Every finding on record at Carolina Village Inc

Based on observations and staff interviews, the facility failed to remove food items past the date indicated for use in the walk-in refrigerator. This practice occurred in 1 of 1 walk-in refrigerator and had the potential to affect food served to residents. Findings included: An observation of the walk-in refrigerator on 01/21/25 at 9:22 AM with the Certified Dietary Manager (CDM) revealed the following: 1 a. A five pound container of sour cream dated 1/13 that had been opened and was available for use. During an interview on 01/21/25 at 9:22 AM the CDM revealed the date on the container was the date the sour cream was opened and she expected it to be discarded on 1/20/25, seven days after being in use. The CDM removed the container of sour cream from the walk-in refrigerator. c. Two containers of ham salad dated 1/20. During an interview on 01/21/25 at 9:22 AM the CDM revealed the date on the ham salad was the use by date and she expected both containers to have been discarded on 1/20/25. The CDM removed both containers of ham salad from the walk-in refrigerator. d. A half quart container of pinto beans dated 1/10 and 1/17. During an interview on 01/21/25 at 9:22 AM the CDM revealed the container of pinto beans was dated with both an open and used by date and she expected the beans to have been discarded on 1/17/25 according to the use by date. The CDM removed the container of pinto beans from the walk-in refrigerator. e. One large metal sheet pan of thawed raw chicken breast dated 1/20 stored on the bottom rack below other food items that were within the use by date and available for use. During an interview on 01/21/25 at 9:22 AM the CDM revealed the chicken was left over from 1/20/25 and should have been discarded on that day. The CDM further revealed it was the responsibility of the Kitchen Supervisor and dietary staff to check the dates on food items available for use and discard if out of date. During an interview on 01/22/25 at 4:38 PM the Kitchen Supervisor revealed he checked the walk-in refrigerator when he first arrived at work at approximately 6:45 AM and removed out of date food items. The Kitchen Supervisor revealed on 01/21/25 the food delivery truck had arrived, and he had not checked the walk-in refrigerator before the observation with the CDM and was why the out of date food items were not removed. During an interview on 01/24/25 at 1:02 PM the Administrator revealed if the use by date indicated a food item should be discarded those items should be removed and not stored in walk-in refrigerator and available for use.

Based on observations, record review, and staff and resident interviews, the facility failed to assess the ability of a resident to self-administer medications and supplements for 1 of 1 resident with medication observed in the room (Resident #3). Findings included: Resident #3 was admitted to the facility 12/12/24 with diagnoses including hypertension (high blood pressure) and hypercholesterolemia (high cholesterol). Review of Resident #3's medical record revealed no documentation that Resident #3 was assessed for self-administration of medications or supplements. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was cognitively intact. Review of Resident #3's physician orders revealed the following: CoQ10 (an antioxidant which protects cells from damage) 400 milligram (mg) daily ordered 12/20/24 Ezetimibe (a medication for high cholesterol) 10 mg once a day ordered 12/13/24 Fish Oil 1200 mg once a day ordered 12/20/24 Flax Seed Oil (a supplement that may decrease inflammation) 100 mg once a day ordered 12/20/24 Garlic Oil 1000 mg once a day ordered 12/20/24 Escitalopram (an antidepressant) 5 mg once a day ordered 12/13/24 Lisinopril 5 mg once a day hold for systolic blood pressure <120 ordered 12/17/24 Psyllium Husk (laxative) 2 capsules once a day ordered 12/20/24 Turmeric (a supplement that may decrease inflammation) 1000 mg once a day ordered 12/20/24 Zinc 30 mg once a day ordered 12/20/24 An observation of Resident #3's overbed table on 01/21/25 at 11:08 AM revealed a cup of medication with approximately nine pills sitting on the table. An interview with Resident #3 at the same date and time revealed she wasn't sure what most of the pills were, but she thought several of them were supplements. She stated she didn't want to take her medications when the nurse brought them to her the morning of 01/21/25 and asked the nurse to leave the medications on her table and she would take them later. Resident #3 stated nurses frequently left medications on her table at her request. An interview with Nurse #2 on 01/21/25 at 11:24 AM revealed when she brought Resident #3 her medications and supplements around 8:30 AM the morning of 01/21/25, Resident #3 did not want to take the medication because she hadn't eaten yet. She stated Resident #3 asked her to leave the medications on her overbed table and told her she would take them later. Nurse #2 stated she should have removed Resident #3's medication from the room instead of leaving it on the overbed table when Resident #3 informed her she did not want to take the medication. She confirmed the medications and supplements in the cup were CoQ 10, Escitalopram, Ezetimibe, Fish Oil, Garlic Oil, Turmeric, Zinc, and Lisinopril. Nurse #2 stated Resident #3's blood pressure was 130/77 the morning of 01/21/25. In an interview with the Director of Nursing (DON) on 01/24/25 at 12:24 PM she confirmed there were no residents with physician orders to self-administer oral medication or supplements. She explained if a resident wanted to self-administer medication, the physician was notified of the request, and she completed an assessment to see if the resident was safe to administer their medication. The DON stated if the resident was assessed as being safe to administer their medication, the interdisciplinary team was notified, and a physician order was obtained. She stated the medications were kept in the nightstand in a locked drawer. The DON stated unless a resident had an order to self-administer medications, the nurse should observe the resident taking medication or remove medication from the room and discard it. An interview with the Administrator on 01/24/25 at 1:01 PM revealed he expected nursing staff to follow facility policy for self-administration of medication or stay with the resident during medication administration.

Based on record review and staff interviews, the facility failed to complete discharge assessments within the regulatory timeframes for 4 of 4 sampled residents reviewed for resident assessment (Residents #38, #8, #24, and #22). The findings included: 1. Resident #38 was admitted to the facility on [DATE]. Facility documentation indicated Resident #38 had been discharged on [DATE]. Review of Resident #38's Minimum Data Set (MDS) assessments revealed no discharge assessment had been completed. An interview on 10/13/22 at 10:00 am with the MDS Coordinator revealed the resident did not have a discharge MDS assessment. She stated that she had missed it. She was unable to remember who had been discharged , because once the resident was discharged from the facility computer system, they were no longer on her MDS calendar. The MDS Coordinator demonstrated how she created a discharge report and how she completed assessments from the list. She indicated she needed to develop a better tracking system. An interview with Director of Nursing (DON) on 10/13/23 at 10:12 AM revealed the discharge MDS assessment for Resident #38 should have been completed at discharge. 2. Resident #8 was admitted to the facility on [DATE]. Facility documentation indicated Resident #8 had been discharged on [DATE]. Review of Resident #8's Minimum Data Set (MDS) assessments revealed no discharge assessment had been completed. An interview on 10/13/22 at 10:00 am with the MDS Coordinator revealed the resident did not have a discharge MDS assessment. She stated that she had missed it. She was unable to remember who had been discharged , because once the resident was discharged from the facility computer system, they were no longer on her MDS calendar. The MDS Coordinator demonstrated how she created a discharge report and how she completed assessments from the list. She indicated she needed to develop a better tracking system. An interview with Director of Nursing (DON) on 10/13/23 at 10:12 AM revealed the discharge MDS assessment for Resident #8 should have been completed at discharge. 3. Resident #24 was admitted to the facility on [DATE]. Facility documentation indicated Resident #38 had been discharged on [DATE]. Review of Resident #24's Minimum Data Set (MDS) assessments revealed no discharge assessment had been completed. An interview on 10/13/22 at 10:00 am with the MDS Coordinator revealed the resident did not have a discharge MDS assessment. She stated that she had missed it. She was unable to remember who had been discharged , because once the resident was discharged from the facility computer system, they were no longer on her MDS calendar. The MDS Coordinator demonstrated how she created a discharge report and how she completed assessments from the list. She indicated she needed to develop a better tracking system. An interview with Director of Nursing (DON) on 10/13/23 at 10:12 AM revealed the discharge MDS assessment for Resident #24 should have been completed at discharge. 4. Resident #22 was admitted to the facility on [DATE]. Facility documentation indicated Resident #22 had been discharged on [DATE]. Review of Resident #22's Minimum Data Set (MDS) assessments revealed no discharge assessment had been completed. An interview on 10/13/22 at 10:00 am with the MDS Coordinator revealed the resident did not have a discharge MDS assessment. She stated that she had missed it. She was unable to remember who had been discharged , because once the resident was discharged from the facility computer system, they were no longer on her MDS calendar. The MDS Coordinator demonstrated how she created a discharge report and how she completed assessments from the list. She indicated she needed to develop a better tracking system. An interview with Director of Nursing (DON) on 10/13/23 at 10:12 AM revealed the discharge MDS assessment for Resident #22 should have been completed at discharge.

Based on observations and staff interviews, the facility failed to label and date food items in 1 of 1 walk-in cooler and 1of 1 walk-in freezer. This practice had the potential to affect the food served to residents. The findings included: An initial tour of the kitchen was made on 8/1/2022 at 11:13 AM with the Dietary Manager (DM). The following problems were observed in the walk-in cooler: 1 opened and used pack of honey smoked turkey breast with no label and no date 1/2 pack of opened and used corn beef with no label and no date 1/2 container of opened and used thousand island dressing with no date 1/4 carton of opened and used milk with no date An observation of the walk-in freezer was made on 8/1/2022 at 11:18 AM with the DM. The observation revealed the following problems: 1/4 bag of opened and used carrots with no label and no date 1/2 bag of opened and used corn with no label and no date 1/2 bag of opened and used tater tots with no label and no date 1/2 bag of opened and used waffle fries with no label and no date 1/4 bag of opened and used string beans with no label and date 1/2 bag of opened and used breaded oysters with no label and no date 1/4 opened and used sugar free lemon meringue pie in covered dish with no label and no date A follow up tour of the kitchen was made on 8/2/2022 at 3:00 PM with the DM. The following problems were observed: 1 scoop observed in the flour bin. The handle was observed to be resting in the flour 1 scoop observed in the sugar bin. The handle was observed to be resting in the sugar An interview was completed with the DM on 8/2/2022 at 3:20 PM. She revealed the staff should label and date items in the refrigerator and freezer when they opened them. The DM stated unlabeled and undated items in the freezer were good for 7 days once opened. She revealed items unlabeled and undated in the cooler were good for 3 days once opened. The DM stated the cooler and freezer were last checked for labeling and dating on 7/29/2022 and on 8/1/2022 after the survey team entered the building. She explained the scoops should not have been left inside the flour or sugar bins and that it was not normal practice. She revealed the bins were last checked the morning of 8/2/2022. An interview was completed with the Administrator on 8/3/2022 at 11:19 AM. He revealed that opened items should have a date to be discarded and that he expected items to have a label and date. He continued to explain that scoops should not be left in bins. The scoops should be in a separate compartment.

Based on observations and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions previously put in place following the recertification survey of 8/04/22. This was for one deficiency cited during the 8/04/22 survey and subsequently recited on the 9/21/22 survey. The repeated deficiency was in the area of Food Safety Requirements. The facility's continued failure during two federal surveys shows a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag is cross referenced to: F812- Based on observations and staff interviews, the facility failed to label, date and seal open food items stored for use in 1 of 1 walk-in freezer and 1 of 1 reach-in cooler. This practice had the potential to affect the food served to residents. On the recertification survey completed 08/04/22 the facility failed to label and date food items in 1 of 1 walk-in cooler and 1of 1 walk-in freezer. This practice had the potential to affect the food served to residents. An interview was conducted on 9/20/22 at 3:50pm with the Administrator who also headed the QAA committee. He stated dietary deficiencies were addressed by the Dietary Manager (DM) and based on reports from the weekly QAA meetings this was being completed. The DM oversaw the monitoring and brought findings to the QAA for discussion and revision. He revealed that items should be labeled & dated once opened.

Based on observations and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions previously put in place following the recertification survey of 8/04/22. This was for one deficiency cited during the 8/04/22 survey and subsequently recited on the 9/21/22 survey. The repeated deficiency was in the area of Food Safety Requirements. The facility's continued failure during two federal surveys shows a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag is cross referenced to: F812- Based on observations and staff interviews, the facility failed to label, date and seal open food items stored for use in 1 of 1 walk-in freezer and 1 of 1 reach-in cooler. This practice had the potential to affect the food served to residents. On the recertification survey completed 08/04/22 the facility failed to label and date food items in 1 of 1 walk-in cooler and 1of 1 walk-in freezer. This practice had the potential to affect the food served to residents. An interview was conducted on 9/20/22 at 3:50pm with the Administrator who also headed the QAA committee. He stated dietary deficiencies were addressed by the Dietary Manager (DM) and based on reports from the weekly QAA meetings this was being completed. The DM oversaw the monitoring and brought findings to the QAA for discussion and revision. He revealed that items should be labeled & dated once opened.

Based on observations, record review, staff interviews, registered dietician (RD) and medical director interview, the facility failed to reweigh a resident to determine if a change in weight status was accurate and notify the RD of a significant weight loss for 1 of 1 resident reviewed for nutrition (Resident #15). The findings included: Resident #15 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #15 had severe cognitive impairment with no behaviors. She required supervision, cueing, and set up for meals. She had a mechanically altered diet, no swallowing or dental issues, was 5 foot 3 inches and weighed 100 pounds. In the past 6 months Resident #15 had no weight loss or it is unknown if weight loss occurred. An annual nutrition evaluation dated 3/5/22 revealed Resident #15 was on an easy to chew diet and was receiving supplements of Med Pass (nutritional supplement) 3 times a day mixed in juice. Resident #15 was to be offered snacks between meals. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Juice 4ounces (oz) with 2oz of Med Pass 3 times a day by mouth supplement with start date of 2/2/22 Diet: Easy to chew consistency with start date of 5/1/20 Weekly weights on Tuesdays due to low body weight with start date of 5/19/20 Resident #15's Care Plan updated on 5/20/22 revealed she was at risk for potential weight loss and other nutritional complications. The goals included the resident will consume at least 50% of meals and will remain free from significant weight loss greater than 7.5% in 3 months. The interventions included obtain and monitor weight as ordered, as needed, and follow up as indicated. Registered Dietician (RD) to evaluate and make recommendations as needed. The residents Care Plan did not address the actual weight loss. Resident #15's electronic medical record (EHR) revealed the following recorded weights: 7/1/22 Resident #15 weight was recorded as 110.4 pounds (lbs) 7/5/22 Resident #15 weight was recorded as 109.2 lbs 7/12/22 Resident #15 weight was recorded as 109 lbs 7/19/22 Resident #15 weight was recorded as 100.2 lbs 7/26/22 Resident #15 weight was recorded as 100 lbs 8/2/22 Resident #15 weight was recorded as 106.4 lbs. An interview was conducted on 8/4/22 at 8:56 AM with Nurse #1. Nurse #1 revealed she entered Resident #15's weight into the EHR on 7/19/22. She noticed the weight loss and reported it to the MDS Nurse. A nurse note dated 7/22/22 authored by the MDS Nurse revealed on 7/12/22 the resident weighed 109 lbs and on 7/19/22 she weighed 100.2 lbs. The note further revealed the weight could have been an error and weights would continue to be monitored. During an interview on 8/3/22 at 3:43 PM the MDS Nurse revealed she was aware of the changes in Resident #15's weight but was not concerned because she thought the weight was an error. She further revealed she did not request or obtain a reweigh for the resident. An observation on 8/2/22 at 8:25 AM revealed Resident #15 was in a small dining area eating breakfast. She had eggs, sausage, and biscuits and gravy. Resident #15 ate approximately 50% of her meal. During an observation on 8/3/22 at 8:18 AM Resident #15 was in a small dining area eating breakfast. Her sausage was cut into bite size pieces. She consumed approximately 50% of her meal. During an interview and observation with Nurse Aide #2 on 8/3/22 at 8:28 AM she revealed Resident #15 sometimes eats well and she sometimes doesn't. The resident doesn't request snacks between meals but if she wanted a snack, she would get her one from the nourishment room. An observation of Resident #15's tray with Nurse Aide #2 revealed Resident #15 ate 50% of her breakfast. A second interview was conducted with Nurse Aide #2 on 8/3/22 at 2:35 PM that revealed nurse aides were responsible for obtaining the resident's weights. The weight was then documented on a sheet called the vital sign report form. The form was given to the nurse to review and enter into the EHR. During an interview on 8/3/22 at 2:55 PM Nurse #1 revealed nurse aides obtained resident weights and reported them to the nurse on a vital sign sheet. Nurses were responsible for reviewing the weights and entering them into the medical record. She further stated that if she had a weight that was a large loss or gain she would reweigh the resident. If the weight was the same, she reported it. An on-site weight was obtained on 8/03/22 at 3:53 PM for Resident #15 by nursing staff. Resident #15 was observed being weighed on the sit-down scale by Nurse #1 and Nurse Aide #2. Resident #15 was placed in the sling of the mechanical lift and the sling was then attached to the lift. The scale was zeroed prior to weighing the resident. Resident #15 was lifted and placed on the seat of the sit scale via mechanical lift. Staff detached the sling from the mechanical lift, allowing the resident's weight to rest on the seat. The weight was obtained and equaled 100.2 lbs. An interview on 8/4/22 at 1:24 PM the Registered Dietician (RD) revealed she had not seen Resident #15 since 3/5/22 and was not aware of the recent weight loss. She further revealed if she were aware she would have added or increased her supplements to increase the resident's calorie and protein intake. The RD explained she was notified of weight loss through the nurses. The nurses would print out a list of weight losses for the week and put them in a box for her to retrieve. If the nurses had and urgent need, they could send her an email. If a resident was identified as at risk for weight loss, she saw them weekly. The RD stated the MDS Nurse was in communication with her and kept her up to date on the residents experiencing weight loss. The RD revealed she had only been working for the facility for a few months. She was part time and was only in the facility 2 days per week. She had not participated in any at risk meetings. An interview on 8/4/22 at 12:57 PM the Medical Director revealed that Resident #15's weight loss was unplanned but not unexpected because she has had ongoing issues with weight loss. The significant weight loss had no adverse outcome to Resident #15. On 8/3/22 at 4:54 PM an interview was conducted with the Director of Nursing. She revealed she reviewed resident weights weekly and was aware of the weight loss. She thought the weight was an error but could not be certain. She further revealed because the weight was thought to be inaccurate or an error, the resident should have been reweighed. If the reweight reflected a significant change, the dietician would have been involved and the MDS and care plans updated.

Based on record review and staff interview the facility failed to maintain an accurate medical record for restorative nursing services for 1 of 1 sampled resident (Resident #27) reviewed for restorative nursing. The findings included: Resident #27 was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of admission minimum data set (MDS) assessment dated [DATE] revealed Resident #27 was moderately cognitively impaired and required limited assistance with one person physical assistance for eating. Resident #27 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #27's medical record from 4/27/22 through 8/4/22 revealed no documentation for restorative nursing care. Interview with RCA #1 on 8/3/22 at 10:50am revealed she had been trained by occupational therapy (OT) on Resident #27's restorative program. RCA #1 further revealed she had documented restorative notes on a notepad. Her documentation would have included the goals she would have worked on with Resident #27. She indicated she was unaware of the need to document progress or refusals of care in the electronic medical record and had no knowledge of where she had placed her notes. RCA #1 revealed she had worked with Resident #27 for five days. Interview with Staff Development Coordinator #1 on 8/3/22 at 3:00pm revealed she was over the restorative nursing program. The assigned restorative aid should document progression of goals, refusals of care and days in which restorative was provided should have been documented in the medical record for Resident #27. During the interview the Staff Development Coordinator #1 was observed to review Resident #27's electronic medical record but was unable to locate documentation that Resident #27 had received restorative care. Staff Development Coordinator #1 revealed RCA #1 might have documented the restorative care on paper, but the documentation should be included in the resident electronic medical record. Interview with Director of Nursing (DON) on 8/4/22 2:50pm indicated that restorative nursing care performed be documented in residents' medical records.

Based on observations, record review, and staff interviews, the facility failed to adhere to a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] # 11). Findings included: Resident #11 was admitted to the facility 6/21/2019 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the ST notes dated 10/4/2019 revealed concern with Resident #11's use of straws as a potential choking hazard. The note stated education was provided to the first shift Nurse Aides (NAs) with good return demonstration. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the ST care plan notes dated 6/11/2020 through 7/1/2020 revealed Resident #11 required careful tray set up and verbal cueing at mealtime, staff were educated on the diet order and limiting items on her tray, and precautions included no straws. The quarterly Minimum Data Set, dated dated dated [DATE] revealed Resident #11 had severe cognitive impairment, no chewing or swallowing issues, and required limited assistance with eating. Review of an updated daily care guide (used by nurse aides) revealed Resident #11 required assistance with eating and interventions included a puree diet, no straws, verbal and physical prompting during meals. The daily care guide stated meal prompting and no straw interventions were the role of the NA. Review of the care plan dated 6/10/2020 revealed Resident #11 had potential for weight loss and nutritional complications. Goals included consuming at least 50% of 2 meals and remaining free from significant weight loss. Interventions included providing and serving the diet as ordered, assisting with tray set up as needed, ensuring all food and beverages complied with dietary restrictions, and no straws. A quarterly review of the care plan on 1/31/21 stated nutritional interventions to address Resident #11's potential for weight loss and nutritional complications included a puree diet, staff assistance with meals, and no straws. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 10/4/2021 at 12:30 PM revealed signage posted a few feet from Resident #11's tray table that stated, no straws and remove items from tray. A meal observation on 10/6/2021 at 8:40 AM in Resident #11's room revealed a straw in her beverage cup. Resident #11 did not consume any fluids during the observation. A meal observation on 10/6/2021 at 1:36 PM in Resident #11's room revealed a straw in her beverage cup. Resident #11 did not consume any fluids during the observation. During an interview on 10/6/2021 at 2:09 PM NA #1 stated she did not set up Resident #11's lunch tray today and did not know who set it up with a straw. Interview with Nurse #1 on 10/6/2021 at 3:19 PM revealed the NAs were responsible for Resident # 11's tray set up. Nurse #1 stated Resident # 11 had potential to choke if she drank from a straw, and choking could result in pneumonia. Nurse #1 stated if she saw a straw in Resident #11's beverage container she would remove it and educate the NA. Interview with the ST on 10/6/2021 at 2:29 PM revealed she ordered no straws for Resident #11 due to coughing and potential for aspiration, and her orders were co-signed by the physician. The ST stated aspiration could result in pneumonia and she posted no straws signage multiple locations in Resident #11's room to alert staff. The interview further revealed the kitchen did not send straws on resident's trays, and the NA or Nurse would have to obtain a straw. Follow up interview with the ST on 10/6/2021 at 5:01 PM revealed Resident #11 should not have a beverage container with a straw in it, related to her impaired swallowing ability. Interview with the Director of Nursing (DON) on 10/6/2021 at 5:11 PM revealed residents' dietary modifications were based on ST recommendations. The DON stated staff providing resident trays were expected to adhere to the correct dietary orders and if the ST thought Resident #11 was at risk for aspiration, she should not have been provided a straw. The DON stated Resident #11's no straws order was in place from 8/2019 and additional signage was posted in her room as staff reminders. The DON further stated these orders were also communicated via the resident's electronic health record and in the daily care guide. The DON stated resident care guides served as a reference for and were signed by the NAs. The interview further revealed straws were kept in the pantry and not sent on the dietary cart. Interview with the Administrator on 10/7/2021 at 12:47 PM revealed if an order stated, no straws it needed to be adhered to. The Administrator stated Resident #11's no straws order was in multiple places for staff reference, including the resident's electronic health record, the NA care guide, and on signs posted in the resident's room. The Administrator stated his expectation was that staff follow these orders, care guides and room signs.

Based on observations, staff interviews, and review of the facility policy entitled Novel Coronavirus Prevention and Response, and Hand Hygiene policy the facility failed to implement these policies when a Housekeeper did not wear a gown as part of the personal protective equipment (PPE) and failed to perform hand hygiene between glove use when cleaning 3 of 3 resident rooms (rooms 117, 127 and 128) that were located on 1 of the facility's quarantine units. The facility also failed to implement their Infection Control Assessment and Response Plan and Hand Hygiene policy when a Dietary Aide failed to wear a face mask that covered her nose and mouth and failed to perform hand hygiene after touching the mask for 1 of 6 dietary staff (Dietary Aide #1) observed working in the kitchen. These failures occurred during a COVID-19 pandemic. Findings included: A review of the facility policy titled, Hand Hygiene Policy and Procedure, revealed the purpose of effective hand hygiene was to reduce the risk of transmission of infection and incidence of healthcare associated infections. Indications for handwashing included for routinely decontaminating hands in the following clinical situations: after contact with inanimate objects in the immediate vicinity of the patient and after removing gloves. A review of the facility policy titled, Novel Coronavirus Prevention and Response, revised on March 2020 under the section titled, Policy Explanation and Compliance Guidelines, discussed interventions to prevent the spread of respiratory germs within the facility. Those interventions included support hand hygiene by employees, to educate staff on proper use of PPE and make PPE, including face mask, eye protection, gowns and gloves available outside the resident's room. Also included in the policy under the section titled, Environmental Infection Control, housekeeping staff were to adhere to transmission-based precautions. 1. A continuous observation from 10:18 AM through 10:58 AM of the designated quarantine unit identified as B hall was made on 09/01/2020. The entrance doors to rooms [ROOM NUMBER] revealed enhanced droplet-contact precautions signs were posted and highly visible. The signs were placed to inform anyone entering the room to follow the instructions that read in part: to perform hand hygiene and wear a protective gown and gloves when entering the room. Those rooms were also supplied with a dispenser of alcohol-based hand rub (ABHR) attached to wall by the entry door and a sink with soap and water available for use. Reusable protective gowns were hung on the entry doors of room [ROOM NUMBER], 127, and 128 and extras were placed in bins between different rooms throughout B hall. At 10:18 AM Housekeeper (HK) #1 was seen in room [ROOM NUMBER] that was occupied by a resident and was not wearing a protective gown. While in the room HK #1 mopped the floor. She then removed and discarded the dirty mop head and the gloves she was wearing in a housekeeping cart located outside the room door. HK #1 then began to vacuum the hallway between rooms [ROOM NUMBERS]. When done vacuuming she put on a new pair of gloves without performing hand hygiene. HK #1 then entered room [ROOM NUMBER] that was occupied by a resident and without a wearing a protective gown began to wipe down the resident's tray table, the dresser, a chair and the window ledge. She removed the gloves she was wearing and discarded them in the housekeeping cart. Without performing hand hygiene, she put on a new pair and returned to the room and began to clean the toilet and wipe down the top of the toilet lid, the water tank and the top and bottom of the toilet seat. HK #1 exited room [ROOM NUMBER] and put away her cleaning supplies and removed the gloves she was wearing. She began to vacuum the hallway between rooms [ROOM NUMBERS] and when finished wrapped the electric cord on a hook on the back of the vacuum cleaner. HK #1 did not have gloves on during the time she used the vacuum cleaner. She pushed her cart to room [ROOM NUMBER] and put on a new pair of gloves without performing hand hygiene and for the first time put on the protective gown hanging on the hook on the door and entered room [ROOM NUMBER] that was occupied by a resident. She began the same cleaning routine. At 10:58 AM HK #1 removed the protective gown and the gloves she was wearing and performed hand hygiene using the ABHR located in room [ROOM NUMBER]. During an interview on 09/01/2020 at 11:02 AM HK #1 explained she received hand hygiene and PPE training since the coronavirus pandemic and should have performed hand hygiene after gloves were removed. HK #1 explained she puts on a new pair of gloves before she enters a resident's room and after she cleaned the bathrooms. When asked about enhanced droplet-contact precautions signs on the doors with instructions to perform hand hygiene and wear a gown and gloves when entering, HK #1 did see the signs on the door and realized she forgot to put on the gown and perform hand hygiene. HK #1 indicated she was unsure about performing hand hygiene before putting on a new pair of gloves. An interview was conducted on 09/02/2020 at 11:38 AM with the Director of Housekeeping (DOH) who explained the staff received a significant amount of infection prevention training from him and the Infection Prevention and Control Nurse since the coronavirus pandemic. The training included donning and doffing of PPE and hand hygiene instructions. He did random observations on the quarantine units to ensure Housekeeping staff practiced infection prevention procedures when entering a room with enhanced droplet-contact precautions. The DOH expected HK #1 to perform hand hygiene before and after the use of PPE which included gloves. The DOH revealed hand hygiene and gowns were used to prevent the spread of infections and PPE instructions guided staff perform hand hygiene and to wear gowns and gloves when entering a resident's room with enhanced droplet-contact precautions. During an interview on 09/01/2020 at 5:15 PM the Director of Nursing (DON) and Infection Prevention and Control Nurse explained the Housekeeping staff were trained the correct steps and use of PPE and to perform hand hygiene when putting on and after removing gloves and indicated there had been a break in infection control. 2. A review of the Infection Control Assessment and Response Plan dated 08/28/2020 revealed the facility had implemented universal mask would be worn by all staff. An observation of kitchen was made on 09/01/2020 at 4:38 PM which revealed Dietary Aide (DA) #1 was wearing a face mask below her nose and not completely covering her mouth. DA #1 was standing at the end of a long metal table with her back to the table. There were no food items at the end of the table where she stood. DA #1 placed her mask over her nose and mouth but did not perform hand hygiene. An interview conducted on 09/01/2020 at 4:43 PM with the Dietary Manager (DM) revealed the expectation of the kitchen employees was to wear a face mask when in the kitchen and if a staff member needed to remove their mask he would expect them to step outside and away from others. Kitchen staff have received multiple trainings related to the proper use of PPE including face mask and hand hygiene techniques. The DM stated he monitored kitchen staff for proper wearing of face mask and directed them to cover their nose and mouth and perform hand hygiene after they touched their mask. A second observation on 09/01/2020 at 4:48 PM revealed while in the kitchen with other staff present DA #1 was wearing her mask below her nose. DA #1 quickly placed her mask to cover her nose but did not perform hand hygiene. During an interview on 09/01/2020 at 5:02 PM Dietary Aide (DA) #1 explained she had received PPE and hand hygiene training since the coronavirus pandemic. She was told to keep her face mask over her nose and mouth and frequently wash her hands. Her reason for removing the mask was because she gets hot. After she had replaced her mask she just forgot to perform hand hygiene. DA #1 was aware she should wear her mask and keep her nose and mouth covered and if she touched it to perform hand hygiene. During an interview on 09/01/2020 at 5:15 PM the DON and Infection Prevention and Control Nurse explained all employees who worked at the healthcare facility which included dietary aides were trained the correct use of PPE and to perform hand hygiene. The DON did not know why DA #1 did not correctly wear her face mask or perform hand hygiene after she touched it and acknowledged there had been a break in infection control.

Based on observations, and staff interview, the facility failed to ensure 3 of 3 dietary aides to wear facial hair covers to provide sanitary conditions during food preparation and failed to discard 3 of 3 expired boxes of juice. Findings included: 1a. During the initial tour of the facility kitchen on [DATE] at 11:00 AM, two male dietary aides were observed preparing food. An observation of Dietary Aide (DA) #1 revealed he was not wearing a facial hair cover while he was cutting fruit on a food preparation table. An observation, at 11:05 AM, of DA #2 revealed he was not wearing a hair net and a facial hair cover while he was cutting additional fruit on the same food preparation table as DA #1. 1b. An observation of a male DA #3 on [DATE] at 2:30 PM revealed he was not wearing a facial hair cover while cutting raw beef on the food preparation table. 2. An observation conducted during the initial tour of the facility kitchen on [DATE] at 11:10 AM revealed 3 of 3 expired 32-ounce pineapple juice boxes were found inside the walk-in cooler. One box of pineapple juice had an expiration date of [DATE] and 2 boxes of pineapple juice had an expiration date of [DATE]. An interview was conducted on [DATE] at 11:45 AM with the Dietary Manager. He stated it was his expectation that dietary aides wore hair covers and facial hair covers when preparing food. He indicated that all dietary staff were responsible for checking food items for an expiration date. In the instance food items were found to be expired, the food item would be discarded immediately. An interview was conducted on [DATE] at 11:50 AM with the Administrator. He stated that his expectation was for expired beverages to be discarded immediately. He further indicated that it was his expectation that male dietary staff wear facial hair covers when preparing food.

Based on observation, record review, and staff interview the facility failed to store medication according to manufacturer's recommendations for 2 of 4 medications observed in the station 2 medication refrigerator, and failed to keep an unattended medication cart locked for 1 of 4 medication carts observed for medication storage (Cart 1B). Findings included: 1.) Review of the facility's Compro 25mg suppository manufacturer's recommendations revised on 11/2016 revealed the medication was to be stored at 68°F to 77°F. During observation of the station 2 medication storage refrigerator on 9/27/17 at 1:15 PM the refrigerator contained 6 doses of Compro 25mg suppositories. The refrigerator temperature was 36°F. During an interview on 9/27/17 at 5:08 PM the Quality Assurance Nurse stated that she was involved in the storage of medications at the facility. She further stated in her experience they had kept the Compro 25mg suppositories in the refrigerator to make sure it stayed cold and kept its shape. She further stated that they will need to work with the pharmacy because the facility does not always get the manufacturer's recommendations from the pharmacy. She added that it was her expectation that manufacturer's instructions would be followed. She further stated that she and the facility were not aware of the manufacturer's recommendations for the storage of Compro. During an interview on 9/27/17 at 5:14 PM the Director of Nursing stated she was not familiar with the storage of Compro. She further stated that it was her expectation that medications be stored according to the manufacturer's recommendations. 2.) Review of the facility's Bisacodyl 10mg suppository manufacturer's recommendations dated 3/2012 revealed the medication was to be stored at room temperature. During observation of the station 2 medication storage refrigerator on 9/27/17 at 1:15 PM the refrigerator contained 28 doses of Bisacodyl 10mg suppositories. The refrigerator temperature was 36°F. During an interview on 9/27/17 at 5:08 PM the Quality Assurance Nurse stated that she was involved in the storage of medications at the facility. She further stated in her experience they had kept the Bisacodyl 10 mg suppositories in the refrigerator to make sure it stayed cold and kept its shape. She further stated that they will need to work with the pharmacy because the facility does not always get the manufacturer's recommendations from the pharmacy. She added that it was her expectation that manufacturer's instructions would be followed. She further stated that she and the facility were not aware of the manufacturer's recommendations for Bisacodyl. During an interview on 9/27/17 at 5:14 PM the Director of Nursing stated that to her knowledge the facility had always kept the Bisacodyl 10mg suppositories in the refrigerator. She further stated that it was her expectation that medications be stored according to the manufacturer's recommendations. 3.) On 9/27/2017 at 7:55 AM medication cart 1B was observed parked outside of room [ROOM NUMBER]. The medication cart lock was observed in the unlocked position. No nursing staff were observed in the area. A few moments later nurse #2 returned to the medication cart and activated the lock. An interview with nurse #2 was conducted on 9/27/2017 at 7:57 AM. The nurse stated the medication cart had been left unlocked and she had activated the lock when she returned to the cart. The nurse stated the medication cart should not be left unlocked. An interview with the Director of Nursing (DON) was conducted on 9/27/2017 at 2:34 PM. The DON stated it was her expectation for medication carts to be locked when out of sight of the nurse.

Based on observations, record review and staff interviews, the facility failed to be free from of a medication error rate greater than 5% as evidenced by 2 medication errors out of 30 opportunities resulting in a medication error rate of 6.66% for 2 of 6 residents (Resident #32 and #114) observed during medication pass. Findings included: 1. On 9/27/2017 at 8:43 AM, nurse #1 was observed preparing medications for administration to Resident #32. The medication pulled for administration included chewable aspirin 81 milligrams (mg). The nurse was observed as she administered the chewable aspirin to Resident #32. A review of Resident #32's signed September 2017 physician orders [REDACTED]. An interview with nurse #1 was conducted on 9/27/17 at 12:52 PM. After reviewing the September 2017 physician orders, the September 2017 Medication Administration Record [REDACTED]. An interview with the Director of Nursing (DON) was conducted on 9/27/17 at 2:34 PM. The DON stated it was her expectation of the nurse who administered medication to check the medication package label against the medication order on the MAR for accuracy. 2. On 9/27/2017 at 8:59 AM, nurse #1 was observed preparing medications for administration to Resident #114. The medication pulled for administration included chewable aspirin 81 milligrams (mg). The nurse was observed as she administered the chewable aspirin to Resident #114. A review of Resident #114's signed September 2017 physician orders [REDACTED]. An interview with nurse #1 was conducted on 9/27/17 at 12:52 PM. After reviewing the September 2017 physician orders, the September 2017 Medication Administration Record [REDACTED]. An interview with the Director of Nursing (DON) was conducted on 9/27/17 at 2:34 PM. The DON stated it was her expectation of the nurse who administered medication to check the medication package label against the medication order on the MAR for accuracy.

Based on observations and staff interviews the facility failed to clean one of three ice scoop holders. The findings are: Observations made on 06/05/14 at 10:45 AM in the facility kitchen indicated dietary staff using ice scoops retrieved from a blue plastic ice scoop holder on top of the ice machine to fill ice chests and glasses for resident use. Observations made on 06/05/14 at 10:50 AM revealed a blue plastic container that was positioned on top of the ice machine in the facility kitchen. A total of four plastic ice scoops were stored inside the container; one large scoop and three smaller scoops. The lower portion of the container had a clear liquid solution which contained a brown floating residue pooled in the bottom. The ice scoops were resting in the liquid and the floating debris. An interview was conducted with the Dietary Manager (DM) on 06/05/14 at 11:00 AM. Upon observation of the ice scoops in the liquid, the DM indicated the ice scoop containers should be cleaned every day. He acknowledged he could not identify the substance in the bottom of the ice scoop holder. He stated that cleaning the container was not on the daily cleaning schedule, but would be added. The DM revealed it was his expectation that the ice scoop container should be cleaned every day.

Based on observation, record review, and staff interviews the facility failed to implement a therapy recommendation for placing a hand roll into the left hand of 1 of 1 sampled residents. (Resident #1). The findings were: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had severe cognitive impairment and required extensive assistance with most activities of daily living (ADL). The MDS also revealed she had no range of motion limitation in both upper and lower extremities. A record review of a care plan revealed a new problem identified on 05/28/14 of contractures to upper and lower left extremities with therapy to evaluate and treat as indicated. A record review of a Rehabilitation Screen dated 05/27/14 revealed that an evaluation was needed because nursing had noted a decline in Resident #1's left hand status. Further review revealed comments by the Therapy Director that use of a left hand roll could improve functional grasp. On 06/04/14 at 3:00 PM Resident #1 was observed with no left hand roll in place. The same observations were made on 06/05/14 at 10:42 AM and 06/05/14 at 1:58 PM. On 06/05/14 at 8:15 AM an interview was conducted with the Therapy Director. He revealed that nursing prompted him to review Resident #1 for a decline in her left hand status. Further interview revealed he recommended that a hand roll be placed in Resident #1's left hand to prevent further decline of functional grasp, and that nursing would be responsible for obtaining the physician order [REDACTED]. On 06/06/14 at 9:30 AM an interview was conducted with Nurse #1 revealed that a soft roll is placed in Resident #1's left hand at times, but she was not sure if it is monitored as to when, and how often to place the roll in her left hand. On 06/06/14 at 3:50 PM the Director of Nursing (DON) was interviewed. She verified that the recommendation for Resident #1 to have a hand roll placed in her left hand was missed by nursing and the recommendation was not implemented. Further interview with the DON revealed that the recommendation should have been clarified with the Therapy Director and implemented.

Based on observations, record review and staff interviews, the facility failed to activate on a personal pad alarm which was care planned for 1 of 3 sampled residents reviewed for falls. (Resident #79). The findings included: Resident #79 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Resident #79 had a care plan developed since 07/17/12 which addressed him being at high risk for falls and having had multiple falls related to incontinence, poor cognitive status, unsteady gait and other factors. The goal was to remain free from a fall and /or a fall related injury for 3 months. Interventions included alarms as ordered for safety and check proper placement and function of alarms. Per nursing notes and post fall review with the Minimum Data Set (MDS) coordinator on 06/05/14 at 3:48 PM, Resident #79 continued to fall as follows: *01/08/14 at 5:20 PM from bed. A concave mattress was ordered. *02/12/14 at 6:20 PM stood up, the alarm rang and he fell from wheelchair. The intervention was to make sure he was toileted after meals. *02/20/14 at 8:00 AM, resident got up, alarm did not ring, and he fell against the wall while on the commode by himself. The alarm was replaced and he was placed on the early riser list. *03/01/14 at 9:00 PM found on floor out of bed, alarm was ringing. It was suspected the alarm startled him so alarm was discontinued and therapy screened him but did not initiate therapy services. *03/13/14 at 6:50 AM found on floor. Therapy screened again and began services since he seemed to be walking more. *03/14/14 at 11:00 PM found sitting on the floor. His medications were reviewed, no changes were made and son requested alarms be implemented again. (replaced after next fall). *03/15/14 2:55 PM found on floor in front of his recliner when staff entered to reimplement the bed and chair alarm. Alarm subsequently replaced after this fall. *03/24/14 at 7:45 PM, resident fell , wife had turned alarm off. Laboratory testing was done and wife was educated to not turn off alarms. *04/05/14 at 9:45 PM staff noticed alarm not functioning, left room to change batteries and resident got up from bed and fell before staff returned with new batteries. Staff was educated. *05/07/14 at 7:45 PM attempted to get up and fell , alarm sounded. *05/12/14 at 1:30 AM found on floor by bed, alarm was ringing. Recreational therapy started-a daytime program. The physician ordered trazodone (an antidepressant) 50 milligrams to be routinely given three times per day as of 05/28/14. The most recent Minimum Data Set (MDS), an annual dated 05/14/14 coded Resident #79 with long and short term memory problems and having severely impaired decision making skills. He was coded with disorganized thinking and inattention, requiring extensive assistance with bed mobility, transfers, and walking. He was unable to stabilize himself without human assistance. Resident #79 was also coded as having 2 or more falls with no injury and 2 or more falls with injury not of a major kind since the previous assessment. The Care Area Assessment related to falls dated 05/15/14 stated Resident #79 had multiple falls since last review and multiple interventions have been tried and were in place. The resident's wife had been educated not to assist Resident #79 out of sitting position by herself, to not turn off alarms, and to call staff for assistance with care. He continued to be a high risk for falls. The current care plan for falls last updated 05/15/14 included the addition of a dycem pad (nonskid surface) in his chairs, a special cushion (curved) and wheelchair (reclining), staff to toilet resident before and after meals, to attempt to get him up prior to breakfast, safety alarms as ordered per family request, and to ensure proper function and placement of alarms as ordered and as indicated. Nursing notes revealed the alarm alerted staff of Resident #79 rising unassisted: *05/14/14 at 5:21 AM, the alarm sounded 2 times this night; *05/17/14 at 10:22 PM alarm sounded and staff found resident attempting to get out of bed; *05/25/14 at 4:57 AM bed alarm sounded several times alerting staff resident was rising unassisted. Current physician orders [REDACTED]. On 06/05/14 at 7:55 AM, Resident #79 was observed in bed with top padded half rails, a concave mattress and the pressure alarm turned on and working. At 8:31 AM Nurse Aide (NA) #1 was observed providing care and transferred Resident #79 into his wheelchair. Resident #79 held onto the arms of the locked wheelchair and used his legs to walk /turn around and sit. At this time the alarm was not yet attached to the wheelchair. At 8:48 AM, NA #1 brought Resident #79 to the small dining area for breakfast. The alarm box was on the back of the wheelchair, however, it was turned off. At 8:53 AM he tried to push himself up from the wheelchair but NA #1 came into the room and moved him closer to the table but did not check the alarm. At 8:58 AM, the Director of Nursing spoke to the resident and did not check the alarm function. From 9:00 AM through 9:09 AM various staff entered and left the area, sometimes having Resident #79 out of staff sight for several minutes. At 9:07 speech therapy assisted the resident with breakfast. At 10:20 AM, he went to an activity and his alarm was noted to still be in the off position. The alarm remained off when he was in the dining room on 06/05/14 at 11:38 AM. Then on 06/05/14 at 1:45 PM, Resident #79 was observed in his room in his recliner. The alarm box had been moved to accommodate him being in the recliner but the alarm remained in the off position. On 06/05/14 at 2:42 PM, NA #1 and surveyor entered the room where the alarm was still in the off position. NA #1 stated he normally always turned the alarm on and off with each transfer and he must have pushed the off switch over accidentally thinking he was turning it on. Review the the Medication Administration Records and Treatment Administration Records for May and June of 2014 revealed no documentation that the alarms were checked as being on and functioning by nursing staff. Interview on 06/05/14 at 3:48 PM with the MDS coordinator revealed that her expectation is that the alarms were in place and functioning. She further stated the alarm alerted staff when he was getting up and third shift was responsible for checking the alarms. The Assistant Director of Nursing stated on 06/05/14 at 4:31 PM stated the alarms were a request by the family. She further stated on 06/06/14 at 2:30 PM that when Resident #79 was alert and awake he was able to walk the entire building. The Director of Nursing stated on 06/06/14 at 3:41 PM that she expected the alarms to be in place for Resident #79. She further stated the nurse aides were responsible for charting the placement and function of the alarms.

Based on observation, record review, and staff interview the facility failed to discard expired medications for 1 of 2 medication storage rooms. The findings were: A review of facility policy regarding expired medications revealed that outdated medications should be removed from stock. On 06/05/14 at 2:00PM 7 vials of single use Lorazepam with an expiration date of 03/01/14 was observed in the 100 hall lock box medication room refrigerator. In addition, 2 single use Miralax power packets with an expiration date 07/13 was observed in the medication room cupboard. On 06/05/14 at 2:05 PM an interview was conducted with Nurse #2. She verified that 7 vials of Lorazepam had an expiration date of 03/01/14. On 6/05/14 at 2:30 PM an interview was conducted with the Pharmacy Consultant. She verified that the 7 bottles of Lorazepam observed in the lock box in the 100 hall medication room refrigerator had an expiration date of 03/01/14, and the two single packets of Miralax had an expiration date of 07/13.

Based on resident interview and staff interviews, the facility failed to deliver residents' mail on Saturdays. The findings included: Resident #69, the resident council representative, stated during an interview on 06/05/14 at 9:31 AM that residents received mail Mondays through Fridays, but not on Saturdays. Resident #69 explained the mail was delivered in bulk, separated and then distributed by volunteers but not on the weekends. Interview with the Activity Director on 06/05/14 at 11:33 AM revealed the mail was delivered to the main building in the village and separated there. During the week the Activity Director or the Social Worker picked up the mail at the main building, sorted it to ensure that bills and items that needed to be sent to the responsible parties were forwarded appropriately, and then volunteers delivered the rest of the mail to the residents. She further stated there used to be a nurse aide who would deliver the mail on Saturdays, however, since the Activity Director or Social Worker were not there on Saturdays to sort the mail, some residents received bills that their responsible parties should have received. To avoid that mistake, Saturday delivery was stopped. Interview with the Social Worker on 06/05/14 at 11:41 AM revealed there was no mail delivery on Saturday. She stated upon admission, a discussion was held with residents and families to discuss what mail should be forwarded to families. The Administrator stated on 06/05/14 at 11:43 AM that he thought a discussion was held during resident council about having no mail delivery on Saturdays,. He further stated there had been no complaints about mail not being delivered on Saturdays as is the current practice. The Administrator provided a resident council meeting note dated 03/28/13 and one just completed dated 06/05/14 that stated the residents were in agreement to having mail delivered 5 days a week.

Based on observations, resident interview and staff interviews, the facility failed to post required information related to Medicare and Medicaid benefits. The findings included: Resident #69, the resident council representative, was interviewed on 06/05/14 at 9:31 AM. She stated she thought information related to Medicare and Medicaid was located in the survey book in the front lobby. An observation on 06/05/14 at 9:50 AM revealed no information regarding Medicare or Medicaid was located in the survey book that was in the front lobby. Continued observations revealed no Medicare or Medicaid information was posted on the walls of the lobby or the halls leading to the resident rooms. Interview with the Administrator on 06/05/14 at 11:47 AM revealed that no one was admitted to the facility under [AGE] years of age and therefore they would already have Medicare benefits. In addition, he stated the facility does not accept Medicaid. He confirmed the information was not posted in the facility. Interview with the Executive Director on 06/05/14 at 12:06 PM revealed that most residents received a senior citizens handbook from the community that provided information about Medicare and Medicaid. This handbook was not routinely given to newly admitted residents. He further stated that the facility usually only accepted residents from the village community who had Medicare and would not need Medicaid. For those discharged back to their homes outside of the village, information about finances and how to contact social security would be verbally provided upon discharge.

Based on observations and staff interviews, the facility failed to date and/or dispose of out of date refrigerated food items available for use in one (1) of three (3) coolers. The findings are: An observation of the kitchen walk-in cooler on 06/13/12 at 9:05 AM revealed the following items: two (2) containers of prepared egg salad, with a piece of masking tape on the container lid dated 06/04/12; a container of prepared ham salad with a piece of masking tape on the container lid dated 06/07/12; a container of baked chicken breasts sealed with plastic wrap not dated; a container of cooked pork, sealed with plastic wrap and dated 06/07/12; and a container of cooked ham sealed with plastic wrap labeled " for chef salads" dated 06/07/12. An interview on 06/13/12 at 9:10 AM with Cook #1, a first shift supervisor, revealed that all cooks and dietary aides were expected to date all food items prior to placing the food item in the cooler. Dietary staff members on each shift were responsible for checking that all opened food items in the cooler were dated and that food items were discarded after three (3) days. Cook #1 was unable to explain why the above mentioned items were still in the cooler. An interview on 06/13/12 at 11:30 AM with Dietary Aide (DA) #1 revealed that food items were to be labeled with the date opened/prepared and disposed of after three (3) days. An interview on 06/13/12 at 11:38 AM with the Dietary Manager (DM) revealed that dietary staff members were instructed to dispose of opened food items after three (3) days. Dietary staff members were expected to date all food items stored. Supervisors (1st and 2nd shift cooks) were expected to check the coolers at the end of each shift to make sure food items were dated and out dated items were discarded. The DM also stated that he checked for unlabeled and outdated food items daily. An interview on 06/13/12 at 11:55 AM with Cook #2, a second shift supervisor, revealed that food items were to be labeled with the date opened/prepared and disposed of after three (3) days. All dietary staff members were responsible for checking that prepared food items were dated and discarded after three (3) days.