Based on observation and interview the facility failed to ensure the controlled box containing narcotics, in the Station 1 medication storage room, was permanently affixed to the inside of the refrigerator. This was observed on 6/20/19 at 10:30 AM during the medication storage observation and affected one of two medication storage rooms observed. Findings include: On 6/20/19 at 10:30 AM the surveyor and Employee Identifier (EI) #12, a Registered Nurse (RN)/Unit Manager, observed the medication storage room on Station 1. EI # 12 was asked if there was a secured box for controlled refrigerated medications. EI #12 replied, yes it is the locked box. EI # 12 was then asked if the locked box was permanently affixed to the refrigerator. EI #12 said the locked box was affixed to the shelf in the refrigerator. EI #12 was asked if the shelf was permanently affixed to the refrigerator, and EI #12 proceeded to pull on the shelf, removing the shelf along with the locked controlled medication box. On 6/20/19 at 10:40 AM, EI #12 was asked if the controlled medication lock box, in the Station 1 medication storage refrigerator, was securely affixed to the refrigerator. EI #12 stated it was not secure. On 6/21/19 at 6:48 PM, EI #2, Director of Nursing (DON), was asked how the narcotic storage box should be in the refrigerator in the medication storage room. EI #2 stated, It should be firmly affixed to the refrigerator and behind two locks. EI #2 was then asked if the shelf that the box was attached to was able to be removed was the box firmly affixed. EI #2 replied, No.

Based on observation, interview, and review of a facility policy titled, Medication Administration Procedures, Eye Drops , the facility failed to ensure that a Licensed Nurse did not take multi-use items into a resident's room and place them on an unclean surface during medication administration of eye drops, then return and place items in the medication cart without first cleaning the items. This deficient practice affected Resident Identifier (RI) # 93, one of one resident observed receiving eye drops, and one of six total residents observed during medication administration observations. Findings include: Review of the facility policy titled, Medication Administration Procedures, Eye Drops, dated 03/11, revealed the following: . Procedures 1. Leave the . outside box on the medication cart. Only take the actual eye drops container into the resident's room. 2. Obtain a clean barrier and place on over-bed table . On 6/19/19 at 4:31 PM, Employee Identifier (EI) #11, a Licensed Practical Nurse (LPN), was observed administering medications to RI #93. EI #11 obtained sani cloths, a tissue box, and RI #93's eye drops, then placed them on the bedside table, without first laying down a barrier. After administering medications, she then returned to the medication cart and placed these items on top of the cart, without first cleaning them. On 6/19/19 at 04:45 PM, EI # 11 was asked why she took the container of sani cloths, the box of tissues, and the box with the eye drops, into the resident's room. EI # 11 said because she was going to clean the bedside table, but her hands were full so she just set it all down. EI #11 explained she should have taken one sani cloth and one tissue into the room. EI #11 was asked what would be the potential harm in placing a multi-use container, such as the sani cloth container, the box of tissues, and the box with eye drops, on the resident's bedside table with no barrier, then returning those items to the medication cart without cleaning them. EI #11 replied that germs could spread, causing cross contamination. On 6/21/19 at 6:48 PM, EI #2, the Director of Nursing, was asked if a nurse should take a box of tissues, a container of sani cloths and a box of eye drops into the resident's room and place them on the bedside table without a barrier, then return them to the cart without cleaning them. EI #2 said no, because that was definitely an infection control issue.

Based on observations, interviews and review of a job description for the Director of Maintenance, the facility failed to ensure Room Locator (RL) #s 19-26 were free of chipped paint and splintered plywood on walls, broken chair rail moulding, scuffed and chipped paint on door facings, misaligned furniture drawers, soap dispenser off wall, broken toilet tissue holder, dangling TV cable and wheelchairs with tape on armrests. This was observed on three of four days of the survey and affected RL #s 19-26, eight of 81 rooms in the facility. Findings Include: A facility document titled, JOB DESCRIPTION . JOB TITLE: Director of Maintenance, with a review date of 6/30/03, documented: . B. DEPARTMENTAL FUNCTIONS . 9. Maintain appearance of building and provide necessary repairs and painting as needed. 23. Paint interiror/exterior surfaces. 26. Repair departmental equipment . On 6/18/19 at 8:51 a.m., the surveyor observed the dresser in RL #19 with the top 2 drawers misaligned, and the 4th drawer difficult to open. On 6/18/19 at 9:17 a.m., the surveyor observed RL #20 with the bathroom soap dispenser and toilet paper holder off the wall. The resident in RL #20 reported that he/she had reported these items to maintenance, who did repair them, but they were now off the wall again. The handle to the bottom drawer of the dresser was half-way detached. On 6/18/19 at 10:50 a.m. the following observations were made: RL #22- the wall at the head of the bed was noted with gouges in the painted plywood applied to the wall. The plywood was splintered. RL #23- the left arm rest of the wheelchair had nursing tape wrapped around it. RL #25- the chair rail moulding around the room was broken at the head of the bed, leaving rough edges. On 6/19/19 at 8:20 a.m. RL #26's door was observed to not completely close and the door facings and wall at the head of the bed had scratched paint. The resident in this room also stated his/her wheelchair was missing a handle (on the brake). On 6/20/19 at 5:13 p.m., the surveyor and Employee Identifier (EI) #3, Director of Maintenance, observed the following: RL #19- the first and second drawers on the dresser were misaligned and the fourth drawer was hard to open. When asked what the concern with the drawers was, EI #3 stated they could be too hard for the resident to open and the drawer could fall out on the resident. RL #20- bottom drawer of the dresser was missing a screw on the handle, causing the handle to dangle. The soap dispenser was off the wall, and the toilet tissue holder was missing half of its mechanism. EI #3 stated this was a problem. RL #21- the TV cable was dangling beside the door over the light switch plate RL #22- the wall at the head of the bed was noted with gouges in the painted plywood applied to the wall. EI #3 was asked what was the concern. EI #3 replied they could get splinters, and it just did not look good. RL #23- the wheelchair armrest was taped with nursing tape. EI #3 agreed it was an issue. RL #25- the chair rail moulding was broken, with sharp, jagged edges. EI #3 observed and agreed it was a hazard. On 6/20/19 at 5:36 p.m. an interview was conducted with EI #3, Maintenance Director, upon conclusion of the observations above. EI #3 was asked what was the concern with the issues that were identified during the rounds. EI #3 answered, someone could get hurt and it just did not look good.

Based on interviews, review of pest control treatment logs, review of a facility policy titled Quality Assurance/Quality Assurance Performance Improvement, review of facility documents titled Quality Assurance Committee Action and Emergency Q.A.P.I. (Quality Assurance Performance Improvement) Meeting Minutes and review of the Administrator's job description, Employee Identifier (EI) #1, the facility's administrator, failed to provide necessary oversight to ensure a Quality Assurance Performance Improvement plan was implemented after the identification of bed bugs on 5/09/19 in Resident Identifier (RI) #41 and RI #105's room, Room Locator (RL) #1, which resulted in the spread of bed bugs. This affected RI #s 41, 42, 46, and 105, four of 11 residents sampled for bed bugs. Bed bugs were identified in 6 of 81 total resident rooms in the facility, as well as in common areas, including the day room and dining room. Findings Include: Cross reference F867 and F925. Review of the job description, last reviewed 6/30/03, for EI #1, the Administrator, revealed: . 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 practicable level of care is provided to the residents. Qualifications .Must possess ability to efficiently .implement and interpret programs, goals, objectives, policies, and procedures necessary for providing quality care .Standard Requirements .Knowledgeable of resident rights and ensures an atmosphere, which allows for .dignity, and well-being of all residents in a safe, secure environment .Essential Job Functions .2. Ensure that each resident receives the necessary nursing, medical and psychological services to attain and maintain the highest possible mental and physical functional status. 3. Plan, develop, organize, implement, evaluate, maintain, monitor and supervise and direct all facility departments and overall operations .7. Plan, develop and maintain an ongoing quality assurance program. 8. Identify problems and deficiencies and develop and implement appropriate plans of action . A review of a facility policy titled, Quality Assurance/Quality Assurance Performance Improvement, effective 11/1/17, documented: .Governance and Leadership Administration is responsible for developing, leading and closely monitoring of QAPI program. . c. The administrator will be the Quality Management Coordinator and responsible for . QAPI Process . Systematic Analysis and Systematic Action . On 5/14/19 the State Agency received a complaint alleging the resident residing in RL #1 was ate up with bed bugs. The complainant alleged the facility was not treating for the bed bugs as they should have. On 6/07/19 the State Agency received a second complaint alleging the facility was infested with bed bugs, and the facility was not properly treating the problem. Review of pest control treatment logs from 5/2019 through present revealed positive bed bug activity in the facility as follows: - 5/10/19 bed bugs noted during treatment on bed by door in RL #1 - 5/16/19 bed bugs noted during treatment; bed bugs crawling on wall in RL #1 - 5/22/19 bed bugs noted during treatment on curtains in RL #1 - 5/23-5/24/19 bed bugs noted during treatment in RL #s 1, 2, 4 and 5; day room and dining room also treated - 6/16/19 bed bugs noted during treatment; bed bugs on bed by door in RL #1 Review of an undated facility document titled Emergency Q.A.P.I. Meeting Minutes revealed bed bugs were noted in one resident room (RL #1) on 5/09/19. These minutes outlined the following Safety plan for resident(s) identified: . clothes secured per protocol, showered, . moved to another room . Review of the facility's Quality Assurance Committee Action plan, dated 5/09/19, revealed the following: .Quality Issue/Problem Bed bugs noted in one resident room (RL #1) . Action 1. both residents received shower and clothing change, clothes/linens secured/washed per protocol . residents moved to another room . rooms secured per policy . On 06/20/19 at 2:54 p.m., Employee Identifier (EI) #13, a Certified Nursing Assistant (CNA), said she saw the bed bugs in RL #1 and reported it to the nurse. EI #13 further stated they were told to take the residents in RL #1 (RI #s 41 and 105) to their room and strip them down and put them in a hospital gown and take them to the shower. She stated she stripped RI #41 and dressed him/her in a hospital gown, but another CNA came and got the resident and took him/her to a room on Station 2 before she could give the resident a shower. She said she then stripped down RI #105 in the room and placed him/her in a gown and another CNA took him/her to Station 2 to be showered. On 06/21/19 at 11:54 a.m., EI #3, Maintenance Supervisor, said he believed the staff needed more training on procedures because the residents from RL #1 were moved into another room before receiving a shower, which he thinks caused them to be spread to another room. EI #3 was asked if the rooms were vacuumed per policy in all the rooms where bed bugs were identified. EI #3 said he could not say that he vacuumed RL #5 because he believed that someone just walked in there with a bed bug on them. He further stated it could have been on him because he had been in there working. EI #3 was asked what was done in RL #5. EI #3 explained that he got the bed bug and flushed it and pest control sprayed, but did not fog or dust in that room. EI #3 was asked how were the mattresses in the rooms cleaned. EI #4 stated the one in RL #1 was thrown away, but in the other rooms, the covers were taken off and run through the washer and dryer. On 06/21/19 at 12:53 p.m., an interview was conducted with EI #4, Housekeeping/Laundry Director. EI #4 was asked what policy did you follow when laundering resident's clothing and cleaning the rooms where bed bugs were identified. EI #4 said the Bed Bugs Policy. EI #4 was asked what did he instruct his housekeeping staff to do in the rooms identified with bed bugs. EI #4 replied all furniture was moved to the center of the room, the rooms were cleaned top to bottom, thoroughly wiped down beds, nightstands and TVs with bleach or pine sol and let the room set for a few days to make sure everything was dead and nothing else had come out and then move the residents back into the room. EI #4 was asked what about the curtains on the windows. EI #4 stated maintenance was supposed to take down the curtains and either he or the floor technicians take down the privacy curtains. EI #4 was asked were all the privacy curtains in the rooms identified with bed bugs taken down. EI #4 said he did not know about RL #5. EI #4 was asked if the clothing was taken out of RL #5 and laundered, the furniture moved to the center of the room, and the room walls and furniture cleaned per protocol and the facility's QAPI plan. EI #4 replied no. EI #4 was asked what was the concern with the protocol for bed bugs not being followed. EI #4 answered spread more bugs. On 06/21/19 at 7:20 p.m., an interview was conducted with EI #1, Administrator. EI #1 was asked to show evidence that the QAPI plan was followed. EI #1 said the plan was to take portions of the Bed Bugs Policy and implement them and for the residents to be showered per protocol. EI #1 was asked how she ensured those things were implemented. EI #1 stated she talked through the entire QAPI plan with each department head, even while she was not in the facility, and gave encouragement and follow-up. EI #1 was asked if she was aware that RI #41 and RI #105's clothing was removed and they were dressed in a gown, but they were placed in another room without first being showered. EI #1 said no. EI #1 was asked if the residents were not showered prior to being placed in another room, was the QAPI plan followed. EI #1 replied if they were not showered first, no. EI #1 was asked if she was aware when a bed bug was found in RL #5, the clothing and privacy curtains were not removed and the bed, floor and crevices were not vacuumed as stated in the QAPI plan. EI #1 said no, she was not aware. EI #1 further stated, as the Administrator, she should have been aware of those things, and that she was ultimately responsible for ensuring the QAPI plan was implemented in the facility.

Based on interviews, review of pest control treatment logs, review of a facility policy titled Quality Assurance/Quality Assurance Performance Improvement, and review of facility documents titled Quality Assurance Committee Action and Emergency Q.A.P.I. (Quality Assurance Performance Improvement) Meeting Minutes, the facility failed to ensure their QAPI plan was implemented to prevent the spread of bed bugs after they were identified on 5/09/19 in Resident Identifier (RI) #41 and RI #105's room, Room Locator (RL) #1. This affected RI #s 41, 42, 46, and 105, four of 11 residents sampled for bed bugs. Bed bugs were identified in 6 of 81 total resident rooms in the facility, as well as in common areas, including the day room and dining room. Findings Include: Cross reference F925. On 5/14/19 the State Agency received a complaint alleging the resident residing in RL #1 was ate up with bed bugs. The complainant alleged the facility was not treating for the bed bugs as they should have. On 6/07/19 the State Agency received a second complaint alleging the facility was infested with bed bugs, and the facility was not properly treating the problem. Review of pest control treatment logs from 5/2019 through present revealed positive bed bug activity in the facility as follows: - 5/10/19 bed bugs noted during treatment on bed by door in RL #1 - 5/16/19 bed bugs noted during treatment; bed bugs crawling on wall in RL #1 - 5/22/19 bed bugs noted during treatment on curtains in RL #1 - 5/23-5/24/19 bed bugs noted during treatment in RL #s 1, 2, 4 and 5; day room and dining room also treated - 6/16/19 bed bugs noted during treatment; bed bugs on bed by door in RL #1 Review of a facility policy titled, Quality Assurance/Quality Assurance Performance Improvement, effective 11/1/17, documented: . c. The QAPI Committee monitors progress to ensure that interventions or actions are implemented and effective . Review of an undated facility document titled Emergency Q.A.P.I. Meeting Minutes revealed bed bugs were noted in one resident room (RL #1) on 5/09/19. These minutes outlined the following Safety plan for resident(s) identified: . clothes secured per protocol, showered, . moved to another room . Review of the facility's Quality Assurance Committee Action plan, dated 5/09/19, revealed the following: .Quality Issue/Problem Bed bugs noted in one resident room (RL #1) . Action 1. both residents received shower and clothing change, clothes/linens secured/washed per protocol . residents moved to another room . rooms secured per policy . On 06/20/19 at 2:54 p.m., Employee Identifier (EI) #13, a Certified Nursing Assistant (CNA), said she saw the bed bugs in RL #1 and reported it to the nurse. EI #13 further stated they were told to take the residents in RL #1 (RI #s 41 and 105) to their room and strip them down and put them in a hospital gown and take them to the shower. She stated she stripped RI #41 and dressed him/her in a hospital gown, but another CNA came and got the resident and took him/her to a room on Station 2 before she could give the resident a shower. She said she then stripped down RI #105 in the room and placed him/her in a gown and another CNA took him/her to Station 2 to be showered. On 06/21/19 at 11:54 a.m., EI #3, Maintenance Supervisor, said he believed the staff needed more training on procedures because the residents from RL #1 were moved into another room before receiving a shower, which he thinks caused them to be spread to another room. EI #3 was asked if the rooms were vacuumed per policy in all the rooms where bed bugs were identified. EI #3 said he could not say that he vacuumed RL #5 because he believed that someone just walked in there with a bed bug on them. He further stated it could have been on him because he had been in there working. EI #3 was asked what was done in RL #5. EI #3 explained that he got the bed bug and flushed it and pest control sprayed, but did not fog or dust in that room. EI #3 was asked how were the mattresses in the rooms cleaned. EI #4 stated the one in RL #1 was thrown away, but in the other rooms, the covers were taken off and run through the washer and dryer. On 06/21/19 at 12:53 p.m., an interview was conducted with EI #4, Housekeeping/Laundry Director. EI #4 was asked what policy did you follow when laundering identified resident's clothing and cleaning the rooms where bed bugs were identified. EI #4 said Bed Bugs Policy. EI #4 was asked what did he instruct his housekeeping staff to do in the rooms identified with bed bugs. EI #4 replied all furniture was moved to the center of the room, the rooms were cleaned top to bottom, thoroughly wiped down beds, nightstands and TVs with bleach or pine sol and let the room set for a few days to make sure everything was dead and nothing else had come out and then move the residents back into the room. EI #4 was asked what about the curtains on the windows. EI #4 stated maintenance was supposed to take down the curtains and either he or the floor techs take down the privacy curtains. EI #4 was asked were all the privacy curtains in the rooms identified with bed bugs taken down. EI #4 said he did not know about RL #5. EI #4 was asked if the clothing was taken out of RL #5 and laundered, the furniture moved to the center of the room, and the room walls and furniture cleaned per protocol and the facility's QAPI plan. EI #4 replied no. EI #4 was asked what was the concern with the protocol for bed bugs not being followed. EI #4 answered spread more bugs. On 06/21/19 at 6:48 p.m. an interview was conducted with EI #2, Registered Nurse (RN)/Director of Nursing. EI #2 was asked if she was aware RI #41 and RI #105 were taken out of RL #1 and taken to another room before being showered (after the identification of bed bugs in their room, RL #1). EI #2 replied no, she was not aware of that. EI #2 was asked did they determine why bed bugs were in the new room. EI #2 stated she did not know, but if the residents did not get showered before they were moved, that was probably why it happened. EI #2 was asked if the Bed Bug policy and QAPI plan were followed if the residents were not showered prior to leaving RL #1. EI #2 said if they did not get showered before they went into another room, no, it was not followed and that was a mistake. EI #2 was asked what was the concern with not following the policy and/or QAPI plan concerning bed bugs. EI #2 said there would be a risk for spreading them. On 06/21/19 at 7:20 p.m. an interview was conducted with EI #1, Administrator. EI #1 was asked to show evidence that the QAPI plan was followed. EI #1 said the plan was to take portions of the Bed Bugs Policy and implement them and for the residents to be showered per protocol. EI #1 was asked how she ensured those things were implemented. EI #1 stated she talked through the entire QAPI plan with each department head, even while she was not in the facility, and gave encouragement and follow-up. EI #1 was asked if she was aware that RI #41 and RI #105's clothing was removed and they were dressed in a gown, but they were placed in another room without first being showered. EI #1 said no. EI #1 was asked if the residents were not showered prior to being placed in another room, was the QAPI plan followed. EI #1 replied if they were not showered first, no. EI #1 was asked if she was aware when a bed bug was found in RL #5, the clothing and privacy curtains were not removed and the bed, floor and crevices were not vacuumed as stated in the QAPI plan. EI #1 said no, she was not aware. EI #1 was asked how staff were trained on the QAPI plan and Bed Bug Policy. EI #1 said she went over the Bed Bug Policy in a staff meeting (verbally), but not the QAPI plan. EI #1 was asked what was the concern with the QAPI plan not being followed. EI #1 said it could contribute to the spread of bed bugs and lack of containment.

Based on interviews, record review, review of a facility document titled Emergency Q.A.P.I. (Quality Assurance Process Improvement) Meeting Minutes, review of the facility's Quality Assurance Committee Action, review of the facility's pest control contract, and review of the facility's policies titled Bed Bugs and Insect and Rodent Control, the facility failed to ensure measures were implemented to provide effective pest control and prevent the spread to other rooms after the identification of bed bugs in Room Locator (RL) #1 on 5/9/19. Resident Identifier (RI) #s 41 and 105, who resided in RL #1, were taken to another room on Station 2 prior to receiving a shower on 5/9/19. Further, RI #s 46 and 42's clothing and other items were not removed from RL #5 after bed bugs were also discovered in that room. Further, RL #5 was not cleaned and vacuumed as outlined in the facility's Quality Assurance Committee Action and Bed Bugs policy. This affected RI #s 41, 42, 46, and 105, four of 11 residents sampled for bed bugs. Bed bugs were identified in 6 of 81 total resident rooms in the facility, as well as in common areas, including the day room and dining room. Findings include: On 5/14/19 the State Agency received a complaint alleging the resident residing in RL #1 was ate up with bed bugs. The complainant alleged the facility was not treating for the bed bugs as they should have. On 6/07/19 the State Agency received a second complaint alleging the facility was infested with bed bugs, and the facility was not properly treating the problem. Review of the facility's pest control contract, revised 9/2013, revealed the following: . CUSTOMER PARTNERSHIP Customer entitled to (Name of Pest Control company) service guarantees only if . Customer has complied with all of the following: . Performs proper post-service cleaning as directed . Review of the facility's policy titles Insect and Rodent Control, effective 3/01/10, revealed: .The facility should have a pest control program to minimize the presence of . insects on the premises . Review of the facility's policy titled Bed Bugs, effective 6/02/14, revealed: PURPOSE: To prevent the spread of bed bugs STANDARD: The facility will make every effort to promptly identify and treat bed bugs . steps will be taken to remove the environmental source or sources of bed bug infestation and to prevent the spread to other resident/guest(s). PROCESS: . II. LAUNDRY DEPARTMENT a. Provide plastic bags (may include dissolvable plastic bags for washing clothes) for laundering and for storing clothes. b. Wash laundry items in hot water with detergent and dry in dryer on high heat for 20 minutes to kill all stages of bed bugs . III. ENVIRONMENTAL SERVICES a. Vacuum all cracks and crevices of room and furniture where bedbugs were discovered. b. Post vacuuming, furniture should be moved to center of room and dresser drawers opened to assist the PMP (Pest Management Professional) c. Mattress should be vacuumed and put into encasements, then cracks and crevices of bed frames vacuumed . Review of an undated facility document titled Emergency Q.A.P.I. Meeting Minutes revealed bed bugs were noted in one resident room (RL #1) on 5/09/19. These minutes outlined the following Safety plan for resident(s) identified: . clothes secured per protocol, showered, . moved to another room . Review of the facility's Quality Assurance Committee Action plan, dated 5/09/19, revealed the following: .Quality Issue/Problem Bed bugs noted in one resident room (RL #1) . Action 1. both residents received shower and clothing change, clothes/linens secured/washed per protocol . residents moved to another room . rooms secured per policy . Review of pest control treatment logs from 5/2019 through present revealed positive bed bug activity in the facility as follows: - 5/10/19 bed bugs noted during treatment on bed by door in RL #1 - 5/16/19 bed bugs noted during treatment; bed bugs crawling on wall in RL #1 - 5/22/19 bed bugs noted during treatment on curtains in RL #1 - 5/23-5/24/19 bed bugs noted during treatment in RL #s 1, 2, 4 and 5; day room and dining room also treated - 6/16/19 bed bugs noted during treatment; bed bugs on bed by door in RL #1 On 6/19/19 at 5:45 p.m., an interview was conducted with Employee Identifier (EI) #14, a Certified Nursing Assistant (CNA). EI #14 was asked if she had ever seen any pests in the facility. EI #14 said yes, bed bugs. EI #14 reported she had seen bed bugs in RL #1, 4, and 6, and indicated RI #41 (who resided in RL #1) had been bitten. EI #14 said pest control had been in and identified the bugs as bed bugs. EI #14 further stated pest control had told them it was the worst bed bug infestation he had ever seen. EI #14 said on 6/5/19, pest control had also identified bed bugs on a couch in the facility lobby. On 6/20/19 at 12:03 p.m., an interview was conducted with EI #17, a CNA. When asked if she was aware of any pest problems in the facility, EI #17 said yes, she had seen bed bugs in RL #4 on 6/03/19. On 6/20/19 at 2:54 p.m., an interview was conducted with EI #13, a CNA. When asked if she had seen bed bugs in the facility, EI #13 said yes, she had seen them in RL #1. EI #13 said they were instructed to to take the residents in RL #1, RI #41 and RI #105, to their room, strip them down, put a hospital gown on them, and take them to the shower. However, EI #13 indicated another CNA came and got RI #41 and took him/her to another room on Station 2 before she could give the resident a shower. EI #13 said she then stripped RI #105 down, put him/her in a gown, and another CNA came and took the resident to a different room on Station 2 to be showered. On 6/21/19 at 10:39 a.m., an interview was conducted with the facility's pest control company. The pest control technician stated he had started treating for bed bugs approximately one month prior. The pest control technician also confirmed he had told staff it was the worst infestation of bed bugs he had ever seen. On 6/21/19 at 11:54 a.m., an interview was conducted with EI # 3, the Director of Maintenance. EI #3 said one of the CNAs reported to the nurse that the resident in RL #1 (RI #41) was putting toilet paper in his/her ears because there were bugs in his/her room. EI #3 then stated he felt staff needed more training on proper bed bug procedures because staff moved RI #41 and RI #105 from RL #1 into another room prior to showering them. EI #3 said he felt this caused the bed bugs to spread to other rooms. When asked if all of the rooms had been vacuumed per the facility policy, EI #3 said he could not say RL #5 had been vacuumed because he thought someone had just walked into that room with a bug on them. When asked what was done to treat RL #5 after the bed bugs were identified, EI #3 said he picked up the bug and flushed it, and had pest control spray the room. When questioned as to how the mattresses were handled in the rooms with bed bugs, EI #3 said the one in RL #1 was thrown away, but the ones in the other rooms only had the mattress covers taken off and run through the washer and dryer. On 6/21/19 at 12:53 p.m., an interview was conducted with EI #4, Housekeeping/Laundry Director. When asked what policy was followed when handling resident's clothing and cleaning rooms identified with bed bugs, EI #4 said the Bed Bug policy. EI #4 said staff were instructed to move the furniture to the center of the rooms, clean top to bottom, thoroughly wipe down beds, night stands and TVs with bleach or pinesol and let everything sit for a few days to be sure the bugs were dead. EI #4 said maintenance was supposed to take down the curtains and privacy curtains in the rooms identified with bed bugs. EI #4 said he was not sure this was done in RL #5. When asked if the clothing was removed from RL #5 and laundered per the Bed Bug policy, EI #4 said no. When asked what the concern was in not following the policy in a room identified as having bed bugs, EI #4 said spreading more bugs. On 06/21/19 at 6:48 p.m. an interview was conducted with EI #2, Registered Nurse (RN)/Director of Nursing. EI #2 was asked if she was aware RI #41 and RI #105 were taken out of RL #1 and taken to another room before being showered (after the identification of bed bugs in their room, RL #1). EI #2 replied no, she was not aware of that. EI #2 was asked did they determine why bed bugs were in the new room. EI #2 stated she did not know, but if the residents did not get showered before they were moved, that was probably why it happened. EI #2 was asked if the Bed Bug policy and QAPI plan were followed if the residents were not showered prior to leaving RL #1. EI #2 said if they did not get showered before they went into another room, no, it was not followed and that was a mistake. EI #2 was asked what was the concern with not following the policy and/or QAPI plan concerning bed bugs. EI #2 said there would be a risk for spreading them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, review of the 2017 Food Code regulations and the facility policies related to Leftover Food Storage and Foods from Families and Friends the facility failed to ensure: 1) Food was consistently labeled with open and use-by date (UBD) and used within seven days after opening; 2) Food below recommended temperatures on the 6/19/19 lunch tray line were reheated to at least 165 degrees Fahrenheit (F); and 3) Residents' refrigerators in three of three nursing station pantries were clean and residents' food was labeled with name and date, and discarded within three days as directed by facility policy. These failures had the potential to affect all 130 residents for whom meals were prepared and served at the time of this survey. Findings Included: 1) FOOD LABELING The facility policy: Leftover Food Storage and Use, with an effective date of 8/15/09, specifies the purpose, To assure that food borne illnesses are avoided. The processes by which this is achieved included: .b. Leftover foods should be covered, labeled and dated. c. Refrigerated leftover foods should be used within 72 hours (three days). If not used within 72 hours, refrigerated foods should be discarded. These foods should be monitored for proper cooling, with times and temperature recorded on a cooling log. The 2017 Food Code regulation 3-501.17, Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. regulation specifies the following: . (B) .refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations . During the initial kitchen tour on 6/18/19 at 8:00 AM, the Surveyor observed two 5-pound containers of commercially prepared Pimento Cheese salad. Neither container had a facility label to indicate to staff, a use-by date. One container (nearly empty) was labeled as opened on 06/06/19, 12 days prior. At this point, the Surveyor asked the Certified Dietary Manager (CDM), Employee Identifier (EI) #10, what the facility's policy was regarding the labeling of opened foods and UBDs. EI #10 stated staff were to put the open date on the items and count down three days for the UBD, if the product lasted that long. 2) TRAY LINE FOOD TEMPERATURES The 2017 Food Code, 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. specifies the following: . (A) Except during preparation, cooking, or cooling . TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 135 degrees F or above . The facility policy, Leftover Food Storage and Use dated 8/15/09, mandates staff to . e. Reheat foods to 165 degrees for at least 15 seconds. On 6/19/19 at 4:35 PM, the Surveyor observed staff check the temperatures of the food placed on the steam table prior to the supper meal. Three pans of food were not at the recommended serving temperature of 135 degrees F or greater, including: a) Steak Fingers: 122 degrees F b) Mashed Potatoes: 132 degrees F c) Ground Steak Fingers: 130 degrees F. At the direction of the CDM, the tray line staff returned the above food to the convection oven for reheating. At 5:30 PM the reheated items were placed back onto the tray line. When the above food was removed from the oven, the Steak Fingers registered a temperature of 145 degrees F. The Mashed Potatoes were found by staff to be 147 degrees F, and the Ground Steak Fingers were 144 degrees F. None of these food items had been reheated to the required temperature of 165 degrees F prior to service. On 6/19/19 at 5:50 PM, the CDM affirmed the above reheated temperatures. When the Surveyor asked to what temperature the food should have been reheated, EI #10 stated 165 degrees F. 3) RESIDENT FOOD STORAGE The facility policy, Foods from Families and Friends, dated 11/28/16, has a purpose: To preserve the resident/guest(s) right to receive gifts of food from family and friends, while reducing the potential for food borne illnesses. The processes by which staff may achieve this purpose include: .b. If food is to be stored, it should be labeled with resident/guest(s) name, dated and stored in airtight container. c. If refrigeration is necessary, food items should be stored in the nursing unit refrigerator or resident/guest(s) room refrigerator, and discarded after 72 hours. On 6/20/19 the Nursing Unit refrigerators identified by staff as used for the storage of residents' food were checked on three of the three nursing stations. The findings for each were as follows: a) Station One On 6/20/19 at 10:10 AM, the small refrigerator located in the Station One pantry was labeled with a sign on the front of the refrigerator door: Resident's Food Only!!! All food placed in refrigerator should have resident's name and date on it.food can only be stored for three days and must be discarded after three days . Stored inside the refrigerator was: 1. an unlabeled, undated bag of Bojangles Chicken and a napkin-wrapped biscuit; 2. a Dinex mug of thickened liquid (grey in color) with no name/date; and 3. a Styrofoam bowl with napkin covering two plastic wrapped slices of cheese, with no date. A Licensed Practical Nurse (LPN) at Station One was questioned at this time (10:10 AM). The LPN, EI #9 verified the refrigerator was used for the storage of residents' food, but could not tell the Surveyor to whom the above unlabeled items belonged. EI #9 verified the food should have a name and date on each. The Station One Registered Nurse/Unit Manager, EI #12, stated on 6/20/19 at 11:00 AM whomever received the food was responsible for the dating and labeling. b) Station Three On 6/20/19 at 10:30 AM, the Station Three Charge Nurse/LPN, EI #8, identified the pantry refrigerator (with a sign indicating it as the residents' refrigerator) as the storage site for residents' food, explaining the residents or family could give their food to a Certified Nursing Assistant (CNA) or an LPN, who would then label the item with the resident's name and date. When asked about the undated food or items without a name, EI #8 stated the food was supposed to be thrown away. Inside the Station Three residents' refrigerator were stored: 1. an opened 8.4-oz aluminum can of Red Bull with no name, date; 2. a zip-lock bag of 10 sliced pepperonis with no name, date; 3. a partially used, wrapped 8 oz bar of cream cheese, with no name or date; 4. a container of fresh broccoli, wrapped in a plastic bag, with no name/date; 5. a Chick-fil-A sack containing waffle fries, with no date; 6. a [NAME] sack with one [NAME] burger/bun and a container of fries, with no date; 7. a Chick-fil-A sack with a chicken pattie/bun and a container of fries, with no name/date; 8. a 750 milliliter (ml) bottle of Evian water with less than 8 oz remaining, with no name/date; 9. a 16 oz bottle of 1000 Island salad dressing with no name/date, and no legible expiration date. A dried red spill was noted in the bottom of the refrigerator, with bits of damp paper on the lower shelf. On 6/20/19 at 10:45 AM, a Housekeeping staff member was cleaning elsewhere in the pantry. When questioned, the Housekeeper, EI #7, explained the refrigerator was supposed to be cleaned on the 3:00 to 11:00 PM shift, and affirmed the inside of the refrigerator needed cleaning. On 6/20/19 at 10:50 AM, the Station Three Charge Nurse, EI #8, could not tell the Surveyor when the residents' refrigerator had last been cleaned, but affirmed it needed cleaning. c) Station Two On 06/20/19 at 11:05 AM, the Rehabilitation Coordinator, EI #6, identified a small refrigerator in the nursing station pantry as that in which residents' food was stored. The refrigerator contained: 1. a large paper cup of Wakey Wakey beverage, warm to the touch on the outside, with a lid over the contents and a tea bag label hanging out. The cup was not labeled with name or date; 2. a 20 oz bottle of Lymonade, partially consumed, with no name/date; and 3. an opened can of Pepsi with a paper napkin stuffed into the drinking hole, with no name or date. On 6/20/19 at 11:08 AM, the Charge LPN for this nursing station, EI #5, confirmed she did not know to whom the above items belonged.

Based on a review of a facility policy titled, Pre-admission Screening for Mental Retardation and Mental Illness, record reviews and interviews, the facility failed to ensure a level II PASARR was completed for RI (Resident Identifier) # 118 transitioning from rehabilitation short term care to long term care. This affected one of 32 residents whose PASARRs were reviewed. RI #118's PASARR (Preadmission Screening for Mental Retardation and Mental Illness) Level I dated 11/07/17, documented the resident has a diagnosis of Schizophrenia and required a Level II screening. The Level II dated 11/20/17, documented the resident was receiving restorative nursing such as Physical Therapy five times a week for four weeks for gait training and therapeutic exercise for short term care. Section VII of the level II documented that if the status changed to long term and or rehab stopped a significant change Level I screening was required within 14 days. Another Level II should have been completed when the resident transitioned from short term care to long term care. On 07/18/18 at 4:23 PM the surveyor conducted an interview with a representative of the Alabama Omnibus Budget Reconciliation Act (OBRA) Office by phone and inquired if the resident was to receive a Level II due to transitioning from short term care for PT to Long Term Care. The representative reviewed the resident's information and confirmed that the resident was to receive another Level II due to transitioning from short term for therapy care to long term care. On 7/19/18 at 7:43 AM EI#4, the facility social worker was interviewed. EI#4 stated that another Level II screening should have been completed when the resident transitioned from short term care for rehabilitation services to long term care because it was considered as a significant change. EI# 4 stated it was missed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of a facility policy Hand Hygiene, the facility failed to ensure: 1) licensed staff did not check tube placement without gloves for Resident Identifier (RI) #12 then without washing her hands return to the medication cart to prepare RI #12's medication; 2) a licensed staff did not drop a tablet on the medication cart then pick up the tablet with her bare hands and place it on the pill splitter. She further failed to wash her hands when leaving RI #26s room and returned to the medication cart. Findings Include: A review of a facility policy Hand Hygiene with an effective date of 9/1/17 revealed: PURPOSE: To provide guidelines to employees for proper and appropriate hand washing techniques that will aide in the prevention of transmission of infections. STANDARD: Hand washing should be performed between procedures with resident .based upon the principle that all blood, body fluids .may contain transmissible infectious agents III. Hand Hygiene .Upon and after coming in contact with a resident . 1) RI #12 was admitted to the facility 8/4/15 and readmitted [DATE] with a diagnosis of Encounter for attention to Gastrostomy. A review of RI #12's July 2018 Physician Orders revealed .BUSPIRONE 15 MG (milligram) TABLET GIVE 1 TAB TID (three times a day) PER GTUBE (by gastrostomy tube) . On 7/17/18 at 12:02 PM Employee Identifier (EI) #3 Licensed Practical Nurse, cleaned the over bed table in RI #12's room then removed her gloves and washed her hands. EI #3 checked gastrostomy placement for RI #12 without gloves and flushed the gastrostomy tube. EI #3 then left RI #12's room and returned to the medication cart and prepared RI #12's Buspar medication. EI #3 took the medication from the medication cart without washing her hands crushed the medication, clicked the computer screen and returned to RI #12's room to administer the medication On 7/17/18 at 12:35 PM an interview was conducted with EI #3, LPN. EI #3 was asked when should you wash your hands. EI #3 replied, before going in and if you go out and reenter the room you should wash your hands. EI #3 was asked if she washed her hands before returning to the medication cart. EI #3 replied, no. EI #3 was asked if she washed her hands after checking the placement of RI #12's tube before leaving the room. EI #3 replied, no. EI #3 was asked what was the harm in not washing your hands when leaving a resident's room before returning to the medication cart. EI #3 replied, spreading germs from the resident's tube then to the medication cart. 2) RI #26 was admitted to the facility 12/1/95 and readmitted [DATE] with a diagnosis of Encounter for attention to gastrostomy. A review of RI #26's July 2018 Physician Orders revealed: .BUSPIRONE 10 MG (milligram) TABLET GIVE 1 TAB PGT (by gastrostomy tube) TID (three times a day) . PEPCID 20 mg .ROBINUL FORTE 2 mg give 1/2 tab . On 7/17/18 at 4:17 PM EI #2, Registered Nurse was observed giving medication to RI #26. EI #2 removed Pepcid from the medication card and placed in a medication cup. EI #2 removed a Robinul tablet and placed it in a medication cup, she then took the pill splitter from the cart and poured the Robinul tablet on the splitter. The tablet dropped on top of the medication cart. EI #2 picked up the tablet with her bare hands and placed it on the pill splitter and cut the tablet in half then placed it in a medication cup. EI #2 removed the Carafate tablet and placed it in a medication cup. EI #2 poured the Valporic acid in a medication cup. EI #2 took all the medications and a cup of water and entered RI #26's room. EI #2 pulled gloves from her uniform pocket and put them on, then proceeded to check tube placement and administered the medications. EI #2 used all the water she carried in to RI #26's room and required more. EI #2 removed her gloves left RI #26's room and returned to the medication cart and poured more water without washing her hands. EI #2 returned to RI #26's room with the water and placed it on the over bed table. EI #3 took gloves from her uniform pocket, put them on and continued with the water flush. On 7/17/18 at 4:36 PM an interview was conducted with EI#2. EI #2 was asked where did she get the gloves from. EI #2 replied, from my pocket. EI #2 was asked if her uniform pocket was clean. EI #2 replied, no. EI #2 was asked why was her uniform pocket not considered clean. EI #2 replied, because it had been against her body. EI #2 was asked what was the harm in using gloves from her pocket that was not clean. EI #2 replied, spreading germs. EI #2 was asked what was the policy when a medication dropped on the medication cart. EI #2 replied, you should discard it. EI #2 was asked if she discarded the tablet and got another. EI #2 replied, no. EI #2 was asked why she did not get another tablet; she replied, she did not know. EI #2 was asked when she left RI #26's room to get more water, what should she have done. EI #2 replied, washed her hands. EI #2 was asked if she washed her hands. EI #2 replied, no. EI #2 was asked why not. EI #2 replied, she was not thinking. On 7/18/18 at 5:30 PM an interview was conducted with EI #1, Director Nursing, Infection Control Nurse. EI #1 was asked what was the policy on what staff should do when leaving a resident's room. EI #1 replied, wash their hands. EI #1 was asked if it would be an acceptable practice for a nurse to check gastrostomy tube placement without gloves and without washing her hands then return to the medication cart to prepare resident medication. EI # 1 replied, no. EI #1 was asked what would the harm be in a nurse not washing her hands when completing tube placement verification then returning to the medication cart to prepare medication. EI #1 replied, the spreading of germs and infection control issues. EI #1 was asked what the policy was when a nurse dropped a tablet on the medication cart while preparing a resident medication. EI #1 replied, they should discard it and get another one. EI #1 was asked what was the policy on where to get gloves from if needed during medication administration. EI #1 replied, they should get them from a glove box on the medication cart or in the resident rooms. EI #1 was asked when should a nurse remove gloves from her uniform pocket to use during medication administration. EI #1 replied, never. EI #1 was asked if a nurse's uniform pocket would be considered clean or dirty. EI #1 replied, dirty. EI #1 was asked what was the harm in a nurse using gloves she pulled from her uniform pocket to administer medications. EI #1 replied, spread germs and infection control. EI #1 was asked when should staff wash their hands during the medication pass. EI #1 replied, before starting, after completing and in between medications if needed, definitely before returning to the medication cart. EI #1 was asked what was the harm in a nurse not washing her hands when leaving a resident room and returning to the medication cart. EI #1 replied, spreading germs and cross contamination.

Based on observations and interviews the facility failed to ensure that dietary staff washed their hands after picking up an item from the floor and returning to their assigned task during lunch tray-line on 7/18/18, prevent dietary staff from entering the kitchen with a cloth apron on during the lunch tray-line on 7/18/18 and prevent the use of bowls with water in them . This had the potential to affect 119 residents receiving meals from the kitchen. On 07/18/18 at 11:45 AM EI#6, a dietary employee, was observed to drop a lid on the floor. EI# 6 picked the lid up off the floor with her gloved hands and placed the lid in dishwashing area. EI# 6 was observed to not remove her gloves, wash her hands or put on new clean gloves and she continued to adjust plates and touch items on resident lunch trays. On 07/18/18 at 2:58 PM an interview was conducted with EI# 6. EI# 6 was asked what she is to do if she drops an item on the floor during her duties in the kitchen? EI# 6 stated she should dispose of the item, take her gloves off, wash her hands and put on new gloves. When asked why that would be important EI # 6 stated to keep from spreading germs. When asked why she did not do that when she dropped the lid on the floor, she stated that she knew she should have but it just didn't click to do it because she had so much on her mind. On 07/18/18 at 11:37 AM EI#5, a dietary employee entered into the kitchen with her apron already on placed her purse down, washed her hands and began to assist with the food on the carts. EI#5 did not change her apron before she began placing ice cream on the resident's trays. On 7/18/18 at 3:20 PM EI #5 was asked if she should have had her apron already on when she entered the kitchen. EI# 5 stated no. EI #5 was asked why she did and she stated because she was running behind so she put it on before entering the kitchen. On 07/17/18 at 11:32 AM during tray-line a bowl was observed with droplets of water inside of it. A dietary employee was observed to put pureed lima beans in the bowl on a resident's tray. At 11:41 AM eight additional bowls and one divided plate were also observed with droplets of water on them. During an interview with EI # 7, the Dietary Manager on 07/18/18 at 5:55 PM, EI# 7 stated that staff should remove gloves and wash their hands after picking up an item from the floor and not come in to the kitchen with aprons already on because of cross contamination and it could cause the transfer of germs. EI# 7 also stated that dinner ware should be free of water because it could make residents sick.

Based on observation and interviews the facility failed to ensure: the grease receptacle was free of an accumulation of a grease like substance. This was observed two of three days of the survey. This had the potential to affect all residents receiving meals from the kitchen. On 07/17/18 at 8:58 AM and on 7/18/18 at 5:49 PM the grease bin located outside in the back of the kitchen was observed with a brown thick grease-like substance on the top of the bin behind the lid. On 7/18/18 at 5:49 PM an interview with EI # 7, the Dietary Manager, was conducted. EI# 7 was asked why the grease receptacle whould be free of an accumulation of a grease like substance on the outside of the receptacle. EI # 7 stated because flies and bugs could get stuck on it. anytime your contaminate your gloves Why should the grease bin be free of an accumulation of a grease like substance on the outside of the bin? A. Flies and bugs could get stuck up on it What is the potential harm of a staff member entering into the kitchen with an apron on and performing their assigned duties such as placing ice cream on residents's meal trays? A. Cross Contamination Why should dinner ware be free of droplets of water when food items are placed on them for resident consumption A. Infection Control What is the potential harm of placing food items on dinner ware with droplets of water which were served for resident consumption? A. Infection control can harm them What is wet nesting? A. When dishes are not air dried and are stacked What is the potential harm for a dietary staff member to pick up an item from the floor and to continue their assigned task without washing their hands.? A. Infection control and cross contamination Reviewed by Ms. [NAME]