Every finding on record at Wesley Place on Honeysuckle

Based on interviews, review of Resident Identifier (RI) #195's medical records, review of a third-party complaint, and the facility's policies titled, Care Plans, Comprehensive Person-Centered and Perineal Care, the facility failed to ensure care planned interventions were developed to instruct staff how to safely position RI #195 in bed during incontinent care; including how many staff members were required to safely provide incontinent care for RI #195. The facility further failed to ensure RI #195's care planned interventions for bilateral half side rails for safety during care was implemented by Certified Nursing Assistance (CNA) #6. This deficient practice affected RI #195; one of 51 sampled residents whose care plans were reviewed. On 09/14/2023, CNA #6 was providing incontinent care to RI #195 without the assistance of another staff. CNA #6 repositioned RI #195 to his/her left side, CNA #6 turned around to obtain a wipe, and when she turned back around RI #195 was sliding from the bed. RI #195 fell head and upper body first from the bed to the floor. According to CNA #6, the left side rail was not in the upright position at this time. RI #195 was sent to the ER (emergency room ) for evaluation and was found to have two brain bleeds, a right-side mandible fracture, dental fractures, a right-side scapula fracture, and a right-side acromion fracture. It was determined the facility's noncompliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, S483.21(b)(1) Develop/Implement Comprehensive Care Plans at a scope and severity of J. On 03/23/2024 at 7:26 PM, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), were provided a copy of the Immediate Jeopardy Templates and notified of the findings of immediate jeopardy in the area of Comprehensive Resident Centered Care Plan, F 656-Develop/Implement Comprehensive Care Plans. The facility implemented corrective actions including ongoing monitoring to correct the identified deficient practice and prevent reoccurrence on 09/18/2023; thus, immediate jeopardy past non-compliance was cited. Cross-Reference F 689. Findings Include: The facility policy titled, Care Plans, Comprehensive Person-Centered, with a revised date of 03/2022, documented, Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical . functional needs is developed and implemented for each resident. Policy Interpretation and Implementation . 7. The comprehensive, person-centered care plan: . b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. A facility policy titled, Perineal Care, with a revised date of 02/2018, documented, Purpose The purposes of this procedure are to provide cleanliness and comfort to the resident . Preparation 1. Review the resident's care plan to assess for any special needs of the resident. RI #195 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include Dysphagia following Cerebral Infarction, Aphasia following Cerebral Infarction, Dementia and Alzheimer's Disease. RI #195's bowel incontinence care plan dated 07/02/2021 documented, . check (RI #195) every two hours and assist with toileting as needed . See care plans on . ADLs (Activities of Daily Living), . RI #195's ADL care plan, dated 07/02/2021, documented, BED MOBILITY: . dependent on two staff for repositioning and turning in bed . TOILET USE: (RI #195) is not toileted. (he/she) requires staff to check and change (him/her) q (every) 2 (two) hours as needed. (he/she) is unable to participate in any aspect of the task. SIDE RAILS: bilateral half rails up as per Dr's (doctors) order for safety during care provision . The care plan did not include instructions on how many staff were needed to assist RI #195 during incontinent care. On 09/15/2023, the State Agency received a complaint that alleged the following: DHR (Department of Human Resources) was notified by the hospital that the resident (RI #195) arrived to the emergency room (ER) with multiple fractures and a head injury that were reported as a result of a fall from bed in the facility that occurred while staff was changing the resident . A review of an ASSOCIATE COUNSELING REPORT for CNA #6, dated 09/20/2023, revealed the following: . Date of Incident 09/14/2023 Time of Incident 3-11 shift . Nature of Incident (explain in detail) Certified nursing assistant failed to follow the care plan for a resident under (his/her) care which resulted in an injury . RI #195's hospital report, documented, Clinical Impressions as of 09/15/2023 . fall, initial encounter subarachnoid bleed . Subdural hematoma . closed fracture of right scapula, unspecified part of scapula, initial encounter closed nondisplaced fracture of acromial process of right scapula, initial encounter . Physical Exam . Swelling at right temporal region . A review of RI #195's ALABAMA CERTIFICATE OF DEATH, with a date of death of [DATE], revealed the following: . CAUSE OF DEATH . Subdural, subarachnoid hematoma due to . Fall at nursing home . An interview was conducted with CNA #6 on 03/20/2024 at 2:08 PM. CNA #6 stated when it came to checking RI #195 required one-person assist, but repositioning required two people. CNA #6 said on 09/14/2023 she was providing incontinent care to RI #195 without the assistance of a second staff. CNA #6 said she repositioned RI #195 for the care and he/she fell from the bed to the floor. CNA #6 said RI #195's right shoulder and head hit the floor first. CNA #6 said after RI #195 fell to the floor, she looked and saw RI #195's side rail on the left side of the bed was down and it should have been up. CNA #6 stated when providing care for RI #195 side rails should have been raised and she was not sure why the side rails were down. CNA #6 said RI #195 was not in a safe position when she was providing care on 09/14/2023, due to the side rail being down. On 03/22/2024 at 2:22 PM a follow-up interview was conducted with CNA #6. CNA #6 said she would have asked a second staff member to assist her with RI #195's incontinent care if his/her care plan indicated two staff were required to provide incontinent care. An interview was conducted with Registered Nurse (RN) #14, former Clinical Coordinator, on 03/22/2024 at 10:07 AM. RN #14 stated the level of assistance required to assist RI #195 depended on what ADL care that was being provided. She stated most of the time RI #195 required two-person assistance. She stated RI #195 was a total assist and they anticipated all of his/her needs. RN #14 stated RI #195's side rail on the left side should have been up when CNA #6 was providing care from the right side of the bed because no one was on the opposite side. A follow-up phone interview was conducted with RN #14 on 03/23/2024 at 5:36 PM. RN #14 stated she completed the ADL care plan for RI #195. She stated she did not remember why there was no assist level on his/her toileting/incontinent ADL care plan. She stated she guessed that she forgot to put one- or two-person assist on the care plan. An interview was conducted with the Director of Nursing (DON) on 03/22/2024 at 1:35 PM. The DON stated RI #195 had a physician's order for bilateral side rails and according to his/her care plan they were to be up for safety during care to assist with bed mobility. She stated an investigation was conducted after RI #195's fall and it was determined that RI #195 fell from the left side of the bed and the left side rail was down. The DON said the side rail should have been up. A follow-up interview was conducted with Director of Nursing (DON) on 03/23/2024 at 11:53 AM. The DON stated the toilet use care plan should have instructed staff on how many staff was needed to assist with changing RI #195. The DON said RI #195's toilet use care plan did not indicate the number of staff needed to assist for toileting. The DON stated RI #195's toileting care plan should have specified an assist level. She stated the level of assistance required was very important information for all staff to know in order to provide care. This deficiency was cited as a result of complaint/report number AL00045797. *************************************************************** The facility took immediate action to correct the noncompliance by: 1. On 09/15/2023 CNA #6 was placed on administrative leave pending results of investigation. CNA #6 was not permitted to work until after 1 on 1 retraining on following the care plans was completed and after CNA #6 received a final warning in her employee file. 2. On 09/15/2023 QAPI meeting held to discuss root cause analysis. 3. On 9/15/2023 all residents care plans were reviewed be RN clinical coordinators/care coordinators for correct information regarding amount of assistance required for ADL care including incontinent care. No discrepancies were identified. 4. Ending on 09/18/2023 all nursing staff including all licensed nurse and CNAs were educated by RN Care Coordinators/RN supervisors on ensuring that the care plan is followed and ensure that staff are aware of the location to view the care plan within the point of care system. Education was completed on 09/18/2023. 5. 09/15/2023 All RN Care Coordinators were provided inservices and re-education to include the ADL sections of the care plan as it relates to the level of assistance required by staff for performing ADL care including incontinent care. 6. Return demonstration of location of the Kardex tab on the point of care tablets was performed on all CNAs by RN coordinators/supervisors by 09/18/2023. 7. Beginning on 09/15/2023, education on care plans to include ADL care completed upon new hire orientation process and at least annually. 8. Care plan compliance monitoring observations began on 09/18/2023 (nurses observed to ensure residents care plans were followed regarding ADL care assist levels). Date of compliance: 09/18/2023 *************************************************************** After review and verification of the information provided in the facility's corrective action plan, in-service education records, monitoring tools, and the facility's investigation, as well as staff interviews, the survey team determined the facility implemented corrective actions from 09/15/2023 through 09/18/2023 with ongoing monitoring implemented; thus, immediate jeopardy past noncompliance was cited.

Based on interviews, record review, the facility's investigative file, hospital record review, the facility policy titled, and review of a third-party complaint, the facility failed to ensure Resident Identifier (RI) #195's upper side rails were up for safety during the provision of incontinent care; and failed to ensure two staff assisted to reposition RI #195 during the incontinent care. On 09/14/2023, Certified Nursing Assistant (CNA) #6 was providing incontinent care to RI #195 without a second staff to assist. CNA #6 repositioned RI #195 to the left side, turned around to obtain a wipe, and when she turned back around RI #195 was sliding from the left side of the bed. RI #195 fell head and upper body first from the bed to the floor. According to CNA #6, the left side rail was not in the upright position at the time. RI #195 was sent to the ER (emergency room ) for evaluation and was found to have two brain bleeds, a right-side mandible fracture, dental fractures, bleeding in the mouth, a right-side scapula fracture, and a right-side acromion fracture. This deficient practice affected RI #195; one of three residents sampled for falls with major injuries. It was determined the facility's noncompliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, S483.25(d) Free of Accident Hazards/Supervision/Devices at a scope and severity of J. On 03/23/2024 at 7:26 PM, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), were provided a copy of the Immediate Jeopardy Template and notified of the finding of substandard quality of care at the immediate jeopardy level in the area of Quality of Care, at F-689-Free of Accident Hazards/Supervision/Devices. The facility implemented corrective actions to correct the identified deficient practice and prevent recurrence on 09/18/2023; thus, immediate jeopardy past non-compliance was cited. Cross-Reference F 656. Findings include: On 09/15/2023, the State Agency received a complaint that alleged the following: DHR (Department of Human Resources) was notified by the hospital that the resident (RI #195) arrived to the emergency room (ER) with multiple fractures and a head injury that were reported as a result of a fall from bed in the facility that occurred while staff was changing the resident . injuries . included two brain bleeds, right side mandible fracture, dental fracture, bleeding in mouth, right side scapula fracture, and right side acromion fracture . RI #195 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include Dysphagia following Cerebral Infarction, Aphasia following Cerebral Infarction, Dementia and Alzheimer's Disease. RI #195's Annual Minimum Data Set assessment, with an Assessment Reference Date of 07/03/2023, revealed RI #195 had short- and long-term memory problems with severely impaired cognition, was totally dependent on staff with the assist of two for bed mobility, and had impairment on both sides of the upper and lower extremities. RI #195's ADL (Activities of Daily Living) care plan, with an initiated date of 07/02/2021, revealed RI #195 had a self-care performance deficit related to Alzheimer's, Dementia, and Contractures. There were interventions for . BED MOBILITY: (name of RI #195) is totally dependent on 2 staff for repositioning . SIDE RAILS: bilateral half rails up as per Dr's order for safety during care provision . A review of RI #195's Order Summary Report (Physicians Orders) with a date order of 07/29/2021, revealed RI #195 had a physician's order for . bilateral 1/2 upper side rails for the purpose of increasing safety per family request . Review of the facility's investigative file revealed a statement given by CNA #6, dated 09/15/2023, which revealed the following: I am used to doing RI #195 by myself because his/her body will stay in one position. He/She had a really big bowel movement and I was trying to push him/her over enough to clean his/her whole back side. I failed to realize that the side rail wasn't up. So, I pushed him/her just a little bit more so I could clean his/her left cheek and then as soon as I turned around to grab the wipes behind me I turned back around and I saw his/her upper body go down first. It was his/her shoulder and head that went down first . On 03/20/2024 at 2:08 PM, an interview was conducted with CNA #6. CNA #6 said RI #195 required total care and when it came to repositioning, RI #195 was a two-person assist. CNA #6 said on 09/14/2023 she was providing incontinent care without the assistance of a second staff. CNA #6 said during the care she turned RI #195 over and pushed RI #195 more toward the edge of the bed so she could clean RI #195. CNA #6 said she turned around to get the wipes which were on the table behind her. CNA #6 said when she turned back around she saw RI #195's upper body and head slide off the left side of the bed to the floor. CNA #6 said RI #195's right shoulder and head hit the floor first. CNA #6 said after RI #195 fell to the floor, she looked and saw RI #195's side rail on the left side of the bed was down and it should have been up. CNA #6 said RI #195 was not in a safe position when she provided care to RI #195 on 09/14/2023, because the side rail was down. CNA #6 said the fall was avoidable because if she had been more aware of the environment she would have seen the side rail was down. On 03/20/2024 at 6:20 PM, an interview was conducted with Licensed Practical Nurse (LPN) #12, the LPN assigned to care for RI #195 on the 3-11 shift on 09/14/2023. LPN #12 said CNA #6 informed her RI #195 had fallen. When she entered the room RI #195 was on the floor on the left side of the bed lying on his/her back. LPN #12 said two staff should have been assisting RI #195 to turn. LPN #12 said RI #195's side rails should have been in the up position at all times. LPN #12 said RI #195's fall was avoidable because CNA #6 should have had someone with her if she was not sure about how to care for RI #195. On 03/22/2024 at 4:16 PM, an interview was conducted with RN #16. RN #16 said she was made aware RI #195 had fallen out of bed on 09/14/2023, when CNA #6 called her. RN #16 said she immediately went to RI #195's room and saw RI #195 on the floor on the left side of the bed. RN #16 said the left side rail was down and it should have been up especially since CNA #6 was repositioning RI #195. On 03/21/2024 at 6:29 PM, a telephone interview was conducted with CNA #13. CNA #13 said RI #195's side rails should have been up at all times. CNA #13 said when she entered the room after RI #195 fell , RI #195 was on the floor on his/her back on the left side of the bed and the left side rail was down. CNA #13 said CNA #6 told her she forgot to let RI #195's side rail back up. RI #195's Progress Notes, dated 09/14/2023, revealed the following: . Note Text: Resident sent to ER via (by way of) Ambulance @ (at) 9pm due to sliding off of bed during care . RI #195's ED (Emergency Department) Provider Notes from the local hospital, with a Date of Service of 09/14/2023, revealed the following: . Chief Complaint Patient present with .Fall Pt (patient) arrived via EMS (Emergency Medical Service) from SNF (Skilled Nursing Facility) nonverbal and bedbound w (with)/contractures of the BUE (Bilateral Upper Extremities). EMS states that while being changed the pt was rolled off the bed to the L (left) side . Physical Exam . (revealed a contusion to the left and right forehead and right mandible) . Clinical Impression as of 09/15/23 . Subarachnoid bleed . Subdural hematoma . Closed fracture of right scapula, unspecified part of scapula . closed nondisplaced fracture of acromial process of right scapula . Medical Decision Making CT (Computed Tomography) scans display subarachnoid hemorrhage and hematoma . Questionable right mandibular fracture and dental fracture which is thought to be the source of the dried blood in the mouth along with a right scapula fracture and acromial process fracture . Problems addressed: Closed fracture of right scapula . Closed nondisplaced fracture of acromial process of right scapula . Subarachnoid bleed . Subdural hematoma . On 03/22/2024 at 10:07 AM, an interview was conducted with Registered Nurse (RN) #14, the former RN/Clinical Coordinator (CC) of the unit RI #195 resided on. RN #14 said RI #195 was pretty much total care, and mostly two-person assist with ADLs. RN #14 said at the time of the incident CNA #6 was the only staff assisting with RI #195's care. RN #14 said the left side rail should have been up while CNA #6 was providing care from the right side. On 03/22/2024 at 7:49 AM, an interview was conducted with the Household Coordinator (HHC) for the unit RI #195 resided on. The HHC said findings from the facility's investigation determined the side rail on the side of the bed RI #195 fell from was not raised and there was only one CNA providing care to RI #195. On 03/21/2024 at 5:51 PM, a telephone interview was conducted with the Medical Director (MD). The MD said he thought the root cause of RI #195's fall was the fact the person assisting RI #195 did not have help. The MD said the side rail being down on the side of the bed RI #195 fell from could have stopped the fall. On 03/22/2024 at 11:18 AM, an interview was conducted with the DON. The DON said from what she could remember, RI #195 was a total care resident and needed two-persons assistance with repositioning. The DON said during RI #195's care, CNA #6 had to turn RI #195 to his/her side. The DON said the investigation determined that CNA #6 rolled RI #195 over to clean his/her bottom and RI #195 went over the left side of the bed while CNA #6 reached for a wipe. The DON said it was discovered through the facility's investigation the left side rail was down. The DON said the fall could have been avoided because RI #195 was a total care resident and was not able to support him/herself from rolling out of the bed. The DON said RI #195 sustained a scapula and mandible fracture which was consistent with RI #195 falling from the left side of the bed. On 03/21/2024 at 10:52 AM, a telephone interview was conducted with RI #195's sponsor. The sponsor said RI #195 required full-time care and was bedridden. The sponsor said as a result of the fall RI #195 had a couple of broken teeth, his/her shoulder was broken, and his/her skull had a fracture. The sponsor said RI #195 passed away on 09/21/2023. A review of RI #195's Discharge Summary from the local hospital RI #195 was transported to on 09/14/2023, revealed the following: . Date of Service: 9/21/2023 . DEATH SUMMARY . Final Diagnosis: Subdural hematoma . Acute problems: Subdural, subarachnoid hematoma due to Fall at nursing home Acute on chronic encephalopathy due to above . Concern for right mandibular fracture- on imaging Right scapula fracture, distal acromion fracture . Death Summary: Patient was admitted to hospitalist service for further evaluation of reported fall at nursing home reportedly while (he/she) was being changed. On admission he had multiple images including CT head, maxillofacial . (He/She) was noted to have right hemispheric subdural hematoma with 7.8 mm (millimeter) in size in parieto-occipital region . Patient's family was aware of (his/her) poor condition . Subsequently patient passed away on 09/21/2023 at 6:59 p.m. A review of RI #195's ALABAMA CERTIFICATE OF DEATH, with a date of death of [DATE], revealed the following: . CAUSE OF DEATH . Subdural, subarachnoid hematoma due to . Fall at nursing home . This deficiency was cited as result of the investigation of complaint/report #AL00045797. ******************************************************* The facility took immediate action: 1. On 09/15/2023 CNA #6 was placed on administrative leave pending results of investigation. CNA #6 was not permitted to work until after 1 on 1 retraining on following the care plans was completed and after CNA #6 received a final warning in her employee file. 2. On 09/15/2023 QAPI meeting held to discuss root cause analysis. 3. On 9/15/2023 all residents care plans were reviewed by RN clinical coordinators for correct information regarding amount of assistance required for ADL care including incontinent care. No discrepancies were identified. 4. Ending on 09/18/2023 all nursing staff including all licensed nurse and CNAs were educated by RN clinical Coordinators/RN supervisors on ensuring that the care plan is followed and ensure that staff are aware of the location to view the care plan within the point of care system. Education was completed on 09/18/2023. 5. 09/15/2023 All RN Care Coordinators were provided inservices and re-education to include the ADL sections of the care plan as it relates to the level of assistance required by staff for performing ADL care including incontinent care. 6. Return demonstration of location of the Kardex tab on the point of care tablets was performed on all CNAs by RN coordinators/supervisors by 09/18/2023. 7. Beginning on 09/15/2023, education on care plans to include ADL care completed upon new hire orientation process and at least annually. 8. Care plan compliance monitoring observations began on 09/18/2023 (nurses observed to ensure residents care plans were followed regarding ADL care assist levels). Date of compliance: 09/18/2023 ************************************************************************************************************************** After review and verification of the information provided in the facility's corrective action plan, in-service education records, monitoring tools, and the facility's investigation, as well as staff interviews, the survey team determined the facility implemented corrective actions from 09/15/2023 through 09/18/2023 with ongoing monitoring implemented; thus, immediate jeopardy past noncompliance was cited.

Based on interviews, record review, the Long-Term Care Resident Assessment Instrument 3.0 Manual, and the facility policy titled Care Plans, Comprehensive Person-Centered, the facility failed to ensure Resident Identifier (RI) #96's Quarterly Minimum Data Set (MDS) assessment dated [DATE], was accurately coded to reflect Resident Identifier (RI) #96's behavioral symptoms. This deficient practice affected one of 51 sampled residents whose MDS was reviewed. Findings include: RI #96 was admitted on [DATE] and diagnoses that included Dementia, Moderate with Mood Disturbance, Alzheimer's Disease Late Onset. A review of facility policy titled Comprehensive Assessments with a Revised date of 03/2022 documented, Policy Interpretation and Implementation 1. Comprehensive assessments are conducted in accordance with criteria and timeframes established in the Resident Assessment Instrument (RAI) User Manual . Section E0200: Behavioral Symptoms of the Long-Term Care Resident Assessment Instrument 3.0 Manual which is also known as the RAI User Manual documented . 1. Review the medical record for the 7 day look-back period . A review of RI #96's behavior progress notes on 04/02/2023 revealed RI #96 was combative during morning care and exhibited physically aggressive behavior. A review of RI #96's Quarterly MDS with an Assessment Reference Date (ARD) of 04/04/2023 Section E0200 Behavioral Symptoms documented: 0. Behavior not exhibited. On 03/21/2024 at 11:55 AM, an interview with Certified Nursing Assistant (CNA) #10 was conducted. CNA #10 stated RI #96 had exhibited resistive behavior during care several times a week for about a year. On 03/21/2024 at 12:53 PM, an interview with Registered Nurse (RN) #7 was conducted. RN #7 stated RI #96 was resistive during care at times. RN #7 stated RI #96 had exhibited those behavior since he/she had been on the unit. On 03/21/2024 at 4:55 PM, an interview with the MDS Coordinator (MDSC). The MDSC said RI #96 was not coded for behavioral symptoms on the MDS with an ARD of 04/04/2023. The MDSC said behavioral symptoms should have been coded on the MDS.

Based on observations, interviews, record review and review of a facility policy titled, Care Plans -Baseline, the facility failed to ensure Resident Identifier (RI) #196's and RI #198's baseline care plans addressed the use of their Continuous Positive Airway Pressure (CPAP) machines. This deficient practice affected RI #196 and RI #198, two of six sampled residents whose baseline care plans were reviewed. Findings include: A review of a facility policy titled, Care Plans-Baseline, with a revised date of 03/2022, revealed the following: . Policy Interpretation and Implementation 1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: . b. Physician orders . 4. c. Any services and treatments to be administered by the facility . RI #196 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included Obstructive Sleep Apnea and Chronic Obstructive Pulmonary Disease. RI #196's March 2024 Order Summary Report (Physician Orders) revealed RI #196 had a physician order dated 03/12/2024 for . CPAP at night set to manufactures guidelines and settings . A review of RI #196's Baseline Care Plan, dated 03/08/2024, revealed under the section Health Conditions/Special Treatments . CPAP - while a resident . was not checked. On 03/19/2024 at 12:03 PM, RI #196's CPAP machine was observed on top of RI #196's dresser drawer. RI #198 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included Acute Respiratory Failure with Hypoxia and Acute Pulmonary Edema. A review of RI #198's Baseline Care Plan, dated 03/15/2024, revealed under the section Health Conditions/Special Treatments . CPAP - while a resident . was not checked. 03/19/2024 at 3:47 PM, RI #198's CPAP machine was observed on top of the nightstand in RI #198's room. On 03/22/2024 at 1:20 PM, an interview was conducted with Licensed Practical nurse (LPN) #17. LPN #17 said RI #198 used his/her CPAP at night, and RI #196 used one as well. On 03/22/2024 at 6:01 PM, an interview was conducted with Registered Nurse (RN) #18/Clinical Coordinator (CC) for the Rehab unit. RN #18 said it was the responsibility of the person that admitted the resident to the facility to develop a resident's baseline care plan. RN #18 said the baseline care plan should address that the resident was using respiratory equipment such as a CPAP. RN #18 said RI #196 used a CPAP. RN #18 looked at RI #196's baseline care plan and said it did not address the use of the CPAP. RN #18 said the care plan should have included the use of the CPAP and that it was an oversite. RN #18 said RI #198 used his/her CPAP. RN #18 said the use of CPAP should have been included on RI #198's baseline care plan but she did not see it on the baseline care plan. RN #18 said the purpose of a baseline care plan was to show what type of care was occurring with the resident. RN #18 said it would be important to ensure all resident's care information was included on the baseline care plan to make sure the resident's care was being properly administered.

Based on observations, interviews, record review and review of facility policies titled, Crushing Medications, Administering Medications, and Gastrostomy/Jejunostomy Site Care, the facility failed to ensure: 1) Resident Identifier (RI) #3 had a crush order to crush his/her Clonazepam 1 mg (milligram) tablet, and 2) RI #40's PEG (Percutaneous Gastrostomy) site was cleaned with peroxide as ordered by the physician. These deficient practices affected RI #3, one of six residents observed during the medication pass administration; and RI #40, one of one resident whose PEG site care was observed. Finding include: 1) RI #3 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of Epilepsy and Dysphasia. A facility policy titled, Crushing Medications, with a revised date of 04/2018, included the following: Policy Statement Medications shall be crushed only when it is . consistent with physician orders. Policy Interpretation and Implementation . 3. In addition, the following guidelines shall be followed when crushing medications: a. The MAR or other documentation must indicate why it was necessary to crush the medication . RI #3's Order Summary Report (Physicians Orders) noted as Active Orders as of 03/20/2024 included: . ClonazePAM Oral Tablet 1 mg .Give 1 tablet by mouth two times a day . Further review of the March 2024 Physicians Orders revealed there was not an order to crush any of RI #3's medications. On 03/20/2024 at 4:19 PM, the surveyor observed Licensed Practical Nurse (LPN) #11 prepare and administer RI #3 his/her medications. LPN #11 placed RI #3's Clonazepam 1 mg tablet in a pill crush pouch and crushed the tablet while stating RI #3's medications were crushed. LPN #11 then administered the medication to RI #3. In an interview on 03/21/224 at 5:21 PM, the surveyor asked LPN #11 was there an order to crush RI #3's medications. LPN #11 reviewed RI #3's electronic Physicians Orders and paper Physicians Orders and stated she did not see one. When asked if there should be an order to crush RI #3's medications before crushing them, LPN #11 stated yes. In an interview on 03/23/2024 at 8:26 AM with Registered Nurse (RN) #7, the Clinical Coordinator (CC) for South Two, was asked if a resident's medication were crushed should there be a crush order. RN #7's response was yes there should be. RN #7 said according to RI #3's Physicians Orders there was not an order to crush RI #3's medications. When asked why it was important to have an order to crush medications before crushing a resident's medication, RN #7 said so the nurse would know which medication could be crushed. In an interview on 03/23/2024 at 10:01 AM with the Assistant Director of Nursing (ADON), the surveyor asked the ADON when a resident's medication was crushed, should there be a crush order. The ADON's response was yes. When asked why it would be important to have a may crush order before crushing a resident's medication, the ADON responded it would alert the staff that it would be ok to crush that medication. 47408 2) A review of a facility policy tilted, Gastostomy/Jejunostomy Site Care, with a revised date of 10/2011, documented: Purpose The purposes of this procedure are to promote cleanliness and to protect the gastrostomy . site from irritation, breakdown and infection. Preparation 1. Verify that there is a physician's order for this procedure. RI #40 was admitted to facility on 03/21/2022 and readmitted on [DATE] with a diagnosis of Gastrostomy Status. RI #40's Order Summary Report (Physicians Orders) for 03/2024, documented: . Clean peg site daily w (with)/ peroxide . 03/22/2024 at 10:10 AM, the surveyor observed LPN #3 clean RI #40's PEG stoma site with soap and water. On 03/22/2024 at 11:58 AM, an interview was conducted with LPN #3. LPN #3 was asked why she did not follow the physicians orders to clean RI #40's PEG site with peroxide. LPN #3 said she thought the order was for soap and water. When asked what was the concern of not following physician orders, LPN #3 said she could cause an infection or the resident could have a reaction to the wrong item used. On 03/23/2024 at 01:47 PM, an interview was conducted with the ADON. The ADON was informed of the surveyor's observation of gastrostomy site care being performed on RI #40 on 03/22/2024 by LPN #3, who used soap instead of peroxide. The ADON said LPN #3 should have followed the physicians orders and used peroxide.

Based on observations, interviews, record review and review of a facility policy titled, Medication Labeling and Storage, the facility to ensure: 1) Resident Identifier (RI) #395's vial of 70/30 insulin was labeled correctly; and 2) an expired bottle of Enteric Coated (EC) Aspirin (ASA) was not left on the medication cart on the Rehab unit. These deficient practices affected RI #395, and had the potential to affect all resident with orders for EC ASA on the Rehab unit. Findings include: Review of a facility policy titled, Medication Labeling and Storage, with a revised date of 02/2023, revealed the following: . Policy Interpretation and Implementation .6. Medications . are labeled accordingly . Medication Labeling . 2. The medication label includes,at a minimum: . 2. d. expiration date, when applicable; e. resident's name . 5. vials that have been opened or accessed (e.g. [for example] needle punctured) are dated and discharged within 28 days . 1) RI #395 was admitted to the facility on [DATE] with a diagnosis of Type Two Diabetes. RI #395's Order Summary Report (Physicians Orders) for March 2024 revealed RI #395 had orders to include Aspirin 325 mg (milligrams) once a day and Novolog mix 70/30 inject ten units subcutaneous two times a day. On 03/22/2024 at 8:55 AM, the surveyor observed Licensed Practical Nurse (LPN) #17 prepare RI #395's medications. LPN #17 went to refrigerator and returned with a vial of Novolog 70/30 for RI #395. The surveyor observed that there no label on the vial of insulin as to when the vial was opened or when the insulin was to be discarded. On 03/22/2024 at 1:20 PM, an interview was conducted with LPN #17. The surveyor asked LPN #17, when a vial of insulin was opened, what type of information should be placed on the vial. LPN #17 said the opened date, the expiration date and the resident's name. LPN said it was important to ensure the vial was labeled with this information so all staff would know who the medication belonged to and how long the medication could be used. LPN #17 said RI #395's vial of 70/30 insulin should have been labeled. On 03/22/2024 at 6:01 PM, an interview was conducted with Registered Nurse (RN) #18/Clinical Coordinator (CC) for the Rehab unit. RN #18 was asked, when insulin was opened, what should be on the vial of the insulin. RN #18 said the residents name, the date opened, and the expiration date. 2) On 03/22/2024 at 8:55 AM, the surveyor observed LPN #17 prepare RI #395's medications. LPN #17 removed a stock bottle of EC ASA 325 mg from the drawer of the medication cart. The bottle of ASA had an expiration date of 10/23 (2023) on the bottle. On 03/22/2024 at 1:20 PM, an interview was conducted with LPN #17. When asked why was there a bottle of expired EC ASA on the medication cart that morning, LPN #17 said she had not noticed the date on it. LPN #17 said expired medication should be placed in a medication destruction box and sent back to the pharmacy. LPN #17 said the expired medication may not have the effectiveness and would not have a therapeutic health benefits to the resident. On 03/22/2024 at 6:01 PM, an interview was conducted with RN #18. RN #18 said expired stock medications should not be on the medication cart. RN #18 said the MAC (Medication Administration Certified), CNA (Certified Nursing Assistant), or the nurse had the responsibility for ensuring expired medications were not left on the medication cart. RN #18 said the medication cart should be checked for expired medication weekly; but the medication nurse should be checking for expired medications when medications are passed. When asked what would there be a potential for when expired medications are left on the medication cart, RN #18 said the resident would get a medication where the effectiveness would be decreased.

Based on observations, interviews, record review, review of facility policies titled, Handwashing/Hand Hygiene and Gastrostomy/Jejunostomy Site Care, and review of guidelines from CDC's (Center for Medicare and Medicare) Core Infection and Prevention and Control Practices for Safe Healthcare in All Settings, the facility failed to ensure: 1) Certified Nursing Assistant (CNA) #19 removed her mask before exiting a resident on Droplet Precautions's room, Resident Identifier (RI) #53, 2) Licensed Practical Nurse (LPN) #3 changed her gloves and sanitized her hands while performing gastrostomy site care on RI #40; and 3) Registered Nurse (RN) #4 did not use her gloved finger to pack foam into RI #295's wound during wound care. Further RN #4 used her ungloved hands and hand sanitizer to clean RI #295's. These deficient practices affected three of 51 sampled residents. Findings include: Review of undated guidelines for CDC's Core Infection and Prevention and Control Practices for Safe Healthcare in All Settings, revealed the following: . Core Practice Category 5d. Risk Assessment with Appropriate Use of Personal Protective Equipment (PPE) . Core Practices . d. Remove and discard PPE, other than respirators, upon completing a task before leaving the patient's room or care area . RI #53 was admitted to the facility on [DATE] and readmitted on [DATE], with a diagnosis of Methicillin Resistant Staphylococcus Aureus (MRSA) Infection. RI #53's Order Summary Report (Physicians Orders) for March 2024 revealed RI #53 was to be on Droplet precautions 3/15-03/21 for MRSA in sputum. RI #53's Care Plan included a care plan for Droplet Precautions r/t (related to) MRSA in sputum, with an initiated date of 03/15/2024, with an intervention for Change PPE prior to caring for another resident . On 03/19/2024 at 3:19 PM, CNA #19 was observed passing ice on the hall. CNA #19 put on a blue surgical mask and took a bag of ice into room RI #53's room. RI #53 had a Droplet Precaution sign on his/her door with instruction to Remove face protection before room exit. On 03/19/2024 at 3:24 PM, CNA #19 exited RI #53's room with the face mask still on, walked down hall with a clear tied bag of trash in her hand and took the bag to the soiled utility room. CNA #19 walked back down the hall with the face mask still on and entered another resident's room. On 03/19/2024 at 3:26 PM, an interview was conducted with CNA #19. CNA #19 said RI #53 was on droplet precautions. CNA #19 said she was required to have on a mask and sanitize her hands when entering RI #53's room. CNA #19 said she should have disposed of the mask in the room. The surveyor asked CNA #19 what type of concern would it be to not dispose of the mask in the correct manner. CNA #19 said germs could be spread. On 03/22/2024 at 6:01 PM, an interview was conducted with Registered Nurse (RN) #18/Clinical Coordinator (CC) for the Rehab unit. RN #18 was asked what type isolation was RI #53 on. RN #18 said RI #53 was on droplet precautions. When asked what type PPE was required when entering RI #53's room, RN #18 said the surgical face mask, gloves and a gown. RN #18 said before exiting the room, the mask should be thrown in the trash receptacle in the bathroom. RN #18 said there was a potential for the spread of infection when the face mask was not removed and staff walked down the hall, and entered other resident's room with the face mask on. On 03/23/2024 at 09:47 AM, an interview was conducted with the Infection Preventionist (IP). The IP was asked, before exiting a resident who was on any type precaution room, where should the face mask be discarded. The IP said in the trash container on the inside of the room. The IP said when this was not done in that manner, the concern was infection control and the potential to spread germs elsewhere. 47408 2) Review of Facility's policy titled, Handwashing /Hand Hygiene, with a Revised date of 08/2015, documented, Policy Statement . This facility considers hand hygiene the primary means to prevent means to prevent the spread of infections. Policy interpretation and Implementation . 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents . 3. Hand hygiene products and supplies ( .alcohol-based rubs,etc) shall be readily accessible . 6. Wash hands with soap (antimicrobial or nonantimicrobial) and water for the following situations: a. When hands are visibly soiled; .7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or nonantimicrobial) and water for the following situations: .b. Before and after direct contact with residents; .e. Before and after handling invasive device (e,g,,urinary catheters .g. Before handling clean or soiled dressings, gauze pads,etc; .k. After handling used dressings . RI #40 was admitted to facility on 03/21/2022 and readmitted on [DATE] with a diagnosis of Gastrostomy Status. RI #40's Order Summary Report (Physicians Orders) for 03/2024, documented: . Clean peg site daily w (with)/ peroxide . On 03/22/2024 at 10:10 AM, Surveyor observed LPN #3 clean RI #40's peg site. While perfoming wound care with gloves on, LPN #3 ran out of gauze, went to RI #40's chest of drawers, and obtained more gauze to clean the stoma. LPN #3 kept on the same pair of gloves and continued to clean the stoma. An interview was conducted with LPN #3 on 03/22/2024 at 11:58 PM. LPN #3 stated it did not cross her mind to remove her gloves before she retrieved the gauze from RI #40's drawer. LPN #3 stated the concern of not changing gloves after touching a potentially soiled/contaminated item was the potential for infection. On 03/23/2024 at 1:47 PM, an interview was conducted with the Infection Preventionist (IP). The IP stated the concern of not changing gloves during wound care was cross-contamination. 3) RI #295 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis to include Heart Failure, Other Disorders of the Lungs, and Unspecified Osteoarthritis. RI #295's Order Summary Report dated 03/19/2024, revealed, Wound Vac intermittent at 125 to Right buttocks wound change q(every)72 hrs (hours). On 03/19/2024 at 11:00 AM, surveyor observed Registered Nurse (RN) #4 perform wound care on RI #295. During care RN #4 packed three pieces of precut foam into RI #295's wound with her gloved fingers. Later in the wound care RN #4 picked up bandage scissors and wiped off the tip of the scissors with hand sanitizer and her bare hands. An interview was conducted with RN #4 on 03/21/2024 at 6:11 PM. RN #4 said Q tips or cotton tipped swabs should be used to pack a wound during wound care. RN #4 stated she used her gloved fingers to pack RI #295's. RN #4 said the scissors should have been cleaned with sani-wipes and stated the concern of not cleaning scissors would be infection control. On 03/23/2024 at 1:47 PM, an interview was conducted with the Infection Preventionist (IP). The IP was informed surveyor observed RN #4 perform wound care on RI #295 on 3/19/2024. The IP stated when packing a wound, a Q tip would be sterile; a gloved hand would not be and it would increase the risk of infection.

Based on observations, interviews and a facility's policy titled, Homelike Environment, the facility failed to ensure rooms on one of seven halls were not found in need of repair. This deficient practice affected eight resident's rooms on one hall. Findings Include: A facility policy titled, Homelike Environment, with a revised dated of 02/2021, revealed, Policy Statement Residents are provided with a safe, clean, comfortable and homelike environment . Policy Interpretation and Implementation . the facility staff and management maximizes, to the extent possible the characteristics of the facility that reflect a . homelike setting . These characteristics include: a. clean, sanitary and orderly environment; . 1. On 03/18/2024 at 5:35 PM the surveyor observed a large amount of wall material missing behind the Resident Identifier (RI) #70's bed. 2. On 03/18/2024 at 5:40 PM the surveyor observed a large amount wall material missing behind the RI #13's bed. 3. On 03/18/2024 at 5:45 PM the surveyor observed a large amount of wall material missing behind RI #43's bed. 4. On 03/18/2024 at 5:50 PM the surveyor observed a large amount of wall material missing behind RI #138 's bed. 5. On 03/18/2024 at 5:55 PM the surveyor observed a large amount of wall material missing behind RI #1's bed. 6. On 03/18/2024 at 6:00 PM the surveyor observed a large amount of wall material missing behind RI #19's bed. 7. On 03/18/2024 at 6:30 PM the surveyor observed a large amount of wall material missing behind RI #67 's bed. 8. On 03/18/2024 at 6:15 PM the surveyor observed a large amount of wall material missing behind RI #40's bed and the ceiling tile over the bed was reddish-brown and sagging. On 03/20/2024 from 1:45 PM to 1:55 PM, the Maintenance Director (MTD) made observation of the noted concerns in residents' rooms. Large chunk of sheetrock was observed missing behind residents' headboards. The ceiling tile directly over RI #40's bed was discolored reddish-brown and sagging. An interview was conducted with the MTD on 03/20/2024 at 2:00 PM. The MTD stated the areas observed on the walls behind the beds in the residents' room were gouges in the drywall. He stated the ceiling over the bed in RI #40's room looked like an old leak. He stated the ceiling was discolored and had a small sag to it. The MTD stated it was unsightly for the facility to have gouges in the resident's walls and sagging, discolored ceiling. The MTD stated it was the facility's job to make their address a better place.

Based on interviews, review of Resident Identifier (RI) #1 and RI #2's billing statements, the facility's Resident Handbook, and a complaint received by the State Survey Agency, the facility failed to refund any and all refunds due to the resident and/or the resident's representative within 30 days from the date of discharge from the facility. This deficient practice affected two of three sampled residents reviewed for refund of personal funds. Findings include: RI #1 was admitted to the facility on [DATE] and discharged home on 5/23/21. On 8/13/21 the State Survey Agency received a complaint which alleged that RI #1's representative had not received a refund of the money paid to the facility for the resident's room and board for the month of May 2021. The complainant felt she was owed for eight days at $70.70 per day for a total of $2,191. A review of RI #1's billing statements revealed a form titled Refund Request for Residents submitted on 7/19/21 for $621.23 with the reason for the refund . (RI #1) was a hospice medicaid resident. was discharged home on 5/23/21. liability amount was paid in full for the month of May, resulting in an overpayment. Therefore a refund is due for the overpayment. The amount of the refund was $621.23. Review of a billing statement for RI #1 with an invoice date of 7/1/21 that included a copy of a facility check made out to RI #1's representative with a date of 7/29/21 revealed the check was in the amount of $621.23. Review of RI #1's Ledger Report revealed a check in the amount of $621.23 with an effective date of 5/31/21 and a billing date of 8/20/21. RI #2 was admitted to the facility on [DATE] and discharged on [DATE]. A review of RI #2's billing statements revealed a Refund Request for Residents was submitted on 6/21/21 with the reason for the refund . (RI #2) was a hospice private pay resident who passed away on 6/4/21. care charge had been paid for the month of June, therefore resulting in an overpayment of . care charges. Therefore a refund is due to the estate. The amount of the refund was $6360.20. Review of RI #2's estate billing statement with an invoice date of 7/1/21 revealed Resident Refund in the amount of $6360.20 and included a copy of a facility check dated 7/29/21, made out to RI #2's representative for the amount of $6,360.20. A review of the facility's Resident Handbook, page 24, revealed the following: . Refund. If you are transferred or discharged before depleting any prepaid charges, a refund of the unused portion of such charges will be made within a reasonable period of time after your transfer or discharge. On 9/9/21 at 8:25 AM, an interview was conducted with Employee Identifier (EI) #3, the bookkeeper. EI #3 was asked when RI #1 was discharged . EI #3 replied, on 5/23/21. EI #3 was asked when she had become aware that RI #1 was owed a refund. EI #3 replied, that she did not know the exact date and did not have a copy of the first refund request that she submitted. EI #3 explained that bills were run around June 20th. The first refund request was for a refund to be issued to Alabama Medicaid, but she later realized that RI #1 was discharged home. When EI #3 realized the error, she called the corporate accounts payable office and told EI #4 to cancel the refund to Alabama Medicaid. EI #3 then submitted a second request for a refund to be issued to RI #1's representative. EI #3 was asked when the second refund request was sent. EI #3 replied, 7/19/21 and that the check was issued on 7/29/21. EI #3 was asked when a refund request is submitted how long did it generally take to be processed. EI #3 replied, usually about 30 days. EI #3 was asked if she was aware that refunds are to be refunded within 30 days from date of discharge. EI #3 replied, no. On 9/9/21 at 9:30 AM, an interview was conducted with EI #4, the Corporate Accounts Payable person. EI #4 was asked what the process was when a refund request was received. EI #4 stated she entered the request into the system and used the statement date as the invoice date and that all invoices were paid within 30 days. EI #4 was asked when she had received the refund request for RI #1. EI #4 replied, she did not have a copy of the first refund request, but she remembers she had a refund payable to the State of Alabama and that EI #3 called and told her to disregard that request. EI #4 was asked if she was aware that refunds must be refunded within 30 days, she replied no. On 9/9/21 at 11:44 AM, an interview was conducted with EI #1, the Administrator. EI #1 was asked what was the policy regarding refunds after a resident was discharged . EI #1 replied, that there was no policy that was directly related to issuing refunds, but the Resident Handbook states refunds will be issued with in a reasonable period of time. EI #1 was asked what he considered a reasonable period of time. EI #1 replied, probably about 30 days to ensure no additional charges needed to be taken out of any prepayment and then request for a refund was submitted to the corporate office for them to issue a check. This deficiency is cited as a result of the investigation of complaint/report number AL 489.

Based on interviews, record review and review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure that Resident Identifier (RI) #8 had a comprehensive care plan developed within 21 days from admission that addressed RI #8's need for assistance with activities of daily living (ADL) and risk of development of pressure ulcers. This affected one of three residents reviewed for completion of comprehensive care plan. Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual dated October 2019 revealed the following: . 4.8 . 8) If the RAI . is not completed until the last possible date (the end of calendar day 14 of the stay) . A complete care plan is required no later than 7 days after the RAI is completed. RI #8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of RI #8's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/29/21, revealed RI #8 had a Brief Interview for Mental Status (BIMS) score of zero, which indicated severe cognitive impairment and RI #8 was at risk of developing pressure ulcers/injuries. Review of RI #8's Braden Scale for Predicting Pressure Sore Risk completed on 4/23/21 revealed a score of 14, indicating RI #8 was at moderate risk for development of pressure ulcers. A review of RI #8's comprehensive care plan revealed a focus area for RI #8 for (Activity of Daily Living) ADL self-care performance deficit with an initiated date, a created date and a revision date of 7/10/2021. Interventions for ADL care were initiated between 7/10/21 and 7/16/21. There was no care plan focus area to address RI #8's risk for pressure ulcer development. On 9/13/21 at 4:50 PM, an interview was conducted with Employee Identifier (EI) #6, Registered Nurse (RN) Clinical Coordinator. EI #6 was asked when RI #8 transferred to her household (South 2). EI #6 replied, 6/4/21. EI #6 was asked when she reviewed the care plan for RI #8 after the transfer to South 2. EI #6 stated she was not sure. EI #6 was asked why RI #8's comprehensive care plan was not completed until 7/10/21. EI #6 stated that was when she noticed it was never completed. EI #6 was asked if she should have known prior to 7/10/21 that the care plan was incomplete. EI #6 stated that she did know the care plan was not complete and had asked EI #5, the MDS Coordinator what she should do about it. EI #6 was asked what she was told by EI #5 to do. EI #6 stated she could not remember. EI #6 was asked if she knew RI #8's care plan was not complete when she was transferred to South 2 on 6/4/21 why did she wait until 7/10/21 to do anything about it. EI #6 stated she wished she would have. EI #6 was asked why it was important to have a care plan completed timely. EI #6 stated because that was the policy. EI #6 was asked what the purpose of the care plan was. EI #6 stated to use as a guide in meeting the resident's individual needs. EI #6 was asked what would happen if there was no guide to go by. EI #6 stated that not everyone would know what care the resident needed and something may be missed. EI #6 was asked who was responsible for completing resident care plans. EI #6 stated, the clinical coordinator of the household. EI #6 was asked what care RI #8 was receiving to prevent the development of pressure ulcers. EI #6 stated when RI #8 came to them on 6/4/21 an air mattress was and applied to RI #8's bed on 6/9/21, RI #8 had heel protectors on, was being turned every two hours, A turn clock was placed at the head of the bed and a sign was put up at the bedside, detailing the skin care the daughter had requested be done daily and heels were being floated with pillows. On 9/13/21 at 5:10 PM, an interview was conducted with EI #5, the MDS Coordinator. EI #5 was asked what the process was for initiating care plans. EI #5 stated when the facility had a new admission, she determined the Assessment Reference Date and what date the care plan would fall on. She would then open the care plan for anyone who needed to edit it. EI #5 was asked when the comprehensive care plan should be completed for a new admission. EI #5 stated 7 days after the completion of the admission Minimum Data Set (MDS) and 21 days after the admitted . EI #5 was asked when RI #8's care plan was opened. EI #5 reviewed the documentation system and stated 4/23/21. EI #5 was asked when RI #8's care plan was completed. EI #5 stated it looked like the only person who initiated a care plan focus area with goals and interventions was the Registered Dietician on 5/3/21. EI #5 was asked when the remainder of the care plan was completed. EI #5 stated between 7/9/21 and 7/11/21. EI #5 was asked who was responsible for initiating the care plan. EI #5 stated the person who has completed the admission MDS. EI #5 was asked who was responsible for completing the admission MDS. EI #5 replied, the clinical coordinators. EI #5 was asked what the purpose of the care plan was. EI #5 replied, to ensure the resident needs are met. EI #5 was asked what should have been done when RI #8 was coded as being at risk for development of pressure ulcers on the admission MDS. EI #5 stated that RI #8's individual risk factors that put her at risk for development of pressure ulcers should be included in the care plan. EI #5 was asked if RI #8's care plan addressed her risk for developing pressure ulcers. EI #5 stated that throughout the care plan some of the risk factors were addressed under the ADL section. EI #5 was asked when that focus was initiated. EI #5 replied, 7/10/21. EI #5 was asked who was responsible for ensuring comprehensive care plans were developed and complete. EI #5 replied, she was. EI #5 was asked should she have known that RI #8's comprehensive care plan was not completed. EI #5 replied, yes, she should have. EI #5 was asked if she knew RI #8's comprehensive care plan was not completed, EI #5 replied, she did not. On 9/14/21 at 4:26 PM, a follow up interview was conducted with EI #5. EI #5 was asked why she did not know that RI #8's comprehensive care plan was not completed. EI #5 stated that she reviewed all initial care plans to make sure all main components were done and that she was very meticulous about that but does not know what happened. EI #5 was asked how she missed RI #8's comprehensive care plan not being completed. EI #5 stated she did not know. This deficiency is cited as a result of the investigation of complaint/report number AL 522.

I. Based on observations, interviews and a review of a facility policy titled, Serving & Storage of Food and a document titled, IN-USE UTENSILS, the facility failed to ensure: 1) Cream of wheat in the dry storage room was sealed; 2) Ham in the refrigerator was labeled and; 3) A scoop was not on laying top of the flour in the flour bin. This had the potential to affect 60 of 60 resident who received meals from the kitchen. II. Based on the facility policies titled, Food Received from the Main Kitchen and Food Preparation, the facility further failed to ensure the facility homemakers serving and plating food for meals on the units: 1. completely contained their hair in hair nets; 2. did not use the same gloves to handle food and non food items; 3. did not use hand sanitizer between glove changes while handling food; 4. did not hold an item removed from the refrigerator against her uniform; 5. did not lay a tong on top of the fries, then with the same gloves on handle non food items and then touched the tongs again to place fries on plates; 6. did not puncture the covering of the meat to check the temperature, and 7. rechecked, after reheating, meat that had tempted at 128 degrees on the tray line. This affected two of two dining areas observed and affected 49 of 49 residents served. Findings Include I. 1) A review of a facility policy titled Serving &Storage of Food with no date, revealed . V. Storing Leftovers .If containers are not sealing adequately, discard them immediately. Once the food is in the appropriate container, use a label to indicate what the food is, Today's date in which food was .prepared, Use date . On 8/27/18 at 3:44 p.m., the surveyor along with EI #14, the cook, toured the dry storage room. The surveyor observed a 28 ounce box of cream of wheat was opened at the top and it was not in a zip loc bag. On 8/30/18 at 10:13 a.m., the surveyor conducted an interview with EI #14, the cook. EI #14 was asked what food item in dry storage was opened at the top of the box. EI #14 replied, the cream of wheat. EI #14 was asked why was the cream of wheat opened. EI #14 replied, it was used and the person did not seal it. EI #14 was asked how should opened food boxes be sealed. EI #14 replied, put food items in a zip loc bag and date it. EI #14 was asked who was responsible for sealing food items after use. EI #14 replied, the cook. EI #14 was asked what did the facility policy say about how food in boxes should be sealed. EI #14 replied, it should be labeled, date it, and whoever used it put their initial on it. EI #14 was asked what was the potential harm to the residents when food products were left opened. EI #14 replied, insects could get in it, there could be bacteria growth and food poison to the residents. 2) A review of a facility policy titled, Serving & Storage of Food with no date revealed: .V. Storing Leftovers .Once the food is in the appropriate container, use a label to indicate what the food is, Today's date/date in which food was .prepared use by date . On 8/27/2018 at 3:44 p.m., the surveyor observed ham in the refrigerator in a medium zip loc bag with no open or use by date on the bag. On 8/30/18 at 10:16 a.m., the surveyor conducted an interview with EI #14. EI #14 was asked what food item in the refrigerator was not labeled. EI #1 replied, ham. EI #14 was asked why was there no name of what the item was or a use by date on the item. EI #14 replied, whoever used it did not label or date it. EI #14 was asked who was responsible for labeling food items once opened. EI #14 replied, whoever was using it at the time. EI #14 was asked what was the facility policy regarding labeling food items once opened. EI #14 replied, everything must be labeled and dated. EI #14 was asked what was the potential harm to the resident when food items were not labeled. EI #14 replied, there could be food poison, bacteria growth, parasites and contamination. 3) A review of a facility document titled, IN-USE UTENSILS, with no date revealed: .KEY TIPS FOR MANAGING IN -USE UTENSILS .They can be stored in the container with foods that don't require time/temperature control as long as the handle doesn't rest in the food. . On 8/27/18 at 3:44 p.m., the surveyor observed a scoop lying down on top of the flour in the flour bin. On 8/30/18 at 10:21 a.m., the surveyor conducted an interview with EI #14. EI #14 was asked what food item had a scoop in it. EI #14 replied, the flour. EI #14 was asked why was a scoop on top of the flour in the flour bin. EI #14 replied, it was there after use. EI #14 was asked what did the facility policy say regarding a scoop being left on top of flour in the flour bin. EI #14 replied, all scoops should be removed. EI #14 was asked who was responsible for making sure scoops were properly stored. EI #14 replied, the one that used it, but shift leaders and supervisor were responsible. EI #14 was asked what was the potential harm to the residents when a scoop was placed on top of the flour in the flour bin. EI #14 replied, the potential for contamination, food poison and bacteria growth. II. A review of a facility policy titled, Food Preparation revealed, .I Safe Food Temperatures . Reheating: 165 degrees or above .Where to Place Meat . Place thermometer . hamburgers . insert in the side of the food . Place the thermometer into the thickest portions of the food . IV. Food Delivery to Households & Neighborhoods .When beginning food preparation or service: . Put on hairnet. Wash hands. Put on gloves. A review of a facility policy titled, Checking Temperatures of Food Received from the Main Kitchen revealed . Procedure: 2. Upon arrival .from the main kitchen, the homemaker will test the temperature of all hot foods that must maintain a temperature of 135 degrees or greater .3. Any hot foods below 135 degrees will be reheated to a minimum of 165 degrees . On 8/27/18 at 5:00 PM, the surveyor observed the supper meal on(NAME)1 Unit. Employee Identifier (EI) #3, homemaker, was observed removing food from a food transport cart in the(NAME)1 kitchen. EI #3's hair was not completely contained under the hair net and EI #3 did not have on an apron. EI #3 was observed putting on a clean pair of black gloves without washing her hands. EI #3 began preparing plates of food for the residents. EI #3 was then observed opening the refrigerator door with the same black gloves on and removed a container of pasta salad. EI #3 held the container against her uniform with one hand and closed the refrigerator door with the other hand. EI #3 then removed the protective wrap from a pan of fries and placed a tong utensil on top of the fries, then picked up a plate and placed fries on the plate. EI#3 laid the tongs back down on top of the fries, with the handle of the tongs touching the fries. EI # 3, with the same black gloves picked up a glass, placed ice and water in the glass, picked up the glass by the drinking rim and placed it on the counter to be given to a resident. EI #3, with the same black gloves on, opened the pantry door and removed a stack of plates then returned to preparing plates of food. EI #3, again with the same black gloves on, removed a container of sliced oranges from the refrigerator. EI #3 removed the plastic covering, then placed orange slices in small serving bowls. EI #3 used the same pair of gloves to touch both food and non food items during the observation. On 8/27/18 at 5:50 PM, an interview was conducted with EI #3, homemaker. EI #3 was asked what was the policy on hair nets. EI #3 replied, all the hair should be under the net. EI #3 was asked if all of her hair was contained in the net. EI #3 replied, no. EI #3 was asked when should she change gloves. EI #3 replied, after touching something other than food. EI #3 was asked when had she changed her gloves. EI #3 replied, she had not changed gloves since she first put them on. EI #3 was asked when should she wash her hands, if she removed the gloves. EI #3 replied, after removing the gloves before putting on clean ones. EI #3 was asked how was she trained to serve meals/food. EI #3 replied, she was trained by another homemaker. EI #3 was asked what was the harm in hair not being contained under the hair net. EI #3 replied, hair could get in the food. EI #3 was asked what was the harm in holding a container against her uniform. EI #3 replied, contamination. EI #3 was asked what were the tasks of a homemaker. EI #3 replied, clean resident rooms then serve the meal. EI #3 was asked if her uniform was clean. EI #3 replied, no. EI #3 was asked what was the harm in using the same gloves to touch utensils then touch food. EI #3 replied, contaminate the foods. EI #3 was asked how many residents received food from the dining area. EI ## replied, 23. EI #3 was asked what were homemaker duties. EI #3 replied, prepare and serve foods to residents. EI #3 was asked if she preformed housekeeping tasks. EI #3 replied yes, she came in at 11:00 AM and did housekeeping tasks, then at 3:00 PM she washed up and went to the dining/kitchen area on the unit and prepared the supper meal. EI #3 was asked how many residents received food from the unit. EI #3 replied, 26. On 8/28/18 at 11:55 AM, the surveyor observed on(NAME)2 Unit the dining and serving of lunch. EI #4, Certified Nursing Assistant and homemaker, was observed placing food from the transport cart onto the counter. EI #4's hair was not completely contained under the hair net. EI #4 was observed taking the temperature of the foods. EI #4 punctured the foil covering on the Salisbury steak to take the temperature. The reading was 128 degrees. EI #4 turned on the heat to the burner. EI #4, with the same gloves on, removed a notebook from a drawer and removed a page and then removed a pen from the pocket of her uniform and recorded the temperatures of the foods on the sheet. She then returned the page to the book and placed the book back in drawer. EI #4 removed her gloves, used hand sanitizer and put on clean gloves. EI #4 then returned to plating food to serve the residents on the unit. On 8/28/18 at 2:15 PM, an interview was conducted with EI #4. EI #4 was asked what was the policy on taking temperatures of foods. EI #4 replied, remove the covering and place the thermometer in the middle of the food, read the temperature and record it. EI #4 was asked when should she puncture the cover wrap over a food item. EI #4 replied, never. EI #4 was asked what should the temperature of the meat be. EI #4 replied,160 degrees. EI #4 was asked what was the temperature of the meat. EI #4 replied, 128 degrees and she turned on the burner to heat it. EI #4 was asked if she re-tempted the meat. EI #4 replied, no. EI #4 was asked if she should have checked the temperature of the meat again before serving. EI #4 replied, yes. EI #4 was asked what was the harm in a meat temperature being too low. EI #4 replied, bacteria could grow. EI #4 was asked when should hand sanitizer be used while serving/plating food. EI #4 replied, it should not be used. EI #4 was asked when should hands be washed during plating food. EI #4 replied, every time you touch something not food you should take those gloves off and wash hands and put on clean gloves. EI #4 was asked what was the policy on covering hair with hair nets. EI #4 replied, all the hair should be completely covered. EI #4 was asked if her hair was completely contained under the hair net. EI #4 replied, no. EI #4 was asked what was the risk of hair not being contained in hair nets. EI #4 replied, hair could fall in the food. EI #4 was asked how were homemakers trained to serve/plate food. EI #4 replied, another homemaker trained them. EI #4 was asked what other duties did homemaker have. EI #4 replied, clean resident rooms, then go to the serving area near meal time and get things ready. On 8/29/18 at 3:00 PM, an interview was conducted with EI #11, Registered Dietian, (RD). EI #11 was asked what were job duties of homemakers. EI #11 replied, serve meals, temp foods, food safety and sanitation. EI #11 was asked who trained the homemakers. EI #11 replied, she did and during orientation job specific, and then with staff homemaker. EI #11 was asked how were homemakers trained to handle and prepare and serve food. EI #11 replied, they had classes once a month and inservice every other month. EI #11 was asked if homemakers cleaned resident rooms then serve resident meals from the individual dining areas. EI #11 replied, yes. EI #11 was asked when should staff have hair out from under the hair net while plating food EI #11 replied, never. EI #11 was asked when should staff plating food change gloves. EI #11 replied, as often as needed after touching anything other than food. EI #11 was asked when should staff wash their hands. EI #11 replied, as often as needed, when touching dirty items they should remove those gloves and wash their hands and put on clean gloves. EI #11 was asked when should staff handle tongs, lay tongs on top of food then touch dirty items. EI #11 replied never. EI #11 was asked what was the policy on using hand sanitizer while handling food. EI #11 replied, it was not to be used at all. EI #11 was asked what was the policy on taking temperatures of foods. EI #11 replied, the temperatures were to be taken when food arrived to the units, if not greater than 135 degrees it was to be reheated, then the temperature was to be taken again to ensure it was 165 degrees or greater. EI #11 was asked when should staff puncture the covering on food to check the temperature. EI #11 replied, never. EI #11 was asked what was the harm in hair not completely contained under the hair net. EI #11 replied, it could contaminate the food. EI #11 was asked what was the harm in not tempting the food correctly. EI #11 replied, it could contaminate the food. EI #11 was asked what was the harm in not washing hands properly while handling food. EI #11 replied, contamination. EI #11 was asked why hand sanitizer should not be used. EI #11 replied, it could contaminate the food.

Based on observation, interview and review of a facility policy Quality of Life - Dignity the facility failed to ensure Resident Identifier (RI) #11 received the supper meal on 8/27/18 and was fed the same time the roommate was fed. This was observed on 8/27/18 and affected one of two residents observed for meals. Findings Include: A review of a facility policy Quality of Life -Dignity with a revised date of (MONTH) 2009 revealed: Policy Statement Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. RI #11 was admitted to the facility 1/22/15 with a [DIAGNOSES REDACTED]. A review of a Quarterly Minimal Data Set with an Assessment Reference Date of 5/31/18 revealed RI #11 was totally dependant for eating. On 8/27/18 at 5:01 PM the surveyor observed the supper meal served to the roommate who required to be fed. On 8/27/18 at 5:40 PM the surveyor observed staff take a tray in to RI #11's room and begin to feed the resident. On 8/28/18 at 4:05 PM, an interview was conducted with Employee Identifier (EI) #13, Clinical Coordinator. EI #13 was asked what was the policy on residents in rooms and meals. EI #13 replied, both should receive the meal and be fed at the same time. EI #13 was asked if RI #11 was fed the same time the roommate was fed. EI #13 replied, no. EI #13 was asked what was the harm in both residents not receiving meals at the same time. EI #13 replied, dignity and the resident not being fed may be hungry and harmed by smelling the food and not eating their own.

Based on observation, interview and review of a facility policy titled, Housekeeping, Cleaning & Laundry, the facility failed to ensure: 1) Resident Identifier(RI) #85's room was clean and free of crumbs, the carpet was not wet and the bathroom was clean and 2) the 600 Hall was free of a urine odor. This was observed on four days of the survey and affected RI #85 and the 600 Hall. Findings Include: A review of a facility policy Housekeeping, Cleaning & Laundry, no date, revealed .II. P.M. Homemaker Duty List The P.M. Homemaker will accomplish daily the following day shift cleaning duties.Clean resident rooms. 1) RI #85 was admitted to the facility 2/17/17 with a [DIAGNOSES REDACTED]. On 8/28/18 at 10:13 AM, during a brief family interview there was concerns voiced about RI #85's room and dirty bathroom. The surveyor observed crumbs on the carpet next to the bed and near the chair. The carpet was also noted wet and stained and the bathroom had trash on the floor. The isolation trash bin was noted full with the lid not completely closed due to trash above the rim. On 8/28/18 at 12:00 PM, the surveyor again observed the stained carpet and wet. The crumbs remained on the carpet next to the bed and around the chair. The bathroom continued to have the trash on the floor. The trash containers were also noted full. On 8/28/18 at 3:57 PM, the surveyor observed RI #85's room. The carpet in room continued to be stained with wet areas and crumbs next to the bed and chair. The trash in the bathroom remained full and trash was again noted on the bathroom floor. On 8/29/18 at 9:00 AM, the surveyor observed RI #85's room. The findings revealed crumbs on the carpet, carpet stained, bathroom trash full and trash on the bathroom floor. On 8/29/18 at 9:10 AM, an interview was conducted with Employee Identifier (EI) #6, the neighborhood coordinator. EI #6 was asked to describe what she observed in RI #85's room. EI #6 replied, crump's on the carpet near the bed and around the chair, stained carpet, the trash needed to be emptied and trash was on the bathroom floor. EI #6 was asked how often were rooms cleaned. EI #6 replied, daily between 11 AM and 3 PM. EI #6 was asked who was responsible for cleaning. EI #6 replied, the homemakers. EI #6 was informed by the surveyor that these observations were noted for four of four days of the survey. EI #6 was then asked what was included in cleaning. EI #6 replied, dusting, vacuuming, mopping, cleaning the bathroom and taking out the trash. EI #6 was asked what was risks for resident rooms not being cleaned. EI #6 replied, it was not a nice atmosphere and unsanitary. 2) From 8/27/18 to 8/30/18 the surveyors noted a urine odor on the 600 Hall. On 8/30/18 at 9:50 AM, a walk through was conducted with EI #12, the Housekeeping Supervisor. EI #12 was asked what did she smell on the 600 Hall. EI #12 replied, urine. EI #12 was asked who was responsible for assuring no urine odors. EI #12 replied, the homemakers. EI #12 was asked if the urine odor should be on the hall. EI #12 replied, no. EI #12 was asked what the harm was with the urine odor on the hall. EI #12 replied, dignity and it was not pleasant. EI #12 added, this was their (resident's) home and it should smell clean. EI #12 was asked who trained the homemakers. EI #12 replied, they have lead homemakers that have been there longer that train the new ones. EI #12 was asked when were resident rooms to be cleaned. EI #12 replied, daily. EI #12 was asked what was involved when cleaning resident rooms. EI #12 replied, vacuuming, wiping , dusting, mopping the floor and emptying the trash. EI #12 was asked when should a room have crumbs next to the bed and chair, stained, wet carpet and the bathroom dirty for three days. EI #12 replied, never.

Based on observation, interview, record review and review of a facility policy titled, Perineal Care of Incontinent Residents, the facility failed to ensure a Certified Nursing Assistant (CNA) performing incontinent care for RI # 85 did not 1. change gloves without washing her hands before applying clean gloves, and 2. did not remove a soiled pad then with same dirty gloves place a clean bed pad. This was observed on 8/29/18 and affected one of two residents observed for incontinent care. Findings Include: A review of a facility policy titled, Perineal Care of Incontinent Residents, no date, revealed .Procedure: .5. Wash your hands .11. Put on clean gloves.15 a.wash . b. rinse .20.put soiled linens in a bag. 21. Remove gloves and discard. PUT ON NEW GLOVES .22. Apply clean undergarments, diaper or underpad. RI #85 was admitted to the facility 2/17/17 with a [DIAGNOSES REDACTED]. A review of a facility lab report revealed: .8/17/18 .Bacteriology .Source : .Urine .Final Report .Confirmed Extended Spectrum Beta-Lactamase (ESBL) organism . On 8/29/18 at 9:17 AM, Employee Identifier's (EI) #8 CNA and EI #9 CNA, were observed performing incontinent care for RI #85. EI #8 gathered the supplies, put on gloves and loosened the brief and cleaned the front side of RI #85. EI #8 turned RI #85 to the left side and removed the soiled brief. EI #8 rolled the soiled pad up and toward the resident. EI #8 the removed her gloves and put on clean gloves, without washing her hands between the glove change. EI #8 placed the clean bed pad and wiped RI #85 one more time to assure the resident was clean. EI #8 changed her gloves, without washing her hands and placed the clean brief under the resident. EI #8 applied skin barrier then removed her gloves and put on a clean pair of gloves; again not washing hands between glove changes. EI #8 secured the brief . EI #8 then turned RI #85 to the right side and EI #9 removed the rolled soiled pad. EI #9 then rolled out the clean pad with the same gloves she had touched the soiled pad with. On 8/29/18 at 9:37 AM, an interview was conducted with EI #8, CNA. EI #8 was asked what was the policy on when to wash hands during incontinent care. EI #8 replied, wash hands before starting, then between glove changes and when finished. EI #8 was asked if she washed her hands between glove changes. EI #8 replied, no. EI #8 was asked if RI #85 was soiled with bowel movement. EI #8 replied, yes. EI #8 was asked if she should have washed her hands between glove changes. EI #8 replied, yes. EI #8 was asked what was the harm in not washing hands between glove changes. EI #8 replied, spread bacteria and infection. On 8/29/18 at 9:40 AM, an interview was conducted with EI #9, CNA. EI #9 was asked what was the policy on touching dirty items then with the same dirty gloves touching clean items. EI #9 replied, she was supposed to remove the dirty items, then remove gloves, wash hands, then put on new gloves and touch clean items. EI #9 was asked when should she remove a dirty pad then with the same gloves roll or touch a clean pad. EI #9 replied, never. EI #9 was asked what was the risk of touching dirty items then clean items with the same gloves. EI #9 replied, it could cause or spread infection. On 8/30/18 at 1:27 PM, an interview was conducted with EI #15, Infection Control Nurse. EI #15 was asked what was the policy on changing gloves and washing hands during pericare. EI #15 replied, wash hands, put on gloves, perform the care, remove the gloves and wash hands. She said they should change gloves and wash their hands at least three times or more, if needed. EI #15 was asked what was the harm of staff not washing hands between glove changes. EI #15 replied, it could cause cross contamination. EI #15 was asked what was the policy on removing soiled items then placing clean items. EI #15 replied, they were to remove the soiled items, then remove their gloves, wash their hands and put on new gloves. EI #15 was asked what was the harm of staff touching soiled items then touching clean items. EI #15 replied, cross contamination.

Based on observation, interview and review of a facility policy Security of Medication Cart, the facility failed to ensure a licensed staff did not leave the medication cart unlocked as she walked away from it. This was observed on 8/27/18 and affected one of six nurses observed for medication pass. Findings Include: A review of a facility policy titled, Security of Medication Cart, with a revised date of (MONTH) 2007 revealed, Policy Statement The medication cart shall be secured during medication passes. Policy Interpretation and Implementation .4. Medication carts must be securely locked at all times when out of the nurse's view. On 8/27/18 at 4:00 PM, the surveyor observed Employee Identifier (EI) #2, Licensed Practical Nurse passing medication. EI #2 was in the medication cart then left the cart and went to a resident's room. EI #2 did not lock the medication cart. Once EI #2 got to the the resident's room she realized she had forgot something and returned to the medication cart. She then realized she had not locked it before leaving it. On 8/27/18 at 4:40 PM an interview was conducted with EI #2. EI #2 was asked what was the policy on locking medication cart. EI #2 replied, it should be locked before walking away from it. EI #2 was asked what was in the medication cart. EI #2 replied, resident medications and overstock medications. EI #2 was asked if the medication cart was locked upon her returning to it. EI #2 replied, no. EI #2 was asked what was the risk of leaving the medication cart unlocked. EI #2 replied, someone could get in it and take medications.

Based on observation, interview and review of a facility policy titled, Perineal Care of Incontinent Residents, the facility failed to ensure a Certified Nursing Assistant(CNA) did not place a soiled brief on the floor and did not touch a clean brief and clean clothing with the same soiled gloves she had on during the provision of incontinent care for Resident Identifier (RI) #10. This was observed on 8/28/18 and affected one of two residents observed for incontinent care. Findings Include: A review of a facility policy Perineal Care of Incontinent Residents revealed: .Procedure: .11. Put on clean gloves. 20.put soiled linens in a plastic bag. 21. Remove gloves and discard. PUT ON NEW GLOVES before continuing with care. 22. Apply clean undergarments, diaper or underpad. RI #10 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 8/28/18 at 11:10 AM, Employee Identifier (EI) #5, CNA was observed performing incontinent care for RI #10. EI #5 put on clean gloves and carried out the incontinent care. When EI #5 removed the soiled bried and placed it on the floor. EI #5 then placed a clean brief and dressed RI #10, using the same soiled gloves she used to clean the resident during the incontinent care. On 8/28/18 at 11:24 AM, an interview was conducted with EI #5. EI #5 was asked where should she place a soiled brief when removed from a resident. EI #5 replied, in a bag in the trash can. EI #5 was asked where did she put the soiled brief. EI #5 replied, on the floor. EI #5 was asked what was the risk of placing a soiled brief on the floor. EI #5 replied, spreading germs. EI #5 was asked when should she change gloves during incontinent care. EI #5 replied, after cleaning and before touching a clean brief and clothing. EI #5 was asked if she had on the same gloves to clean RI #10, then put on the clean brief and clothes. EI #5 replied, yes. EI #5 was asked when should she wash her hands while performing incontinent care. EI #5 replied, she should have changed gloves after cleaning RI #10 and washed her hands, then put on clean gloves to place the brief and clothes on. EI #5 was asked what was the risk of not changing gloves and not washing her hands after removing the soiled brief. EI #5 replied, it could contaminate the clean brief and clothes and spread germs. On 8/30/18 at 1:27 PM, an interview was conducted with EI #15, Infection Control Nurse. EI #15 was asked what was the policy on changing gloves and washing hands during pericare. EI #15 replied, wash hands, put on gloves, perform the care, remove the gloves and wash hands. She said they should change gloves and wash their hands at least three times or more, if needed. EI #15 was asked what was the harm of staff not washing hands between glove changes. EI #15 replied, it could cause cross contamination. EI #15 was asked what was the policy on removing soiled items then placing clean items. EI #15 replied, they were to remove the soiled, then remove their gloves, wash their hands and put on new gloves. EI #15 was asked what was the harm of staff touching soiled items, then touching clean. EI #15 replied, cross contamination. EI #15 was asked where should soiled items be placed. EI #15 replied, in a clear bag and taken to the soiled utility room. EI #15 was asked when should staff place soiled items on the floor. EI #15 replied, never. EI #15 was asked what would be the harm in placing soiled items on the floor. EI #15 replied, cross contamination.

Based on observation, interview and a review of a facility policy titled Food -Related Garbage and Rubbish Disposal, the facility failed to ensure the dumpster door on the dumpster was closed. Findings Include: A review of a facility policy titled Food-Related Garbage and Rubbish Disposal, with a revised date of (MONTH) 2006 revealed, .Policy Interpretation and Implementation . 7. Outside dumpster provided by garbage pick up services will be kept closed and free of surrounding litter . On 8/27/18 at 4:07 p.m., the surveyor along with EI #14, the cook observed the dumpster door opened at the side. On 8/30/18 at 10:25 a.m., the surveyor conducted an interview with EI #14. EI #14 was asked what did she observe regarding the dumpster door on 8/27/18. EI #14 replied, the door on the rear was left opened. EI #14 was asked who was responsible for making sure the dumpster doors were closed. EI #14 replied, whoever put the boxes in after every use. EI #14 replied, kitchen should go and check behind staff. EI #14 was asked what did the facility policy say regarding keeping the dumpster doors closed. EI #14 replied, dumpster doors must stay closed at all time. EI #14 was asked what could potentially happen when the dumpster doors are left opened. EI #14 replied, to keep it closed to keep rodents out.

Based on interviews, review of the facility's policy titled Wesley Manor Laboratory Protocol, a complaint received by the Alabama State Survey Agency and Resident Identifier (RI) #1's medical record, the facility failed to identify and respond to the critical laboratory (lab) value that was reported to the facility. On 5/14/2018, RI #1 had a lab specimen drawn for a [MEDICATION NAME] and [MEDICATION NAME] level. The results of the lab tests were faxed to the facility on [DATE] at 8:12 AM; however, the Medical Doctor and/or Nurse Practitioner were not made aware of the lab results until 5/17/2018. RI #1's [MEDICATION NAME] level was critically high at 52.0; normal range is 10.0 to 20.0. After assessment by Employee Identifier (EI) #1, the Nurse Practitioner, RI #1 was transferred and admitted to the local hospital. RI #1's admitting [DIAGNOSES REDACTED]. This deficient practice affected RI #1, one of six sampled residents reviewed for laboratory services and placed the resident in immediate jeopardy for serious injury, harm and/or death. On 7/5/2018 at 5:10 PM, the Administrator and Director of Nursing were notified of the findings of immediate jeopardy in the area of Laboratory, Radiology and Other Diagnostic Services, F770. Findings include: The facility's undated policy titled Wesley Manor Laboratory Protocol documented Labs are obtained per physician orders [REDACTED]. Any criticals called in to the facility should be called in to the physician for further orders. Faxed lab results that are within normal limits should be placed in the physician box, faxed to the physician for review or nurse practitioner box on each unit for their review. All labs that results within normal limits can be faxed or placed in the physician/nurse practitioner box for their review on next visit. On 6/28/2018, the Alabama State Survey Agency received a complaint which alleged the facility continued to administer RI #1 [MEDICATION NAME] medication without knowing the resident's [MEDICATION NAME] level. RI #1 was originally admitted to the facility 8/5/2010. RI #1 has a medical history to include [DIAGNOSES REDACTED]. RI #1's care plans titled (RI) #1 will remain free from injury related to [MEDICAL CONDITION] activity through review date and (RI #1) will maintain lab values within therapeutic range per MD (Medical Doctor) through review date both initiated on 6/20/2017, had interventions of . Monitor labs and report any sub therapeutic or toxic results to MD . Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated . RI #1's physician's orders [REDACTED]. [MEDICATION NAME] & [MEDICATION NAME] LEVEL Q3 (every three) MONTHS (FEB/MAY/AUG/NOV) . RI #1's physician orders [REDACTED].#1 was ordered [MEDICATION NAME] Suspension ([MEDICATION NAME]) Give 100 mg (milligram) via (by way of) G (gastrostomy)-Tube two times a day related to [MEDICAL CONDITION] . [MEDICATION NAME] Solution 100MG/ML (milliliter) (LevETIRAcetam) Give 7.5 ml via [DEVICE] three times a day related to [MEDICAL CONDITION] . RI #1's progress note written by EI #4, a Licensed Practical Nurse (LPN) and dated 5/14/2018 11:14 PM, documented . CNA (Certified Nursing Assistant) says she observed residents mouth tremble and eyes roll. Resident is on meds for [MEDICAL CONDITION] and we are waiting results of labs drawn this am. (morning) will continue to monitor. On 7/4/2018 at 2:30 PM, an interview was conducted with EI #4, the LPN assigned to care for RI #1 during the 3:00 PM to 11:00 PM shift on 5/14/2018. EI #4 stated she was aware the resident had labs because she took the bandage off. EI #4 explained that she had went into the nurse charting room several times during her shift on 5/14/2018 and noted nothing on the fax machine. When asked if she should have followed up on the lab, EI #4 replied, she only follow-up on labs that came to the facility by way of the fax machine. EI #4 was asked how the facility was notified of lab results. EI #4 stated, the lab faxes the results but if they were critical, they must call and talk with a nurse. When asked who had access to the fax machine, EI #4 said there was only one fax machine and the nurses are the ones that removed labs results from the facility machine. When asked if she had removed RI #1's lab results from the fax machine, EI #4 said no. EI #4 explained the lab results were faxed to the facility on [DATE] and she did not work on that day. EI #4 was then asked about the entry in RI #1's medical record dated 5/14/2018 11:14 PM, which revealed a CNA observed the resident's mouth tremble and eyes roll. When asked if this were signs of [MEDICAL CONDITION] activity, EI #4 said it could be but not always. EI #4 said she couldn't get the lab results because at that time, the lab was closed. When asked if she passed off in report that RI #1 had labs and the facility was awaiting the lab results, EI #4 said she didn't recall. In a follow-up interview on 7/5/2018 at 9:56 AM, EI #4 was asked who was responsible for checking the fax machine. EI #4 replied, anyone can check the fax but the nurses should check it. EI #4 explained, if the nurses were conducting medication pass, it would take a while to get the fax. RI #1's laboratory report revealed on 5/14/2018 at 9:09 AM, a specimen of blood was drawn from the resident for a [MEDICATION NAME] and [MEDICATION NAME] level. RI #1's [MEDICATION NAME] level was high at 48.97; normal range is 6.00 to 46.00. RI #1's [MEDICATION NAME] level was critically high at 52.0; normal range is 10.0 to 20.0. The report further revealed, RI #1's laboratory test results were faxed to the facility on [DATE] at 8:12 AM. RI #1's progress note dated 5/17/2018 8:41 AM, documented . resident transferred r/t (related to) 52.0 [MEDICATION NAME] level [MEDICATION NAME] 48.97, to be evaluated . vitals (b/p (blood pressure) 102/68, pulse 46, O2sat 97% temp (temperature) 97.0 . On 7/3/2018 at 10:20 AM, EI #3, the LPN assigned to care for RI #1 at the time the resident was sent to the hospital on [DATE], was asked why the resident was sent out. EI #3 said because of the critical [MEDICATION NAME] level. When asked how she was made aware of the critical [MEDICATION NAME] level, EI #3 said when the Nurse Practitioner (EI #1) pulled lab results from his box. According to EI #3, the Nurse Practitioner asked her if she had seen the lab results and EI #3 said no. When asked how RI #1 was, EI #3 said the resident was no different than his/her usual state. When asked about RI #1's low heart rate, EI #3 stated the resident has [MEDICAL CONDITION] and his/her heart rate fluctuated. EI #3 was asked how lab results were received in the facility. EI #3 replied, they come to the fax. RI #1's Medical Visit (physician's/physician's extender progress note) dated 5/17/2018, documented . Lab noted drawn on 5-14-18 with elevated [MEDICATION NAME] of 52, reference range is 10-20, . (RI #1) is non verbal r/t [MEDICAL CONDITION], (he/she) is lying in bed, does not awaken to verbal or tactile stimuli which is unlike (him/her). Pulse 42. NSG (nursing) reports (he/she) has continued) to receive (his/her) [MEDICATION NAME] the last two days . SUMMARY OF FINDINGS Elevated [MEDICATION NAME] level . Lethargy . PLAN ER (emergency room ) eval (evaluation) r/t elevated [MEDICATION NAME]/[MEDICATION NAME] level . [MEDICAL CONDITION], lethargy . RI #1's physician order [REDACTED]. During an interview on 7/3/2018 at 8:50 AM, EI #1, the Nurse Practitioner stated RI #1's labs were drawn on 5/14/2018 because that was the routine day for them to be done. EI #1 confirmed he was not notified of RI #1's critical [MEDICATION NAME] lab results. EI #1 explained when he did rounds in the facility on 5/17/2018, he discovered RI #1's lab results in the Nurse Practitioner/Medical Doctor's box located on the chart rack on Station Three. When asked who had access to the box, EI #1 said everyone. EI #1 stated when he went to assess the resident, RI #1 was in his/her normal state. When asked what the common signs were of elevated [MEDICATION NAME] level, EI #1 said lethargy, dizziness and drowsiness. EI #1 was asked, when he expected to be notified of lab results. EI #1 replied, when deemed critical. When asked why RI #1 was sent to the hospital, EI #1 said based on the resident's [MEDICATION NAME] level, he felt it was best to send the resident out to have repeat labs and to be evaluated. RI #1's Medication Administration Record [REDACTED]. The resident was administered 100 mg of [MEDICATION NAME] once in the morning on 5/17/2018. RI #1 was administered 100mg of [MEDICATION NAME] three times a day from 5/1/2018 to 5/16/2018 and once in the morning on 5/17/2018. In a follow-up telephone interview on 7/5/2018 at 9:40 AM, EI #1, the Nurse Practitioner was asked what could have occurred when RI #1 continued to be administered [MEDICATION NAME] with a critical [MEDICATION NAME] level of 52. EI #1 said liver and neurological damage. When asked if RI #1's [MEDICATION NAME] level was high enough to cause liver and neurological damage, EI #1 said possibly that is why he sent RI #1 out. EI #1 was asked, how the facility receive lab results. EI #1 said by way of fax. When asked how he was made aware of lab results, EI #1 said if the lab results are normal, they are placed in his box and he reviews during his visits (rounds) on Tuesdays and Thursdays; however, if abnormal or critical, they call for further orders. The Patient Care Report from the local ambulance service indicated on 5/17/2018 at 8:26 AM . dispatched non emergency to Wesley Place . for patient (RI #1) with abnormal lab results to be transported to (local hospital) ER for eval. reference to patients [MEDICATION NAME], and [MEDICATION NAME] levels were elevated. EMS (emergency medical services) arrived on scene to find patient alert to verbal stimuli, per RN (Registered Nurse) at bedside pt (patient) was in (his/her) normal L[NAME] (level of consciousness) and responsiveness. Bedside RN stated the physician did there (their) rounds this morning and wanted patient to be seen at the hospital due to the increased medication levels. Vital Signs were obtained and revealed patients pulse to be 42 (Pt has a [DIAGNOSES REDACTED]. The local hospital's Emergency Department's documentation dated 5/17/2018, documented . Chief Complaint: Pt sent from NH (nursing home) with abn (abnormal) [MEDICATION NAME] level drawn on 5/14, pt is n-verbal (non verbal), contracted, EMS reports pt brady (bradycardic) at 40. History of Present Illness The patient presents . from Wesley . with abnormal labwork which was drawn 3 days ago. The results came back today with elevated [MEDICATION NAME] level. Not knowing the lab results (he/she) has continued to be medicated with [MEDICATION NAME] . In the emergency room , RI #1's pulse rate was listed as critically low at 41 beats per minute. RI #1's [MEDICATION NAME]'s level was critically high at 45.5 and [MEDICATION NAME] level was high at 86.4. RI #1's [DIAGNOSES REDACTED]. RI #1's condition was guarded and the resident was admitted to the hospital to the Inpatient Telemetry Unit. In a telephone interview on 7/3/2018 at 8:45 AM, RI #1's responsible party stated someone from the nursing home called her on 5/17/2018 and told her RI #1 was being sent out to the hospital because the resident's [MEDICATION NAME] level were high. RI #1's responsible party stated she later found out labs had been drawn on 5/14/2018; however, the Nurse Practitioner did not find out the results until he visited the facility on 5/17/2018. On 7/3/2018 at 4:23 PM, a telephone interview was conducted with EI #5, the LPN who documented administering [MEDICATION NAME] and [MEDICATION NAME] medication to RI #1 during the mornings of 5/15/2018, 5/16/2018 and 5/17/2018. EI #5 was asked if she was aware labs had been drawn for RI #1 on 5/14/2018. EI #5 stated she was aware now that RI #1 was due for routine labs and the Nurse Practitioner found in his box critical [MEDICATION NAME] lab results for the resident. When asked who was assigned to check the fax machine for labs, EI #5 said no one specific, all the nurses just check the fax machine randomly during their shift. When asked who was responsible for follow up on labs, EI #5 replied, whoever the nurse was that got the lab results off the fax machine. EI #5 explained if the results were abnormal, the nurse was expected to call the Nurse Practitioner or Medical Doctor for further orders. When asked who had access to the fax machine, EI #5 said anyone that went into that area to chart. In a follow-up telephone interview on 7/5/2018 at 9:35 AM, EI #5, a LPN was asked if she was aware RI #1 had lab drawn on 5/14/2018. EI #5 replied, she was not. EI #5 explained she recalled the Nurse Practitioner (EI #1) being angry when he found the lab results in his box. According to EI #5, the Nurse Practitioner wanted to know why it hadn't been addressed. EI #5 stated if she would have known labs were drawn, she would have followed up on the labs the next day. During an interview on 7/3/2018 at 9:30 AM, the Director of Nursing (DON), EI #6, was asked how lab results were reported to the facility. EI #6 replied, the lab usually called the facility Monday thru Friday 7:00 AM to 5:00 PM. When asked who discovered RI #1's critical lab results, EI #6 stated, the Nurse Practitioner when he visited on 5/17/2018. EI #6 stated she became aware after the Nurse Practitioner found the lab results in his box. When asked why no one was specifically assigned to follow up on labs, EI #6 explained on all units the nurse on duty was to check the fax machine through their shift and handle any lab results that came in. EI #6 was asked, how she ensured the lab results received were reported to the physician. EI #6 replied, if the lab results were within normal limits, the lab results should be placed in the Nurse Practitioner's box for review during their visit on Tuesdays and Thursdays; however, if the labs results were critical or abnormal, the nurse who removed the results from the fax should notify the Nurse Practitioner or Medical Director for further orders. When asked if this was done, EI #6 said no. EI #6 explained she could not determine who removed RI #1's lab results from the fax machine and placed in the Nurse Practitioner's box. According to EI #6, the nurse on duty denied removing the fax and the Nurse Practitioner stated the results were not in his box when he visited the facility on 5/15/2018. EI #6 stated anyone had access to the fax machines on the units. When asked if there was a failure in the system of receiving and reporting critical lab values, EI #6 said yes. EI #6 was asked if RI #1 continued to be administered [MEDICATION NAME] on 5/15/2018, 5/16/2018 and 5/17/2018. EI #6 answered yes. During an interview with the Executive Director, EI #7, on 7/3/2018 at 11:15 AM, he stated the facility never received a call from the lab about the critical lab results. On 7/3/2018 at 10:00 AM, an interview was conducted with EI #8, the facility's Medical Director and RI #1's attending physician. When asked how should RI #1's critical [MEDICATION NAME] lab results be reported to the facility, EI #8 replied he or the Nurse Practitioner should have been notified first. When asked what evidence EI #8 had to support the lab should have notified him or the Nurse Practitioner of a critical lab values, EI #8 there was no written protocol just a verbal agreement. EI #8 was asked why was there a delay in reporting RI #1's critical lab results to the facility. EI #8 stated he didn't know. When asked if the system failed in responding to RI #1's critical lab results, EI #8 replied yes. On 7/3/2018 at 10:40 AM, an interview was conducted with a representative of the (Name) Clinic PC, the company responsible for collecting RI #1's lab specimens on 5/14/2018. The representative acknowledged RI #1's lab results were faxed to the facility on [DATE] at 8:12 AM. When asked what the procedure was for reporting lab results to the facility, the representative stated the lab faxed the results the reports to the facility when the results are received; however, if the results are received after hours, the results are not faxed until the next day. RI #1's laboratory report revealed on 5/14/2018 at 9:09 AM, a specimen of blood was drawn from the resident for a [MEDICATION NAME] and [MEDICATION NAME] level. RI #1's [MEDICATION NAME] level was high at 48.97; normal range is 6.00 to 46.00. RI #1's [MEDICATION NAME] level was critically high at 52.0; normal range is 10.0 to 20.0. The report further revealed, RI #1's laboratory test results were . Called to, Read back and Confirmed by: DR. (Name) 5/14/18 1851 (6:51 PM) . On 7/3/2018 at 2:40 PM, an interview was conducted with the physician the lab reported RI #1's critical lab values to 5/14/2018 at 6:51 PM. During the interview, the physician stated he had no recollection of being notified of RI #1's critical lab results. According to the physician, typically the nursing home lab results go the Nurse Practitioner. The physician did acknowledge speaking with EI #8, the facility's Medical Director, after the problem was identified about the lack of communication with the critical lab results. During an interview on 7/5/2018 at 12:39 PM, the Administrator for the (Name) Clinic PC, the company responsible for collecting RI #1's lab specimens on 5/14/2018, stated after it was discovered there was delay in communicating critical lab results, the clinic changed their protocol. According to the clinic's Administrator, prior to 5/17/2018, the clinic faxed all lab results to the facility; however, since 5/17/2018, the clinic now faxes and calls the facility with abnormal lab results. ************************ On 7/7/2018 at 4:50 PM, the facility provided an Acceptable Allegation of Compliance, which documented: Lab 1). On 5/14/2018 an order was received for a lab to be drawn for (RI #1). The lab was obtained for a [MEDICATION NAME] level. On 5/14/2018 at 18:51 pm Dr. (name), on call physician for (name) Clinic PC was notified by the lab at (name of lab) of the test results. (Name of lab) is the subcontractor for (Name) Clinic PC. (Name of lab) conducts lab testing for certain labs on behalf of (Name) Clinic, PC and reports those results to (Name) Clinic PC in accordance with their protocols. At 8:11 am on 5/15/2018 a copy of the results were faxed to the facility. At some point between 5/15/18 and 5/17/18 the results were placed in the nurse practitioners mailbox. On 5/17/2018 the Nurse Practitioner rounded and reviewed the lab report and ordered the resident to be sent to the hospital for review and evaluation of resident's [MEDICATION NAME] level. Resident was admitted to the hospital. On 5/22/2018 resident returned and readmitted to the facility with orders for monitoring and administration of (his/her) [MEDICATION NAME] as per physician orders. 2) Any resident with Lab tests ordered has the potential to be affected by this practice. The Director of Nursing has reviewed all other resident's orders written for lab tests, 5/14/2018 through current to ensure lab results were communicated to the treating physician/physician extended. All other resident orders for lab tests were performed as ordered and results communicated to physicians appropriately. This review began on 5/27/2018 and remains ongoing through (MONTH) 7, (YEAR). 3) Director of Nursing met with the Medical Director on 5/22/2018 to discuss the reporting of the results to an un-affiliated physician and failure of the lab to place a call to the facility regarding those results. Administrator present to (Name) Clinic PC to discuss concerns and expectations regarding the calling of Critical Lab findings to the facility and the ordering physician/physician extended on 5/23/2018. On (MONTH) 23, (YEAR) (Name) Clinic PC lab confirmed that they would begin the process of calling the facility for critical lab results as well as faxing the results to the household (facility) and the Director of Nursing. The facility confirms that (Name) Hospital, the only other lab used by the facility, calls the facility for critical lab values and faxes the results to both the household (facility) and to the Director of Nursing. Director of Nursing and Administrator revised lab procedures on (MONTH) 25, (YEAR) to include notification procedure for contacting the physician/physician extended of critical labs. On (MONTH) 5, (YEAR) Director of Nursing initiated education for all licensed staff on the revised lab procedures. This process began on (MONTH) 5, (YEAR). By (MONTH) 5, (YEAR) 100% of all RNs had received training on the revised lab procedure. As of 7:37 pm on (MONTH) 5, (YEAR) all nurses that are currently providing care in the facility have been trained on the revised lab procedure. Effective immediately, no nurse will be allowed to provide care until they have received training on the revised lab procedure. 4) Beginning on 6/2/2018 the Director of Nursing or RN Clinical Leader began receiving a duplicate copy of all lab results for the purpose of monitoring critical lab results to ensure that the physician was notified within the one hour time frame. Lab results received within clinical guidelines will be held for review by the physician on his/her next scheduled visit unless instructed otherwise in the lab test order. As of (MONTH) 7 (YEAR), there have been no issues with the reporting of critical lab results to the physicians. ************************* After reviewing the facility's information provided in their A[NAME] and verifying the immediate actions had been implemented, the scope/severity level of F700 was lowered to a D level on 7/7/2018, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on interviews and review of Employee Identifier (EI) #7, the facility's Executive Director's (Administrator) job description and EI #6, the Director of Nursing's job description, the facility's administrative staff, responsible for the day-to-day operation of the facility and the overall operation of the Nursing department, failed to ensure there was a policy/protocol that directed the staff who was responsible for following up on lab results and how critical laboratory (lab) test results should be handled. On 5/14/2018, Resident Identifier (RI) #1 had a lab specimen drawn for a [MEDICATION NAME] and [MEDICATION NAME] level. The results of the lab tests were faxed to the facility on [DATE] at 8:12 AM; however, the physician and/or Nurse Practitioner were not made aware of the lab results until 5/17/2018. RI #1's [MEDICATION NAME] level was critically high at 52.0; normal range is 10.0 to 20.0. The Director of Nursing (DON) acknowledged someone removed the results from the fax machine and did not report the results to the physician and/or Nurse Practitioner. During routine rounds in the facility on 5/17/2018, EI #1, the Nurse Practitioner discovered the lab results in his box for review. After assessment by the Nurse Practitioner, RI #1 was transferred and admitted to the local hospital. RI #1's admitting [DIAGNOSES REDACTED]. This deficient practice affected RI #1, one of six sampled residents reviewed for laboratory services and placed the resident in immediate jeopardy for serious injury, harm and/or death. On 7/5/2018 at 5:10 PM, the Administrator and Director of Nursing were notified of the findings of immediate jeopardy in the area of Administration, F 835. Findings include: Refer to F770 The ADMINISTRATOR JOB DESCRIPTION signed by EI #7, the Executive Director (Administrator), documented General Purpose: To direct the day-to-day functions of the facility in accordance with current federal, state and local standards governing long-term care facilities to ensure that the highest degree of quality care can be provided to the residents at all times . The unsigned DIRECTOR OF NURSING JOB DESCRIPTION for EI #6 documented General Purpose: To plan, organize, develop and direct the overall operation of the Nursing Services Department in accordance with current federal, state and local standards governing the facility, as as may be directed by the Administrator, to ensure that the highest degree of quality care is maintained at all times . During an interview on 7/3/2018 at 10:20 AM, EI #3, a LPN was asked how lab results were received in the facility. EI #3 replied, they come to the fax. In an interview with the House Supervisor, EI #2 on 7/3/2018 at 3:40 PM, she was asked where she placed items removed from the fax machine. EI #2 stated, she never took anything off the fax but if she did, she would give it to the nurse on duty. On 7/3/2018 at 4:23 PM, a telephone interview was conducted with EI #5, a LPN. When asked who was assigned to check the fax machine for labs, EI #5 said no one specific, all the nurses just check the fax machine randomly during their shift. When asked who was responsible for follow up on labs, EI #5 replied, whoever the nurse was that got the lab results off the fax machine. EI #5 explained if the results were abnormal, the nurse was expected to call the Nurse Practitioner or Medical Doctor for further orders. When asked who had access to the fax machine, EI #5 said anyone that went into that area to chart. In an interview on 7/4/2018 at 2:40 PM, EI #3, a Licensed Practical Nurse (LPN) was asked who was responsible for checking the fax machine. EI #3 replied, any nurse on any shift. In an interview on 7/5/2018 at 9:56 AM, EI #4, a LPN was asked who was responsible for checking the fax machine. EI #4 replied, anyone can check the fax but the nurses should check it. EI #4 explained, if the nurses were conducting medication pass, it would take a while to get the fax. On 7/3/2018 at 10:00 AM, an interview was conducted with EI #8, the facility's Medical Director and RI #1's attending physician. When asked how should RI #1's critical [MEDICATION NAME] lab results be reported to the facility, EI #8 replied he or the Nurse Practitioner should have been notified first. When asked what evidence EI #8 had to support the lab should have notified him or the Nurse Practitioner of a critical lab values, EI #8 there was no written protocol just a verbal agreement. EI #8 was asked why was there a delay in reporting RI #1's critical lab results to the facility. EI #8 stated he didn't know. When asked if the system failed in responding to RI #1's critical lab results, EI #8 replied yes. During an interview with the Executive Director, EI #7, on 7/3/2018 at 11:15 AM, he stated the facility never received a call from the lab about the critical lab results. During an interview on 7/3/2018 at 3:15 PM, EI #6, the Director of Nursing (DON) was asked if she had done an investigation to determine the root cause of why there was a delay in notifying the physician of RI #1's critical lab results. EI #6 replied yes, the failure occurred when someone removed the results from the fax machine and placed it in the Nurse Practitioner's box without notifying the Nurse Practitioner or the physician. In a follow-up interview on 7/4/2018 at 2:10 PM, EI #6, the DON was asked how long it took for the facility to receive [MEDICATION NAME] lab results back. EI #6 replied, it varies but usually within a day. EI #6 was asked when she would have done a follow-up on RI #1's lab results. EI #6 said she should have followed up the next day. When asked if she followed up the next day, EI #6 said no. When asked why she had not followed up, EI #6 replied she was unaware that routine labs had been drawn and not returned. EI #6 was asked what the lab should do with lab results. EI #6 answered, the lab should notify the facility. ************************ On 7/7/2018 at 4:50 PM, the facility provided an Acceptable Allegation of Compliance which documented: Administration 1). The facility failed to ensure that administrative staff had a clear policy/protocol regarding who was responsive for ensuring that lab results received via fax machine were removed from the fax machine and reported to the physician in a timely manner. 2) Director of Nursing met with the Medical Director on 5/22/2018 to discuss the reporting of the results to an un-affiliated physician and failure of the lab to place a call to the facility regarding those results. Administrator presented to (Name) Clinic PC to discuss concerns and expectations regarding the calling of Critical Lab findings to the facility and the ordering physician/extender on 5/23/2018. On (MONTH) 23, (YEAR) (Name) Clinic, PC confirmed that they would begin the process of calling the facility for critical lab results as well as faxing the results to the household (facility) and the Director of Nursing. The facility confirms that (Name) Hospital, the only other lab used by the facility, calls the facility for critical lab values and faxes the results to both the household (facility) and to the Director of Nursing. 3) Director of Nursing and Administrator revised lab procedures on (MONTH) 25, (YEAR) to include notification procedure for contacting the physician/physician extender of critical labs. On (MONTH) 5, (YEAR), the Director of Nursing and Administrator developed a laboratory guidelines policy detailing how physicians will be notified of laboratory testing results for both routine/non-critical results and for critical or high values. (See attachment A: Laboratory Guidelines Policy). On (MONTH) 5, (YEAR) the facility Quality Assurance committee met to review and approve the facility policy on processing lab results. On (MONTH) 5, (YEAR) Director of Nursing initiated education for all licensed staff on the revised lab procedures. This process began on (MONTH) 5, (YEAR). By (MONTH) 5, (YEAR) 100% of all RNs has received training on the revised lab procedure. As of 7:37 pm on (MONTH) 5, (YEAR) 100% nurses that are currently providing care in the facility have been trained on the revised lab procedure. Effective immediately, no nurse will be allowed to provide care until they have received training on the revised lab procedure. On (MONTH) 6, (YEAR), the Director of Nursing and Administrator developed two policies. The first policy provides a detailed procedure for lab receipt and processing by the clinic house supervisor on evening, nights, and weekends, and a detailed policy for ensuring that critical lab values are communicated to the Medical Director in the event that a treating physician cannot be reached in a timely manner. (See Attachment B: Director of Nursing Management of Inability to Inform Treating Physician of Critical Lab Value Results and Lab Result Receipt and Processing by the Clinical House Supervisor (E/N/WE). Effective immediately, all evening, night, and weekend supervisors will be inserviced regarding the Lab Result Receipt and Processing Policy for clinical house supervisors prior to beginning their assigned shift. No clinical house supervisor will be allowed to begin work until completion of the inservice. Training began on these policies on (MONTH) 6, (YEAR) and 100% of the evening, night and weekend supervisors have received training by 5:51 PM on (MONTH) 7, (YEAR). Effective (MONTH) 6, (YEAR), the Administrator and Director of Nursing developed a policy regarding auditing of labs ordered for the preceding 24 hours. (See Attachment D) The household clinical leader/designee will be responsible for auditing the labs ordered for the preceding 24 hour period to ensure that the results for the labs ordered have been returned to the facility or for calling the lab to follow up on results or confirm that the testing process is still underway. Effective immediately, all household clinical leaders will be inserviced regarding this new policy prior to beginning their assigned shift. No household clinical leader/designee will be allowed to begin work until completion of the inservice. 4) Beginning on 6/2/2018 the Director of Nursing or designee began inservicing a duplicate copy of all lab results from both (Name of Clinic) and (Name of Hospital) for the purpose of monitoring critical lab results to ensure that the physician was notified within the one hour time frame. As of (MONTH) 7, (YEAR), there have been no issues with the reporting of critical lab results to the physicians. The administrator will provide monitoring and oversight of the implementation of this allegation of compliance. ************************* After reviewing the facility's information provided in their A[NAME] and verifying the immediate actions had been implemented, the scope/severity level of F835 was lowered to a D level on 7/7/2018, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on observations, review of the Food Code 2013 and interviews, the facility failed to ensure: 1) the garbage receptacles in the kitchen remained covered at all times on three of three days of the survey; and 2) a Dietary Aide, Employee Identifier #5, did not place the thermometer used to take temperatures in her pocket, remove the thermometer from her pocket with gloved hands, and proceed to take the temperature of the food items with the same gloved hands. These deficient practices had the potential to affected all 155 residents receiving meals from the kitchen. Findings Include: 1) A review of the 2013 Food Code, page 170, documented: . 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: (A) Inside the FOOD ESTABLISHMENT if the receptacles and units: (1) Contain FOOD residue . On 07/25/17 at 3:15 p.m., during the initial tour of the kitchen, the surveyor observed two large grey garbage receptacles with the opening cut out of the top. On 07/26/17 at 10:49 a.m., the surveyor observed a garbage can near the ice cream freezer. The receptacle was not covered. Used gloves and empty coke cans were observed in the receptacle. On 07/25/17 at 10:50 a.m., the surveyor observed another garbage can by the produce freezer which was uncovered. There were several opened cans in the receptacle. Employee Identifier #4, the Dietary Manager, said the contents of the cans were used to prepare the lunch meal. On 07/25/17 at 10:51 a.m., the surveyor observed two garbage receptacles in the kitchen area. There were openings on the top of both receptacles. On 07/26/17 at 10:36 a.m., the surveyor observed two garbage receptacles near the produce freezer and ice cream chest. Both receptacles remained uncovered. On 07/27/17 at 9:58 a m., the surveyor observed the two garbage receptacles in the kitchen area. Both remained with the opening cut out of the top. On 07/27/17 at 10:19 a.m., the surveyor conducted an interview with EI #4. The surveyor asked EI #4 how should the garbage can in the kitchen be. EI #4 replied, Covered at all times. 2) On 07/26/17 from 11:15 a.m. until 12:25 p.m., the surveyor observed a Dietary Aide, EI #5, checking cooked food item temperatures and the temperature of the milk. The surveyor observed EI #5 remove a digital thermometer from a drawer in the kitchen then glove. EI #5 used an alcohol prep to clean the thermometer probe and proceeded to check the temperature of the sliced turkey with the same gloves still on. EI #5 then checked the temperature of the pureed vegetable after cleaning the thermometer probe. EI #5 placed the thermometer back in her pocket. EI #5 then regloved, removed the thermometer from her pocket and with the same gloves on checked the temperature of the chopped turkey. EI #5 proceeded to clean the thermometer with an alcohol prep and placed the thermometer back in her pocket. When asked to take a temperature of the milk, EI #5 again removed the thermometer from her pocket, gloved and cleaned the thermometer with an alcohol prep. EI #5 checked the temperature of the milk, with the same gloves she had on when she removed the thermometer from her pocket. On 07/27/17 at 10:19 a.m., the surveyor conducted an interview with EI #4. The surveyor shared the above observation with EI #4. The surveyor asked EI #4, what was there a potential for when dietary staff take the thermometer out of their pocket and continue to check temperatures of food without putting on clean gloves. EI #4 replied, Contamination. On 07/27/17 at 12:56 p.m., the surveyor conducted a telephone interview with EI #5. The surveyor asked EI #5, when she finished taking the temperature of the food, where did she store the thermometer. EI #5 said she usually stored the thermometer on the counter. EI #5 said she was nervous was why she had the thermometer in her pocket. The surveyor aked EI #5 was the pocket of a uniform dirty or clean. EI #5 said it was dirty. The surveyor asked EI #5, when you place a gloved hand in the pocket of a uniform, and use the same hand to check food temperatures with, what was that a potential for. EI #5 said cross contamination. The surveyor asked EI #5, after she removed the thermometer from her pocket, checked the food temperature, did she change her gloves. EI #5 said no.