Every finding on record at Woodland Village Rehabilitation and Healthcare Cen

Based on interviews, record review and review of a facility policy titled Select Menus, the facility failed to ensure Resident Identifier (RI) #81's food preferences for his/her supper meals on 05/04/21 and 05/05/21 were honored. This affected RI #81, one of five sampled residents reviewed for food preferences. Findings Include: Review of a facility policy titled Select Menus, with an effective date of 11/28/16, revealed the following: . Policy Selective menus will be provided to all residents within allowed dietary restrictions . Procedure 1. Selective menus are provided to all residents to make their own menu selections . Responsibility The Dietary Director is responsible for the implementation and overall compliance of this policy and procedure. RI #81 was admitted to the facility on [DATE]. RI #81's quarterly Minimum Data Set assessment, with an Assessment Reference Date of 04/14/21, revealed RI #81 scored 15 on the Brief Interview for Mental Status, indicating RI #81 was cognitively intact. On 05/04/21 at 8:56 AM, RI #81 informed the surveyor sometimes dietary would not send what he/she requested them to send. RI #81 said the residents get to choose what they want the day before by writing their request on a piece of paper. On 05/04/21 at 5:59 PM, RI #81's supper meal was observed by the surveyor. RI #81 was served a peanut butter and jelly sandwich, a bowl of cream of chicken soup, a bowl of ambrosia salad, a pack of Ms. Dash and a pack of salt and pepper. RI #81 said he/she did not want the ambrosia salad and he/she did not get his/her apple sauce and ice cream. Review of RI #81's supper meal tray card, dated 05/04/21, revealed RI #81 received everything he/she requested except the apple sauce and marble ice cream. On 05/04/21 at 6:10 PM, the surveyor conducted an interview with Employee Identifier (EI) #3, the Certified Nursing Assistant (CNA) assigned to care for RI #81. When asked who would be responsible for ensuring food items the resident requested were on the meal tray, EI #3 said the kitchen. On 05/05/21 at 6:22 PM, RI #81 was observed feeding him/herself the supper meal. RI #81 was served a peanut butter and jelly sandwich, potato wedges, a bowl of cream of chicken soup and marble ice cream. Review of RI #81's supper meal tray card, dated 05/05/21, revealed RI #81 received everything he/she requested except the apple sauce. On 05/06/21 at 10:27 AM, the surveyor conducted an interview with EI #1, the Registered Dietician. The surveyor asked EI #1 what system did the facility have in place for residents to request food items for their meals. EI #1 said the residents have tray tickets that were printed out which go to the hall the day before. EI #1 said typically the CNAs go around and ask the residents what they would like to eat for the next day for breakfast, lunch and dinner all at the same time. EI #1 said the tray tickets were returned to dietary and used to prepare the residents' food request. When asked who was responsible for ensuring the residents receive the requested food items, EI #1 said the staff on the tray preparing line. The surveyor asked EI #1 if a resident did not receive the requested food items, were their food preferences being honored. EI #1 said no.

Based on observation, interview, review of the Food and Drug Administration (FDA) (YEAR) Code, review of the facility's procedure for cleaning the coffee machine, and review of the facility's Dietary Cleaning - Daily Cleaning Schedule, the facility failed to: 1) ensure there was an air gap between the sewer system and the drains from the dishwashing machine, the three-compartment pot and pan sink, and the two-compartment food preparation sink; 2) prevent flies from entering the kitchen and contaminating food, food-contact surfaces and nonfood-contact surfaces; 3) ensure the final rinse of the dishwasher consistently reached a minimum of 180 degrees Fahrenheit (F) to sanitize the dishware, utensils and equipment for each wash and rinse cycle of the dishwashing machine; 4) ensure the steam table was working properly to maintain the temperature of foods at 135 degrees F or higher; 5) ensure the coffee machine was cleaned daily; 6) keep the personal belongings of staff separate from stored food items; and 7) ensure the fan grill of Walk-in Cooler #1 was clean and free of an accumulation of a dark-colored substance. This had the potential to affect 128 residents receiving meals from the facility's kitchen, 128 of 130 residents. Findings include: 1) The FDA (YEAR) Food Code included the following: . 5-402.11 Backflow Prevention. (A) . a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. On 06/24/19 at 04:10 PM, there were no air gaps observed for three PVC ([MEDICATION NAME] chloride) drain pipes, which extended through a wall opening from the dirty side of dishwashing area into the clean side of the dishwashing area. These drain pipes extended down into a floor drain located on the clean side of the dishwashing area with no air gaps between the ends of the drain pipes and the top of the floor drain. On 06/24/19 at 04:22 PM, the three-compartment pot and pan sink was observed to have a P-trap style drain. There was no air gap. The three-compartment pot and pan sink drain appeared to have a direct connection to the sewer. Also, the two-compartment food preparation sink had a P-trap drain and there was no air gap. The two-compartment food preparation sink drain appeared to be a direct connection to the sewer. In addition, one of the previously noted PVC pipes (coming through the wall and down into a floor drain) was a drain from the dishwashing machine. The dishwashing machine drain pipe descended into the sewer floor drain and there was no air gap. On 06/25/19 at 09:11 AM, Employee Identifier (EI) #2, a Dietary Manager (DM), was asked what was the potential problem with the dishwashing machine drain pipe not having an air gap, due to the drain pipe extending down into the floor drain. EI #2 stated backflow could be a problem. EI #2 was asked if there was an air gap for the dishwashing machine drain pipe. EI #2 answered, No. Upon being asked what was the potential problem, EI #2 said, Contamination. On 06/25/19 at 10:30 AM, EI #8, the facility's contract plumber, was interviewed. EI #8 confirmed that the three-compartment pot and pan sink drain and the two-compartment food preparation sink drain each needed an air gap. 2) The FDA (YEAR) Food Code included the following: . 6-202.15 Outer Openings, Protected. (A) . outer openings of a FOOD ESTABLISHMENT shall be protected against the entry of insects . by: . (D) . the opening shall be protected by the entry of insects . by: . (2) Properly designed and installed air curtains to control flying insects; or (3) Other effective means. 6-501.111 Controlling Pests. . The PREMISES shall be maintained free of insects . On 06/24/19 at 03:30 PM, during the initial tour of the facility's kitchen, three flies were observed. Two flies were seen to land on the door of the reach-in refrigerator. On 06/25/19 at 09:30 AM, the control of the fly fan at the kitchen's back door was noted to be on the low setting. The air flow was felt. The air flow was very lightly coming out of one side of the fly fan. The fly fan was not producing enough air flow to prevent flies from entering the kitchen. In addition, two bug lights were noted in the kitchen area; one of the two bug lights was not lit and therefore was not functioning. On 06/25/19 at 11:32 AM, a fly was observed sitting on a tray cart rack in the kitchen. On 06/25/19 at 11:37 AM, a fly was observed sitting on the tray line in the kitchen. On 06/25/19 at 11:51 AM, a fly was observed on a resident tray located on the tray line in the kitchen. On 06/25/19 at 11:53 AM, a fly landed on a bowl lid on the tray line in the kitchen. On 06/25/19 at 11:57 AM, a fly landed on the handle of a serving spoon for the pureed greens in the kitchen. On 06/25/19 at 04:03 PM, EI #2, DM, was interviewed. Upon being asked if he had noticed the flies in the kitchen, EI #2 said yes. When asked how long he had seen flies in the kitchen, EI #2 said today. EI #2 was asked what was being done to help prevent the flies. EI #2 said the bug light was working now, but was not previously plugged in (when observed by the surveyor). EI #2 further said half of the (fly fan) blower was not working. EI #2 also said the facility had a pest control contract for the kitchen. On 06/25/19 at 04:15 PM, EI #1, the Registered Dietitian (RD), was asked if she had noticed flies in the kitchen. EI #1 answered yes, yesterday. EI #1 stated she had been at this facility full-time for one week, but previously had come to the facility weekly. EI #1 was asked how long she had noticed the flies. EI #1 said they come and go. EI #1 further said there was a truck delivery yesterday and the driver propped the door open. When asked if she was referring to the outside door of the dry goods storage room being propped open, EI #1 said yes. EI #1 was asked what was being done to prevent the flies from entering the kitchen. EI #1 stated they had pest control, try to keep things clean, and try to keep the doors closed. When asked if she was aware of the nonfunctional fly fan on the door to the dry goods storage room, EI #1 stated no. On 06/26/19 at 06:39 AM, the surveyor entered the kitchen for breakfast tray line and observed flies. The flies noted included the following: one on the tray line roller, one on a plastic lid, and one flying around the bacon. On 06/26/19 at 06:56 AM, one fly was observed resting on a slice of toast on the steam table. On 06/26/19 at 07:25 AM, one fly was observed on the plastic bag containing pancakes to be used for service on the steam table. 3) The FDA (YEAR) Food Code included the following: . 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair . 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. (A) . in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than . 194 . (degrees) F . or less than: (2) . 180 . (degrees) F . On 06/25/19 at 09:00 AM, EI #4, a Dietary Aide (DA) and EI #5, a DA, were working in the dirty side of the dishwashing room. EI #4 placed the dirty dishes in racks and then into the conveyer-style dishwasher. The final rinse temperature was observed to be 176 degrees F for this cycle. When asked what was the final rinse temperature supposed to be, EI #4 stated, right in there. Then EI #4 said, in a questioning manner, 160 degrees F. The other DA, EI #5, said it should be 180 degrees F and she further stated it was 180 degrees F this morning. The dietary aides were asked who usually checked the final rinse temperature. EI #5 answered I do. When asked if the final rinse temperature was now reaching 180 degrees F, EI #4 and EI #2, DM, both answered, No. When asked what would be the harm of the dishes not being sanitized at 180 degrees F, EI #4 stated I don't know. EI #2 stated the problem would be bacteria and contamination and it could make people sick. On 06/25/19 at 09:05 AM, EI #6, the Maintenance Director, and EI #7, the Corporate Maintenance Director, came to the kitchen to work on the dishwasher final rinse temperature issue. The final rinse temperature was noted to go back up to 182 degrees F once, but it would not consistently stay at 180 degrees F or above for each cycle. For subsequent cycles it fell back to 176 degrees F and therefore did not sanitize the dishes. 4) The FDA (YEAR) Food Code included the following: . 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) . TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At . 135 . (degrees) F . or above . 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair . On 06/25/19 at 10:50 AM, the lunch tray line was observed. EI #9, the AM Cook, was observed to properly calibrate the thermometer and then check the temperatures of the food being held on the steam table for the lunch tray line. One of the steam table tanks was missing the light over its control knob and the knob appeared damaged. The pureed foods were located in this tank and most of the pureed items were below the acceptable holding temperature of 135 degrees F. These temperatures were as follows: - pureed pork chop 110 degrees F - pureed baked chicken 80 degrees F - pureed rice 100 degrees F - pureed squash 100 degrees F 06/25/19 11:53 AM, the water temperature in the pureed foods' steam table tank was checked and found to be 90 degrees F. On 06/26/19 at 06:39 AM, the breakfast tray line was observed. EI #10, the AM Cook properly calibrated the thermometer and checked the temperatures of the food being held on the steam table for breakfast. The following items were below the acceptable holding temperature of 135 degrees F: - Pureed Eggs 130 degrees F - Mechanical Meat - EI #10 said it was cold These items were in the same steam table tank as the pureed foods from the day before that were not at the appropriate temperature. This steam table tank was still missing the light over its control knob and the knob still appeared damaged. EI #10 stated she had told two previous bosses about the broken light and that it had not been working for about two to three years. On 06/26/19 at 07:44 AM, EI #1, the RD, said the steam table had just recently quit working and she had previously been watching the temperatures and they had been okay. EI #1 said a work order had been placed the day before for the steam table tank (element) in question. When asked how long the light had not been working on the steam table for that tank (element), EI #1 stated she did not know. 5) The FDA (YEAR) Food Code included the following: . 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. On 06/24/19 at 03:53 PM, upon opening the front of the coffee machine dispenser, a dark sticky substance was observed inside the machine. EI #2, DM, was asked what was the issue with the dark sticky substance accumulated inside the coffee machine. EI #2 stated contamination and potential for pests. On 06/24/19 at 04:30 PM, EI #1, the RD, was asked how often the coffee machine's dispenser spouts were cleaned. EI #1 said daily. When asked who was responsible for cleaning the coffee machine, EI #1 said she would find out. EI #1 then walked to meet with EI #3, a DA. EI #3 was asked who was responsible for cleaning the coffee machine. EI #3 answered the night shift dietary aide. On 06/25/19 at 04:48 PM, the Dietary Cleaning - Daily Cleaning Schedule was viewed with EI #1. The Dietary Cleaning - Daily Cleaning Schedule documented (MONTH) 18, 2019 as the last date the coffee machine was cleaned. EI #1 also provided the procedure for cleaning the coffee machine and it documented that the coffee machine was to be cleaned at the end of shift daily. EI #1 stated, according to the cleaning schedule documentation, it looked like the coffee machine had not been cleaned since (MONTH) 19th. EI #1 was asked had the coffee machine not been cleaned from (MONTH) 19, 2019 to (MONTH) 23, 2019 per the cleaning sign-off sheet and if it had been a total of five days that the coffee machine not been cleaned. EI #1 answered correct. 6) The FDA (YEAR) Food Code included the following: .3-305.12 Food Storage, Prohibited Areas. FOOD may not be stored: (A) In locker rooms; . (C) In dressing rooms; . On 06/24/19 at 03:43 PM, the emergency food and water supplies were observed to be located within a room containing staff personal items, to include: a half consumed bottle of water, a [NAME]et, and a purse. These personal staff items were stored on top of the boxes of food and water. EI #2, DM, was present for this observation. On 06/25/19 at 04:03 PM, EI #2 was interviewed about the room containing emergency food and water supplies along with staff personal items. EI #2 was asked what was the function of this room. EI #2 said it previously was a staff break room and it was changed to an emergency food storage room. When asked what was the problem with personal items being stored with food, EI #2 said contamination. During an interview on 06/25/19 at 04:15 PM, EI #1, the RD, was asked what was the function of the room by the back door of the kitchen. EI #1 said staff puts their stuff in the closet/cabinet there and it also holds the food for emergency use. EI #1 was asked if a purse, a [NAME]et, and a half consumed bottle of water should be placed upon the food and water boxes stored in the room. EI #1 said it should not be there. EI #1 further said it could be an infection control problem. When asked how she would define this room, if it was a break room or a locker room or a storeroom, EI #1 said it is a locker room. 7) ) The FDA (YEAR) Food Code included the following: . 3-305.11 Food Storage. (A) . FOOD shall be protected from contamination by storing the FOOD: (2) Where it is not exposed to . dust, or other contamination . On 06/24/19 at 03:37 PM, during the initial kitchen tour with EI #2, DM, an accumulation of a dark-colored substance was seen on the fan grill of Walk-in Cooler #1. When asked what was the problem with the dark-colored substance blowing through the fan grill and into the cooler, EI #2 said possible contamination. On 06/24/19 at 04:30 PM, the surveyor along with EI #1, the RD, viewed Walk-in Cooler #1. EI #1 was asked what was the dark-colored substance on the fan grill. EI #1 said lint, it's dirty.

Based on record review, a facility policy titled MDS (Minimum Data Set) 3.0 Completion, a facility document titled Resident Smokers and interview, the facility failed to ensure Resident Identifier (RI) #89's Annual MDS with an Assessment Reference Date (ARD) of 4-16-18 was marked to show RI # 89 was a smoker. This affected 1 of 27 sampled residents whose MDS's were reviewed Findings Include: A facility policy tilted MDS 3.0 Completion, revised 2-1-17, documented: . Policy Residents are assessed, using comprehensive assessment process, in order to identity care needs . RI # 89 was readmitted to the facility on [DATE]. A review of an undated facility document tilted Resident Smokersrevealed RI # 89 was a smoker. RI # 89's Annual MDS, with an ARD of 4-16-18, was not marked to show he/she was a smoker. An interview was conducted with Employee Indentifier (EI) # 1, MDS Coordinator, on 6-7-18 at 9:17 a.m. EI # 1 stated she was familiar with RI # 89 and he/she was a smoker. EI # 1 stated the MDS dated [DATE] should be marked to show he/she was a smoker. EI # 1 stated it was not marked due to a data entry error. EI # 1 further stated it was important for the MDS to be coded correctly to show an accurate picture of the resident.

Based on observations, record review, and interviews, the facility failed to ensure Resident Identifier (RI) #6 was provided fluids and a communication sheet as care planned and RI #4 was provided nail care as care planned. These failures affected RI #4 and RI #6, two of 21 sampled residents for whom care plans were reviewed. Findings include: 1) RI #6 was readmitted to the facility on [DATE]. RI #6 has a medical history to include: Cognitive Communication Deficit. RI #6's care plan titled I have impaired cognition . with a problem onset date of 01/14/2016, had a documented approach of . Therapy has placed a communication sheet on my laptray to help me communicate better with staff regarding my needs. On 02/23/2016 at 5:00 PM, RI #6 was observed in a wheelchair with a laptray at the Nurses' Station. No communication sheet was observed. The surveyor attempted to converse with the resident, but RI #6 gave no verbal response. On 02/23/2016 at 5:15 PM, Employee Identifier (EI) #4, a Certified Nursing Assistant (CNA) was asked if RI #6 could speak. EI #4 said no. When asked how staff communicated with RI #6, EI #4 said the resident sometimes said yes or no, but other times the staff had to think really hard about what RI #6 may need. On 02/24/2016 at 7:50 AM, RI #6 was again observed in a wheelchair with a laptray at the Nurses' Station. No communication sheet was noted. On 02/24/2016 at 8:20 AM, EI #5, a CNA, was observed returning RI #6 to the Nurses' Station. A communication sheet was now taped to RI #6's laptray. EI #5 was asked when the communication sheet was placed on RI #6's laptray. EI #5 said it was lost until today. EI #5 explained RI #6 used to have a different laptray with the sheet on it. When asked if RI #6 utilized the communication sheet, EI #5 said yes. EI #6, a Registered Nurse Supervisor, was interviewed on 02/24/2016 at 3:47 PM. When asked if RI #6 was verbal, EI #6 explained RI #6 said yes or no but did not use complete sentences. EI #6 said from what she understood, therapy was using the communication sheet as a tool to assist RI #6 with communication. When asked why the communication sheet was not on RI #6's lap tray that morning or the previous day, EI #6 said RI #6 had two lap trays and one of them was broken. EI #6 did not recall when RI #6's lap tray broke but said it appeared staff did not move the communication sheet when the lap tray was replaced. When asked why it would be important to ensure the laptray was available for RI #6 to use, EI #6 said it was a means of encouraging any additional communication. EI #6 stated the communication sheet was another avenue to assist RI #6 in communicating. 2) On 1/14/2016 was readmitted to the facility. RI #6's care plans titled I am at risk for alterations in my nutrition/hydration status . with a problem onset date of 1/14/2016, had an approach of . I am offered 3 nectar bev. (beverages) w/ (with) meal trays . RI #6's breakfast, lunch and supper tray card dated 2/24/2016, documented . Offer 3-8oz. (ounces) Nectar Beverages . During the breakfast meal observation on 2/24/2016 at 8:00 AM, RI #6 was offered 1-4oz cup of nectar tea. During the lunch meal observation on 2/24/2016 at 12:24 PM, RI #6 was offered 1-8oz. cup of thickened milk and 2-4oz of thickened tea. During the supper meal observation on 2/24/2016 at 5:38 PM, RI #6 was offered 1-4oz. cup of thickened tea. Employee Identifier (EI) #13, a Certified Nursing Assistant (CNA), was asked, how much fluid was offered to RI #6 for each meal, EI # 13 said they normally try to get the resident to drink two 4 ounce beverages with each meal. EI #6, a Registered Nurse Supervisor, was interviewed on 2/25/2016 at 9:05 AM. EI #6 explained CNAs are told to provide three options of something to drink with meal trays. When asked why it was important to provide multiple options, EI #6 said for hydration needs and to offer a variety of choices. After reviewing RI #6's traycards, EI #6 said staff should be providing six 4 ounce beverages with each meal. When asked what potential harm could occur if staff were not providing fluids as planned, EI #6 said dehydration. EI #14, the facility's Dietitian, was interviewed on 2/25/2016 at 11:00 AM. EI #14 said RI #6's fluid needs were approximately 1257 to 1466 milliliters per day. When asked what amount of fluid RI #6 should receive with each meal tray, EI #14 said staff offer three, 8 ounce beverages with meals. She said the resident does not have to accept all three but staff need to offer them and encourage the resident to drink them. After discussing the meal observations on 2/24/2016, EI #14 was asked how they could ensure RI #6's fluid needs were met. EI #14 again said staff were supposed to offer three beverages, at least 720 milliliters with each meal. When asked if serving three beverages served a purpose, EI #14 said to ensure residents get more fluids. EI #14 then said RI #6's fluid needs had not been met with meals. When asked what potential harm could occur if staff do not provide fluids as planned, EI #14 said RI #6 might not get enough fluids and could potentially become dehydrated. 3) RI #4 was admitted to the facility on [DATE]. RI #4's care plan titled I need assistance with my ADL (activities of daily living) care . with a problem onset date of 11/17/2015, listed an approach of . * I will have my nails kept clean and well trimmed per staff . During the initial tour of the facility on 02/23/2016 beginning at 10:40 AM, RI #4 asked the surveyor if she (surveyor) could cut toenails. RI #4 went on to state his/her toenails had not been cut. RI #4 said his/her toenails hurt and explained a lot of times in the mornings he/she had to keep moving them because they hurt. On 02/24/2016 at 10:45 AM, RI #4 again asked the surveyor if she could cut his/her toe nails. The surveyor then asked Employee Identifier (EI) #5, a Certified Nursing Assistant (CNA) if she could remove RI #4's socks and shoes. After RI #4's socks and shoes were removed, the resident's toenails were observed to be thick, yellow, and rough. The nails were extremely long and extended past the end of the toes. Some of the nails curled over the tip of the toe around to the bottom pad of the toes. Some nails were also observed to curl between the toes. When asked how she would describe RI #4's toe nails, EI #5 said long. During an interview on 02/24/2016 at 10:55 AM, EI #12, the Treatment Nurse, was asked if she could go observe RI #4's toes. After removing RI #4's left sock and shoe, EI #12 said, Ooh yes, that is long, and then stated she could definitely try to trim some of the nails. EI #12 was asked to describe RI #4's toe nails. EI #12 said they were thick and long. When asked why it was important to avoid toe nails that long, EI #12 said they will catch on socks and shoes and become uncomfortable.

Based on observations, record review, and interviews, the facility failed to ensure Resident Identifier (RI) #6, a resident with impaired communication skills, was provided a communication sheet to facilitate communication of needs. This affected RI #6, one of five residents sampled for language and communication. The facility further failed to ensure RI #4 was provided nail care. This affected RI #4, one of five residents sampled for ADL (activities of daily living) concerns. Findings include: 1) RI #6 was readmitted to the facility on [DATE]. RI #6 has a medical history to include: Cognitive Communication Deficit. RI #6's care plan titled I have impaired cognition . with a problem onset date of 01/14/2016, had a documented approach of . Therapy has placed a communication sheet on my laptray to help me communicate better with staff regarding my needs. On 01/18/2016, RI #6 was referred to Speech Therapy (ST). The Speech Therapy Plan of Care, for care dates 01/18/2016 through 01/27/2016, documented the following: . Reason for Referral: . referred to ST by nursing after recent hospitalization for . inability to express basic wants and needs . RI #6's Functional Maintenance Plan, dated 01/27/2016, indicated RI #6 required a communication board on the wheelchair's arm rest to assist with basic wants and needs. On 02/23/2016 at 5:00 PM, RI #6 was observed in a wheelchair with a laptray at the Nurses' Station. No communication sheet was observed. The surveyor attempted to converse with the resident, but RI #6 gave no verbal response. On 02/23/2016 at 5:15 PM, Employee Identifier (EI) #4, a Certified Nursing Assistant (CNA) was asked if RI #6 could speak. EI #4 said no. When asked how staff communicated with RI #6, EI #4 said the resident sometimes said yes or no, but other times the staff had to think really hard about what RI #6 may need. On 02/24/2016 at 7:50 AM, RI #6 was again observed in a wheelchair with a laptray at the Nurses' Station. No communication sheet was noted. On 02/24/2016 at 8:20 AM, EI #5, a CNA, was observed returning RI #6 to the Nurses' Station. A communication sheet was now taped to RI #6's laptray. EI #5 was asked when the communication sheet was placed on RI #6's laptray. EI #5 said it was lost until today. EI #5 explained RI #6 used to have a different laptray with the sheet on it. When asked if RI #6 utilized the communication sheet, EI #5 said yes. EI #6, a Registered Nurse Supervisor, was interviewed on 02/24/2016 at 3:47 PM. When asked if RI #6 was verbal, EI #6 explained RI #6 said yes or no but did not use complete sentences. EI #6 said from what she understood, therapy was using the communication sheet as a tool to assist RI #6 with communication. When asked why the communication sheet was not on RI #6's lap tray that morning or the previous day, EI #6 said RI #6 had two lap trays and one of them was broken. EI #6 did not recall when RI #6's lap tray broke but said it appeared staff did not move the communication sheet when the lap tray was replaced. When asked why it would be important to ensure the laptray was available for RI #6 to use, EI #6 said it was a means of encouraging any additional communication. EI #6 stated the communication sheet was another avenue to assist RI #6 in communicating. 2) The facility's policy titled Foot Care, revised 06/01/2002, revealed the following: Purpose To assist in the prevention of infection, odors and injury to soft tissues. Policy The appropriate foot treatment shall be provided by the Licensed Nurse as ordered and/or indicated . RI #4 was admitted to the facility on [DATE]. RI #4's care plan titled I need assistance with my ADL (activities of daily living) care . with a problem onset date of 11/17/2015, listed an approach of . * I will have my nails kept clean and well trimmed per staff . RI #4's Minimum Data Set with an Assessment Reference Date of 01/11/2016, indicated RI #4 was moderately impaired in cognitive skills for daily decision making, with a Brief Interview for Mental Status (BIMS) score of 11. RI #4 required limited assistance with personal hygiene. During the initial tour of the facility on 02/23/2016 beginning at 10:40 AM, RI #4 asked the surveyor if she (surveyor) could cut toenails. RI #4 went on to state his/her toenails had not been cut. RI #4 said his/her toenails hurt and explained a lot of times in the mornings he/she had to keep moving them because they hurt. On 02/24/2016 at 10:45 AM, RI #4 again asked the surveyor if she could cut his/her toe nails. The surveyor then asked Employee Identifier (EI) #5, a Certified Nursing Assistant (CNA) if she could remove RI #4's socks and shoes. After RI #4's socks and shoes were removed, the resident's toenails were observed to be thick, yellow, and rough. The nails were extremely long and extended past the end of the toes. Some of the nails curled over the tip of the toe around to the bottom pad of the toes. Some nails were also observed to curl between the toes. When asked how she would describe RI #4's toe nails, EI #5 said long. During an interview on 02/24/2016 at 10:55 AM, EI #12, the Treatment Nurse, was asked if she could go observe RI #4's toes. After removing RI #4's left sock and shoe, EI #12 said, Ooh yes, that is long, and then stated she could definitely try to trim some of the nails. EI #12 was asked to describe RI #4's toe nails. EI #12 said they were thick and long. When asked why it was important to avoid toe nails that long, EI #12 said they will catch on socks and shoes and become uncomfortable.

Based on observations, record review, and interviews, the facility failed to ensure Resident Identifier (RI) #6, a resident diagnosed with [REDACTED]. This affected RI #6, one of twelve residents sampled for hydration concerns. Findings include: From 1/9/2016 to 1/14/2016, RI #6 was a patient in a local hospital. The physician's orders [REDACTED]. On 1/14/2016 was readmitted to the facility. RI #6's care plans titled I am at risk for alterations in my nutrition/hydration status . with a problem onset date of 1/14/2016, had an approach of . I am offered 3 nectar bev. (beverages) w/ (with) meal trays . RI #6's Significant Change in Status Minimum Data with an assessment reference date of 2/1/2016, indicated RI #6 required limited assistance with eating. RI #6's breakfast, lunch and supper tray card dated 2/24/2016, documented . Offer 3-8oz. (ounces) Nectar Beverages . During the breakfast meal observation on 2/24/2016 at 8:00 AM, RI #6 was offered 1-4oz cup of nectar tea. During the lunch meal observation on 2/24/2016 at 12:24 PM, RI #6 was offered 1-8oz. cup of thickened milk and 2-4oz of thickened tea. During the supper meal observation on 2/24/2016 at 5:38 PM, RI #6 was offered 1-4oz. cup of thickened tea. Employee Identifier (EI) #13, a Certified Nursing Assistant (CNA), was asked, how much fluid was offered to RI #6 for each meal, EI # 13 said they normally try to get the resident to drink two 4 ounce beverages with each meal. EI #6, a Registered Nurse Supervisor, was interviewed on 2/25/2016 at 9:05 AM. EI #6 explained CNAs are told to provide three options of something to drink with meal trays. When asked why it was important to provide multiple options, EI #6 said for hydration needs and to offer a variety of choices. After reviewing RI #6's traycards, EI #6 said staff should be providing six 4 ounce beverages with each meal. When asked what potential harm could occur if staff were not providing fluids as planned, EI #6 said dehydration. EI #14, the facility's Dietitian, was interviewed on 2/25/2016 at 11:00 AM. EI #14 said RI #6's fluid needs were approximately 1257 to 1466 milliliters per day. When asked what amount of fluid RI #6 should receive with each meal tray, EI #14 said staff offer three, 8 ounce beverages with meals. She said the resident does not have to accept all three but staff need to offer them and encourage the resident to drink them. After discussing the meal observations on 2/24/2016, EI #14 was asked how they could ensure RI #6's fluid needs were met. EI #14 again said staff were supposed to offer three beverages, at least 720 milliliters with each meal. When asked if serving three beverages served a purpose, EI #14 said to ensure residents get more fluids. EI #14 then said RI #6's fluid needs had not been met with meals. When asked what potential harm could occur if staff do not provide fluids as planned, EI #14 said RI #6 might not get enough fluids and could potentially become dehydrated.

Based on observation, interviews and record review, the facility failed to ensure Employee Identifier (EI) #1, a Registered Nurse (RN) cleansed the syringe used for sublingual (SL) medication administration prior to storing the used syringe in the medication cart. Further, the facility failed to ensure EI #1 washed her hands after she removed gloves and before touching the medication cart. This affected Resident Identifier (RI) #2, one of eleven residents observed during medication pass. Findings include: The facility's policy and procedure titled, Medication - Sublingual/[MEDICATION NAME] Administration with revised date of 02/01/2015 documented: . Procedure . 6. The medication syringe should be rinsed and dried after each use and placed in the container utilized for the storage of the resident's medication or discarded and a new medication syringe used with each administration of the medication . The facility's policy titled Handwashing - Hand Hygiene with a revised date of 02/01/2015 documented: Purpose To prevent the spread of infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors 5. Employees must wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: .c. Before and after direct resident contact . q. After contact with a resident's mucous membranes and body fluids or excretions; . u. After removing gloves . 7. Hand hygiene is always the final step after removing and disposing of personal protective equipment. RI #2 was readmitted to the facility on [DATE]. RI #2's Physician Orders for the month of February 2016 revealed that RI #2 was to receive [MEDICATION NAME] 0.5 ML (milliliter) sublingual every four hours and 1.5 ML sublingual thirty minutes prior to wound care every day. During medication administration on 02/24/2016 at 08:05 AM, after EI #1, the RN, administered sublingual 0.5 ML of [MEDICATION NAME] to RI #2, EI #1 removed her gloves and placed the syringe in a container in the medication cart. EI #1 then re-entered the room and washed her hands. EI #1 did not rinse the syringe after use or wash her hands after removing her gloves and prior to touching the medication cart. During an interview on 02/24/2016 at 08:18 AM, EI #1 stated she had administered [MEDICATION NAME] sublingually to RI #2 and the syringe had touched the resident's mouth. EI #1 further stated she had placed the syringe back in the medication cart then she had washed her hands. EI #1 was asked if the used syringe should be rinsed prior to being put back in the medication cart. She stated that she was not sure. EI #1 was asked what the potential for harm was in placing a syringe into a resident's mouth then placing it back into the medication cart. EI #1 stated infection control. EI #1 was asked what should be done after removing her gloves. She stated wash my hands. When asked if she had washed her hands immediately after removing her gloves, EI #1 stated she had put the syringe in the medication cart and then washed her hands. EI #1 was asked if she had washed her hands after removing her gloves and prior to touching the medication cart. EI #1 stated no. When asked what the potential for harm was in not washing her hands before touching other items such as the medication cart, EI #1 stated cross contamination and infection control. On 02/24/2016 at 2:58 PM, EI #3, the Infection Control Nurse was asked what should be done with a syringe after it is used for sublingual medication administration. She stated, Throw it away. When asked if the used syringe should be placed in the medication cart, EI #3 stated if a medication comes with it's own syringe, the nurse should clean the syringe, let it dry and then put it back in it's own box. EI #3 was asked what the potential for harm was if a syringe was used for SL medication administration then placed back in the medication cart. She stated contamination of other medications, the used syringe with out being cleaned can grow bacteria. EI #3 was asked when hands should be washed during medication pass. She stated before starting the medication pass and after each resident. When asked what should be done after removing gloves, EI #3 stated, wash your hands. EI #3 was then asked what the potential for harm was in not washing your hands after removal of gloves. She stated bacteria and germs could be spread to other residents. EI #3 was asked what the nurse should do after administering SL medications and prior to opening the medication cart. She stated, wash hands. When asked why it was important to wash your hands after administering SL medications and prior to opening the medication cart, EI #3 stated because you don't know if the last surface had bacteria on it and handwashing is the best way to prevent infections.

Based on interviews and record reviews, the facility's Administrator, who is responsible for the direct day-to-day functions of the facility in accordance with current federal, state and local standards governing long-term care facilities failed to: 1. Have a system in place for the staff to readily identify a resident's code status during an emergency situation; 2. Ensure non-licensed staff knew how to promptly respond to a medical emergency when Resident Indentifer (RI) # 34, a resident, who was a Full Code, stopped breathing during incontinence care during the third shift on [DATE]; and 3. Report Employee Identifier (EI) #1, a Registered Nurse (RN), to the Alabama Board of Nursing for performing outside her scope of practice when EI #1 chose not to initiate CPR on a resident who was a Full Code. These failures affected RI #34, one of four sampled residents reviewed for emergency response, with the potential to affect the remaining 61 of 135 residents in the facility identified as being a full code on [DATE]. On [DATE] at 1:28 PM, the facility's Administrator, Director of Nursing, Vice President of Operations, Vice President of Quality Assurance and Registered Dietician were notified of the findings of substandard quality of care at the immediate jeopardy level "J" in the area of Administration, F 490. Findings include: Cross reference F 224, F 281, and F 309. The "Administrator Job Description - Administrative Services" dated [DATE], documented " ... General Purpose: To direct the day-to-day functions of the facility in accordance with current federal, state and local standards governing long-term care facilities to ensure that the highest degree of quality care can be provided to the residents at all times ... Essential Job Functions: A. Administrative Functions Duties: ... ensure that each resident receives the necessary nursing, medical and psychological services to attain and maintain the highest possible mental and physical functional status ... ." EI #1 acknowledged in an interview on [DATE] at 10:40 AM, that to find out a code status of a resident staff would need to look at the resident's medical chart. During an interview on [DATE] at 11:58 AM, EI #8, the Medical Records Director, was asked, how the staff identified a resident's code status. EI #8 explained that code status was printed on the physician's orders [REDACTED]. On [DATE] at 2:09 PM, EI #2, a CNA was asked what was she trained to do in an emergency. EI #2 stated, get the nurse right away. In an interview on [DATE] at 5:15 PM, EI #6, the Administrator was asked if any disciplinary action was taken against an employee. EI #6 stated she verbally counseled EI #1. When asked if any licensed staff were reported to the Alabama Board of Nursing, EI #6 said no because EI #1 acted within her professional judgment. When asked if it was in a nurses' scope of practice to determine whether or not they would initiate CPR on a full code resident, EI #6 stated the nurse should follow the resident's Advance Directive. EI #6 was asked how did the staff know the residents' code status. EI #6 stated, review the medical record. EI #6 further stated CNAs were trained upon hire to alert the charge nurse of any change in a resident's condition. In a follow up interview on [DATE] at 10:30 AM, EI #6 was asked, how would the staff find a residents' code status, if the medical record was unavailable. EI #6 stated the staff could review the Medication Administration Record [REDACTED]. EI #6 was asked if she felt following the above actions would cause a delay in the resident's care. EI #6 stated she didn't think so because it had not been a problem before. ************************* On [DATE] at 7:00 PM, the facility submitted an acceptable Allegation of Compliance for F 490, which documented Facility failed to ensure that non-licensed staff knew what to do when the resident appeared to stop breathing, did not immediately identify RI #34 code status and failed to report the RN to the Alabama Board of Nursing. 1. RN who failed to administer CPR to RI #34 placed on Administrative Leave by Corporate Staff and reported to the Alabama Board of Nursing on 03.05.15. 2. 03.05.15 - Reviewed MAR's to ensure the plastic red sleeve was placed in front of each MAR indicated [REDACTED]. Note: A plastic green sleeve indicates a Full Code or no advanced directive. 3. 03.05.15 - Stat Communication Inservice Education for all staff by Corporate Consultant and Administrator/Director of Nursing. Any staff not available or not scheduled to work will not be allowed to report to the hall for work until in-servicing is completed. 4. 03.05.15 - Inservice all staff on Advance Directives and "Red Star" system. Any staff not available or not scheduled to work will not be allowed to report to the hall for work until in-servicing is completed. 5. 03.05.15 - Inservice all staff on Neglect and Providing Goods and Services Necessary to care for that Resident. Any staff not available or not scheduled to work will not be allowed to report to the hall for work until in-servicing is completed. 6. 03.05.15 - Licensed Nurses inserviced on CPR Policy and Procedure dated 03.01.15 by Corporate Consultants. 7. 03.05.15 - Reviewed all residents for Code Status and ensured that the facility has placed a " Red " Star by the resident ' s name on the outside of the door to indicate a DNR. No Star indicates a "Full Code." This deficiency cannot be corrected for RI #34 who is deceased . We are requesting Immediate Jeopardy be removed effective 03.05.15" ************************* After reviewing the facility's information provided in their Allegation of Compliance and verifying the immediate actions had been implemented, the scope/severity level of F 490 was lowered to a "F" level on [DATE] at 10:18 AM, to allow the facility time to monitor and revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 852.

Based on interviews and record reviews, Employee Identifier (EI) #1, a Registered Nurse (RN), willfully neglected to perform Cardiopulmonary Resuscitation (CPR) on Resident Identifier (RI) #34, a resident with Full Code status. Code status describes what type of intervention a health care facility will conduct should a resident stop breathing and/or heart stops beating. Full code status means, when a resident stops breathing and/or heart stops beating, staff are to immediately initiate emergency medical services in an attempt to revive the resident. On [DATE] during the third shift (11:00 PM - 7:00 AM), RI #34 was found without a pulse or respirations. Instead of initiating CPR, EI #1 called for the assistance of a licensed nurse in training (EI #5), to verify whether or not RI #34 had a heart beat, blood pressure or respirations. Once EI #5 acknowledged RI #34 did not have a pulse or respirations, both nurses failed to initiate any emergency medical services, including CPR. Instead, they contacted RI #34's sponsor, the facility's Administrative Staff (Administrator and DON), the physician and the funeral home. RI #34 was pronounced dead on [DATE] at 12:20 AM, by the physician by telephone. This deficient practice affected RI #34; one of four sampled residents reviewed for emergency response, and placed RI #34 in immediate jeopardy because it was likely to cause serious harm, injury or death. On [DATE] at 1:28 PM, the facility's Administrator, Director of Nursing, Vice President of Operations, Vice President of Quality Assurance, and Registered Dietician were notified of the findings of substandard quality of care at the immediate jeopardy level "J" in the area of Resident Behavior & Facility Practices, F 224. Findings include: On [DATE], the State Agency received a complaint. According to the anonymous caller, there was talk going around the nursing home that Employee Identifier (EI) #1, a Registered Nurse (RN) did not perform Cardio [MEDICAL CONDITION] Resuscitation (CPR) and let a resident die. The facility's "In-Service Training Class Attendance Record" for [DATE] documented "Subject(s) Abuse & Neglect ... According to the Nursing Home Reform Act of 1987, all residents in nursing homes are entitled to receive quality care and live in an environment that improves or maintains the quality of their physical and mental health. This entitlement includes freedom from neglect ... Neglect is the failure to care for a person in a manner, which would avoid harm and pain, or the failure to react to a situation which may be harmful. Neglect may or may not be intentional ... It is a violation of State and Federal law for any person, including facility staff, volunteers, visitors, family members or guardians, or another resident, to neglect or abuse a resident ... ." RI #34 was admitted to the facility on [DATE], with a medical history to include: [MEDICAL CONDITION] Disease, [MEDICAL CONDITIONS] and History of Stroke. RI #34's "Physician Orders" for [DATE] indicated RI #34 did not have a Do Not Resuscitate (DNR) order nor did the resident have an Advance Directive; therefore, RI #34 was a Full Code. Full Code status means that if a resident stops breathing and/or heart stops beating, staff are to immediately initiate emergency medical services, including CPR, in an attempt to revive the resident. Refer to F 309 In an interview on [DATE] at 10:40 AM, EI #1, an RN acknowledged that she was working in the facility the night RI #34 died . When asked what happened, EI #1 stated the night RI #34 died , she was in another resident's room administering medications when EI #3, a Certified Nursing Assistant (CNA) came to her and told her to come to RI #34's room when she could. EI #1 stated after she finished administering medications to the other resident, she walked to RI #34's room. EI #1 stated she arrived in RI #34's room about two to four minutes after EI #3 asked her to come to RI #34's room. When EI #1 walked in RI #34's room, she stated the resident was blue and cold;. EI #1 was asked what RI #34's code status was. EI #1 replied, Full Code. When asked, what should be done if a resident is a Full Code, EI #1 stated CPR should be performed. EI #1 acknowledged she was certified in CPR, with additional training in ACLS (Advanced Cardiac Life Support). EI #1 was asked, if CPR should have been performed on RI #34 and she replied yes. EI #1 explained the steps she took when she first found RI #34 blue and cold however, EI #1 acknowledged she did not perform CPR because in her nursing judgment CPR would not have helped RI #34. On [DATE] 2:04 PM, [DATE] at 4:29 PM, [DATE] at 9:54 AM, attempts were made to contact EI #5 by telephone. The phone number was not in service. EI #5 ended her employment with the nursing facility, without notice on [DATE]. According to www.heart.org, "Advanced Cardiovascular Life Support (ACLS) is an advanced, instructor-led classroom course that highlights the importance of team dynamics and communication, systems of care and immediate post-cardiac-arrest care. It also covers airway management and related pharmacology ... ACLS is designed for healthcare professionals who either direct or participate in the management of cardiopulmonary arrest and cardiovascular emergencies. This includes personnel in emergency response, emergency medicine, intensive care and critical care units ... ." An American Heart Association (AHA) document titled, "CPR: Legal and Ethical Issues" with a copyright date of 2006 documented " ... If it's part of your job, you have a duty to give CPR to a victim of [MEDICAL CONDITION] ... ." The facility's policy titled "Cardiopulmonary Resuscitation (CPR) for Adults (LNPP 200) revised [DATE], documented "Purpose To ventilate and establish circulation on a resident with absence of respiration and pulse Policy Cardiopulmonary resuscitation shall be performed only by personnel who have completed a CPR certification class and hold a current certification ... Procedure ... 3. ... Begin cardio-pulmonary resuscitation immediately if the resident has: a. no pulse b. no respiration c. unresponsiveness 4. If not breathing, give 2 ventilations ... ." During an interview on [DATE] at 5:15 PM, EI #6, the Administrator, was asked if CPR should have been initiated on RI #34. EI #6 stated yes. Then EI #6 was asked why CPR was not initiated. According to EI #6, EI #1 felt RI #34 had been deceased for several minutes, since the resident's body was cold. EI #6 further stated that EI #1 felt she would do more harm than good. EI #6 added that she completed a verbal counseling with EI #1. According to a typed document dated [DATE] "Verbal Counsel/Education" was done with EI #1 on "1. When any resident is found in distress or non-responsive staff must immediately call STAT (immediately) ... 3. Immediately initiate CPR on all residents that are Full Code and contact EMS (Emergency Medical Services), MD (Medical Doctor) and sponsor. CPR must continue until EMS arrives at bedside ... ." This document was signed by EI #1, the Director of Nursing and the Administrator. In a follow up interview on [DATE] at 10:30 AM, EI #6, the Administrator, was asked what she considered neglect. EI #6 replied, not providing the care and services necessary to take care of the residents. When asked, if not performing CPR on a Full code resident was considered neglect, EI #6 stated she wasn't there. ************************* On [DATE] at 7:00 PM, the facility submitted an acceptable Allegation of Compliance for F 224, which documented: RN willfully did not administer CPR to RI #34 that was a Full Code. 1. RN who failed to administer CPR to RI #34 placed on Administrative Leave by Corporate Staff and reported to the Alabama Board of Nursing on 03.05.15. 2. 03.05.15 - Reviewed MARs to ensure the plastic red sleeve was placed in front of each MAR indicated [REDACTED]. Note: A plastic green sleeve indicates a Full Code or no advanced directive. 3. 03.05.15 - Stat Communication Inservice Education for all staff by Corporate Consultant and Administrator/Director of Nursing. Any staff not available or not scheduled to work will not be allowed to report to the hall for work until in-servicing is completed. 4. 03.05.15 - Inservice all staff on Advance Directives and "Red Star" system. Any staff not available or not scheduled to work will not be allowed to report to the hall for work until in-servicing is completed. 5. 03.05.15 - Inservice all staff on Neglect and Providing Goods and Services Necessary to care for that Resident. Any staff not available or not scheduled to work will not be allowed to report to the hall for work until in-servicing is completed. 6. 03.05.15 - Licensed Nurses inserviced on CPR Policy and Procedure dated 03.01.15 by Corporate Consultants. This deficiency cannot be corrected for RI #34 who is deceased . We are requesting Immediate Jeopardy be removed effective 03.05.15 ************************* After reviewing the facility's information provided in their Allegation of Compliance and verifying the immediate actions had been implemented, the scope/severity level of F 224 was lowered to a "D" level on [DATE] at 10:18 AM, to allow the facility time to monitor and revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 852.

Based on interviews and record reviews, the facility failed to ensure Employee Identifier (EI) #1, a Registered Nurse (RN), acted within her nursing scope of practice when she failed to provide Cardiopulmonary Resuscitation (CPR) to Resident Identifier (RI) #34, a resident with Full Code status, during the third shift (11:00 PM - 7:00 AM) on [DATE]. EI #1 stated in her professional opinion, CPR would not have made a difference for RI #34; it would have done more harm than good. Instead of initiating CPR, EI #1 obtained the assistance of another licensed nurse (EI #5) to verify whether or not RI #34 had a heart beat, blood pressure or respirations. After neither nurse was able to obtain a pulse or heart beat from RI #34, they telephoned RI #34's family, the facility's administrative staff, the physician and the funeral home. According to the facility's policy, CPR should be performed on a resident unless there is a Do Not Resuscitate (DNR) order in the resident's medical record. RI #34 did not have a DNR order of Advanced Directive therefore, RI #34 was a Full Code. Without the initiation of CPR or the notification of Emergency Medical Services (EMS), RI #34 was pronounced dead by the physician via phone on [DATE] at 12:20 AM. This deficient practice affected RI #34; one of four sampled residents reviewed for emergency response, and placed RI #34 in immediate jeopardy because it was likely to cause serious harm, injury or death. On [DATE] at 1:28 PM, the facility's Administrator, Director of Nursing, Vice President of Operations, Vice President of Quality Assurance and Registered Dietician were notified of the findings of substandard quality of care at the immediate jeopardy level "J" in the area of Resident Assessment, F 281. Findings include: Cross reference to F 224 and F 309. On [DATE], the State Agency received a complaint. According to the anonymous caller, there was talk going around the nursing home that Employee Identifier (EI) #1, a Registered Nurse (RN), did not perform Cardio [MEDICAL CONDITION] Resuscitation (CPR) and let a resident die. RI #34 was admitted to the facility on [DATE], with a medical history to include: [MEDICAL CONDITION] Disease, [MEDICAL CONDITIONS] and History of Stroke. RI #34's "Physician Orders" for [DATE] indicated RI #34 did not have a Do Not Resuscitate (DNR) order or an Advance Directive; therefore, RI #34 was a Full Code. Full Code status means that if a resident stops breathing and/or heart stops beating, staff are to immediately initiate emergency medical services, CPR, to revive the resident. Page 299 of Chapter 23 titled "Legal Implications in Nursing Practice" of "Fundamentals of Nursing Eighth Edition" with a copyright date of 2013, documented " ... If a patient does not have a DNR order, health care providers need to make every effort to revive the patient ... CPR is an emergency treatment provided without patient consent. Health care providers perform CPR on an appropriate patient unless there is a DNR order in the patient's chart ... ." According to the Alabama Board of Nursing, Alabama Administrative Code Chapter 610-X-6 Standards of Nursing Practice " ... 610-X-6-.03 Conduct and Accountability. The registered nurse and licensed practical nurse shall: (1) Have knowledge and understanding of the laws and rules regulating nursing. (2) Function within the legal scope of nursing practice ... (7) Accept individual responsibility and accountability for judgments, actions and nursing competency, remaining current with technology and [MEDICATION NAME] consistent with facility policies and procedures ... 610-X-6-.04 Practice of Professional Nursing (Registered Nurse Practice (1) The practice of professional nursing includes, but is not limited to: ... (b) Provision of care supportive to or restorative of life and well-being ... ." In an interview on [DATE] at 10:40 AM, EI #1, an RN acknowledged she was working in the facility the night RI #34 died . When asked what happened, EI #1 stated the night RI #34 died , she was in another resident's room administering medications when EI #3, a Certified Nursing Assistant (CNA) came to her and told her to come to RI #34's room when she could. EI #1 stated after she finished administering medications to the other resident, she walked to RI #34's room. EI #1 stated she arrived in RI #34's room about two to four minutes after EI #3 asked her to come to RI #34's room. When EI #1 walked in RI #34's room, she stated the resident was blue and cold. EI #1 was asked what was RI #34's code status. EI #1 replied, Full Code. When asked, what should be done if a resident is a Full Code, EI #1 stated CPR should be performed. EI #1 acknowledged that she was certified in CPR, with additional training in ACLS (Advanced Cardiac Life Support). EI #1 was asked, should CPR have been performed on RI #34 and she replied yes. EI #1 explained the steps she took when she first found RI #34 blue and cold however, EI #1 acknowledged she did not perform CPR because in her nursing judgment CPR would not have helped RI #34. On [DATE] 2:04 PM, [DATE] at 4:29 PM, [DATE] at 9:54 AM, attempts were made to contact EI #5 via telephone. The phone number was not in service. EI #5 ended her employment with the nursing facility, without notice on [DATE]. RI #34's "Record of Death - Alabama" indicated the physician, EI #7, was notified on [DATE] at 1:00 AM, forty minutes later, that RI #34 had expired on [DATE] at 12:20 AM. ************************* On [DATE] at 7:00 PM, the facility submitted an acceptable Allegation of Compliance for F 281, which documented: Failed to ensure that RN failed to provide RI #34 CPR that was a Full Code. The RN acted out of her scope of practice determining not to provide CPR. 1. RN who failed to administer CPR to RI #34 placed on Administrative Leave by Corporate Staff and reported to the Alabama Board of Nursing on 03.05.15. 2. 03.05.15 - Reviewed MARs to ensure the plastic red sleeve was placed in front of each MAR indicated [REDACTED]. Note: A plastic green sleeve indicates a Full Code or no advanced directive. 3. 03.05.15 - Stat Communication Inservice Education for all staff by Corporate Consultant and Administrator/Director of Nursing. Any staff not available or not scheduled to work will not be allowed to report to the hall for work until in-servicing is completed. 4. 03.05.15 - Inservice all staff on Advance Directives and "Red Star" system. Any staff not available or not scheduled to work will not be allowed to report to the hall for work until in-servicing is completed. 5. 03.05.15 - Inservice all staff on Neglect and Providing Goods and Services Necessary to care for that Resident. Any staff not available or not scheduled to work will not be allowed to report to the hall for work until in-servicing is completed. 6. 03.05.15 - Licensed Nurses inserviced on CPR Policy and Procedure dated 03.01.15 by Corporate Consultants. This deficiency cannot be corrected for RI #34 who is deceased . We are requesting Immediate Jeopardy be removed effective 03.05.15 ************************* After reviewing the facility's information provided in their Allegation of Compliance and verifying the immediate actions had been implemented, the scope/severity level of F 281 was lowered to a "D" level on [DATE] at 10:18 AM, to allow the facility time to monitor and revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 852.

Based on interviews, medical record review and the 2010 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care, the facility's nursing staff failed to provide immediate emergency medical services to Resident Identifier (RI) #34, a resident identified as having Full Code status. Code status describes what type of intervention a health care facility will conduct should a resident stop breathing and/or heart stops beating. Full Code status means when a resident stops breathing and/or heart stops beating, staff are to immediately initiate emergency medical services, Cardiopulmonary Resuscitation (CPR), in an attempt to revive the resident. During the third shift (11:00 PM - 7:00 AM) on [DATE], RI #34 experienced shallow breaths, then became unresponsive during incontinence care. Instead of promptly alerting licensed nursing staff or Emergency Medical Services (EMS), Employee Identifier (EI) #3, a Certified Nursing Assistant (CNA) left RI #34's room to physically locate the Registered Nurse, EI #1, that was on duty. After not being able to locate the nurse, EI #3 returned to RI #34's room. Then EI #2, a CNA, left RI #34's room to locate the nurse. After locating the nurse, EI #2 asked the nurse, EI #1, to come to RI #34's room. When EI #1 entered RI #34's room, she found the resident blue and cold. EI #1 then left out of the resident's room to retrieve her stethoscope. When EI #1 re-entered the resident's room, she along with EI #5, a Licensed Practical Nurse (LPN) verified that RI #34 did not have a heart beat or respirations. EI #1 then left out of RI #34's room again, to review the resident's medical record to determine the resident's code status. After verifying the resident's code status from the resident's medical record located at the nurses' station, EI #1 re-entered the room and chose not to perform CPR on RI #34, who was a Full Code resident found without a pulse or heartbeat. EI #1 decided in her nursing judgment CPR would not have helped the resident. After deciding not to perform CPR on a Full Code resident, the licensed nurses notified the resident's family, the facility's Administrative staff, the physician and the funeral home. According to the death record, RI #34's physician was notified at 1:00 AM, 40 minutes later. This deficient practice affected RI #34; one of four sampled residents reviewed for emergency response, and placed RI #34 in immediate jeopardy because it was likely to cause serious harm, injury or death. On [DATE] at 1:28 PM, the facility's Administrator, Director of Nursing, Vice President of Operations, Vice President of Quality Assurance and Registered Dietician were notified of the findings of substandard quality of care at the immediate jeopardy level "J" in the area of Quality of Care, F 309. Findings include: On [DATE], the State Agency received a complaint. According to the anonymous caller, there was talk going around the nursing home that Employee Identifier (EI) #1, a Registered Nurse (RN), did not perform Cardio [MEDICAL CONDITION] Resuscitation (CPR) and allowed the resident die. The "2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care" with a copyright date of 2010 documented " ... Part 4: CPR Overview ... The Universal Adult Basic Life Support (BLS) Algorithm is a conceptual framework for all levels of rescuers in all settings. It emphasizes the key components that any rescuer can and should perform. When encountering a victim of sudden adult [MEDICAL CONDITION], the lone rescuer must first recognize that the victim has experienced a [MEDICAL CONDITION], based on unresponsiveness and lack of normal breathing. After recognition, the rescuer should immediately activate the emergency response system, get an AED/defibrillator, if available, and start CPR with chest compressions. If an AED is not close by, the rescuer should proceed directly to CPR. If other rescuers are present, the first rescuer should direct them to activate the emergency response system and get the AED/defibrillator; the first rescuer should start CPR immediately ... If an AED/defibrillator is not available, continue CPR without interruptions until more experienced rescuers assume care ... rescuers should start CPR immediately if the adult victim is unresponsive and not breathing or not breathing normally ... CPR improves the victim's chance of survival by providing heart and brain circulation. Rescuers should perform chest compressions for all victims in [MEDICAL CONDITION], regardless of rescuer skill level, victim characteristics, or available resources ... ." An American Heart Association (AHA) document titled, "CPR: Legal and Ethical Issues" with a copyright date of 2006 documented " ... If it's part of your job, you have a duty to give CPR to a victim of [MEDICAL CONDITION] ... ." RI #34 was admitted to the facility on [DATE], with a medical history to include: [MEDICAL CONDITION] Disease, [MEDICAL CONDITIONS] and History of Stroke. RI #34's "Physician Orders" for [DATE] indicated RI #34 did not have a Do Not Resuscitate (DNR) order nor did the resident have an Advance Directive; therefore, RI #34 was a Full Code. Full Code status means that if a resident stops breathing and/or heart stops beating, the resident wants staff to immediately initiate emergency medical services, CPR, to revive the resident. On [DATE] at 2:09 PM, EI #2, the Certified Nursing Assistant (CNA), who performed incontinence care on RI #34 during the third (11:00 PM - 7:00 AM) shift on [DATE], was interviewed. When EI #2 was asked what happened the night RI #34 expired, she explained how she was preparing to change RI #34 when the resident stopped breathing. EI #2 sent EI #3, a CNA, to find the nurse assigned to the hall, EI #1. About three minutes later, EI #3 returned to RI #34's room alone because she was unable to find the nurse. EI #2 stated she then went out of the room to locate the nurse. After finding the nurse, EI #2 informed EI #1 that RI #34 had just passed. According to EI #2, after the nurse entered the resident's room, EI #2 left out to retrieve supplies to perform post mortem care on RI #34. When asked if CPR was performed, EI #2 stated no. On [DATE] at 2:23 PM and [DATE] at 3:52 PM, attempts were made to contact EI #3 by telephone however, the phone number was not a working number. A review of EI #3's personnel file indicated no other phone numbers were listed. EI #3 ended her employment with the nursing facility on [DATE]. In an interview on [DATE] at 10:40 AM, EI #1, an RN acknowledged she was working in the facility the night RI #34 expired. When asked what happened, EI #1 explained the night RI #34 passed away, she was in another resident's room administering medications when EI #3, a Certified Nursing Assistant (CNA) came and informed her to come to RI #34's room when she could. EI #1 stated after she finished administering medications to the other resident, she walked to RI #34's room. EI #1 stated she arrived in RI #34's room about two to four minutes after EI #3 asked her to come to RI #34's room. When EI #1 walked in RI #34's room, she described the resident as blue and cold. When asked, what she did when she found RI #34 blue and cold, EI #1 stated she went and touched RI #34. According to EI #1, the CNAs in the room stated they thought RI #34 had passed away when they were turning the resident during care. EI #1 reasoned that based on her expertise, she was certain RI #34 was deceased . EI #1 stated she left the room to get her stethoscope from the nurses' station. EI #1 returned to RI #34's room and listened for the resident's heart tone and respirations,but there were none. EI #1 then asked the nurse in training (EI #5) to listen for RI #34's heart tone and respirations. According to EI #1, eight to ten minutes had passed, from the time she went to review RI #34's medical record to determine the resident's code status. When asked, why didn't she check RI #34's code status when she left to retrieve her stethoscope, EI #1 stated she didn't think about it, but she should have. After determining the resident's code status, EI #1 then returned to the resident's room. EI #1 explained that given the condition of RI #34's body, she did not need to initiate CPR. EI #1 was asked what RI #34's code status was and she replied, Full Code. When asked, what should be done if a resident was a Full Code, EI #1 replied CPR should be performed. EI #1 was then asked, should CPR have been performed on RI #34 and she said yes. EI #1 acknowledged that she did not perform CPR because in her nursing judgment, CPR would not have helped RI #34. EI #1 also acknowledged that she was certified in CPR, with additional training in ACLS (Advanced Cardiac Life Support). On [DATE] 2:04 PM, [DATE] at 4:29 PM, [DATE] at 9:54 AM, attempts were made to contact EI #5 via telephone. The phone number was not in service. EI #5 ended her employment with the nursing facility, without notice on [DATE]. RI #34's "Departmental Notes" dated [DATE] 3:33 AM, written by EI #1 documented " ... CNA's alerted nursing staff to residents passing at 12:20. CNA's reported that resident appeared to have passed away while they were repositioning her during peri care. Death verified by nurses X (times) 2, absence of heart tones and breath sounds noted. Sponsor, SNF Administrator and DON, (EI #7) MD all notified of resident's passing. Post mortem care provided. (Name) funeral home notified for resident pick up ... ." RI #34's "Record of Death - Alabama" indicated the physician, EI #7, was notified on [DATE] at 1:00 AM, 40 minutes later, that RI #34 had expired on [DATE] at 12:20 AM. ************************* On [DATE] at 7:00 PM, the facility submitted an acceptable Allegation of Compliance for F 309, which documented: Failed to initiate CPR to RI #34 that was a Full Code that was found with no pulse or respiration. 1. RN who failed to administer CPR to RI #34 placed on Administrative Leave by Corporate Staff and reported to the Alabama Board of Nursing on 03.05.15. 2. 03.05.15 - Reviewed MAR's to ensure the plastic red sleeve was placed in front of each MAR indicated [REDACTED]. Note: A plastic green sleeve indicates a Full Code or no advanced directive. 3. 03.05.15 - Stat Communication Inservice Education for all staff by Corporate Consultant and Administrator/Director of Nursing. Any staff not available or not scheduled to work will not be allowed to report to the hall for work until in-servicing is completed. 4. 03.05.15 - Inservice all staff on Advance Directives and "Red Star" system. Any staff not available or not scheduled to work will not be allowed to report to the hall for work until in-servicing is completed. 5. 03.05.15 - Inservice all staff on Neglect and Providing Goods and Services Necessary to care for that Resident. Any staff not available or not scheduled to work will not be allowed to report to the hall for work until in-servicing is completed. 6. 03.05.15 - Licensed Nurses inserviced on CPR Policy and Procedure dated 03.01.15 by Corporate Consultants. This deficiency cannot be corrected for RI #34 who is deceased . We are requesting Immediate Jeopardy be removed effective 03.05.15 ************************* After reviewing the facility's information provided in their Allegation of Compliance and verifying the immediate actions had been implemented, the scope/severity level of F 309 lowered to a "D" level on [DATE] at 10:18 AM, to allow the facility time to monitor and revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 852.

Based on observations, record review and interview: 1) MACHINE DISHWASHING The facility failed to assure dishes and utensils were effectively sanitized to destroy potential food borne organisms. a. Flatware was observed wet and nested. b. Sectional plates were not air dried. (2013 Food Code) 4-901.11. 2) LIGHT BULBS, PROTECTIVE SHIELDING The facility failed to assure light bulbs were shielded, coated or otherwise shatter-resistant in areas exposed to food, clean equipment, utensils, or unwrapped single-service articles. (Food Code 6 -202.11). 3) The facility failed to remove dented cans from the active inventory. 4) CLEANING OF EQUIPMENT 4-602.11 (A)&(E.2) Iced Tea Dispenser Spigot when disassembled failed to be clean to sight. 5) PREVENT POTENTIAL CROSS-CONTAMINATION HYGIENIC PRACTICES. ? Staff failed to effectively utilize hair restraints (beard cover) and a large hair net to keep hair restrained. 6) The facility failed to designate a person in charge who was present at the food establishment during all hours of operation and could demonstrate knowledge of foodborne disease prevention, application of the Hazard Analysis and Critical Point principles and the requirements of the food code. (One of the three cooks/supervisors was Serv-Safe qualified. (Food Code 2-202.11) The above practices posed the potential for food contamination and compromised food safety. This had the potential to affect all 138 residents receiving meal trays from dining services. Findings include: 1) MACHINE DISHWASHING The facility failed to assure dishes and utensils were effectively sanitized to destroy potential food borne organisms. a. Flatware was observed wet and nested. b. Sectional plates were not air dried. (2013 Food Code) 4-901.11. The 2013 Food Code by the United States Public Health (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 or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 ..." On 1/28/2015 at 9:10 AM, clean spoons were observed wet nested. Failure to clean/sanitize both back and front of spoons during nesting creates an atmosphere for potential bacterial growth. The CDM, EI #5 was asked, to elaborate i.e. are any elements present for growth of bacteria? EI # 5 responded, "Yes, Ma'am". 2) LIGHT BULBS, PROTECTIVE SHIELDING The facility failed to assure light bulbs were shielded, coated or otherwise shatter-resistant in areas exposed to food, clean equipment, utensils, or unwrapped single-service articles. The 2013 Food Code by the United States Public Health (USPHS) and the Food and Drug Administration (FDA) included the following: "Functionality 6-202.11 Light Bulbs, Protective Shielding. (A) Except as specified in ? (B) of this section, light bulbs shall be shielded, coated, or otherwise shatter-resistant in areas where there is exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; or unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. (B) Shielded, coated, or otherwise shatter-resistant bulbs need not be used in areas used only for storing FOOD in unopened packages, ..." On 1/28/2015 at 9:30 AM, the refrigerator bulbs were observed in the presence of the CDM (Certified Dietary Manager) EI #5. The light bulb in the North Hall resident nourishment refrigerator was observed to not be covered nor shatter resistant. The light bulb in the West Hall refrigerator was not shatter resistant nor covered said EI #5. This was two of three resident nourishment refrigerators. 3) The facility failed to remove dented cans from the active inventory. On 1/27/2015 at 4:15 PM during the initial kitchen tour, dented cans were found stored on the rolling rack. A can of fruit was identified with a compromised seal. This can had been labeled with a purchase date. A second can was found with a compromised seal which was stored in the active inventory. 4) CLEANING OF EQUIPMENT .. 4-602.11 (A)&(E.2) Iced Tea Dispenser Spigot: The 2013 Food Code by the United States Public Health (USPHS) and the Food and Drug Administration (FDA) included the following: "4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (E) Except when dry cleaning methods are used as specified under ? 4-603.11, surfaces of UTENSILS and EQUIPMENT contacting FOOD that is not TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cleaned: (1) At any time when contamination may have occurred; (2) At least every 24 hours for iced tea dispensers and ..." On 1/27/2015 at 4:15 PM, the facility was observed to have two 5 gallon and two 10 gallon tea dispensers. The spigot of one container was disassembled and found to contain a brown colored solid debris adhering to the internal part. A review of the facility policy/procedure titled "Spicket-Cleaning" and revised 12/01/13 indicated that spickets should be taken off before cleaning. On 01/27/15 at 4:15 PM, the spigot had been taken off, but staff failed to disassembled the plunger/activator. This resulted in failure to remove all build up. 5) PREVENT POTENTIAL CROSS-CONTAMINATION HYGIENIC PRACTICES. ? A male manual dishwasher, EI #1 was observed not wearing a beard cover. A female food service employee, EI #2 was observed with long unrestrained hair at the clean side of the dishmachine. Staff failed to effectively utilize hair restraints (beard cover) and hair net large enough to keep hair from contacting exposed food, clean equipment etc. The 2013 Food Code by the United States Public Health (USPHS) and the Food and Drug Administration (FDA) included the following: "Hair Restraints 2-402.11 Effectiveness. (A) Except as provided in ? (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES." On 1/28/2015 at 8:55 AM, Employee Identifier (EI) #1 was observed processing items at the Manual Dishwashing sink. EI #1 was observed with facial hair on the chin and on the upper lip (a mustache). The chin hair was covered with a beard restraint, but the mustache was not covered. On 1/28/2015 at 8:55 AM, the facility Consultant Dietitian, EI #3 was asked, was the mustache covered? EI #3 responded, "No, Ma'am". On 1/28/2015 at 9:00 AM, EI #2 was observed working at the machine dishwashing clean area. Long strands of hair was observed not covered and was below the net along the neck. A review of the facility policy titled "Personal Hygiene" and identified as DPP 702 indicated: "...a. Hairnet ...covering the entire head. A facial restraint must be worn by any dietary staff with a beard or mustache..." 6) The facility failed to designate a person in charge who was present at the food establishment during all hours of operation and could demonstrate knowledge of foodborne disease prevention, application of the Hazard Analysis and Critical Point principles and the requirements of the food code. "Responsibility 2-101.11 Assignment. (A) Except as specified in ? (B) of this section, the PERMIT HOLDER shall be the PERSON IN CHARGE or shall designate a PERSON IN CHARGE and shall ensure that a PERSON IN CHARGE is present at the FOOD ESTABLISHMENT during all hours of operation. (B) In a FOOD ESTABLISHMENT with two or more separately PERMITTED departments that are the legal responsibility of the same PERMIT HOLDER and that are located on the same PREMISES, the PERMIT HOLDER may, during specific time periods when food is not being prepared, packaged, or served, designate a single PERSON IN CHARGE who is present on the PREMISES during all hours of operation, and who is responsible for each separately PERMITTED FOOD ESTABLISHMENT on the PREMISES. Knowledge 2-102.11 Demonstration. Based on the RISKS inherent to the FOOD operation, during inspections and upon request the PERSON IN CHARGE shall demonstrate to the REGULATORY AUTHORITY knowledge of foodborne disease prevention, application of the HAZARD Analysis and CRITICAL CONTROL POINT principles, and the requirements of this Code. The PERSON IN CHARGE shall demonstrate this knowledge by: (A) Complying with this Code by having no violations of PRIORITY ITEMS during the current inspection;..." On 1/27/2015 at 4:30 PM, the Certified Dietary Manager (CDM), EI #5 was asked how many Cooks/Supervisors were serv-safe qualified. EI #5 responded that only the CDM and Assistant Dietary Manager was serv-safe qualified. A review of the January 2015 schedule, there was one serv-safe qualified employee to cover 2 shifts seven days a week for January 2015.

Based on observation, record review and interview the facility failed to ensure the door to URI (Un-sampled Resident Identifier) #1's room was closed while resident was using the bedpan. This affected 1 of 21 sampled residents. Findings Include: Review of a facility policy titled "Dignity" with an effective date of 1/1/15 documented: "...Procedure...10. Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care... 11. Staff shall promote dignity and assist resident as needed by: ... b. Promptly responding to the resident's request for toileting assistance..." URI #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of URI #1's most recent significant change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/22/14 revealed URI #1 had a BIMS (Brief Interview for Mental Status) of 15 indicating URI #1 was cognitively intact. The MDS also indicated URI #1 required total assistance of 2 for toileting. URI #1 was occasionally incontinent of bladder. On 1/27/15 at 5:00 PM URI #1 was was lying in bed sleeping, privacy curtain was pulled between URI #1 and the roommate with the door to the room fully open. URI #1 used the call light to summon assistance and a CNA (Certified Nursing Assistant) responded and asked, "Are you finished." On 1/27/15 at 5:07 PM the surveyor asked EI (Employee Identifier) #8, CNA if URI #1 was on a bed pan. EI #8 said yes. On 1/29/15 at 2:30 PM an interview was held with EI #8. EI #8 was asked what have you been taught about preserving the residents privacy and dignity. EI #8 said that they should pull the curtains and make sure the door is closed. EI #8 was asked did you do that on 1/27/15 at approximately 5:00 PM with URI #1. She replied I must not have. On 1/29/15 at 3:55 PM an interview was conducted with EI #9, RN (Registered Nurse)/DON (Director of Nursing). EI #9 was asked what her staff had been taught regarding privacy and dignity during ADL (Activities of Daily Living). EI #9 replied they should shut the door and pull the curtain. EI #9 was asked what the staff should do when placing a resident on a bed pan to which she replied, they should always keep the resident covered and shut the door.

Based on observation, record review and interview the facility failed to assure the nutritional care plan for a restricted fluid diet was implemented and evaluated for Resident Identifier (RI) #13, one of one resident sampled on fluid restriction. Findings include: RI #13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Set (MDS), dated [DATE], RI #13 was assessed as having moderately impaired cognitive status and required set-up for dining. On 01/27/15 at 4:48 PM a half liter of Diet Coke was observed on the bedside table of RI #13. On the door was a sign that noted resident was on fluid restriction. Labs drawn on 1/07/15 revealed a sodium of 128 (normal is 137-145). A 1500 cc (cubic centimeters) fluid restriction was ordered at that time and the fluids were divided. Sodium redraw on 1/10/15 was 129 and on 1/14/15 the sodium was 131. The Registered Dietitian (RD) note dated 1/28/2015, indicated a phone order was received for a 1500 cc fluid restriction due to low sodium (lab value). The plan recommended by the RD was 240 cc TID (3 times per day) w (with)/ meals, 120 cc TID w/ snacks and 100 cc w/ med pass (x4), 20 cc q (every) day prn (as requested). An observation on 1/28/2015 at the noon meal revealed the direct care staff provided an additional 240 cc (cup of coffee) in addition to the 240 cc of Iced Tea consumed. A request to view documentation of fluid monitoring revealed data was not in measurable terms and failed to capture additional fluid provided. The data was reviewed on the MAR (Medication Administration Record) which revealed a check mark which indicated the fluids were provided but did not reveal the amount consumed. On 1/28/2015 at 4:00 PM the findings were discussed with the RD, Employee Identifier (EI) #3. EI #3 stated the staff and family needed to be educated. The RD said the cola on the night stand was brought in by the family.

Based on observation, interview and record review, the facility failed to ensure licensed staff washed their hands during the provision of wound care of RI (Resident Identifier) #3's two stage II pressure ulcers, after cleaning each wound and before applying medication and a clean dressing. This affected one of two residents observed for wound care. Findings include: RI #3 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The readmission MDS (Minimum Data Set) with an assessment reference date of 02/25/2014, assessed RI #3 with severely impaired cognition and dependent on staff for activities of daily living. RI #3 was also assessed on the MDS as having two stage II pressure ulcers. The physician orders [REDACTED]. "Clean pressure ulcer to left heel with NS (normal saline). Pat dry. Apply Bard wipe to periwound. Apply small amount of Santyl ointment to slough on wound bed. Cover with [MEDICATION NAME] gauze and Combiderm Q (every) D (day) and PRN (as needed) till healed. Clean right buttocks ulcer with NS. Pat dry. Apply Bard wipe to periwound. Apply [MEDICATION NAME] Active cavity dressing. Cover with Combiderm QD and PRN till healed." On 02/26/2014 at 8:45 AM, LPN (Licensed Practical Nurse) wound nurse, EI #7 was observed providing wound care to the buttock and the left heel for RI #3. EI #7 removed the dressing from the buttock area, then removed her gloves and used hand gel. After applying gloves, EI #7 measured the wound area as 3.5 cm (centimeters) in length x (by) 2.3 cm in width, and then cleaned the area. Without washing her hands, using hand gel or changing her gloves, she proceeded to apply the [MEDICATION NAME] dressing, and cover the wound with a new dressing. EI #7 then provided care to the pressure ulcer on the left heel. This wound was also identified by EI #7 as a stage II pressure ulcer. EI #7 washed her hands, applied gloves and removed the sock and soiled dressing from RI #3's left foot. EI #7 then removed her gloves and went to the cart to obtain more supplies. She reentered the room and without washing her hands, she applied gloves. EI # 7 then measured the area and cleaned the area with normal saline and 4x4s. Without washing her hands or changing her gloves, EI #7 applied Santyl ointment (a [MEDICATION NAME] agent) to the area and covered it with a dressing. The review of the facility's "Handwashing / Hand Hygiene" policy (revised 01/11/2007) revealed: "Policy Handwashing/hand hygiene is regarded by this facility as one of the single most important means of preventing the spread of infections." "A. When to Wash Hands (at a minimum) ...10. After contact with any body fluids. 11. After handling any contaminated items... B. Procedure for Using Alcohol Hand Sanitizer ...5. Always wash hands with soap and water after blood or body fluid exposure..." A review of the "Fundamentals of Nursing" Potter-Perry Eighth edition, with a copyright date of 2013, revealed on page 410, "Asepsis. ... Contaminated hands of health care workers are a primary source of infection transmission in health care settings." Page 1217 showed: "Skin Integrity and Wound Care ...Implementation ...Clean ulcer thoroughly with normal saline or cleaning agent... Remove gloves, perform hand hygiene, and apply clean or sterile gloves." On 02/26/2014 at 2:35 PM, EI #7, was interviewed. EI #7 was asked if she thought it was important to wash her hands after cleaning a wound. EI # 7 stated it was important and it was so she did not contaminate it. The infection control nurse, EI #8, was interviewed on 2/26/2014, at 3:00 PM. EI #8 was asked when should a nurse wash her hands during wound care. EI #8 replied, before starting, when changing gloves and after the finish of the procedure. EI # 8 was asked how important was it to wash hands, and change gloves after cleaning a wound. EI #8 stated it was very important, because they do not want to contaminate the new dressing.

Based on observation, interview, and record review, the facility failed to ensure incontinent care was provided in a manner to prevent the potential for recurrent UTIs (Urinary Tract Infections), by staff members not separating the residents' labia. This affected RI (Resident Identifier) #6, RI #8, and RI #13, three of three residents observed for incontinence care. Findings include: 1) RI #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #13's Quarterly MDS (Minimum Data Set) Assessment (with an assessment reference date of 02/03/14) revealed she was moderately cognitively impaired and required extensive physical assistance from one staff member for toileting. RI #13 was assessed as always incontinent of urine and frequently incontinent of bowels. A review of RI #13's microbiology report dated 01/05/14 revealed RI #13 had growth of Escherichia coli in her urine [MEDICAL CONDITION]. A review of RI #13's physician phone orders dated 01/05/14 revealed an order for [REDACTED]. On 02/25/14 at 3:10 PM, RI #13 was observed for incontinent care, which was provided by two CNAs (Certified Nursing Assistants). EI (Employee Identifier) #6 applied wash cream to a cloth and wiped across the pubic area. She changed the position of the cloth, then wiped the right groin area. EI #6 changed the position of the cloth again and wiped the left groin area. EI #6 placed her hand on the pubic area and pulled up. She changed the position of the cloth for the forth time and wiped across the labia. EI #6 discarded the cloth. EI #6 did not separate the labia during this incontinent care. 2) RI #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a laboratory report for a chemistry profile dated 12/5/2013, the CRNP (Certified Registered Nurse Practitioner) wrote an order on the report: "1 UA (urinalysis) C&S (culture and sensitivity) d/t (due to) (increased) WBC (White Blood Count). 2 [MEDICATION NAME] 1 m (gram) IM (intramuscular) now after UA obtained." The significant change MDS with an assessment reference date of 12/06/2013, was reviewed. RI #6 was assessed with [REDACTED]. On 2/26/2014 at 9:50 AM, EI #11, a CNA (Certified Nursing Assistant) was observed providing incontinence care for RI #6. EI #11 wiped across the pubic area with a wet washcloth containing cleaner. After changing positions of the cloth, EI #11 wiped the right and left groin. Obtaining another wet cloth with cleaner, EI #11 wiped down across the labia. EI #11 did not separate or wash the labia to be sure RI #6 was thoroughly cleaned. On 02/26/2014 at 3:00 PM, the Infection Control/Staff Development LPN (Licensed Practical Nurse) EI #8, was interviewed. EI #8 was asked as a nurse if she was taught to separate the labia on a female resident during incontinence care. EI #8 stated she was and that it was important to ensure there was no bacteria to cause urinary tract infections. On 02/26/2014 at 3:55 PM, EI #11 was interviewed. When asked if he had been instructed on incontinence care for a female, he stated he had. EI #11 was asked what he had been told regarding cleaning a female resident in the front. EI #11 responded he was told to separate the labia and wash the resident. 3) RI #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Admission MDS dated [DATE] assessed RI #8 with a BIMs (Brief Interview of Mental Status) score of 5, indicating she was severely cognitively impaired. RI #8 was assessed as being dependent for all activities of daily living, and incontinent of bladder and bowel. She was also coded as having a urinary tract infection in the past 30 days. On 02/25/2014 at 3:50 PM, EI #12 (CNA) was observed providing incontinence care for RI #8. EI #12 wet wash cloths in the bathroom and placed them into a plastic bag. EI #12 unfastened RI #8's brief. With a wet cloth EI #12 wiped across the pubic area. Changing the position of the cloth, she wiped the left groin area. Changing position of the cloth, she wiped the right groin. Without separating the labia, EI #12 wiped across the labia from front to back. RI #8 was then placed onto her side and the buttocks were cleaned. EI #12 obtained another wet cloth and wiped the rectal area three times, changing the position of the cloth with each wipe. EI #12 was interviewed on 02/26/2014 at 4:00 PM. EI #12 was asked if she had been taught to separate the labia of female residents when providing incontinence care. EI #12 stated she had. When EI #12 was asked why this was important, she stated it was to prevent urinary tract infections. A review of the Potter-Perry "Fundamentals of Nursing" Eighth edition, with a copyright date of 2013, revealed on page 1060, unit 7: "Physiological Basis for Nursing Practice ...Preventing infection. One of the most important considerations is to prevent infection of the urinary system. Good perineal hygiene that includes cleaning the urethral meatus after each voiding or bowel movement is essential. ..."

Based on record review and interview, the facility failed to ensure the current physician orders [REDACTED]. This affected one of twenty-one active sampled residents whose physician orders [REDACTED]. Findings include: RI #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. When the physician orders [REDACTED]. (milligrams) to be administered at 8 AM as well as the 60 mg. to be administered at 1 PM. The first order with a start date of 4/24/13 was written as "[MEDICATION NAME] 40 mg , [MEDICATION NAME] 20 mg tablet. Give 1 tab of 40 mg and 1 tab of 20 mg to equal to 60 mg PO qAM (every morning) with a time code of 8AM and the second order with a start date of 12/6/13 for [MEDICATION NAME] 20 mg tablet, 3 tabs (60 mg) PO QD with a time code of 8AM. There was a clarification order dated 12/6/13 at 6 PM "Give [MEDICATION NAME] 60 mg qd (every day) PO (per orum or by mouth) qAM, Give [MEDICATION NAME] 60 mg qd PO @ (at) 1 PM." Both orders for [MEDICATION NAME] remained on the physician order [REDACTED]. On 2/26/14 at 11:40 AM EI (Employee Identifier) # 9, Registered Nurse and EI#10, Assistant Director of Nursing, were asked how many orders for [MEDICATION NAME] were on the current orders. Both stated there were three and they also reviewed the clarification order. Both were asked what should have happened. EI #9 stated after the order was taken and clarified, the order for 4/24/13 should have been d/ced (discontinued). When asked if that was done EI #10 stated, "No ma'am it had not been marked through".

Based on observation, interview, and record review, the facility failed to ensure the walk-in freezer in the kitchen was free of an accumulation of ice on the compressor pipes and ceiling. This had the potential to affect all 135 of 135 residents who receive meals from the kitchen. Findings include: A review of the facility policy titled, "Repair Requisition" (no date) revealed: "...Purpose: To assist in the prompt repair of equipment...that may be broken or have failed. ...Requests for repairs to equipment...should be communicated...to the maintenance department..." A review of the Maintenance Director's job description (dated 03/01/11) revealed: "General Purpose: To plan, organize and direct the overall operation of the department in accordance with current federal, state and local standards, ensuring that the facility is maintained in a safe, comfortable condition. ... A. Maintenance Functions ...coordinate maintenance services with other departments...ensure proper maintenance of the facility including ...equipment... ." On 02/25/14 at 10:34 AM, during the initial tour of the kitchen, the walk-in freezer contained frozen water droplets on the ceiling in front of the compressor and behind the compressor. There was also an accumulation of ice on two pipes connected to the compressor. On 02/26/14 at 9:00 AM, the walk-in freezer was observed again. There was a build-up of ice on the two pipes connected to the compressor and droplets of ice on the ceiling in front of and behind the compressor. The Corporate Dietitian, EI (Employee Identifier) #3 said they put in a work order on 02/25/14 for the Maintenance Director (EI #5) to look at the compressor. On 02/27/14 at 9:13 AM, the Dietary Manager (EI #4) was asked if she was aware of the ice build-up in the freezer before the surveyor came into the facility on [DATE]. She responded, "No ma'am." EI #4 was asked what dietary's responsibility was in monitoring ice build-up. She said as dietary staff members put away stock, if they notice ice build-up they should notify maintenance. EI #4 explained that dietary staff monitor the temperature of the freezer three times a day. EI #4 was asked how they communicate with the maintenance department. She said they put a work order into the computer system and they have to put where it is, a description of the issue, and choose the severity (low, medium, high, or critical). EI #4 explained that after they put in a work order on 02/25/14, the Maintenance worker removed the ice, went into the attic, and caulked a space that may have been leaking warm air, which was causing condensation. EI #4 was asked what the potential problem was with ice build-up in the freezer. She said it could cause the compressor to shut down, the temperature to get too warm, and the food could spoil. On 02/27/14 at 9:37 AM, the Corporate Dietitian (EI #3) was asked if she was aware of the ice build-up in the freezer before 02/25/14. She replied, "No." EI #3 was asked what dietary's responsibility was regarding ice build-up in the freezer. She said if they see ice build-up they should notify maintenance. EI #3 explained that the dietary staff members monitor the temperature of the freezer and if it is not zero degrees or below they should notify maintenance. EI #3 was asked what the potential problem was with ice build-up in the freezer. She said if it builds up too much it might not work properly, food would not be at the right temperature, and the food would begin to thaw. A review of the "Walk In Freezer Temperature Log" for February 1st through February 26th revealed temperatures for three shifts every day. All the temperatures were in the negative range except for three shifts, which documented zero degrees. On 02/27/14 at 9:50 AM, the Maintenance Director (EI #5) was asked what the maintenance department's responsibility was for the freezer in the kitchen. He said if any issues come up dietary puts in a work order and maintenance takes care of it. EI #5 explained that he was notified Tuesday of the ice build-up, so he sealed (with caulking) the area around the pipe in the ceiling where air was leaking in. EI #5 was asked if he did a routine check of the freezer. He said his department does a daily temperature check. EI #5 was asked if he specifically checks for ice build-up. He replied, "No."

Based on observations, record review, and interview, the facility failed to toilet and reposition Resident Identifer (RI) #2 from 8:10 AM until 12:50 PM on 12/12/12. RI #2 was identified by the Treatment Nurse (Employee Identifier) EI #1 with a current stage four pressure ulcer to her coccyx area. This affected one of one sampled residents with a pressure ulcer. Findings include: RI #2 was admitted to the facility on [DATE] with [MEDICAL CONDITION] and a history of falls. RI #2 was readmitted to the facility on [DATE] with Aftercare related to a Traumatic [MEDICAL CONDITION] and an Unstageable Pressure Ulcer. The Significant Change Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/02/12 revealed the resident required extensive assistance with bed mobility, and was totally dependent on staff for transfers. RI #2 was incontinent of bowel and bladder and was totally dependent on staff for toileting needs. The MDS revealed the resident was only able to move from a sitting to a standing position with staff assistance. The MDS also identified the resident had an unstageable pressure ulcer with "Necrotic tissue (Eschar)-black, brown, or tan tissue that adheres firmly to the wound bed or ulcers edges, may be softer or harder than surrounding skin." The Care Assessment Triggers (CAT) worksheet for the pressure ulcer revealed the resident had an actual pressure impaired skin integrity. The resident was to be turned and repositioned per her individual turn schedule, and staff were to provide incontinent care as needed. RI #2's skin integrity care plan revealed: "...Actual impaired skin integrity related to pressure ulcer to... coccyx, arterial ischemic ulcer to both heels, limited mobility,..." The approaches included: "... Monitor for s/s (signs and symptoms) or c/o (complaints of) pain r/t (related to) wound and give pain meds as needed. Document effectiveness... Document weekly and prn (as needed) on wound condition... turn and reposition per turn schedule..." RI #2 was observed on 12/12/2012 at 7:40 AM for incontinent care and wound care. At 8:10 AM, after the provision of care, two Certified Nursing Assistants (CNAs), EI #3 and EI #4 were observed to transfer the resident into a pedal (Broda) chair and moved RI #2 out of the room, sitting the resident in front of the nursing station. RI #2 was observed continuously from 8:10 AM until 12:50 PM. During the observation the following was observed: 8:20 AM, resident sitting in the pedal chair in front of nursing station asleep. 8:35 AM, RI #2 continued to sit in the pedal chair asleep in front of the nurse's station. 8:39 AM, RI #2 was awake, moving herself in the pedal (Broda) chair from the wall to the middle of the hall in front of the nurse's station. A staff member came by and said she was going to move her from the middle of the hallway and moved the resident back to the wall. 8:45 AM, EI #2 a staff member walked up and spoke to RI #2, calling the resident by name. The resident was not repositioned. 9:00 AM- 9:10 AM, RI #2 was observed sitting in the pedal chair asleep in front of the nursing station. 9:14 AM, RI #2 was moved to her room by the medication nurse and a CNA. The resident's door was left open, and the nurse was observed to give the resident medication. No one moved or adjusted RI #2 in her pedal chair. 9:15 AM, RI #2 was moved back to the hall in her pedal chair and placed in front of the nurses desk. 9:20 AM, RI #2 was moved by staff to the dining room for activities. 9:30 AM, RI #2 was observed in the dining room sitting in the pedal chair asleep during the activity. 9:40 AM, the resident continued to sleep in the pedal chair in the dining room. 9:50 AM, RI #2 was patted by a staff member and asked if she was going to participate in the activities. The resident did not respond. 10:00 AM, RI #2 was pushed in the pedal chair to the middle of the room and given a Styrofoam noodle to use for the activity. RI #2 was observed to hold a purple Styrofoam noodle with both hands, and three staff members were present at this time. 10:05 AM, a staff member moved RI #2's pedal chair, and the resident was still holding a purple Styrofoam noodle. RI #2 was not repositioned. 10:10 AM-10:20 AM, a staff member was observed to hold RI #2's right hand, containing the noodle, and assisted the resident with hitting the ball on the floor. 10:23 AM, staff were observed to move RI #2 back from the center of the room so other residents could play the game. The resident was observed sitting with nine other residents at this time in activities. 10:25 AM, RI #2's visitor was observed to come into the dining room and move RI #2 in the pedal chair to her room. However, the visitor did not close the door and did not reposition RI #2 at this time. 10:32 AM, an activity staff member entered the resident's room and asked if the resident needed her nails done, saying she would return. This staff member did not reposition RI #2. 10:50 AM, a housekeeper entered RI #2's room. 11:00 AM, RI #2 was moved in her pedal chair to the restorative dining room. 11:30 AM, RI #2 was observed sitting in her pedal chair in the dining room with another resident. RI #2 was observed sitting at the table feeding herself. 11:45 AM, RI #2 continued to sit in the same area in the dining room, with staff sitting beside the resident and assisting with her meal. 12:15 PM, RI #2 continued to sit in the dining room with staff assisting with her meal. 12:30 PM, staff continued to feed resident. RI #2 was observed to eat very slowly. 12:31 PM, RI #2 was moved from the restorative dining room to the hall outside her room in front of the nurse's station. The resident's visitor pushed the pedal chair into her room. RI #2's visitor did not close the door or reposition the resident. 12:40 PM, the resident continued to sit in the pedal chair, in her room with her visitor. 12:50 PM, a therapist entered the resident's room and took (by pushing her chair) RI #2 to therapy. She told the visitor she would be gone about 30 minutes. 12:55 PM, the therapist (EI #5) was asked if she was going to walk the resident. EI #5 replied, "Yes," and she thought the Occupational Therapist (OT) and Speech Therapist (ST) would be working with the resident that day. At 1:00 PM, therapy staff were observed walking the resident with a staff member on each side and one staff was walking behind the resident. On 12/13/12 at 7:15 AM, EI #3 was asked if she provided care for RI #2 on 12/12/12. EI #3 said she had. EI #3 was asked if RI #2 was incontinent of bowel and bladder and had a pressure ulcer. EI #3 said yes, RI #2 was incontinent and had a pressure ulcer on her coccyx. EI #3 was asked how often she toileted a resident who was incontinent. EI #3 said they usually try to check them every two hours. EI #3 was asked if RI #2 was toileted every two hours on 12/12/12 between 8:10 AM and the time she returned from therapy after 1:00 PM. EI #3 replied "No." EI #3 was asked why not. EI #3 replied, "It was a very busy day..." EI #3 was asked how care was provided for a resident that had a pressure ulcer. EI #3 said they usually put the resident back to bed after meals. EI #3 said they positioned RI #2 from side to side because she had a pressure sore on the coccyx. EI #3 was asked how often RI #2 was repositioned on 12/12/12. EI #3 said they got the resident up yesterday morning, but she did not remember what time it was when they put her to bed. EI #3 was asked if RI #2 was repositioned in the pedal chair after she was gotten up on 12/12/12. EI #3 said, "No." EI #3 was asked why not. EI #3 said she did not know. At 12/13/12 at 7:42 AM, EI #4 was asked if she worked with RI #2 on 12/12/12. EI #4 replied she did. EI #4 was asked how often RI #2 was checked and changed for incontinence care. EI #4 said they had to check her every two hours. EI #4 was asked how she provided care for a resident with pressure ulcers. EI #4 said the resident is normally laid down after meals and turned from side to side. EI #4 was asked when RI #2 was laid down or repositioned on 12/12/12. EI #4 said it was after the trays were picked up after lunch. EI #4 was asked if the resident had already been to therapy when she was laid down. EI #4 said "Yes" she believed so. EI #4 was told the resident was toileted at 8:10 AM and was asked if RI #2 was toileted anytime before she was laid down after therapy. EI #4 replied she did not personally check or change her. EI #4 was asked if the resident was repositioned after she was placed in the pedal chair at 8:10 AM. EI #4 replied she had not repositioned RI #2. On 12/13/12 at 2:45 PM, the Unit Manager/Registered Nurse, EI #6 was asked how often a resident, who is incontinent, is to be checked and changed. EI #6 said at least every two hours. EI #6 was asked why. EI #6 said it was to make sure they do not have skin breakdown and to keep them dry. EI #6 was asked how often a resident with a pressure ulcer is to be turned and repositioned. EI #6 said if the resident is not able to reposition themselves they should be repositioned every two hours. EI #6 said if the pressure ulcer is on the sacrum (coccyx) the resident is turned from side to side as much as possible. EI #6 was asked why RI #2 was not checked, changed, or repositioned from 8:10 AM until after 12:50 PM on 12/12/12. EI #6 said she thought the nurse and CNA checked the resident when medications were given. EI #6 was asked if they would have checked, changed or repositioned RI #2 with the resident's door open. EI #6 replied, "No," that is not an approach they teach.

Based on observation, interview and record review, the facility failed to put appropriate interventions in place for Resident Identifier (RI) #2 and RI #3 to try to prevent future falls. Both residents had a history of [REDACTED]. Findings Include: A review of the facility's policy, "Incident Investigations Investigative 24 Hour-Post Fall Monitoring with a revised date of 4/01/12 documented: "... Fall assessment conclusion shall be documented by the Fall Committee with corrective actions in place, for example, changes in care plan approaches, assessment of medications, indicated lab work, changes in environment, physician interventions..." A review of the facility's policy titled, "Care Plan/Goals and Objectives" (revised 02/01/05) documented: "...Goals and Objectives are reviewed and/or revised: when there has been a significant change in the resident's condition..." 1) RI #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. RI #3's Significant Change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/13/12 documented RI #3 scored a 4 out of a possible 15 on the Brief Interview for Mental Status (BIMS). This indicated RI #3 was severely cognitively impaired. RI#3 required extensive assistance with ADL's (activities of daily living) such as bed mobility, transfers, toileting, locomotion on and off unit and dressing. The Care Assessment Triggers (CAT) revealed RI #3 triggered for falls since he had disturbances of balance, gait and positioning ability. A review of the Fall Risk Assessment for RI #3 dated 2/23/12, revealed anyone with a total score of 10 or above represented a high risk. RI #3 scored a 17 on the assessment. A review of RI #3's Functional Management Program for Physical Therapy dated 11/26/12, documented, "... Transfers from bed/chair using a gait belt for safety requiring max assist x 2...safety awareness severely impaired... " A review of the Incident Investigation Reports documented RI #3 had the following falls: a) On 3/20/12 at 5:00 AM, a CNA informed the nurse that the resident was on the floor next to his mat. The corrective action to prevent a recurrence was for OT (Occupational Therapy) to eval (evaluate) for re-arrangement of furniture in the resident's room. The Care Plan did not document this intervention. EI (Employee Identifier) #2 (Director of Nursing-DON) was interviewed on 12/13/12 at 2:10 PM. RI #3's fall was discussed with EI #2. EI #2 was asked if the intervention for the fall was for OT (Occupational Therapy) to evaluate and re-arrange the furniture in the resident's room. EI #2 said it was. EI #2 was asked how she would know what therapy did if it was not on the care plan. EI #2 said if it was an OT evaluation, it should be in the OT notes. EI #2 was asked if there was documentation in the therapy notes. EI #2 reviewed RI #3's therapy notes and replied, "The intervention is not in here." EI #2 was asked if she saw any intervention in the care plan. She said she did not. b) On 9/7/12 at 5:15 PM, a resident told a nurse that RI #3 was on the floor in his room. The Incident Investigation Report documented "... call light was in reach but not on. Bed alarm sounded. Floor alarm did not sound...Summary of corrective action taken to prevent a recurrence ...PT/OT evals ordered. Assessed floor alarm-was noted to not be plugged into box completely-fixed into box appropriately. Restorative assessed alarms and discontinued bed alarm box. OT it did not sound as loudly as it should..." On 12/13/12 at 2:10 PM, EI #2 was interviewed regarding the fall. EI #2 was asked what the intervention was. EI #2 said a PT (Physical Therapy)/OT evaluation was ordered. EI #2 said the floor alarm was not plugged into the box completely. EI #2 was asked what PT did. She said PT picked RI #3 up for therapy and OT did not pick him up. EI #2 later said RI #3 was already on the PT caseload. EI #2 was asked why would they order a PT evaluation if RI #3 was already on a PT caseload. EI #2 stated, "I got you, he was already on PT; they are just getting notified." c) On 10/04/12 at 9:00 PM, a CNA heard an alarm as she was going down the hallway. RI #3 was observed falling backwards while he was at the nurse's station. The Incident Investigation Report documented the corrective action to prevent a recurrence was for a PT/OT evaluation. On 12/13/12 at 2:10 PM, EI #2 was asked if the intervention for the fall on 10/04/12 was PT/OT to evaluate and treat as needed. EI #2 said it was. RI #2's Care Plan was reviewed. There was no new intervention on the Care Plan. d) RI #3 had another fall on 10/17/12 at 8:25 PM. The Incident Investigation Report documented, "...Summary of corrective action to prevent a recurrence, PT/OT evaluation ordered and consult with Activities Department related to providing activities/intervention with resident later in the day and one on one..." EI #2's care plan did not have an intervention for this date. An interview was conducted with EI #2 on 12/13/12 at 2:10 PM. EI #2 was asked what the intervention was for RI #3. EI #2 said a PT/OT eval was ordered again and a consult with Activities because a lot of falls were in the afternoon and at night. EI #2 said she had RI #3 sit in her office with her in the past. When asked what had the Activity Department done to help decrease falls for RI #3, EI #2 said she would have to talk with them (Activity Department). RI #3's Care Plan was reviewed. There was no documentation regarding any activity interventions to try to prevent further falls. RI #3 was observed on all three days of the survey. He was observed lying in bed in his room, sitting in his chair at the nurse's station and in the dining room. RI #3 sat still and did not speak unless spoken to. 2) RI #2 was admitted to the facility on [DATE] with a History of Falls, Alzheimer's Disease, and Vascular Dementia. RI #2 was readmitted to the facility on [DATE] with Aftercare related to a Traumatic Hip Fracture and an Unstageable Pressure Ulcer. The admission MDS with an assessment reference date of 10/04/12 revealed RI #2's BIMS score was a three out of a possible 15, indicating the resident was severely cognitively impaired. RI #2's functional status revealed the resident required extensive assistance with bed mobility, transfer, dressing, toileting, and personal hygiene. The MDS also identified the resident had a history of [REDACTED]. The fall risk assessment dated [DATE] revealed a resident whose grand fall assessment total is greater than ten or above represented the resident was a high risk for falls. RI #2's grand total score was 21, indicating the resident was a high fall risk. RI #2's care plan for Vascular Dementia dated 09/28/12 revealed RI #2's Cognitive Deficit and Dementia had gotten worse and RI #2 had problems with verbalizing her needs, memory and understanding others. The Significant Change Minimum Data Set with a reference date of 11/02/12 revealed the resident required extensive assistance with bed mobility, and was totally dependent on staff for transfers. RI #2 was incontinent of bowel and bladder and was totally dependent on staff for toileting needs. The MDS revealed the resident was only able to move from a sitting to a standing position with staff assistance. The MDS also revealed the resident had a history of [REDACTED]. The Care Assessment Triggers (CAT) with an assessment reference date (ARD) of 10/04/12 revealed RI #2 had a history of [REDACTED]. The CAT with an ARD of 11/02/12 revealed RI #2 had a history of [REDACTED]. A review of RI #2's fall investigation revealed RI #2 had a fall on 10/19/12. The investigation revealed the resident was found on the floor between the bed and the bathroom and the resident was telling staff she had to get out of there. The facility's intervention was to educate the resident on the use of the call light and encourage the use of non-skid socks. A review of a fall investigation for RI #2 dated 10/22/12 (three days later) revealed RI #2 was found on the floor in front of the nurse's station. RI #2 was transported to the local hospital where she was diagnosed with [REDACTED]. On 12/13/12 at 2:10 PM, the DON (EI #2) was asked about the intervention put in place on 10/19/12. EI #2 was asked if a resident with a BIMS score of three was able to be re-educated. EI #2 replied, "No."