Every finding on record at Wiregrass Rehabilitation Center & Nursing Home

Based on observations, interviews and a review of facility policies titled, Food Storage: Cold Foods, Outside Food, and Hand Hygiene, the facility failed to ensure: 1. Food items in the kitchen refrigerator were labeled with an open and use by date; 2. food items brought in from the outside and stored in the nourishment refrigerators on the unit were labeled with the resident's name and dated; 3. and dietary staff washed his/her hands when entering the kitchen on 03/23/22. This deficient practice affected 70 of 70 residents receiving meals from the kitchen. Findings Include: 1.) A review of a facility policy titled, Food Storage: Cold Foods, with a revised date of 4/2018 revealed: Policy Statement All . Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA (Food and Drug Administration) Food Code. Procedures . 5. All foods will be stored wrapped or in a covered containers, labeled and dated, . On 03/22/22 at 8:41 AM, accompanied by EI (Employee Identifier) #3, the Dietary Manager, the surveyor observed (6) Sausage Links and (2) Muffins in the refrigerator with no open or use by date. On 03/24/22 at 9:04 AM an interview was conducted with EI #3. EI #3 was asked during the initial kitchen tour on 03/22/22 what food items were in the kitchen refrigerator without a label. EI #3 said six sausage links and two muffins. EI #3 was asked when should food be labeled. EI #3 said when we get ready to put it away, store it and before we put it in the refrigerator. EI #3 was asked what should be included on the label. EI #3 said the name of the item, date it was prepared/opened and then a use by date. EI #3 was asked should these food items have been labeled. EI #3 said yes, they should have been labeled. EI #3 was asked why should food items be labeled. EI #3 said to prevent spoilage, to know when something was going out of date and if not labeled, it was not safe for human consumption. 2.) A review of a facility policy titled, Outside Food, with a reviewed date of 1/2022 revealed: . POLICY: Safety considerations require that food brought into the facility from the outside is appropriately stored. PROCEDURE: 1. Foods or beverages brought in from the outside should be labeled with the resident's name, room number, and dated with the current date the item(s) brought to the facility and stored. On 03/24/22 at 9:29 AM, the surveyor observed the 100 hall Nourishment Refrigerator. The surveyor observed the following items in the freezer not labeled: a bag of fish sticks, two containers of [NAME] ice cream, one-pint size and a one and a half quart size. On 03/24/22 at 9:33 AM an interview was conducted with EI #1, Registered Nurse, Nursing Supervisor. EI #1 was asked what items in the freezer were not labeled. EI #1 said two containers of [NAME] ice cream, one-pint size and a one and a half quart size and a 60 ounce bag of fish sticks. EI #1 was asked was this a resident refrigerator. EI #1 said yes it was. EI #1 was asked should the food items in the freezer have been labeled. EI #1 said yes, they should have been labeled. EI #1 was asked what should be included on the label. EI #1 said the resident's name, the date it was brought in or opened. EI #1 was asked what was the harm with the food items in the resident nourishment refrigerators not being labeled. EI #1 said you do not know who it belongs to, when it was opened or when it needed to be thrown out. On 03/24/22 at 9:40 AM, the surveyor observed the 300 hall nourishment refrigerator accompanied by EI #1. The surveyor observed a box of Red [NAME] pizza in the freezer opened with no label. EI #1 was asked should the Red [NAME] pizza be labeled. EI #1 said yes. EI #1 was asked who was responsible for ensuring food items put in the nourishment refrigerator was labeled. EI #1 said whoever receives the food items from the family/visitor. EI #1 was asked what was the harm of the resident food items not being labeled. EI #1 said not knowing which resident it belongs to and when it needed to be thrown out. EI #1 was asked what harm would it cause the resident if eaten. EI #1 said the resident could become sick. 3.) A review of a facility policy titled, Hand Hygiene, with a revised/reviewed date of 4/2021 revealed: . Policy: All staff will perform hand hygiene procedures to prevent the spread of infection to other . residents . This applies to all staff working in all locations within the facility. On 03/23/22 at 11:05 AM, the surveyor observed EI #4, a Dietary Aide, coming back in the kitchen with a black cart, she pushed the cart into the dry storage area, went on the meal preparation side, then went and got a cart (food), and did not washed her hands. On 03/23/22 at 11:07 AM, an interview was conducted with EI #4. EI #4 was asked where did she go with the black cart. EI #4 said to empty the boxes. EI #4 was asked did she go outside to the dumpster. EI #4 said yes. EI #4 was asked when she returned to the kitchen did she wash her hands. EI #4 said no she did not. EI #4 was asked should she have washed her hands. EI #4 answered yes. EI #4 was asked what was the importance of washing hands. EI #4 said to prevent the spread of germs in the kitchen. On 03/24/22 at 09:15 AM an interview was conducted with EI #3. EI #3 was asked what was the policy/procedure for staff washing their hands when they come in the kitchen. EI #3 said when they (staff) return from outside, they are getting ready to perform a task, or preparing food, they should wash their hands. EI #3 was asked how often should the staff wash their hands. EI #3 said when they enter the kitchen, any time they are doing multi tasks, and when they are transitioning from one task to another. EI #3 was asked what was the harm of not washing your hands when entering the kitchen. EI #3 said food borne illness can be transferred from your hands to utensils, cups, plates or food.

Based on interviews, review of a Physician's Progress Note, and review of the facility Resident Assessment Instrument Policy, the facility failed to develop interventions to address Resident Identifier (RI) #2's identified skin condition. This affected RI #2, one of fifteen residents, who's care plans were reviewed. Findings Include: A review of the facility policy with a subject of . RAI (Resident Assessment Instrument) Policy . DATE (S) REVISED/REVIEWED . 10/2021 . XI. Care Plans . The care plan will be revised on an ongoing basis . in order to reflect changes in the resident and the care that the resident is receiving. RI #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a Progress note by the Medical Director of the facility dated 11/10/21 revealed, . SKIN: Extensive excoriations. They appear to be in areas where she can reach, along with some erythematous papules. A review of the most recent shower sheet assessment dated [DATE] revealed, . Any reddened areas? Yes (an X placed indicated as applicable) . Comments: All over body . A review of RI #2's Comprehensive Care Plan with a last review date of 11/12/21 revealed, . Care Plan Goal Remains free from skin breakdown through next review. On 03/22/22 at 12:10 PM an interview was conducted with RI #2. RI #2 stated he/she picks the scabs off of the sores on the leg. On 03/24/22 at 8:28 AM an interview was conducted with Employee Identifier (EI) #1, Unit Nursing Supervisor. EI #1 was asked how long had RI #2 had sores that had not healed. She answered off and on for 6 months. EI #1 was asked what the care plan indicated regarding RI #2 picking scabs from those sores. EI #1 answered there was not anything, adding they would have to rectify that. EI #1 was asked what was the concern of not implementing concerns individual to RI #2 in his/her plan of care. EI #1 answered RI #2 could have worsening condition of the sores and the potential for infection. EI #1 was asked what was the purpose of a resident's plan of care. She answered to guide the care of that resident so everyone was aware of that resident's needs. On 03/24/22 at 11:36 AM an interview was conducted with EI #2, a Licensed Practical Nurse/MDS Assistant Coordinator. EI #2 was asked what the purpose for a comprehensive plan of care was. She answered to provide care to best meet the problems and goals of the resident. EI #2 was asked if RI #2's plan of care included scratching the scabs from their left lower leg. She answered they updated it that day to reflect it more thoroughly. EI #2 was asked why they updated it. She answered to better provide interventions specific to his/her scratching of scabs. EI #2 was asked what was the potential concern of the care plan not identifying this concern that has been present for six months. She answered the risk for infection.

Based on observations, interviews and review of a facility policy titled, Food Storage: Cold Foods, the facility failed to ensure: 1. foods stored in the walk-in cooler were labeled with an open and/or use by date; and 2. Enchilada Sauce with an open date of [DATE] and the manufactures label with instructions to Refrigerate after opening was not stored in the dry storage area. This had the potential to affect 78 of 78 residents receiving meals from the facility kitchen. Findings include: A review of a facility policy titled, Food Storage: Cold Foods with a last revised date of ,[DATE] revealed, Policy Statement All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA (Food and Drug Administration) Food Code. Procedures . 5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. On [DATE] at 4:15 PM, the surveyor conducted the initial kitchen tour with Employee Identifier (EI) #5, Assistant Dietary Manager. Observation of the main kitchen cooler revealed, one cardboard box labeled romaine lettuce. On the outside of the box was a label with a date of [DATE] written on it. Inside the cardboard box was five heads of wilted romaine lettuce. EI #5 was asked what did the date on the label signify. EI #5 replied, the date the romaine lettuce came in. EI #5 was asked was there a use by date (UBD) on the cardboard box of romaine lettuce. EI #5 replied, no. EI #5 was asked should there have been a UBD on the box of lettuce. EI #5 replied, yes. An observation was made of a full size, metal warming pan covered with plastic wrap and labeled with a date of [DATE]. The metal pan contained ground meat. EI #5 was asked what was in the metal warming pan. EI #5 replied, taco meat. EI #5 was asked what was the UBD on the label. EI #5 replied, there was not a UBD on the label. EI #5 was asked what the UBD should have been. EI #5 replied, [DATE]. EI #5 was asked what should have been done with the taco meat. EI #5 replied, it should have been thrown out. On [DATE] at 4:35 PM EI #1, District Manager in Training took over for EI #5. Surveyor conducted the remainder of initial kitchen tour with EI #1. The surveyor observed a full size, metal warming pan on the bottom shelf of a storage rack in the cooler. The metal warming pan was covered with plastic wrap and a label identifying the contents of the pan as pepper steak with a preparation date of [DATE]. EI #1 was asked what was the UBD. EI #1 replied, there was not a UBD. EI #1 was asked if the pepper steak had been served since [DATE]. EI #1 replied, he did not know. The surveyor continued with an observation of the freezer with EI #1. In the freezer the surveyor observed an opened cardboard box labeled beef patties. The inside plastic packaging had been opened. EI #1 was asked what was the open date on the beef patties. After inspecting the box of beef patties EI #1 replied, there was no open date. EI #1 was asked how many beef patties remained in the box. EI #1 counted 30 remaining beef patties. On [DATE] at 4:45 PM, an observation of the dry storage room was conducted with EI #1. On the top shelf of a metal storage rack the surveyor observed a 138 ounce bottle of Enchilada Sauce. The outside of the bottle contained a label with an open date of [DATE]. No UBD was on the label. In addition, the bottle of Enchilada Sauce contained a manufactures label with instructions to Refrigerate after opening. EI #1 was asked if the Enchilada Sauce had been refrigerated. EI #1 replied, no. EI #1 was asked how much Enchilada Sauce was left in the bottle. EI #1 replied, about three-fourths (,[DATE]). On [DATE] at 10:38 AM, an interview was conducted with EI #1, District Manager in Training. EI #1 was asked what was the policy regarding food storage. EI #1 replied, whenever food comes in it was labeled with a received by date and rotated. EI #1 was asked what was the policy regarding the storage of food that was prepared in the facility. EI #1 replied, food should be labeled with the date it was made and the date it should be disposed of. EI #1 was asked for foods prepared in the facility, what was the time frame from the date it was prepared to the date it should be disposed of. EI #1 replied, there was a different shelf life for different products. EI #1 was asked if the taco meat was prepared on [DATE], when should it have been disposed of. EI #1 replied, it was his understanding it should be disposed of at the end of the day. EI #1 was asked who was responsible for labeling food items to be stored in the cooler. EI #1 replied, whoever handled the product or received the product. EI #1 was asked who was responsible for ensuring that food items in the cooler/freezer were labeled, stored and disposed of properly. EI #1 replied, the account supervisor. EI #1 was asked who was the account manager. EI #1 replied, with the name of the dietary manager. EI #1 was asked what was the potential risk to the residents if food in the cooler/freezer was expired or past the UBD or dispose of date. EI #1 replied, any type of food borne illness. EI #1 was asked if the Enchilada Sauce manufactures label instructed refrigerate after opening. EI #1 replied, yes it did. EI #1 was asked was that item refrigerated. EI #1 replied, no. EI #1 was asked should the manufactures label instructions be followed. EI #1 replied, yes. EI #1 was asked what was the risk to residents when food items needed refrigerating and was not. EI #1 replied, any type of food borne illness. EI #1 was asked when a box of romaine lettuce with a received date of [DATE] should be disposed of. EI #1 replied, five days. On [DATE] at 10:46 AM, an interview was conducted with EI #2, a cook. EI #2 was asked what was the policy on UBDs for food items stored in the facility cooler. EI #2 replied, first in first out. EI #2 was asked what was a UBD. EI #2 replied, anything that was not used was thrown out after three days. EI #2 was asked when should food items prepared in the facility be labeled. EI #2 replied, the day they were prepared. EI #2 was asked what information should the label contain. EI #2 replied, what the food item was, when it was made and the day it expired. EI #2 was asked what should be done with food items that are past the UBD. EI #2 replied, the food item should be thrown away. EI #2 was asked who was responsible for ensuring that food items in the facility cooler that were expired get thrown out. EI #2 replied, usually the cook, but everyone was responsible. EI #2 was asked who was responsible for labeling food before putting it in the cooler. EI #2 replied, the person that was putting the food in the cooler. EI #2 was asked what was the risk to residents when expired food items were in the cooler. EI #2 replied, it can make the residents sick and cross contamination. EI #2 was asked if a bottle of enchilada sauce with manufacture label containing the instruction to refrigerate after opening, where should this have been stored. EI #2 replied, in the cooler. EI #2 was asked what was the risk to the residents if it was not stored in the cooler. EI #2 replied, it could have molded and made people sick. EI #2 was asked if a box of romaine lettuce was received on [DATE] when should the romaine lettuce be disposed of. EI #2 replied, one week.

Based on observation, record review and interview, the facility failed to ensure that: 1. Resident (RI) #41 had heel positioner to bed, floated heels when in bed, and (specific named boot) on while in bed, as indicated by Physician orders [REDACTED]. 2. RI #62 had (name of specific) boots on at all times except when in shower as indicated by Physician orders [REDACTED]. This affected two of four residents sampled for range of motion concerns. Findings include: 1. RI #41 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #41 had a [DIAGNOSES REDACTED]. On 01/08/2020 at 2:24 p.m., a record review of RI #41's physician's orders [REDACTED]. Review of the resident's care plan revealed, . Care Plan Goal Will have no decline in (Activities of Daily Living) ADL performance through next review. x 3 months . Intervention HEEL POSITIONER TO BED, CHECK PLACEMENT EVERY SHIFT, FLOAT HEELS WHEN IN BED. Status Active . Start Date 11/21/19 Intervention (name of specific ) boots on bilateral feet while in bed. Status Active . Start Date 12/18/19 . On 01/08/2020 at 2:51 p.m., an observation was made with Employee Identifier (EI) #4, Director of Nurses (DON), of RI #41. RI #41 was in bed there; were no heel positioner, the heals were not floated, and the resident did not have on the boots. On 01/08/2020 at 5:35 p.m., and interview was conducted with EI #4, DON. EI #4 was asked, did RI #41 have boots on. EI #4 replied, no. EI #4 was asked, did RI #41 have a heal positioner applied. EI #4 replied, no. EI #4 was asked were RI #41's heels floated. EI #4 replied, no. EI #4 was asked, why were these things not done. EI #4 replied, because the Certified Nursing Assistants (CNA's) and Charge Nurse failed to ensure that they were in place. EI #4 was asked, what was the potential concern of the resident not having the boots on, heal positioners applied, and not having the heals floated. EI #4 replied that the resident could get breakdown and have skin problems. 2. RI #62 was admitted to the facility on [DATE]. RI #62 had a [DIAGNOSES REDACTED]. On 01/08/2020 at 4:00 p.m., a review of RI #62's physician's orders [REDACTED]. A review of the resident's care plan revealed, . Category Skin . Intervention (name of specific named) Boots at all times except when in shower. Status Active . Start Date 1/15/19 . On 01/08/2020 at 4:18 p.m., RI #62 was observed sitting in the 200 hall in a wheel chair by the outside door. RI #62 did not have on the boots. On 01/08/2020 at 4:36 p.m., an observation was made with EI #4 of RI #62 not wearing the boots. On 01/08/2020 at 5:35 p.m., an interview was conducted with EI #4. EI #4 was asked, what was RI #62 supposed to have on his/her feet. EI #4 replied, the boots. EI #4 was asked, did RI #62 have them on. RI #4 replied, no. EI #4 was asked, why were the boots not on. EI #4 replied, because the CNA's and Charge nurse failed to follow through. EI #4 was asked, who was responsible for ensuring RI #62 had them on. EI #4 replied CNA's. EI #4 was asked, what was the potential concern with RI #62 not having on the boots. EI #4 replied, skin issues.

Based on observation, record reviews, interviews and a review of the facility policy titled, STANDARD POLICIES & PR[NAME]EDURES, the facility failed to ensure that Employee Identifier (EI) #3 put on gloves before giving an insulin injection to (Resident Identifier) RI #68. This had the potential to effect one of five sample residents for insulin injection. Findings Include: A review of a facility policy titled STANDARD POLICIES & PR[NAME]EDURES, with a reviewed date of 5/2019 revealed .Procedure: Using Gloves .Purpose .To prevent the spread of infection .to resident and employees .[NAME] Gloves must be worn during all vascular procedures. RI #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI # 68's doctor's order, dated 10/1/19, revealed .[MEDICATION NAME] 70-30 vial. ADMINISTER 20 UNITS SUBQ (subcutaneous) EVERY MORNING . 01/08/2020 at 8:33 a.m., during the administration of medication, EI #3, Licensed Practical Nurse, knocked on RI #68's door and explained what she was going to be giving. The nurse gave the resident the po (by mouth) medication. EI #3 then gave RI #68 an injection of 20 units of insulin without putting on gloves. The nurse put the needle in a sharp's container, sanitized her hands and signed off the medication. On 01/08/2020 at 09:02 a.m., an interview was conducted with (Employee Identifier) EI #3, License Practical Nurse (LPN). EI #3 was asked, when did she put on gloves before giving the insulin. EI #3 replied, she put the gloves on when she opened the pill. EI #3 was asked, did she put gloves on before giving the insulin. EI #3 replied, the gloves are supposed to be put on; but the reason she did not was because of the skin reaction and her skin allergy was getting worst. EI #3 said she had a very bad reaction to [MEDICATION NAME], latex and vinyl gloves. EI #3 was asked, what was the potential harm in not putting on gloves before giving an injection. EI #3 replied, exposure to blood. EI #3 was asked, what was the facility's policy on putting on gloves before giving an insulin injection. EI #3 replied, put on gloves, before giving injections, when doing an accu-chek, during a dressing changing and all of that. On 01/08/2020 at 09:19 a.m., an interview was conducted with EI #4 (Director of Nursing) DON. EI #4 was asked, what were they doing about EI #3's allergy to latex gloves. EI #4 replied, she did not know about it but will address it immediately. EI #4 was asked, was she aware of the allergy to latex gloves. EI #4 replied, no she was not, but there were a couple of others that had allergy to latex, EI #3 was not in the mix. EI #4 was asked, what was the harm in a nurse not wearing gloves when giving an insulin injection. EI #4 replied, infection control. EI #4 was asked, what was the policy on wearing gloves. EI #4 replied, she would have to pull the policy to see.

Based on observations, interview, and review of a facility policy titled FOOD AND SUPPLY STORAGE, the facility failed to ensure that a box of ice cream in the walk-in freezer was not spilled with 20 individual cups on the floor and the remainder of the box on the floor. This had the potential to affect 72 residents receiving meals from the kitchen. Findings Include: A review of a facility policy titled, FOOD AND SUPPLY STORAGE with a revision date of 8/2018 revealed, .FROZEN STORAGE store food items 6 inches above the floor . On 12/17/18 at 1:51 PM, during the initial tour of the kitchen with Employee Identifier (EI) #9 the surveyor observed 20 single cups of vanilla ice cream on the floor in a corner of the walk-in freezer. Also, the box containing the remainder of the ice cream cups was on the floor. On 12/19/18 at 10:25 AM, an interview was conducted with EI # 9, Executive Chef. EI #9 was asked what did they see in the walk-in freezer on Monday 12/17/18 during the initial tour of the kitchen. EI #9 stated a box of ice cream cups spilled to the floor. EI #9 was asked how many individual vanilla ice cream cups were on the floor. EI #9 replied, 15 to 20. EI # 9 was asked if the remainder of the ice cream cups in the box was on the floor. EI #9 replied, yes. EI #9 was asked who was responsible to maintain that area. EI #9 replied, the entirety of kitchen staff. EI #9 was asked why was that area not maintained properly. EI # 9 replied that the shelf had been overfilled and was unbalanced. EI #9 stated something like the door closing must have jostled them to cause them to fall off the shelf to the floor. EI #9 was asked what was the potential harm of food items being on the floor in storage areas, such as coolers and freezers. EI #9 stated the issue was contamination; either physical or biological. EI # 9 also stated it could cause a slip hazard.

Based on observation, interview and review a facility policy Medication Administration, the facility failed to ensure licensed staff locked the medication cart before walking away and leaving the cart on the hall. This was observed on 12/17/18 and affected one of five nurses observed. Findings Include: A review of a facility policy titled Medication Administration with a reviewed date of 8/01 revealed: POLICY: .PR[NAME]EDURE: Medication carts must be kept locked when not in use (i.e. when the nurse is in the resident's room or whenever the nurse is away from the cart) during medication pass. On 12/17/18 at 3:36 PM, Employee Identifier (EI) #2, Licensed Practical Nurse, rolled the medication cart from the medication room to the hall. EI #2 left the medication cart in the hall and went into the charting room. At 3:42 PM, EI #2 returned to the medication cart with sanitation wipes. The surveyor asked EI #2 if the medication cart was locked. EI #2 replied, no. EI #2 was asked when should the medication cart be locked. EI #2 replied, anytime the nurse was not in front of it. EI #2 was asked if she was standing in front of the medication cart. EI #2 replied, no. EI #2 was asked what was the harm in the medication cart being left unattended and unlocked in the hall. EI #2 replied, a resident with dementia or other could get in the medication cart. EI #2 was asked if there were residents in the hall when she left the medication cart unlocked. EI #2 replied, yes. On 12/19/18 at 2:52 PM, an interview was conducted with EI #1, Assistant Director of Nursing (ADON). EI #1 was asked what was the policy for locking the medication cart when not in attendance. EI #1 replied, the medication cart should be locked at all times when the nurse was not in it giving medications. EI #1 was asked when should a nurse leave a medication cart in the hall being unlocked and unattended. EI #1 replied, never. EI #1 was asked what was the harm in a medication cart on a hall left unlocked and unattended. EI #1 replied, a resident or anyone could get in it.

Based on observation, interview and review of facility policy SOILED BRIEF/UNDERPAD DISPOSAL, the facility failed to ensure a Certified Nursing Assistant (CNA) did not place a trash bag of soiled items on the floor in the hall as she exited a resident room. This was observed on 12/17/18 . Findings Include: A review of a facility policy titled SOILED BRIEF/UNDERPAD DISPOSAL with a revised date of 11/2018 revealed: Procedure: Soiled Brief/Underpad Disposal .STANDARD: Soiled briefs or underpads should be disposed of in specifically designated laundry hampers or waste containers. On 12/17/18 at 3:57 PM, Employee Identifier (EI) #3, CNA was observed placing a bag of soiled items on the floor in the hall as she exited a resident's room. EI #3 then went into another resident's room and closed the door. The soiled bag remained on the floor until EI #3 came out of the room approximately 10 minutes later. On 12/17/18 at 4:10 PM, an interview was conducted with EI #3. EI #3 was asked what was the policy on where to place soiled items when leaving a resident's room. EI #3 replied, in a trash bag then in the soiled cart. EI #3 was asked when should she place a bag of soiled items removed from resident's room on the floor. EI #3 replied, they were instructed to take it to a soiled cart. EI #3 was asked what was in the trash bag. EI #3 replied, a wet brief. EI #3 was asked what was the harm in placing it on the floor. EI #3 replied, cross contamination and another resident could have picked it up. On 12/19/18 at 2:45 PM, an interview was conducted with EI #1, Assistant Director of Nursing/Infection Control. EI #1 was asked what was the policy on where staff should place soiled items when leaving a resident's room. EI #1 replied, it should stay in the garbage receptacle then taken to the three section soiled cart, not on the floor. EI #1 was asked when should a CNA place a trash bag of soiled items on the floor in the hall. EI #1 replied, never. EI #1 was asked what was the harm in a CNA placing a bag trash bag of soiled items on the floor in the hall. EI #1 replied, it could spread infection, germs or bacteria.

Based on observations, interviews and review of a facility policy titled Storage of Equipment, the facility failed to ensure resident use equipment was not stored in the open area across from the resident dining/activity room at the end of 300 hall. This was visible to residents and visitors and was noted to emit an urine odor. This was observed on three of four days of the survey and had the potential to affect 76 of 78 residents in the facility. Findings Include: A review of a facility policy titled Storage of Equipment, with a effective date of 11/2017 revealed: Policy: It is the policy of this facility for resident equipment to be stored in non-resident areas. On 12/17/18 at 1:21 PM, the surveyor observed stored equipment in an open area at the end of 300 hall, in front of the activities/dining room . The equipment was visible to residents and visitors. The stored equipment consisted of 3 shower beds, a stretcher, stand lift, Hoyer lift, shower chair and a 3 compartment soiled linen cart. The area was also noted with an urine odor. Three residents were observed in the dining/activity room, one still being fed lunch by the staff. On 12/17/18 5:15 PM, the equipment remained and the urine odor was still noted. Nine residents were observed in the dining/activity room waiting for the supper meal. On 12/18/18 at 9:17 AM, the equipment remained visible to residents and visitors in the area across from the dining/activity area. The area remained noted with the unpleasant odor of urine. On 12/18/18 at 12:30 PM, the surveyor observed the lunch meal in the dining/activity room. The surveyor observed nine residents in the dining room. The resident use equipment remained in the area across from the dining room and also noted was a 3 compartment soiled linen cart. The surveyor noted an odor in the area of the equipment. On 12/19/18 at 9:20 AM, an interview was conducted with Employee Identifier (EI) #6, Certified Nursing Assistant (CNA). EI #6 was asked what did she see in the area, across from the dining/activity room. EI #6 replied, shower beds, a stretcher, a shower chair and lifts. EI #6 was asked who used the equipment. EI #6 replied, they did for the residents. EI #6 was asked what hall used the equipment. EI #6 replied, all the halls. EI #6 was asked what hall used the activity/dining room. EI #6 replied, all the halls at times, most of the time residents from 100 and 300 hall go there for meals. EI #6 was asked who cleaned the equipment. EI #6 replied, the shower aides cleaned the shower beds and shower chair after each shower. EI #6 was asked what smell did she noticed. EI #6 replied, a urine odor. EI #6 was asked why was there a urine odor. EI #6 replied, she was not sure. EI #6 was asked should there be equipment and a urine odor in a resident area/near a resident area. EI #6 replied, no. EI #6 was asked what was a concern of a urine odor and equipment stored in a resident area. EI #6 replied, it was not homelike. On 12/19/18 at 9:26 AM, an interview was conducted with EI #5, a shower CNA. EI #5 was asked where was equipment stored. EI #5 replied, it was stored there at the end of the hall (300); the shower beds were to be returned to the shower room after showers were completed. EI #5 was asked what time were showers usually completed. EI #5 replied, around 1:45 PM most days. EI #5 was asked who was responsible for cleaning the equipment. EI #5 replied, they cleaned the shower bed and chair after each resident use. EI #5 was asked what smell did she notice. EI #5 replied, she was not sure, maybe a slight urine odor. EI #5 was asked if residents and visitors used the dining/activity room there where the equipment was stored. EI #5 replied, yes. On 12/19/18 at 9:30 AM, an observation and interview was conducted with EI #4, Maintenance staff. Upon the surveyor and EI #4 approaching the area across from the dining/activity room, the surveyor asked EI #4 what he saw. EI #4 replied, shower beds, a stretcher, a shower chair, a soiled cart and lifts. EI #4 was asked was that a storage area. EI #4 replied, it was, but it should not be. EI #4 was asked if the dining/activity room was used by residents and visitors. EI #4 replied, yes. EI #4 was asked where should equipment be stored. EI #4 replied, probably somewhere else. EI #4 was asked what did he smell. EI #4 replied, a slight urine odor. EI #4 was asked where was the odor from. EI #4 replied, it could be the shower beds. EI #4 was asked who was responsible for cleaning the equipment. EI #4 replied, he was not sure, the CNAs or housekeeping. EI #4 was asked what would the risks be in the equipment being stored in that area. EI #4 replied, it was a resident area and more of an eye sore.

Based on record review, interview and review of a facility policy RESIDENT ASSESSMENT INSTRUMENT POLICY, the facility failed to ensure that Resident Identifier (RI)#65, a resident receiving anticoagulation medication had a care plan. This affected one of 24 residents whose care plans were reviewed. Finding Include: A review of a facility policy titled Resident Assessment Instrument with a date of 11/2017 revealed: Policy: Resident Assessment Instrument . XI. On admission interim care plans will implemented based on nursing assessment, resident and/or representative input RI #65 was admitted on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. A review of RI #65's (MONTH) (YEAR) Physician order [REDACTED]. MONITOR FOR EXCESSIVE BLEEDING AND BRUISING . On 12/18/18 at 2:00 PM the surveyor reviewed RI #65 care plan which revealed no care plan for the Xarelto. On 12/18/18 at 2:15 PM an interview was conducted with Employer Identifier (EI) #8 License Practical Nurse (LPN), Minimum Data Set (MDS). EI #8 was asked where was the risk for bleeding care plan. EI #8 replied, she did not see the care plan there. EI #8 was asked what was the facility policy on a risk for bleeding care plan. EI #8 replied, if they were on an anticoagulant or aspirin medication they should have a care plan in place. EI #8 was asked what was the potential harm of not having a care plan in place. EI #8 replied, to ensure follow up with laboratory test so they (residents) could be monitored. EI #8 was asked who was responsible for doing the care plan. EI #8 replied, the MDS staff.

Based on a review of a facility policy titled, ACTIVITIES PROGRAM record reviews and interviews the facility failed to ensure an ongoing group activities program was offered as scheduled for the weekend as identified by residents in attendance for resident council on 02/28/2018. This affected five of eight residents, RI (Resident Identifiers) #'s 2,5, 26, 39 and 43, who attended resident council on 02/28/2018. Findings include: A review of a facility policy titled, ACTIVITIES PROGRAM with a issue date of 11/2017 revealed the following: .I.the facility will involve each resident in an ongoing program of activities . On 02/28/2018 at 3:00 p.m., a resident council meeting was conducted with eight residents in attendance. Five residents RI #'s 2, 5, 26, 39 and 43 informed the surveyor the scheduled weekend group activities were not being offered. The residents further explained they had not been offered activities for the last four weeks of (MONTH) (YEAR) due to the CNAs (Certified Nursing Assistant) being pulled from activities to work on the halls. The surveyor asked the residents had they reported this to staff. The residents voiced they had reported this to nurses and to the Activity Director, EI (Employee Identifier) # 3. The residents also informed the surveyor they would like to have more group activities offered throughout the weekend. RI #2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review or RI #2's Activity Care Plan with a start date of 02/12/2018 revealed the resident being invited to group activities. On 02/28/2018 at 5:15 pm an interview was conducted with RI #2 regarding the issue identified in resident council about group activities on the weekend. RI #2 was asked how many group activities had been offered during the weekend. RI #2 said none. RI #2 was asked why should the facility offer group activities on the weekend. RI #2 explained if they did not have activities they would just sit with nothing to do. RI #2 was asked how many activity staff provided group activities during the weekend. RI #2 said none because the activity staff did not work on Saturdays and Sundays. RI #2 was asked would he/she like more activities offered throughout the weekend. RI #2 said sure. RI #2 was asked who had he/she spoken with about their wanting more activities offered on the weekend. RI #2 explained they had spoken with the Activity Director. RI #2 was asked what happened when he/she were not offered ongoing activities on the weekends. RI #2 said he/she ended up with nothing to do and did not like to just sit. RI # 5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #5's Care Plan with a start date of 01/19/2018 revealed the resident enjoyed doing things with groups. On 03/01/2018 at 1:48 p.m., an interview was conducted with RI #5 regarding the issue identified in resident council about group activities on the weekend. RI #5 was asked how many group activities had been offered during the weekend. RI #5 said they had not had any. RI #5 was asked why should the facility offer group activities on the weekend. RI #5 explained they would not have anything to do to get them up and going. RI #5 was asked how many activity staff were providing group activities during the weekend. RI #5 said one. RI #5 was asked would he/she like more activities offered throughout the weekend. RI #5 said yes. RI #5 was asked who had he/she spoken with about their wanting more activities offered on the weekend. RI #5 explained he/she had spoken with CNAs and nurses. RI #5 was asked what happened when he/she were not offered ongoing activities on the weekends. RI #5 said he/she would go to bed since there would be nothing else to do. RI #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #26's Care Plan with a start date of 06/19/2017 revealed as an intervention the resident liked doing things with others and enjoyed dominoes and bingo. On 02/28/18 at 5:50 p.m., an interview was conducted with RI #26 regarding the issue identified in resident council about group activities on the weekend. RI #26 was asked how many group activities had been offered during the weekend. RI #26 said none that he/she could recall. RI #26 was asked why should the facility offer group activities on the weekend. RI #26 explained they would not have anything to do to get them up and going if activities was not offered on the weekend. RI #26 was asked how many activity staff were providing group activities during the weekend. RI #26 explained if they had one activity person for weekend activities, the facility would pull them away from activities to help on the hall. RI #26 was asked would he/she like more activities offered throughout the weekend. RI #26 said yes, because it would make it interesting instead of having the resident in their rooms with nothing to do. RI #26 further explained they only had church on Sundays and that would be it. RI #26 was asked who had he/she spoken with about his/her wanting more activities offered on the weekend. RI #26 said he/she had not spoken with staff but had spoken about it with other residents. RI #26 was asked what happened when he/she was not offered ongoing activities on the weekends. RI #5 said he/she would become bored with nothing to do. RI #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review or RI #39's Care Plan with a start date of 01/09/2018 revealed the resident chose bingo as his favorite activity. On 02/28/18 at 5:38 p.m., an interview was conducted with RI #39 regarding the issue identified in resident council about group activities on the weekend. RI #39 was asked how many group activities had been offered during the weekend. RI #39 said activities on the weekends had stopped because the staff had been pulled out of activities to work on the halls. RI #39 was asked why should the facility offer group activities on the weekend. RI #39 explained because there would be nothing to do. RI #39 was asked how many activity staff were providing group activities during the weekend. RI #39 said there had not been any activities because the staff had been pulled out of activities to work on the halls. RI #39 was asked would he/she like more activities offered throughout the weekend. RI #39 said yes, he/she would like more activities on the weekends especially bingo. RI #39 was asked who had he/she spoken with about his/her wanting more activities offered on the weekend. RI #39 explained he/she had spoken with a nurse but could not recall her name. RI #39 was asked what happened when he/she was not offered ongoing activities on the weekends. RI #39 explained he/she would end up sleeping or sitting on the porch watching cars go by. RI #39 further explained he/she did not like being in his/her room all day. RI #43 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #43's Care Plan with a start date of 01/09/2018 revealed the resident enjoyed doing things with groups of people. On 03/01/18 at 1:55 p.m., an interview was conducted with RI #43 regarding the activities issue discussed in resident council. RI #43 explained they had not had activities on the weekend due to not having enough activity staff for the month of February. RI #43 was asked why should the facility have an ongoing group activities on the weekend. RI #43 explained activities on the weekends would keep the residents from getting depressed or becoming home sick. RI #43 also stated some residents cry because they did not have relatives to visit and activities helped keep their minds off of that. On 03/01/2018 at 2:15 p.m., an interview was conducted with EI 3, Activity Director. EI #3 was asked what days did she directly provide activities to residents. EI #3 said Monday thru Friday and the CNAs were to carry on with activities on the weekend. EI #3 was asked was she aware staff had been pulled to work on the halls on the weekend and activities had not been offered as scheduled to residents. EI #3 said she was aware. EI #3 was asked why should activities be offered as scheduled on the weekends. EI #3 said to keep the residents engaged and active. EI #3 was asked what may occur when group activities were not offered as scheduled on the weekend. EI #3 explained if they are not doing independent activities themselves they may become board.

Based on record reviews, observations and interviews, the facility failed to ensure: 1. that spoons, forks, knives were not wet nesting in a cylinder and pans were not wet netting on the dry rack, 2. dented cans were not in with regular cans, 3. a staff member had a hair net on while in the kitchen, 4. plates were not dirty or stained and, 5. food items were labeled. This had the potential to affect 80 of 81 resident who receive meals from the kitchen. Findings Include: 1) A review of a policy titled, STORAGE OF POTS, DISHES, FLATWARE, UTENSILS with a effective date of January, 2015 revealed: Policy: Pots, dishes, and flatware are stored in such a way as to prevent contamination by splash, dust, pests or other means. Procedure: . Air dry pots, dishes, flatware, and utensils before storage, or store in a self-draining position. Do not stack or store when wet . On 1/18/2017 at 11:00 a.m., the survey observed pans stacked on top of each other. The pans were stacked wet on top of each other. One pan was face up with water in it ready to be used. Spoons, forks and knives were wet nesting in a cylinder. On 1/19/2017 at 8:00 a.m., an interview was conducted with Employee Indentifer (EI) #4, Executive Chef. EI #4 was asked did he see spoons, forks, knives and pans that were wet nesting. EI #4 replied, yes ma'am. EI #4 was asked did he remove the knives, forks, and spoon from the line, EI #4 replied, he did not., they needed to be utilized. EI #4 was asked who was responsible for making sure utensils were dry. EI #4 replied, he was and EI #6, patient service. EI #4 was asked what did the facility policy say about wet nesting. EI #4 replied, allow the utensils to air dry at an angle so the water can run down. EI #4 was asked did you see a pan ready to use with water in. EI #4 replied, yes ma'am. EI #4 was asked what was the potential harm when pans, spoons, forks and knives were wet nesting and given to the resident. EI #4 replied, the potential development of mildew. On 1/19/2017 at 8:50 a.m., an interview was conducted with EI #6, patient services. EI #6 was asked did you see spoons, forks and knives wet nesting. EI #6 replied, yes, they were wet. EI #6 was asked who was responsible for making sure utensils were dry. EI #6 replied, he was supposed too, but was told to do another task. EI #6 was asked how should utensils be allowed to dry. EI #6 replied, they should air dry for 30 minutes. EI #6 was asked what was the potential harm when spoons, forks and knives were wet nesting and given to the residents. EI #6 replied, He did not know. On 1/19/2017 at 8:48 a.m., an interview was conducted with EI #5, cook. EI #5 was asked to explain what he saw on the ready to use pan rack. EI #5 replied, some of the pans had water around them. EI #5 was asked how were they stacked. EI #5 replied on top of each other. EI #5 was asked what was the potential harm when pans are wet nesting. EI #5 replied, growth of harmful bacteria. 2) A review of a policy titled, FOOD PRODUCTION SERVICE STORAGE AND DISTRIBUTION STANDARDS with an effective date of January, 2015 revealed: .GUIDELINES FOR DENTED CANS . there is a designated place in the storeroom for dented cans which are ultimately discarded . On 1/17/2017 at 4:50 p.m., the surveyor observed a can of beef broth with a dent at the top near the opening, a can of tomatoes dented at the top, crushed pineapples dented and ripe olives dented at the top and bottom. On 1/19/2017 at 8:14 a.m., an interview was conducted with EI #4. EI #4 was asked why were there dented cans in with regular cans. EI#4 replied, staff restocking lead to the cans falling onto the floor. EI #4 was asked what was the facility policy on dented cans. EI #4 replied, put the can in a separate storage rack. EI #4 was asked who was responsible for removing dented cans from the regular can section. EI #4 replied, whoever was stocking. EI #4 was asked what was the potential harm if residents were served food from dented cans. EI #4 replied [DIAGNOSES REDACTED]. On 1/19/2017 at 9:40 a.m., an interview was conducted with EI #3, dietary manager. EI #3 was asked what was the facility policy on dented cans. EI #3 replied, put it on a log sheet, date and throw away. EI #3 was asked who was responsible for removing dented cans from the regular can section. EI #3 replied, employees who come across it. EI #3 was asked what was the potential harm if residents were served food from dented cans. EI #3 replied, food poison. 3) A review of a policy titled, HAIR RESTRAINTS with an effective date of March, 2013 revealed: Policy: Associates will wear hair restraints regardless of length of hair . at all times in the kitchen . On 1/18/2017 at 11:00 a.m., the surveyor observed the cook in the kitchen with no hair net on under her hat. The back part of her hair was not covered and she was serving food. On 1/19/2017 at 9:47 a.m., an interview was conducted with EI #3. EI #3 was asked when should staff wear hair nets in the kitchen. EI #3 replied, at all times. EI #3 was asked was there a worker in the kitchen without a hair net. EI #3 replied, yes. EI #3 was asked what was the facility policy on wearing hair nets in the kitchen. EI #3 replied, wear a hair net all the times. EI #3 was asked what was the potential harm when hair nets are not worn in the kitchen. EI #3 replied, contamination of hair getting into the food. On 1/19/2017 at 1:12 p.m., an interview was conducted with EI #7, patient service. EI #7 was asked when should you wear hair nets in the kitchen. EI #7 replied, at all times. EI #7 was asked did she have a hair net on 1/18/2017. EI #7 replied, no. EI #7 was asked why not. EI #7 replied, she was busy and forgot. EI #7 was asked what was the facility policy on wearing hair nets in the kitchen. EI #7 replied, they must have one on at all times. EI #7 was asked did she serve food with no hair net on. EI #7 replied, yes. EI #7 was asked what was the potential harm when hair nets were not worn in the kitchen. EI #7 replied, hair can get into the food. 4) A review of a policy titled, CHIPPED AND DAMAGED CHINA with an effective date of January, 2015 revealed: Policy: Cups, saucers, plates, dishes, glasses, and trays . All damaged items are immediately taken out of service and discarded .Procedure: .1. Consider any tableware found with chips, cracks, or glazing to be damaged and discard them immediately . On 1/18/2017 at 11:00 a.m., the surveyor observed the cook, serving plates with stains in them or dirty. The plates had scratches and were brown looking. There were four plates with dried eggs embedded into the plate. On 1/19/2017 at 8:06 a.m., an interview was conducted with EI #4. EI #4 was asked when were stained plates used to serve the residents. EI #4 replied, yesterday, 1/18/2018. EI #4 was asked why were they used. EI #4 replied, they had to be used for the residents. EI #4 was asked what was the facility policy on serving stained and dirty plates to the residents. EI #4 replied, stained plates were not to be used and dirty plates were to be put to the side. EI #4 was asked who was responsible for making sure plates were clean and free from stains. EI #4 replied, EI #7. EI #4 was asked what was in some of the dirty plates. EI #7 replied, dried eggs. On 1/19/2017 at 9:44 a.m., an interview was conducted with EI #3. EI #3 was asked when were stained and dirty plates used. EI #3 replied, at the lunch menu on 1/18/2017. EI #3 was asked why were they used. EI #3 replied, they did not look stained, and they were thrown away. EI #3 was asked what was the facility policy on serving stained or dirty plates to the residents. EI #3 replied, throw them out. EI #3 was asked why were some of the plates dirty. EI #3 replied, eggs were baked on. EI #3 was asked what was the potential harm when residents were served food on dirty plates. EI #3 replied, food poison. On 01/19/2017 at 1:22 p.m., an interview was conducted with EI #7. EI #7 was asked when were stained plates used to serve the residents. EI #7 replied, yesterday, 1/18/2017. EI #7 was asked why were they used. EI #7 replied that was all they had. EI #7 was asked how many plates were taken out because they were dirty or stained. EI #7 replied, seven dirty plates, stained plates were to many to count. EI #7 was asked what was the facility policy on serving stained or dirty plates to the residents. EI #7 replied, do not do it. EI #7 was asked, what was in some of the dirty plates. EI #7 replied, eggs. EI #7 was asked why was it there. EI #7 replied, someone did not scrub the plate. EI #7 was asked what was the potential harm when residents are served food from dirty plates. EI #7 replied, contamination or bacteria. EI #7 was asked did she serve food on dirty plates. EI #7 replied, yes. 5) A review of a policy titled, FOOD PRODUCTION SERVICE STORAGE AND DISTRIBUTION STANDARDS with an effective date of January, 2015 revealed: . FOOD STORAGE PROCEDURES . Any opened or prepared products should be labeled and dated . On 1/17/2017 at 5:15 p.m., the surveyor observed french fries, chicken fingers, chicken patties and potato tots opened with no identifying information on the packages. On 1/19/2017 at 9:52 a.m., an interview was conducted with EI #3. EI #3 was asked when should food items be labeled. EI #3 replied, upon opening. EI #3 was asked who was responsible for labeling. EI #3 replied, the person who opened it. EI #3 was asked what was the facility policy on labeling food items. EI #3 replied, label and date it when opening. EI #3 was asked what was the potential harm when food was not labeled in the refrigerator, freezer or dry storage. EI #3 replied, food hazard. On 1/19/2017 at 1:29 p.m., an interview was conducted with EI #7. EI #7 was asked what was in the refrigerator opened with no open or use by date. EI #7 replied, chicken tender, potato tots and chicken breast. EI #7 was asked why was it not labeled with an open and expiration date. EI #7 replied, whoever took it out last did not put a label on it. EI #7 was asked who was responsible for labeling. EI #7 replied, everyone in the kitchen. EI #7 was asked what was the facility policy on labeling. EI #7 replied, everything that was opened had to be labeled. EI #7 was asked what was the potential harm when food was not labeled in the refrigerator, freezer, or dry storage. EI #7 replied, contamination, bacteria, and death. EI #7 was asked what should be on the food label. EI #7 replied, the item name, date, time and how long before it expires.

Based on observations, record review and interview the facility failed to ensure a safe environment by having unsecured power cord, surge protector and refrigerators were stored off the residents floor for Resident Identifier (RI) #9 and having unsecured power strips with multiple power cords plugged into it for two of the four units surveyed. This affected one sampled resident and two of four halls surveyed. In addition the facility failed to provide a mattress that fit the bed frame for RI #4, creating the potential to fall and become entrapped. This affected one of ten residents assessed for a proper fitting mattress. Findings include: 1. The facility Standard Policy & Procedures with an issue date of 02/2016 revealed, .5. Any major electrical equipment/appliance must be plugged directly into a wall outlet. (not into a surge protector). On 1/18/17 at 10:55 a.m., RI #9's room was observed to have the following: 1. The unsecured electrical cord for the air mattress was noted to be on the floor from the distal end of the bed, running across the floor to an electrical outlet power strip that was laying un-tethered on the floor adjacent to the wall. The un-tethered power strip also had two other small electronic devise cords attached. The small refrigerator sitting directly on the floor was plugged into the surge protector. RI #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum (MDS) data set [DATE] revealed RI #9 had a brief interview for mental status (BIMS) score of four which indicated RI #9 had severe decision making skills. RI #9 was totally dependent for all activities of daily living. On 1/19/17 at 1:30 p.m., Employee Identifier (EI) #1, Administrator accompanied the surveyor to observe RI #9's room. When asked what he observed, he replied, The surge protector is on the floor, the cord to the air mattress is laying on the floor-- from the bed and the refrigerator is on the floor. The surge protector should not be lying there. When asked what was the potential for problems, EI #1 replied there was a trip hazard from the cords and a fire hazard from the appliances. During a tour with EI #2, the facilities maintenance director on halls one and three, Surge Protectors were noted to be in Room Locator (RL)'s #13, #1, #2, #3, #4, #5, #24, #25 and RL #7. When asked what type issues or harm was there to have the power strips, RI #2 said trip (hazard) and electrical hazards. RI #2 further stated they should be mounted on the wall. 2) An Owner's Operator and Maintenance Manual for RI #4's bed documented: . The manufacturer recommends that the mattress be centered on the bed frame. Otherwise, individuals may become entangled between the bed rail and the bed frame. Replacement mattresses . with dimensions different from the original equipment supplied or specified by the bed frame manufacturer are not interchangeable. Variations in bed side rail design, width and thickness or firmness of the mattress could cause/contribute to entrapment. RI (Resident Identifier) #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An Admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/2/2016 indicated RI #4 required extensive assistance of two plus person physical assist with bed mobility and had lower extremity impairments on both sides. RI #4's January 2017 physician's orders [REDACTED]. On 1/18/2017 at 9:54 a.m., an observation of incontinent care was performed for RI #4. RI #4 was noted in bed with quarter side rails in use. When the CNAs (Certified Nursing Assistants) pulled the sheet and blanket down to perform the care, it was observed the mattress did not fit the bariatric bed frame: The bed frame was exposed on the left side of the bed approximately three to four inches, and the right side of the bed frame was exposed approximately five to six inches. The surveyor asked RI #4 about the mattress to the bed. RI #4 stated It's been like that since I've been here. On 1/18/2017 at 10:57 a.m., an interview was conducted with EI (Employee Identifier) #8, RN (Registered Nurse) Supervisor. EI #8 was asked to accompany the surveyor to RI #4's room. When asked what type of bed the resident had, EI #8 said a bariatric bed. EI #4 was asked if the mattress properly fit the bed frame, and EI #8 said no. EI #8 was asked should the mattress completely cover and appropriately fit the bed frame. EI #8 said, yes. EI #8 was asked was the bed frame visible on both sides of the mattress. EI #8 said, yes. EI #8 was asked what was the potential harm for a resident when a mattress did not properly fit the bed frame. EI #8 said the resident could get caught between the rails. On 1/18/2017 at 11:30 a.m., an interview was conducted with EI #9, DON (Director of Nursing). EI #9 was asked to accompany the surveyor to EI #4's room. EI #9 was asked what type of bed did RI #4 have. EI #9 said a bariatric bed. When asked did the mattress on the the bed fit the bariatric bed frame, EI #9 lifted back the sheet and blanket to look at the mattress and stated the mattress fit head to toe but not on the sides. EI #9 was asked if the mattress should fit the bed frame appropriately and cover the bed frame. EI #9 said yes. EI #9 was asked how much bed frame did she see on the right and left sides of the mattress. EI #9 said at least four inches on each side, it could be more. EI #9 was asked what was the potential harm for a resident when a mattress did not properly fit the bed frame. EI #9 said the resident could get entrapped. During a follow-up interview on 01/19/2017 at 2:20 p.m., EI #9, the DON, was asked how often were bed frames and mattresses checked for problems. EI #9 stated yearly and when problems are found. EI #9 was asked who was responsible for checking and identifying problems with the bed frames and mattresses. EI #9 said nursing.

Based on observations and interview the facility failed to ensure a homelike environment of the facility by: 1). Doorways were free of chipped and flaking paint in three of four units. 2). Doors and the corner molding of the old 300 Unit Nursing Station were free of sharp, jagged corners and edges. 3) The shower unit for the 100/200 unit was free of broken tile, shower vent was free of lint and dust, and the ceiling above the sprinkler head was free of dust. This affected three of four units in the facility. Findings include: On 01/19/17 at 12:50 p.m. during a walking tour with Employee Identifier (EI) #2, Facilities Maintenance Director, the following areas were observed and identified. Room Locator (RL) #9 there was a black mark on the wall and a hole in the wall. RL #10 was observed to have broken and jagged areas. RL #11 was observed to have broken tile in the shower area, the shower vent was observed with lint and dust. There was dust also observed on the ceiling above the sprinkler head also in RL #11. RL #12 was observed to have torn and jagged areas just above the kick plate. RL #13 (several rooms on the unit) were observed with doorways with chipped and flaking paint. There were jagged and sharp edges on the corner moldings of RL #14. There were chipped and flaking paint on the hallway door and bathroom door of RL #15. There was chipped and flaking paint on the hallway and bathroom door for RL #16 and the door was observed to have sharp, jagged areas. RL #17 was observed to have chipped, flaking paint and the door had jagged rough areas. RL #18 was observed to have chipped, flaking paint. The doorway of RL #19 was observed to have chipped paint, the door had sharp and gouged areas. RL #20's back side of the was observed to have gouged areas and also the bathroom door to RL #20. The right side of the door was jagged on RL #21. The area above the kick plate on the door for RL #22 was scraped and gouged. On 01/19/17 at 1:30 p.m., an interview was conducted with EI #2, Facilities Maintenance Director. EI #2 was asked who was responsible for the overall maintenance of the nursing home. EI #2 replied, me. When asked how are maintenance issues submitted, EI #2 replied, the maintance request form is located on each hall, they are filled out and we pick them up twice daily. EI #2 was asked what kind of harm or issue could come to a resident with the jagged door areas. EI #2 replied, skin tear.

Based on observations, record review, and interview, the facility failed to ensure the dish machine reached and maintained a wash temperature of 160 degrees Fahrenheit (F) and a rinse temperature of 180 degrees F. Further, the facility failed to monitor the concentration of bleach used as a back-up sanitizer to assure the dishes were properly sanitized. This had the potential to affect all 76 residents for whom meals were prepared and served during the survey. Findings include: During the initial tour of the kitchen on 12/08/2015 at 8:50 AM, the surveyor observed staff utilizing the dish machine. Two cycles were observed and the following temperatures were noted: wash- 118.1 degrees F and rinse- 107.5 degrees F. The digital display also gave an error message designated by an exclamation point inside a triangle that stated low rinse temperature. Employee Identifier (EI) #3, the Dietary Manager, stated the machine should wash at a temperature of 160 degrees F and rinse at 180 degrees F. The Dietary Manager also stated they do not test the concentration of the sanitizer used with the machine, only temperatures because their servicing company came out to check the machine one time per month. Staff continued to use the machine. The facility's Dishmachine Temperature Log listed the following specifications for use: .Temperature Goals: Wash-160 Rinse-180 Chlorine = 100 ppm (parts per million). Review of the Dishmachine Temperature Logs for July 2015 through December 2015 revealed the facility had stopped documenting checks of the chlorine concentration beginning in November. For the month of November 2015, the dishmachine had not reached the temperature requirements for the following dates: 1-6, 8-13, 16-24, or the 30th. There was no documentation of temperatures on the 7, 14-15, 25, or the 29th. For December 2015, the machine did not reach the required temperatures on the 2-8th. There was no documentation for the 1st. A service/repair man with the facility's dishmachine servicing company was interviewed on 12/09/2015 at 11:19 AM. He stated the facility owned its machine. He said when he took over, the machine was functioning as a high temperature machine. The service/repair man stated he had replaced the booster heater but a few months later the temperatures were dropping. He said at that point, for safety purposes, he added bleach to the machine to sanitize the dishes. The repairman said with bleach the minimum temperature for the water would be 120 degrees F for the wash and 130 degrees for the rinse. He explained at higher temperatures of 170-175 degrees F the water can burn off the bleach. When asked if the facility should be monitoring the concentration of bleach, he said if the machine is not up to the proper temperatures they should. When asked how frequently staff should be monitoring the water temperature and concentration, he stated one time per shift and monitoring throughout. He explained the facility should be checking the chlorine to ensure at a concentration of 50 to 100 ppm on the final rinse if the machine was not up to the proper temperatures. The service/repair man stated if the facility was not checking the concentration of the bleach they could not ensure the dishes are sanitized. EI #3, the Dietary Manager, was interviewed on 12/09/2015 at 3:45 PM. EI #3 explained their dishmachine was a hot water machine but they also had bleach on it as a back up in case the temperature was not high enough. She said there were no temperature requirements for the bleach. She also stated they did not have a manual or any paperwork on the operating specifications of their machine. EI #3 said if the temperature was less than 180 degrees F the sanitizer was on the machine but said staff should also notify her so she can have service check the machine. EI #3 said staff had never reported to her the temperatures were not high enough. When asked how she could ensure the dishes were sanitized if they were not checking the bleach concentration, EI #3 said you can not. She said they do not check it every day, just randomly. She then said they should really be checking the concentration of the bleach anytime the machine was not hot enough.

Based on observations, record review, and interview, the facility failed to ensure residents with physician's orders for mechanical soft and pureed therapeutic diets were served the portion sizes as planned for the 12/09/2015 breakfast meal. This had the potential to affect all 35 residents with orders for mechanical soft or pureed diets. Findings include: Review of the facility's preplanned menu for the 12/09/2015 breakfast meal listed the following planned portion sizes: Mechanical soft sausage: #12 scoop (1/3 cup) with 2 ounces gravy Pureed Belgian Waffle: #6 scoop (2/3 cup) Pureed strawberries: #12 scoop Pureed Sausage: (2) #30 scoops (to equal approximately 2 ounces) During trayline observations on 12/09/2015 beginning at 6:34 AM, staff were observed using only one #30 scoop to serve residents with orders for pureed meat, only half of the amount planned. The pureed waffles and strawberries were prepared together, instead of two separate items. Staff used a #12 scoop to serve the waffles combined with strawberries. Staff did not adjust the serving size to take into account the the two items were combined. Also, staff used a #16 scoop (1/4 cup) for the mechanical soft sausage, less than the amount planned. Employee Identifier (EI) #3, the Dietary Manager, was interviewed on 12/09/2015 at 3:45 PM. During the interview, EI #3 reviewed the preplanned menus and confirmed the planned portion sizes as listed above. After reviewing the menu for the mechanical soft sausage, EI #3 said, Oh, we didn't serve that with gravy. She also stated using a #16 scoop was significantly less than the planned portion size. EI #3 also explained the planned portion sizes of the pureed waffle and strawberries should have been combined to equal one cup, and stated they had only served 1/3 cup to residents. When asked about the pureed meat, EI #3 stated she noticed staff was using only one #30 scoop but said she did not want to correct them in front of the surveyor. EI #3 stated if staff did not serve the portion sizes as planned it could result in weight loss and stated she did not want the residents to be hungry. EI #4, the facility's dietitian, was interviewed on 12/09/2015 at 3:10 PM. EI #4 stated the current menus were new and she was unaware staff were combining the pureed waffles and strawberries. EI #4 said she would not recommend combining the two. EI #4 explained the serving sizes are based on the nutritional analysis of the menu and said if staff did not follow it, they did not provide the menu she approved. EI #4 said residents were shorted about 15 grams of carbohydrates. When asked about staff using a #16 scoop for the mechanical soft sausage instead of a #12, EI #4 said residents were getting less fat and calorie content and a little less protein. She said the same was true for the pureed sausage, residents received half of the portion size planned. When asked why it was important for staff to serve the correct portion sizes, EI #4 said to ensure residents are getting the proper nutrition and needs are met.

Based on observations, record review, and interviews, the facility failed to ensure Resident Identifier (RI) #9 was served the 12/09/2015 lunch meal at the same time as the other resident seated at the same table in a manner to preserve RI #9's dignity. This affected RI #9, one of nine residents for whom meals were observed. Findings Include: RI #9 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of RI #9's quarterly Minimum Data Set Assessment, dated 11/25/2015, indicated RI #9 required set-up assistance with meals. On 12/09/2015 at 12:05 PM RI #9 was observed in the main dining room, seated at a table with one other resident. RI #9 and the other resident were seated directly across from one another. RI #9 did not have a lunch tray; however the other resident at the table had received a tray and set-up assistance and was eating the meal. RI #9 stated, I don't got one yet, and I'm hungry. It was noted there were no other trays for staff to pass out and staff were waiting on the next cart of trays from the kitchen. At 12:15 PM, Employee Identifier (EI) #1, a Licensed Practical Nurse, was noted entering the dining room with one tray, which was delivered to RI #9. EI #1 said he was unsure how long RI #9 had been waiting for a tray but said he noticed the other resident was already eating. EI #1 said he did not think the facility had a policy on serving residents meals seated at the same table , but said he did not like seeing someone eat in front of someone without a tray. EI #1 said it would make him feel hungry. The other resident seated with RI #9 had completed 75 percent of the meal by the time RI #9 received a tray. EI #2, the Director of Nursing (DON), was interviewed on 12/09/2015 at 1:18 PM. EI #2 provided a copy of a new policy addressing meal service in the dining room. She stated there was no policy in effect prior; however, explained their routine had always been to serve all residents at a table before moving to another table. EI #2 was asked how long would be permissible for a resident to sit waiting on a tray while residents at the same table ate their meal. EI #2 said less than a minute if at all possible. The DON explained she had spoken with the Dietary Manager that afternoon because trays for residents seated at the same table should not be split up on two separate carts. EI #2 said RI #9 had been eating in the dining room for three weeks and it should not have happened. EI #2 stated she would be mad if someone at the table had finished their meal and she had not received hers. EI #2 said it was a dignity issue.

Based on observations, record review and interview: 1. The facility failed to assure dishes and utensils were effectively sanitized by the dishmachine to prevent potential food borne illness. 2. The facility failed to follow correct manual dishwashing procedures by assuring the correct water temperature for accurately determining the chemical concentration of final rinse water. 3. The facility failed to ensure hot foods were maintained at 135 degrees of above when served by the trayline. Failure to monitor/document was observed on two of four days of the survey. 4. The facility failed to assure plates and equipment (blender) were air dried (2013 Food Code 4-901.11). 5. The facility failed to prevent potential cross contamination by bare hand food contact by direct care staff during resident dining. The above practices posed the potential for food contamination and compromised food safety. This had the potential to affect 71 of 73 residents who received meal trays from dining services. Findings include: 1. The facility failed to assure dishes and utensils were effectively sanitized by the dishmachine to prevent potential food borne illness. The 2013 Food Code by the United States Public Health Service (USPHS) and the Food and Drug Administration (FDA) included the following: "4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. (A) Except as specified in ? (B) of this section, in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90oC (194oF), or less than: (1) For a stationary rack, single temperature machine, 74oC (165oF); or (2) For all other machines, 82oC (180oF)." "4-501.15 Warewashing Machines, Manufacturers' Operating Instructions. (A) A WAREWASHING machine and its auxiliary components shall be operated in accordance with the machine's data plate and other manufacturer's instructions." On 12/10/14 at 9:00 AM, the dishmachine gauges registered 135 degrees Fahrenheit (F) for the wash temperature and 135 degrees F. for the final rinse temperature. A review of the posted "Dishmachine Temperature Log" revealed guidance to staff: "Temperature Goals: Wash 160; Rinse 180 Chlorine:= 100 PPM (Parts Per Million). The columns identified "wash", "rinse", sanitizer checked (staff initials) and readings for Morning, Midday and Evening. The documented temperature for 12/10/14 was wash 160 and rinse 180. The surveyors observation of the machine operation indicated temperatures were not as documented. On 12/10/14 at 9:05 AM, the CDM (Certified Dietary Manager), EI #5 was interviewed. EI #5 indicated the machine was modified to use both high temperature and chemicals for sanitizing. EI #5 stated, "Supervisors are to check the chemical concentration each meal". EI #5 was asked, does the record show that supervisors have determined the chlorine concentration each meal? EI #5 responded, no. The facility policy/procedure subject "Temperature Monitors", dated 4/7/97 and revised 8/22/13 was reviewed. The "Supervisors Check List" documented "Dishmachine temperature/chlorine checked and recorded." On 12/11/14 at 1:30 PM, the data plate of the dishmachine indicated: "Wash 160, Rinse 180". The final rinse temperature was sub-standard and efficacy of any chemical utilized was not monitored. 2. The facility failed to follow correct manual dishwashing procedures by assuring the correct water temperature for accurately determining the chemical concentration of final rinse water. On 12/08/14 at 6:00 PM, manual dishwashing was observed. The method for sanitizing was chemical (Quat). A review of the December 2014, monitoring log revealed a PPM score was recorded but no water temperature monitoring documented for 22 of 22 opportunities. A review of the manufacturer's directions revealed that chemical concentration "testing solution should be at room temperature - 65 F-75 degrees F." The rationale was "Quat test strips are sensitive and they should be read at room temperature...higher temperatures will result in inaccurate readings." Staff failed to monitor water temperature. On 12/09/14 at 11:15 AM, the final rinse water temperature measured 114 degrees F. The CDM EI #5 was asked, does staff monitor and document water temperature? EI #5 responded, no Ma'am not for that compartment sink. 3. The facility failed to assure hot foods were maintained at 135 degrees or above when served by the trayline. Failure to monitor/document was observed on two of four days of the survey. The 2013 Food Code by the United States Public Health Service (USPHS) and the Food and Drug Administration (FDA) included the following: "3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under ?3-501.19, and except as specified under ? (B) and in ? (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57oC (135oF) or above..." On 12/08/14 at 5:30 PM, an observation was made of residents eating in the main dining room. The menu entree was "Chicken Tenders". A resident was observed to have been served Steak/Gravy. A review of the facility tray line holding temperature log revealed that no monitoring data was recorded for the steak/gravy served. On 12/11/14 at 9:08 AM, the CDM EI #5 was asked, during the supper meal on 12/08/14, did the staff monitor/document the holding temperature of Steak/Gravy served instead of Chicken Tenders? EI #5 responded, No. On 12/09/14 at 11:55 AM, the trayline was observed. Puree diet plan was for Mashed Potatoes/Gravy. The holding temperature of the gravy was not documented. The diet summary recorded by the CDM EI #5 indicated a census of 12 residents with a diet order for Puree. On 12/11/14 at 9:08 AM, EI #5 was asked, Did staff monitor/document temperature for the gravy served on 12/09/14 (Mashed Potatoes) prior to surveyor identifying. EI #5 responded, No. 4. The facility failed to assure plates and equipment (blender) were air dried. The 2013 Food Code by the United States Public Health Service (USPHS) and the Food and Drug Administration (FDA) included the following: "Drying 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried ..." An observation on 12/08/2014 at 5:45 PM of the blender stored on the stand with top covering revealed water was pooled and standing on the bottom of the container. The evening Food Service Supervisor, Employee Identifier (EI) #4 was asked, what do you see? EI #4 responded "water". EI #4 was asked, what was it supposed to be? EI #4 responded, "dry". The Certified Dietary Manager (CDM), EI #5 was interviewed on 12/11/14 at 9:08 AM and asked if the blender had been air dried on 12/08/14 and the response was no. On 12/09/14 at 11:55 AM deep plastic plates were observed on the tray line. Seven of 7 contained moisture. On 12/11/14 at 9:08 AM EI #5 was asked to recall the observation on 12/9/14 of deep plates with moisture and not air dried. EI #5 was asked, what was the problem (not air dried) per your Serv-Safe training? EI #5 responded that moisture was an element for potential bacterial contamination. 5) The facility failed to prevent potential cross contamination by bare hand contact by direct care staff during resident dining. Review of a facility policy titled, "FOOD SERVING" with a revised date of 04/04/04 revealed the following: "...The food should be served using santized utensils and equipment. If the food server's hand should come into contact with the food during serving, gloves should be worn..." The 2013 Food Code by the United States Public Health Service (USPHS) and the Food and Drug Administration (FDA) included the following: "... Preventing Contamination by Employees 3-301.11 Preventing Contamination from Hands... (B) ... FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing EQUIPMENT. (C) FOOD EMPLOYEES shall minimize bare hand and arm contact with exposed FOOD that is not in a READY-TO-EAT form..." RI #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of RI #17's Admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/26/14 revealed RI #17 required set up help for eating. On 12/09/14 at 12:18 P.M. during a meal observation, RI (Resident Identifier) #17 was seated at a table in the 500 Hall dining room. EI #2, CNA (Certified Nursing Assistant) set up RI #17's meal tray. RI #17 asked for salt and pepper on the sandwich. EI #2 took the bread off of the sandwich with her bare hands, put the salt and pepper on the sandwich and then replaced the bread on the sandwich with her bare hands. On 12/10/14 at 10:00 A.M. EI #2, CNA was interviewed and asked how did she normally set up a resident's meal tray for them. EI #2 stated they would tell the resident's what they were having and what was on his/her tray, open packets and straws and would ask the resident if he/she wanted condiments or salt and pepper and if they did they would fix their food the way they wanted. When asked how she set up RI #17's tray on 12/09/14 EI #2 stated she did not remember but she would always fix the meal tray for RI #17. When asked if she had worn gloves while fixing RI #17's tray, EI #2 replied, "No." EI #2 was asked what was the potential harm if a resident's food was touched with bare hands, to which she replied, "Pass along germs." On 12/10/14 at 4:22 P.M. EI #3, DON (Director of Nursing) was asked what the CNAs were taught regarding serving resident's their meal trays and setting them up, to which she replied, "They should use hand sanitizer between trays, if they need help with cutting up meats, open up any condiments, set up drinks and make sure what they have on their tray is what is on their tray card." EI #3 was asked if the CNAs were taught to wear gloves when setting up a resident's tray to which she replied, "No." When asked what was the potential for harm if a resident's food was touched with bare hands, EI #3 replied, "It's an infection control issue."

Based on record review and interview the facility failed to ensure an active QA (Quality Assurance) Committee was in place and met at least quarterly to discuss QA issues and the effectiveness of the QA program. The facility further failed to ensure the Medical Director was a vital member of the QA Committee and provided input into the QA issues and activity. These failures had the potential to affect all 73 residents in the facility. Findings Include: On 12/10/14 at 11:05 A.M. the surveyor asked for a QA policy and sign in sheets from their meetings. The surveyor was informed the facility did not have a policy on QA and there were no sign in sheets. The surveyor was presented with a typed description of the facility's "Daily Resident Care Meetings." The description had the time the meetings were held, attendees included, and what areas of care were discussed. Nowhere in this description did it include the medical director as an attendee or QA issues that were identified or the effectiveness of the QA process. The document provided was not a QA document and nowhere in the document did it state it was part of a QA program. On 12/10/14 at 9:45 A.M. EI (Employee Identifier) #3, DON (Director of Nursing) and acting Administrator was asked if the facility had a formal QA Committee to which she answered yes. When asked who was on this committee EI #3 stated it was herself, the assessment nurses, RN (Registered Nurse) supervisors and Social Services. She further stated they met weekly, every Friday. EI #3 was asked what formal method(s) did the facility have to identify issues that would require QA activity to which she answered by telling what areas of care they looked at each week and did not give a definitive answer to the question asked. When asked what formal method(s) did the facility have to identify deficiencies and evaluate the effectiveness of the QA process, EI #3 stated they just review policies and procedures and if they identify a new problem they present it to the group. EI #3 further stated she just wrote down what happened to make sure everything had been addressed. When asked if the Medical Director was involved in these meetings, EI #3 said he was not. On 12/10/14 at 4:35 P.M. a follow-up interview was conducted with EI #3. EI #3 was asked what her weekly meetings were called to which she replied, "focus meetings." When asked how the committee identified current and ongoing issues that required committee attention, EI #3 stated they review the 24 hour reports from Monday - Friday. EI #3 was also asked what method(s) did the committee use to develop action plans for such identified issues to which she replied, "Other than one of us being assigned to follow-up, that's how we do it." EI #3 was then asked how were action plans implemented and followed up upon to make sure they were effective to which EI #3 replied, "Just by following up with the individual who was responsible for doing it and making sure it was handled appropriately."

Based on record review and interviews the facility failed to ensure Unsampled Resident Identifier (URI) #'s 1-6 received their absentee ballot applications in a timely manner resulting in denial of their ballots. This affected 6 of 14 registered voters in the facility. Findings Include: Review of a facility policy titled, "Voting Policy" with the most recent revised date of 10/05/2000 revealed the following: "...STATEMENT OF PURPOSE: To establish a Voting Policy in order to protect the resident's right to vote...Procedure: ...If the resident's sponsor is unable to assist resident with voting and makes a request to Social Services or Activities Personnel, an absentee ballot will be provided...In the event that family members are unavailable and resident request to fill out absentee ballot, the resident may request assistance from individual of choice." On 12/09/2014 at 3:00 P.M. a Resident Group Meeting was held with 10 residents in attendance. Out of those 10 residents in attendance, 6 residents stated they were registered voters. The residents were asked if they were able to vote in the most recent elections held in November. They stated they were not because their absentee ballot applications were turned in too late resulting in denial of their ballots. 1) URI #1 was admitted to the facility on [DATE]. Review of URI #1's most recent Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 09/28/14 revealed URI #1 had a BIMS (Brief Interview for Mental Status) of 15 indicating URI #1 was cognitively intact. On 12/10/14 at 2:02 P.M. URI #1 was asked if he/she was a registered voter to which URI #1 replied "Yes." When asked if he/she received an absentee ballot for the most recent elections, URI #1 stated they did not. URI #1 further stated he/she spoke with EI (Employee Identifier) #1, Activity Director and was told EI #1 had called the court house and was told absentee ballot applications had been denied because they were late. 2) URI #2 was admitted to the facility on [DATE]. Review of URI #2's most recent Quarterly MDS with an ARD of 10/26/14 revealed URI #2 had a BIMS of 9 indicating URI #2 was moderately cognitively impaired. On 12/10/14 at 3:50 P.M. URI #2 was asked if he/she was a registered voter to which URI #2 replied, "Yes." When asked if he/she had received an absentee ballot for the most recent election, URI #2 said no. 3) URI #3 was admitted to the facility on [DATE]. Review of URI #3's most recent MDS with an ARD of 12/05/14 revealed URI #3 had a BIMS of 15 indicating URI #3 was cognitively intact. On 12/10/14 at 2:12 P.M. URI #3 was asked if he/she was a registered voter to which URI #3 replied, "Yes." When asked if URI #3 received an absentee ballot for the most recent election in November, URI #3 said no. URI #3 further stated the applications were late when they (the residents) got them and therefore were late being turned in. Therefore, they could not vote. 4) URI #4 was admitted to the facility on [DATE]. Review of URI #4's most recent Quarterly MDS with an ARD of 11/16/14 revealed URI #4 had a BIMS of 9 indicating URI #4 was moderately cognitively impaired. On 12/10/14 at 3:14 P.M. URI #4 was asked if he/she was a registered voter to which URI #4 replied, "Yes." When asked if URI #4 received an absentee ballot for the most recent election in November, URI #4 said he/she thought so but was unsure if it counted or not because they were late. 5) URI #5 was admitted to the facility on [DATE]. Review of URI #5's most recent Quarterly MDS with an ARD of 11/30/14 revealed URI #5 had a BIMS of 15 indicating URI #5 was cognitively intact. On 12/10/14 at 3:09 P.M. URI #5 was asked if he/she was a registered voter to which URI #5 said "Yes." When asked if URI #5 received an absentee ballot for the most recent election in November, URI #5 said he/she did but they were turned in late so the vote did not count. 6) URI #6 was admitted to the facility on [DATE]. Review of URI #6's most recent Quarterly MDS with an ARD of 10/12/14 revealed URI #6 had a BIMS of 15 indicating URI #6 was cognitively intact. On 12/10/14 at 3:06 P.M. URI #6 was asked if he/she was a registered voter to which URI #6 replied, "Yes." When asked if he/she received an absentee ballot for the most recent election in November, URI #6 stated yes but they were turned in late. On 12/10/14 at 8:43 A.M. EI #1 was interviewed and asked who was responsible for obtaining the applications for absentee ballots to which EI #1 replied, "I am." EI #1 further stated the absentee ballots were supposed to be submitted 30 days prior to an election. However, when asked were the voters applications submitted timely so they could vote, EI #1 stated she had sent the applications back but did not know it was supposed to be 30 days prior to the election therefore, they were never sent the ballots. When asked why the ballots were not received EI #1 said the applications were mailed late. EI #1 was asked why should the residents who were registered voters be able to vote, EI #1 stated, "Because that's their right."