Every finding on record at Augusta Medical CTR Skilled Ca

Based on observations, staff interviews, and facility document, it was determined that the facility staff failed to prepare and store food in a safe and sanitary manner for one of one unit. The findings included: The facility staff failed to hold the cold food at a safe temperature, to label food items for storage, and to discard food by the used by date. On 5/13/24 at 6:30 p.m. a tour of the facility's kitchen was conducted. During the observation of the refrigerator, there was kidney beans, beets, prunes, celery - which was brown, and cut red onions stored in containers with no labels. Also found were sliced green peppers that had brown spots on them, sliced eggs that had a white milky appearing liquid in the container with them, blueberries that were shriveled and mushy in appearance, opened ranch dressing that was beyond the use by date, sliced red onions that had liquid in the container with them, and unwrapped cheese that had visible mold on one corner. All of these items were still in the refrigerator two days past the used by date and available for use. The freezer section was observed to contain a package of frozen hamburger with a label that had a use by date of 5/9/24. While observing facility staff obtaining temperatures of the food being served, the chicken salad registered at 42.4 degrees Fahrenheit and the cold bacon registered at 43.0 degrees Farhenheit. On 5/13/24/ at 6:45 p.m., an interview was conducted with the nutrition service supervisor. When asked about proper food storage, the nutrition service supervisor verbalized that every item that is placed in the refrigerator or freezer should have a label with a use by date. The nutrition service supervisor verbalized that depending on the item, labels are good for 3-5 days, stating again that all items should be labeled when placed in the refrigerator or freezer. When questioned further, the nutrition service supervisor verbalized that items should be rotated in the refrigerator and freezers daily and that out of date items should be removed. When the package of meat was pointed out, the nutrition service supervisor verbalized that the hamburger's date was too old to still be in the freezer and did not know why it was not removed during the daily rotations of the food. On 5/15/24 at 10:00 a.m., a review of the facility documentation was conducted. The facility policy titled, Nutrition Services Infection Control Policy, read in part, .Any outdated perishables will be discarded. Foods should be refrigerated at 41 degrees or below. If food items are to be directly placed in the refrigerator they are to be lightly covered, labeled, and dated. All refrigerated items are to be used in 72 hours or frozen for future use. No additional information was provided.

Based on observation, resident interview, family interview, staff interview, and facility documentation review, the facility staff failed to maintain a resident's personal privacy affecting one resident (Resident #110- R110) in a survey sample of 11 residents. The findings included: For R110, the facility staff failed to ensure the resident's privacy was maintained during care, conversations with visitors, and during phone calls, due to the constant monitoring of the resident while in their room, via a video camera with auditory monitoring being observed by a staff member 24 hours a day. On 5/13/24 at 6:15 p.m., upon the survey team's arrival to the unit, it was observed that in the hallway across from the nursing station there were several devices that were on vertical poles, that could be moved around and at the top, there was a camera. On 5/13/24 at 6:30 p.m., R110 was observed to be on the telephone in the room and was not available for an interview. On 5/14/24 at 09:13 AM, observations were conducted in R110's room. It was noted that one of the video cameras on the pole was observed in the room. R110 was asked about the device, and he stated that it keeps an eye on him and will scold him if he tries to get up. When asked how it made him feel to know someone was watching him all the time, R110 said, not good, uncomfortable. R110 was asked if he agreed to it being in the room and R110 said, no, all the rooms have it. The survey team did not observe this device in other resident rooms on the unit. R110 went on to say that if he tries to get up it will tell him to stop and wait for someone to come help him. On 5/14/24 at approximately 9:30 a.m., an interview was conducted with the Director of Nursing (DON). The DON was asked about the device in R110's room. The DON explained that it was a virtual monitor that is a video camera and has the option for audio. A virtual monitor tech is upstairs and can watch and listen to him and can talk to him. The DON asked if the resident consented to such device. The DON explained that they are educated on the device and what it does but no formal consent it obtained. On 05/14/24 at 09:55 a.m., during a clinical record review, a Virtual Sitter Patient Initiation Report Form was noted. The form indicated that for R110 the initiation criteria identified was: falls, medical device interference (pulling of lines), dementia, poor short-term memory, impulsivity, and foley in place. Review of the physician orders revealed no order for the virtual monitor. During the clinical record review, it was noted that on 5/13/24, R110 sustained a fall, which required sutures for a laceration to the head. On 05/14/24 at 10:01 a.m., the DON provided the surveyor with an education document, that he indicated is reviewed with residents and/or families. The DON also assisted the surveyor in reviewing R110's clinical record and on 5/7/24, which was the day of admission, R110's behavior was noted as attempt to get OOB [out of bed], confused and noted, observation status initiated, monitoring type virtual, education provided. There was no evidence of any consent of such device by the resident and/or family. On 05/14/24 at 10:37 a.m., a telephone interview was conducted with the daughter of R110. The daughter was asked about the virtual monitor and stated, I don't like that the machine can hear us when we are there privately, if there was some button that showed it was muted would be great. The family member said that she wasn't aware initially that there was a 2-way microphone and wasn't told that they could listen and communicate through the device. She went on to say that the facility staff just brought it in, there was no discussion as to if they wanted it or it being optional. She said that at one time her father had a roommate, and she didn't know if the roommate was aware that they could watch him as well. During the above conversation with R110's daughter, she said, If he said he didn't want it, it's not his option, it's the nurses, he doesn't like it. it is creepy, that someone can watch and hear all the time. She added, If I were a patient rehabilitating, I would be very offended to have that in my room, as a woman to have body parts exposed, it would be very intrusive, and sometimes it is embarrassing if staff listen to us, because he picks at me. I would want them to ask me. On 05/14/24 at 01:02 p.m., R110 was interviewed again. R110 said, It doesn't feel too good to know they are watching and listening all the time. On 5/14/24 at approximately 2 p.m., the surveyor visited the virtual monitor technician (other staff #1- OS#1), in their office. It was noted that OS #1 was sitting in front of two large screens that had multiple residents with a live video feed of their room. It was noted that one Resident, who was located elsewhere within the hospital and not on the skilled care unit, was being assisted with a bed bath by two staff members, and the resident's body could be seen unclothed. OS #1 adjusted the camera to take the resident's body out of view and indicated she did that because the surveyor was in the room, but normally wouldn't adjust it. OS #1 was observed to talk to residents through the camera device/virtual monitor located in the resident's room and could hear what the resident was saying. OS #1 stated that during care such as baths, nursing staff are to call the virtual monitor tech and ask them to turn the privacy screen on, which was like a screen saver on a computer. OS #1 said, staff rarely remember to call to have this done. When asked if there was a way for nursing staff to turn off the device during care, OS #1 said, no, they have to call us and tell us to put a privacy screen on. OS #1 went on to explain the device cannot be disengaged by the resident, staff, or visitors to stop the monitoring or allow for privacy. On 5/14/24 at 3 p.m., during an end of day meeting, the above concerns were shared with the director of nursing. When asked if consent is obtained prior to the virtual monitor being used, the DON stated that it was part of the consent to treat. On 05/15/24 at 08:37 a.m., the DON reported to the survey team that the virtual monitor for R110 had been discontinued following the end of day meeting. On 05/15/24 at 08:42 a.m., an interview was conducted with RN #2 (registered nurse). RN#2 said the virtual monitor is used if a patient is confused, impulsive and high fall risk. When asked if this is something that the doctor must order and consent be obtained for, RN #2 said, no, and explained that a nurse can initiate it and no physician order is needed. RN #2 said, they [the resident and/or family] are aware, we tell them what it is, that it is a camera it can keep eyes on you and keep you safe, it can speak to you, and you can speak to them. When asked about privacy during care, RN #2 said, If we are going to bathe or toilet a resident we call, and the virtual monitor and they will turn camera off. On 5/15/24, a review of the facility document titled Resident Rights was conducted. This document read in part, As a resident on our skilled nursing unit, we want you to be informed and involved in making decisions about your care. All residents shall have rights, which include, but are not limited to the following: . 9. Each resident may communicate privately with individuals of his/her choice . The document titled, Virtual Sitter: Patient Monitoring Technology was reviewed. It read, Patient safety and privacy are our highest priorities at [facility name redacted]. For this reason, we are using a virtual sitter for your safety. Virtual sitter is a patient monitoring device to assist your care team to maintain your safety and required medical treatment. Examples include fall prevention and keeping lines and devices in place; all of which can lead to a delay in healing and recovery. How the virtual sitter works: never records video or audio, video camera and two-way audio- trained staff member to see and speak to you, . Privacy mode (no video or audio) is used when a doctor or nurse is providing care or dressing, bathing, and using the toilet. When the light goes off, privacy mode is on. No additional information was provided.

Based on resident interview, staff interview, facility policy review and clinical record review, the facility stafffailed to develop baseline care plans to address immediate care needs and failed to provide a written summary of the plan for seven of seven new admission residents in the survey sample. Baseline care plans for Residents #65, #66, #67, #69, #165, #168 and #169 did not include all immediate care needs regarding management of a PICC (peripherally inserted central catheter), pain management, therapy services, medications and/or anticoagulant use. These residents nor their representatives were provided a written summary of the baseline care plan. The findings include: 1. Resident #65 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission assessment dated [DATE] assessed Resident #65 as alert, oriented and able to understand instructions. Resident #65's clinical record documented physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The record documented a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #65's baseline care plan dated 7/8/21 included no problems, goals and/or interventions regarding pain management or therapy services and included no list of current medications. There was no evidence in the clinical record that a baseline care plan summary was given to the resident or the resident's representative. 2. Resident #66 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission assessment dated [DATE] listed the resident as confused with visual/hearing impairments. Resident #66's clinical record documented physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The record documented physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #66's baseline care plan dated 6/30/21 included no problems, goals and/or interventions regarding pain management or anticoagulant use. The plan listed a speech therapy evaluation but made no mention of occupational or physical therapies. There was no evidence in the clinical record that a baseline care plan summary was given to the resident or the resident's representative. 3. Resident #67 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission assessment dated [DATE] as alert, oriented and able to understand instructions. Resident #67's clinical record documented physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #67's baseline care plan dated 7/6/21 included no problems, goals and/or interventions regarding pain management or daily use of an anticoagulant. There was no evidence in the clinical record that a baseline care plan summary was given to the resident or the resident's representative. 4. Resident #69 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission assessment dated [DATE] assessed Resident #69 as alert and oriented. Resident #69's clinical record documented physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The record documented physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #69's baseline care plan dated 7/5/21 included no problems, goals and/or interventions regarding anticoagulant use, prescribed therapies, diabetes or pain management. There was no evidence in the clinical record that a baseline care plan summary was given to the resident or the resident's representative. On 7/13/21 at 2:54 p.m., the director of nursing (DON) was interviewed about baseline care plans and any written summary provided to residents. The DON stated, We don't print it out [baseline plan] and hand it to them. The DON stated the baseline care plan was developed at the bedside with the nurse, resident and/or their family. The DON stated the information from the baseline plan was entered into the health record system by a unit tech and updated daily. The DON stated copies of the baseline plan were not provided to the residents and/or families. On 7/14/21 at 7:27 a.m., the DON was interviewed again about baseline care plans for Residents #65, #66, #67 and #69 that made no mention of anticoagulant use, pain management, medications or therapy services provided. The DON stated baseline care plans were completed usually within two hours of admission. The DON stated the admitting nurse reviewed the care plan goals and resident needs when the baseline care plan was developed. The DON stated again that the residents and families were not provided a written summary or copy of the baseline plan. On 7/14/21 at 7:52 a.m., Resident #65 was interviewed about his baseline care plan. Resident #65 stated he did not recall any information about a care plan and did not receive a copy of a care plan. Resident #65 stated discharge instructions were provided from the hospital but he was not aware of a baseline plan since admission to the skilled unit On 7/14/21 at 7:55 a.m., Resident #66's family member was interviewed about a baseline care plan or written plan summary upon admission. The family member stated they received discharge papers from the hospital but did not get a written care plan summary upon admission to the skilled unit. The family members looked through papers at the bedside and stated the hospital discharge summary was all that had been provided. On 7/14/21 at 9:19 a.m., Resident #67 was interviewed about his baseline care plan or written plan summary. Resident #67 stated he had some papers from the hospital but he had received no copy or summary of a care plan since his admission to the skilled unit. On 7/14/21 at 9:21 a.m., Resident #69 was interviewed about her baseline care plan and any plan summary provided by the facility. Resident #69 stated she did not get a summary or copy of a care plan. Resident #69 stated she thought her medications were the same as when she was hospitalized but she had not received a medication list since admission to the skilled unit. These findings were reviewed with the DON on 7/14/21 at 12:30 p.m. 5. Resident #165 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent minimum data set (MDS) dated [DATE] was the 5-day admission assessment and assessed Resident #165 as moderately impaired for daily decision making with a score of 11 out of 15. On 07/13/2021 during the tour, observed outside of Resident #165's room was an Isolation Contact sign including instructions to wear personal protective equipment (PPE) before entering the room. Observed outside the room were new PPE supplies and hand sanitizer. The unit manager (RN #1) was asked why Resident #165 was on isolation. RN #1 stated the isolation was related to Resident #165 having MRSA and full PPE was required to enter the room. On 07/13/2021 at 2:30 p.m., Resident #165 was interviewed regarding the quality of care since her admission. Resident #165 stated things were going well and she planned to discharge home once she completed her antibiotics. Resident #165 was asked if staff wore PPE each time they entered the room. Resident #165 stated, yes, they do. I understand between this pandemic and me having MRSA they have to protect themselves and all of the patients. Resident #165's clinical record was reviewed on 07/13/2021. The admission assessment dated [DATE] documented .isolation contact. A review of the baseline care plan did not document goals and/or interventions isolation contact and social services/discharge goals. A review of the electronic clinical record and the paper chart did not document evidence that a copy of the baseline care plan had been provided to Resident #165. On 07/14/2021 at 10:00 a.m., Resident #165 was interviewed about care plan participation. Resident #165 was asked if she had received a copy of the baseline care plan and/or medications since being admitted . Resident #165 stated, I remember getting some papers from the hospital when I discharged . No one has had a meeting with me since I've been here about my care or given me any papers. The nurse will tell me what medications they give me each shift, but I don't have a list of medications. Resident #165 was asked if she received a summary of her initial care needs/goals developed at admission. Resident #165 stated, no. On 07/14/2021 at 11:00 a.m., the DON was asked if the isolation precautions and social service/discharge interventions should have been included on the baseline care plan. The DON stated yes. The DON stated the residents were followed by case management services for assistance with discharge plans. 6. Resident #168 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent minimum data set (MDS) dated [DATE] was the 5 day admission assessment and assessed Resident #168 as cognitively intact for daily decision making with a score of 14 out of 15. During the initial tour Resident #168 was interviewed regarding the quality of care since his admission. Resident #168 stated, things are fine. This is a wonderful place and they treat me great. Resident #168 was asked about his discharge plans. Resident #168 stated, right now they are focusing on getting me stronger and clearing up the knee infection with the use of antibiotics. My plans are to discharge home as soon as the doctor releases me. Resident #168's clinical record was reviewed on 07/13/2021. Observed on the Admission: Medical History and Functional Status form was the following: .Anti-Coagulant Therapy - Yes. A review of the baseline care plan did not document goals and/or interventions for anti-coagulant use and social services/discharge goals. A review of the electronic clinical record and the paper chart did not document evidence that a copy of the baseline care plan had been provided to Resident #168. On 07/14/2021 at 9:15 a.m., Resident #168 was interviewed regarding about care plan participation. Resident #168 was asked if he received a copy of his baseline care plan and/or medication list since his admission. Resident #168 stated, I recall receiving some discharge papers from the hospital., but I haven't received any forms while I've been down here. I'm not aware of having a care plan meeting since I've been down here. The staff come in here daily and ask me about my goals for the day and I just simply tell them I want to get stronger and return home to my wife. Resident #168 was asked if he received a summary of his initial care needs/goals developed at admission. Resident #168 stated, no. On 07/14/2021 at 11:00 a.m., the DON was asked if the anti-coagulant use and social service/discharge interventions should have been included on the baseline care plan. The DON stated yes. The DON stated the residents were followed by case management services for assistance with discharge plans. The above findings were discussed with the DON during a meeting on 07/14/2021 at 12:30 p.m. 7. Resident #169 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission assessment assessed Resident #169 as alert and oriented. During the initial tour Resident #169 was interviewed regarding the quality of care since his admission. Resident #169 stated, I'm glad to be here. There were several other locations that I was offered. However, this one was the best with 5 stars. So far things have been going great. I've got this PICC line in my arm they are treating the infection that started after my last surgery. I know I will be here at least until August 3 to complete these antibiotics. I hope to go home and eventually get fitted for my prosthetic leg. Resident #169's clinical record was reviewed 07/13/2021. Observed on the Patient Summary was the following antibiotic medications [MEDICATION(S)] (Rocephin), [MEDICATION(S)] (Flagyl), and [MEDICATION(S)] HCL. A review of the baseline care plan did not document goals and/or interventions for the use of the antibiotics and social service/discharge goals. A review of the electronic clinical record and the paper chart did not document evidence that a copy of the baseline care plan had been provided to Resident #169. On 07/14/2021 at 7:27 a.m., the director of nursing (DON) was interviewed regarding the baseline care plan. The DON stated the baseline care plan was completed at bedside with the resident and/or family usually about 2 hours after admission. The DON was asked if a copy of the baseline care plan was provided to the resident and/or family member. The DON stated no, they are given a copy of their medications. The DON was asked if the resident and/or family member were required to sign anything to document their receipt of the medication list. The DON stated, no. The DON was asked if the medication list was printed and provided to the resident and/or family member then why wasn't the care plan printed and provided as well. The DON stated, we just don't print them [care plan]. It is not part of our practice to give a copy of the baseline care plan. On 07/14/2021 at 9:00 a.m., Resident #169 was interviewed regarding care plan participation. Resident #169 stated, I remember getting some hospital discharge papers, but no one has discussed with me my plan of care over here. The nurses in come in and talk with me and therapy has cut me back to three days because I'm so independent. Resident #169 was asked if he was provided with a summary of his initial care needs and/or medication list. Resident #169 stated, no. On 07/14/2021 at 11:00 a.m., the DON was asked if the antibiotic use and social service/discharge interventions should have been included on the baseline care plan. The DON stated yes. The DON stated the residents were followed by case management services for assistance with discharge plans. The above findings were discussed with the DON during a meeting on 07/14/2021 at 12:30 p.m. A review of the facility's Care Plans policy (revised 6/19) documented the following under Procedure: 1. The admitting nurse will initiate the baseline plan of care by adding appropriate interventions to the work list and baseline care plan based on problems identified on the admission assessment within 8 hours of admission. 2. This includes dietary and activity orders, treatments, and patient preferences. This information is reviewed with the patient/patient representative .

Based on staff interview, facility policy review and clinical record review, the facility staff failed to provide written notice of the bed-hold policy for one of ten residents in the survey sample, Resident #10. No written notice of the bed-hold policy was provided to Resident #10 upon admission or at the time of transfer to the hospital. The findings include: Resident #10 was admitted to the facility on [DATE] and discharged to the hospital on 4/16/21. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The minimum data set (MDS) dated [DATE] assessed Resident #10 as cognitively intact. Resident #10's clinical record documented the resident was discharged to the hospital on 4/16/21 due to increased shortness of breath and tachycardia. The clinical record documented no evidence a written notice of the bed-hold policy was provided to the resident or the resident's representative. There was no documentation the resident or his representative was informed of a bed-hold policy at the time of admission or transfer to the hospital. On 7/14/21 at 11:41 a.m., the director of nursing (DON) was interviewed about the facility's bed-hold policy and written notices to residents. The DON stated beds were held for residents for three days for residents out of the facility on leave or after transfer to the hospital. The DON stated no written notice about bed-holds was provided to residents. The DON stated at the time of discharge the admissions nurse talked with the resident or family about bed-holds. The DON stated, I don't think there is anything in writing. The facility's admission packet included no information about a bed-hold policy. The facility's policy titled Leave of Absence (issued 5/95) documented, .If a patient is sent emergently off the unit, a courtesy bed-hold will be in place for three (3) consecutive nights until the account is discharged . This finding was reviewed with the DON on 7/14/21 at 12:30 p.m.

Based on staff interview and facility document review, the facility to perform facility wide resident testing every 3-7 days as set forth by the Secretary for a COVID-19 outbreak. Findings were: On 11/12/2020 at approximately 1:30 p.m. an interview was conducted with the DON (director of nursing). He stated that the facility had been conducting biweekly testing of all staff due to the county positivity rate greater than 10%. He stated that on 10/15/2020 one staff member had tested positive for COVID-19. All residents were tested on [DATE] with all negative results. The facility continued biweekly testing of staff but did not test residents. The DON was asked why the residents had not been tested . He stated, The Local Health Department said we did not need to test our residents, just the staff. The DON was asked if he was familiar with the guidance from CMS dated 08/26/2020. He stated, We questioned this up front, we asked the questions to the local health department. We were told there was no benefit in testing the residents. He stated he had spoke with OS (other staff) #1 at the local health department. Her number was requested. Facility policies regarding testing for COVID-19 were also requested. OS #1 was contacted on 11/12/2020 at 1:45 p.m. The above conversation was discussed. She stated, We have worked in correlation with the facility and the District Health Director (OS #2). I am going to need to go back and look at my notes, I am very familiar with the guidance. I will look at what I have and call you back. At approximately 2:30 p.m. the District Health Director called. She stated that she had been contacted by (Name of OS #1) and was calling to assist. The above information from the facility was discussed. She stated. I am familiar with the facility .it's really unique in that it is an acute rehab facility in the hospital. They only take patients from in house. (Name of OS #1) called and spoke with me about your questions. She did not say that (not to test residents). We talked to the facility in July about the reopening guidelines. One of the things we discussed was the short length of stay for their residents. We have shared all of the new guidance with all our facilities. (Name of OS #1) does not remember talking to them in October. I'm not sure I was even aware they had a positive staff member in October. At 2:45 p.m., a meeting was held with the DON. Dates for facility testing of staff and residents was requested. On 10/15/2020, 15 residents were tested for COVID-19, all were negative. No further testing of residents occurred until 11/08/2020 when one resident exhibited increased confusion and anxiety. The physician ordered a COVID test which was reported on 11/09/2020 as positive. In response to those results, the facility tested all residents with positive results for three. All resident with positive results were moved from the facility back to the respiratory/COVID unit of the hospital. The DON stated that the facility would be conducting twice a week testing based on the positive test result of the resident tested on [DATE], with the next test scheduled for 11/12/2020. The facility did not have a policy regarding COVID-19 testing. The DON stated they are using the guidelines from the Virginia Department of Health and the CDC (Centers for Disease Control). He presented pages 3, 4, and 5 from the CMS guidelines issued on August 26, 2020. He also presented a flow chart from the CDC titled Consideration for Interpreting [MEDICATION NAME] Test Results in Nursing Homes. No further information was obtained prior to the exit conference on 10/09/2020.

Based on observations and staff interview, the facility failed to ensure two ice machines that produce ice for patient use, and one ice machine that produced ice for non-patient use had a drain system air gap. In the Laundry, a wall mounted circulating fan had an accumulation of lint. The findings were: During the General Observations tour at 2:30 p.m. on 11/16/17, the following was noted: 1. In the Nursing Unit Kitchen, a counter top ice machine, located next to a hand washing sink, did not have an air gap. The drain line for the ice machine was connected directly to the hand washing sink out flow line above the trap. 2. In the Main Kitchen, a full size ice machine, located on the floor near a walk-in cooler, did not have an air gap. The drain line for the condenser unit, and the drain line for the ice holding bin were laying directly on top of the floor drain. Both the Nursing Unit Kitchen ice machine and the Main Kitchen ice machine produce ice for patient use. 3. In the Laundry room, a counter top ice machine, located next to a hand washing sink, did not have an air gap. The drain line for the ice machine was connected directly to the hand washing sink out flow line above the trap. It is duly noted that the ice machine in the Laundry does not produce ice for patient use. 4. In the Laundry room, a wall mounted circulating fan, located above several laundry bins, had an accumulation of lint on the fan screen. The fan was operating at the time of the observation. The findings were discussed with the Director of Skilled Nursing, the Director of Plant Operations, and the survey team during a meeting at 9:00 a.m. on 11/17/16.

Based on observations and staff interview, the facility failed to properly dispose of garbage and refuse, and failed to maintain the dumpster area in a manner that was free of debris. The findings were: The initial tour of the main Kitchen, which was conducted beginning at approximately 10:45 a.m. on 11/15/16, included the Dumpster/Loading Dock Area. The surveyor was accompanied by the Director of Food Services during the tour. At the Dumpster/Loading Dock area, the Food Services Director indicated there were two dumpsters, one for cardboard and the other for general waste. The general waste dumpster was missing, and the Food Services Director said it must have just been picked up. On the ground around the metal base into which the dumpster is secured, there was an accumulation of leaves and trash, including blue, latex gloves. Also on the loading dock, immediately adjacent to the dumpster access, were two blue trash carts containing clear plastic bags. The bags were filled with blue sheets and clear, plastic oxygen equipment. The Food Services Director said the carts contained surgical trash. The findings were discussed with the Director of Skilled Nursing during a meeting with the survey team at 4:20 p.m. on 11/16/16.

Based on observations, staff interview, and review of facility documents, the facility staff failed to store, prepare and serve food in a sanitary manner in the main kitchen and in a small kitchen on the Skilled Nursing Unit. A tour of the Main Kitchen and the Nursing Unit Kitchen found expired dairy items; open, undated and uncovered food items in the dry storage room, walk-in coolers and freezer; food at an incorrect temperature on the food line; personal items, including a prescription medication stored behind a coffee maker; no test strips available for both three compartment sinks; a dirty can opener; a lack of sanitation during the test of food temperatures; a food service employee without a beard guard. The findings were: 1. The initial tour of the main Kitchen was conducted beginning at approximately 10:45 a.m. on 11/15/16. The surveyor was accompanied by the Director of Food Services during the tour and the following observations were made: A. Catering Area immediately adjacent to the Main Kitchen: At the three compartment sink, the surveyor asked if there were any test strips for checking the chemical sanitization levels used during the wash, rinse and sanitization process. We did have (the test strips), the Director of Food Services said. Maybe they fell . Maybe someone took them to the Kitchen. The Director of Food Services went on to explain that although the three compartment sinks are used, anything washed in the sinks is taken and run through the dishwasher. Maybe we should be checking the water. On a stainless steel table in the Catering area, there was an accumulation of dried, black debris at the base of a table mounted can opener. On a stainless steel table next to the three compartment sink was a large coffee maker along with a large, circular urn for tea. Stored behind the coffee maker were an number of personal items, including a pair of black gloves, a large soda cup, a dozen brown eggs in a clear plastic container, and a small bottle of prescription medicine labeled [MEDICATION NAME] and bearing the name of an individual identified by the Director of Food Services as an employee in the Catering area. (NOTE: [MEDICATION NAME] is an antiinfective used in the treatment of [REDACTED]. Ref. Mosby's 2017 Nursing Drug Reference, 30th Edition, page 453.) At 7:45 a.m. on 11/16/16, the employee, identified as Nutrition Assistant # 2 (NA # 2), whose name appeared on the [MEDICATION NAME] label, was interviewed. Asked where she works, NA # 2 said she primarily works in the dining and catering areas. When asked if the [MEDICATION NAME] belonged to her, NA # 2 said, Yes. I have psoriasis. My doctor thinks it is related to my pregnancy and she is trying the [MEDICATION NAME] to treat it. NA # 2 went on to say that the facility and the Food Services Director were aware of her condition. Asked about the other items behind the coffee maker, NA # 2 said she didn't know who the gloves belonged to, but that the eggs belonged to another employee who brought them in to sell. Regarding the soda cup, NA # 2 said, We aren't allowed to have them (drinks) on the floor (food preparation area), so we keep them there. At approximately 8:00 a.m. on 11/16/16, the Food Services Director was interviewed regarding NA # 2's skin condition. The Food Services Director said he was aware of her condition, that she had been seen by the hospital's Employee Health Department, and cleared to work in her current capacity. B. Main Kitchen area: In the Dry Storage area, the following items were open and undated; a small bag of Trail Mix that had been repackaged by the kitchen staff; a bulk bag of Trail Mix; a bag of Whole Grain Elbow Macaroni; a bag of Corn Bread Mix. In the first of two walk-in coolers, a container of cooked chicken was not tightly sealed. As soon as the Food Services Director touched the lid to check the date, the lid popped off. In a walk-in freezer, there were two open bags of frozen raspberries. One bag was not dated, and the other bag, which was loosely wrapped, had a date that was not legible. In the second walk-in cooler, there were three crates, partially filled with half pint cartons of milk. All the cartons of milk had an expiration date of 11/12/16. The crates of expired milk were adjacent to crates of milk, also half pint cartons, that were not expired and that were in use. There was no signage on the expired milk crates to indicate the milk was not to be used. Those are set aside to return to the vendor for credit, the Food Services Director said. Also in the cooler was a small bag of cubed, white potatoes that was not dated; and a small, rectangular pan labeled Roasted Garlic that was not covered or dated. There was also a rectangular pan labeled Tomato Paste that was covered and dated 11/13 - 4/13. Asked what 11/13 - 4/13 meant, the Food Services Director said, I don't know. During the tour, the surveyor and the Food Services Director passed by the food service line. The Food Services Director volunteered to check the temperatures of the food on the line. Of the approximaltely 15 food items checked, only the macaroni and cheese at 132 degrees failed to reach the appropriate temperature. The macaroni and cheese was taken off the line. Prior to checking the food temperatures, the Food Services Director obtained an antiseptic wipe with which to clean the probe on the thermometer. After checking the temperature of approximately six or seven food items using the same wipe, the Food Services Director obtained another wipe which he used to clean the thermometer probe as he checked the rest of the food temperatures. While the food temperatures were being checked, a food service employee was observed plating food to be served. The employee, who had a short beard, was not wearing a beard guard. C. Dish Washer Room: A second three compartment sink was found in the Dish Washer Room. Asked if there were any test strips, the Food Services Director said there were none. D. Following the tour of the Kitchen, the surveyor requested and received the facility's policies on food storage and personal hygiene. Review of the Food Storage policy, dated 6/24/16, noted the following: Procedures 1. Perishable Storage b. All food items are labeled, dated, and securely wrapped or covered. e. Any outdated perishables will be discarded following the guidelines in the 'Leftover Food' policy. All outdated perishables awaiting vendor pickup and credit will be placed in a separate container away from the dated products and clearly marked 'OUTDATED-DO NOT USE.' Frozen Storage b. All food items are labeled, dated, and securely wrapped or covered. Review of the Nutrition Services Infection Control Policy, dated 7/14/16, noted the following: Procedures 1. Personal Hygiene: c. The hair must be restrained with either a cap or hair net .Beard nets required for beards over 1/2 inch long. 5. Food Storage: d. Any outdated perishables will be discarded. Outdated Milk may be retained for pick up but kept in a separate area with labeled container marked 'DO NOT USE - OUTDATED PRODUCT.' It should be noted that the facility's policy requiring a beard net for beards over 1/2 inch long is in direct conflict with the Virginia Food Regulations which note that, Except as provided under subsection B of this section, food employees shall wear hair restraints, such as hats, hair coverings or nets, beard restraints The food regulation makes no allowance for the length of the beard. (Ref. Virginia Food Regulations, Part II, Article 4, 12 VAC 5-421-240 Effectiveness of hair restraints.) 2. Beginning at approximately 2:30 p.m. on 11/16/16, a General Observations tour of the nursing unit, Kitchen and Laundry was started and the following observations were made: A. Nursing Unit Kitchen The refrigerator in the Unit Kitchen contained an unopened carton of Imperial Thickened Dairy Drink with a use by date of 3/30/16, and a carton of Silk Soy Milk with a use by date of 6/25/16. B. Catering Area immediately adjacent to the Main Kitchen: At the three compartment sink area the Patient Services Manager for food services was asked about test strips. The Patient Services Manager said there were no test strips and added that We really don't use the sinks that way. We send everything to the dish washer. Behind the coffee maker located on the table next to the three compartment sink there was a soft drink cup and a carton of Silk Milk. Also behind the coffee maker was a clear plastic container holding what appeared to be personal items. NA # 3, who was with the surveyor at the time said the container had, Random things. Stuff that doesn't need to be behind there. C. Main Kitchen area: The small, rectangular pan labeled Roasted Garlic observed on 11/15/16, was still in the walk-in cooler, not covered or dated. The food service employee observed plating food on 11/15/16 was observed in the food preparation area. The employee, who had a short beard, was not wearing a beard guard. D. Dish Washer Room: While at the three compartment sink in the Dish Washer Room, the Patient Services Manager was asked about test strips. The Patient Services Manager indicated there were none at the sink area, but he was able to obtain one from a drawer in a table adjacent to the Dish Washer Room. The Patient Services Manager took the test strip, activated the chemical feed system, and held the test strip under the sanitization chemical feed line. After about 30 seconds the Patient Services Manager stopped the chemical flow and then showed the strip to the surveyor. The reading on the strip reflected straight concentration of the sanitization chemical and not a reading of the diluted sanitization chemical used during the sanitization process. During a meeting with the Director of Skilled Nursing Services and the survey team at 4:20 p.m. on 11/16/16, the findings of the Kitchen and General Observation tours was discussed.

Based on staff interview and clinical record review, facility staff failed to offer non-pharmacological interventions to address pain control for one of ten residents in the survey sample, Resident #1. Resident #1 was administered [MEDICATION NAME] or Tylenol 17 times during the dates of 10/17/2016 through 11/15/2016 for complaints of pain. Use of non-pharmacologic interventions was implemented only three (3) times according to documentation in the EMR (electronic medical record). Findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was an initial assessment with an ARD (assessment reference date) of 10/24/2016. Resident #1 was assessed as cognitively intact with a total cognitive score of 13 out of 15. Resident #1's electronic medical record was reviewed on 11/15/2016 at approximately 12:00 p.m. Documentation in the record included where this resident had received [MEDICATION NAME] 25mg (milligrams) by mouth a total of six times and had received Tylenol 650mg by mouth a total of eleven times for various complaints of pain since his admission on 10/17/2016. Subsequent review of Resident #1's CCP (comprehensive care plan) included a plan for pain with interventions that included, .non-pharmacological interventions . The DON (director of nursing) was interviewed at 3:45 p.m. regarding non-pharmacological interventions and where this would be documented in the EMR. The DON stated, Let me research a little bit and see what information you all have access to in the medical record. The DON approached the conference room on 11/16/2016 at approximately 9:30 a.m. with a paper copy of what the nurse's see in the EMR when documenting pain and interventions. The DON stated, This is what the nurses see when they document pain. It has an area here for 'Pain Alleviating Treatment Provided' with nine treatments listed that can be checked if used. It doesn't show up on your side unless you click on the time when a pain assessment was completed. This surveyor observed 17 pain assessments with interventions listed, only three assessments included non-pharmacological interventions. The DON was advised of the above information during a meeting with the survey team on 11/16/2016 at 4:20 p.m. No further information was received by the survey team prior to the exit conference on 11/17/2016.

Based on medication pass and pour observation, hand hygiene observation, staff interview and facility document review, facility staff failed to follow infection control practices on the skilled unit. Facility staff failed to follow proper technique for dropped medications during the medication pass and pour observation and failed to perform proper hand hygiene during two separate observations. Findings included: A medication pass and pour observation was performed on 11/16/2016 at approximately 8:10 a.m. with LPN #1 (licensed practical nurse), this surveyor and a federal oversight surveyor. During medication administration to the first resident a pill was dropped onto his gown. LPN #1 caught the pill on the resident's gown and placed back into the medication administration cup. The resident then took the pill. LPN #1 was not wearing gloves during the administration of his pills. LPN #1 applied gloves to apply eye ointment to this resident. After removal of the gloves LPN #1 went into the resident's bathroom, turned on water in the sink, wet her hands, applied soap, rubbed together for approximately five seconds, rinsed, turned off water faucets with her bare, wet hands and dried with a paper towel. During pill administration to a second resident at approximately 8:25 a.m., a pill was dropped onto the resident's bedside table. LPN #1 picked the pill up with a gloved hand and administered said pill to the resident. LPN #1 was interviewed on 11/16/2016 at approximately 10:30 a.m. by this surveyor. LPN #1 stated, I usually wash my hands if they come in contact with bodily fluids, giving eye drops, insulin, stuff like that. Otherwise I use hand sanitizer. Normally use gloves if giving eye drops, insulin, cleaning a patient. Don't like to use gloves when opening pills. They sometimes break and a piece of the glove gets in the pills. I open packets so I don't touch the pills. If I drop a pill on the floor or somewhere I will get another one. If drops on their clothes or something I just let them take it. The DON (director of nursing) was interviewed 11/16/2016 at 1:30 p.m. The DON stated, There is no specific policy that mentions what to do if meds are dropped. This policy, referring to Medication Administration Definitions just states what to do in case of med errors or missed doses. Regarding his expectation for dropped medications, Actually would depend on the scenario. If it dropped on the floor or table I would probably return it and get another one. If it dropped on their gown or clothing I probably would not get another one. Some patients have dexterity issues and I'd say it happens. RN #3 (registered nurse) was observed washing her hands after removing gloves on 11/16/2016 at approximately 4:00 p.m. RN #3 used a motion sensored sink. She wet her hands, applied soap, rubbed approximately five seconds, rinsed and then dried with a paper towel. The DON was informed of the above hand washing observations by this surveyor during a meeting with the survey team on 11/16/2016 at approximately 4:20 p.m. This surveyor requested a copy of the facility hand hygiene policy. On 11/17/2016 at approximately 8:00 a.m. the DON presented a copy of the facility hand hygiene policy to this surveyor. The Hand Hygiene Policy Issued 11/95; Revised 2/02; Reviewed 8/13 included, 1. Purpose: Your hands serve as the common vehicle in almost every transfer of potential pathogens from one patient to another .hand hygiene is the single most important measure for preventing the spread of infection .3. Procedure: Hand washing .B. Steps: 1. Wet hands with warm water and apply soap .2. Wash hands vigorously for FIFTEEN seconds .4.Avoid touching the sink and faucets with your hands .5. Rinse hands under running water .6. Pat hands and wrists dry with a paper towel. 7. Turn off the faucets and open door using a paper towel, to avoid re-contaminating your hands . No further information was received by the survey team prior to the exit conference on 11/17/2016.

Based on observation, staff interview and facility document review, facility staff failed to treat a pressure ulcer in a sanitary manner for one of 10 residents in the survey sample, Resident #1. RN #3 (registered nurse) failed to use proper hand hygiene, set up a clean working field, opened sterile dressing packages and placed onto an unclean working field, performed a clean dressing change with contaminated gloves and dressing supplies, and returned multi-use dressing change supplies back to the night stand while wearing contaminated gloves during a dressing change to a sacral pressure ulcer on Resident #10. Findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was an initial assessment with an ARD (assessment reference date) of 10/24/2016. Resident #1 was assessed as cognitively intact with a total cognitive score of 13 out of 15. Resident #1's electronic medical record was reviewed on 11/15/2016 at approximately 12:00 p.m. Physician orders [REDACTED]. Wound care documentation included care of a sacral pressure ulcer. On 11/16/2016 at approximately 3:40 p.m. this surveyor spoke with RN #3 regarding Resident #1's pressure ulcer. RN #3 stated, Last night when I changed his dressing the area was healed so I left it open to air. We can go assess how the area looks now. Last night it was all dried up. RN #3, this surveyor and a federal oversight surveyor entered Resident #1's room. RN #3 informed Resident #1 why were in the room and the resident repositioned himself in the bed onto his right side. RN #3 donned a pair of clean gloves and exposed Resident #1's sacral area. The sacral area was red in the midline and out onto both buttocks. Three open areas were noted, one on the left buttock and two on the right buttock. RN #3 stated, It has opened up again, so let me get his dressing change stuff and I will cover it back up. RN #3 covered the exposed area while she retrieved dressing change supplies from Resident #1's nightstand on the opposite side of the bed. She gathered a bottle of dermal wound cleanser, a package of 4x4's, a skin prep package, an Allevyn dressing and a box with a tube of Iodosorb ointment. She went out into the hallway to the medication cart and obtained two packages of sterile cotton swabs and returned to the bedside. RN #3 placed all the wound care supplies onto Resident #1's bedside table. She did not clean the bedside table or place a clean barrier over the table. RN #3 opened the Allevyn dressing, pulled it halfway out of the package and placed it on the bedside table. She took the Iodosorb tube out of the box, removed the lid and placed onto the bedside table. She opened the package of sterile 4x4's and wet them with dermal wound cleanser. She then turned to the resident, exposed his sacral area, patted the reddened areas with the dermal wound cleanser on the 4x4's, discarded the 4x4's in the bedside trash can, removed a sterile cotton swab and squeezed Iodosorb ointment onto the tip. RN #3 applied Iodosorb ointment to all three open areas using the same cotton swab, discarded the first swab, opened a second swab, applied Iodosorb ointment to the tip of the second swab and applied this to the lowest open area on the right buttock. Both swabs were discarded into the bedside trash can. RN #3 applied skin prep to the outer edges of Resident #1's sacral area, removed the Allevyn dressing from its package, removed the cover and placed the Allevyn dressing over Resident #1's sacral area. RN #3 assisted Resident #1 to remain on his right side with pillows behind his back and one between his knees, then covered the resident with his bed linens. She gathered all the dressing change supplies from the bedside table and placed them back into the drawer of the nightstand. At that time RN #3 removed the pair of gloves she donned at the start of the wound observation and used hand sanitizer. RN #3 was never observed washing her hands or using hand sanitizer during the entire wound assessment or dressing change procedure. The DON (director of nursing) was informed of the above observation during a meeting with the survey team on 11/16/2016 at 4:20 p.m. This surveyor requested any facility policies pertaining to clean dressing change techniques during the meeting. On 11/17/2016 at 8:00 a.m. the DON brought this surveyor a Hand Hygiene Policy Issued 11/95; Revised 2/02; Reviewed 8/13 and a reference used by the facility for clean dressing change techniques from Clinical Nursing Skills & Techniques by Potter and Perry. The DON stated, We use Potter and Perry. The nursing standard for dressing changes. The Hand Hygiene Policy included the following: 1. Purpose: Your hands serve as the common vehicle in almost every transfer of potential pathogens .2. Policy: Hands should be cleansed routinely: Before having contact with the patient; Between every patient contact and after handling contaminated articles; After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient; .After contact with a patient's intact skin; .before donning gloves . Potter and Perry steps for treatment of [REDACTED]. Assemble supplies at bedside .3. Perform hand hygiene and apply clean gloves. Open sterile packages and topical solution containers. Keep dressings sterile .4. Remove bed linen and arrange patient's gown to expose ulcer and surrounding skin .5. Remove old dressing and discard in appropriate receptacle .Remove gloves and discard. 6. Perform hand hygiene and change gloves. 7. Clean wound thoroughly with normal saline or prescribed wound-cleansing agent from least contaminated to most contaminated area. 8. Apply topical agents to wound using cotton-tipped applicators or gauze as ordered .9. Apply prescribed wound dressing .10. Reposition patient comfortably off pressure ulcer. 11. Remove gloves and dispose of soiled supplies. Perform hand hygiene. (1) No further information was received by the survey team prior to the exit conference on 11/17/2016. (1) Potter, Patricia A. and Perry, Anne Clinical Nursing Skills & Techniques. 8th Edition St. Louis: Mosby, Inc. 2014

Based on observations and staff interview, the facility failed to post the daily staffing level on the Skilled Nursing Unit, including the name of the facility, current date, number of staff and hours worked, and the current facility census. The findings were: During the General Observations tour at 2:45 p.m. on 11/16/16, there was no signage found on the nursing unit to advise residents, family members, and general public of the name of the facility, the current date, the number of licensed and certified staff (Registered Nurses, Licensed Practical Nurses and Certified Nursing Assistants) working on each shift for the current date, the hours worked, and the current census. The lack of staffing information signage was discussed with the Skilled Nursing Director and the survey team during a meeting at 4:20 p.m. on 11/16/16.

Based on observations and staff interview, the facility staff failed to post the location of the most recent survey results, and failed to clearly identify the results, which were found posted on a bulletin board. The findings were: During the General Observations tour of the facility at 2:45 p.m. on 11/16/16, a sheaf of papers was found tacked to a bulletin board across from the Nurses Station. The top page of the papers was a cover letter from the Virginia Department of Health indicating that the accompanying papers were the most recent survey results. There was no signage on the bulletin board to identify the papers as the survey results, and there was no way to identify the papers as the survey results without reading the cover letter. There was also no signage in the immediate vicinity of the Nurses Station, nor any where else on the nursing unit, to advise of the availability and location of the most recent survey results. The survey results, including the signage and location, were discussed with the Skilled Nursing Director and the survey team during a meeting at 4:20 p.m. on 11/16/16.

Based on staff interview and clinical record review, the facility staff failed to ensure a complete minimum data set (MDS) for one of 5 residents in the survey sample. Resident #5's admission MDS dated [DATE] included no assessment of the resident's pain in section J0300. The findings include: Resident #5 was admitted to the facility on [DATE] and discharged on [DATE]. [DIAGNOSES REDACTED]. The MDS dated [DATE] assessed Resident #5 as cognitively intact and with no communication problems. Resident #5's closed record was reviewed on 10/14/15. Section J of the resident's admission MDS assessment dated [DATE] documented a pain assessment interview should be conducted with Resident #5. Section J0300 documenting the resident's interview responses regarding pain presence, pain frequency, pain effect on function and pain intensity was incomplete and marked only with dashes. On 10/14/15 at 3:50 p.m. the registered nurse (RN #1) responsible for MDS assessments was interviewed regarding the incomplete assessment for Resident #5. RN #1 stated Resident #5 was admitted with multiple fractures, was able to respond to interview questions and make her needs known. RN #1 stated she had no explanation why the pain interview assessment was not completed for Resident #5. RN #1 stated the admission MDS section documenting the pain interview responses was usually completed. Regarding the missing pain assessment for Resident #5, RN #1 stated, I don't know why. These findings were reviewed with the director of nursing on 10/14/15 at 5:00 p.m. and on 10/15/15 at 10:20 a.m.

Based on staff interview, employee record review, and facility document review, the facility staff failed to implement the policy and procedure for abuse prevention, specifically the screening of new employees. The facility staff failed to perform a Virginia State Police Criminal Records Check for one of one new employee. The findings were: During the entrance conference at 11:00 a.m. on 9/30/14, the Director of the Skilled Nursing Unit was asked to provide a list of all new employees hired for the unit in the four month period preceding the survey. The Unit Director indicated that only one new employee had been hired in that time period. At 9:30 a.m. on 10/1/14, the Human Resources Manger provided the personnel file of the individual that was hired. The surveyor and the Human Resources Manager reviewed the file of the individual, a Licensed Practical Nurse hired on 7/28/14. Review of the file revealed the employee's license, sworn statement, and references were all in order. Asked about the Virginia State Police Criminal Records Check, the Human Resources Manager said, "I'm sorry, it was not done. I'm as sorry about this as you are." The facility's Abuse Police, under the section "Procedure," noted the following, "Human Resources will screen employees for criminal history per Criminal Records Check Policy." The facility's Background Check (Criminal Records Check Policy) noted the following, "...If the criminal check is not received within 30 days, the employee cannot be scheduled until it is received...." The Director of the Skilled Nursing Unit was present at the time the personnel file was reviewed.

Based on staff interview, employee record review, and facility document review, the facility staff failed to implement policies and procedures for abuse prevention. The facility staff failed to implement policies and procedures for abuse screening prior to employment, for two of five employees (records). Findings include: On 08/21/13 at 11:15 a.m., the Human Resources Manager, also known as OS (other staff) # 4 was interviewed with the survey team during the employee criminal background review. The DON (director of nursing) was present in the meeting as well. During the interview, OS # 4 was asked to provide verification of the criminal background check through the Virginia State Police for two of five employee records checked (employee # 1 and employee # 5). While reviewing employee record # 1 without verification of a criminal background check, OS # 4 stated, "It wasn't done...done the wrong one...I'm just as sick as you are." During the employee # 5 record review without verification of a criminal background check, OS # 4 stated, "Same deal, the wrong criminal background check was done." OS # 4 was asked again when the individuals were hired. OS # 4 stated that employee # 1 was hired October 1, 2012 and employee # 5 was hired January 7, 2013. OS # 4 stated toward the DON, "...we need to get these done the next time they (employee # 1 ad # 5) work." The facility's policy on screening employees was requested at this time. At approximately 11:50 a.m., the policy information was presented and reviewed. The policy titled, "Abuse Policy" documented: "...Human Resources will screen employees for criminal history per Criminal Records Check Policy." The policy titled, "Background Checks (Criminal Records Check Policy)" documented: "...If the criminal check is not received within 30 days, the employee cannot be scheduled until it is received..." The administrator and DON (director of nursing) were made aware in a meeting with the survey team on 08/21/13 at approximately 12:00 p.m.

Based on medication pass and pour observation, staff interview, clinical record review and facility document review the facility staff failed to follow professional standards of nursing practice for 1 of eight residents in the survey sample: Resident # 5. Resident # 5's potassium chloride supplement (Klor-Con) was crushed prior to administration. Findings include: Resident # 5 was admitted to the facility 8/8/13 with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a 5 day admission assessment dated [DATE]. Resident # 5 was coded with moderate cognitive impairment with a total summary score of 10 out of 15. On 8/21/13 a medication pass and pour observation was conducted with LPN (licensed practical nurse) # 1 beginning at approximately 7:55 a.m. At approximately 8:25 a.m. LPN # 1 entered Resident # 5's room to administer the morning medications. Medications for Resident # 5 included Klor-Con 10 meq (millequivalents) two tablets every day. LPN # 1 asked Resident # 5 how she was doing. Resident # 5 stated "Well, not too good; I had to have that thing down my throat after I got choked the other day. All my medicines now have to be either liquid or needs to be crushed." LPN # 1 expressed her concern for the resident, then looked at this surveyor and stated "I've been off a couple of days, this is news to me!" LPN # 1 then poured the pills in the medicine cup into a small plastic bag to crush them. After pouring all the pills in the bag, LPN # 1 (with a gloved hand) removed 2 pills from the bag, and proceeded to crush the remaining pills. This surveyor asked LPN # 1 why she had removed the 2 pills. LPN # 1 stated "Those are rather large pills; that's her potassium and I am going to crush those separately because it will be too much to put in a little cup of applesauce." LPN # 1 then proceeded to crush the potassium pills and administer them to Resident # 5. LPN # 1 then stated "I will call the pharmacy later and get them to send some liquid potassium." On 8/21/13 at approximately 9:45 a.m. the DON (director of nursing) was asked for a policy on medication administration as related to crushing medications. The DON stated there was not a specific policy for that. The DON was then asked if Klor-Con could be crushed. He replied "I think so, but I'm not sure. Let me see what I can find out." The Drug Information Handbook for Nursing 8th Edition lists Klor-Con as an oral medication that should not be crushed because it is an extended release product. The reference states concerning extended release products, "The formulation of some tablets is specialized as to allow the medication within it to be slowly released into the body. This is sometimes accomplished by centering the drug within the core of the tablet, with a subsequent shedding of multiple layers around the core." Page 1010 in the Drug Information Handbook for Nursing 8th Edition states concerning taking the medication Klor-Con, "...tablets should be swallowed whole; do not crush or chew." (1) On 8/21/13 at approximately 11:20 a.m. the DON told this surveyor "I verified with the pharmacy that the Potassium should not be crushed." On 8/21/13 at approximately 11:35 a.m. LPN # 1 was asked about crushing the potassium. LPN # 1 stated "I never knew it couldn't be crushed. I was going by what the resident told me that her medications now needed to be crushed." This surveyor asked LPN # 1 about dissolving the medication in water as directed in the electronic medication administration system. The facility's pharmacist was also present during this time, and LPN # 1 asked the pharmacist "What's the difference in dissolving it in water or crushing it and putting it in applesauce? It will dissolve in the applesauce!" The pharmacist stated "That's a very good question, but the potassium is a 'do not crush' medication. When the medication is dissolved, the granules inside the coating may remain stable; crushing may damage them since it is an extended release medication." On 8/21/13 at approximately 12:05 p.m. the DON gave this surveyor a copy of a manual printed from the electronic system entitled "Oral Dosage Forms That Should Not Be Crushed" and stated "This is a manual available to staff from an online manual; all staff has access to this information." The Klor-Con potassium Extended release tablets were included in the manual. On 8/21/13 at approximately 12:20 p.m. the DON and the administrative director were informed of the above findings during a meeting with facility staff. No further information was provided prior to the exit conference. (1) Turkoski, Beatrice B., Brenda R. Lance and Mark F. Bonfiglio. Drug Information Handbook for Nursing 2007. Hudson, Ohio: Lexi-Comp, 2006.

Based on observation and staff interview, the facility staff failed to prepare and distribute food in a sanitary manner. Ready for use food preparation/serving pans were stored nested and wet in the main kitchen. The findings include: On 8/13/12 at 1:55 p.m. the facility's kitchen was inspected during the initial tour of the facility accompanied by the nutrition production manager. Stainless steel preparation/serving pans, identified by the production manager as clean and ready to use, were stacked on a storage rack. Twenty large, 2 inch deep hotels pans were nested and wet. Humidity and moisture were present on the inside pan surfaces and visible when the stacked pans were separated. The production manager stated at this time that the pans were not supposed to be stored wet. The production manager stated they routinely stored pans on a drying rack prior to stacking/nesting on the ready to use rack. On 8/14/12 at 10:40 a.m. an additional inspection of the ready to use pan storage was conducted accompanied by the executive chef. Thirteen deep loaf type pans identified as ready to use were observed nested and wet. Moisture was observed on the inside of the pan surfaces with water running around the edge of the pans when separated. The executive chef was interviewed at this time about the wet pans. The executive chef stated the pans were supposed to be dried on a rack prior to storage. The executive chef stated, "It's an ongoing reminder, re-training (about pan storage). We need to spread out the pans more on the drying rack." These findings were reviewed with the executive director and director of nursing services on 8/14/12 at 11:15 a.m.

Based on observation and staff interview the facility staff failed to procure, store, prepare and distribute food in a sanitary manner. Expired milk was observed in the facilities main kitchen accessible for use. The finding include: An initial tour of the facilities main kitchen was conducted on 10/18/11 at 10:50 a.m. Observed in a walk-in refrigerator were 6 one gallon containers of whole milk. Upon further observation 5 of the six containers of milk had an expired used by date. They are as follows: One gallon expired 10/13/11, two gallons expired 10/14/11, two gallons expired 10/16/11, and one gallon had a used by date of 10/23/11. None of the 6 gallons of milk were opened. Out of the 6 gallons of milk observed, there was only one gallon of milk that was still usable. All 6 gallons of milk were adjacent to each other and stored on a shelf along with individual milk containers. The five gallons of expired milk was accessible to dietary staff and none of the five gallons had any identifying marks, stickers or tags indicating the staff not to use, (except for the printed on use by date from the manufacturer). At this time the executive chef was interviewed concerning the finding. The executive chef verbalized that staff knew not to use the milk. At this time this surveyor expressed concern that the milk in question was among other milk and accessible to staff as opposed to putting the milk in a separate area. The executive chef verbalized that it was common practice to store the expired milk in the refrigerator until the contractor could pick the milk up and the facility would get a credit, and also verbalized that it is done this was so the milk won't spoil and smell. The above finding was brought to the attention of the director of nursing (DON) and the administrator during an end of day facility staff/surveyor meeting on 10/18/11. At this time a policy was asked for pertaining to storage of expired foods/milk. On 10/19/11 at 9:45 a.m. a policy was obtained for expired milk. Review of the policy revealed the issued date of the policy that read 10/19/11. The policy also read in part "This (expired milk) should be placed in the refrigerator in a separate container and held until the next delivery date from the dairy. The dairy delivery driver will collect the out-of-date milk..." At this time the executive vice president chief nursing officer (administrative staff #3, AS #3) was questioned regarding the date of the policy. AS #3 verbalized that a policy could not be found regarding storage of expired foods/milk so a policy was written . AS #3 went onto verbalize that she would look again for a policy in the kitchen. At 10:35 on 10/19/11 AS #3 returned to this surveyor and verbalized that a existing policy could not be found. On 10/19/11 at 11:30 a.m. the director of dietary verbalized that the gallons of whole milk are used in recipes for cooking. No other information was presented to the survey team concerning the above finding prior to exit conference on 10/19/11.