monitor and document this resident's behaviors. EI #1 was asked if the behavior sheets were complete and had all identified behaviors listed for RI #1. EI #1 replied they were incomplete and not done routinely. EI #1 further stated there was no listing of rolling into the parking lot on the (Behavior Management) sheets. EI #1 was asked if RI #1 was at risk for an accident by being unsupervised outside. She answered yes. EI #1 was asked why and she answered cognitive problems with Dementia. EI #1 was asked if the accident on 10/28/2016 was avoidable. She replied yes. EI #1 was asked if the care plan for RI #1 was appropriate for needs with measurable interventions. She answered no. An interview was conducted on 11/12/2016 at 6:39 p.m., with EI #2, the Administrator. EI #2 was asked if he was aware of the frequency RI #1 was being found in the parking lot. EI #2 replied if this resident was being found in the parking lot, yes, he should have known. EI #2 was asked if the accident on 10/28/2016, involving RI #1, was avoidable. EI #2 replied he could not answer that. EI #2 added yes, since hind-site was 20/20, they could have locked all the doors and not let anybody outside, but we were not a prison. The surveyor shared with EI #2 the elopement tool for RI #1 that revealed a [DIAGNOSES REDACTED]. EI #2 was asked if RI #1 was considered unsafe (to be outside). He answered no. EI #2 was asked why and he answered because that tool (the elopement tool) was not all incomprehensible, plus there was individualized judgement involved. EI #2 was asked who would be responsible for updating and revising the care plan. EI #2 replied the Care Plan/MDS coordinator and nursing doing assessments based on departmental needs. ****************************************************** AOC (Allegation of Compliance) On 11/12/16 at 11:26 a.m., the facility provided the following AOC: F-323 - Accident Prevention 1. Incident occurred on October 28, 2016, and resident was sent to hospital for evaluation and treatment. Upon his readmission on October 31, 2016, affected resident was reassessed and Care Plan for affected resident was updated, to provide that he/she would wear a wander-guard to alert staff if he/she tried to exit the facility. That if he/she wished to exit the facility that he/she could do so only with direct staff supervision at all times while he/she was outside. Resident is also receiving physical, speech and occupational therapy. On October 28, 2016, staff on duty were inserviced on safety. Charge nurses were instructed to pass this on during pre-shift report. 2. On October 28, 2016, the DON, ADON, and MDS Coordinator met in ADON's office and reviewed all residents who did not have wander-guard bracelets and independently would sit on the porch to determine if any of those ever showed signs of wandering into the parking lot. No other residents were identified as having a propensity to wander off of the porch. Facility has a secure unit for those residents at risk for wandering or are issued wander guard bracelets. On October 28, 2016, all staff on duty were inserviced on safety related to this incident. Charge nurses were instructed to pass this on during pre-shift report. On November 11, 2016, all staff on duty were re-inserviced by DON or designee on importance of care plans, quality assurance and accident prevention. Those staff not on duty will be called and inserviced and no staff can come on duty without this in-service training. Charge nurses were instructed to ensure staff knew and were following this training. In addition, on November 11, 2016, Administrator, DON, ADON, both MDS Coordinators, and Infection Control RN took current census and identified those who could move independently and either did not have a wander guard bracelet or were not in the secure unit. Then using the Risk of Elopement/Wandering Review Tool the those independently mobile residents were re-assessed and none were identified as an elopement risk. Care plans and ADLs were updated to reflect any potential risk factors identified. On November 11, 2016, all staff on duty and those reporting to work were inserviced on any changes and a note was placed on time clock so that staff reporting to duty will be apprised to report to charge nurse for in-service training prior to taking assignment. 3. On October 28, 2016, all staff were inserviced that all residents who sit outside were to be supervised. On November 11,2016, all staff on duty were re-inserviced by DON or designee on importance of care plans

Based on observations, interviews, and document reviews, the facility failed to ensure the ice machine used to serve ice to residents was not found with a dark slimy substance and with condensation dripping from it and onto the ice on 11/08/16. This was observed one of five survey days and had the potential to affect all 69 residents served meals from the kitchen. Findings include: A review of a facility policy dated May 2014, revealed, . Ice Policy Statement It is the center policy that ice is prepared and distributed in a safe and sanitary manner. Action Steps . 2. The Food Services Director will coordinate with the Maintenance Director to ensure that the ice machine will be disconnected, cleaned and sanitized quarterly and as needed, or according to manufacturer guidelines. 4. The Food Services Director will ensure the ice bins are cleaned monthly and as needed. A review of the 2013 Food Code revealed, . 4-602.11 Equipment Food-Contact Surfaces and Utensils.* (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be cleaned: . (4) In EQUIPMENT such as ice bins and BEVERAGE dispensing nozzles and enclosed components of EQUIPMENT such as ice makers, cooking oil storage tanks and distribution lines, BEVERAGE and syrup dispensing lines or tubes, coffee bean grinders, and water vending EQUIPMENT: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold. An observation was made during the initial tour of the kitchen on 11/08/16 at 5:36 p.m. of the ice dispenser with condensation on the ceiling of the ice storage bin dripping onto the ice below. The condensation was observed to be dripping from a dark area. EI (Employee Identifier) #14, the Dietary Manager, was asked about the appearance and she responded, That's rust. EI #14 was asked to wipe the area with a paper towel. When asked if what was on the paper towel slimy, she answered yes. The paper towel was observed to have a moderate amount of dark brownish slimy substance present. No rust was noted to be left in the area after it was wiped. An interview was conducted with EI #14 at 6:37 p.m. on 11/10/16. EI #14 was asked how machinery/containers that come into contact with food should be maintained. She answered, They should be clean. EI #14 was asked what was the potential concern of condensation dripping on ice that was falling from a slimy substance. She answered, Cross contamination. An interview was conducted with EI #15, the Registered Dietitian/Licensed Dietitian at 7:08 p.m. on 11/10/16. EI #15 was asked how machinery/containers that come into contact with food should be maintained. She answered free of dust, debris or any contaminates and sanitized as the policy indicated. EI #15 was asked what was the potential concern of condensation dripping onto ice that was falling from a slimy substance. She answered, Potential cross contamination.

This deficiency was written as a result of complaint #AL 777. Based on interviews and record reviews, the facility failed to ensure: 1. Documentation was completed every shift daily regarding Behavioral Monitoring for RI (Resident Identifier) #1 and #12; and 2. There was documentation of assessments by the Social Worker related to the behavior management program for RI #1. This affected RI #s 1 and 12, two of thirteen sampled residents. Findings include: 1) A review of an undated Facility Policy and Procedure titled, Behavior Management Program Policy, revealed, Policy: Residents who display mental or psychosocial adjustment difficulty should receive appropriate services, in an attempt to correct the problem. Policy Explanation and Compliance Guidelines: 1. Assessment a. Behaviors shall be identified through the RAI (Resident Assessment Instrument) process and through staff interaction. b. Further assessments to identify and manage behaviors may be conducted. c. Identified behaviors should be evaluated for frequency, duration and intensity for a pattern for 7 days by the documentation on MAR (Medication Administration Record) or other specified location d. The Interdisciplinary Team should decide which residents need a behavior management program. e. The plan of care should be reviewed at least quarterly for continued need of behavior management and appropriate interventions. A review of the Facility's undated Policy and Procedure titled, Charting, revealed, Purpose: Documenting information on the resident in the medical record provides a means of communication between the physician and other professionals contributing to the resident's care, and a basis for planning care. Documentary evidence of the course of treatment during each admission and a way to record the care received. Policy: Charting will be done on all residents to maintain a complete and accurate medical record. Procedure: . 2. Record on the medical record only information that relates to the resident's health problems and medical record 3. Follow the guidelines below to chart information correctly on the medical record. 4. Use the guidelines below to record information appropriately. d. Describe actual behavior, not judgement . A review of RI #1's medical record revealed the resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's Significant Change MDS (Minimum Data Set), assessment dated [DATE], revealed RI #1's BIMS (Brief Interview for Mental Status) score of 9 out of a possible 15, indicating moderate impairment for daily decision making skills. RI #1 used a wheelchair device for mobility. A review of the instructions for use of the MOOD/BEHAVIOR MONITORING tool revealed, Directions: At the end of each shift, document the presence or absence of each symptom by using a O or X . Initial in space provided. A review of the documentation forms for MOOD/BEHAVIOR MONITORING for RI #1 revealed missing documentation for April 2016 as follows: Hallucinations - no documentation for 4/01-1st and 3rd shifts, 4/02-2nd shift, 4/03-3rd shift, 4/06-1st shift, 4/07- all 3 shifts, 4/08-1st shifts, 4/09- all 3 shifts, 4/10-1st and 3rd shifts, 4/11-1st shift, 4/12-1st shift, 4/13-1st shift, 4/14- 1st shift, 4/15-1st and 2nd shifts, 4/16-1st and 3rd shifts, 4/17-1st shift, 4/18-1st shift, 4/19-1st and 2nd shifts, 4/20-1st shift, 4/21-1st shift, 4/22-all 3 shifts, 4/23-all 3 shifts, 4/24-all 3 shifts, 4/25- 1st and 3rd shifts, 4/26- 1st and 3rd shifts, 4/27- 1st and 3rd shifts, 4/28- 1st and 3rd shifts, 4/29- 1st and 3rd shifts, 4/30-all 3 shifts; Delusions - no documentation for 4/01-1st and 3rd shifts, 4/02-2nd shift, 4/03- 3rd shift, 4/06-1st shift, 4/07- all 3 shifts, 4/08- 1st shifts, 4/09-all 3 shifts, 4/10-1st and 3rd shifts, 4/11-1st shift, 4/12-1st shift, 4/13-1st shift, 4/14-1st shift, 4/15-1st and 2nd shifts, 4/16-1st and 3rd shifts, 4/17-3rd shift, 4/18-1st shift, 4/19-1st and 2nd shifts, 4/20-1st shift, 4/21-1st shift, 4/22-all 3 shifts, 4/23-all 3 shifts, 4/24-all 3 shifts, 4/25- 1st and 3rd shifts, 4/26- 1st and 3rd shifts, 4/27- 1st and 3rd shifts, 4/28- 1st and 3rd shifts, 4/29- 1st and 3rd shifts, 4/30-all 3 shifts; Physical behavioral symptoms directed toward others - no documentation for 4/01 through 4/30 was the same as for the Hallucinations; Verbal behavioral symptoms directed toward others - no documentation for 4/01 through 4/30 was the same as for the Hallucinations; Other behavioral symptoms not directed toward others - no documentation for 4/01 through 4/30 was the same as for the Hallucinations; Rejected evaluation or care that is necessary to achieve resident's goals for health and well being - no documentation for 4/01 through 4/30 was the same as for the Hallucinations; Wandering - no documentation for 4/01 through 4/30 was the same as for the Hallucinations. A review of the documentation forms for MOOD/BEHAVIOR MONITORING for RI #1 revealed missing documentation for May 2016 as follows: Hallucinations, Delusions, Physical behavioral symptoms directed toward others, Verbal behavioral symptoms directed toward others, Other behavioral symptoms not directed toward others, Rejected evaluation or care that is necessary to achieve resident's goals for health and well being, and Wandering. The only documentation for May 2016 was on the 3rd shift for 5/12, 5/13, and 5/14. There was no other documentation for May 2016 regarding Mood/Behavior Monitoring. A review of the documentation forms for MOOD/BEHAVIOR MONITORING for RI #1 revealed missing documentation for June 2016 as follows: Hallucinations - no documentation for the 6/1 through 6/9-all shifts, 6/10- 3rd shift, 6/11- all shifts, 6/12- 3rd shift, 6/13 through 6/14- 2nd and 3rd shift, 6/15 through 6/19- 1st and 3rd shifts, 6/20 through 6/21- all shifts, 6/22 through 6/23- 2nd and 3rd shifts, 6/24-1st and 3rd shifts, 6/25 through 6/29- all shifts, and 6/30- 2nd and 3rd shifts. These same missing entries on the Mood/Behavior monitoring tool were found for Delusions, Physical behavioral symptoms directed toward others, Verbal behavioral symptoms directed toward others, Other behavioral symptoms not directed toward others, Rejected evaluation or care that is necessary to achieve resident's goals for health and well being, and Wandering for the month of June 2016. A review of the documentation forms for MOOD/BEHAVIOR MONITORING for RI #1 revealed missing documentation for July 2016 as follows: Hallucinations - no documentation for 7/01 through 7/03- 1st and 3rd shifts, 7/04 through 7/09- all shifts for each day, 7/10- 2nd and 3rd shifts, 7/11 through 7/12- 1st and 3rd shifts, 7/13- all shifts, 7/14- 1st and 2nd shifts, 7/15 through 7/17- all shifts for each day, 7/18 through 7/19- 1st and 3rd shifts, 7/20 through 7/21- all shifts each day, 7/22- 1st and 2nd shifts, 7/23 through 7/24- all shifts each day, 7/25 through 7/27- 1st and 3rd shifts, 7/28 through 7/30- all shifts for each day, 7/31- 1st and 3rd shifts. These same missing entries on the Mood/Behavior monitoring tool were found for Delusions, Physical behavioral symptoms directed toward others, Verbal behavioral symptoms directed toward others, Other behavioral symptoms not directed toward others, Rejected evaluation or care that is necessary to achieve resident's goals for health and well being, and Wandering for the month of July 2016. No MOOD/BEHAVIOR MONITORING for RI #1 documentation was found in the medical record or provided by the facility for the months of August 2016 through September 2016. A review of the documentation forms for MOOD/BEHAVIOR MONITORING for RI #1 revealed missing documentation for October 2016 as follows: Hallucinations - no documentation for 10/01 through 10/24- all shifts, 10/25- 3rd shift, 10/26 through 10/27- 2nd and 3rd shift. A review of the documentation forms for MOOD/BEHAVIOR MONITORING for RI #1 revealed missing documentation for November 2016 as follows: Hallucinations - no documentation for the 11/01- 3rd shift, 11/02- 2nd and 3rd shifts. A review of the medical record for RI #12 revealed a re-admission date of [DATE] with [DIAGNOSES REDACTED]. A review of the Quarterly MDS, assessment dated [DATE], revealed RI #12 scored 15 out of a possible 15 BIMS score. This indicated RI #12 was cognitively intact for daily decision making skills. RI #12 was assessed as totally dependent on staff for transferring and required supervision oversight/set up only with locomotion both on and off the unit. The resident was identified as having ROM (Range of Motion) impairment upper and lower to one side. A review of the documentation forms for MOOD/BEHAVIOR MONITORING for RI #12 revealed missing documentation for October 2016 as follows: Hallucinations - no documentation for 10/25-3rd shift, 10/26 through 10/27-2nd and 3rd shift, 10/28 through 10/29-3rd shift, 10/30-all 3 shifts, 10/31-3rd shift. These same missing entries on the Mood/Behavior monitoring tool were found for Delusions, Physical behavioral symptoms directed toward others, Verbal behavioral symptoms directed toward others, Other behavioral symptoms not directed toward others, Rejected evaluation or care that is necessary to achieve resident's goals for health and well being, and Wandering for the month of October 2016. A review of the documentation forms for MOOD/BEHAVIOR MONITORING for RI #12 revealed missing documentation for November 2016 as follows: Hallucinations - no documentation for 11/01 through 11/02- all 3 shifts, 11/04- all 3 shifts, 11/06-1st and 2nd shift, 11/07- 1st and 3rd shift, 11/08-2nd and 3rd shifts, 11/09- all 3 shifts. These same missing entries on the Mood/Behavior monitoring tool were found for Delusions, Physical behavioral symptoms directed toward others, Verbal behavioral symptoms directed toward others, Other behavioral symptoms not directed toward others, Rejected evaluation or care that is necessary to achieve resident's goals for health and well being, and Wandering for the month of November 2016. On 11/10/2016 at 4:31 p.m., a phone interview was conducted with EI (Employee Identifier) #9, a CNA (Certified Nursing Assistant). EI #9 was asked if she documented the behavior of RI #1 being in the parking lot. EI #9 replied she did not know. EI #9 further stated she did not report this behavior to a nurse. On 11/10/2016 at 5:15 p.m., EI #13, a CNA, was interviewed. EI #13 was asked if RI #1's behaviors were monitored by her. EI #13 replied the CNAs document the monitoring in the behavior book everyday and report behaviors to the nurse. On 11/10/2016 at 6:50 p.m., an interview was conducted with EI #7, an RN (Registered Nurse)/MDS (Minimum Data Set)/Care Plan Coordinator. EI #7 was asked if behavior monitoring for RI #1 was being conducted. EI #7 looked at the behavior monitoring sheets and said basically nothing was done from 2013 until October 2016 and these behavior monitoring sheets did not include the behavior of RI #1 going out into the parking lot. EI #7 also stated the behavior management plan required documentation every shift and everyday. On 11/11/2016 at 12:35 p.m., an interview was completed with EI #4, a CNA. EI #4 was asked how often she saw RI #1 in the parking lot and she stated all the time, sometimes every day. EI #4 was asked if she documented this behavior and where was it documented. EI #4 stated it would be in the behavior documentation book at the nurses station. EI #4 replied she did not know if she had ever documented this behavior problem of resident being in parking lot. An interview was conducted with EI #1, the Director of Nursing, on 11/12/2016 at 4:30 p.m EI #1 was shown the behavior management form used by the facility. EI #1 was asked if assessments were done correctly. EI #1 replied the forms were incomplete and were not done routinely and there was no listing of RI #1's behavior of rolling into the parking lot. 2) A review of RI #1's medical record revealed no documentation of the Social Worker's assessments of RI #1's Behavior Management Program. An interview was conducted with EI #19, the Social Worker, on 11/12/2016 at 1:22 p.m EI #19 was asked about her quarterly assessments of RI #1 and how she collected data. EI #19 replied she did a mood symptom and frequency assessment. She reviewed 14 days back on the mood evaluation. She interviewed the resident and reviewed nursing notes, CNA documentation and obtained first hand information from direct care staff. When EI #19 was asked where the documentation related to the behavior management program that was related to her assessment for RI #1, EI #19 said there was none.

Based on observations, interviews, and record reviews, the facility failed to ensure RI (Resident Identifier) #5 received ADL (Activity of Daily Living) care as indicated in the resident's assessment by not removing facial hair. This affected RI #5, one of thirteen sampled residents. Findings include: A review of an undated facility policy titled, Shaving of Male Residents/Female Facial Hair, revealed, . (Men/Women) with facial hair, be sure it is alright with them to shave or pluck chin or other facial hair. Using a disposable safety razor gently remove facial hair from affected areas and then apply lotion to skin. A review of the medical record for RI #5 revealed a re-admission date of [DATE] with [DIAGNOSES REDACTED]. A review of the Quarterly MDS (Minimum Data Set), assessment dated [DATE], revealed RI #5 had severe cognitive impairment with long and short term memory deficit. The assessment indicated RI #5 required extensive assistance with ADLs (Activities of Daily Living) to include hygiene and bathing. A review of RI #5's plan of care, with a next review date of 12/19/16, revealed a Problem/Need of . Requires supervision to limited assistance with ADL's r/t (related to) impaired thought processes . Approaches . Daily grooming & (and) hygiene: . An observation was made on 11/09/16 at 10:04 a.m. of RI #5 with visible facial hair on the sides of the upper lip and under the chin. The hairs under the chin were greater than half an inch long. The hairs on the lip were on the side area of the lip and a moderate amount. An observation was made on 11/10/16 at 10:32 a.m. of RI #5 with visible facial hair on the upper lip and under the chin. There were no changes in the appearance of the facial hair. An interview was conducted with EI (Employee Identifier) #16, a CNA (Certified Nursing Assistant), at 4:15 p.m. on 11/10/16. EI #16 was asked what assistance RI #5 required with grooming. She answered, Total. We do everything for him/her. He/she may assist. EI #16 was asked who was supposed to provide that care. She answered, The CNA and then the Nurse. EI #16 was asked who was responsible for removing RI #5's facial hair. She answered, The CNA. EI #16 was asked what was the facility's policy regarding removal of facial hair. She answered, We shave them. EI #16 was asked why RI #5 was observed on 11/9/16 and 11/10/16 with long white hairs under the chin and hair on the upper lip. She answered, I don't know. EI #16 was asked what was the concern when a resident does not receive the needed assistance with grooming. She answered, I would be upset, I wouldn't want to look unkept. EI #16 was asked to observe RI #5's face and describe what she saw. She answered, Hairs on (RI #5's) chin that are long. Lip on sides (have) patches. An interview was conducted with EI #17, an LPN (Licensed Practical Nurse), at 4:27 p.m. on 11/10/16. EI #17 was asked what assistance RI #5 required with grooming. She answered (RI #5) required extensive to total assistance. EI #17 was asked who was supposed to provide that care. She answered the CNA or then the Nurse. EI #17 was asked who was responsible for removing RI #5's facial hair. She answered the CNA or then the Nurse, usually with their bath. EI #17 was asked what was the facility's policy regarding removal of facial hair. She answered shave them if they have facial hair. EI #17 was asked why RI #5 was observed on 11/9/16 and 11/10/16 with long white hairs under the chin and hair on the upper lip. She answered because they haven't done it with the a.m. care. EI #17 was asked what was the concern when a resident did not receive the needed assistance with grooming. She answered they were not getting proper grooming. EI #17 was asked to observe RI #5's face and describe what she saw. She answered, Some long white hairs on (RI #5's) chin . thick patches of white hair on the sides. An interview was conducted with EI #18, an RN (Registered Nurse), at 4:36 p.m. on 11/10/16. EI #18 was asked what assistance RI #5 required with grooming. She answered total to extensive assistance. EI #18 was asked who was supposed to provide that care. She answered the CNA. EI #18 was asked who was responsible for removing RI #5's facial hair. She answered the CNA. EI #18 was asked what was the facility's policy regarding removal of facial hair. She answered, Keep it shaved, monitor; Keep the resident presentable. EI #18 was asked why RI #5 was observed on 11/9/16 and 11/10/16 with long white hairs under the chin and hair on the upper lip. She answered, It was hard to see. EI #18 was asked what was the concern when a resident does not receive the needed assistance with grooming. She answered, The grooming will not get done. EI #18 was asked to observe RI #5's face and describe what she saw. She answered, Long hairs under (RI #5's) chin. Patches of hair on each side.

Based on interviews and record reviews, the facility failed to implement a Behavior Management program regarding RI #1's behavior of self-propelling in the wheelchair into the parking lot unsupervised. This affected RI #1, one of five residents sampled for behaviors. Findings include: A review of RI #1's medical record revealed RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's Significant Change MDS (Minimum Data Set), assessment dated [DATE], revealed RI #1's BIMS (Brief Interview for Mental Status) RI #1 scored a 9 out of a possible 15, indicating moderate impairment for daily decision making skills. RI #1 used a wheelchair device for mobility. A review of RI #1's Care Plan indicated a Problem/Need Section with a Problem Onset date of 01/01/2013 for Behavior Management. On 12/11/2013, the behavior of RI #1 rolling the wheelchair into the parking was added to the care plan. However, there were no interventions/approaches added to the care plan to address the behavior of RI #1 rolling the wheelchair into the parking lot. A record review of RI #1's care plan meeting notes to include the following dates: 9/9/2015, 9/10/2015, 9/18/2015, 9/24/2015, 11/20/2015, 2/24/2016, 11/20/2015, 3/1/2016, and 5/18/2016, indicated RI #1 continued to have behavior issues at times. The care plan meeting notes did not address RI #1 rolling in a wheelchair into the parking lot. A care plan meeting on 8/17/2016 continued to discuss RI #1's behaviors and included RI #1 rolling into the parking lot in a wheelchair. There were no new approaches documented at this time on the care plan. A review of RI #1's Departmental Notes dated 8/23/16 regarding the Care Plan meeting held on 8/17/16 revealed, . He/she remains on Behavior Management for cursing at staff, rolling (his/her) wheelchair into the parking lot unattended, . An interview was conducted with EI #19, the Social Worker, on 11/12/2016 at 1:22 p.m EI #19 was asked to describe or explain the statement documented on the 8/17/2016 care plan meeting. EI #19 stated this was a hazard for RI #1 and was care planned as a behavior. Nursing staff told this resident not to do this on 12/11/2013 because RI #1 was in a wheelchair and may not be visible. This behavior and safety issue remained on RI #1's care plan to be monitored. EI #19 was asked if she was aware this was an ongoing behavior. EI #19 replied no, she was not aware this was an ongoing behavior. EI #19 was asked if she had known this safety/behavior was an ongoing issue for RI #1, would she have been involved. EI #19 replied yes, she would have gone to the RN (Registered Nurse) to discuss RI #1's wishes and needs to go outside safely. EI #19 was asked about her quarterly assessments of RI #1 and how she collected data. EI #19 replied she did a mood symptom and frequency assessment. She reviewed 14 days back on the mood evaluation. She interviewed the resident and reviewed nursing notes, CNA documentation and obtained first hand information from direct care staff. EI #19 was asked where the documentation related to the behavior management program was as related to her assessment for RI #1. EI #19 said there was none.

Based on observations, interviews and review of facility policies and the Food and drug Administration (FDA) Food Code 2013, the facility failed to ensure: 1. Raw chicken was stored in the refrigerator in a manner to prevent cross contamination 2. Staff member Employee Identifier (EI) #5 washed her hands and changed her apron after handling dirty dishes and prior to removing a rack of clean dishes out of the dish washing to prevent the potential for cross contamination 3. Staff utilizing the three compartment sink for manual dish washing ensured the Auto Chlor Sanitizer parts per million (ppm) was at the appropriate level according to the manufactory recommendation was 200 parts per million. This had the potential to affect all 72 residents receiving meals from the kitchen. Findings include: 1. A facility policy titled Food Storage: Cold with an revision date of May 2014, documented: Policy Statement It is the center policy to insure (ensure) all Time/Temperature Control for safety (CS), frozen and refrigerated food items, will be appropriately stored in accordance with guidelines of the USDA (United States Department of Agriculture) Food Code. Action Steps . 5. The Food Services Director/Cook(s) insures that all food items are stored properly in covered containers, labeled and dated, and arrange in a manner to prevent cross contamination . Review of the facility ServSafe document titled HOW TO STORE FOOD PROPERLY documented: Best Practices for Storing Food Store raw meat, poultry and seafood below cooked or ready-to-eat food . Review of the Food and Drug Administration Food Code 2013, Chapter 3 Food, page 68, revealed the following: . Preventing Food and Ingredient Contamination 3-302.11 Packed and Unpacked Food-Separation, Packing, and Segregation (A) FOOD shall be protected from cross contamination by: (1) . separating raw animal FOOD during storage, preparation, holding, and display from: . (b) Cooked READY-TO-EAT FOOD; (c) . commercially processed and packaged, ready-to-eat food . On 1/5/16 at 11:47 AM, the Surveyor during the initial tour of the kitchen and accompanied by EI #4, the CDM (Certified Dietary Manager), the Surveyor observed a silver pan covered with foiled labeled raw chicken on a rack in the meat refrigerator. A tray of nourishment with the time 2 PM and the date of 1/5/16 labeled on them. The CDM identified lunch meat (ham) in a plastic bag with a date of 1/3/16-1/10/16. On 1/7/16 at 11:51 AM, the Surveyor conducted an interview with EI #4. The Surveyor asked EI #4, how should raw chicken be stored in the refrigerator. EI #4 replied on the lowest shelf. EI #4 was asked what was stored underneath the raw chicken. EI #4 replied the slice ham in a bag and some nourishments was stored underneath the raw chicken. EI #4 was asked what is the facility policy on storing raw chicken. EI #4 replied it should be stored at the bottom shelf with nothing underneath it. EI #4 was asked what the potential harm was in storing raw chicken above nourishment and ham in the refrigerator. EI #4 replied that it was cross contamination. 2. Review of the Food and Drug Administration Food Code 2013, Chapter 2 Management and Personnel, page 47, revealed the following: . 2-301.14 When to Wash FOOD Employees shall clean their hands and exposed portions of their arms . immediately before . working with exposed FOOD, clean EQUIPMENT and UTENSILS . On 1/5/2016 at 1:54 PM, while in the kitchen, the Surveyor observed a staff member EI #5, a Dietary Aide/Head Cook, without gloves on, rinsed and racked dishes then place the dishes in the automatic dishwasher machine. EI #5 proceeded to the clean side and pulled a rack of dishes out of the washing machine without washing her hands or changing her apron. On 1/7/16 at 11:51 AM in an interview with EI #4, EI #4 was asked when a Dietary Staff member goes from the dirty to the clean side of the dish washing room what should be done. EI #4 replied she should have washed her hands. EI #4 was asked what should have been done with the apron EI #5 had on going from dirty to clean side of the dish washing room. EI #4 replied it should have been changed. EI #4 was asked what was the facility policy on what a dietary staff member should do when working on the dirty dish washing side and then going to the clean side. EI #4 replied they should always wash their hands. EI #4 was asked what potential harm can occur if Dietary Staff member does not wash their hands or change their apron before going from dirty dish washer side to the clean dishwasher side. EI #4 replied, Infection. 3. Review of a facility policy titled, Manual Ware Washing with a revision date of May 2014, documented: Policy Statement It is the center policy to insure (ensure) all service ware and cook ware that is not processed through the dish machine will be manually washed and sanitized. Action Steps 1. The Food Services Director insures that the Dining Service staff is knowledgeable in proper techniques for . sanitizing . A facility document titled Precision QAC QR5 revealed the Auto Chlor should be at 200 ppm (parts per million). On 1/6/16 at 11:24 AM, after preparing clean dish water in the three compartment sink the sanitizing solution was checked by a staff member with the results 400 ppm. In an interview with EI #4 on 1/7/16 at 11:51 AM, EI #4 was asked according to the manufactory recommendation what should ppm be in the three compartment sink. EI #4 replied the recommendation was 200. EI #4 was asked what was the ppm on 1/6/16 in the three compartment sink at 11:24 AM. EI #4 replied 400. EI #4 was asked what should have been done if the ppm was not according to manufactory recommendation. EI #4 replied to retest it. EI #4 was asked what was the facility policy on the ppm in the three compartment sink. EI #4 replied there was not one, they go by the manufactory recommendation. EI #4 was asked what potential harm can occur if the ppm is too high or not according to the manufactory's recommendation. EI #4 replied she did not know.

Based on observation, interview, and review of a facility policy titled MEDICATION STORAGE IN THE FACILITY, the facility failed to ensure stock controlled drug, injectable (Lorazepam) Ativan 2 mg (milligrams)/ml (milliliter) 4 vials that were stored in a locked box compartment that was not permanently affixed to the inside of the refrigerator. Also, the facility failed to ensure nine unsampled residents who were prescribed injectable Ativan 2 mg were stored in a locked box compartment that was not permanently affixed to the inside of the refrigerator. The total amount of Ativan 2 mg vials observed in the unsecured box compartment were 39 vials of controlled drug. One of three medications rooms were affected and nine of nine unsampled residents who were prescribed injectable Ativan 2 mg were affected by this deficient practice. Findings Included: A facility policy titled MEDICATION STORAGE IN THE FACILITY Revised August 2014, documented the following: CONTROLLED SUBSTANCE STORAGE Policy Medications included in the Drug Enforcement Administration (DEA) classification as controlled substance are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations . Procedures A. The director of nursing, in collaboration with the consultant pharmacist, maintains the facility's compliance with federal and state laws and regulations in the handling of controlled substances . B. Schedule (II-V) medications and other medications subject to abuse or diversion are stored in a permanently affixed, (double-locked) compartment separate from all other medications or per (by) state regulation . C. Controlled-substance that require refrigeration are stored within a locked box within the refrigerator. This box must be attached to the inside of the refrigerator . On 1/7/16 at 2:55 p.m., the surveyor conducted an observation of the medication room where the E-Kit (Emergency Kit) and STAT Box (Emergency Box Of Medication) are stored. On 1/7/16 at 3:00 p.m., during the observation of the medication room, the surveyor ask the Director Of Nursing (DON), Employee Identifier (EI) #1 if there were any controlled narcotics in the refrigerator. EI #2 said yes, stock Ativan and resident's Ativan. EI #2, a medication nurse who opened the refrigerator with a key. The surveyor observed a locked metal box and clear plastic box lying on a rack, that was not permanently affixed to the inside of the refrigerator. EI #1 lifted each box and they were easily removed from the refrigerator. There were four stock Ativan 2 mg injectable vials, and 40 injectable Ativan 2 mg vials that were prescribed for use as prn (as needed) medication for nine resident who resided on the Alzheimer secure unit. On 1/7/16 at 3:05 p.m., the surveyor conducted an interview with the DON, EI #1. How long has the facility stored Ativan in this refrigerator, in a box that was not permanently affixed inside the refrigerator. EI #1 said she been the DON for 2 years and it (the Ativan) has been like that since then. EI #1 said she was the Assistant Director Of Nursing (ADON) for 6 years and the Ativan was stored like that in the same manner in the refrigerator and not permanently affixed. The surveyor asked EI #1 how should the narcotic be stored in the refrigerator. EI #1 said in a locked box, under two locks and that's all.

Based on observations, interview and review of a facility policies and the Food and Drug Administration (FDA) Food Code 2013, the facility failed to ensure the lid on one of three dumpster's remained closed on 1/5/16. The facility further failed to ensure trash was kept on the inside of the dumpster's to prevent the potential for rodents and pest attractions. This had the potential to affect all 74 residents residing in the facility. Finding Include: A facility policy titled Disposal of Garbage and Refuse Policy with no date documented: Disposal of Garbage and Refuse The facility shall properly dispose of garbage and refuse. Policy Explanation and Compliance Guidelines: . 6. Refuse containers and dumpster's kept outside the facility should have tightly fitting lids and should be kept covered when not being loaded. 7. garbage should not accumulate or be left outside the dumpster. Review of the FDA Food CODE 2013, Chapter 5 Water, Plumbing, and Waste, pages 168 and 170, revealed the following: . 5-501.15 Outside Receptacles (A) Receptacles and waste handling units for refuse, recyclables, and returnables used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers . 5-501.110 Storing Refuse, Recyclables, and Returnables. REFUSE, recyclables, and returnables shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents . 5.501.13 Covering Receptacles. Receptables and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: . (B) With tight-fitting lids or doors if kept outside the FOOD ESTABLISHMENT . During the initial tour of the kitchen on 1/5/2016 beginning at 11:47 AM, the surveyor accompanied by Employee Identifier (EI) #4, the CDM (Certified Dietary Manager) to the area where the dumpster's were located. The surveyor observed two dumpster's outside the kitchen area and another dumpster adjacent to the other two dumpter's observed to have the lid opened. The surveyor also observed debris on the ground next to the single dumpster. On 1/7/16 at 11:51 AM, the surveyor conducted an interview with EI #4. The surveyor asked EI #4 how should the lids be on the dumpster's outside. EI #4 replied, closed at all times. EI #4 was asked how should the area on the ground be around the dumpster. EI #4 replied it should be clean and free of debris. EI #4 was asked what she observed on the ground around the dumpster on 1/5/16. EI #4 replied a lot of boxes. EI #4 was asked how did she observe he lid on the single dumpster on 1/5/16. EI #4 replied it (lid) was partially closed. EI #4 was asked what was the facility policy on the dumpster. EI #4 replied they should be closed and free of debris at all times. EI #4 was asked what is the potential harm if the dumpster was not closed all the way and debris was on the ground around the dumpster. EI #4 replied it can attract pest and rodents.

Based on observations, interviews, record review and review of a facility policy titled Medication Administration - General Guidelines, the facility failed to ensure a medication nurse, Employee Identifier (EI) #3, did not signed her initial on the MAR (Medication Administration Record) before she administered medications to Resident Identifier (RI) #10 on 1/6/16. This deficient practice affected RI #10, one of 10 residents observed during the Medication Administration Observation and 1 of 3 medication nurses observed during the Medication Administration Observation conducted on 1/6/16 - 1/7/16. Findings Include: Potter and Perry, Fundamentals of Nursing, Eighth Edition, 2013, page 586, documents: . Right Documentation . After administering a medication, indicate which medication was given on the patient's (Medication Administration Record) MAR . Record each medication on the patient's MAR as soon as you give medication to a patient . A facility's policy titled Medication Administration - General Guidelines with an effective date of 1/1/2015 documented: Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration) . Procedures: . D. Documentation . 1. The individual administers the medication dose records the administration on the resident's (MAR) directly after the medication is given . RI #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #10's physician's orders [REDACTED]. . Potassium CL (Chloride) 20 MEQ (milliequivalents) TABLET ER (Extended Release) Give 1 Tablet By Mouth Three Times A Day with Food, [MEDICATION NAME] 200 MG (milligrams) 1 once a day at 12 PM (12 noon), Ropinirole 0.5 MG Tablet Give 1 Tablet By Mouth Three Times A Day, [MEDICATION NAME] 0.5 MG Give 1 Tablet By Mouth Once A Day At 1 PM, . On 1/6/2016 at 12:08 p.m., the surveyor observed EI #3 prepare the above medications for administration to RI #10. EI #3 removed the medication from the medication cards and signed her initials on the MAR. Then EI #3 carried these medications into the dining room and administered RI #10 the above medications. On 1/6/16 at 4:48 p.m., the surveyor conducted an interview with EI #3. The surveyor asked EI #3 when giving a resident medication when should the nurse sign the MAR. EI #3 said she would sign the MAR when she was ready to administer the medicine. The surveyor asked EI #3 if she had ever been told or read a policy or standard that said sign the MAR after the medication have been given to the resident. EI #3 said no. EI #3 said she would pull the medications, then administer the medication. EI #3 said, then she would sign the MAR. The surveyor asked EI #3 did she do this during the medication pass when she administered RI #10's medication. EI #3 said no, she don't think so. On 1/6/16 at 5:00 p.m., the surveyor conducted an interview with EI #1, the Director Of Nursing (DON), EI #1. The surveyor asked EI #1, what should the nurses do while passing medications to the residents. EI #1 said follow the 6 rights and make sure she (the nurse) sign out for all the medications she gives on the MAR. The surveyor asked EI #1, should the nurse sign the MAR before the medications are administered to the resident. EI #1 said no, the nurses should sign their initials on the MAR after the medications are administered to the resident.

Based on observation, interviews and record reviews, the facility failed to ensure a licensed staff nurse Employee Indentifer (EI) #6, washed or sanitized her hands after changing gloves during the provision of wound care to Resident Identifier (RI) #4. This affected one of two residents observed for wound care. Findings include: Review of a facility policy titled Hand Washing with no date, documented: Policy: The purpose of this procedure is to provide guidelines for the proper hand washing to prevent the spread of infection to other personnel, residents and visitors. Compliance Guidelines: All facility personnel must wash their hands for 15 seconds under the following conditions: . 3. After handling contaminated objects . 13. After handling items potentially contaminated with . secretions . 15. After removing gloves . Review of the facility policy and procedure titled Wound Care/ Treatment Guidelines with no date, documented: . Wound Care Policy (Steps) . 10. Gloves are put on prior to starting treatment 11. Old bandages are removed and placed in plastic bag for disposal 12. Gloves are removed and hands are washed and mew gloves are applied 13. Wounds are cleaned per facility protocol 14. Gloves are removed and hands are washed 15. Medication, dressing, etc. are applied. Remove gloves and wash hands . RI #4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of RI #4's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) date of 12/9/15, revealed RI #4 had short term and long term memory problems. The MDS also revealed RI #4 had a Stage 2 pressure ulcer. On 1/6/16 at 4:40 PM during wound care, EI #6, the LPN (Licensed Practical Nurse) Treatment Nurse, was observed to wash her hands and gloved. Saturated 4X4 with with wound cleanser and cleansed RI #4 right hip wound from inner to outer and tossed the 4X4 into a plastic bag. EI #6 then reach back into the clean field and picked up another 4X4 and patted the wound dry, then washed her hand and applied more gloves. EI #6 took a skin prep and wiped around the wound and took those gloves off and applied another pair without washing her hands. EI #6 then applied the boarder gauze with [MEDICATION NAME] ointment to RI #4 wound. On 1/7/16 at 12:30 PM EI #6, the LPN Treatment Nurse was interviewed by the Surveyor and asked, what should be done when changing gloves. EI #6 replied to wash your hands. EI #6 was asked after cleansing a wound and and before touching a clean 4X4 what should be done. EI #6 stated, Take those gloves off and wash your hands that way you won't come in contact with nothing else. EI #6 was asked after cleansing around the wound with a skin prep and taking off the gloves and before applying another pair of gloves what should have been done. EI #6 replied to wash your hands. EI #6 was asked what the facility policy was on changing gloves and handwashing. EI #6 stated, Wash hands before putting them on and wash hand after taking off them. EI #6 was asked what potential harm can occur to the resident if the hands are not washed or sanitized after changing gloves or going from dirty to clean and not washing hands. EI #6 stated, It could spread infections. On 1/7/16 at 3:40 PM the Surveyor conducted an interview with EI #7, the RN (Registered Nurse) ADON (Assistant Director of Nursing). EI #7 was asked during wound care when going from dirty to clean what should be done. EI #7 replied to take off those dirty gloves, wash hands, and put on a clean pair. EI #7 was asked after cleansing a wound and before patting it dry with a clean 4X4 what should be done. EI #7 replied to wash hands and put on more gloves. EI #7 was asked after prepping around a wound with a skin prep and before applying a clean dressing what should be done. EI #7 replied to wash hands and apply clean gloves. EI #7 was asked what was the facility policy on on changing gloves. EI #7 stated, Anytime going from dirty to clean wash hands and change your gloves. EI #7 was asked what potential harm can occur if hands are not washed or sanitized after changing gloves and the gloves are not changed going from dirty to clean during wound care. EI #7 stated, A potential to spread bacteria.

Based on observations, interviews and record review, the facility failed to post nurse staffing information prior to the beginning of the shift as required. On 06/03/2015 there was no staff posting observed prior to the 7A-3P shift or the 3P-11P shift. This was observed on one (1) of one day of the survey and had the potential to affect all 78 residents residing in the facility The facility further failed to ensure there were a Report of Nursing Directly Responsible for Resident Care form for each day of the past 18 months (May 2014 through June 2015). Also, the Report of Nursing Directly Responsible for Resident Care forms did not contain all of the federally required data. Findings Include: A review of a facility policy titled (Name of the Facility) Nursing Service Staffing Levels Policy with no date revealed: . 2. The specific nursing staff numbers and the census will be posted daily in a prominent location in the facility with the following information a. Facility name b. Current date c. Total number of licensed and unlicensed nursing staff responsible for direct care per shift d. Resident census. On 06/03/2015 at 9:00 AM, the surveyor observed the posting of the Report of Nursing Directly Responsible for Resident Care form. The Report of Nursing Directly Responsible for Resident Care form was dated 06/02/2015 and did not include information for the Night (11P-7A) shift. There also was no Report of Nursing Directly Responsible for Resident Care form posted for the 7A-3P shift at that time. On 06/03/2015 at 3:10 PM, the surveyor observed the Report of Nursing Directly Responsible for Resident Care form posted. The nurse staffing information (the number of RN's (Registered Nurse), LPN's (Licensed Practical Nurse) and CNA's (Certified Nursing Assistant) responsible for resident care) and the census was not documented on the form for the 3P-11P shift. On 06/04/2015 at 11:35 AM, the surveyor along with EI (Employee Identifier) #1, the ADON (Assistant Director of Nursing)/Staffing Coordinator reviewed the Report of Nursing Directly Responsible for Resident Care forms for the past 18 months. A review of the Report of Nursing Directly Responsible for Resident Care forms from May 2014 through June 2015 revealed the facility had no evidence the forms had been done for the following days: Year 2014 There were no Report of Nursing Directly Responsible for Resident Care forms for the entire months of January through April. May: 1st-13th, 15th-28th, 30th, 31st. June: 1st-3rd, 5th, 6th, 9th-23rd, 26th-29th. July: 1st, 3rd-22nd. August: 4th, 5th, 7th-10th, 23rd-25th, 28th. September: 5th, 26th. October: 3rd, 4th, 10th, 18th, 27th. November: 7th, 10th, 15th, 21st, 25th, 28th-30th. December: 5th, 13th, 14th, 24th, 25th, 27th. Year 2015 January: 2nd, 10th, 16th, 21st, 24th, 25th, 31st. February: 2nd, 7th, 13th, 21st, 27th. March: 8th, 12th, 13th, 16th, 22nd, 28th. April: 2nd, 4th, 18th, 19th, 24th, 28th. May: 1st, 2nd, 8th, 11th, 16th, 22nd, 25th. Further review of the Report of Nursing Directly Responsible for Resident Care forms for May 2014 - June 2015, revealed the data did not contain one or more of the Federally required information for nurse staff posting (i. e. (for example) the facility name, the census, the total number of nursing staff working each shift and the actual hours worked by nursing staff). On 06/04/2015 at 11:35 AM, the surveyor conducted an interview with EI #1. EI #1 was asked who was responsible for posting the daily nurse staffing. EI #1 said EI #2, a RN who worked the 7A-3P shift. EI #1 was asked who was responsible overall for daily nurse staffing postings. EI #1 said she knew when it was supposed to be posted and what information was supposed to be on it. EI #1 was asked when were the daily nurse staffing postings done for each shift. EI #1 said first thing every morning. EI #1 said EI #2 came in at 6:00 AM or 6:30 AM and completed the form. EI #1 was asked who posted the daily nurse staff posting on 6/03/2015 for the 3P-11P shift. EI #1 said she did. EI #1 was asked what time was the 3P-11P daily nurse staffing posted on 6/03/2015. EI #1 said she thought shortly after 3:30 PM. EI #1 was asked when was it supposed to be posted. EI #1 said she did not know that there was a specific time. EI #1 was asked if she was aware that it was to be posted prior to the beginning of each shift. EI #1 said no. EI #1 was asked what information should be documented on the daily nurse staffing form. EI #1 said the number of nurses in the building, LPNs, RNs, CNAs and whether they are direct or indirect care. EI #1 was asked if the facility name was documented on any of the daily nurse staffing forms. EI #1 said no. EI #1 was asked should the facility name be documented on the form. EI #1 said probably. EI #1 was asked what the facility's policy said about the information that should be present on the daily nurse staffing forms. EI #1 said facility name, date, total number staff of licensed and unlicensed nursing staff responsible for direct care per shift and resident census. EI #1 was asked if the daily nurse staffing forms that were provided to the surveyor was all that the facility had for the past 18 months. EI #1 said, They were all that we could locate, yes ma'am. EI #1 was asked if she was able to supply the surveyor with 18 months of daily nurse staff postings. EI #1 said, We went back to May 2014, so no. EI #1 was asked why she was not able to supply the surveyor with 18 months of daily nurse staff postings. EI #1 said, Because the DON (Director of Nursing) prior to now, we cannot find where she was keeping copies. The change of DON occurred October 17, 2014. EI #1 was asked should the facility be able to provide the surveyor with 18 months of daily nurse staffing postings. EI #1 said yes. EI #1 was asked how many months of daily nurse staffing postings were present. EI #1 said, About 12 months. On 06/04/2015 at 12:40 PM, an interview was conducted with EI #2. EI #2 was asked if she posted the 7A-3P daily nursing staffing on 06/03/2015. EI #2 said yes. EI #2 was asked what time she posted the daily nursing staffing. EI #2 said, It had to be close to 9:00 AM. EI #2 was asked if she was aware that nursing staffing should be posted for each shift prior to the beginning of the shift. EI #2 said yes. EI #2 said normally it was but yesterday she went to check on a patient before she did it. Chenelle Beacham, RN Sylvia Forman, RN

Based on observations, interview, and record reviews, the facility failed to: 1. Ensure wet nesting was not observed in the facility's kitchen on 11/4/14 and 11/5/14, two of three survey days. 2. Prevent the potential for cross contamination by a staff member, who picked up a wet paper towel off of the floor, and placed it on top of a serving table. These deficiencies had the potential to affect all 74 residents receiving meals from the kitchen. Findings Include: 1. Wet Nesting A review of the facility's policy (with no date) titled: "Pot Washing Dishwashing in Three Compartment Sink," revealed: "Policy: Utensils and dishes washed by hand will be clean and sanitized. Procedure: ... 2. Wash pots thoroughly inside and out. Use a fiber brush or stainless steel sponges to remove cooked on food and grease. ... 9. Allow pots to drain and air dry. ..." During the tour on 11/4/14 at 2:45 PM, the surveyor observed 4 of 4 large cooking sheet pans stacked wet, and stored near a stove in the kitchen. Two of the four pans had a residual of grease. EI (Employee Identifier) #1, the facility's Dietary Manager, was present during the observation. On 11/5/14 at 10:45 AM, three of three serving trays were stacked wet with food particles observed on the surface of the trays. The trays were stacked near the dish washing area. An interview was conducted with EI #1 on 11/6/14 at 1:30 PM. The surveyor shared the above observations of wet nesting on 11/4/14 and 11/5/14 with EI #1. The surveyor asked what the concern was when wet nesting was observed in the kitchen. EI #1 stated, "It could cause bacteria." 2. Potential for cross contamination. A review of the facility's policy (with no date) titled: "Required Cleaning and Sanitation... POLICIES: FOOD CONTACT SURFACES... To prevent cross-contamination, kitchenware and food-contact surfaces of equipment shall be washed, rinsed, and sanitized after each use and following any interruption of operations during which time contamination may have occurred. ..." During an observation of the tray line on 11/5/14 at 12:05 PM, EI #1 dropped a wet paper towel onto the floor. EI #1 picked up the wet paper towel and placed it on a serving table that had individual servings of salad for residents. An interview with EI #1 was conducted on 11/6/14 at 1:30 PM. The surveyor asked EI #1 if the top of the serving table was sanitized after the contaminated paper towel was removed from it. EI #1 said she did not know, she was working at the stove. The surveyor asked EI #1 what the concern was when an item was dropped on the on the floor and placed on top of a serving table. EI #1 stated, "Contamination."

Based on observations, interviews and record reviews, the facility failed to ensure a CNA (Certified Nursing Assistant) washed her hands and changed her gloves: 1. After removing shoes and pants prior to performing incontinence care, and 2. After removing stool from RI (Resident Identifier) #9's bottom prior to placing a clean brief, pants, and shoes on the resident. A review of RI #9's medical record revealed RI #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #9's Annual MDS (Minimum Data Set) with an assessment reference date of 7/6/14, revealed RI #9 had long and short term memory problems, and was severely impaired for decision making. RI #9 required extensive to total assistance for all activities of daily living, and was coded as always incontinent of bowel and bladder. During an observation of incontinence care on 11/5/14 at 4:30 PM, the CNA, EI (Employee Identifier) #4 washed her hands and applied gloves. EI #4 removed RI #9's shoes and pants. EI #4 did not wash her hands or change her gloves. EI #4 provided incontinence care with the contaminated gloves, which included opening the labia of RI #9. The resident had expelled a small amount of liquid stool. EI #4 did not wash her hands or change her gloves. EI #4 turned RI #9 onto the right side. EI #4 removed stool from RI #9's bottom. She did not remove the contaminated gloves after providing incontinence care. EI #4 applied clean brief, pants, and shoes, then removed the contaminated gloves and washed her hands. An interview was conducted with EI #4 on 11/5/14 at 5:05 PM. The surveyor asked EI #4 when did she change her gloves and wash her hands during the above incontinence care observation. EI #4 stated, "I washed my hands before I started care, and after I finished." The surveyor asked EI #4 if she washed her hands or changed her gloves after removing RI #9's shoes and pants, prior to providing incontinence care. EI #4 stated, "No ma'am." The surveyor asked EI #4 if she washed her hands or changed her gloves after removing stool from RI #9's bottom, and prior to applying a clean brief, pants, and shoes. EI #4 stated, "No ma'am." The surveyor asked why not and EI #4 stated, "I get nervous." The surveyor asked EI #4 what the concern was, with the above observations. EI #4 stated, "Contamination." An interview was conducted with the Director of Nursing of the facility, EI #3, on 11/6/14 at 4:10 PM. The surveyor asked EI #3 when should staff wash their hands and change gloves while cleaning stool off of residents, during incontinence care. EI #3 stated, "Before they start and when they get finished, and any time they have to change gloves in-between." The surveyor asked EI #3 to give an example of when gloves should be changed in-between care. EI #3 stated, "Well if they got BM (bowel movement) on their gloves." The surveyor discussed the above observations with EI #3. EI #3 was asked what the concern was. EI #3 stated, "You are contaminating the clean clothes. You need to wash your hands because there might be germs on the shoes and clothes."

Based on observations and interviews, the facility failed to ensure a foley catheter urinary drainage bag was observed in a dignity bag. This affected RI (Resident Identifier) #6 and was observed on two of three survey days. This resident was one of two residents sampled for foley catheters. A review of the medical records revealed RI #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly MDS (Minimum Data Set) for RI #6, with an ARD (Assessment Reference Date) of 09/15/2014, revealed a BIMS (Brief Interview for Mental Status) score of zero out of a possible fifteen points. This indicated that RI #6 was severely impaired for decision making skills. RI #6 was coded as needing total assistance with all ADLs (Activities of Daily Living). RI #6 was coded as requiring an indwelling foley catheter and always incontinent of bowel. On 11/4/2014 at 5:40 PM, an observation was made of RI #6's foley catheter urinary drainage bag hanging on the left side of the bed which was facing the door. The urinary drainage bag was not in a dignity bag. On 11/05/2014 at 7:45 AM, an observation was made of RI #6's foley catheter urinary drainage bag hanging on the left side of the bed which was facing the door. The urinary drainage bag was not in a dignity bag. On 11/05/2014 at 11:10 AM, an observation was made of RI #6's foley catheter drainage bag hanging on the right side of the bed which was away from the door. The urinary drainage bag was not in a dignity bag. On 11/05/2014 at 3:15 PM, an observation was made of RI #6's foley catheter urinary drainage bag hanging on the left side of the bed which was facing the door. The urinary drainage bag was not in a dignity bag. On 11/06/2014 at 1:20 PM, an interview was conducted with EI (Employee Identifier) #2, a CNA (Certified Nursing Assistant). EI #2 was asked who was responsible for placing a urinary drainage bag in a dignity bag. EI #2 stated, a CNA. EI #2 was asked why it was important for a urinary drainage bag to be inside of a dignity bag. EI #2 stated it had to do with a resident's privacy and letting everyone know a resident had a catheter. EI #2 stated, "Keeping it from touching the floor, getting any infection in it." On 11/06/2014 at 2:30 PM, an interview was conducted with EI #3, the DON (Director of Nursing.) EI #3 was asked who was responsible for placing a urinary drainage bag in a dignity bag. EI #3 stated an LPN (Licensed Practical Nurse). EI #3 was asked why it was important for a urinary drainage bag to be inside of a dignity bag and she stated, "It's dignity."

Based on observations, interviews, and record reviews, the facility failed to ensure: 1) Dietary staff's earrings were covered while in the food preparation area, on 2 of 3 survey days. 2) Dietary staff's hair was not exposed while in the food preparation area, on 2 of 3 survey days. 3) Dietary staff's aprons were not soiled while in the food preparation area, on 1 of 3 survey days. 4) The food temperatures were assessed on the trayline, and at the appropriate degrees for food service to the residents. This was observed during the lunch trayline observation on 12/11/2013. 5) Sanitary practices were used when washing flatware, cups, and glasses; and flatware was not handled with ungloved hands. This was observed on 12/10/2/2013. 6) Leftover food was discarded within 72 hours after being placed in the refrigerator. This was observed on 1 of 3 survey days. 7) Mighty shakes (milkshake supplements) were dated with a thaw date, as observed on 1 of 3 survey days. 8) Trash cans were observed uncovered in the kitchen area when not in use. This was observed on 1 of 3 survey days. This had the potential to affect 77 residents who received foods and/or supplements from the kitchen. 1) Based on "FDA (Food and Drug Administration) Food Code 2009: Chapter 2 - Management and Personnel 2-303.11 Prohibition. Except for a plain ring such as wedding band, while preparing FOOD, FOOD EMPLOYEES may not wear jewelry including medical information jewelry on their arms and hands." Based on the facility's policy titled, "Orientation and Education 3-Q Uniform Dress Code POLICIES: ... Jewelry must be limited to wedding rings, service pins, watches, or button-type earrings." During the tour of the facility on 12/10/2013 at 3:05 PM, EI (Employee Identifier) #6, a Dietary Aide / Head Cook, was observed to be wearing large black earrings while working in the kitchen area. On 12/11/2013 at 11:25 AM, EI #5, the Dietary Manager, was observed wearing gold hoop earrings, uncovered, while in the kitchen assisting to re-heat and test temperatures of potatoes. In an interview with EI #5 on 12/12/2013 at 3:17 PM, she was asked about the facility's policy on earrings. EI #5 responded, they "Should be studs and no dangling earrings." EI #5 was asked about the potential negative outcomes of earrings exposed, and she stated, "Could get in patients' food". In an interview on 12/12/2013 at 4:07 PM, with EI #8, the District Manager, he was asked about the facility's policy on earrings. EI #8 stated, "We prefer they be small and nothing dangling with potential to fall in food." EI #8 was asked about the potential negative outcomes of exposed earrings, and he stated, "Could fall in food and would be a physical contaminant if it happened." 2) Based on "FDA Food Code 2009: Chapter 2 - Management and Personnel ... Hair Restraints 2-402.11 Effectiveness. (A) ... FOOD EMPLOYEES shall wear hair restraints such as ... hair coverings or nets, beard restraints, and clothing that covers body hair, ...to effectively keep their hair from contacting exposed food; ..." During the tour of the facility on 12/10/2013 at 3:05 PM, EI #7, a Dietary Aide, was observed with hair uncovered at the nape of her neck, and on the sides. On 12/11/2013 at 8:00 AM, EI #9, Dietary Aide, was observed in the kitchen area with some hair exposed on the sides, while working in the dishwashing area. On 12/11/2013 at 11:25 AM, EI #8 was observed while in the kitchen area with some hair exposed at the nape of his neck, and some on his jaws, that were uncovered by hair net and beard cover. On 12/11/2013 at 11:55 AM, EI #8 assisted staff with heating and testing temperatures of potatoes, with some hair exposed at the nape of his neck and some on his jaws. An interview with EI #5 was conducted on 12/12/2013 at 3:17 PM. EI #5 was asked about the facility's policy on hair nets. EI #5 responded, "Just wear a hair net. All hair is to be covered." EI #5 was asked about the potential negative outcomes if hair was uncovered and she stated, it "Could get in patients' food; would be a big turn-off." On 12/11/2013 at 4:07 PM, an interview was conducted with EI #8. EI #8 was asked about the facility's policy on hair nets and facial hair in the kitchen. EI #8 stated, "Hair nets to cover all hair. Beard guards to be worn for all beards." EI #8 was asked about the potential negative outcomes if hair was uncovered and he stated, "Could fall in food and would be a physical contaminant if it happened." 3) Based on "FDA Food Code 2009: Chapter 2 - Management and Personnel ... Outer Clothing 2-304.11 Clean Condition. FOOD EMPLOYEES shall wear clean outer clothing to prevent contamination of FOOD, EQUIPMENT, ...." Based on the facility's policy entitled, "Orientation and Education 3-Q Uniform Dress Code POLICIES: ... Replace soiled aprons as often as necessary. ..." On 12/11/2013 at 11:55 AM, EI #6, EI #7, EI #9, and EI #12, a Relief Cook, were all observed with dirty aprons. An interview was conducted with EI #5 on 12/12/2013 at 3:17 PM. EI #5 was asked about the facility's policy on aprons in the kitchen. EI #5 stated if aprons were soiled, they should be changed. EI #5 was asked about the potential negative outcomes for dirty aprons and she responded, "Somebody may not want to eat if dirty aprons seen." On 12/12/2013 at 4:07 PM, an interview was conducted with EI #8. EI #8 was asked about the facility's policy on aprons in the kitchen. EI #8 responded, "We don't mandate they be worn; if staff chooses, it's their choice." EI #8 was asked about the potential negative outcomes with dirty aprons, and he stated, "Same as clothes that are dirty; could be rubbing up against pots, pans or utensils used for cooking." 4) Based on "FDA Food Code 2009: Chapter 3 - Food ... (1) The FOOD shall have an initial temperature of 5 Degrees C (Celsius) (41 Degrees (F) Fahrenheit) or less when removed from cold holding temperature, or 57 Degrees C (135 Degrees Fahrenheit) or greater when removed from hot holding temperature control; ..." During trayline observation on 12/11/2013 at 11:30 AM, food temperatures were taken and the mashed potatoes were observed to be 132 degrees F. The mashed potatoes were reheated by EI #8 and found with a temperature of 158 degrees F at 12:00 PM. The potatoes were reheated again by EI #8 and EI #5. At 12:14 PM the temperature of the potatoes was 166 degrees F. At 12:18 PM, the first food cart was stopped by the surveyor, before leaving the kitchen because the temperatures had not been checked on the Cinnamon Apples, sliced and pureed. Also, the glasses of Glucerna shakes had not been checked for appropriate temperatures. The surveyor requested to have temperatures of the baked Cinnamon Apples, sliced and pureed, and shakes (in glasses) tested ; The temperatures were as follow: 1) Cinnamon Apple slices were 68 degrees F 2) Pureed Apples were 62 degrees F 3) Glucerna Shakes were 48 degrees F EI #5 stated the apples were, "room temp". EI #5 placed the Glucerna shakes in the freezer until 12:40 PM. The temperatures were noted to be 44 degrees F. EI #5 returned the supplements to the freezer until 12:45 PM. Temperatures were found to be 36 degrees F at this time. On 12/12/2013 at 3:17 PM, an interview was conducted with EI #5. EI #5 was asked what was the procedure for trayline temperatures. EI #5 stated, they should be taken before serving all foods and supplements. EI #5 was asked what were the acceptable temperatures for hot and cold foods. EI #5 responded, 140 degrees and above for holding hot foods and 41 degrees and below for cold foods. EI #5 was asked if temperatures were taken for apples, supplements and alternates on 12/11/2013 during the lunch trayline, before being sent out to the floor. EI #5 stated, "No ma'am. They got caught up and maybe nervous because you were there." On 12/12/2013 at 4:07 PM, an interview was conducted with EI #8. EI #8 was asked what was the facility's procedure for trayline temperatures. EI #8 stated that temperatures were taken for every food item and recorded. EI #8 was asked what were the acceptable temperatures for hot and cold foods. EI #8 stated that hot foods should be 140 degrees F or above, and cold foods 41 degrees F or below. EI #8 was asked if temperatures were taken for apples, supplements and alternates on 12/11/2013 during lunch before being sent out to the floor. EI #8 responded, "I don't specifically know." EI #8 further stated, "Apples should have been 140 degrees F or more." 5) Based on the "Food Code U.S. Public Health Service FDA 2013 ...4-603.13 Loading of Soiled Items, ... Soiled items to be cleaned ...loaded into racks, trays or baskets or onto conveyors in a position that: ... (B) Allows the items to drain." "Food Code U.S. Public Health Service FDA 2013 ... 4-903.11 Equipment, Utensils, ... (2) Where they are not exposed to splash, dust, or other contaminants; and..." On 12/11/2013 at 9:06 AM, EI #9 was observed working in the dishwashing area. EI #9 was noted to rinse and stack dishes in the dish racks. EI #9 loaded plates at this time, into the dishwasher; She tested the wash water per QAC space (Quaternary) Chemical Test Strips and strips read 200 ppm (parts per million). The rinse water temperature read 148 degrees F (Fahrenheit). EI #9 loaded a rack with cups and glasses, and ran through the dishwasher, not covered with a second rack. At the completion of this wash cycle, four glasses were observed turned up with water in them. EI #9 was asked how they kept glasses from being turned up during washing, and she stated she did not know. After checking with EI #5, EI #9 stated, they would just have to re-run the cups and glasses if water was in them. EI #9 was observed to wash utensils. EI #9 removed utensils from soaking , rinsed them, and placed them into the dishwasher on a flat rack one time only. After removing utensils from the dishwasher, EI #9 stated, "we let them dry". Minutes later, using ungloved hands, utensils were sorted and placed in cylinders with eating ends down. EI #9 then stated utensils were ready for use at 9:49 AM. An interview was conducted with EI #5 on 12/12/2013 at 3:07 PM. EI #5 was asked about the procedures used for washing cups, glasses and flatware. EI #5 stated, "Separate glasses and cups. Spray them off. Place them in a tray and send through the dish machine; pull out and let air dry." "Flatware should be put in soaking pan; removed and placed on rack and sent through dish machine; remove from dish machine and let air dry. Then put up." She stated, "not to touch eating end." She further stated, if particles were seen, the dishes were to be sent back through the dish machine. EI #5 was asked about the potential negative outcome of not placing a second rack over the top of glasses and cups, and running through the dish machine. EI #5 stated, "Could set up bacteria." On 12/12/2013 at 4:07 PM, an interview was conducted with EI #8. EI #8 was asked about the facility's policy for washing flatware. EI #8 stated flatware should be washed on a flat rack, then sorted and washed two more times. EI #8 stated that flatware should be sorted and placed on flat racks for the second and third washings. 6) Based on facility's policy entitled, "Healthcare SERVICES GROUP SOLUTIONS * PERFORMANCE * RESULTS Leftovers ... Food should be discarded if not used within 3 days." On 12/10/2013 at 3:07 PM, the following items were found in the middle reach-in refrigerator: 1) Used "Fish Oil" in bucket with "11/30" 2) Slice of pecan pie with a resident's name and 12-3" 3) "Cranberry Sauce 12-4-13" covered with foil. EI #5 removed this item at this time. An interview was conducted on 12/12/2013 at 3:17 PM with EI #5. EI #5 was asked what was the facility's policy on dating and storing leftover food items. EI #5 stated, "Date everything in refrigerator and freezer; Have 72 hours to discard if not used." EI #5 was asked what was the date on the items in the refrigerator and she stated, the "date items put in fridge or freezer." EI #5 was asked about the slice of pecan pie found in the refrigerator on 12/10/2013, during the tour. EI #5 stated, the pecan pie was brought to a resident by his family and "he doesn't want you to throw his food away." EI #5 was asked when the cranberry sauce, observed in the refrigerator on 12/10/13 during tour, should have been discarded, and she stated, "on the 7th." 7) Based on Manufacturer's information, presented to surveyor by the facility, entitled "UNINTENDED WEIGHT LOSS Frozen Shakes Product Information ...Shelf Life ... 14 days after thawing when stored refrigerated ..." On 12/10/2013 at 3:20 PM, during the tour of the facility, 71 thawed Vanilla Shakes were observed in the front refrigerator. Per EI #5, they "came in Friday" (12/6/13) and she "didn't pay attention no date of expiration was on them." 2 boxes with 50 each of Strawberry/ Banana and 1 box with 75 Vanilla shakes "came in today." These were removed from the refrigerator and placed in the deep freezer by EI #5 at this time. During the interview conducted with EI #5 on 12/12/2013 at 3:17 PM, EI #5 was asked how long Mighty shakes could be kept in refrigerator, once thawed. EI #5 stated, "14 days." EI #5 was asked if the thawed shakes found in the refrigerator on 12/10/13 were dated, and why or why not. EI #5 stated, "No, normally when they are taken out, a date is on the box, but no date was on the boxes." EI #5 was then asked how would they know how long shakes had been thawed if they were not dated. EI #5 stated, "We know when they came in and they never stay in longer than 14 days. I order every Thursday and it comes in on Fridays." EI #5 was asked about the potential negative outcomes if shakes were given to residents more than 14 days after being thawed. EI #5 stated, "Just milk. Don't know what it could do. Never thought of it that way." An interview was conducted with EI #8 on 12/12/2013 at 4:07 PM. EI #8 was asked how long Mighty shakes could be kept in the refrigerator, once thawed. EI #8 stated, "14 days." EI #8 was asked how would he know how long shakes had been thawed if they were not dated. EI #5 stated, "I would go back and look at an invoice to know." EI #8 was asked about the potential negative outcomes if given to a resident past the 14 days. EI #8 stated, "Could potentially become a hazardous food at that point." 8) Based on the "Food Code U.S. Public Health Service FDA 2013 ... 5-501.113 Covering Receptacles. Receptacles and ... shall be kept covered: ...and not in continuous use; ..." During the kitchen tour on 12/10/2013 at 3:13 PM, two large gray trash cans were observed uncovered, and no staff was noted in close proximity. An interview was conducted with EI #5 on 12/12/2013 at 3:17 PM. EI #5 was asked what was the facility's policy on trash cans in the kitchen. EI #5 stated, they "Should be covered at all times when not being used." On 12/12/2013 at 4:07 PM, an interview was conducted with EI #8. EI #8 was asked what was the facility's policy on trash cans in the kitchen. EI #8 responded that cans should be covered unless in use.

Based on observations, interviews and record reviews, the facility failed to ensure that comprehensive care plans were revised to meet the individual needs for cognitively impaired residents. This affected RI (Resident Identifier) #'s 2, 8, and 12, three of six residents sampled for Activity Care Plans. Findings include: Potter and Perry, "FUNDAMENTALS OF NURSING", 7th Edition, copyright 2009, page 262 documented: "...Select interventions that will resolve the client's problems and achieve the goals and outcomes." Page 264 documented: "...Goals of Care A client-centered goal is a specific and measurable behavior or response that reflects a client's highest possible level of wellness and independence in function." A review of the clinical record revealed RI #2, a resident admitted on [DATE], had a [DIAGNOSES REDACTED]. A review of the Quarterly MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 10/20/13, revealed RI #2 had short and long term memory loss and was moderately impaired for daily decision-making. A review of RI #2's care plan indicated an intervention for her cognitive impairment related to memory loss was to provide an activity calendar in her room. Observations of RI #2's room found no activity calendar present for 3 of 3 survey days. A review of the clinical record revealed RI #8, a resident re-admitted on [DATE], had a [DIAGNOSES REDACTED]. A review of the Quarterly MDS with a ARD of 10/9/13, revealed RI #8 had short and long term memory loss and was moderately impaired for daily decision-making. A review of RI #8's care plan indicated an intervention for his cognitive impairment related to short term memory loss was to provide an activity calendar in his room. Observations of the RI #8's room found no activity calendar present for 3 of 3 survey days. A review of the clinical record revealed RI #12, a resident admitted on [DATE], had a [DIAGNOSES REDACTED]. A review of the Quarterly MDS with a ARD date of 10/21/13 revealed RI #12 had short and long term memory loss and was moderately impaired for daily decision-making. A review of RI #12's care plan indicated an intervention for his cognitive impairment related to short term memory loss was to provide an activity calendar in his room. Observations of the RI #12's room found no activity calendar present for 3 of 3 survey days. An interview with the Activity Staff member on the secure unit, EI (Employee Identifier) #1, on 12/12/2013 at 3:03 PM, revealed that activity calendars were not posted in residents rooms. The method used to promote participation of the residents was to announce after breakfast what activity was planned. When asked if the activity calendar posted in the cognitively impaired resident's room would be effective, EI #1 stated, "No." An interview with EI #2, MDS and Care Plan Coordinator, was conducted on 12/12/2013 at 3:14 PM. When asked if the intervention of an activity calendar posted in a cognitively impaired resident's room would be effective, EI #2 stated, "No." When asked what the potential negative outcome would be if the care plan was not individualized for residents, EI #2 stated, "It, care plan, cannot be carried out."