Every finding on record at Willowbrooke Ct Skilled Care CTR Westminster VLG

Based on observation, interview, record review, and review of the facility policy, the facility failed to store, prepare, and serve food under sanitary conditions for 38 of 38 residents who received food prepared in the kitchen. Observations on 4/6/21 in the kitchen revealed uncovered, unrefrigerated, and unlabeled food, no dates on prepared food, storage containers containing debris and unclean workstations. Findings include: An initial tour of the kitchen was conducted on 4/6/21 at 9:21 am. Upon inspection of the sandwich prep refrigerator located by the steamtable, the following items were observed: Sliced lemons covered with no date, sliced red onion covered with no date, a green pepper cut open sitting on top of other food items unwrapped, yellow sliced cheese wrapped with no date, white sliced cheese wrapped with no date, a small container of chicken salad with no date of preparation or expiration, and a small container of egg salad with no date of preparation or expiration. An inspection of the reach-in refrigerator located by the toaster, the following items were observed: One sixth (1/6) pan of red sauce with no label identifying the contents and no date of expiration, one sixth (1/6) pan white sauce with no label identifying the content and no date of expiration, one half (1/2) gallon Cambro of red sauce with no label identifying the contents and no date of expiration, one half (1/2) pan of cooked noodles with no date of preparation or expiration, one sixth (1/6) pan of raw shrimp with no date of expiration, and two (2) one sixth (1/6) pans of raw chicken with no date of expiration. During an observation of the prep area by the cooks, the following items were observed: One sixth (1/6) pan of chopped tomatoes sitting on the counter next to toaster unrefrigerated and no date of preparation or expiration, eight (8) bags of opened bread with no date of opening or expiration, exposed slices of bread in the bottom of the storage container, one half (1/2) pan of cooked bacon and sausage covered with no date of preparation sitting on the counter by the toaster unrefrigerated, an opened box of eight (8) croissants with no date of expiration, one sixth (1/6) pan of cooked scrambled eggs with cheese sitting on the prep counter unrefrigerated, uncovered with no date of preparation or expiration, and one sixth (1/6) pan of pureed meat uncovered and unrefrigerated. During an inspection of the reach-in refrigerator labeled number five (#5), the following was observed: One sixth (1/6) containers of: sliced cucumbers, chopped onions, olives, shredded cheese, sliced mushrooms and parmesan cheese were uncovered with no dates of preparation and expiration, six (6) Styrofoam containers of ambrosia with no date of preparation or expiration, one (1) gallon of mayonnaise opened with no date of opening or expiration, one (1) gallon of mayonnaise opened with no lid and no date of opening, one (1) gallon of Caesar salad dressing opened with no date of opening or expiration, and a 12-quart Cambro with yellow liquid with no label identifying the contents and no date of preparation or expiration. The bottom of the refrigerator contained dried pieces of food and debris. An inspection of the dry storage room revealed six (6) Cambro storage bins with dirty lids. The bins labeled rice flour, rice and cornmeal had scoops in the product. The baseboard by the entrance to the bakery was missing and the wall was broken, exposing the interior of the wall. During an observation of the walk-in freezer, the following items were observed: A bag of frozen Brussel Sprouts was opened exposing the contents, ice had formed on the top of the product and a tray of 12 vegie burgers were unwrapped with no date of expiration. An inspection of the walk-in refrigerator revealed a large Cambro of fruit cocktail that had no date of preparation or expiration. Two (2) trays of sliced carrots, one (1) tray of asparagus and 16 bowls of fresh fruit were uncovered with no date of preparation or expiration. An inspection of the cook's area revealed a build-up of grease on the floor and fryer mechanism around the deep fryer. A one half (1/2) pan labeled roux, undated and unrefrigerated, was stored on the bottom shelf. An opened box of cream of wheat cereal had no date of opening and there was an undated opened bag of grits. The shelves were covered with a white dried substance. In an interview on 4/6/21 at 12:22 p.m. with the Certified Dietary Manager (CDM), he/she stated that he/she had been the manager of the kitchen since January of 2021. An observation of the cleaning schedule was conducted with the CDM. The posted cleaning schedule dated 3/19/21 through 3/25/21 and titled Culinary Sanitation Schedule had three pages of 26 kitchen sanitation assignments. On 3/19/21 and 3/25/21, there were no signatures on the schedule indicating completion of cleaning duties. On 3/20/21, 13 of the 26-kitchen sanitation assignments had signatures of completion. On 3/21/21, there were three (3) of 26 tasks signed as completed. On 3/22/21, there were two (2) of 26 tasks signed as completed. On 3/23/21, there were five (5) of 26 tasks signed as completed. On 3/24/21, there were five (5) of 26 tasks signed as completed. The CDM stated that the schedule was maintained and monitored for completion by the executive chef who was currently on vacation and unavailable for an interview. The CDM stated that it was his/her responsibility to maintain and monitor the schedule when the executive chef was not available. He/she stated that he/she was not aware there was not a current cleaning schedule posted. He/she agreed that an unsigned cleaning tasks would indicate an incomplete task and that all the spaces on the cleaning schedule should be signed as completed. During the interview the CDM was asked if there was any current sanitation in-service provided for the kitchen staff. The CDM stated that he/she did huddles with the staff to cover topics because he/she was concerned with group meetings due to the pandemic. The DM provided copies an in-service dated 6/30/2020 which included topics of wrapping, labeling, dating, and re-closing bags. The in-service was signed by 17 employees that had attended the training. The DM stated that this had been the last documented official in-service. The DM also provided a copy of the huddle attendance sheet. A review of the attendance sheet dated 1/26/21, 2/1/21, and 2/24/21 documented the employees who were in attendance of the meetings, but no topics were documented for those meetings. The meeting dated 3/9/21 documented the employees who attended with a topic sheet attached which included labeling and dating, kitchen, and service area inspection as discussion topics. A review of the policy titled Cleaning and Sanitation Culinary and Nutrition Department, dated 11/13, documented that the Culinary and Nutrition (CNS) Services management team was responsible for developing a written daily cleaning schedule and assuring compliance with the schedule. A review of the policy titled Date Marking Read-To-Eat Foods, dated 12/17, documented that all ready-to-eat foods must be labeled with the product name, and date the product was prepared or opened and the date the product should be used by and that all potentially hazardous foods should be refrigerated at 41 degrees or below.

Based on observations, interviews, and review of a facility policy titled PERSONAL APPEARANCE STANDARDS, the facility failed to ensure: 1) opened and undated foods were not observed in the freezer; 2) the ice machine was not found with a black residue inside the ice storage compartment; and 3) hair was not uncovered on staff while working in the kitchen. This had the potential to affect all forty-two residents receiving meals from the kitchen. Findings Include: 1) On 2/12/2019 at 7:56 AM, during the tour of the kitchen, a brown paper bag of hashbrowns was observed opened and exposed with no date. A brown paper bag of tater tots was also observed open and exposed to air, without a date. On 2/14/2019 at 1:35 PM, Employee Identifier (EI) 3, the Director of Culinary Services, was interviewed. When asked what the facility's policy was regarding opened and undated food items in the freezer, EI #3 said the items should be sealed and dated, and if there was no date, the item should be discarded. He said if items were open and exposed or undated, there was a potential for contamination. 2) On 2/12/2019 at 7:56 AM, during the tour of the kitchen the ice machine was noted with a black substance on the left wall, above the ice. A black substance was also noted on the white strip that crosses over the ice, and attaches to the ceiling of the ice storage bin. On 2/14/2019 at 11:03 AM , EI #3 was asked to use a white napkin or paper towel to wipe across the left wall inside the storage unit containing ice. As EI #3 wiped the black residue with the dry white napkin, residue was observed on the napkin, and EI #3 confirmed its presence. EI #3 then wiped the white strip with the napkin, and a moderate amount of black residue was observed on the napkin. The same residue was noted when EI #3 wiped the back of the ice storage unit above the ice. During an interview on 2/14/2019 at 1:35 PM, EI #3 said the black substance was observed in the ice machine because it was not being cleaned as frequently as it should. EI #3 also stated the black residue/substance inside the ice storage unit created the potential for contamination. 3) Review of the facility policy titled PERSONAL APPEARANCE STANDARDS, revised 1/2016, revealed the following: .PR[NAME]EDURE: 3. Freshly shaven face 4. Men with facial hair, moustache and/or beard, must wear a bear guard while in the production kitchen. 5. Hair restraints such as hats, hair coverings, or nets, and clothing that cover's body hair shall be worn when in the production area where food is prepared or plated . On 2/13/19 at 5:04 PM, EI #9 was observed in the kitchen with two hair pieces outside of his hair restraint. 02/13/19 at 5:26 PM EI #9 was observed in the kitchen washing dishes with two long pieces of hair hanging out of his hair restraint. EI #9 then walked over beside the food tray line. EI #9 confirmed he had hair outside of his hair restraint. When asked the concern with that, EI #9 said the hair could get into the residents' food. On 2/13/19 at 5:06 PM EI #7, a Cook, was observed at tray line with a hat on, but no mustache restraint. On 2/13/19 at 5:38, EI #3, the Director of Culinary Services, confirmed the male staff member in the serving area (EI #7) had a mustache, but was not wearing a restraint. EI #3 said EI #7 should have been wearing a mustache restraint to prevent hair from getting in the food and causing cross contamination. EI #7, the Cook, was interviewed on 2/13/19 at 5:43 PM. EI #7 confirmed he was not wearing a mustache restrain when he was on the serving line. EI #7 said the concern in that was that hair could get in the food and cause contamination.

Based on observations, interviews and record reviews, including the facility's policy titled, SUBJECT: OPERATIONAL STANDARDS REFRIGERATOR, and the Food and Drug Administration Food Code, the facility failed to ensure: 1) a container of chopped fruits, a tray of hamburger patties, and a container of green beans had an expiration date on them; 2) a tray of fruit cups and bowls of bread pudding were covered and dated; and 3) a pan of brownies in the cooler was covered. This affected 40 of 40 residents who receive a meal from the kitchen. Findings Include: A review of the Food and Drug Administration Food Code 2013, Chapter 3 Food Storage page 76, revealed the following: .3-305-11 Food Storage : (A) Except as specified in (B) and (C) of this section, Food shall be protected from contamination by storing the FOOD: .(2) Where it is not exposed to splash, dust, or other contamination; and A review of a facility policy, SUBJECT: OPERATIONAL STANDARDS REFRIGERATOR, with a revision date of 2/17, revealed: POLICY: To strive to ensure all refrigerators (kitchens, pantries and country kitchens) are maintained at all times. PR[NAME]EDURE: .4. Food is properly stored in appropriate containers labeled with product name, date prepared/opened, use-by date and employee initials 1) During the initial tour of the kitchen on 2/26/18 at 4:15 p.m., containers of chopped fruit (pineapple, honey dew melon, and cantaloupe) were observed to not have expiration dates. A tray of hamburger patties and a container of cooked green beans also did not have expiration dates on them. An observation was made of the dessert refrigerator. There was a tray of fruit cups and bread pudding with no covering or expiration dates. Further, a half pan of brownies was observed uncovered and without an expiration date. On 3/01/18 at 2:53 p.m., an interview was conducted with EI (Employee Identifier) #4, Director of Culinary and Nutrition Services. EI #4 was asked if these foods should have been dated with an expiration date. EI #4 answered yes. EI #4 was asked why they were not properly dated. EI #4 explained the sous/chef placed the items in the cooler, put his initial on them, but failed to put an expiration date. EI #4 was asked how should food be stored in the cooler. EI #4 said they should be placed in a container, covered and dated. EI # 4 was asked what was the facility's policy regarding the proper storage of foods. EI #4 said food should have a date of when it was placed in the cooler, when it was opened, and when it should be discarded. EI #4 was asked what was the concern of not having foods labeled properly. EI #4 said spoilage and foodborne illness. On 3/01/18 at 3:00 p.m., an interview was conducted with EI #5, the Executive Chef. EI #5 was asked should a container of pineapple, honeydew melons, and cantaloupe have been stored in the cooler without an expiration date. EI #5 answered no. EI #5 was asked why they did not have the proper labeling. EI #5 said she did not believe it was labeled because the sous/chef did not know better and she believed he just overlooked it. EI #5 was asked would staff know when these foods should be discarded if they were not dated. EI #5 said it should be automatically thrown out if there were no dates. EI #5 was asked how should foods be stored in the cooler. EI #5 said foods should be covered and labeled and dated. EI #5 was asked why was a tray of fruit bowls, cups of bread pudding, and a half of pan of brownies with a knife laying in the pan stored in the dessert cooler without covering or expiration dates on them. EI #5 said someone failed to follow company procedure. EI #5 was asked should foods be stored without being covered. EI #5 said no. EI #5 was asked what was the concern of not having foods labeled properly. EI #5 said residents and guest could potentially become ill from undated and spoiled foods.

Based on interviews and a review of the facility policy and procedure titled, Subject: Quality Assurance, Performance Improvement (QAPI) and Compliance Program, the facility failed to ensure the QAPI committee reviewed and identified the required regulatory change for reporting allegations of abuse within two hours to the State Agency. This affected three of three reported allegations of abuse submitted to the Alabama Department of Public Health and had the potential to affect all residents involved in abuse allegations residing in the facility. Findings Include: A review of a facility policy titled,Quality Assurance, Performance Improvement and Compliance Manual, revealed: Subject: Quality Assurance, Performance Improvement (QAPI) and Compliance Program Purpose: The purpose of . is to take a proactive approach to strive to continually improve the quality of life, care and services for our residents, caregivers, and other partners legally, morally and ethically. To do this, employees will participate in ongoing QAPI and compliance efforts through the continuous evaluation of care and services provided on behalf of Improvement (QAPI) and Compliance Program. There are five (5) elements (building blocks) for developing, implementing, and sustaining QAPI and compliance. 1. Design and Scope - The QAPI and Compliance program should: . c. Address systems of care and management practices, including clinical care, quality of life, resident choice toward a person-centered environment, and care transitions. d. Aim for safety and high quality using best practices 2. Governance and Leadership - Administration should: a. Develop and lead the QAPI and Compliance program m. Ensure each department provides documented, routine, scheduled training, mandatory compliance education, code-of-conduct, in-services, that include all employees, advising them of the changes in policy, procedures, . Three allegations of abuse that were facility-reported to the State Agency were reviewed. The allegations revealed the following: 1) An allegation of Physical Abuse with the alleged occurrence date and time of 12/09/2017 at 10:30 a.m. was submitted to the Alabama Department of Public Health on 12/10/2017 at 10:49 a.m. 2) An allegation of Physical Abuse with an alleged occurrence date and time of 12/17/2017 at 12:00 p.m. was submitted to the Alabama Department of Public Health on 12/20/2017 at 9:40 a.m. 3) An allegation of Verbal Abuse with an alleged occurrence date and time of 1/29/2018 at 7:00 p.m. was submitted to the Alabama Department of Public Health on 1/30/2018 at 12:46 p.m. An interview was conducted on 03/01/2018 at 11:30 a.m. with EI (Employee Identifier) #2, the Administrator. EI #2 was asked how he was made aware of changes in policy and procedures. Also, how he was made aware of the changes to the reporting regulation on abuse. EI #2 replied it was reviewed with him. EI #2 was asked who reviewed the changes at the QAPI meeting on 12/17. EI #2 replied he and the Regional Director of Nursing reviewed the changes. EI #2 stated that he assumed the two hour rule was in the revision, however, he had not read it all. EI #2 stated QA policy changes was only a very small part of what they (QAPI) did. EI #2 reported the changes had been discussed in the Regional Director of Nursing and the Regional Administrators meeting. EI #2 stated no one attending the QAPI meeting had identified the two hour requirement was not in the revision. An interview was conducted on 03/01/2018 at 2:45 p.m. with EI #3, the Regional Director of Nursing. EI #3 was asked how changes in policy were shared with the facility and if the changes were to be presented to the QAPI committee. EI #3 replied each facility received the updated and changed policies and the new/revised policies were presented to the QAPI committee for approval prior to sharing with the staff.

Based on interviews and a review of a facility policy titled, Abuse, Neglect . the facility failed to ensure the Abuse Policy indicated the reporting time of alleged abuse within two hours of being reported by staff to administration. This affected RI #4, #5, and #15, three of three residents named in allegations of abuse reviewed and had the potential to affect all residents involved in abuse allegations residing in the facility. Findings Include: A review of the facility's policy titled, SUBJECT: ABUSE, NEGLECT, INVOLUNTARY SECLUSION, EXPLOITATION, AND MISAPPROPRIATION OF PROPERTY PREVENTION, with a revision date of 11/17, revealed: POLICY: To strive to ensure residents will be safeguarded and protected from any form of abuse, . PURPOSE: The purpose of this policy is to promote the maintenance of a living environment that fosters the reporting of concerns/problems and protects residents; preserving their dignity and quality of life . Reporting: . 4. The executive director, administrator, or designee will take the following actions: A. Notify the appropriate state agency immediately (within 24 hours) . Three allegations of abuse that were facility-reported to the State Agency were reviewed. The allegations revealed the following: 1) An allegation of Physical Abuse with the alleged occurrence date and time of 12/09/17 at 10:30 a.m. was submitted to the Alabama Department of Public Health on 12/10/17 at 10:49 a.m. 2) An allegation of Physical Abuse with an alleged occurrence date and time of 12/17/17 at 12:00 p.m. was submitted to the Alabama Department of Public Health on 12/20/17 at 9:40 a.m. 3) An allegation of Verbal Abuse with an alleged occurrence date and time of 1/29/18 at 7:00 p.m. was submitted to the Alabama Department of Public Health on 1/30/18 at 12:46 p.m. On 02/28/18 at 4:18 p.m., an interview was conducted with EI (Employee Identifier) #1, the Director of Nursing. EI #1 was asked what was the facility's policy regarding reporting allegations of abuse. EI #1 replied the abuse policy indicated any suspicion of any types of abuse should be reported immediately by the staff to a supervisor or to the Abuse Coordinator. EI #1 said if there was bodily injury, they (facility) have to report it within two hours and, other than that, they have 24 hours to report. EI #1 was given a copy of the facility's Abuse Policy to review and was asked where the above information mentioned was located in the Abuse Policy. EI #1 stated the policy provided was not the policy on the reporting times and that it was in another policy. EI #1 provided the policy related to reporting times. However, the policy provided to the surveyor was in regards to crimes related to the elderly. The policy did not include the required two hour reporting of alleged abuse. On 03/01/18 at 8:14 a.m., an interview was conducted with EI #2, the Administrator. EI #2 was asked what was the regulation requirement for reporting alleged abuse. EI #2 replied if there was willful physical abuse they (facility) have a two hour window to report the alleged abuse. EI #2 further stated that all other reportable concerns or complaints of possible abuse were to be reported within 24 hours by the facility. EI #2 indicated he was the Abuse Coordinator and he was responsible for getting the reports done per policy. EI #2 was asked who reviewed and revised policies and procedures. EI #2 replied policies and procedures were reviewed and revised at the corporate level. EI #2 continued to say, he learned about the new revision and new policies and procedures at regional meetings and when new policies were sent out. EI #2 added the two hour rule was just an over-site by all of them. EI #2 stated he knew there was a new two hour regulation. EI #2 continued by stating he really did not read the new revision that closely. EI #2 stated he thought the regulation was included in the revision done on 11/17.

Based on record review of the policy titled, SUBJECT: ABUSE, NEGLECT, INVOLUNTARY SECLUSION, EXPLOITATION, AND MISAPPROPRIATION OF PROPERTY PREVENTION, and interviews, the facility failed to ensure the Governing Body maintained a process that ensured the abuse policy contained the correct time frame for reporting alleged abuse. This was evidenced by the Abuse Policy not indicating the required two hour reporting period for all alleged abuse. This affected RI (Resident Identifier) #4, #5, and #15, three of three residents with facility reported alleged abuse allegations and had the potential to affect all residents involved in abuse allegations who reside in the facility. Findings Include: A review of the facility's policy titled, SUBJECT: ABUSE, NEGLECT, INVOLUNTARY SECLUSION, EXPLOITATION, AND MISAPPROPRIATION OF PROPERTY PREVENTION, with a revision date of 11/17, revealed: POLICY: To strive to ensure residents will be safeguarded and protected from any form of abuse, . Reporting: . 1. Anyone who finds injury of unknown origin must immediately report the incident. 2. Anyone who witnesses and/or suspects an incident of resident abuse (verbal, sexual, mental, or physical), neglect, mistreatment, exploitation, involuntary seclusion, and misappropriation of property must immediately report the incident. 4. The executive director, administrator, or designee will take the following actions: A. Notify the appropriate state agency immediately (within 24 hours .) . Three allegations of abuse that were facility-reported to the State Agency were reviewed. The allegations revealed the following: 1) An allegation of Physical Abuse with the alleged occurrence date and time of 12/09/17 at 10:30 a.m. was submitted to the Alabama Department of Public Health on 12/10/17 at 10:49 a.m. 2) An allegation of Physical Abuse with an alleged occurrence date and time of 12/17/2017 at 12:00 p.m. was submitted to the Alabama Department of Public Health on 12/20/17 at 9:40 a.m. 3) An allegation of Verbal Abuse with an alleged occurrence date and time of 1/29/18 at 7:00 p.m. was submitted to the Alabama Department of Public Health on 1/30/18 at 12:46 p.m. 03/01/18 8:14 a.m., an interview was conducted with EI (Employee Identifier) #2, the Administrator. EI #2 was asked what was the regulation requirement for reporting alleged abuse. EI #2 replied if there was willful physical abuse they had a two hour window to report. EI #2 said with all other reportable concerns, they had 24 hours. EI #2 stated he was the Abuse Coordinator so he was responsible for getting the reports done per policy. EI #2 was asked who reviewed and revised policy and procedures. EI #2 replied it was done at the corporate level. EI #2 stated he learned about it at meetings and when new policies were sent out. EI #2 said the two hour rule was just an over-site by all of them. EI #2 stated he knew there was a new two hour regulation for reporting. EI #2 continued and said he really did not read the new revision that closely. An interview was conducted on 03/01/18 at 2:45 p.m. with EI #3, the Regional Director of Nursing. EI #3 was asked what was the required time frame for reporting allegations of abuse. EI #3 replied their policy was based on the Elder Justice Act. This surveyor explained the question was about abuse and not a crime. EI #3 was asked again what was the required reporting time for alleged abuse. EI #3 replied it was 24 hours. EI #3 then called the Clinical Supervisor and returned a call to this surveyor. EI #3 said she was told by the Clinical Supervisor they missed it, they all missed it, (all DON's, Corporate Compliance, and Corporate Regulatory). EI #3 said they missed the word or. EI #3 was asked who and how were polices reviewed and revised. EI #3 replied the Regional DONs review and revise policy and procedure. Once the revision was completed the policy/procedure was reviewed by Corporate Compliance then the Corporate Regulatory Department reviewed the policy/procedure before releasing the new or revised policy/procedure to the facility. EI #3 stated as she said, they (Regional DON, Corporate Compliance and Corporate Regulatory) all missed it (the language for the two hour reporting period for all alleged abuse). EI #3 was asked if the changes were introduced to the QAPI (Quaility Assurance/Performance Improvement) Committee and to the Governing Body. EI #3 replied no not the way they should have been. EI #3 was asked should the QAPI Committee and Governing Body have been made aware of the new regulatory requirements of reporting all alleged abuse in two hours. EI #3 replied yes.

Based on interviews, the Abuse Policy, and Alleged Abuse Reports submitted to the State Agency from 11/17 to 02/18, the facility failed to ensure the Administrator, who was responsible for the overall management of the facility, and the Director of Nursing, who was responsible for the overall management of the Nursing Department, ensured the facility reported alleged abuse of three residents within the two hour required time period. This affected RI (Resident Identifier) #4, #5, and RI #15, three of three residents named in alleged abuse incidents from 11/17 through 2/18, and had the potential to affect all residents involved in abuse allegations residing at the facility. Findings Include: A review of the facility's policy titled, SUBJECT: ABUSE, NEGLECT, INVOLUNTARY SECLUSION, EXPLOITATION, AND MISAPPROPRIATION OF PROPERTY PREVENTION with a revision date of 11/17, revealed: POLICY: To strive to ensure residents will be safeguarded and protected from any form of abuse, . PURPOSE: The purpose of this policy is to promote the maintenance of a living environment that fosters the reporting of concerns/problems and protects residents; preserving their dignity and quality of life . Reporting: . 1. Anyone who finds injury of unknown origin must immediately report the incident. 2. Anyone who witnesses and/or suspects an incident of resident abuse (verbal, sexual, mental, or physical), neglect, mistreatment, exploitation, involuntary seclusion, and misappropriation of property must immediately report the incident. 4. The executive director, administrator, or designee will take the following actions: A. Notify the appropriate state agency immediately (within 24 hours .) . A review of Abuse allegations submitted by the facility to the State Agency revealed: An allegation of physical abuse with the alleged occurrence date and time of 12/09/17 at 10:30 a.m. was submitted to the Alabama Department of Public Health on 12/10/17 at 10:49 a.m. An allegation of physical abuse with an alleged occurrence date and time of 12/17/17 at 12:00 p.m. was submitted to the Alabama Department of Public Health on 12/20/17 at 9:40 a.m. An allegation of verbal abuse with an alleged occurrence date and time of 1/29/18 at 7:00 p.m. was submitted to the Alabama Department of Public Health on 1/30/18 at 12:46 p.m. On 02/28/18 at 4:18 p.m., an interview was conducted with EI (Employee Identifier) #1, the DON (Director of Nursing). EI #1 was asked what was the facility's policy regarding reporting allegations of abuse. EI #1 replied the abuse policy was any suspicion of any type of abuse should be reported immediately by the staff to a supervisor or the Abuse Coordinator. If there was bodily injury, they have to report to the State Agency within two hours. EI #1 added other than that, they have 24 hours to report all other allegations. EI #1 was given a copy of the facility's Abuse Policy to review and was asked where the above information mentioned was located. EI #1 stated the policy provided was not the policy on the reporting times and that it was in another policy. EI #1 provided the policy related to reporting times. However, the policy provided to the surveyor was in regards to crimes related to the elderly. The policy did not include the required two hour reporting of abuse. EI #1 was asked if the facility had reported any allegations of abuse in the past twelve months. EI #1 replied yes they had. The surveyor gave EI #1 copies of the allegations of abuse for (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR). EI #1 was asked had the facility met the requirement of the reporting of abuse. EI #1 replied no. EI #1 was asked why the allegations of abuse were not reported within two hours. EI #1 replied there was confusion with the new regulations about the two hour time frame. EI #1 added they thought they still had 24 hours, unless there was serious bodily injury. EI #1 was asked who was responsible for reporting alleged abuse to the State Agency. EI #1 replied the Administrator and herself, the DON. An interview was conducted on 03/01/18 at 8:14 a.m. with EI #2, the Administrator. EI #2 was asked what the facility's abuse policy indicated regarding the reporting of alleged abuse. EI #2 replied with the new regulation there was a new requirement that with willful physical abuse they had a two hour window to report to the State Agency. EI #2 added with all other reportable concerns they had 24 hours to report. EI #2 reported he was the Abuse Coordinator, so he was responsible to get the reports done per policy. EI #2 was asked if the facility had any allegations of abuse in the past twelve months that had been reported to the State Agency. EI #2 replied yes. EI #2 was asked how many and he replied six, with only three occurring since the new regulations went into place. EI #2 was asked to review each of the three allegations reported since the new regulation became effective (MONTH) 28, (YEAR). EI #2 stated all three allegations were related to alleged abuse, were reported immediately to a supervisor, and reported within 24 hours to the State Agency. EI #2 was asked if the facility was in compliance with the new reporting requirement of reporting all alleged abuse within two hours. EI #2 replied no. EI #2 was asked if he knew about the new regulation of reporting all alleged abuse within two hours. EI #2 replied yes, but it had to be willful physical abuse to be reported in the two hour regulation. EI #2 said he was aware the regulations were changed in (MONTH) of (YEAR) to the two hour rule for an allegation of willful intent of abuse. EI #2 stated it was his understanding as he said above, policies on abuse were reviewed with him with the changes also. EI #2 was asked who reviewed the abuse policy and changes with the QAPI (Quality Assurance and Performance Improvement) committee at the meeting on 12/17. EI #2 replied he did, (the Administrator) and EI #3, the Regional Director of Nursing. EI #2 stated he just assumed the two hour rule was in the revision, he did not read it all.

Based on interviews, review of abuse allegation files, and the review of a facility policy titled, Abuse, Neglect ., the facility failed to ensure three allegations of abuse were reported to the State Agency within two hours of being reported by staff to the administration. This affected RI (Resident Identifier) #4, #5, and #15, three of three residents named in allegations of abuse the facility reported to the State Agency and had the potential to affect all residents involved in abuse allegations residing in the facility. Findings Include: A review of the facility's policy titled, SUBJECT: ABUSE, NEGLECT, INVOLUNTARY SECLUSION, EXPLOITATION, AND MISAPPROPRIATION OF PROPERTY PREVENTION, with a revision date of 11/17, revealed: POLICY: To strive to ensure residents will be safeguarded and protected from any form of abuse, . PURPOSE: The purpose of this policy is to promote the maintenance of a living environment that fosters the reporting of concerns/problems and protects residents; preserving their dignity and quality of life . Reporting: . 4. The executive director, administrator, or designee will take the following actions: A. Notify the appropriate state agency immediately (within 24 hours) . Three allegations of abuse that were facility-reported to the State Agency were reviewed. The allegations revealed the following: 1) An allegation of Physical Abuse with the alleged occurrence date and time of 12/09/17 at 10:30 a.m. was submitted to the Alabama Department of Public Health on 12/10/17 at 10:49 a.m. 2) An allegation of Physical Abuse with an alleged occurrence date and time of 12/17/17 at 12:00 p.m. was submitted to the Alabama Department of Public Health on 12/20/17 at 9:40 a.m. 3) An allegation of Verbal Abuse with an alleged occurrence date and time of 1/29/18 at 7:00 p.m. was submitted to the Alabama Department of Public Health on 1/30/18 at 12:46 p.m. On 02/28/18 at 4:18 p.m., an interview was conducted with EI (Employee Identifier) #1, the DON (Director of Nursing). EI #1 was asked what was the facility's policy regarding reporting allegations of abuse. EI #1 replied the abuse policy indicated any suspicion of any types of abuse should be reported immediately by the staff to a supervisor or the Abuse Coordinator. EI #1 further stated if there was bodily injury they (facility) had to report it within two hours. EI #1 was asked if the above allegations of abuse were reported as the regulation required within two hours and EI #2 replied no. An interview was conducted on 03/01/18 at 8:14 a.m. with EI #2, the Administrator. EI #2 was asked what the facility's abuse policy indicated regarding the reporting of alleged abuse. EI #2 replied with the new regulation there was a new requirement that with physical abuse they had a two hour window to report it and all other reportable issues they had 24 hours to report. EI #2 stated he was the Abuse Coordinator and he was responsible for completing the reports per policy. EI #2 was asked if the facility had any allegations in the past twelve months that had been reported to the State Agency. EI #2 replied yes. EI #2 was asked how many and he replied six, but only three since the new regulations went into place. EI #2 was asked to review each of the three allegations reported since the new regulation became effective (MONTH) 28, (YEAR). EI #2 stated all three allegations were related to alleged abuse, were reported immediately to a supervisor, and reported within 24 hours to the State Agency. EI #2 was asked if the facility was in compliance with the new reporting requirement of reporting all alleged abuse within two hours. EI #2 replied no. EI #2 was asked if he knew about the new regulation of reporting all alleged abuse within two hours. EI #2 replied yes, but it had to be willful physical abuse to be reported in the two hour regulation. EI #2 said he was aware the regulations were changed in (MONTH) of (YEAR) to the two hour rule for an allegation of willful intent of abuse. An interview was conducted on 03/1/2018 at 2:45 p.m. with EI #3, the Regional Director of Nursing. EI #3 was asked what was the required time frame for reporting allegations of abuse. EI #3 replied their policy was based on the ELDER JUSTICE ACT. This surveyor explained the question was about abuse and not a crime. EI #3 was asked again what was the required reporting time for alleged abuse. EI #3 replied it was 24 hours. EI #3 then called the Clinical Supervisor and was told by the Clinical Supervisor, We missed it, we all missed it. All DON's, Corporate Compliance, and Corporate Regulatory. We missed the word or which makes all alleged abuse reportable within two hours.

Based on interviews and a review of POTTER/PERRY, FUNDAMENTALS OF NURSING the facility failed to ensure the documents of an abuse investigation were complete and correct as evidenced by forms with no dates, times, and incorrect dates. This was revealed in one of three allegations of abuse reported to the State Agency and affected RI (Resident Identifier) #4, one of three reports reviewed for alleged abuse. Findings Include: A review of POTTER/PERRY, FUNDAMENTALS OF NURSING, 9TH EDITION, Chapter twenty-six, Documentation, page 361, revealed: .Guidelines for Quality Documentation, . High quality documentation is necessary to enhance efficient, individualized patient care. Quality documentation has five important characteristics: it is factual, accurate, complete . Accurate . you need to date and time all entries in medical records and there needs to be a method to identify the author of all entries. A review of the allegation of abuse report for RI #4 revealed the following: A facility form titled, Incident Report Residents & (and) Visitors had an entry space for the date and time at the top of the form. The entry date on the form was 12/9/17, with a time entry of 10:30 (the Administrator stated he entered the time, the nurse did not). The form required additional resident information, such as name, room number, record number, diagnoses, medications, and information related to the incident, such as what happened to the resident, if the incident was witnessed and by whom, and who was notified about the incident. At the bottom of the form there was a place for the signature of the author, Person/title Preparing Report: (signed by the nurse completing the form). DATE: (ACTUAL DATE WRITTEN IN) 8/9/17. There was a hand written document in the file, written by the same nurse who signed the incident report, with a date of 12/9/17 and a time of 1:50 (did not indicate a.m. or p.m.). In this allegation of abuse file for RI #4, there was a witness statement dated 10/9/17. In addition, another witness statement was dated at the top of the form 12/9/17 and at the bottom of the page dated 12/10/17. A review of the nursing notes for RI #4 for 12/9/17, revealed a time entry of 4:00 p.m. by the R.N. (Registered Nurse) supervisor who reported the allegation of abuse to the Abuse Coordinator. A review of all nursing documentation for RI #4 was reviewed for 12/9/17 and there were no other entries made for 12/9/17. On 2/28/18 at 11:49 a.m. an interview was conducted with EI (Employee Identifier)#7, a LPN (Licensed Practical Nurse). EI #7 was the charge nurse working on the 7-3 shift on 12/9/17, when the alleged physical abuse was observed and reported. EI #7 was asked if EI #6, a CNA, reported anything to her on 12/9/17, regarding RI #4, the resident listed in the abuse allegation. EI #7 replied yes. EI #7 stated that EI #6 reported RI #4 was slapped in the face by a visitor. EI #7 was asked what was done. EI #7 replied EI #6 (CNA) was instructed to report the incident to the Supervisor on the shift. EI #7 also stated the incident was reported by her to the Supervisor. EI #7 was asked what time the incident occurred. EI #7 replied it was in the morning. EI #7 was asked where the documentation of EI #6's report to her was located. EI #7 replied it was not documented. On 02/28/18 at 2:01 p.m., an interview was conducted with EI #6. EI #6 was asked to look at the witness statement she completed. EI #6 stated the statement was her writing, however, the date entry did not look like her hand writing. EI #6 stated she wrote the statement but she did not know if she could say she put the date on the form at the top. EI #6 said the statement was brought back to her to date and she dated the statement at the bottom by her name. On 2/28/18 at 4:18 p.m., the surveyor asked EI #1, DON (Director of Nursing) to look at RI #4's 12/9/17 allegation of abuse investigation report. EI #1 was asked if she saw anything unusual about the documents in the report. EI #1 replied yes the dates were all over the place. EI #1 stated the report should have been checked more carefully for correctness, completeness, full dates and times on reports. On 03/01/2018 at 11:30 a.m., EI #2, the Administrator, was asked to look at the abuse allegation file for RI #4. EI #2 was asked if he saw anything that was a possible concern to him in the file. EI #2 stated the CNA (EI #6) changed her story a little. EI #2 was asked about the dates and times on the different documents in the file. EI #2 replied he entered this 10:30 time on the incident report. EI #2 was asked where he obtained that time and EI #2 could not determine the answer to the question. An interview was conducted with EI #3, the Regional DON, at 2:45 p.m. on 03/01/2018 related to the documentation issues in RI #4's alleged abuse file. EI #3 was asked if she had reviewed this file and she replied no, however, she should have before it was sent to anyone. EI #3 stated documentation was to be complete and accurate on all forms to include dates and times with the signature of the person documenting.

Based on observation, interview, and review of a facility policy titled, POSTING OF NURSING STAFF INFORMATION, the facility failed to ensure staff posting was not completed on all shifts prior to the shift worked. This was observed on two of four survey days and had the potential to affect all residents in the facility. Findings Include: A review of a facility policy titled, POSTING OF NURSING STAFF INFORMATION, with a revision date of 7/16, revealed: POLICY: To strive to post staffing information as scheduled for a twenty four (24) hour period. PR[NAME]EDURE: .2. The information should be posted at the beginning of each shift, with any needed changes made as soon as possible. On 2/27/18 at 12:50 P.M., the DAILY NURSE STAFFING FORM was observed in a plastic stand at the nurses station with the total hours of all three shifts filled out completely. Included on the staffing form was the number of RNs (Registered Nurse), LPNs (Licensed Practical Nurse), and CNAs (Certified Nursing Assistant) for night shift, day shift, and evening shift with scheduled hours worked included. On 2/28/18 at 7:30 A.M., the DAILY NURSE STAFFING FORM was observed in a plastic stand at the nurses station. All shifts were filled in with numbers of each staff (RNs, LPNs, CNAs) and scheduled hours worked also filled out. On 2/28/18 at 9:31 A.M., an interview was conducted with EI (Employee Identifier) #1, DON (Director of Nursing). EI #1 was asked who was responsible for posting the Daily Nurse Staffing Form and she stated she typed it up. EI #1 stated the CNA who did the staffing gave her the weekly break down of staffing and then she (EI #1) placed it in the computer. EI #3 was asked when was the Daily Nurse Staffing Form completed. EI #1 stated the CNA gave it to her on Monday and she (EI #1) completed the staffing form for Tuesday through Friday and then placed it at the nurses station so everyone could see it. EI #1 was asked what did the facility's policy indicate regarding the posting of the nurse staffing form and she stated it was supposed to be done daily. EI #1 further stated the schedule was done a month ahead and for the weekends, the CNA gave it to her on Friday and she (EI #1) did the staffing form for Saturday, Sunday, and Monday. EI #1 was asked what was the regulatory requirement for posting of nursing staff daily and she stated she did not know. EI #1 was asked if the Nursing Staffing Form was completed for the whole day for all three shifts prior to the shifts being worked. EI #1 stated yes, she filled it out before the next shift, it was completely filled out for all shifts.

Based on an interview and record reviews, the facility failed to ensure new employees were screened for abuse prior to hire. This was identified in 56 of 88 personnel files reviewed of newly hired employees. Findings include: A review of the facility's Policy and Procedure titled, ABUSE POLICY, dated 9/04/15, revealed, . Screening: All prospective employees are required to complete a background check and drug screen prior to employment. The screening also includes verification of valid professional credentials and whether or not the prospective employee is or has been listed on the Alabama Nurse Aide Abuse Registry. On 11/05/2015, personnel files of employees hired between October 2, 2014 and November 05, 2015 were reviewed. The record reviews revealed 56 employees had not been pre-screened against the Abuse Registry prior to employment. These staff members included RNs (Registered Nurses), LPNs (Licensed Practical Nurses), CNAs, Housekeeping staff, and Dietary staff. On 11/05/2015 at 5:50 PM, an interview was conducted with EI #1, Director of Nursing/Abuse Coordinator. EI #1 was asked who was responsible for screening employees for abuse. EI #1 stated, Initial screen(ing) is (done by) the HR (Human Resource) Director. EI #1 was asked when potential new hires should be screened for abuse. EI #1 stated, Prior to hire during the background (check). EI #1 was asked how abuse screenings were checked. EI #1 stated, Background check, ABN(Alabama Board of Nursing), and ADPH(Alabama Department of Public Health) CNA (Certified Nursing Assistant) registry. EI #1 was asked what was the purpose of screening for abuse. EI #1 stated, (To) keep our residents safe. EI #1 was asked why the abuse registry was not checked prior to hire. EI #1 stated, I don't know. EI #1 was asked what was the potential harm of not screening for abuse prior to hire. EI #1 stated, We could hire someone who has abused someone and put our residents at harm. EI #1 was asked who was responsible for monitoring to ensure the abuse registry screenings were being performed. EI #1 stated, I would assume the HR (Human Resources) Department. EI #1 was asked what was the facility's policy in regards to screening for abuse. EI #1 stated, That you are screened before hire. The surveyor was not able to interview the HR Director because she was out on sick leave.

Based on an observation, interview, and record reviews, the facility failed to ensure: RI (Resident Identifier) #5 was instructed to rinse their mouth with water after being administered an [MEDICATION NAME] Diskus inhalation treatment on 11/4/2015. This affected RI #5, one of eleven residents observed for medication pass. Findings include: A review of a document titled, .HIGHLIGHTS OF PRESCRIBING INFORMATION . revised: 7/2014 REVEALED: .INDICATIONS AND USAGE [MEDICATION NAME] DISKUS is a combination product containing a corticosteroid and . WARNINGS AND PRECAUTIONS . [MEDICAL CONDITION][MEDICATION NAME] infection of the mouth and pharynx may occur. Monitor patients periodically. Advise the patient to rinse his/her mouth with water without swallowing after inhalation to help reduce the risk. A review of the medical record for RI #5 revealed the resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #5's physician's orders [REDACTED]. .[MEDICATION NAME] 250-50 DISKUS INHALE ONE (1) PUFF BY MOUTH TWICE DAILY, Rinse mouth after each administration . On 11/4/15 at 8:10 AM, a medication pass was observed for RI #5 by EI (Employee Identifier) #2, an LPN (Licensed Practical Nurse). EI #2 was observed to administer the resident the [MEDICATION NAME] inhaler. EI #2 did not instruct RI #5 to rinse their mouth after the medication was administered. On 11/4/15 at 1:05 PM, an interview was conducted with EI #2. EI #2 was asked what was the procedure for administering an [MEDICATION NAME] Diskus inhalation treatment to a resident. EI #2 stated, Wipe it off, the top with a tissue. Put it on a barrier, lay it down, and the final step is to rinse their mouth . EI #2 was asked if she instructed RI #5 to rinse their mouth out with water after the administration of the medication on 11/4/15. EI #5 stated, I hope I did. I think I did. Did I. The surveyor and EI #2 discussed the above observation. EI #5 was asked what was the concern when a resident did not rinse their mouth after [MEDICATION NAME] was administered. EI #5 stated, They can get ulcers in their mouth. They can get sores.

Based on observations, interview, and document reviews, the facility failed to ensure food was stored, prepared, and served in a manner to prevent the potential for cross-contamination and food borne illness by the following: 1. Thermometers were not inside of the walk-in freezer on 2 of 3 survey days, and a thermometer was not in the walk-in cooler on 1 of 3 survey days. 2. The ice cream was not frozen solid on 3 of 3 survey days. 3. Wet nesting was observed on 3 of 3 survey days. 4. A dietary staff member was observed with hair exposed while handling food on the lunch tray line observation on 10/1/14. 5. An electric cord was observed on top of the open plate warmer during the lunch tray line on 10/1/14. These deficiencies had the potential to affect 54 residents served meals from the kitchen. Findings include: 1. Thermometers: A review of the US FDA (United States Food and Drug Administration) Food Code with the copyright date of 2013, revealed, "4-204.112 Temperature Measuring Devices. (A) In a mechanically refrigerated or hot FOOD storage unit, the sensor of a TEMPERATURE MEASURING DEVICE shall be located to measure the air temperature or a simulated product temperature in the warmest part of a mechanically refrigerated unit and in the coolest part of a hot FOOD storage unit. (B) Except as specified in ? (paragraph) (C) of this section, cold or hot holding EQUIPMENT used for TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be designed to include and shall be equipped with at least one integral or permanently affixed TEMPERATURE MEASURING DEVICE that is located to allow easy viewing of the device's temperature display..." During the tour on 9/30/14 at 11:33 AM, no thermometer was observed in the walk-in cooler. During the tour on 9/30/14 at 11:35 AM, no thermometer was observed in the walk-in freezer. On 10/1/14 at 10:50 AM, no thermometer was observed in the walk-in freezer. EI (Employee Identifier) #8, the executive Chef in the dietary department, was asked should the walk-in cooler and freezer have thermometers. EI #8 said thermometers had not been in the walk-in freezer or cooler since she started working in the kitchen, but she had some on order. An interview was conducted on 10/2/14 at 1:15 PM, with EI #9, the facility's Registered Dietitian. The surveyor asked EI #9 what the concern was, when thermometers were not inside the walk-in cooler and walk-in freezer. EI #9 said it was always good to have an internal thermometer, because the outside thermometer could give a false reading. EI #9 said if there was a malfunction, staff would know sooner, with the internal thermometer, the actual temperature of the food inside. 2. Ice Cream: A review of the US FDA Food Code with the copyright date of 2013, revealed: "Temperature and Time Control 3-501.11 Frozen Food; Stored frozen foods shall be maintained frozen." During the tour on 9/30/14 at 11:35 AM, containers of ice cream were not frozen solid. One of the containers had a deep indentation when squeezed by the surveyor. On 10/1/14 at 10:55 AM, a second observation of the containers of the ice cream in the walk in freezer was made. A container of ice cream was soft and the top lifted when the container was squeezed on the sides. EI #8, was given the container of soft ice cream. EI #9 observed the container of soft ice cream. On 10/2/14 at 9:06 AM, a third observation of soft ice cream in the walk-in freezer was made. EI #9 was present during the observation. An interview was conducted on 10/2/14 at 1:15 PM, with EI #9. The surveyor shared the observation of the soft ice cream on 3 of 3 survey days. EI #9 said the ice cream should have been a little more firm. The surveyor asked EI #9 how should items be stored in the freezer. EI #9 said it should be frozen solid. 3. Wet Nesting: A review of the US FDA Food Code with the copyright date of 2013, revealed: "Drying 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and sanitizing, equipment and utensils: (A) Shall be air-dried or used after adequate draining... before contact with food; ..." During a tour of the kitchen on 10/30/14 at 11:41 AM, four of five pans were observed stacked wet near the tray line, with water droplets on the surface. EI #9 observed the wet nesting. On 10/1/14 at 8:45 AM, two of three large cooking sheet pans were observed stacked on a shelf, wet with water on their surface. EI #9 observed the wet nesting. On 10/2/14 at 9:10 AM, 8 of 8 large cooking sheet pans were observed stacked and were dripping wet on a shelf. EI #9 was present during the observation. An interview was conducted with EI #9 on 10/2/14 at 1:15 PM. The surveyor discussed the observation of wet nesting observed on three of three survey days. EI #9 was asked what was the concern when wet nesting was observed in the kitchen. EI #9 stated, "The moisture can allow potential bacteria or mold to grow." 4. Hair exposed: A review of the US FDA (United States Food and Drug Administration) Food Code with the copyright date of 2013. revealed: "Hair Restraints 2-402.11...FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings, or nets, beard restraints, and clothing that covers body hair..." During the lunch tray line observation on 10/1/14 at 11:33 AM, EI #8 added pork chops to the tray line, and obtained a temperature of the meat. EI #8 was wearing a hat that covered the top and sides of her hair. However, one third of her hair was exposed in the back from ear to ear. EI #8 had her hair pulled back in to a ball that was not covered. An interview was conducted with EI #9 on 10/2/14 at 1:15 PM. The surveyor asked EI #9 what the concern was when hair was not completely covered in the kitchen. EI # 9 stated, "Direct food handling and servicing, we would like for it to be fully covered." The surveyor asked EI #9 what was the concern when hair was not completely covered while handling food and taking food temperatures on the tray line. EI #9 stated, "It can fall into the food and cause a contaminant." 5. Plate Warmer: During the lunch tray line on 10/1/14 at 11:40 AM, the electrical cord to the plate warmer was observed on top of the opened plate warmer. The cook moved the electrical cord, and it fell in to the plate warmer. EI #9 caught the electrical cord before it touched the plates. During the interview with EI #9 at 1:15 PM, the surveyor asked what was the concern when the electrical cord was observed on top of the open plate warmer. EI #9 stated, "It was on the floor. It did fall into the warmer, but I caught it before it touched anything. That is a hard one to manage. It is a tripping hazard if it is left on the floor."

The facility failed to ensure licensed nurses washed their hands in a manner to prevent the potential for cross-contamination, by turning off water faucets with their wet, bare hands. This had the potential to affect RI (Resident Identifier) #'s 1, 3, 9, and 10, four of twelve sampled residents. Findings include: A review of Potter and Perry Fundamentals of Nursing 7th Edition, revealed, "... Skill 34-1 HAND HYGIENE ... STEPS ... l. Turn off water with foot or knee pedals. To turn off hand faucet, use clean, dry paper towel: avoid touching handles with hands ..." A review of the facility's document titled, "Handwashing/Hand Hygiene," dated 7/1/14, revealed, "Policy This policy is to provide guidelines to employees for proper and appropriate hand washing and hygiene techniques that will aid in the prevention of the transmission of infections. Objective To prevent and to control the spread of infectious diseases. ... Steps in the Procedure ... 2. ... Do not touch fingertips to inside of sink. 3. Dry hands thoroughly with paper towels and then turn off faucets. ..." A review of the medical records revealed RI # 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #3's Admission MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 9/17/14, revealed a BIMS (Brief Interview for Mental Status) score of 13 out of a possible score of 15. This indicated RI #3 was cognitively intact for daily decision making skills. This MDS also indicated RI #3 required limited to extensive assistance with ADLs (Activities of Daily Living). On 10/1/14 at 8:15 AM, EI (Employee Identifier) #1, an LPN (Licensed Practical Nurse), was observed to administer medications to RI #3. During this medication pass, EI #1 washed her hands, rinsed her hands, and turned the water faucets off with her wet bare hands each of the three times observed. EI #1 then got paper towels and dried her hands. On 10/1/14 at 9:35 AM, EI #2, the Infection Control Nurse, performed wound care for RI #3. At the end of the wound care observation, EI #2 removed the glove from her right hand, then removed the disposable items from the over bed table and placed them in a red bag. EI #2 removed her left glove and washed her hands. EI #2 was observed to wash her hands, rinse them, then turned the water faucets off with her wet, bare hands. EI #2 then got paper towels and dried her hands. A review of the medical records indicated RI #9 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of an MDS for RI #9 with an ARD of 8/25/14, indicated RI #9 had short and long term memory problems, and was moderately impaired for daily decision making skills. This MDS also indicated RI #9 was totally dependent on staff for ADLs. On 10/1/14 at 10:15 AM, EI #1 was observed to administer crushed medications to RI #9, via Gastrostomy Tube. During this medication administration, EI #1 washed her hands 4 different times. Each time EI #1 washed her hands, rinsed them, and turned the water faucets off with her wet, bare hands. EI #1 then obtained paper towels and dried her hands. A review of the medical record revealed RI #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Significant Change MDS for RI #1 with an ARD of 7/8/14, revealed a BIMS score of 8 out of a possible score of 15. This indicated RI #1 was moderately impaired for daily decision making skills. This MDS also indicated RI #1 required total assistance with ADLs, and was incontinent of bowel and bladder. On 10/1/14 at 11:30 AM, an observation was made of EI #5, an LPN, during a medication pass for RI #1. After EI #5 administered [MEDICATION NAME] Insulin subcutaneously to RI #1, EI #5 removed her gloves and washed her hands at the resident's sink. After EI #5 rinsed her hands, she turned the water faucets off with the backs of her wet, bare hands, pulled a paper towel out of the container on the wall, dried her hands and then discarded the paper towel in the trash can. A review of the medical records revealed RI #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #10's Initial Assessment MDS with an ARD of 9/23/14, revealed a BIMS score of 15 out of a possible 15. This indicated RI #10 was cognitively intact for daily decision making skills. This MDS also indicated RI #10 required extensive assistance with ADLs. On 10/1/14 at 4:30 PM, EI #4, a Registered Nurse, was observed to administer medications to RI #10. Twice during this medication administration, EI #4 was observed to wash her hands. EI #4 rinsed her hands and turned the water faucets off with her wet bare hands. EI #4 then dried her hands with paper towels. On 10/1/14 at 5:23 PM, an interview was conducted with EI #4. EI #4 was asked how hand washing should be done, according to policy and procedure. EI #4 stated, "... Soap on hands and scrub 15 to 20 seconds, in between fingers and under nails. Rinse. Grab paper towels and dry hands, and turn the water off with paper towels." EI #4 was asked how she turned the water off during the observation at 4:30 PM, on 10/1/14. EI #4 replied, "Probably not the way I was supposed to. I turned the water off without the paper towels. I got nervous." EI #4 was asked if it was appropriate to turn the water off using wet, bare hands. EI #4 said, "No, because bacteria is on the sink handles and gets right back on your hands." EI #4 was asked what the potential harm was of turning water off with wet bare hands. EI #4 stated, "Bacteria back on your hands and transfer of bacteria to other patients, med (medication) cart, door knobs, etc (et cetera)." On 10/2/14 at 12:40 PM, an interview was conducted with EI #1. EI #1 was asked what the procedure was for hand washing, according to policy and procedure. EI #1 stated, "Water on. Lather your hands at least for 1 minute. Then rinse and dry (your hands). You should use paper towels to turn off the water faucets." EI #1 was asked how she turned the water off, during the observations on 10/1/14. EI #1 stated, "I don't think I used the paper towels to turn the water off. I was nervous." EI #1 was asked if it was appropriate to turn the water off with wet, bare hands. EI #1 stated, "No ma'am. I knew I did it as soon as I did it." EI #4 was asked why it was not appropriate. She stated, "Because that's the way germs can be transmitted back onto your clean hands." EI #1 was asked what the potential harm was of turning the water off with wet, bare hands. EI #1 stated, "You could contaminate other areas with germs on your hands. You could contaminate someone else." On 10/2/14 at 12:52 PM, an interview was conducted with EI #5. EI #5 was asked what the policy and procedure was for hand washing. EI #5 stated, "Water warm. Wet your hands and lather it up. Take as long as it takes to sing (the) happy birthday song. Rinse hands and let water run down. Dry your hands then get another paper towel and turn the water off." EI #5 was asked how she had turned the water off during observation on 10/1/14 at 11:30 AM, when she medicated RI #1. EI #5 stated, "... I probably did use the back of my hand to turn the water off. I've done that before." EI #5 was asked if it was appropriate to use the back of her wet, bare hands to turn off the water faucets. EI #5 stated, "No. Because the faucet could be contaminated and it's considered dirty." EI #5 was asked what the potential harm was of using the back of her wet, bare hands to turn off the water faucets. She replied, "You could transfer something from that faucet." On 10/2/2014 at 1:20 PM, an interview was conducted with EI #2. EI #2 was asked what the procedure was for hand washing, according to policy and procedure. EI #2 stated, "We turn on the water. Get soap and wash for 20 seconds. Then we rinse, grab a tissue and dry your hands. Use tissue to turn off the faucet." EI #2 was asked how she washed her hands during the observation of wound care for RI #3 on 10/1/14. The surveyor shared observation of the wound care, and of the last hand washing done by EI #2. EI #2 stated, "I know not to do that." EI #2 was asked if it was appropriate to turn water off with wet, bare hands. EI #2 replied, "No. Because it's an infection control thing and you will get germs back on your hands." EI #2 was asked what the potential harm was of turning water off with wet, bare hands. She replied, "Having germs on your hands and taking it somewhere else; to whatever else I touch."

Based on an observation, interviews, and record reviews, the facility failed to ensure: 1) A CNA (Certified Nursing Assistant) opened the labia during incontinence care for RI #1(Resident Identifier). 2) A CNA checked and cleaned the front of RI #1's perineal area during incontinence care. 3) A CNA changed gloves and washed her hands after removing stool from RI #1 during incontinence care. This affected RI #1, one of one resident observed for incontinence care. Findings include: A review of, "POTTER & PERRY... Fundamentals of Nursing...7th Edition...reprint 2009," revealed: "...page 655...Chapter 34 Infection Prevention and Control... 2. If hands are not visibly soiled, use an alcohol=based waterless antiseptic agent for routinely decontaminating hands in all other clinical situations:... c. After contact with body fluids or excretions, ... d. When moving from a contaminated body site to a clean body site during client care. ... h. After removing gloves..." A review of, "POTTER & PERRY... Fundamentals of Nursing...7th Edition...reprint 2009," revealed: "...page- 878 and 879...39-2...Perineal Care... 3. Apply clean gloves, ... Perform hand hygiene... 15. Provide Perineal care A. Female perineal care ... (4) Wash labia majora. Use nondominant hand to gently retract labia from thigh; with dominant hand, wash carefully in skin folds. ... (5) Separate labia with nondominant hand to expose urethral meatus and vaginal orifice. With dominant hand, wash downward from pubis area toward rectum in one smooth stroke ... 17. Remove clean gloves, dispose in proper receptacle, and perform hand hygiene...." A review of RI #1's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's Significant Change in Status, MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 7/8/14, indicated RI #1 had a BIMS (Brief Interview for Mental status) score of 8 out of a possible 15. This indicated RI #1 was moderately impaired for daily decision making. RI #1 required extensive assistance with transfers, dressing, toileting and personal hygiene. RI #1 was totally dependent on staff for bathing. RI #1 was coded as always incontinent of bowel and bladder. On 10/1/14 at 3:50 PM, an observation was made of incontinence care for RI #1. The incontinence care was performed by EI #7, a CNA. EI #7 opened the adult brief and folded it between RI #1's upper thighs. EI #1 used a disposable wipe and wiped across the top of RI #1's perineal area twice without changing the position of the disposable wipe. EI #7 obtained a clean disposable wipe and wiped the right groin in a downward motion and discarded the wipe, then wiped the left groin in a downward motion, and discarded the wipe. EI #7 did not open the labia or clean the front of RI #1's perineal area. RI #1 was rolled onto the left side and a small to moderate of stool was observed on RI #1's bottom. EI #7 wiped RI #1's buttock twice with separate disposable wipes in an upward motion. Stool was observed on both of the disposable wipes. EI #7 removed the gloves, but did not wash her hands. EI #7 obtained another disposable wipe and wiped between the buttocks cheeks from front to back. Stool was observed on the disposable wipe. EI #7 did not wash her hands or change gloves. EI #7 removed the soiled brief and placed a clean brief under RI #1's bottom. EI #7 began to secure the adult brief. The surveyor requested for EI #7 to wipe between RI #1's buttocks folds. When EI #7 wiped the resident's bottom, stool was observed on the disposable wipe. EI #7 continued to put the adult brief on RI #1, and then pulled the resident's pants up. EI #7 did not ensure all of the stool was removed from RI #1's bottom. EI #7 then washed her hands. On 10/1/14 at 4:45 PM, an interview was conducted with EI #7. EI #7 was asked how she was taught to provide incontinence care. EI #7 stated, "Wash your hands and explain the care/procedure, that you are going to do for the patient, and proceed to give care to the resident. Wash your hands and clean up the area, and wash your hands." EI #7 was asked how did she provide incontinence to RI #1 during the above observation. EI #7 stated, "I wiped RI #1 across, just under the belly. After that, I wiped down the groin area on both sides. You are always suppose to wipe from front to back because you don't want them to get a UTI (Urinary Tract Infection). I know I did not wipe down the front like I should have. I forgot to do that." EI #7 was asked when she was asked to wipe RI #1's bottom from front to back, what did she observe. EI #7 stated, "Yes, just a little bit of feces. We have to make sure to wipe between the labia, to make sure the feces is out." The surveyor asked EI #7 why she did not wipe the front or open the labia of RI #1 during incontinence care. EI #7 stated, "Well, I was just nervous to tell the truth. I probably just forgot. I was more nervous than anything." The surveyor shared the observation of the above incontinence care with EI #7. EI #7 was asked what the concern was when the disposable wipe's position was not changed with each wipe during incontinence care. EI #7 stated, "Are they really clean? You have to make sure they are really clean." EI #7 was then asked what the concern was when stool was not completely removed from the resident's bottom during incontinence care. EI #7 said the resident could get an infection. The surveyor asked EI #7 when did she wash her hands and change gloves during incontinence care for RI #1. EI#7 stated, "Before I started and when I realized RI #1 had BM (bowel movement)." EI #7 was asked when should staff wash their hands and change their gloves during incontinence care for residents. EI #7 said staff should wash their hands and change every time when cleaning BM (bowel movement). The surveyor asked what the concern was when, hands were not washed and gloves were not changed during incontinence care. EI #7 stated, "There might be BM still on the gloves." On 10/2/14 at 11:25 AM, an interview was conducted with EI #2, the Infection Control Nurse. The surveyor asked EI #2, how were staff instructed to provide incontinence care, for a female resident. EI #2 said she followed the facility's policy on perineal care. EI #2 said she had the staff members read the policy before hand, to make sure she tells staff the procedure. The surveyor asked EI #2 when should staff change position of the disposable wipe during incontinence care. EI #2 stated, "I have them throw it away or turn it over with each wipe. ...They have to have a clean side of the wipe." The surveyor asked EI #2 what the concern was, when the disposable wipe's position was not changed while cleaning stool from a resident's bottom. EI #2 stated, "It gives chance to spread bacteria." The surveyor asked EI #2 when hands should be washed during incontinence care. EI # 2 stated, "We have them (staff) wash before they start, and change gloves between taking the brief out and putting a clean one on. Then they wash their hands afterwards." EI #2 was asked what the potential harm was when the labia was not opened and cleaned during incontinence care. EI #2 stated, "It does not have to be opened as long as they (staff), wipe the front of the perineal area. They can actually, wipe without spreading the labia open." The surveyor shared to observation of the above incontinence care. The surveyor asked EI #2, what the potential harm was, when stool was not completely cleaned from a resident's bottom, during incontinence care. EI #2 stated, "There is a potential for it to dry on them (the residents), and get red areas. Stool will make you raw."

Based on observations, interview, and document reviews, the facility failed to ensure food was served in a manner to prevent the potential for cross-contamination and food borne illnesses by the following: 1. The dish machine's wash cycle was not set at the proper temperature. 2. The silverware was not properly cleaned during a dishwashing observation on 10/22/13. 3. The dietary worker dropped dish towels on the floor then put them back in to a cabinet under the tray line with clean towels. The dietary worker was observed to multitask and had the potential for cross contamination during the lunch trayline observation on 10/22/13. 4. The milk was not at the proper temperature during the tray line observation on 10/22/13. 5. The garbage can was not covered in the dish washing area on 10/23/13. 6. The pantry floor had more than a week's worth of a dark substance on 2 of 3 survey days. These deficient practices had the potential to affect 20 residents in certified beds, on the hall that meals were served from the dietary department. Findings include: 1. Dishwasher: The facility presented the manufacture's information for the dish washer in the kitchen that revealed: date 2012, "...SPECIFICATION ...OPERATING TEMPERATURES Wash (min) (minimal) 140(degree symbol) F (Fahrenheit)" On 10/22/13 at 8:50 AM, an observation of the dishwasher was done. The wash cycle temperature was 135 degrees F. On 10/22/13 at 8:53 AM, an observation of the dishwasher was done. The wash cycle temperature was 135 degrees F. On 10/22/13 at 9:15 AM, an observation of the dishwasher was done. The wash cycle temperature was 125 degrees F. On 10/23/13 at 10:17 AM, an observation of the dishwasher was done. The wash cycle temperature was 130 degrees F. A review of the facility's, "...DISHMACHINE TEMPERATURE RECORD..." revealed for the month of October 1-21, 2013: The breakfast, lunch, and dinner wash temperatures were documented at 120 degrees F. On 10/22/13, the breakfast and lunch wash temperatures were documented at 120 degrees F, but the dinner wash temperature was documented at 130 degrees. On 10/23/13 the breakfast wash temperatures was unable to be determined, because the hand writing was difficult to understand. The documentation was either 120 or 130. All of the temperatures on the October log, for the wash cycle were below the manufactures' recommendations. An interview was conducted on 10/23/13 at 2:10 PM, with EI (Employee Identifier) #5 RD (Registered Dietician). The surveyor asked EI #5 what the correct temperature was for the dishwasher. EI #5 said he thought it was between 120 and 150 degrees F. EI #5 was asked to review the manufactures' guidelines that revealed the wash cycle temperature should be 140 degrees F. The surveyor shared the observations of the dishwashing temperatures for 2 of 3 survey days. EI #5 was asked what the potential negative outcome was when the dishwashing temperatures were not at the correct temperature. EI #5 said it could interfere with the chemicals and the dishes would not be able to be properly cleaned. 2. Silverware/Flatware: A review of the facility's policy entitled, "Section: SANITATION AND INFECTION CONTROL Subject: REQUIRED CLEANING AND SANITIZATION" with a revision date of 11/09, revealed: "...Flatware shall be washed, rinsed, and sanitized three times...Separate forks, knives, and spoons in new cylinder with handles facing down in flatware cylinders. Run through machine again. Place forks, knives, and spoons in new cylinder with handles facing up and run through dish machine for a third time. ..." During an observation 10/22/13 at 9:15 AM, the dietary worker sprayed the silverware in a rack, and ran it through the dish machine. He performed the steps twice. The worker then placed the silverware in a cylinder with the handles up and ran it through the dish machine. The worker said they would now be allowed to dry. The surveyor asked if the silverware would be sent through with the handles down then sent through with the handles up, and the response was, no. The surveyor observed cleaned silverware in a cylinder air drying and a spoon was observed soiled with a smeared substance. EI #5 and the executive chef of the facility were present during the observation. An interview was conducted on 10/23/13 at 2:10 PM, with EI #5. The surveyor asked EI #5 what the process for cleaning silverware was. EI #5 explained, "Put it in the sanitizing solution, put it flat and run it through the dish washer times 3, then rack it with the handles up then down and run it each time through the dish washer." The surveyor shared the concern regarding the dietary worked who was not aware the silverware needed to be sent through the dish machine with the handles down, then up and allowed to air dry. EI #5 was asked what the potential negative outcome was when silverware was not cleaned properly. EI #5 said sanitizer could remain on the silverware and the potential for a dirty surface could cause cross contamination. 3. Cross Contamination: A review of the facility's policy entitled, " Section: SANITATION AND INFECTION CONTROL Subject: DISPOSABLE GLOVE USE" with a revision date of 3/11, revealed: "...Disposable gloves must be changed when dirty or ripped and when moving from one task to another. Hands must be washed ... after removing disposable gloves. ..." A review of the facility's policy entitled, "Section: SANITATION AND INFECTION CONTROL Subject: HAND HYGIENE" with a revision date of 11/09, revealed: "POLICIES: In the Food & Nutrition Services department: All employees associated with the handling of food shall wash hands. Hands are washed with soap and water at the following times: ...After touching hair, skin, beard or clothing ...After any other activity that may contaminate the hands..." During the tray line observation on 10/22/13 the following observations were made: At 11:05 AM, a dietary worker, EI #6 dropped the dish towels on the floor then put them back in the cabinet under the trayline with the other clean towels. EI #5 removed the dish cloths that were dropped on the floor but neither staff cleaned the surface where the contaminated towels were placed in the cabinet. EI #6 did not wash her hands or change her gloves. At 11:10 AM, EI #6 left the trayline and was observed to fill bowls of chilled strawberry soup. She wiped the edges of the bowls with a dish towel then placed the towel on various areas of the tray with bowls of soup. EI #6 wiped her gloved hands on the towel then placed it back on the tray with the soup bowls. EI #6 did not wash her hands or change her gloves. At 11:15 AM, EI #6 went over to the trayline and took the temperature of the pureed lima beans. She did not sanitize the thermometer prior to taking the temperature. EI #6 then placed 2 towels on the tray line. One of the towels was placed in front of the stir fried vegetables and the second towel was placed in front of the pureed items. EI #6 then draped a towel over her uniform tie. EI #6 was observed to wipe her gloved hands on the towel draped over her uniform tie. At 11:30 AM, one of the towels in front of the pureed items was observed hanging over the edge of the pureed stir fried vegetables. The other towel on the trayline was observed to touch 2 of the stir fried items (broccoli and a Chinese green bean). At 11:37 AM, EI #6 dropped a tray card on the floor, picked it up and placed it on the trayline table. She did not change her gloves or wash her hands. At 11:40 EI #6 used the same contaminated gloves that she used to pick up the tray card from the floor to pick up plates. Her contaminated gloved hands were observed to touch the inside of the plates prior to plating the food. This observation was observed on the regular and sectional plates. At 11:40 AM, EI #6's gloves were wet and stuck to her hands. At 11:45 AM, the worker who was observed to cover the food on the trayline was observed in and out of the cooler to obtain various items to place on the trayline. This dietary worker was observed to reach into the insulated tops with the same gloves used to go in and out of the cooler. At 11:45 AM, the towel in front of the stir fried vegetables was observed hanging over the edge of the container. EI #6 was observed to lean and used her gloved hands in a walking motion, to move down the trayline table. At 11:50 AM, EI #6 was observed to adjust her glasses twice and continued to plate the resident's food. She was perspiring on her face. She did not wash her hands or change her gloves. During the above observations the workers multitasked with contaminated gloved hands. An interview was conducted on 10/23/13 at 2:10 PM, with EI #5. The surveyor shared the above observations with him then asked what the potential negative outcome of the observations was. EI #5 said, "Cross contamination." The surveyor asked EI #5 what the concern was regarding the worker who put the towels that she dropped on the floor, back into the cabinet with the clean towels under the trayline. EI #5 said you could not differentiate from the clean and dropped items on the floor, and the dropped towels could be used and contaminate other surfaces. 4. Improper Milk Temperature: A review of the "Food Code U.S. Public Health Service FDA 2005", revealed, "2-501.16 Potentially Hazardous Food (Time/Temperature Control for Safety Food), Hot and Cold Holding... (2) At a temperature specified in the following: (a) 5(Degree symbol) C (Celsius) (41 (degree symbol)F) or less..." During the lunch trayline observation on 10/22/13 at 11:00 AM, the temperature of the milk on the trayline was 44 degrees F. The milk was removed from the cooler near the trayline. The outside temperature of the cooler was 42 degrees F. An interview was conducted on 10/23/13 at 2:10 PM, with EI #5. The surveyor asked EI #5 what the temperature of the milk should be on the trayline. EI #5 stated, "Below 41." The surveyor asked EI #5 if he remembered the temperature of the milk during the trayline observation. EI #5 said, "I believe it was 44." The surveyor asked EI #5 where the milk was stored during the trayline. EI #5 said in the cooler beside the trayline. When the surveyor asked EI #5 what was the concern when milk was not at the proper temperature on the trayline, EI #5 said if the temperature was at the danger line it could cause bacteria, and the residents could become sick. EI #5 said the concern with the milk was addressed because it was reading warmer the day of the interview and they placed the milk on ice to help correct the problem. 5. Uncovered Garbage Can: On 10/23/13 at 10:40 AM, the garbage can in the dishwashing area was not covered. The top of the garbage can was lying on top of another garbage can. No staff was in the area. No dishwashing was in process. An interview was conducted on 10/23/13 at 2:10 PM, with EI #5. The surveyor asked EI #5 what was the concern with the above observation. EI #5 said if someone bumped into the uncovered can it could spill over and contaminate the area. 6. Dirty Pantry Floor: During the tour on 10/21/13 at 10:20 AM, the pantry floor was observed to be dirty. On 10/23/13 at 10:15 AM, the pantry floor remained soiled with more than a week's worth of a dark substance with tracks of foot prints. An interview was conducted on 10/23/13 at 2:10 PM, with EI #5. The surveyor shared the observation of the pantry floor that was soiled on 2 of 3 survey days. The surveyor asked what was the concern with the observations. E #5 said insects could be attracted and eat into the food.

Based on observation, interviews and record reviews, the facility failed to ensure that RI (Resident Identifier) #9 did not complain of having long, ugly toenails during an observation of the resident's toenails on 10/23/2013. Also, the facility failed to ensure RI #9's toenails were cut in 3 to 8 months as stated by her spouse, during an interview. This affected RI #9, 1 of 3 residents interviewed during the survey. Findings include: 1) RI #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a quarterly MDS (Minimum Data Set) for RI #9 with an Assessment Reference Date of 10/10/13 revealed, RI #9 was coded as having a BIMS (Brief Interview for Mental Status) score of 11 out of a possible 15. This score indicated RI #9 was moderately impaired for cognitive function. RI #9 was coded as being totally dependent on staff for locomotion, on and off the unit. RI #9 required limited assistance for dressing and personal hygiene, and extensive assistance for bathing. A review of RI #9's Physicians Orders revealed an order to "Trim finger and toe nails monthly on the 7th 3-11 shift." A review of RI #9's Care Plan with a start date of 07/29/2013 notes the following: "Nail Care Daily as needed; trim fingernails and toenails monthly and as needed - Podiatry consult as needed." The Care Plan was last reviewed on 10/10/2013. A review of RI #9's Treatment Record for October 2013, indicated care was done for resident's toenails and fingernails. Treatment records for August and September does not indicate that treatment was done. RI #9's husband was present on 10/22/2013 at 4:25 PM, during a resident interview. He complained that they have "been wanting her toenails looked at for 7 to 8 months." RI #9's husband stated he had just told them again about it. On 10/23/2013 at 8:25 AM, RI #9 complained that her toenails were "long and ugly." The surveyor observed that RI #9's toenails were long, but not grossly long, or curled. RI #9's husband was present and stated he had been trying to get the resident's toenails cut for 3 to 8 months. On 10/23/2013 at 3:00 PM, during an interview with EI (Employee Identifier) #1 CNA (Certified Nursing Assistant), EI #1 was asked how often she looked at RI #9's feet and toenails. EI #1 stated she observed RI #9's toes every day when she washed her feet and applied lotion to them. EI #1 further stated if anything was seen like fungus or toenails needed cutting, she would let the nurse know. EI #1 was asked if RI #9 or her husband had requested to have her toenails cut. EI #1 stated no request had been made to her. EI #1 was asked who would cut the resident's toenails and fingernails. EI #1 stated the podiatrist and sometimes the nurse. She stated if the family agreed, they could be seen by the podiatrist, otherwise the nurse cuts the nails. During an interview with EI #4 LPN (Licensed Practical Nurse), on 10/23/2013 at 3:20 PM, EI #4 was asked if she had noticed RI #9's toenails and she replied that she had not. EI #4 was asked if RI #9 or her husband had requested to have her toenails cut. EI #4 stated they had not made a request to her. An interview was conducted with EI #3, DON (Director of Nursing) on 10/23/2013 at 5:30 PM. EI #3 was asked how often were residents toenails observed and by whom. EI #3 replied, monthly and as needed. EI #3 also stated the podiatrists came every six weeks and a foot clinic was recently started with the CRNP (Certified Registered Nurse Practitioner). EI #3 was asked how was care of toenails documented and by whom. EI #3 replied on the treatment sheet, by the nurse. EI #3 also stated the CNA(s ) can make sure they were clean, but the trimming was done by the nurse. She stated if nails were thick and mycotic, they referred the resident to the podiatrist. EI #3 was asked what happened when there was a request to cut the toenails. EI #3 replied, if they were able to cut the nails, they did. If they were too thick, the facility offered to take the resident out if the podiatrist was just there. EI #3 was asked to review the treatment sheet for RI #9. EI #3 replied that RI #9's toenails had been cut on 10/7/2013. EI #3 was asked if RI #9 or her husband had requested to have her toenails cut. EI #3 stated no request had been made to her.

Based on observation, interviews and record reviews, the facility failed to ensure that RI (Resident Identifier) #9's ADL (Activity of Daily Living) Care Plan was followed by: 1) Toenails were to be trimmed monthly and as needed. 2) Podiatry was to be consulted as needed. This affected RI #9, one of eleven sampled residents whose care plans were reviewed. Findings include: RI #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a quarterly MDS (Minimum Data Set) for RI #9 with an Assessment Reference Date of 10/10/13 revealed, RI #9 was coded as having a BIMS (Brief Interview for Mental Status) score of 11 out of a possible 15 points. This score indicated RI #9 was moderately impaired for cognitive function. RI #9 was coded as being totally dependent on staff for locomotion, and on and off the unit. RI #9 required limited assistance for dressing and personal hygiene, and extensive assistance for bathing. A review of RI #9's Physicians Orders revealed an order to "Trim finger and toe nails monthly on the 7th 3-11 shift". A review of RI #9's Care Plan with a start date of 07/29/2013 notes the following: "Nail Care Daily as needed; trim fingernails and toenails monthly and as needed - Podiatry consult as needed". This care plan was last reviewed on 10/10/2013. A review of RI #9's Treatment Record for October 2013, indicated care was done for residents toenails and fingernails. Treatment records for August and September does not indicate that treatment was done. A resident interview was conducted on 10/22/2013 at 4:25 PM. RI #9's husband was present. He complained that they have "been wanting her toenails looked at for 7 to 8 months". RI #9's husband stated he just told them about it again. On 10/23/2013 at 8:25 AM, RI #9 complained that her toenails were "long and ugly". The surveyor observed that RI #9's toenails were long, but not grossly long, or curled. RI #9's husband was present and stated he had been trying to get the resident's toenails cut for 3 to 8 months. On 10/23/2013 at 3:00 PM, during an interview with EI (Employee Identifier) #1, CNA (Certified Nursing Assistant), EI #1 was asked how often she looked at RI #9's feet and toenails. EI #1 stated she observed RI #9's toes every day when she washed her feet and applied lotion to them. EI #1 further stated if anything was seen like fungus or toenails needed to be cut, she would let the nurse know. EI #1 was asked if RI #9 or her husband had requested to have her toenails cut. EI #1 stated no request had been made to her. EI #1 was asked who would cut the resident's toenails and fingernails. EI #1 stated the podiatrist and sometimes the nurse. She stated if the family agreed the resident could be seen by the podiatrist, otherwise the nurse would cut their nails. During an interview with EI #4, an LPN (Licensed Practical Nurse) on 10/23/13 at 3:20 PM, the surveyor asked if she noticed RI #9's toenails. EI #4 replied she had not. EI #4 was asked if RI #9 or her husband had requested to have her toenails cut. EI #4 stated they had not made a request to her. An interview was conducted with EI #3, DON (Director of Nursing) on 10/23/2013 at 5:30 PM. EI #3 was asked how often were residents' toenails observed and by whom. EI #3 replied, monthly and as needed. EI #3 also stated the podiatrists came every six weeks. EI #3 added that a foot clinic was recently started with the CRNP (Certified Registered Nurse Practitioner). EI #3 was asked how was care of toenails documented and by whom. EI #3 replied on the treatment sheets, by the nurse. EI #3 also stated the CNA(s) could make sure feet and nails were clean, but toenail trimmings were done by the nurse. She stated if nails were thick and mycotic, they referred the resident to the podiatrist. EI #3 was asked what happened when there was a request to have toenails cut. EI #3 replied, if the nurses were able to cut the nails, they did. If the nails were too thick, the facility offered to take the resident out, if the podiatrist was recently there. EI #3 was asked if RI #9 or her husband had requested to have her toenails cut. EI #3 stated no request had been made to her.

Based on an observation, interviews, and record reviews, the facility failed to ensure a staff member provided incontinence care and catheter care for RI (Resident Identifier) #6, a resident with a history of a recent UTI (Urinary Tract Infection), to prevent potential cross contamination. This affected RI #6, one of two residents observed for incontinence care. Findings include: A review of the facility's Policy and Procedure titled "Perineal Care" with a revised date of September 2005, revealed "Purpose - The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. ... Steps in the Procedure - ... 9. For a female resident: a. Wet washcloth and apply soap or skin cleansing agent or use an incontinent wipe b. Wash perineal area, wiping from front to back. (1) Separate labia and wash area downward from front to back. (Note: If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently rinse and dry the area.) (2) Continue to wash the perineum moving from inside outward to thighs, alternating from side to side, and using downward [MEDICAL CONDITION]. Do not reuse the same portion of washcloth or wipe to clean. ... e. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. Do not reuse the same washcloth or incontinent wipe to clean the labia. ..." A review of RI #6's medical record revealed RI #6 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #6 had an indwelling Foley catheter due to [MEDICAL CONDITION]. A review of RI #6's laboratory results on the medical record revealed a Urinalysis that was obtained on 8/5/13 which indicated a small amount of Urine Occult Blood, a small amount of Urine Protein, and a large amount of Urine Leukocytes. A urine culture and sensitivity was also performed which indicated a Colony Count of > (greater than) 100,000 COL/ML (Colonies per milliliter) and the Microbiology results were [DIAGNOSES REDACTED] Pneumoniae. A review of the physician's orders [REDACTED]. A review of a quarterly MDS (Minimum Data Set) for RI #6 with an Assessment Reference Date of 8/4/13 revealed, RI #6 was coded as having a BIMS (Brief Interview for Mental Status) score of 11 out of a possible 15. This score indicated RI #6 was moderately impaired for cognitive function. RI #6 was coded as being totally dependent on staff for transfers, toileting, and bathing. RI #6 was coded as being occasionally incontinent of bowel function and having an indwelling catheter. On 10/22/13 at 10:25 AM, the surveyor observed EI (Employee Identifier) #1, CNA (Certified Nursing Assistant), provide AM care including incontinence care and Foley catheter care for RI #6. EI #2 (CNA) assisted EI #1 with the care provided to RI #6. EI #1, using a wipe, cleansed RI #6's rectal area in an upward motion. The surveyor observed a moderate amount of brown stool on the wipe prior to EI #1 discarding the wipe. EI #1 then cleansed the rectal area a second time in an upward motion, rotated the wipe, cleansed the left buttock in an upward motion and discarded the wipe. EI #1, after cleansing the buttock, failed to remove her gloves and wash her hands. EI #1 then used a clean wipe and cleansed the catheter tubing from the insertion site downward toward the drainage bag connection. After cleansing the catheter, EI #1 then obtained a clean wipe and cleansed the perineal area from front to back. On 10/23/13 at 2:45 PM, an interview was conducted with EI #1. EI #1 was asked when was the last inservice provided regarding incontinence care and catheter care. EI #1 stated that inservices were provided this summer. EI #1 was asked what was taught. EI #1 stated for incontinence care, to inform the resident of what would be done, wash your hands, fill the basin with water, place soap on the wash cloth and cleanse the perineal area. EI #1 stated for catheter care, the tubing should be held securely and to wash down the tubing to prevent a UTI. EI #1 was asked when should gloves be changed and hands washed during incontinence care. EI #1 stated hands should be washed before incontinence care and every time you change the water you should wash your hands and change your gloves. EI #1 was asked why should hands be washed and gloves be changed. EI #1 stated to prevent UTIs and to try and keep everything clean. EI #1 was asked what was the potential negative outcome for residents if gloves were not removed and hands washed after cleaning stool from a resident prior to cleansing the catheter tubing and the perineal area. EI #1 stated the resident could get an infection. EI #1 was asked if she removed her gloves and washed her hands after cleaning stool from RI #6, prior to cleaning the catheter tubing and the perineal area. EI #1 stated, "I don't recall going there to wash hands." On 10/23/13 at 5:15 PM, an interview was conducted with EI #3 DON (Director of Nursing). EI #3 was asked when was the last inservice provided for staff regarding incontinence care and catheter care. EI #3 stated the inservice was within the past year for incontinence care and catheter care. EI #3 was asked what was taught. EI #3 stated, "encourage the use of wipes, one wipe/one swipe, front to back." EI #3 was asked when should gloves be changed and hands washed during incontinence care. EI #3 stated before and after care was provided and before a clean brief was placed on, hands should be washed and gloves changed. EI #3 also stated if the gloves were visibly soiled or torn to change gloves and wash hands. EI #3 was asked if a resident had stool on them, how should the CNA clean the resident. EI #3 stated the resident should be turned to the side and the CNA should clean the stool from front to back away from the urethra. EI #3 was asked if gloves should be changed and hands washed prior to peri-care. EI #3 stated, "yes." EI #3 was asked what was the potential negative outcome for the resident if gloves were not removed and hands washed after cleansing stool from a resident, prior to providing perineal and catheter care. EI #3 stated, "UTI."

Based on observations, interviews, and record reviews, the facility failed to ensure that licensed staff followed physicians orders by: 1) staff did not assess blood pressure and pulse prior to administering an anti-hypertensive medication to RI (Resident Identifier) #8. 2) staff administered ophthalmic drops at 9:00 AM and only administered 1 drop to each eye, instead of 2 drops as ordered for RI #11. Eye drops were ordered to be administered as needed at bedtime. 3) RI #9's toenails were not trimmed monthly on the 7th as ordered by the physician. This affected RI #8, #9, and #11, 3 of the 11 sampled residents. Findings include: 1) RI #8 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #8's Admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 7/14/13, documented a BIMS (Brief Interview for Mental Status) of 8/15 indicating RI #8 was moderately impaired for cognition and decision making. A review of RI #8's physician's orders [REDACTED]. "[MEDICATION NAME] 25 MG GIVE ONE (1) TABLET BY MOUTH TWICE DAILY, HOLD DOSE IF HR (heart rate) < (less than sign) 60 OR SBP (systolic blood pressure) < 120". On 10/22/2013 at 9:00 AM, EI (Employee Identifier) #4, an LPN (Licensed Practical Nurse) administered an anti-hypertensive medication orally to RI #8, but did not assess her blood pressure and pulse prior to administering the medication, as ordered. On October 23, 2013 at 3:20 PM, during an interview with EI #4, she was asked if vital signs were assessed for residents, how often, and by whom. EI #4 stated, vital signs were assessed by the CNA(s) (Certified Nursing assistants) every Wednesday for all residents, and temperatures were checked every shift if residents were on antibiotics. EI #4 further stated the nurses checked apical pulses for residents getting [MEDICATION NAME]. EI #4 stated, if something was going on medically with a patient, then she would take the vital signs herself. EI #4 was asked where were vital signs documented, and by whom. EI #4 stated when the CNA(s) assessed vital signs, they documented them on a Vital Sign Log Sheet, the nurses reviewed the vital signs and the secretary recorded the vital signs into the resident's charts. EI #4 was asked what was the BP(Blood Pressure) and HR (heart rate) for RI #8 on 10/22/2013, prior to 9:00 AM. EI #4 stated that she would need to pull the flow sheet, they should have been done before lunch. EI #4 was asked were the BP and heart rate for RI #8 checked on 10/22/2013 AM and why. EI #4 then stated that RI #8 should not have had any vital signs taken because she had nothing going on with her. EI #4 was asked what [MEDICATION NAME] was given for and she replied high blood pressure. EI #4 was then asked about the possible side effects to this medication and she stated blood pressures could be lowered and it could cause heart rates to be low. EI #4 was then asked what could happen to a resident if their blood pressure or pulse was low and they were given [MEDICATION NAME]. EI #4 stated they could become dizzy, pass out and be unsteady. EI #4 was asked if she checked the BP or pulse for RI #8 prior to administering [MEDICATION NAME] on 10/22/2013 at 9:00 AM. EI #4 stated no. She was not aware there was an order to check them. During an interview with EI #3 DON (Director of Nursing) on October 23, 2013 at 5:30 PM, EI #3 was asked what could happen to a resident if the systolic blood pressure was less than 120 or pulse less than 60 and the resident was given [MEDICATION NAME]. EI #3 stated that the medication could cause some [MEDICAL CONDITIONS], or syncopal episodes if the medication was administered. EI #3 was asked if a physician's orders [REDACTED]. EI #3 stated, hold the medication if the blood pressure and pulse were below the given parameters. EI #3 stated, the nurse should check the blood pressure and pulse before giving the medication. 2) RI #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #11's Physicians Orders for October 2013 revealed an order for [REDACTED]. On 10/22/2013 at 9:07 A.M., EI #4 administered 1 drop of [MEDICATION NAME] Ultra to each eye of RI #11 instead of 2 drops each eye at bedtime, as needed. During an interview with EI #4 on 10/23/2013 at 3:20 PM, EI #4 was asked if there would be a problem if eye drops were given in the morning instead of at bedtime as ordered. EI #4 stated she was sure there was a reason the medication was ordered to be given at bedtime instead of at 9:00 AM, but she would need to find out. She further stated that [MEDICATION NAME] was usually given for dry eyes. EI #4 stated she would have to look up the medicine to determine if instilling only 1 drop instead of 2 drops to each eye would result in the resident still having dry eyes. An interview was conducted with EI #3, the DON (Director of Nursing), on 10/23/2013 at 5:30 PM. EI #3 was asked if an order revealed, "administer two gtts (drops) to each eye at bedtime PRN (as needed)", was it ok to administer 1 drop to each eye at 9:00 A.M. EI #3 stated no, that's not what the order said. EI #3 was asked why would [MEDICATION NAME] Eye drops be ordered for bedtime. EI #3 stated, that she had no idea. She stated she knew it was for dry eyes, but not why, just for bedtime. She was asked would there be a problem if drops were not given at bedtime and given in the AM. EI #3 stated, if orders read to be given at bedtime then a new order from the doctor would be needed. EI #3 also stated, you could not give it at any other time. EI # 3 was asked what would be the problem if only 1 drop was administered, rather than the 2 drops as ordered. EI #3 stated, you had to follow physicians orders. 3) RI #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a quarterly MDS (Minimum Data Set) for RI #9 with an Assessment Reference Date of 10/10/13 revealed, RI #9 was coded as having a BIMS (Brief Interview for Mental Status) score of 11 out of a possible 15. This score indicated RI #9 was moderately impaired for cognitive function. RI #9 was coded as being totally dependent on staff for locomotion, on and off the unit. RI #9 required limited assistance for dressing and personal hygiene, and extensive assistance for bathing. A review of RI #9's Physician order [REDACTED]." A review of RI #9's Treatment Record for October 2013, indicated care was done for resident's toenails and fingernails. Treatment records for August and September does not indicate that treatment was done. On 10/22/2013 at 4:25 PM, RI #9's husband was present, during a resident interview and complained that they have "been wanting her toenails looked at for 7 to 8 months". RI #9's husband stated he had just told them again about it. On 10/23/2013 at 8:25 AM, RI #9 complained that her toenails were "long and ugly." The surveyor observed RI #9's toenails were long, but not grossly long, or curled. RI #9's husband was present and stated he had been trying to get resident's toenails cut for 3 to 8 months On 10/23/2013 at 3:00 PM, during an interview with EI (Employee Identifier) #1 CNA (Certified Nursing Assistant), EI #1 was asked how often she looked at RI #9's feet and toenails. EI #1 stated she observed RI #9's toes every day when she washed her feet and applied lotion to them. EI #1 further stated if anything was seen like fungus or toenails needed cutting, she would let the nurse know. EI #1 was asked if RI #9 or her husband had requested to have her toenails cut. EI #1 stated no request had been made to her. EI #1 was asked who would cut the resident's toenails and fingernails. EI #1 stated the podiatrist and sometimes the nurse. She stated if the family agreeed, they could be seen by the podiatrist, otherwise, the nurses cut the nails. During an interview with EI #4 LPN (Licensed Practical Nurse), on 10/23/2013 at 3:20 PM, EI #4 was asked if she had noticed RI #9's toenails and she replied that she had not. EI #4 was asked if RI #9 or her husband had requested to have her toenails cut. EI #4 stated they had not made a request to her. During an interview with EI #3 DON (Director of Nursing) on 10/23/2013 at 5:30 PM, EI #3 was asked how often were residents toenails observed and by whom. EI #3 replied, monthly and as needed. EI #3 also stated the podiatrists came every six weeks and recently a foot clinic was started with the CRNP (Certified Registered Nurse Practitioner). EI #3 was asked how was care of toenails documented and by whom. EI #3 replied on the treatment sheet, by the nurse. EI #3 also stated the CNA(s) could make sure they were clean, but the trimming was done by the nurse. She stated if nails were thick and mycotic, they referred the resident to the podiatrist. EI #3 was asked what happened when there was a request to have toe nails cut. EI #3 replied, if nurses were able to cut the nails, they did. If nails were too thick, the facility offered to take the resident out if the podiatrist was recently there. EI #3 was asked if RI #9 or her husband had requested to have her toenails cut. EI #3 stated no request had been made to her.