Every finding on record at Wetumpka Health and Rehabilitation, LLC

Based on observation; interview; the 2022 United States (U.S.) Food and Drug Administration (FDA) Food Code; the facility's policies for Leftover Food Storage and Use, Dish Machine Sanitization, Food Cooking and Serving Temperatures, Food Preparation Guidelines, Cleaning of Miscellaneous Equipment and Utensils, Calibrating and Sanitizing Thermometers, Cleaning Schedules, and Insect and Rodent Control; the facility's food holding temperature record, reports from the facility's dishmachine service provider; and facility work order #954; the facility failed to ensure: badly stained dishware was properly cleaned or removed from service to residents, the dishwashing machine's final rinse temperature reached 180 degrees Fahrenheit (F) on 12/05/2023, coffee cups did not have built-up residue inside the cups, dietary staff knew the correct temperature for calibration when using the ice water method for checking a bi-metallic stem food thermometer, hot food holding temperatures on the steamtable were checked prior to meal service, dietary staff knew the temperature to reheat food after the hot food holding temperature fell below 135 degrees F, debris was cleaned from the floor under the work tables, equipment, and elsewhere on the kitchen floor, there was not a direct connection between the dishwashing machine drain pipe and the floor drain, and holes were not present in the kitchen walls. This had the potential to affect 113 of 113 residents receiving meals from the facility's kitchen. Findings include: The facility's policy for Leftover Food Storage and Use, dated 09/12/2019, included the following: . PURPOSE: . To assure that food borne illnesses are avoided. PROCESS: . e. Reheat foods to 165 degrees for at least 15 seconds . The facility's policy for Dish Machine Sanitization, dated 08/10/2018, included the following: . PURPOSE: . To prevent the spread of bacteria that may cause food borne illnesses. STANDARD: Dish machines should be operated in accordance with manufacturer's instructions, in order to promote sanitation of dishes and utensils. PROCESS: . b. Dish machines using hot water for sanitizing may be used if the temperature of the wash water is maintained at the level specified by the manufacturer (or state and local guidelines if more stringent). c. Dish machine wash, rinse, and internal surface temperatures should be recorded at the beginning of each dishwashing period and observed periodically during the dishwashing process. d. Any observation of a wash or rinse temperature that is not within the desired range, should be reported immediately to the Dietary Manager . for repair by the maintenance department. Dishwashing should be suspended and action taken . The facility's policy for Food Cooking and Serving Temperatures, dated 08/23/2017, included the following: . PURPOSE: Safe and sanitary food handling practices include effective control of food temperatures, in order to prevent food borne illnesses. STANDARD: According to federal regulations, food . should be served attractively at proper temperatures. PROCESS: . II. Food Holding and Serving Temperatures: a. Hot foods should be served and held at temperatures indicated in the attached exhibit to this policy. Proper Food Serving and Holding Temperatures . Serving/Holding Temperature - Fahrenheit Meat 135 degrees Vegetables 135 degrees Soups 135 degrees . Pureed Foods 135 degrees . The facility's policy for Food Preparation Guidelines, dated 08/10/2018, included the following: . PURPOSE: . Food should be palatable, attractive, and at the proper temperature, as determined by the type of food, to ensure resident/guest(s) satisfaction. STANDARD: . Food . should be served attractively at proper temperatures. PROCESS: . g. Food should be protected from contamination, while being stored, prepared and served to resident/guest(s). To prevent growth of pathogenic organisms: . 2. Held above 135 (degrees) F (Fahrenheit) . The facility's policy for Cleaning of Miscellaneous Equipment and Utensils, dated 09/03/2019, included the following: . 8. Dishes: . Soak or rinse dishware as needed . Maintain wash temperature at a minimum of 150 degrees F . Maintain rinse temperature at a minimum of 180 degrees F . 9. Dishes, Destaining: (as needed) Soak clean dishes in destaining solution . The facility's policy for Calibrating and Sanitizing Thermometers, dated 02/01/2002, included the following: . PURPOSE: Accurate, clean thermometers should be used for the measurement of food . serving temperatures. STANDARD: Thermometers should be calibrated . PROCESS: I. Calibration: . a. Prepare a 50/50 ice and water mixture. Submerge the sensor of the thermometer in the solution until the needle stops moving. Use a small wrench to turn the calibration nut until the thermometer reads 32 degrees Fahrenheit . The facility's policy for Cleaning Schedules, dated 08/10/2018, included the following: . PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses. STANDARD: Cleaning schedules should be developed and posted by the FNS (Food and Nutrition Services) Manager. PROCESS: . e. The FNS Manager should supervise adherence to the cleaning schedule, and inspect the kitchen weekly for cleanliness. The facility's policy for Insect and Rodent Control, dated 02/01/2002, included the following: . PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses. PROCESS: . f. Cracks in walls, floors, along baseboards or ceilings should be reported to maintenance for repair. The 2022 U.S. FDA Food Code included the following: . 3-305.14 Food Preparation. During preparation, unPACKAGED FOOD shall be protected from environmental sources of contamination. 3-403.11 Reheating for Hot Holding. (A) . TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the FOOD reach a temperature of at least 74 C (165 F) for 15 seconds. 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) . TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 C (135 F) or above . 4-203.11 Temperature Measuring Devices, Food. (B) FOOD TEMPERATURE MEASURING DEVICES that are scaled only in Fahrenheit shall be accurate to +/-2 F in the intended range of use. 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair . (B) EQUIPMENT components such as doors, . fasteners, . shall be kept intact, tight, and adjusted . 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. (A) . the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90 C (194 F), or less than: . (2) For all other machines, 82 C (180 F). 4-502.11 Good Repair and Calibration. (A) UTENSILS shall be maintained in a state of repair . or shall be discarded. (B) FOOD TEMPERATURE MEASURING DEVICES shall be calibrated in accordance with manufacturer's specifications as necessary to ensure their accuracy. 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 5-402.11 Backflow Prevention. (A) . a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. 6-501.11 Repairing. PHYSICAL FACILITIES shall be maintained in good repair. 6-501.12 Cleaning, Frequency and Restrictions. (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. 6-501.114 Maintaining Premises, Unnecessary Items and Litter. The PREMISES shall be free of: . (B) Litter. During the initial kitchen tour on 12/05/2023 at 9:17 AM; the AM Cook, AM Diet Aide, #1, AM Diet Aide #2, and Relief Cook/Aide were observed working in the kitchen area. At 10:20 AM, the ongoing dishwashing of breakfast trays/dishes by three staff was observed: AM Diet Aide #2 was breaking down trays and scraping dishes, AM Diet Aide #1 was pre-rinsing and loading trays/dishes into the dishwashing machine, and the Relief Cook/Aide was unloading cleaned trays/dishes from the dishwashing machine. Observed Relief Cook/Aide unloading and putting away five badly stained 4-ounce bowls. The bowls were stained brown with scratch marks. When asked about these bowls, the Relief Cook/Aide said they had been cleaned. Later, the Dietary Manager (FNS Manager) saw these stained bowls and threw them into the trash. During this dishwashing observation, the dishwashing machine's Final Rinse thermometer needle never moved from 120 degrees F after a rack of plates was sent through. When asked about the Final Rinse only being 120 degrees, all three staff knew this meant the dishes were not being sanitized. At 10:35 AM, fine debris was observed scattered underneath the equipment and tables/counters. At 10:40 AM, an observation of coffee mugs set up by the coffee station for trayline revealed 13 of 17 coffee mugs had residue build-up inside. At 12:15 PM, the trayline for assembling the residents' lunch meals was ongoing. At 12:41 PM, one stained 4-ounce bowl was observed on top of a stack of bowls to be used for trayline service. At 12:45 PM, this bowl was placed on the lower shelf of cart and not observed to be used. The report from the facility's dishmachine service provider, dated 12/05/2023 at 4:25 PM, included the following: . Extra Service Request . Request Description: Not reaching temp (temperature) Service Comments: Machine is working properly. May have been low on water, float may have been stuck or didn't give machine time to heat up . On 12/06/2023 at 11:18 AM, preparation for lunch was ongoing in the kitchen. At 11:24 AM, the Dietary Manager said both cooks knew how to calibrate thermometers. The Dietary Manager said the cooks usually did it before breakfast, but they also could do it before lunch. At 11:26 AM, the PM Cook had placed the stem of a bi-metallic food thermometer in a cup of ice water slush. The PM Cook said he was calibrating the food thermometer to 40 degrees Fahrenheit. When questioned, the PM Cook said he thought each degree mark was one degree. Each degree mark on the bi-metallic thermometer being used indicated two degrees. When asked what training he had received on calibrating thermometers; the PM Cook said he had attended an in-service last week on calibrating the thermometer. The Dietary Manager was asked to provide a copy of the handout from the in-service. The Dietary Manager provided facility policies for Calibrating and Sanitizing Thermometers, Food Preparation Guidelines, and Food Cooking and Serving Temperatures. The PM Cook verified he was given these policies during the in-service. The Dietary Manager had also printed and provided a copy of the policy for reheating leftovers (Leftover Food Storage and Use), but she said she did not teach that because they did not use leftovers. At 11:49 AM, the AM Cook was observed working on the lunch trayline with other Dietary staff. Holding food temperatures had not yet been taken per the PM Cook. The AM Cook moved aside for the PM Cook to take the main meat temperature with an accurate food thermometer. The temperature of the Braised Beef Tips was 160 degrees F. When asked if he was going to check the temperatures of the other food on the trayline the PM Cook said no, not now. The PM Cook said he did not want to interrupt once the line was started. When asked if the food temperatures had already been taken, he said no. The PM Cook displayed the facility's food holding temperature record for the Lunch trayline, dated Wednesday 12/06/2023, on which he had recorded the Braised Beef Tips temperature. There were no other lunch food temperatures recorded on the document. Upon being asked if this was a common occurrence, the PM Cook said, Yes, if we are running late. The PM Cook said the temperatures would be checked and recorded at the end of the Lunch trayline, before the line was broken down and cleaned. At 11:52 AM, the Dietary Manager and Registered Dietitian (RD) began to question the PM Cook, so the reasoning for no Lunch trayline temperatures being taken was shared with them. Between 11:55 AM and 12:00 Noon, the remaining holding temperatures of food on the Lunch trayline were taken and recorded. The facility's food holding temperature record for the Lunch trayline on Wednesday, 12/06/2023, included a temperature of 120 degrees for Pureed Braised Beef Tips in Gravy. The pan of Pureed Braised Beef Tips in Gravy was removed from the steamtable and placed in the steamer by the AM Cook. When asked to what temperature she was going to heat the Pureed beef, the AM Cook said 135 degrees (F). Upon being told it would be considered a leftover since the temperature had fallen below 135 degrees F, the AM Cook said it would need to be heated up to 155 degrees (F). At 12:26 PM, the Pureed beef was placed on the direct heat of the stove to reach a temperature of 180 degrees F. Also at this time, three badly stained 4-ounce bowls were observed on the lower shelf of a cart holding side bowls to be used for trayline service. At 4:23 PM, the RD said the facility's dishmachine service repairman could not find anything wrong with the dishwashing machine and thought it was operator error. The RD said the repairman reviewed specific operation points, which the RD had begun sharing with the Dietary staff. The training points included the following: The tank has to be completely full. The water in the tank has to be allowed to heat up. At 4:45 PM, the Maintenance Director verified the drain pipe extending into the floor drain was from the dishwashing machine. Per the Maintenance Director's measurement, the dishmachine drain pipe extended into the floor drain by ten inches. The Maintenance Director said there was a clamp, which had previously held the drain pipe up and out of the floor drain. At 4:50 PM, the hole in the tile wall, near base of wall between the doorway and the end of the dishmachine table was pointed out to Maintenance Director. When asked the concern for a hole in the wall like that in the kitchen, the Maintenance Director said it could lead to a rodent problem. The Maintenance Director said he did regular rounds through the kitchen to check the fire extinguishers and other things, but he did not check for holes in the walls. At 4:54 PM, debris was observed on the floor under the tables adjoining the 3-Compartment Pot and Pan Sink and under the sink. Some orange items were observed under the tables also. In addition, there was debris observed on the floor under the Preparation Sink and the adjoining table. On the 12/07/2023 dated report from the facility's dishmachine service provider, sent to the facility at 9:47 AM, the following was included: . Quick Call Comments Called saying machine wasn't heating. Had water valve on overflowing . The facility work order #954, dated 12/07/2023 at 11:44 AM included the following: . Hole in baseboard of dish room . There is a hole in the baseboard of dish room behind dish machine . On 12/07/2023 at 12:30 PM, there was still debris on the kitchen floor. The orange items under the tables adjoining the 3-Compartment Pot and Pan Sink were four aerosol can caps. There was also a build-up of dark residue on the grate of the floor drain located by steamer. At 3:47 PM, viewed the debris on the kitchen floor with the Dietary Manager and RD. Also checked the inside of coffee mugs ready for service with the Dietary Manager and RD. Ten of the twelve coffee mugs checked had built-up residue inside. On 12/07/2023 at 4:05 PM, the Dietary Manager was interviewed. The Dietary Manager said it was important for food thermometers to be checked and correctly calibrated to get accurate food temperatures. The Dietary Manager also said the temperatures of hot foods should be checked before putting them on the steam table and then checked again before the trayline meal service begins to make sure the foods are at a proper temperature. The Dietary Manager said dishware with bad stains or built-up residue should be thrown into the garbage. The Dietary Manager further said badly stained dishware should be discarded when it cannot be cleaned and chipped dishes should be thrown away immediately. The Dietary Manager said the final rinse of the facility's dishwashing machine should be 180 degrees Fahrenheit so the heat sanitizes the dishes. The Dietary Manager was asked why the final rinse not reach 180 degrees or higher on Tuesday, 12/05/2023. The Dietary Manager said the facility's dishmachine repair service said the water from the water heater could affect the final rinse, if the water could not heat up. The Dietary Manager said she was also told that the plug of the dishmachine was not closed properly, it was not in the proper position, and water was steadily running through the machine and out the drain; therefore the temperature started to drop as the dishwashing machine was being operated, because water was steadily flowing out of the machine. When asked what kitchen floor debris usually consisted of, the Dietary Manager said food, paper, trash, and some liquids. The Dietary Manager said debris should be removed from the kitchen floor because it is a falling hazard, it doesn't look good, and it could attract bugs. The Dietary Manager further said it was not acceptable for floor debris to remain under tables and equipment. The Dietary Manager said the problem with built-up residue inside the coffee mugs was that it could not be declared sanitized, it did not look good, and it had the potential for cross-contamination. When asked the problem with the dishwasher drain pipe extending into the floor drain, the Dietary Manager said you could have backsplash. Upon being asked the problem with having a hole in the wall of the kitchen, the Dietary Manager said a snake or rodent or critters could come in. The Dietary Manager said kitchen maintenance concerns should be reported upon discovery, when seen. The Dietary Manager said the facility used TELS, a computer communication, to report maintenance issues. The Dietary Manager further said if she saw the Maintenance Director in the hall or in a morning meeting, she would also tell him verbally in addition to TELS. The Dietary Manager said the kitchen's usual Cleaning Schedule was not done for the end of November or, so far, for December. On 12/07/2023 at 4:45 PM, the RD was interviewed. The RD said it was important for food thermometers to be checked and calibrated correctly, because we want to serve the food at the proper temperature and do not want to cause food borne illness in immuno-compromised people. The RD said holding temperatures of hot food on the trayline should be checked at the start of service, before the first tray is plated, to ensure items are at a safe temperature. The RD also said dishware with bad stains or built-up residue should be thrown away if it cannot be cleaned. According to the RD, the final rinse temperature of the dishwashing machine should be 180 degrees F to ensure proper sanitizing of the dishware. The RD was asked why the final rinse did not reach 180 degrees or higher on Tuesday, 12/5/2023. The RD said the machine had to be turned on and the tank filled with water; then before washing the dishes, time had to be allowed for the machine to heat up the water. When asked what kitchen floor debris usually consisted of, the RD said food particles, grease, and trash. The RD said debris should be removed from the kitchen floor for safety and so as to not attract bugs or rodents. When asked if it was acceptable for floor debris to remain under tables and equipment, the RD said no, everything is elevated and/or on wheels and rollers, so it can be cleaned under. The RD said the problem with built-up residue inside coffee mugs was that bacteria can harbor in the residue. The RD said there was no air gap to prevent backflow if the dishwasher drain pipe extended into the floor drain. The RD said the problems with having a hole in the wall of the kitchen were that it was unsightly, proper cleaning could not occur, and critters could possibly come through the wall and into the kitchen. The RD said kitchen maintenance concerns should be reported through the facility's maintenance log, TELS. The RD further said both she and the Dietary Manager could do it, as could anyone with access to the facility computer. The RD also said Dietary staff can report maintenance concerns to the Dietary Manager for input into the system.

Based on a test tray observation, interview, medical record review, and review of the facility's policies for Food Preparation Guidelines and Food Taste Test; the facility failed to ensure meals, other than pureed meals, were served at an acceptable warm temperature for lunch on 12/06/2023. This had the potential to affect 110 of 113 residents receiving meals from the facility's kitchen. This also affected two residents who said hot food was served cold, Resident Identifier (RI) #30 and RI #85. Findings include: The facility's policy for Food Preparation Guidelines, dated 08/10/2018, included the following: . PURPOSE: . Food should be palatable, attractive, and at the proper temperature, as determined by the type of food, to ensure resident/guest(s) satisfaction. STANDARD: . Food . should be served attractively at proper temperatures. The facility's policy for Food Taste Test, dated 02/01/2002, included the following: . Purpose: Foods with a distinctively good taste and appearance help promote the resident/guest(s) dietary intake. Process: . c. Check the food for: . Hot foods hot and cold foods cold 1.) During a trayline observation for the residents' lunch service on 12/06/2023, beginning at 11:49 AM, the documented food temperatures included: Braised Beef 160 degrees Fahrenheit (F), Noodles 145 degrees F, and Fried Okra 135 degrees F. At 12:23 PM, the Registered Dietitian (RD) received request for one Regular test tray and one Pureed test tray to be prepared at the end of the lunch trayline process. At 12:26 PM, it was noted that each meal plate had an insulated underliner and insulated dome. At 12:52 PM, the plating of trays for the last cart began. At 1:03 PM, the plating of the test trays began (one Regular diet and one Pureed diet). At 1:06 PM, the last cart was fully loaded and left the kitchen. At 1:09 PM, the last cart arrived on Unit 3. At 1:09 PM, the service of trays began with six Certified Nursing Assistants (CNAs) delivering resident lunch trays from the cart. At 1:25 PM, the last resident was tray was served. At 1:27 PM, the Regular diet test tray was tested with the Dietary Manager and RD attending. The Regular diet test tray included Braised Beef over Noodles and Fried Okra. Butter was placed on each of the plated hot food items. The butter did not melt on the Noodles, the Braised Beef, or the Fried Okra. The Braised Beef over Noodles was not hot when tasted. The Fried Okra was not hot when tasted. On 12/07/2023 at 3:54 PM, the Dietary Manager was interviewed. Upon being asked the problem with hot food not being served warm, the Dietary Manager said the residents are going to complain. The Dietary Manager further said the food does not taste as good. On 12/07/2023 at 4:38 PM, the RD was interviewed. Upon being asked the problem with hot food not being served warm, the RD said the temperature danger zone for immunocompromised residents. 21055 2) Resident Identifier (RI) #30 was admitted to the facility on [DATE] and readmitted on [DATE]. A review of RI #30's December 2023 Physician Orders revealed RI #30 was to receive a Regular diet. RI #30's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 10/12/2023, revealed RI #30 scored a 13 on the Brief Interview for Mental Status (BIMS) meaning RI #30 was cognitively intact. On 12/05/2023 at 12:29 PM, RI #30 stated foods were served cold all the time at breakfast, lunch, and dinner. RI #30 could not remember who he/she had voiced their concerns to; but said nothing had been done. 3) RI #85 was admitted to the facility on [DATE]. A review of RI #85's December 2023 Physician Orders revealed RI #85 was to receive a NAS (No Added Salt) diet. RI #85's quarterly MDS assessment, with an ARD of 11/10/2023, revealed RI #85 scored a 15 on the BIMS meaning RI #85 was cognitively intact. On 12/05/2023 at 11:55 AM, the surveyor conducted an interview with RI #85. RI #85 said sometimes lunch and dinner were cold. RI #85 said he/she was told it would be taken care of, but nothing had changed. This deficiency was cited as a result of the investigation of complaint/report number AL00043922.

Based on observations, interviews, review of the the 2022 United States (U.S.) Food and Drug Administration (FDA) Food Code, and review of the facility's policies for Garbage and Refuse and Insect and Rodent Control, the facility failed to ensure the garbage dumpster was closed, the grease refuse container was closed, the grease refuse container was not leaking, and the dumpster area was not littered with food-related trash and other items. This affected one of one garbage dumpster and one of one grease refuse container; and had the potential to affect 114 of 114 residents in the facility. Findings include: The facility's policy for Garbage and Refuse, dated 02/01/2002, included the following: . PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses. STANDARD: Garbage and refuse containers should be free from cracks or leaks and covered when not in use. PROCESS: . e. Refuse containers and dumpsters kept outside the facility should have tightly fitting lids and should be kept covered when not being loaded. The facility's policy for Insect and Rodent Control, dated 02/01/2002, included the following: . PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses. PROCESS: . e. Garbage should be disposed of according to policy. The 2022 U.S. FDA Food Code included the following: . 5-501.13 Receptacles. (A) . receptacles and waste handling units for REFUSE . and for use with materials containing FOOD residue shall be durable, cleanable, insect- and rodent-resistant, leakproof, and nonabsorbent. 5-501.15 Outside Receptacles. (A) Receptacles and waste handling units for REFUSE . with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers. (B) Receptacles and waste handling units for REFUSE . shall be installed so that accumulation of debris and insect and rodent attraction and harborage are minimized and effective cleaning is facilitated . 5-501.110 Storing Refuse, Recyclables, and Returnables. REFUSE . shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. 5-501.111 Areas, Enclosures, and Receptacles, Good Repair. receptacles for REFUSE . shall be maintained in good repair. 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE . shall be kept covered: . (B) With tight-fitting lids or doors if kept outside the FOOD ESTABLISHMENT. 5-501.115 Maintaining Refuse Areas and Enclosures. A storage area and enclosure for REFUSE . shall be maintained free of unnecessary items . and clean. On 12/06/2023 at 4:10 PM, the dumpster area was observed with the Dietary Manager. The grease refuse container was open. The Dietary Manager said the lid would not close properly and then demonstrated that the lid would not fully shut. A pool of liquid was observed that was formed from liquid coming from the base of the grease refuse container. Upon touching the liquid, it was found to be a clear oil. In addition, the right-hand side door of the garbage dumpster was wide open. Observed on the ground by the grease container and the garbage dumpster were: four plastic gloves, one straw, one butter container, several plastic/bags, three pieces of plastic cutlery, the feces of a medium-small animal, an inhaler in a small plastic bag, and an open tube of fungal ointment. When asked the potential problem of the open grease refuse container, the open garbage dumpster, and the food-related items and other trash scattered on the ground; the Dietary Manager said it could attract animals. When asked the potential concern to residents, the Dietary Manager said it was a health hazard for residents. On 12/06/2023 at 4:20 PM, the dumpster area was observed with the Registered Dietitian (RD). The RD said the condition of the grease refuse container, the open dumpster, and the condition of the dumpster area had the potential to attract rodents, which might make their way into the building and possibly affect the resident's health.

Based on observations, interviews and review of a facility policy titled, Resident Environmental Quality, the facility failed to ensure an end cap on a hand rail on one hallway was not missing; six air conditioner vents were free of dried dustlike condensations; five ventilation returns were free of dust and dried condensations that were dark in color; the corner trim was not missing and exposing nails at a nurses' station; and one fire extinguisher box was free of a brown colored substance. These deficient practices were observed during the survey and affected three of the six halls at the facility. Findings include: Review of a facility policy titled, Resident Environmental Quality, with an effective date of 03/01/2010, revealed the following: PURPOSE: The facility should be designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel and the public. PROCESS: a) Preventative maintenance schedules, for the maintenance of the building and equipment, should be followed to maintain a safe environment. On 12/05/2023 at 10:28 AM, a brown rustlike substance was observed around the fire dispenser holder on the 200 hall. On 12/05/2023 at 10:42 AM, the corner of a nurses station was observed with wood trim missing; with nails visible. On 12/05/2023 at 11:23 AM, the surveyor observed a black colored substance on five ceiling register vents on the 200 hall; and a dustlike substance on six of the returns on the 200 hall also one wall register was observed with a dark substance around it. The same observation was made on 12/06/2023 at 1:27 PM of a black color substance on the ceiling register vents on the 200 hall and dust like substance observed on 6 returns and one return on the wall of the 200 hall was observed with a dark discolor. On 12/05/2023 at 12:38 PM, a vent was observed on the 200 hall with a dark colored substance around all four sides of the air vent. On 12/06/2023 at 10:56 AM, an observation was made of the register in the ceiling vent on the 300 hall to have dust like particles. On 12/07/2023, starting at 5:00 PM, the surveyor made observations of the facility's environment with the Maintenance Director (MTD) #26. On 12/07/2023 at 5:10 PM, the register in the ceiling on the 300 hall was observed by the MTD #26. MTD #26 was asked to describe what he saw. MTD #26 said he saw a heavy dust build up. When asked how often were the registers were cleaned, MTD #26 said they should be cleaned every month or two and as needed. When asked what was the concern with the registers not being clean, MTD #26 said it was unsightly and dust could be inhaled. An observation was made by MTD #26 of the nursing station with the front piece missing a trim at the corner. MTD #26 was asked what he saw, and replied a missing trim and exposed trim nail. The surveyor asked what would be the concern with a missing trim having an exposed trim nail. MTD #26 said a resident could get a skin tear if they were to get on it. On 12/07/2023 at 5:20 PM, the surveyor with the MTD #26 observed dust like substance on six return registers on the ceiling of the 200 hall. One return in the ceiling was noted with dark discoloring around it. On the tour with the MTD #26, he indicated there was dust on the ceiling returns and on one, it looked like there was dried condensation and dust. On 12/07/2023 at 5:26 PM, a black colored substance was noted on five ceiling register vents on the 200 hall. The Maintenance Director was asked what was on the vents, and replied dried condensation and said it looked unsightly. On 12/07/2023 at 5:27 PM, MTD #26 observed the missing end of the hand rail on the 200 hall and said, the end cap had come off and he was unaware of it. When asked what the concern was of having a missing end cap from a hand rail, MTD #26 said a resident could possibly get a skin tear. On 12/07/2023 at 05:34 PM, an observation of the fire extinguisher box on the 200 hall was made. MTD #26 was asked what was on the box, and replied it appears like it was rust. When asked why rust was on the box, MTD #26 said it was old and could use repainting. When asked what was the concern with there being rust on the box, MTD #26 said it was unsightly.

Based on an interview, review of Facility Reported Incidents (FRIs) received by way of the Alabama Department of Public Health Online Incident Reporting System and review of a facility policy titled, Abuse, Neglect, Misappropriation of Resident /Guest Property, Suspicious Injuries of Unknown Source, Exploitation, the facility failed to ensure the five (5) day investigation reports were submitted to the State Agency (SA) within the required timeframe after the initial reports were received. This affected six of 12 months of FRIs received by the State Agency in 2022. Findings include: Review of a facility policy titled, Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, with an effective date of 10/15/2022, revealed the following: . PURPOSE: This policy (the Policy) is concerned with all incidents and accidents involving resident/guest(s). The facility will investigate and document all incidents and accidents involving resident/guest(s). Certain incidents and accidents involving residents/guests must also be reported to the appropriate state agencies. The investigation protocol for incidents and accidents is set forth in Section VI of this Policy. VI. Investigations and Facility Response to Incidents or Accidents a) The facility will report all instances of alleged or suspected abuse, including verbal and mental abuse, neglect, suspicious injuries of unknown origin, exploitation and misappropriation of resident/guest property in the following manner: b) Investigation and Reporting Steps . A complete and thorough investigation must be conducted on all incidents including suspicious injuries or unknown origin, whether reportable or not, within five working days to determine the cause of the injury or incident. If reportable to the State Agency, the facility will make an investigation report within five (5) working days to the State Agency. Review of the Alabama Department of Public Health Online Incident Reporting System revealed the following: 1) Confirmation Number: 20220308008, an allegation of Verbal Abuse occurred on 03/08/2022 at 6:33 PM. The facility's initial report was submitted to the State Agency on 03/08/2022 at 8:21 PM; however, the facility's five day report was not submitted to the State Agency until 03/17/2022, 9 days later. 2) Confirmation Number: 20220628009, an allegation of Physical Abuse occurred on 06/28/2022 at 3:12 PM. The facility's initial report was submitted to the State Agency on 06/28/2022 at 5:16 PM; however, the facility's five day report was not submitted to the State Agency until 07/21/2022, 23 days later. 3) Confirmation Number: 20220710004, an allegation of Physical Abuse occurred on 07/09/2022 at 3:36 PM, and was reported to Administrator on 07/10/22. The facility's initial report was submitted to the State Agency on 07/10/2022; however, the facility's five day report was not submitted to the State Agency until 07/18/2022, 8 days later. 4) Confirmation Number: 20220727008, an allegation of Physical Abuse occurred on 07/27/2022 at 6:59 PM. The facility's initial report was submitted to the State Agency on 07/27/2022 at 8:54 PM; however, the facility's five day report was not submitted to the State Agency until 08/08/2022, 11 days later. 5) Confirmation Number: 20220808013, an allegation of Sexual Abuse occurred on 08/08/2022 at 2:23 PM. The facility's initial report was submitted to the State Agency on 08/08/2022 at 4:30 PM; however, the facility's five day report was not submitted to the State Agency until 08/17/2022, 9 days later. 6) Confirmation Number: 20220831001, an allegation of Physical Abuse occurred on 08/30/2022 at 5:45 PM, and was reported to the Administrator on 08/31/2022 at 9:26 AM. The facility's initial report was submitted to the State Agency on 08/31/2022 at 9:26 AM; however, the facility's five day report was not submitted to the State Agency until 09/19/2022, 19 days later. 7) Confirmation Number: 20220901017, an allegation of Verbal Abuse occurred on 09/01/2022 at 6:30 PM. The facility's initial report was submitted to the State Agency on 09/01/2022 at 9:21 PM; however, the facility's five day report was not submitted to the State Agency until 09/19/2022, 18 days later. 8) Confirmation Number: 20220902007, an allegation of Misappropriation of Resident Property occurred on 09/01/2022 at 11:00 AM. The facility's initial report was submitted to the State Agency on 09/02/2022 at 3:43 PM; however, the facility's five day report was not submitted to the State Agency until 09/19/2022, 17 days later. 9) Confirmation Number: 20220920001, an allegation of Fire/Smoke occurred on 09/19/2022 at 12:33 PM. The facility's initial report was submitted to the State Agency on 09/20/2022 at 12:11 PM; however, the facility's five day report was not submitted to the State Agency until 10/04/2022, 14 days later. 10) Confirmation Number: 20221021001, an allegation of Physical Abuse occurred on 10/21/2022 at 9:00 AM. The facility's initial report was submitted to the State Agency on 10/21/2022 at 9:22 AM; however, the facility's five day report was not submitted to the State Agency until 11/03/2022, 13 days later. On 12/07/2023 at 5:06 PM, the surveyor conducted a telephone interview with the former Administrator. The former Administrator said he was the Abuse Coordinator at the facility from April of 2021 through November of 2022. The former Administrator said his job responsibilities as the Abuse Coordinator was to report any kind of suspected allegation of abuse to Alabama Department of Public Health (ADPH) in a timely manner. The former Administrator said the time frame for submitting the summary after the initial report have been submitted to ADPH was five days. The former Administrator said back in 2022, he could not say why the 10 FRIs receive by ADPH were not submitted in that timeframe. When asked why it would be important to submit the five day summary report to ADPH after the initial report of abuse has been submitted, the former Administrator said because if mistreatment had occurred you would want to make sure the staff or the resident had been removed to protect the other residents and it was regulatory that you report in that time frame. This deficiency was cited as a result of the investigation of complaint/report number AL00042202.

Based on an interview, review of the facility's Non-Controlled Medication Destruction Records, and review of a facility policy titled, Non-Controlled Medication Destruction, the facility failed to ensure destruction dates and required signatures were on the non-controlled medication destruction sheets. This deficient practice affected non-controlled medication destruction sheets reviewed for one of 12 months in 2022, two of 12 months in 2023; and 12 non-controlled medication destruction sheets with no destruction dates or signatures. Findings include: Review of a facility policy titled, Non-Controlled Medication Destruction, with a date of 04/2020, revealed the following: Policy Discontinued medications, expired medications, and medications left in the facility after a resident has expired or has been permanently discharged are destroyed or disposed of per federal/state regulations. Procedure . 3. The registered nurse and/or pharmacist witnessing the destruction . ensures that the following information is entered on the Record of Medication Destruction form . A. Date of destruction . J. Signature of witnesses, two witnesses required for non-controlled substances (for example, a pharmacist in Alabama and a registered nurse) in the designated areas on the destruction form. On 12/07/2023 at 4:43 PM, the surveyor reviewed the non-controlled medication drug disposition records from January 2022 through November 2023; the following was noted: 1) one Non-Controlled Drug Medication Destruction sheet for the month of October 2022 had only one signature, 2) 25 of the 25 Non-Controlled Drug Medication Destruction sheets for the month of June of 2023 did not have the required two signature; and eight of the 25 Non-Controlled Drug Medication Destruction sheets had no destruction dates, 3) 11 of the 11 Non-Controlled Drug Record of Medication Destruction sheets for the month of August 2023 did not have the required signatures; and 4) there were 12 Non-Controlled Drug Record of Medication Destruction sheets with no signatures or destruction dates on the sheets. On 12/07/2023 at 5:16 PM, an unsuccessful telephone attempt was made to contact the Consultant Pharmacist. On 12/07/2023 at 5:18 PM, the Director of Nursing (DON) verified the Record of Medication Destruction Non-Controlled Drugs sheets with the missing signatures and dates. When interviewed, the DON was asked how many signatures were required for non-controlled medication destruction sheets. The DON said two, the pharmacist and a nurse.

Based on interviews, record review and review of facility policies titled, Change of Room or Roommate and Change in Medical Condition of Resident/Guest(s), the facility failed to: 1) notify the sponsor of Resident Identifier (RI) #265 when RI #265 was placed in a different room after returning to the facility after an emergency room (ER) visit on 02/13/2023, 2) ensure RI #9's Medical Doctor (MD) and sponsor were notified when RI #9 attempted to leave the facility on 07/14/2023, 3) notify the sponsor when RI #9 was sent to the hospital on 08/05/2023; and 4) notify the MD and sponsor when RI #9 missed a dialysis appointment on 11/25/2023. These deficient practices had the potential to affect RI #9 and RI #265, two of 37 sampled residents. Findings include: 1) Review of a facility policy titled, Change of Room or Roommate, with an effective date of 11/28/2016, revealed the following: . PURPOSE: Room changes can be frightening for a resident/guest unless the resident/guest is informed in advance and given the opportunity to have input in the decision. STANDARD: . In addition, the resident/guest has a right to be informed, in advance and to receive written notice, of any change in room . and reason for change . PROCESS: . The Licensed Nurse should refer request for changes in rooms or roommates to the Social Service Designee. Once a decision has been made, the resident/guest should be given as much advance notice as practicable. The nursing staff can assist the resident/guest to adjust to the new room or roommate by: 1. Informing the resident/guest and family, as soon as possible, of the room or roommate change . RI #265 was admitted to the facility on [DATE] and discharged from the facility on 02/16/2023. A review of RI #265's Resident Status History List (list of rooms resident resided in while at facility) revealed the following: RI #265 was admitted to room Room Locator (RL) #1 on 02/02/2023 RI #265 was sent to the ER from RL #1 on 02/13/2023 RI #265 returned from theER on [DATE] and was placed in RL #2 RI #265 was sent to the ER from RL #2 on 02/16/2023. On 12/06/2023 at 12:14 PM, a telephone interview was conducted with RI #265's sponsor. RI #265's sponsor said RI #265 was moved to a different unit after RI #265 had a fall and she was never notified RI #265 was being moved. RI #265's sponsor said she found out about the room change when she went to the nursing home to visit RI #265 after RI #265 was sent back to the facility after a fall. On 12/07/2023 at 4:46 PM, an interview was conducted with the Admissions Coordinator who said, RI #265's sponsor should have been notified of the room change and the reason for the room change; and it would have been the responsibility of the nurse or social services to notify the sponsor of the room change. On 12/07/2023 at 4:55 PM, a telephone interview was conducted with the Licensed Practical Nurse (LPN) #18, who according to RI #265's nurses notes dated 02/13/2023, documented RI #256 arrived back to the facility from the ER. LPN #18 said she did not know why RI #265 was placed in RL #2. LPN #18 said she did not recall telling RI #265's family RI #265 had been moved to a different room. When asked where would/should there be evidence the family had been notified when a resident was placed in a different room, LPN #18 said, in the nurses notes. LPN #18 said, it would be important to notify the family that the resident was placed in a different room so the family would know where their loved one was when they visited. On 12/07/2023 at 5:28 PM, an interview was conducted with the Director of Social Services (SS) #11. The surveyor reviewed RI #265's Resident Status History List with SS #11 and asked to which room was RI #265 admitted . SS #11 said RL #1 and RI #265 was sent out of the facility from that room on 02/13/2023. When asked when RI #265 returned to the facility on [DATE], what room RI #265 returned to, SS #11 said RL #2. SS #11 said she did not know why RI #265 was placed in RL #2 instead of back in RL #1. When asked who would inform the family of the room change, SS #11 said normally the admission person. SS #11 said, nursing staff was responsible for notifying RI #265's family when RI #265 was placed in a new room. SS #11 said the evidence that the family had been notified should be in the nurses notes. On 12/07/2023 at 6:49 PM, the surveyor conducted an interview with the Director of Nursing (DON). The DON said when a resident is sent out to the ER and returns and is placed in a different room the family should be notified. When asked where the nurses would document the family had been notified the resident had been placed in a different room, the DON said, in the nurses notes. A review of RI #265's nurses notes from 02/13/2023 through 02/16/2023 (when RI #265 was discharged from the facility) revealed there was not any documentation in RI #265's nurses notes where RI #265's sponsor had been notified of when and why RI #265 was placed in RL #2 after return to the facility from theER on [DATE]. 41928 2) A facility policy titled, Change in Medical Condition of Resident/Guest(s), with an effective date of 11/28/2016, documented: . PURPOSE: To keep the physician, who is in charge of medical care, and family members/legal representatives, responsible for health care decisions and other resident/guest representative informed of the resident/guest(s) medical condition so they may direct the plan of care as needed. STANDARD: Notification of the physician, legal representative, or interested family member, should occur promptly, . when there is a change in the resident/guest(s) condition. Change of condition is defined as: . A need to alter treatment . A decision to transfer or discharge the resident/guest from the facility . RI #9 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnosis to include End Stage Renal Disease, Dependence on Renal Dialysis, Retention of Urine, Alzheimer's Disease and Dementia. RI #9's care plan titled, POTENTIAL FOR ELOPEMENT R/T (related to) NEW ENVIRONMENT with a start date of 05/23/2023 documented: . Intervention . CONTACT FAMILY/RESPONSIBLE PARTY TO SIT WITH RESIDENT WHEN EXIT SEEKING/EXIT ATTEMPTS ARE OBSERVED . RI #9's Departmental Notes documented: . 7/14/2023 10:53 AM . RESIDENT WAS FOUND AT THE FRONT DOOR GOING OUT DOOR AS ANOTHER SPONSOR WAS LEAVING OUT. RESIDENT ASSISTED BACK IN FACILITY. NO INJURIES TO RESIDENT. RESIDENT AGITATED AND FUSSING AT STAFF. REDIRECTED BACK TO (HIS/HER) HALL. A telephone interview was conducted with RI #9's representative on 12/06/2023 at 3:20 PM. RI #9's representative stated the facility let RI #9 get out of the facility. RI #9's representative stated a staff member in the business office told her. 3) RI #9's Departmental Notes documented: . 8/5/2023 8:20 AM . RESIDENT TAKEN TO (name of local hospital ER) FOR VIOLENT BEHAVIORS AGAINST CNAs (HIS/HER) ROOMMATE AND THE NURSE. RESIDENT WAS TAKEN VIA (by way of) (name of ambulance service)WITH POLICE ESCORT. RESIDENT WAS CALM AT THE TIME AND WAS COOPERATIVE. In the continued telephone interview with RI #9's representative on 12/06/2023 at 3:20 PM, RI #9's representative stated the facility sent RI #9 out to the hospital and no one informed her. RI #9's representative stated RI #9 was sent to hospital on Saturday, and she did not find out about it until Tuesday. 4) RI #9's December 2023 Physician Orders, documented: . RESIDENT TO GO TO DIALYSIS EVERY TUESDAY, THURSDAY, SATURDAY. RI #9's care plan for Renal Disease: Requires Dialysis every Tues (Tuesday), Thursday and Saturday . chair time at 11:00am . Intervention . Provide/Coordinate transportation to the dialysis center . A telephone interview was conducted with RI #9's representative on 12/05/2023 at 1:30 PM. RI #9's representative stated RI #9 missed his/her dialysis appointment about two weeks ago. RI #9's representative stated she was told on Sunday, the day after, when she came to the facility to visit RI #9. An interview was conducted with Licensed Practical Nurse (LPN) #17 on 12/06/2023 at 12:22 PM. LPN #17 stated RI #9 missed his/her dialysis appointment on 11/25/2023, due to not having a ride. LPN #17 stated she did not notify the representative until the next day (Sunday) because she thought she would come in on Saturday to visit and she was going to tell her then. LPN #17 stated she got busy, and the representative did not come on 11/25/2023. LPN #17 stated the procedure was to notify the representative the day of the missed appointment. A follow-up interview was conducted with LPN #17 on 12/07/2023 at 12:30 PM. LPN #17 stated she did not notify RI #9's physician when RI #9 missed his/her dialysis appointment. LPN #17 admitted no one was notified of RI #9's missed dialysis appointment, and both the physician and sponsor should have been notified. An interview was conducted with Director of Nursing (DON) on 12/07/2023 at 5:54 PM. The DON stated no one was notified when RI #9 was found leaving out of the building. The DON stated the sponsor and physician should have been notified. The DON stated the nurse did not document anyone was notified when RI #9 was sent to hospital on 08/05/2023 for a Psychiatric evaluation. The DON stated the physician and sponsor should have been notified. The DON stated the sponsor and physician should have been notified when RI #9 missed a dialysis appointment on 11/25/2023. The DON stated she did not see where the physician or sponsor was notified on 11/25/2023, when RI #9 missed the dialysis appointment. The DON admitted the facility's Change in Medical Condition of Resident/Guest(s) policy was not followed on 07/14/2023, 08/05/2023 and 11/25/2023. The DON stated the concern of not making notifications to the family is the family would not not know what was going on with their loved one. The DON also stated the physician might have wanted RI #9 to go to the hospital for dialysis when RI #9 missed his/her dialysis appointment on 11/25/2023. This deficiency was cited as a result of the investigation of complaint/report number AL00045824.

Based on interviews, record review and review of a facility policy titled, Pre- Admission Screening for Mental Retardation and Mental Illness, the facility failed to: 1) ensure a new Level 1 was completed when Resident Identifier (RI) #59 was identified to have a new diagnosis of Anxiety on 03/27/2021; and 2) resubmit a Level 1 Preadmission Screening and Resident Review (PASRR) for Resident Identifier (RI) #64 upon readmission to the facility on [DATE], with new diagnoses of Post-traumatic Stress Disorder (PTSD) and Borderline Personality Disorder (BPD). This deficient practice had the potential to affect RI #'s 59 and 64, two of six residents reviewed for PASRRs. Findings include: A review of a facility policy titled Pre-Admission Screening for Mental Retardation and Mental Illness, with an effective date of 07/15/2009, revealed the following: . PURPOSE: To ensure that individuals with mental retardation or mental illness receive the care and services they need, in the most appropriate setting and have medical needs that outweigh their mental needs. STANDARD: . According to federal regulations, mental illness is defined as the individual has serious mental illness if the individual meets the following requirements on diagnosis, level of impairment and duration of illness. The individual has a major mental disorder, which is: A schizophrenic, mood, paranoid, panic or other severe anxiety disorder; somatoform disorder; personality disorder; other psychotic disorder; or another mental disorder . PROCESS: . Residents identified through the PASRR process as having an MI (Mental Illness) or MR (Mental Retardation) diagnosis must be assessed by the nursing facility on an ongoing process to identify any significant changes. Those residents identified as having a significant change must have an updated Level I screening within 14 days of significant change. The original document for the Level I/or Level II determinations will be retained in the medical chart behind the Social Services tab. 1) Review of a PASRR Level I Screening & (and) Results for Mental Illness (MI) / Intellectual Disability (ID) form for RI #59, dated 01/11/2018, revealed RI #59 was not identified to have Generalized Anxiety Disorder at this time. A review of RI #59's Admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 01/17/2018, revealed RI #59 was not coded as having a diagnosis of Anxiety during this assessment period. Further review of the PASRR revealed facility staff received and reviewed the PASRR, dated 01/17/2018, on 03/02/2018. A review of RI #59's Diagnosis/History list revealed RI #59 was given a diagnosis of Anxiety Disorder, Unspecified, with an onset date of 03/27/2021. A review of RI #59's quarterly MDS assessment, with an ARD of 08/19/2021, revealed RI #59 was coded as having a diagnosis of Anxiety Disorder and Psychotic Disorder during this assessment period. On 12/06/2023 at 11:29 AM, during an interview with the Social Service Director (SS) #11, she said the process for the facility to identify residents with a mental disorder prior to admission was to review all the record before the resident was admitted to the facility. SS #11 said the Nurse Practitioner or the Medical Doctor will report medications added after admission, and that was how she identified residents with newly identified Mental Disorder (MD) or a related condition. SS #11 said she reviewed the record after residents returned from a hospital visit for new diagnoses and new medications. SS #11 said she was the one responsible for making the referral to the appropriate state designated authority when a resident is identified as having an evident or possible MD, or related condition. When SS #11 was asked if a resident is identified as having newly-evident or possible MD, or a related condition after admission, what was the facility's process for referring the resident to the appropriate state-designated authority, SS #11 said she would submit for a new level and that agency would notify the facility when information was due; and if it required submission for a level II. SS #11 was asked if RI #59 was identified as having a new diagnosis requiring a new level. SS #11 said yes, for the diagnosis of Anxiety. SS #11 said with the new diagnosis of Anxiety a referral was not made to the appropriate state authority because she missed it. SS #11 said the policy for completing the PASRR was prior to admission and when a new diagnosis was added. SS #11 said the concern in not getting the PASRR updated was the communication of new diagnosis or medications. 48195 2) RI #64 was admitted to the facility on [DATE]. RI #64's PASRR dated 07/22/2022 revealed: . no need for Level 2 evaluation due to no evidence of suspected Mental Illness . RI #64 was readmitted to the facility on [DATE] with new diagnoses of PTSD and BPD. RI #64's quarterly MDS assessment, with an ARD of 09/28/2022, and RI #64's significant change MDS assessment, with an ARD of 05/09/2023 were reviewed and revealed the new diagnosis of PTSD was listed under Section I. On 12/05/2023 at 3:49 PM, an interview with RI #64's family was conducted and revealed RI #64 was diagnosed with PTSD and BPD during an inpatient hospital stay on 08/21/2022. A review of RI #64's medical record revealed no new updated PASRR was completed for RI #64 when RI #64 was readmitted to the facility from the inpatient hospital stay on 08/30/2022. On 12/07/2023 at 8:54 AM, an interview was conducted with the facility's Director of Social Services (SS) #11. SS #11 said the PASRR should be completed on admission and when there is a new mental health diagnosis. The surveyor asked what was the process when it was determined that a resident has a new mental health diagnosis. SS #11 said the nurses would notify her department when a new mental health diagnosis was made so a new Level 1 could be completed. The surveyor asked if RI #64 had any new mental health diagnoses. SS #11 said yes, RI #64 received a new diagnosis of PTSD and BPD in August of 2022. SS #11 stated she was unaware of the diagnoses until this week. The surveyor asked when should a new PASRR have been completed for RI #64. SS #11 said when the new mental health diagnosis was identified a new Level I should have been completed.

Based on observations, interview, resident record review, and review of a facility policy titled, Oxygen Administration, the facility failed to ensure a physician order was obtained for Resident Identifier (RI) #314's oxygen use. This deficient practice had the potential to affect RI #314, one of three residents sampled for respiratory care. Findings include: Review of a facility policy titled, Oxygen Administration, with an effective date of 12/08/2005 revealed: PURPOSE: To administer high purity oxygen for the treatment of certain diseases or conditions. STANDARD: Oxygen should be administered under orders of the attending physician, . PROCESS: 1. Obtain physician's orders for the rate of flow and route of administration of oxygen . RI #314 was admitted to the facility on [DATE] with a diagnosis of Acute Respiratory Failure with Hypoxia. On 12/05/2023 at 11:36 AM, RI #314 was in bed with oxygen on. On 12/06/2023 at 11:52 AM, RI #314 was receiving oxygen at two liters per minute. On 12/07/2023 at 8:43 AM, was receiving oxygen at two liters per minute by nasal cannula. A review of RI #314's November/December 2023 Physicians Orders List revealed there was no physician's order for RI #314's oxygen use. An interview was conducted with the Registered Nurse (RN)/Unit Manager (UM) #16 on 12/07/2023 at 10:54 AM. RN #16 stated RI #314 was admitted to the facility on [DATE]. RN #16 said RI #314 was receiving continuous oxygen. RN #16 stated there was not a physician's order for RI #314's oxygen use, but there should have been a physician's order for RI #314's oxygen use. RN #16 stated it was important to have a physician's order for RI #314's oxygen use because it was a medication and you have to have an order for medication.

Based on interviews, record review and review of a facility policy titled, Pressure Injury, the facility failed to ensure treatments were provided to Resident Identifier (RI) #265's Stage I sacrum pressure ulcer as ordered by the physician. This deficient practice affected RI #265, one of five sampled residents reviewed for pressure ulcers. Findings include: RI #265 was admitted to the facility on [DATE] and discharged on [DATE]. A review of RI #265's Wound Assessment Report, with an assessment date of 02/02/2023, revealed RI #265 had a Stage I pressure ulcer to his/her sacrum on admission. The Wound Assessment Report also revealed RI #265's physician was notified and new orders were received. RI #265's February 2023 Physician Orders revealed RI #265 had treatment orders as follows: . WOUND STAGE 1 SITE SACRUM CHANGE DSG. (dressing) Q (every) MWF (Monday/Wednesday/Friday) CLEANSE W/NS (with Normal Saline)WASH APPLY SKIN PREP AND SILICONE DRSG (dressing) . RI #265's Actual skin breakdown care plan, with a start date of 02/05/2023, revealed RI #265's care plan had an intervention to . Perform wound care as ordered . A review of RI #265's February 2023 Treatment Administration Record (TAR) revealed there was no evidence treatment was provided to RI #265's sacrum pressure ulcer on Monday 02/06/2023, Friday 02/10/2023, Monday 02/13/2023 or Wednesday 02/15/2023. RI #265 discharged from the facility on 02/16/2023. On 12/07/2023 at 10:41 AM, a telephone interview was conducted with RI #265's physician. The surveyor shared with RI #265's physician when RI #265 was admitted to the facility on [DATE], RI #265 was admitted with a Stage I to his/her right sacrum. The orders were written to clean the area with NS, wash and apply skin prep and silicone dressings on MWF; but when looking at the treatment records, there was no evidence this was done on four of five times the treatments were due. When asked what he would expect the nurses to do when there was an order to provide treatment to a pressure ulcer, RI #265's physician said to do what the order says. RI #265's physician said it would be important for nurses to provide pressure ulcer treatments as ordered to prevent the ulcer from progressing and getting worse. On 12/07/2023 at 11:03 AM, the surveyor conducted an interview with the Treatment Nurse/Licensed Practical Nurse (LPN) #24. LPN #24 said according to RI #265's admission physician orders RI #265 was admitted with a Stage 1 pressure ulcer to the sacrum. LPN #24 said the type treatment implemented on admission was to cleanse the pressure ulcer with NS wash, apply skin prep and Silicone dressing on MWF. When asked where would there be evidence treatments were being performed as ordered by the physician, LPN #24 said on the TAR. LPN #24 said looking at RI #265's TAR the only treatment done was one day on the 8th (February 2023), according to RI #265's records. The surveyor asked LPN #24 why it would be important to treat a residents pressure ulcer as ordered by the physician. LPN #24 said so the pressure ulcer did not worsen and healed as quickly as possible. On 12/07/2023 at 11:38 AM, the surveyor conducted an interview with the LPN/SDC (Staff Development Coordinator). The SDC said back in February of 2023, she believed she was helping to provide care to pressure ulcers. The SDC said according to RI #265's admission wound assessment note, RI #256 was admitted to the facility with a Stage 1 sacral pressure ulcer. The SDC said the type treatment implemented on admission was to cleanse with NS wash, apply skin prep, and a Silicone dressings every MWF. The SDC said the evidence treatments were being performed as ordered by the physician would be on the TAR. The SDC said looking at RI #265's February 2023 TAR she saw that she provided the treatment to RI #265's sacrum pressure ulcer on the 8th (February 2023). The SDC said according to RI #265's TAR, RI #265 did not received treatment for four days. The SDC admitted she was helping to fill in as the wound care nurse at that time. When asked why it would be important to treat a resident's pressure ulcer as ordered by the physician, the SDC said so the pressure ulcer did not progress to a higher stage.

Based on interviews, resident record review, and review of a facility policy titled, Hemodialysis Care, the facility failed to ensure Resident Identifier (RI) #9 received care and services related to dialysis when RI #9 missed a dialysis appointment on 11/25/2023. This deficient practice affected RI #9, one of one resident sampled for dialysis care and services. Findings include: A facility policy titled, Hemodialysis Care, with an effective date of 11/01/2001, documented: PURPOSE: To provide care for residents receiving hemodialysis. PROCESS: 1. Arrange for transportation to and from dialysis, per physician's orders . 9. In case of an emergency, contact the dialysis center and arrange for emergency dialysis transportation, as needed . RI #9 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include End Stage Renal Disease, Dependence on Renal Dialysis and Retention of Urine. RI #9's December 2023 Physician Orders, documented: . RESIDENT TO GO TO DIALYSIS EVERY TUESDAY, THURSDAY, SATURDAY. RI #9's care plan for Renal Disease: Requires Dialysis every Tues (Tuesday), Thursday and Saturday . chair time at 11:00am . Intervention Provide/Coordinate transportation to the dialysis center . Review of RI #9's Departmental Notes for 11/25/2023, revealed there was no evidence attempts were made to contact another transportation company for transport to RI #9's dialysis appointment. RI #9's Departmental Notes dated 11/27/2023 at 12:34 PM, revealed the Registered Nurse (RN) Unit Supervisor documented: Late entry for 11/25/23 . (Name of contract transportation company) did not arrive to transport patient. Patient being transported today to (name of dialysis company) and will resume (his/her) normal schedule. A telephone interview was conducted with RI #9's representative on 12/05/2023 at 1:25 PM. RI #9's representative stated RI #9 missed his/her dialysis appointment two weeks ago on a Saturday. An interview was conducted with the Licensed Practical Nurse (LPN) #17 on 12/06/2023 at 12:22 PM. LPN #17 stated RI #9 missed a dialysis appointment on 11/25/2023. LPN #17 stated RI #9 missed the appointment due to RI #9 not having transportation. LPN #17 stated the contract transportation company did not come for RI #9. LPN #17 stated she called the contract transportation company and received no answer. LPN #17 stated she called the local ambulance company; however, they could not transport RI #9 due to emergency calls. A follow-up interview was conducted with LPN #17 on 12/07/2023 at 12:30 PM. LPN #17 stated she was unaware of a backup plan for dialysis residents when transportation was not available. LPN #17 admitted she should have contacted the Medical Director (MD) to inform him of RI #9's missed appointment and followed any orders given by the MD. LPN #17 stated the potential harm of a resident missing a dialysis appointment was the resident could have fluid overload and become septic. An interview was conducted with the Registered Nurse (RN)/Unit Manager (UM) on 12/07/2023 at 10:27 AM. The UM stated the backup plan for a resident not having transportation to a dialysis appointment would be to arrange transportation with the local ambulance company. The UM stated the concern of a resident missing a dialysis appointment was fluid overload, toxins could build up in the system, heart and blood pressure problems and an altered level of consciousness. An interview was conducted with Director of Nursing (DON) on 12/07/2023 at 5:54 PM. The DON stated the backup plan when a resident does not have transportation to a dialysis appointment is the facility will get non-emergent transport through the local ambulance company. The DON reviewed RI #9's nurses notes and stated she did not see what was done when RI #9 missed his/her dialysis appointment on 11/25/2023. The DON stated the concern of a resident missing a dialysis appointment is blood pressure problems, the resident being admitted to the hospital, and increased confusion. This deficiency was cited as a result of the investigation of complaint/report number AL00045824.

Based on an observation, interviews, and review of a facility policy titled, Storage of Medications and Biologicals, the facility failed to ensure Resinol (a medicated ointment typically used for itch relief and skin rashes) was stored in the original container in Resident Identifier (RI) #9's room. This had the potential to affect RI #9, one of 23 sampled residents. Findings include: A facility policy titled, Storage of Medications and Biologicals, with a reviewed date of 04/2020, documented: . Policy Medications and biologicals are stored safely, securely, and properly . Procedures 1. The provider pharmacy dispenses medications in containers that meet legal requirements. Medications are kept in these containers. Transfer of medications from one container to another is done only by the pharmacy. RI #9 was admitted to the facility on [DATE] and readmitted on [DATE], and had diagnoses to include End Stage Renal Disease, Dependence on Renal Dialysis, Retention of Urine, Alzheimer's Disease and Dementia. A telephone interview was conducted with RI #9's representative on 12/05/2023 at 1:24 PM. RI #9's representative stated medication had been left in RI #9's room. RI #9's representative stated the medication was in a urine cup. RI #9's representative stated she put the medication in the closet. On 12/05/2023 at 12:45 PM, an observation of RI #9's room was conducted with License Practical Nurse (LPN) #20. When LPN #20 opened RI #9's closet, a gray plastic bag with a tube of Vitamin A&D ointment, a tube of Periguard, a tube of Resinol cream and a specimen container with a cream in it, which was labeled Resinol, was observed. LPN #20 stated she did not know why the Resinol was in the specimen container. An interview was conducted with the Registered Nurse (RN)/Unit Manager (UM) on 12/07/2023 at 10:27 AM. The UM stated medicine should stay in its original container. The UM said medicine was not allowed to be in a specimen cup. The UM stated the concern of medication not being stored in its original container was not knowing the date it was opened or the expiration date. The UM said she could not be 100 percent sure what was in the container and it could be contaminated. An interview was conducted with the Director of Nursing (DON) on 12/07/2023 at 5:54 PM. The DON stated Resinol should never be stored in a specimen container. The DON stated it should be stored in its original container with RI #9's name and date opened on the container. The DON stated the concern of medication not being stored in the original container was there was no way to verify what was in the container, which could result in an error.

Based on observations, interviews, record review, and review of the facility policy titled, Standard Precautions, the facility failed to ensure Certified Nursing Assistant (CNA) #12, did not create the potential for cross-contamination when she wiped feces from the floor with a dry towel and failed to use an appropriate disinfectant. Multiple staff were observed walking through the area after the feces was removed and before the floor was disinfected. This was observed on 12/05/2023. This deficient practice had the potential to affect one unit of the facility. Findings include: Review of a facility policy titled, Standard Precautions, with an effective date of 11/16/2016 documented: Purpose: It is the intent of this facility that: 1) all resident/guest blood, body fluids excretions and secretions other that sweat will be considered potentially infectious; 2) Standard Precautions will be used for all residents/guest. spills of blood or other body fluids should be removed and the area decontaminated . The disinfectant should be EPA (Environmental Protection Agency) registered and have a kill data against Hepatitis B and HIV or should be tuberculocidal. Resident Identifier (RI) #514 was admitted to the facility 11/16/2023. On 12/05/2023 at 09:29 AM, during an observation of the 300 hall, RI #514 was observed in the hallway with feces falling from his/her brief to the floor. CNA #12 led RI #514 back to his/her room while a staff member placed a towel over the bowel movement. On 12/05/2023 at 09:33 AM, CNA #12 returned to the area and began wiping the feces from the floor using a dry white towel. While wiping up the feces, CNA #12 stepped on the towel and pushed the towel around on the floor. CNA #12 walked a few steps and took the same towel and wiped feces from another area on the floor. CNA #12 used the same soiled towel to wipe feces from a third area on the floor. CNA #12 then put the feces covered towel in a garbage bag. CNA #12 did not disinfect the areas on the floor and left the area unsupervised. On 12/05/2023 at 09:38 AM, an observation was made of a staff member walking where feces had been on the floor. On 12/05/2023 at 09:43 AM, a housekeeping staff was observed walking where feces had been on the floor. The area had not been disinfected at that time. On 12/05/2023 at 09:51 AM, an observation was made of two staff members walking where the feces had been on the floor. On 12/05/2023 at 09:54 AM, an observation was made of a staff member walking where the feces had been on the floor. The area had not been disinfected at that time. On 12/05/2023 at 10:06 AM, an interview was conducted with CNA #12. CNA #12 stated she used a dry towel to clean up the feces from the floor. CNA #12 stated she was going to let the janitor know to sanitize the area because there was a trail of feces on the floor. CNA #12 said no one had supervised the area where feces had been on the floor. CNA #12 stated the floor should have been cleaned with a sanitizer from the janitor, but she had not notified anyone to sanitize the area. On 12/05/2023 at 10:16 AM, an interview was conducted with Licensed Practical Nurse (LPN) #13. LPN #13 stated there was loose stool on the floor in the hallway. LPN #13 stated the floor should have been cleaned with a towel, then the area should have been cleaned with a disinfectant. LPN #13 stated CNA #12 should have disinfected and sanitized the area that was contaminated with feces. LPN #13 stated no one supervised the area until the floor could be sanitized. LPN #13 stated the potential harm was that people could walk through the area that was contaminated with feces and track it into other rooms. LPN #13 said the floor should have been sanitized. On 12/07/2023 at 6:49 PM, the surveyor conducted an interview with the DON (Director of Nursing)/Infection Preventionist (IP). The IP said CNA #12 should have used a bleach wipe to clean the floor and then called housekeeping. The IP said when the floor was not cleaned in that manner there was a potential for contamination and spreading germs because people were walking in the hallway.

Based on an observation, interviews, review of the 2022 United States (U.S.) Food and Drug Administration (FDA) Food Code, and a facility work order # (number) 953, the facility failed to ensure the Walk-in Cooler had an interior push handle on the door for emergency exit. This affected one of two walk-in food cooling units in the facility's kitchen. Findings include: The 2022 U.S. FDA Food Code included the following: . 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair . (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted . During the initial kitchen observation on 12/05/2023 at 9:26 AM, the Walk-in Cooler contained food items and staff was going in and out of it. There was not an interior handle on the Walk-in Cooler door. On 12/05/2023 at 9:39 AM, the AM Cook said the interior handle had been missing since she came back to work at the facility two years ago. On 12/05/2023 at 9:50 AM, the Dietary Manager and the Registered Dietitian each said they had not noticed the Walk-in Cooler's interior door handle was missing. On 12/06/2023 at 4:50 PM, the Maintenance Director said he has started looking for someone to repair the emergency push handle for the Walk-in Cooler door. The facility's Work Order #953, dated 12/07/2023 with a time of 11:41 AM, included the following: . Emergency exit button missing from WIC (Walk-In Cooler) . During an interview on 12/07/2023 at 4:05 PM, the Dietary Manager said the Walk-in Cooler's interior door handle was not in good repair. The Dietary Manager explained the interior door handle was an emergency release to free oneself if locked inside the Walk-in Cooler. The Dietary Manager said kitchen maintenance concerns should be reported upon discovery. The Dietary Manager further said the facility used a computer communication program called TELS to report maintenance issues, but she also will tell the Maintenance Director verbally, in addition to TELS. During an interview on 12/07/2023 at 4:45 PM, the Registered Dietitian said the Walk-in Cooler's interior door handle was important to be able to get out in an emergency. The Registered Dietitian also said the Walk-in Cooler's interior door handle was not in good repair. The Registered Dietitian said kitchen maintenance concerns could be reported via the Maintenance Log (TELS) by the Dietary Manager or herself or anyone with access to the facility computer. The Registered Dietitian further said Dietary staff could report kitchen maintenance concerns to the Dietary Manager for input into the system.

Based on interviews, the facility's Meal Tray Service Schedule, and the facility's policy for Master Meal Schedule, the facility failed to ensure no more than 14 hours were scheduled between the service of Supper and the service of the Breakfast meal times. This had the potential to affect 113 of 113 residents receiving meals from the facility's kitchen. Findings include: The facility's policy for Master Meal Schedule, dated 08/10/2018, included the following: . PURPOSE: To provide resident/guest(s) with at least three meals daily, at regular times, comparable to normal mealtimes in the community. STANDARD: According to federal regulations, three meals should be served at regularly scheduled times. No more than a 14-hour span between supper and breakfast should occur. PROCESS: The FNS (Food and Nutrition Services) Manager . should determine regular meal times and document those times . The facility's Meal Tray Service Schedule, undated, included the following: . Breakfast 1st Cart (Secure Unit): 7AM . 2nd Cart (Unit 3): 7:10am . 3rd Cart (Unit 2): 7:20am . 4th Cart (Unit 3): 7:30am . 5th Cart (Unit 2): 7:40am . 6th Cart (Unit 3): 7:50am . 7th Cart (Unit 2): 8:00am . 8th Cart (Unit 3): 8:10am . Supper 1st Cart (Secure Unit): 4:45P [PM] . 2nd Cart (Unit 3): 4:55pm . 3rd Cart (Unit 2): 5:05pm . 4th Cart (Unit 3): 5:15pm . 5th Cart (Unit 2): 5:25pm . 6th Cart (Unit 3): 5:35pm . 7th Cart (Unit 2): 5:45pm . 8th Cart (Unit 3): 5:55pm . The Dietary Manager (FNS Manager) was interviewed on 12/07/2023 at 3:54 PM. When asked the time between the service of supper for Cart #1 on the Secure Unit and the service of breakfast for Cart #1 on the Secure Unit, according to the facility's Tray Service Schedule, the Dietary Manager said 14 hours and 15 minutes. When asked the time between the service of supper for Cart #8 on Unit 3 and the service of breakfast for Cart #8 on the Unit 3, the Dietary Manager said 14 hours and 15 minutes. The Dietary Manager said the established service times for resident meals exceeded the 14 hours allowed between the supper meal and the next day breakfast meal. The Dietary Manager said this might affect Diabetic residents. The Dietary Manager further said a person with a good appetite might experience hunger due to this schedule. The Registered Dietitian (RD) was interviewed on 12/07/2023 at 4:38 PM. When asked the time between the service of supper for Cart #1 on the Secure Unit and the service of breakfast for Cart #1 on the Secure Unit, according to the facility's Tray Service Schedule, the RD said it was over 14 hours by 15 minutes. When asked the time between the service of supper for Cart #8 on Unit 3 and the service of breakfast for Cart #8 on the Unit 3, the RD said 14 hours 15 min. The RD said the established service times for resident meals exceeded the 14 hours allowed between the supper meal and the next day breakfast meal. Upon being asked how could this affect residents, the RD said we don't want them to be hungry. The RD further said we want the residents to eat and to have their meals in a timely manner, so as to not adversely affect their nutritional status.

Based on observation, interview, resident record review, the 2017 Food Code, the food temperature record,the menu for breakfast on 07/11/2022, the Physician Orders List for Dietary, and the facility's policies for Tray Assembly, Tray Distribution, and Food Taste Test; the facility failed to ensure the coffee and grits served at breakfast on 07/11/2022 were received at an appetizing temperature upon delivery to residents. This affected Resident Identifiers (RI) #9 and #10 and had the potential to affect all residents receiving meals from the facility kitchen, 109 of 111 residents. Findings include: The facility's policy for Food Taste Test, dated 02/01/2002, included the following: . PURPOSE: . help promote the resident/guest(s) dietary intake. PROCESS: . c. Check the food for: . Hot foods hot . The facility's policy for Tray Distribution, dated 02/01/2002, included the following: . PURPOSE: To facilitate the rapid and accurate distribution of meal trays to resident/guest(s). PROCESS: . b. As trays are received by the nursing department, meals should be served first to resident/guest(s) requiring assistance with set-up only, or those resident/guests who eat independently. The 2017 United States (U.S.) Public Health Service and U.S. Food & (and) Drug Administration (FDA) Food Code included the following: . 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair . The facility's policy for Tray Assembly, dated 08/10/2018, included the following: . PURPOSE: . provide foods that are at proper temperature . PROCESS: . e. equipment designed to maintain temperature should be used. RI #9 was admitted to the facility on [DATE]. RI #9's July 2022 Physician Orders revealed a NAS (No Added Salt) diet order, with a start date of 07/22/2021. RI #9's Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/06/2022, revealed the resident had adequate ability to hear, clear speech, the ability express ideas and be understood, and the ability to understand the verbal content of others. The BIMS (Brief Interview for Mental Status), included in this Annual MDS, revealed a score of 15, which indicated RI #9 was cognitively intact. The Annual MDS also documented RI #9 was functionally independent for eating and drinking and only required setup help. During an interview on 07/10/2022 at 4:57 PM, RI #9 said the food was terrible. RI #9 said breakfast was cold, further saying the coffee and grits were cold. RI #9 also said the food was cold at lunch and supper. The resident had spoken to the facility administrator, but RI #9 said it was still a problem. RI #10 was admitted to the facility on [DATE] and readmitted on [DATE]. The Physician Orders List for Dietary, dated 07/10/2022, documented a Regular Diet order, dated 05/10/2022, for RI #10. RI #10's Quarterly MDS, with an ARD of 02/28/2022, revealed the resident had adequate ability to hear, clear speech, the ability express ideas and be understood, and the ability to understand the verbal content of others. The BIMS, included in this Quarterly MDS, revealed a score of 14, which indicated RI #10 was cognitively intact. During an interview on 07/10/2022 at 5:15 PM, RI #10 said the coffee was lukewarm and the grits were not always hot. RI #10 further said there was only a 50 percent chance of the grits being hot at breakfast. RI #10 said he would be happy with a hot cup of coffee at breakfast. Breakfast tray line was observed on 07/11/2022 beginning at 6:45 AM. The AM Cook, Employee Identifier (EI) #3, had placed the food on the tray line and recorded the temperatures. The food temperatures were recorded on the Diet Guide Sheet for the Week 1 Menu, Day 2, Breakfast, Monday, 07/11/2022. The grits temperature was documented as 198 degrees Fahrenheit (F). At 6:55 AM, sixteen cups of coffee had been poured into insulated mugs and covered by the AM Dietary Aide, EI #2. The square coffee holder/dispensor unit in the coffee making machine was observed to be open at the top. EI #2 explained the original unit had a broken dispenser knob and they had borrowed a unit from another facility, but the lid for the borrowed unit would not fit in the coffee machine and the original unit's lid would not work with the borrowed unit. So, the coffee just dripped from the coffee making machine into the open coffee holder/dispenser unit and no lid was used. At 6:58 AM, the plate warmer lowerator power indicator light was observed to be off. Surveyor held her hand by the plates and over the well of the lowerator, but no heat was felt. The breakfast tray line started at 7:05 AM. It had been ten minutes since the sixteen cups of coffee were poured at 6:55 AM. At 7:06 AM, observed insulated domes being used to cover food on the China plates atop insulated underliners. Also observed that the plate warmer lowerator power indicator light was now on. There were 28 plates stacked above the top of the plate warmer lowerator well and these plates were not hot. At 7:12 AM, the surveyor requested the last tray on the 300 Hall for a test tray. Observed coffee poured into seven insulated mugs and covered by EI #2. At 7:16 AM, observed coffee poured into ten insulated mugs. At 7:18 AM, observed coffee poured into five insulated mugs. Then an additional eight mugs of coffee were poured. At 7:30AM, the test tray was plated. At 7:34 AM, the cart with the test tray was transported out of the kitchen. At 7:35 AM, the cart arrived on 300 Hall, South Wing. There were thirteen trays on the cart, twelve resident trays and one test tray. At 7:41 AM, two staff members sanitized their hands and approached the cart. One staff member pushed the cart down the North Wing and then pushed it back to the central area of the 300 Hall without removing any trays. At 7:43 AM, two trays were served on the North Wing by two staff members. At 7:45 AM, two more trays were served on the East Wing. Then the cart was pushed to the West Wing of the 300 Hall. There were nine trays, including the test tray, still on the cart. At 7:47 AM, one tray was served on the West Wing. At 7:49 AM, a second tray was served on the West Wing. At 7:50 AM, another tray was served. At 7:51 AM, the cart was transported back to the North Wing. At 7:54 AM, one additional tray was served on the North Wing. At 7:55 AM, The cart was transported to the South Wing. One tray was served. At 7:56 AM, The cart was transported to the plastic barrier of the Isolation Area. A staff member donned a gown and gloves to transfer the disposable meal containers to the Isolation Area. At 8:00 AM, one tray was removed from the cart by a staff member and taken to the North Wing. At 8:01 AM, the last isolation meal was transferred to the Isolation Area, 26 minutes after the cart arrived on the 300 Hall. The test tray was removed from the cart. At 8:02 AM, the test tray was reviewed with the Dietary Manager, EI #1, and the Registered Dietitian, EI #4. The temperature of the grits was taken for comparison to the tray line temperature. The grits were 92 degrees F, a drop of 106 degrees from 198 degrees F. The surveyor and EI #1 tasted the grits, and both said the grits were not hot. EI #4 and the surveyor tasted the coffee. When asked if the coffee was hot, EI #4 said no. The surveyor agreed the coffee was not hot. EI #1, the Dietary Manager, was interviewed on 07/11/2022 at 11:20 AM. Upon being asked about the coffee machine repair issue, EI #1 said the attachment for the nozzel (dispensor/spigot) of the square coffee holder/dispensor unit was broken during cleaning. When asked if the coffee equipment had been repaired in a timely manner, EI #1 said, No. This started the last week of April or the first of May and this is now July. EI #1 was asked if the issue with the equipment had influenced the coffee temperature. EI #1 said, Yes, it could have. EI #1 was asked about the back and forth manner of delivery observed on the 300 Hall at breakfast that morning. EI #1 said those were not the people who normally pass trays. EI #1 further said the Unit Managers want the trays of residents who need to be fed to be on the last cart so they can be passed last and an aide is available to feed the resident. EI #1 said the trays could have been handed out better, that is why it appeared disorganized. When asked if any complaints had been received about the food, EI #1 said the coffee drinkers have told her that their coffee is fine for lunch and supper, but they wanted it hotter at breakfast. EI #1 was asked when should the plate warmer lowerator be turned on. EI #1 said if the cook gets here at 5:30 AM, it should be turned on then, but no later than 6 AM so the plates can heat up. EI #1 further said the hot plates will help keep the food hot. EI #3, the AM Cook, was interviewed on 07/11/2022 at 12:12 PM. EI #3 was asked when was the plate warmer lowerator supposed to be turned on for the breakfast line. EI #3 said I don't know. EI #3 further said the plate warmer they had was torn up and when she came back from being off the new one was here, but no one told her how to use it. EI #3 was asked why was the plate warmer lowerator not turned on until the breakfast tray line started. EI #3 said she turned it on at the start of tray line. At 12:40 PM on 07/11/2022, EI #4 said she had checked with EI #1 and found out that no Inservice had been given on the new plate warmer lowerator.

Based on observations, interviews, record reviews, review of a facility form Shower Schedule and a facility policy Hygiene and Grooming, the facility failed to ensure Resident Identifiers (RI) # 5, and 6 received showers and bed baths per shower schedule. This citation was written as a result of the investigation of complaint AL 899 and affected two of two residents sampled for Activities of Daily Living (ADL)s. Findings Include: A review of a facility form titled SHOWER SCHEDULE revealed 6-2 DAY SHIFT . Even numbered Private rooms Monday Wednesday Friday .2 - 10 Tuesday, Thursday & Saturday Odd rooms B Bed .Private rooms . BED BATHS ARE GIVEN ON NON SHOWER DAYS INCLUDING SUNDAYS. A review of a facility policy titled Hygiene and Grooming with an effective date of 10/1/2010 revealed PURPOSE: Good hygiene and grooming help prevent the spread of infection and promote the resident's feelings of self worth and dignity. STANDARD: Guidelines for the provision of hygiene and grooming services are: Shower, tub or complete bed bath . RI #5 was admitted to the facility on [DATE] and readmitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of RI #5's care plan revealed . Bath per schedule . A review of the Shower Schedule indicated RI #5 was scheduled for showers on Tuesday, Thursday and Saturdays and dates according to June and July calendar RI #5 should have received showers on June 2, 4, 7, 9, 11, 14, 16, 18, 21, 23, 25, 28, and 30 and July 2, 5, 7, 9 and 12. A review of a facility computer driven form titled New Bath Report revealed no showers or baths documented for June or July. An entry dated 6/8/22 with no documentation and 6/16/22 marked as no bath. A review of RI #5's Quarterly MDS with and ARD of 4/12/22 revealed, the resident required physical help with bathing. On 7/10/22 at 11:15 AM, during the initial tour of the facility, RI #5 was observed and interviewed. RI #5 was wearing a gray colored long sleeve thermal type shirt and a brief and said had not had a bath today. On 7/11/22 at 8:25 AM, an observation of RI #5 revealed having on no pants and a dark gray long sleeve shirt. On 7/11/22 at 5:00 PM resident continues with same long sleeve gray shirt on. On 7/12/22 at 8:23 AM, an observation was made of RI #5. RI #5 continues with the same gray long sleeve shirt on which was also observed on 7/10/22 and 7/11/22. On 7/12 22 starting at 8:34 through 10:55 AM, RI #5 was continuously observed for care. At 10:40 AM staff entered the room for check and change for RI #5. The staff performed incontinent care and changed the bed linens, however, RI #5 continued with the same gray shirt on. When the staff left the room the surveyor asked RI #5 how long had the gray shirt been on. RI #5 stated a while maybe three or four days. RI #5 replied, no. When asked if a bed bath had been given yesterday (7/11/22), RI #5 replied, no. RI #6 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of RI #6's Admission MDS with an ARD of 6/28/22 revealed RI #6 requiring extensive assistance with personal hygiene and bathing. A review of EI #6's care plan revealed . Bath per schedule . A review of the Shower Schedule revealed RI #6 scheduled for showers on Tuesday, Thursday and Saturdays. A review of the June and July Calendar revealed RI #6 should have received showers on June 23, 25, 28, and 30 and July 2, 5, 7, and 12. A review of RI #6's New Bath Report does not indicate any showers for June or July. On 7/10/22 at 11:35 AM, RI #6 was observed and interviewed during the initial tour of the facility. RI #6's RP was visiting and said he/she visits every day and RI #6 was there for a 21 day stay and he/she was not sure if RI #6 had showers since there. RI #6 was asked about showering and said had not had a shower since there. On 7/12/22 at 2:01 PM, an interview was conducted with Employee Identifier (EI) #5, Certified Nursing Assistant. A review of staff assignment sheets indicated EI #5 assigned to RI #5 on 7/11/22. EI #5 was asked what were her duties during shift when she works the hall. EI #5 replied, to take care of the patient, bathing, brushing teeth, change clothing. EI #5 was asked, how often showers were given; she replied three times a week and bed baths everyday a shower was not given. EI #5 was asked, how often were residents' clothing changed; she replied, every day. EI #5 was asked when should residents clothing be changed. EI #5 replied, every day. EI #5 was asked why did RI #5 have on the same clothing he/she had on Sunday 7/10/22. EI #5 replied, she could not tell her why. EI #5 was asked, what was the problem in residents clothing not being changed daily. EI #5 replied, it was a problem that the resident was wearing the same dirty clothing every day. EI #5 was asked, why showers and bed baths were not being given daily. EI #5 replied, she could not answer that question. EI #5 was asked, when was RI #6 to get shower. EI #5 replied, Tuesdays, Thursdays and Saturdays. EI #5 was asked if RI #6 was to have received a bed bath on 7/11/22; she replied, yes. EI #5 was asked if she gave RI #6 a bed bath on 7/11/22; she replied, no. When asked why not she replied because when she went in RI #6's room RI #6 was already dressed. EI #5 was asked to review RI #6's bath report, then she was asked how many baths RI #6 received in June and July. EI #5 replied, none. On 7/12/22 at 3:32 PM an interview was conducted with EI #7, Registered Nurse, Unit Manager. EI #7 was asked how often were residents to receive showers. EI #7 replied, whatever three days as scheduled per shower schedule, and then bed baths on the other days, residents were to receive bed baths on the days they do not receive a shower. EI #7 was asked to review RI #5's bath documentation then asked if RI #5 had received showers as scheduled. EI #7 replied, it was not documented. After reviewing bath documentation for RI #6, EI #7 was asked if RI #6 received showers as scheduled. EI #7 replied, she could not say. EI #7 was asked, why would RI #6 say they had not received a bath during the whole stay. EI #7 replied, she could not say that RI #6 did. EI #7 was asked, why would RI #5 say they had not received a bath. EI #7 replied, potentially RI #5 did not get a bath. EI #7 was asked, why would RI #5 have on the same shirt since Sunday 7/10/22. EI #7 replied, she could not answer that. EI #7 was asked if RI #5 should have on the same shirt since Sunday; she replied, no. EI #7 was asked, why should RI #5 not have on the same shirt since Sunday. EI #7 replied, because if you were bathed and changed you would not have on the same clothes and you would not go to bed with the same clothes worn during the day. EI #7 was asked, when should residents clothing be changed. EI #7 replied, when they wake up, when they are soiled, after a bath and when they go to bed. EI #7 was asked, where was documentation that showers or baths were done. EI #7 replied, she did not have anything documented. EI #7 was asked in reviewing ADL sheet for RI #5, how many baths should he/she have received in June and July. EI #7 replied, 13 scheduled days for June and 5 days for July. EI #7 was asked how many documented; she replied, none. EI #7 was asked what was the harm in clothes not being changed daily; she replied, hygiene it was part of daily cleaning. EI #7 was asked how could the facility verify residents received baths as scheduled. EI #7 replied, whatever documentation we have was what they could verify. EI #7 was asked how could the facility verify residents received baths as scheduled. EI #7 replied, by the computer sheet. EI #7 was asked how many baths were recorded for RI #5 for June and July; she relied, none. EI #7 was asked how many baths were recorded for RI #6 for June and July. EI #7 replied, none and 17 should be recorded. EI #7 was asked why should baths be documented. EI #7 replied that was how could prove baths given. EI #7 was asked what was the harm in residents not receiving showers as scheduled; she replied, infection.

Based on observation, interviews and a facility policy titled, Cleaning of Miscellaneous Equipment and Utensils, the facility failed to ensure plates were allowed to air dry before stacking them during the lunch meal on 4/25/19. This deficient practice had the potentials to affect all 112 residents receiving meals from the dietary department. Findings include: A review of a facility policy titled, Cleaning of Miscellaneous Equipment and Utensils with an effective date of (MONTH) 23, (YEAR), revealed: . 8.allow dishes to air dry . On 04/25/19 at 12:27 p.m., the surveyor observed Employee Indentifier (EI) #2, the Cook, remove plates from the tray and stack them on top of each other immediately after they came through the dish rinse cycle and were still wet. On 04/25/19 at 3:19 p.m., the surveyor conducted an interview with EI #2. The surveyor asked EI #2 how did she stack the plates that came out of the dishwasher. EI # 2 said when the plates came through the dishwasher, she was supposed to let them dry then set them in the place for the plates. EI #2 confirmed she did not do that. The surveyor asked EI #2 what could be caused, with the plates not having proper time to dry. EI #2 said she did not know what it would cause but she knew they needed to dry. On 04/25/19 at 3:32 p.m., the surveyor conducted an interview with EI #3, Dietary Staff member. The surveyor asked EI #3 how were the plates stacked that came out of the dishwasher. EI #3 said the plates were stacked on top of other wet plates. The surveyor asked EI #3, according to the policy, how were dishes to dry. EI #3 said air dry. The surveyor asked EI #3 was there time allowed today for the plates to air dry. EI #3 said no. The surveyor asked EI #3 what concerns were there with this. EI #3 said bacterial growth.

Based on interviews and record review, the facility failed to ensure: 1) Resident Identifier (RI) #52 was not coded as having a Foley Catheter on his/her Quarterly Minimum Data Set (MDS) assessment, dated 02/18/19; and 2) RI #114's Discharge MDS assessment, dated 03/20/19, identified RI #114 as being discharged to another facility. These deficient practices affected RI #'s 52 and 114, two of 31 sampled residents whose MDS assessments were reviewed. Findings Include: 1) RI #52 was admitted to the facility on [DATE], and readmitted on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #52's Quarterly MDS assessment, with an Assessment Reference Date (ARD) of 02/18/19, assessed RI #52 as having a Brief Interview for Mental Status (BIMS) score of 13, indicating RI #52 was cognitively intact. RI #52 was further assessed as having an indwelling catheter during this assessment period. On 04/24/19 at 9:36 a.m., the surveyor asked RI #52 if he/she had a Foley catheter. EI #52 said he/she did not have a Foley catheter. On 04/25/19 at 9:17 a.m., the surveyor conducted an interview with Employee Identifier (EI) #4, the LPN (Licensed Practical Nurse) assigned to care for RI #52 on the 7 a.m. -3 p.m. shift on 04/25/19. EI #4 confirmed RI #52 did not have a Foley catheter. On 04/25/19 at 2:47 p.m., the surveyor conducted an interview with EI #5, a LPN working in the MDS department. When asked if RI #52 had a Foley catheter, EI #5 looked at RI #52's 02/18/19, Quarterly MDS assessment and stated RI #52 was coded as having one, but she did not code that, someone else did. EI #5 said the restorative nurse, EI #6, coded RI #52 as having the Foley catheter. On 04/25/19 at 2:58 p.m., the surveyor conducted an interview with EI #6, the Restorative Nurse. The surveyor asked EI #6 did RI #52 have a Foley catheter. EI #6 said no. When asked if RI #52 had a Foley catheter during the 02/18/19, Quarterly MDS assessment period, EI #6 said no. EI #6 said RI #52 should not have been coded as having a Foley catheter during this assessment period. The surveyor asked EI #6 was RI #52's 02/18/19, Quarterly MDS assessment accurate if RI #52 was coded as having a Foley catheter during this assessment period and he/she did not have one. EI #6 said no. 2) RI #114 was admitted to the facility on [DATE], and discharged on [DATE]. A review of RI #114's (MONTH) 2019 Physician order [REDACTED].#114 was to be discharged to another nursing facility on 03/20/19. A review of RI #114's Departmental Notes revealed RI #114 was transferred to the other nursing care facility on 03/20/19. RI #114's Discharge MDS Assessment with an ARD of 3/20/19, revealed RI #114 was discharged to an acute hospital. On 04/25/19 at 4:47 p.m., the surveyor conducted an interview with EI #1, the RN (Registered Nurse) MDS Coordinator. The surveyor asked EI #1, according to RI #114's Departmental Notes ,dated 03/20/19, where was RI #114 discharged to. EI #1 said (Name of nursing facility). The surveyor asked EI #1, according to RI #114's Discharge MDS dated [DATE], under discharge status, what was coded. EI #1 said acute care. The surveyor asked EI #1 was this an accurate assessment. EI #1 said no. EI #1 said RI #114 was discharged to a long term care facility.

Based on observations, interview, record review and review of a facility policy titled, BASELINE CARE PLAN PROT[NAME]OL, the facility failed to ensure Resident Identifier (RI) #163 had a baseline care plan addressing the use of his/her nebulizer treatments. This deficient practice affected RI #163, one of two sampled residents whose baseline care plans were reviewed. Findings include: A review of an undated facility policy titled, BASELINE CARE PLAN PROT[NAME]OL, revealed the following: Process to establish a baseline care plan that contains the required elements within the 48 hour time frame . Baseline care plans should contain at a minimum . Initial Goals based on admission orders [REDACTED]. RI #163 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #163's (MONTH) 2019 Physician order [REDACTED]. On 04/24/19 at 10:46 a.m., the surveyor observed a nebulizer mask and machine in RI #163's room. On 04/25/19 at 10:55 a.m., record review revealed there was no baseline care plan for the nebulizer treatments. On 04/25/19 at 3:14 p.m., the surveyor conducted an interview with Employee Identifier (EI) #7, the RN (Registered Nurse) Unit Manager. The surveyor asked EI #7 was RI #163 admitted with an order for [REDACTED].#7 said yes. When asked if a baseline care plan was done for RI #163, EI #7 said she did not see one. When asked what was the purpose of a baseline care plan, EI #7 said so staff would know what the expected plan of care for the resident was.

Based on observation, interview and record review, the facility failed to assess Resident Identifier (RI) #2 when she began to cry out in pain throughout wound care on 06/04/2014. Even though the Treatment Nurse, Employee Identifier (EI) #1, stated she apologized to the resident, she continued with the wound care. EI #1 did not stop the treatment and assess the resident for pain and did not provide pain relieving measures. This affected 1 of 2 residents observed for wound care. Findings include: Review of the facility policy "Pain Management and Assessment" Effective Date 10/1/2010, documented under the heading "Standard: ... The pain assessment ... should be conducted ... when new or worsening pain is evident ... Process: I General Information ... a) Pain is any type of physical pain or discomfort in any part of the body. ... Pain is very subjective, pain is whatever the experiencing person says it is and exists whenever he or she says it does. b) Pain can cause suffering... f) Most residents ... will require regularly dosed pain medications, and some will require additional PRN (as needed) pain medications for breakthrough pain." The facility provided a "... Risk Protocol for Pressure Ulcer ... " document, revised 2-18-08. The document contained the protocol, PAIN EVALUATION AND MANAGEMENT. "Evaluation. Evaluate all patients for pain related to the pressure ulcer or its treatment. Management. Manage pain by eliminating or controlling the source of pain. Because pain may be evoked or may be especially acute during dressing changes and debridement, the caregiver should try to prevent such discomfort or take steps to relieve it..." RI #2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. According to a facility "Wound Flow Record A 10/10" form, dated 05/27/2014, RI #2 was readmitted with a Stage III wound to her right buttock and a Stage III to her right posterior thigh. Both wounds were originally identified on 05/19/14, date of previous readmission to the facility from a hospitalization . A wound care observation conducted by a surveyor on 06/04/14 at 3:50 PM, determined the wounds were located on the left buttock and left posterior thigh. RI #2's current Significant Change In Status Minimum Data Set (MDS) assessment, dated 06/03/2014, identified the resident with short and long term memory problems and severely impaired for daily decision making. Generalized pain and no neurological [DIAGNOSES REDACTED].#2 received scheduled pain medication and received no pain medications as needed. RI #2's pain included non-verbal sounds (crying, whining, gasping, moaning or groaning). RI #2's showed evidence of pain 1 to 2 days in the last 5 days of the assessment period. The MDS also indicated RI #2 was admitted with two Stage III pressure ulcers. Review of RI #2's June 2014 Medication Administration Record [REDACTED]. The pain medication [MEDICATION NAME] 5-325 milligrams one tablet for pain as needed every six hours was discontinued on 6/03/14. Review of RI #2's care plan related to pain included approaches of "... Attempt t(to) measure resident's pain level using pain scale 1-10 ..." On 06/04/14 at 3:50 PM, during a pressure ulcer dressing change and wound care observation, when EI #1 Licensed Practical Nurse (LPN) Treatment Nurse, began to remove the old dressing, RI #2 began to cry out "oh oh oh" in pain. EI #1 continued to remove the dressing. When EI #1 began to wipe the pressure ulcer with a 4x4 gauze, RI #2 again cried out in pain. EI #1 measured the two pressure ulcers while RI #2 continued to cry out in pain. EI #1 began to apply Santyl ointment to the wound beds and RI #2 again cried out in pain. RI #2 continued to cry out in pain as EI #1 applied the new dressings to the pressure ulcers. On 06/04/14 at 4:10 PM, RI #2 was asked if ten was the worse pain and zero was no pain, how bad was she hurting during wound care. RI #2 said ten. On 06/06/14 at 2:15 PM, EI #1 was asked, when RI #2 cried out in pain what did she do. EI #1 said she apologized to RI #2 for hurting her. EI #1 was asked when RI #2 was crying out in pain, did she offer anything else for breakthrough pain relief. EI #1 said no she did not. On 06/06/14 at 4:20 PM, EI #2 the Director of Nursing (DON) was asked, what should the treatment Nurse have done when RI #2 began to cry out in pain during removal of the dressing. EI #2 said, stopped removing the dressing. EI #2 was asked when the resident continued to cry out in pain during the cleansing of the pressure ulcer, what should the Nurse have done. EI #2 said, check and make sure she had pain medication. EI #2 was asked, when RI #2 continued to cry out in pain during the application of Santyl ointment to the pressure ulcer, what should the Nurse have done. EI #2 said, the Nurse should have assessed her for pain and asked RI #2 if she needed something else other than the patch. EI #2 was asked when should the Nurse have checked for pain medicine given to RI #2. EI #2 said, before she did the treatment.