Based on interview, a review of residents council meeting minutes and a review of a facility policy titled, POLICY: Grievances/Concerns, the facility failed to act promptly to resolve the resident council members grievances regarding dirty meal trays left in the dining room overnight. This deficient practice affected 2 of 2 residents who had voiced concerns in resident group meetings of the trays being left in the dining room overnight. Findings include: A review of a facility policy titled, POLICY: Grievances/Concerns, with no effective date revealed: . POLICY: . The Facility will promptly investigated grievances/concerns . in an effort to seek a resolution while keeping the resident, . appropriately apprised of its progress towards a prompt resolution . A review of the resident council meeting minutes dated September 24, 2018 documented: . RI (Resident Indentifer) #9 and RI #10 voiced that trays are being left out to long after meals cause gnats and files . Resident council meeting minutes dated October 29, 2018 documented: Trays are still being left out overnight . A resident council meeting was held on 4/10/19 at 9:30 a.m. Residents voiced concerns about dirty meal trays being left in the dining room over night. RI #9 said he/she gets up at 5:00 a.m. and goes in the dining at 6:00 a.m. to get coffee and has observed dirty trays left from the night before from residents eating late. A review of facility reoccurring memos sent out to Register Nurses (RN), Licensed Practice Nurse (LPN) and Certified Nursing Assistance (CNA) documented the following: 08/27/2019 . The resident in Resident council c/o (complain of) trays not being picked up and returned to the the kitchen. They said it would cause bugs . 08/30/18 . Nurses and RN supervisors, please make sure staff is returning all meal trays to the kitchen. The residents are complaining about meal trays being left in the dining room after super and is causing bugs . 1/16/2019 . CNA's Memo: I have observed several trays not picked after meals today, please pick these up after every meal, this is not optional An interview was conducted with Employee Identifier (EI) #5, Activity Director/ Social Services on 4/10/19 at 11:04 a.m. EI #5 was asked when did RI #9 and/or resident council members discuss the concerns about dirty trays left in the dining room overnight. EI #5 said RI #9 discussed the concern in the group meeting on September 17, 2018. EI #5 was asked what was done about the concerns. EI #5 said, EI #1, Administrator was at the meeting and EI #6, Dietary Manager became aware of the concern. EI #5 was asked how did EI #6 become aware of the resident council concern. EI #5 said EI #6 received a copy of the resident council meetings minutes and an e-mail. EI #5 was asked what was done about the residents' concerns about the dirty trays being left in the dining room overnight. EI #6 said she did not know what was done. On 4/11/19 at 9:06 am., an interview was conducted with EI #6. EI #6 was asked did RI #9 and/or resident council members discuss a concern with her about dirty meal trays being left in the dining room overnight. EI #6 said yes RI #9 had discussed this concern with her. EI #6 was asked what was done about resolving this concern. EI #6 said CNAs were told to get the trays back to the kitchen in a timely matter by, 7 pm. EI #6 said, We keep a tray cart, by the kitchen so the CNAs can put any left overs trays on them and the kitchen staff gets them in the morning. EI # 6 was asked how does the facility communicate to residents the progress or resolution of a concerns. EI #6 said, We usually go back to the resident and let them know. EI #6 was how did the facility/she communicate with RI #9 or resident council about the resolution to his/her or their concern. EI #6 said she talked to RI #9 about the resolution. EI #6 was asked if she had any documentation regarding her discussion about the resolution with RI #9. EI #6 said no she did not have any documentation. EI #6 was asked since the residents in the council meetings and RI #9 continued to voice their concern about this issue, had it been revolved to their satisfaction. EI #6 said, I guess not. EI #6 was asked what was the potential harm for residents with dirty trays being left in the dining room overnight. She replied, maybe cause bugs and ants, a pest control issue. On 4/11/19 at 9:42 a.m., an interview was conducted with EI #7, Director of Nurses (DON). EI #7 was asked if the residents in council meeting and RI #9 had continue to voiced concerns about trays being left in the dining room overnight and had this concern been resolved. EI #7 said, apparently not. EI #7 was asked why had this concern not been resolved. EI #7 said because the staff have not followed instructions. EI #7 was asked should resident concerns be resolved if possible. EI #7 said, yes.

Based on interview, record review, and review of a facility policy titled, Abuse, Neglect and Exploitation, the facility failed to ensure an allegation of abuse was reported within the two hour time frame. This was noted on one of two Facility Reported Incidents reviewed during the survey. Findings Include: A review of the facility's Policy & Procedure titled Abuse, Neglect and Exploitation with a Reviewed/Revised date of 12/28/16, revealed, Policy: Each resident has the right to be free from abuse, . Residents must not be subject to abuse by anyone, including, but not limited to; facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends or other individuals. Policy Explanation and Compliance Guidelines: . 4. Physical Abuse includes, but not limited to hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. The facility must: . 13. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: a. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the advents that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other official (including the State Survey Agency and adult protected services where state law provides for jurisdiction in long-term care facilities) in accordance with State law. A review of the Online Incident Reporting confirmation dated 2/24/18 revealed: Date/Time Submitted: Saturday, February 24, 2018 1:06:58 PM . Incident Type . Physical Abuse . Date and time of incident or alleged incident 2/24/2018 Time: 10:56 AM . On 3/15/18 at 4:34 p.m., an interview was conducted with EI (Employee Identifier) #2, the Director of Nursing/Abuse Coordinator. EI #2 was asked what was the definition of physical abuse. EI #2 answered, It includes but is not limited to hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. EI #2 was asked what must the facility do in response to an allegation of abuse. EI #2 answered, Ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment including injuries of unknown source and misappropriation of resident property are reported immediately but not later than two hours. EI #2 was asked when did the February 24, 2018 allegation of abuse occur and she answered 10:56 a.m. EI #2 was asked when did facility staff report the allegation to the State Agency and she answered, 1:06:58 p.m. EI #2 was asked when did the Abuse policy indicate the allegation should have been reported. EI #2 answered, Within two hours. EI #2 was asked why the allegation was not reported within the designated two hour time frame. EI #2 answered, I didn't realize it had to be. I thought we had 24 hours because there was no serious bodily injury. EI #2 was asked who was responsible for ensuring allegations of abuse are reported in a timely manner and she answered, That would be me. EI #2 was asked what was the concern of not reporting allegations of abuse within two hours. EI #2 answered, Not following policy. This deficiency was cited as a result of the investigation of facility reported incident #AL00035600.

Based on observations and interviews the facility failed to ensure window seals were not found with blankets and towels folded in them to prevent draftiness in resident rooms. This affected RL (Room Locators) 1 through 5, five of fifty-six rooms that were observed. Findings Include: An observation was made on 3/14/18 at 7:43 a.m., of RL #3. It was noted there was one or more pieces of cloth rolled up on the ledge of the window. An observation was made on 3/14/18 at 3:32 p.m., of RL #5 with a rolled up piece of cloth in the window seal. An observation was made on 3/14/18 at 3:33 pm., of RL #3. The cloth remained rolled up in the window seal. Observations noted during a tour of the facility on 3/5/18 were as follows: 11:00 a.m. RL #1, towels were in the window. 11:10 a.m. RL #2, a blanket was in the window. 11:15 a.m. RL #3, a blanket was in the window. 11:15 a.m. RL #4, a blanket was in the window. 11:16 a.m. RL #5, a blanket was in the window. An interview was conducted on 3/15/18 at 2:37 p.m. with EI (Employee Identifier) #5, the Director of Maintenance, while touring the above mentioned rooms. EI #5 was asked to describe what he saw in the window ledges of the identified resident rooms. RL #1 - EI #5 reported, Towels. EI #5 was asked why were they there. EI #5 answered, I don't know, but when it was super cold some windows didn't seal and they may have put towels in them. RL #5 - EI #5 reported, A bedspread, probably the same issue, if I had to guess. RL #4 - EI #5 reported, A bedspread. RL #3 - EI #5 reported, The same thing. RL #2 - EI #5 reported, Bedspread. An interview was conducted on 3/15/18 at 2:48 p.m. with EI #5. EI #5 was asked what was the purpose of the thermal blankets in the window seals. EI #5 replied, I would guess it was to seal the window better. EI #5 was asked if that was the appropriate choice for sealing the windows in resident rooms. EI #5 answered, It's not the best choice. EI #5 was asked if the blankets/bedspreads in window seals were homelike in appearance and he answered, I guess not. EI #5 was asked if the blankets in the windows appeared functional, sanitary, and comfortable. EI #5 answered appearance wise no, but functionally, it's doing it's job. EI #5 was asked what would be the desired way to seal cold air out of the windows. EI #5 answered, Put new windows in. EI #5 was asked what the facility policy was regarding providing a functional, sanitary, and comfortable environment. EI #5 answered, Our goal is to provide the best environment we are capable of providing. An interview was conducted on 3/15/18 at 4:56 p.m., with EI #2, the Director of Nursing. EI #2 was asked why were thermal blankets folded in resident room window seals. EI #2 answered, Because it's cold and they say it gets drafty. EI #2 was asked if she would consider that way of handling drafty windows, to be clean, functional, and comfortable. EI #2 answered, Probably not. An interview was conducted on 3/15/18 at 5:32 p.m., with EI #1, the Administrator. EI #1 was asked why were thermal blankets folded in resident room window seals. EI #1 answered, Residents or sponsors put them there and I suppose they think there is some coldness coming through them. EI #1 was asked if she would consider that way of handling drafty windows, to be clean, functional, and comfortable. EI #1 answered, Clean, but not functional and comfortable.

Based on observations, interviews, and review of facility policies titled, Monitoring of Milk Temperature, Labeling food for Freezer, Cleaning of Ice Machine, Ice Chest and Scoops and a facility document titled, Temperature Log for Serving Line, the facility failed to ensure: 1) the temperature of the milk was taken before leaving the kitchen; 2) hamburger meats in the freezer were labeled; 3) the ice machine was free of a black substance on the inside; and 4) residents' serving trays were not on the table. This had the potential to affect 71 of 77 residents who received meals from the kitchen. Findings Include: 1) A review of a facility policy titled, Monitoring of Milk Temperature with a copyright date of 2017 revealed: Policy: It is the policy of this facility to maintain temperatures of milk at a temperature of 41 degrees or below . 1. All milk will be kept in the refrigerator until time to prepare trays on the tray line. The temperature will be taken before each meal and temperature recorded. A review of a document titled, Temperature Log for Service Line with a date of March 11-17, 2018, revealed no milk temperature was taken for Wednesday, March 14, 2018. On 3/14/2018 at 10:59 a.m., the surveyor observed on the food cart during the lunch meal, seven milk cartons leaving the kitchen going to the dining hall. On 3/14/2018 at 11:59 a.m., the surveyor observed twelve milk cartons on the 700 hall food cart. On 3/14/2018 at 12:01 p.m., the surveyor observed six milk cartons on the 600 hall food cart. On 3/14/2018 at 12:09 p.m., a family member came out of room on the 600 hall and asked for another milk because the milk that was given was sour. On 3/15/2018 at 12:07 p.m., the surveyor conducted an interview with (Employee Identifier) EI #6, the Cook. EI #6 was asked what was the temperature of the milk on 3/14/2018. EI #6 replied, she did not know. EI #6 was asked who took the temperature of the milk. EI #6 replied, she did not know. EI #6 was asked why the milk temperature was not taken. EI #6 replied, they were scared. EI #6 was asked who was responsible for taking the temperature of the milk. EI #6 replied, the person on nourishment. EI #6 was asked what was the potential harm to the resident when the resident received soured milk. EI #6 replied, it can cause problems, stomach aches and diarrhea. On 3/15/2018 at 2:02 p.m., the surveyor conducted an interview with EI #4, the Supervisor. EI #4 was asked what was the temperature of the milk on 3/14/2018. EI #4 replied, she did not see any temperature. EI #4 was referring to the temperature log. EI #4 was asked who took the temperature of the milk. EI #4 replied, no one. EI #4 was asked what was the potential harm to the residents when the residents received soured milk. EI #4 replied, it could make them sick. EI #4 was referring to the residents. On 3/15/2018 at 2:42 p.m., an interview was conducted with EI #3, the Dietary Manager. EI #3 was asked did a family member ask for another milk because the milk that was given was soured. EI #3 replied, yes. EI #3 was asked what was the potential harm to the resident when the resident received soured milk. EI #3 replied, a bad taste and make the resident sick. 2) A review of a facility policy titled, Labeling food for Freezer with a copyright date of 2017 revealed: Policy: It is the policy of this facility to label all food going in to freezer. 1. All food going in to freezer will be wrapped in cellophane wrap and the placed in a zip lock bag with the current date and a used by date of seven days after current day. The food item will be documented on the Ziploc bag. On 03/13/2018 at 2:09 p.m., the surveyor observed hamburger meat opened in the freezer in a medium zip lock bag with no open and use by date and a medium amount of hamburger meat wrapped in saran wrap with no open or use by date. On 3/15/2018 at 1:48 p.m., the surveyor conducted an interview with EI #4. EI #4 was asked what food items in the freezer had no open or use by date. EI #4 replied, ground beef. EI #4 was asked to describe the first and second package of hamburger meat. EI #4 replied, the first hamburger meat was frozen in a zip lock bag and the second was unthawed in saran wrap. EI #4 was asked why was the food not labeled. EI #4 replied, she guessed she forgot. EI #4 was referring to a dietary worker. EI #4 was asked who was responsible for labeling food items. EI #4 replied the person who used it. EI #4 was asked what did the facility policy say regarding labeling open food items. EI #4 replied, discard after three days if not used. EI #4 was asked when should food items be labeled. EI #4 replied, the date they were opened and used. EI #4 was asked what labeling information should be on open food items. EI #4 replied, what it contained, the date it was put in and the date it should be used by. EI #4 was asked what was the potential harm to the resident when open food items were not labeled and placed back into the freezer. EI #4 replied, the residents can get sick. 3) A review of a policy titled, Cleaning of Ice Machine, Ice Chests and Scoops with a copyright date of 2017 revealed: Purpose: To help keep the ice free of potentially harmful microorganisms. To distribute clean ice to residents . To keep the machine clean under optimal operating conditions . On 3/14/2018 at 10:25 a.m., the surveyor observed the back panel on the inside of the ice machine was dirty with a black substance. On 3/15/2018 at 1:57 p.m., an interview was conducted with EI #4. EI #4 was asked what was the black substance in the ice machine. EI #4 replied, mildew she believed. EI #4 was asked why was it there. EI #4 replied, it had not been cleaned. EI #4 was asked where was it located in the ice machine. The surveyor was talking about the black substance. EI #4 replied, on the lid crease part of the machine. EI #4 was asked who was responsible for cleaning the ice machine. EI #4 replied, maintenance. EI #4 was asked when was it cleaned last. EI #4 replied, she could not tell the surveyor. EI #4 was asked how much of the black substance was on the dish cloth she had wiped across it with. EI #4 replied, it was quite a bit. EI #4 was asked what was the potential harm to the residents when there was a black substance in the ice machine and the ice was placed in the residents glasses from that machine. EI #4 replied, they could get sick. On 3/15/2018 at 2:31 p.m., the surveyor conducted an interview with EI #5, the Maintenance Supervisor. EI #5 was asked what was the black substance in the ice machine. EI #5 replied, he did not know. EI #5 was asked why was it there. EI #5 replied, that was a good question. EI #5 was asked where was it located in the ice machine. EI #5 replied, on the chute. EI #5 was asked who was responsible for cleaning the ice machine. EI #5 replied, he was now. EI #5 was asked when was it cleaned last. EI #5 replied, he did not know. On 3/15/2018 at 2:36 p.m., an interview was conducted with EI #3, the Dietary Manager. EI #3 was asked what was the black substance in the ice machine. EI #3 replied, she did not know. EI #3 was asked how much of the black substance was on the dish cloth. EI #3 replied, it appeared to be a large amount. EI #3 was asked what was the potential harm to the residents when there was a black substance in the ice machine and the ice from that machine was placed in the resident glasses. EI #3 replied, it could make them sick. 4) On 3/15/2018 at 11:28 a.m., on the 800 hall the surveyor observed nine residents with trays under their plates. On 3/15/2018 at 2:13 p.m., the surveyor conducted an interview with EI #4. EI #4 was asked what was under the residents' plates. EI #4 replied, trays. EI #4 was asked why were the trays under the resident plates. EI #4 replied, that was how they served them. EI #4 was asked who was responsible for removing the trays. EI #4 replied, the CNAs (Certified Nursing Assistants). EI #4 was asked when having trays on the tables, was this a home like environment. EI #4 replied, no ma'am. On 3/15/2018 at 2:45 p.m., the surveyor conducted an interview with EI #3. EI #3 was asked what was under the residents plates in the dining room. EI #3 replied, the hot plate and tray. EI #3 was asked when having trays on the table, was this a home like environment. EI #3 replied, no.