Every finding on record at Crowne Health Care of Thomasville

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

Based on observations, interview and the facility's Nursing Staff Directly Responsible for Resident Care form, the facility failed to ensure the nurse staffing data was posted on the evening shift on 4/10/19. This was observed on one of three days of the survey. The facility further failed to consistently include the actual total hours worked by nursing staff each shift. This deficient practice was observed on three of three days of the survey and had the potential to affect 71 of 71 residents in the facility. Findings included: On 4/10/19 at 4:16 p.m., an observation was made of the nurse staffing data form. The evening shift nurse staffing data was not posted. Also, the nurse staffing data did not contained the actual number of hours worked for licensed staff on 4/9/19, all shifts and 4/10/19 day shift. On 4/11/19 at 10:18 a.m., an interview was conducted with EI (Employee) #2, Admissions and Medical Records Coordinator. EI #2 was asked who was responsible for posting the nurse staffing data. EI #2 said she was responsible for posting the nurse staffing data for the evening shift. EI #2 was asked why was the nurse staffing data not posted for the evening shift on 4/10/19. EI #2 said because she was not at work. EI #2 was asked when she is out, who was responsible for posting the nurse staffing data. EI #2 said as far as she knew no one. EI #2 was asked what information should be included in the daily nurse staffing data. EI #2 said the total number of RN's (Registered Nurses), LPN's (Licensed Practical Nurses) and CNA's (Certificate Nursing Assistant). EI #2 was asked should the number of hours worked be included in the nurse staffing data. EI #2 said she had not been told the actually hours worked had to be there. EI #2 was asked should the number of hours worked be left blank. EI #2 said she thought it should be filled out. EI #2 was asked why was the number of hours worked on the nurse staffing data sheet not filled out. EI #2 said, Because she had not been told that it was a requirement. EI #2 was asked how long she had been responsible for the posting of nurse staffing data. She replied, about one year.

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

Based on interview, record review, and review of a facility policy titled, Abuse, Neglect and Exploitation, the facility failed to ensure an allegation of abuse was reported within the two hour time frame. This was noted on one of two Facility Reported Incidents reviewed during the survey. Findings Include: A review of the facility's Policy & Procedure titled Abuse, Neglect and Exploitation with a Reviewed/Revised date of 12/28/16, revealed, Policy: Each resident has the right to be free from abuse, . Residents must not be subject to abuse by anyone, including, but not limited to; facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends or other individuals. Policy Explanation and Compliance Guidelines: . 4. Physical Abuse includes, but not limited to hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. The facility must: . 13. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: a. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the advents that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other official (including the State Survey Agency and adult protected services where state law provides for jurisdiction in long-term care facilities) in accordance with State law. A review of the Online Incident Reporting confirmation dated 2/24/18 revealed: Date/Time Submitted: Saturday, (MONTH) 24, (YEAR) 1:06:58 PM . Incident Type . Physical Abuse . Date and time of incident or alleged incident 2/24/2018 Time: 10:56 AM . On 3/15/18 at 4:34 p.m., an interview was conducted with EI (Employee Identifier) #2, the Director of Nursing/Abuse Coordinator. EI #2 was asked what was the definition of physical abuse. EI #2 answered, It includes but is not limited to hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. EI #2 was asked what must the facility do in response to an allegation of abuse. EI #2 answered, Ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment including injuries of unknown source and misappropriation of resident property are reported immediately but not later than two hours. EI #2 was asked when did the (MONTH) 24, (YEAR) allegation of abuse occur and she answered 10:56 a.m. EI #2 was asked when did facility staff report the allegation to the State Agency and she answered, 1:06:58 p.m. EI #2 was asked when did the Abuse policy indicate the allegation should have been reported. EI #2 answered, Within two hours. EI #2 was asked why the allegation was not reported within the designated two hour time frame. EI #2 answered, I didn't realize it had to be. I thought we had 24 hours because there was no serious bodily injury. EI #2 was asked who was responsible for ensuring allegations of abuse are reported in a timely manner and she answered, That would be me. EI #2 was asked what was the concern of not reporting allegations of abuse within two hours. EI #2 answered, Not following policy. This deficiency was cited as a result of the investigation of facility reported incident #AL 600.

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

Based on observations, record reviews, interviews, and review of Potter and Perry Fundamentals related to Skin Integrity and Wound Care the facility failed to ensure Employee Identifier (EI) #1, a Registered Nurse (RN), provided wound care in manner to promote healing of the wounds for Resident Identifier (RI) #6 and RI #7. During the survey, EI #1 was observed providing wound care treatments for RI #6 and RI #7. EI #1 failed to wash her hands and/or wear gloves during wound care for RI #6 and RI #7 and wiped RI #7's wound in a back and forth motion, increasing the potential for contaminating the wound. Further, the RN used a contaminated tongue depressor to transfer a wound care powder into a medication cup prior to providing wound care for RI #7. These deficient practices affected RI #6 and RI #7, two of two sampled residents observed for wound care. Findings Include: A review of Potter - Perry Fundamentals of Nursing Ninth Edition, Chapter 48, page 1227, Skin Integrity and Wound Care revealed: SKILL 48-3 Applying Dry and Moist Dressings . STEP . IMPLEMENTATION . 5. With gloved hand carefully remove gauze dressings one layer at a time, taking care not to dislodge drains or tubes. 8. Open sterile dressing tray or individually wrapped sterile supplies. Place on bedside table and apply clean gloves. 9. Clean wound with solution. Using gauze or antiseptic swab, clean from least contaminated area . Remove and dispose of gloves and perform hand hygiene. 10 . b. Apply clean gloves . e. Measure wound. Then remove and dispose of gloves. Perform hand hygiene. 11. Apply dressing: a. Dry dressing (1) Apply clean or sterile gloves. Rationale . Some agencies or condition of wound requires sterile gloves. Allows handling of sterile supplies without contamination 1. A review of RI #7's medical record revealed the resident was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #7 was also diagnosed with [REDACTED]. A review of RI #7's Significant Change MDS (Minimum Data Set), with an Assessment Reference Date (ARD) of 12/09/16, revealed RI #7 had long and short term memory problems, and was moderately impaired for decision making. RI #7 was coded as requiring extensive to total assistance for ADLs (Activities of Daily Living). RI #7 had a [MEDICAL CONDITION] for bowel care and had an indwelling catheter for urinary output. On 2/08/17 at 9:45 a.m., Employee Identifier (EI) #1, the Wound Care Registered Nurse for the facility, was observed performing wound care for RI #7. EI #1 was not observed to wash her hands or use alcohol gel prior to setting up the supplies for RI #7's wound care. The set up included a calcium alginate product, normal saline, a package of gauze, and a powdered wound care product. The supplies were set up with bare hands. EI #1 used a tongue depressor that was observed on top of a piece of paper on top of the wound care cart to put the wound care powder into a medication cup. EI #1 cut tape with scissors from the wound care cart. EI #1 did not sanitize the scissors. EI #1 opened a package of gauze and removed some of them with her bare hand. She then gathered the supplies and took them into RI #7's room with her bare hands, and put the items on top of a covered bed side table. EI #1 opened and dated wound care supplies. EI #1 then washed her hands and applied gloves. RI #7 was positioned to the left side. EI #1 did not wash her hands or change gloves. EI #1 removed the old dressing from RI #7's unstageable wound on the outer buttocks. EI #1 did not wash her hands or change her gloves. EI #1 sprayed the wound with a wound cleanser and cleaned the wound with a gauze dressing from inner to outer wound bed. EI #1 did not wash her hands or change her gloves. The wound had a foul odor and had a large amount of serosanguineous drainage. She measured the wound. EI #1 did not wash her hands or change her gloves. She applied a wound care ointment with a cotton tip applicator. EI #1 touched a piece of paper that had orders for the wound care, and continued to dress RI #7's wound. EI #1 did not wash her hands or change her gloves. She sprayed the unstageable wound on RI #7's genital area, and wiped the wound inner to outer wound bed. EI #1 measured the wound. EI #1 did not wash her hands or change her gloves. She cleaned and dressed the wound with the wound powder that was set up earlier in the observation with the tongue depressor. EI #1 then covered both wounds with a border dressing without washing her hands or changing her gloves. EI #1 then washed her hands, applied gloves, and removed a dressing from RI #7's unstageable wound on the right heel. EI #1 cleaned the wound, and then measured the wound. She did not change her gloves or wash her hands. The RN applied the wound powder to the wound bed and covered the wound with a border dressing. RI #7 was turned over onto the right side. EI #1 did not change her gloves or wash her hands. She sprayed and cleaned the wound on the left heel around and then in a back and forth motion. She did not clean the wound from the inner wound bed outward in a circular motion. EI #1 dried the wound in the same manner. She then measured the wound. She did not wash her hands or change her gloves. EI #1 applied the powdered wound care product and covered the wound. She did not wash her hands or change her gloves. 2. A review of RI #6's medical record revealed the resident was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #6 was also diagnosed with [REDACTED]. A review of RI #6's Significant Change MDS, with an Assessment Reference Date (ARD) of 01/03/17, revealed RI #6 had a BIMS (Brief Interview for Mental Status) score of 0 out of a possible 15 points. This score indicated RI #6 had severe cognitive impairment. RI #6 was coded as requiring extensive to total assistance for ADLs. RI #6 was incontinent of bowel function and had an indwelling catheter for urinary output. On 2/08/17 at 10:20 a.m., EI #1 was observed performing wound care for RI #6. EI #1 was not observed to wash her hands or use alcohol gel prior to setting up the supplies for RI #6's wound care. EI #1 cut a wound care product without sanitizing the scissors she obtained from the wound cart. She put gauze pads in medication cups with her bare hands after going in and out of the wound cart. EI #1 put the wound care supplies on a covered bedside table, and opened wound care packages with her un-sanitized bare hands. EI #1 washed her hands and applied gloves. She removed the old dressing from RI #6's wound on the right foot that was draining a large amount of tan drainage. EI #1 did not wash her hands or change her gloves. EI #1 cleaned the wound with the contaminated gauze soaked in saline, without washing her hands or changing her gloves. EI #1 measured the wound, without washing her hands or changing her gloves. EI #1 dressed RI #6's wound. EI #1 cut a gauze wrap with scissors from EI #2, the LPN (Licensed Practical Nurse)'s pocket, who was assisting with the positioning of the residents during the wound care observations. EI #1 taped the dressing in place, washed her hands and applied gloves. She measured the two wounds on RI #6's left mid outer foot. She removed her gloves, and without washing her hands, obtained gauze from the wound care cart with her bare hands. EI #1 sprayed the wounds with wound cleanser. She washed her hands and applied gloves and wiped and rubbed both wound areas in a circular motion, and back and forth. She then applied a skin protecting product, in a circular motion. RI #6 was positioned on the left side, and the used items were disposed of. On 02/09/17 at 10:20 a.m., an interview was conducted with EI #2, the facility's Treatment Nurse. The surveyor asked EI #2 when she should wash her hands during wound care, especially when more than one wound was involved, and the wounds were draining. EI #2 stated, I would wash before I clean my wound. We are supposed to wash between each wound, clean the next wound, wash and change to clean gloves. We clean the wound and use the same process. EI #2 was asked when she changed gloves during wound care. EI #2 stated, When I wash my hands, I put on a clean pair gloves. The surveyor asked EI #2 when she should sanitize scissors used during wound care. EI #2 stated, They should be cleaned before you go in, and after wound care, with sani-wipes. The surveyor asked EI #2 how she was instructed to clean the wounds during wound care. EI #2 stated, We should wipe inside to outside. EI #2 was asked what she observed during the wound care for RI #6 and RI #7. EI #2 stated, Her (EI #1) cleaning process was not as I do. She cleaned several wounds before she washed her hands and changed gloves, I did notice that. EI #2 was asked what the concern was when gloves were not changed and hands were not washed between wounds, after the soiled dressings were removed. EI #2 stated, Contamination. On 2/9/17 at 10:45 a.m., an interview was conducted with EI #1, Wound Care Nurse/RN. EI #1 was asked when you should wash your hands during wound care, especially when more than one wound was involved and the wounds were draining. EI #1 stated you wash them before the wound care, after you clean the wound, then dressing the wound. EI #1 stated you would wash your hands after the wound was dressed and you go to the next wound. EI #1 was asked when she had washed her hands during the wound care for RI #6. EI #1 stated she knew she washed her hands when she got in the room and she knew she washed before she did wound care to the foot. EI #1 stated she left the room and did not remember, she hoped she washed her hands in between. EI #1 was asked when she washed her hands during wound care for RI #7. EI #1 stated she knew she washed them when she went into the room. She stated she washed her hands in between doing the buttocks and the feet and before she came out of the room. EI #1 was asked when should she sanitize scissors during wound care for residents. EI #1 stated before you use them and after you use them with the Sani Klenz cloth. EI #1 was asked when she had sanitized her scissors during wound care for RI #7 & RI #6. EI #1 stated she had not. EI #1 stated she had cut tape. EI #1 stated EI #2 also had a pair of scissors. EI #1 was asked how did she put the wound powder in the medication cups prior to providing wound care for RI #7. EI #1 stated she used a tongue depressor to scoop it out with. EI #1 was asked where the tongue depressor was laying prior to using it to put the wound powder in the medication cups. EI #1 stated they were in a plastic bag in the treatment cart. The surveyor shared the observation of the tongue depressor that was observed on a piece of paper on top of the wound care cart. EI #1 stated she probably did take it out of the plastic bag and put it there, if the surveyor saw it there. The surveyor shared the observation of the wound care for RI #7 and RI #6 and asked EI #1 what was the concern regarding the wound care. EI #1 stated that it was contamination. EI #1 was asked how she was instructed to provide wound care for residents regarding cleaning the wound. EI #1 stated she was instructed to clean from inside to outside. EI #1 was asked how she obtained the 4 X 4(s) used to provide wound care for RI #6 and RI #7. EI #1 stated with her fingers, with ungloved hands. EI #1 was asked what was the concern when 4 X 4(s) were obtained from the treatment cart with bare hands prior to providing wound care and the was cleaned in a back and forth motion. EI #1 stated the concern with the 4 X 4(s) was you are introducing germs to it. It is no longer clean. On 02/09/17 at 1:45 p.m., an interview was conducted with EI #3, the facility's ADON (Assistant Director of Nursing) and Infection Control Coordinator. The surveyor asked EI #3 when should nurses wash their hands and change gloves during wound care. EI #3 stated,Nurses should wash their hands before wound care, and during wound care, after taking off old dressings, and any time during wound care if they are going from one site to another. They are to wash their hands and apply gloves. Of course at the end of the wound care, they are to wash their hands. EI #3 was asked when should scissors be sanitized during wound care. EI #3 stated, Prior to use, if they are not new scissors and prior to going from one site to another. The surveyor asked EI #3 how should nurses obtain gauze out of the wound cart. EI #3 said their hands should be cleaned. The surveyor discussed the transfer of the wound care powder with the contaminated tongue depressor. EI #3 stated, If she was going to use a tongue depressor, she should have used a clean one.

Based on observations, interviews, and record reviews, the facility failed to ensure: 1. The Certified Nursing Assistant (CNA) washed hands and changed gloves after removing gloves while removing stool from Resident Identifier (RI) #17. 2. The Licensed Practical Nurse (LPN) did not open the crush bag with the ungloved finger of her bare hands during medication pass for RI #13. 3. The licensed nurse rinsed and dried the feeding syringe after administering medications, formula, and or flushing the Gastrostomy (G) tube for RI #6. Water was observed inside the feeding syringe and plastic bag on 02/08/17 and 02/08/17, two of three survey days. These deficiencies affected Resident Identifer (RI) #6, RI #13, and RI #17, three of seventeen sampled residents. Findings include: 1. A review of RI #17's medical record revealed the resident was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 02/09/17 at 8:50 a.m., an observation was made of incontinence care for RI #17. The incontinence care was performed by EI (Employee Identifier) #4. EI #4 provided incontinence care for RI #17, and during the removal of stool during the care, EI #4 changed gloves, but did not wash her hands. On 2/09/17 at 1:40 p.m., an interview was conducted with EI #4. The surveyor asked EI #4 when she should wash her hands during incontinence care, especially when stool was involved. EI #4 stated, Between every time I do a procedure, before I start and after care. The surveyor asked EI #4 when she washed her hands during the incontinence care observation for RI #17. EI #4 stated, I washed them before I went in and after I put everything up. The surveyor asked EI #4 what was the concern when hands were not washed after gloves were removed, while cleaning stool off of a resident. EI #4 stated, It can spread germs. I just forgot to do it. I should wash between every time I change my gloves. 2. A review of RI #13's medical record revealed the resident was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 2/08/17 at 10:55 a.m., EI #5, a LPN was observed administering medications via a Gastrostomy tube for RI #13. EI #5 was observed to open the crush bag by sticking her right index finger of her bare hand into the crush bags. She failed to wash her hands prior to setting up the medications for RI #13. 3. A review of RI #6's medical record revealed the resident was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During a medication pass observation on 2/8/17 at 3:45 p.m., the feeding syringe for RI #6 was observed with water in the syringe and plastic bag. On 2/9/17 at 8:00 a.m., the feeding syringe for RI #6 was observed with water in the syringe and plastic bag. On 2/9/17 at 2:25 p.m., the feeding syringe for RI #6 was observed with water in the syringe and plastic bag. EI #3 the facility's Infection Control Coordinator was present during the observation. On 2/09/17 at 2:00 p.m., an interview was conducted with EI #3. The surveyor asked EI #3 when staff should wash their hands during incontinence care, especially when stool was involved. EI #3 stated, If gloves are soiled while removing stool, they should remove their gloves and wash their hands, and apply new gloves to continue. The surveyor discussed the observation when EI #4 did not wash her hands after removing gloves while cleaning stool off of RI #17's bottom. EI #3 was asked what the concern was. EI #3 stated, The concern is contamination. EI #3 was asked how staff should clean the feeding syringe after administering formula, medications, and/or a flush via Gastrostomy tube. EI #3 stated, They are to get the syringe separate, pat dry, and place the syringe back in the bag. After the surveyor and EI #3 observed the wet feeding syringe and plastic bag for RI #6, EI #3 was asked what the concern was. EI #3 stated, The concern is for potential for growth of bacteria. EI #3 was asked how should staff open the crush bags during medication pass. EI #3 stated, They should squeeze the bag to open it. The surveyor asked EI #3 what was the concern when a nurse stuck the finger of their bare hand into the crush bag, EI #3 stated, Contamination.

Based on an observation, interviews, and record reviews, the facility failed to ensure: 1) A CNA (Certified Nursing Assistant) did not reuse a wipe soiled with stool to perform incontinence care on RI (Resident Identifier) #9, and 2) A CNA washed her hands after taking off gloves soiled with stool and before donning clean gloves, then continuing incontinence care. This affected RI #9, one of two residents observed for incontinence care. Findings include: A review of the facility's document with a revision date of 02/15/2014 and titled, "Thomasville Health Care and Rehabilitation Center Infection Control Hand Washing," revealed "You should wash your hands: ... After taking off gloves. After touching blood, body fluids, secretions, and contaminated items, whether or not gloves are worn. ... Or at any time when you know your hands are dirty, visible or invisible." A review of the facility's document with a revision date of 04/1/2014 and titled "Thomasville Health Care and Rehabilitation Center Pericare" revealed ... "11. Remove the gloves... and wash your hands. 12. Put on clean gloves." A review of the facility's document with a date of 02/23/2015 titled, "CARE PLAN Thomasville HealthCare & (and) Rehabilitation Center Name: (RI #9)... Problem: Inadequate control with multiple daily episodes of incontinence... 02/29/2014 Nurse Aide-- Perineal care after each soiling using perineal care facility protocol... 02/23/2015 MANIFESTED BY: Totally Incontinent of Bowel and bladder... Nurse Aide-- Check Q (every) 2 hrs.(hours), pericare after each incontinence..." A review of POTTER - PERRY FUNDAMENTALS OF NURSING, PAGE 1031, Skill 38-2 Perineal Care, revealed, "... 11. Change gloves when they are soiled. Perform hand hygiene." A review of POTTER - PERRY FUNDAMENTALS OF NURSING, PAGE 789 revealed, "...Hand hygiene includes... hand washing with soap and water when hands are visibly soiled, ... Contaminated hands are a prime cause of cross infection." A review of the medical record revealed RI #9 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. (history) [MEDICAL CONDITION], Malignant Neoplasm Bladder, Pressure Ulcer and Incontinence of Bowel and Bladder. A review of the Significant Change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 02/13/2015 revealed RI #9 was severely impaired for cognitive daily decision making skills. This MDS also indicated RI #9 required extensive and total assistance with ADLs (Activities of Daily Living) and was incontinent of Bowel and Bladder. On 02/24/2015 at 4:48 PM, an observation was made of EI (Employee Identifier) #3 and EI #4, both CNAs entering RI #9's room. EI #3 washed her hands, donned her gloves and pulled the curtains. EI #4 washed her hands, donned her gloves and lowered the resident's head of bed. EI #3 wiped downward on the right side of the groin where stool was noted on her gloves. EI #3 took off her gloves, but did not wash her hands before donning new gloves. A new wipe was used to wipe the upper pubis area from right to left. EI #3 took a new wipe and wiped downward on the right side of the groin. A new wipe was obtained and the left side of the groin was wiped in a downward motion. The resident was turned to her right side and a new wipe was used to wipe from right to left on the upper buttock area where stool was noted. She did not wash her hands or change gloves. EI #3 then wadded up several wipes and wiped the rectal area in an upward motion twice with the same wipe revealing stool on the wipe. She did not wash her hands or change gloves. EI #3 took a new wipe and wiped the rectal area again in an upward motion revealing stool on the wipe. EI #3 then used that same wipe to wipe upward again. EI #3 was observed again taking off her soiled gloves and replacing them, without washing her hands, before returning to position the resident. On 02/25/2015 at 1:50 PM, an interview was conducted with the EI #5, the Infection Control Nurse. EI #5 was asked what should be done with gloves when they became soiled with stool during incontinence care. She stated, "They should be removed, wash their hands, put on another pair to continue care to maintain cleanliness, (and) protect from infection." EI #5 was asked should hands be washed after gloves are soiled with stool and before continuing with incontinence care. She stated, "Yes." EI #5 was asked what should be done when wipes become soiled with stool during incontinence care. She stated, "Discard it and get another wipe to prevent infection." EI #5 was asked what potential harm could occur to a resident if soiled gloves were not changed and hands were not washed during incontinence care. She stated, "(The residents) run the risk for possible infection." On 02/25/2015 at 2:20 PM, an interview was conducted with EI #3. EI #3 was asked if she performed incontinence care on RI #9. She stated, "Yes ma'am I did." EI #3 was asked what should have been done when stool was seen on her gloves while performing incontinence care on RI #9. She stated, "Throw it away." EI #3 was asked if she continued to use a wipe to perform incontinence care after stool was seen on the gloves. She stated, "Not the entire time." EI #3 was asked what could potentially happen to wipes if they become soiled with stool and were used repeatedly to wipe a resident during incontinence care. EI #3 stated, "It could get contaminated." She was asked what could potentially happen to a resident if wipes that had become soiled with stool were repeatedly used to wipe a resident during incontinence care. EI #3 stated, "(RI #9) could get further infection and she could get worse." On 02/26/2015 at 7:43 AM, an interview was conducted with EI #6, the DON (Director of Nursing). EI #6 was asked what were staff taught to do when gloves become soiled with stool during incontinence care. EI #6 stated, "They should change their gloves and wash their hands." EI #6 was asked what were staff taught to do when wipes become soiled with stool, during incontinence care. EI #6 stated, "Throw it away." EI #6 was asked if a nurse or CNA performing incontinence care should reuse a wipe that has stool on it. EI #6 stated, "No." EI #6 was asked after throwing away gloves soiled with stool, should staff wash their hands before donning new gloves and continuing incontinence care. EI #6 stated, "Yes."

Based on observations and interviews, the facility failed to ensure four ceiling tiles on the 600 hall, between rooms 609 and 616, did not have dark black, gray to brown stains on the tiles. This was observed on three of four survey days, on one of four halls. Findings Include: A surveyor made observations on 2/24/2015 at 4:00 PM. The surveyor observed the ceiling tiles outside of room 609 and room 616. There were four tiles noted to have a dark black and gray substance with a beige to brown ring of discoloration around the black and gray substance. These areas on the four ceiling tiles varied in size. The largest area of discoloration was approximately eight inches in circumference. The other areas observed on the other three ceiling tiles were irregular in shape and they were approximately four to six inches in size. On 2/25/2015 at 11:00 AM, the ceiling tiles were observed outside of room 609 and room 616. The four tiles were noted to continue to have a dark black and gray substance with a beige to brown ring of discoloration around the black and gray substance. On 2/25/2015 at 2:12 PM, a surveyor observed the ceiling in the hallway outside of room 616. There were two areas on one tile close to the room door which had a black substance on the ceiling tile, approximately the size of a tennis ball (2.5 inches in diameter) and the other area was approximately the size of a saucer (6 inches in diameter). Another tile was observed between rooms 614 and 616 with a black substance on the tile approximately four to five inches in length. On 2/26/2015 at 8:06 AM, the four ceiling tiles outside of room 609 and 616 continued to have a dark black and gray substance with a beige to brown ring of discoloration around the black and gray substance. On 2/26/2015 at 8:01 AM, an interview was conducted with EI (Employee Identifier) #1, the Maintenance Supervisor. EI #1 was asked what were the ceiling tiles suppose to look like. EI #1 replied, "Clean, white, sealed and no stains. Sometimes we have stains (on the ceiling tiles) from water." EI #1 was asked how often were the ceiling tiles inspected. EI #1 replied, "We look at them constantly." EI #1 was asked who was responsible for checking and changing the ceiling tiles. EI #1 replied, "Anything we find we do a work order. Anyone (in maintenance) can change it, I am the responsible person." EI #1 was asked what would warrant the need to change a ceiling tile. EI #1 replied, "Anything, chips, stains, not seating right." EI #1 was shown the discolored ceiling tiles on hall 600 and asked, if these four ceiling tiles needed to be changed. EI #1 replied, "These need to be changed, (they are) stained really bad, we had an issue with the roof top air conditioner. We had water coming out of it and that is what this is probably from." EI #1 was asked to describe what he saw on these four ceiling tiles. EI #1 replied, "Water stains, spots four to eight inches in diameter, dark and middle even darker coloring on four tiles." EI #1 was asked if there was some type of check off sheet used to show routine maintenance checks of the facility. EI #1 replied, "Nothing scheduled." EI #1 was asked what potential harm could occur from not changing these ceiling tiles which were in this condition. EI #1 replied, "The main thing is it is looking bad." On 2/26/2015 at 8:15 AM, an interview was conducted with EI #2, the Administrator. EI #2 was asked what were the ceiling tiles suppose to look like. EI #2 replied, "The original color, stain free." EI #2 was asked how often were the ceiling tiles inspected. EI #2 replied, "Kind-of constantly, we replace them as needed. As they are noticed they are reported and changed out. We have had recent air conditioner work on the roof done and this may have caused it, but I am not sure." EI #2 was asked who was responsible for checking and changing the ceiling tile. EI #2 replied, "Maintenance is responsible for checking and changing. We are all responsible for reporting anything seen." EI #2 was shown the four ceiling tiles on the 600 hall and asked if these four ceiling tiles needed to be changed. EI #2 replied, "Yes they do, looks like they are wet or have been wet." EI #2 was asked to describe what she saw on these four ceiling tile. EI #2 replied, "Four tiles, several small areas that are wet or have been wet. They go from light brown to gray to black, a couple of small areas that are black to gray." EI #2 was asked what potential harm could occur from not changing these four ceiling tiles. EI #2 replied, "If leak bad enough could drip to the floor but these are not that bad."

Based on observations, interviews, and record reviews, the facility failed to ensure: 1) Mighty Shakes observed in the reach-in refrigerator were labeled in a manner in which the thaw date was evident. This was observed on 2 of 3 days of the survey. 2) Dietary staff did not wear loop or dangling earrings while in the kitchen 3) Dietary staff did not contaminate clean plates by placing her hand in the middle of the plates and then serve food on the plates 4) The pork meat served on buns was at least 135 degrees F (Fahrenheit) on tray line prior to serving; and 5) Tea and water were not served with melted ice on supper meal on 6/11/13 and lunch meal on 6/12/13. This had the potential to affect 66 of 66 residents that receive a meal from the kitchen. Findings include: 1) A review of the Food and Drug Administration's 2009 Food Code Chapter 3 Section 501.17 revealed, "...(D) A date marking system...(3) Marking the date or day the original container is opened in a FOOD ESTABLISHMENT, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed..." On 6/11/13 at 10:58 AM, during the initial tour of the kitchen, a box of Mighty Shakes were on the bottom shelf of the reach-in refrigerator that were not labeled with a thaw date. At 5:29 PM on 6/11/13, the Mighty Shakes were observed on trays with a resident's name but no thaw date. The Mighty Shakes went out of the kitchen on a cart for delivery. On 6/12/13 at 10:49 AM, two boxes of Mighty Shakes were observed in the reach-in refrigerator with no thaw dates. At 10:51 AM, Mighty Shakes were observed on a tray, on a cart in the kitchen with residents names on the Mighty Shakes, but no thaw date. 2) A review of a facility's policy titled, "EMPLOYEE SANITARY PRACTICES, Revised May 8, 2003," revealed, "POLICY: All employees shall: ...8. Only wedding band, watch, and stud earrings allowed with regard to jewelry. ...10. Use these procedures in handling clean china, glasses and silverware: ...*Pick up dishes by their rims..." On 6/11/13 at 4:46 PM, a dietary staff member was observed in the kitchen on the tray line, wearing large loop earrings while serving plates during the supper meal. On 6/12/13 at 10:46 AM, two dietary staff members were observed wearing large earrings in the kitchen. One of the staff members was wearing dangling gold earrings with a design on them. The second dietary staff member was wearing large gold loop earrings. At 10:53 AM on 6/12/13, during the lunch tray line, a dietary staff worker was observed wearing large gold loop earrings while she plated the food on the tray line. 3) On 6/11/13 at 5:12 PM, during the supper tray line, the server was observed resting her left hand in the middle of a clean plate. EI (Employee Identifier) #1 (Dietary Manager) removed the plate immediately and informed the dietary staff worker not touch the middle of the plate. On 6/11/13 at 5:35 PM, the dietary staff worker serving on the supper tray line was observed resting her left hand in the middle of a clean plate, then plated food to be served to residents. The plated food was put on a metal warming plate and sent out of the kitchen to be delivered to a resident. The same dietary staff worker was observed 3 more times putting her hand in the middle of the plates during the supper tray line, and continued to plate food that was served to the residents. 4) A facility's policy titled, "FOOD TEMPERATURES, Revised September, 2005," revealed, "Policy: Foods will be maintained at proper temperatures to insure food safety. Procedure: 1. The point of service temperature to residents will be within the range of 120-140 degrees based on the resident's preference. ...3. The cook is responsible to see that all food is at the proper temperature..." A review of the Food and Drug Administration's 2009 Food Code Chapter 3 Section 3-202.11, revealed, "Temperature. ...(D) Potentially hazardous food (time/temperature control for safety food) that is cooked to a temperature and for a time specified under ?? 3-401.11 - 3-401.13 and received hot shall be at a temperature of 57oC (Celsius)(135oF) or above..." On 6/11/13 at 4:46 PM, a dietary worker was seen placing the pork meat on the hamburger buns, placing them in a steel pan, and then covering the pan with clear wrap. The same dietary worker, wearing large loop earrings, took the temperature of the pork meat sandwich. The temperature was 120 degrees F. The staff person did not remove the sandwiches or notify other dietary staff of the temperature of the pork meat. She served the sandwiches with other items on the menu and the trays were delivered out of the kitchen. The dietary staff person was asked what should the temperature of the hot foods be on the tray line. She stated, "140 degrees." 5) During the same supper meal observation on 6/11/13 at 5:09 PM, cups with water and tea were observed covered with lids and on trays in a metal cart. The ice was melted in the tea and water that were served on the resident's trays delivered from the kitchen. At 10:46 AM on 6/12/13, a tray with small cups of water, with no ice were observed on a cart. At 11:35 AM on 6/12/13, the tray cart for the 600 Hall was observed leaving the kitchen for delivery, and the ice was melted in the covered cups of tea and water. On 6/12/13 at 12:20 PM, meal trays were observed being served to residents with melted ice in the tea and water. On 6/13/13 at 10:10 AM, EI #1 was interviewed and asked what was the policy regarding dietary staff wearing jewelry. She stated they could only wear stud earrings and a band ring, but no loop earrings. During the same interview, she was asked how were Mighty Shakes thawed. EI #1 stated they were brought in from the freezer to the refrigerator. EI #1 stated they were supposed to put a thaw date on them. She said they had to put a label on the individual Mighty Shakes. During the same interview, EI #1 was then asked what should the temperature of hot food items be on the tray line. She stated 135 degrees and above. She was asked who was responsible for taking the temperatures EI #1 stated, the cook who documented the temperature. EI #1 was asked how did she monitor the food temperatures, EI #1 stated that she checked the sheets everyday. She was then asked if the temperature was not at the level, what should staff do. EI #1 stated they should take it off the line, go back and heat it, and check the temperature again. She was then asked how often are the thermometers calibrated, she stated every week and she had a sheet for it. EI #1 was asked what was the potential harm if food was not at proper temperature on the tray line. She stated somebody could get sick. She was asked how should staff handle cookware such as plates. EI #1 stated they should touch around the edges and they should not touch where the food goes. They grab the sides with utensils, grab the end and never touch the part that goes into the resident's mouth. She was asked what harm could occur if serving items were not handled properly. EI #1 stated it was messed up and it's contaminated. On 6/13/13 at 7:58 AM, EI #3 (Dietary Staff) was interviewed. She was asked how should plates be handled in the kitchen. EI #3 stated they were picked up on the edge. EI #3 said they could not put their hand in the middle of the plate because that was where the resident's food went. She was asked why not, she stated that it was not sanitary. EI #3 was asked what was the dress code for dietary staff. She stated no jewelry, they could wear small earrings. EI #3 said staff could wear a band but nothing big and flashy. During the interview, EI #3 was observed wearing large gold loop earrings.

Based on observation, interview, and record reviews, the facility failed to ensure 2 of 3 dumpsters lids/doors were closed. This was observed on 6/11/13, during the initial tour of the facility, and had the potential to affect 70 residents residing in the facility. Findings include: A review of the Food and Drug Administration's 2009 Food Code Chapter 5 Section 5-501.113, revealed, "Covering Receptacles. Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: ...(B) With tight-fitting lids or doors if kept outside the food establishment..." A review of a facility's document titled, "Dietary Policies, Revised August, 2006," revealed, "...Waste will be disposed of in the garbage disposal and garbage cans lined with heavy duty plastic liners. These will be emptied after each meal and the waste will be placed in the dumpster located at the back of the 500 hall. (Name of waste removal company) picks the waste up 3 x (times) a week. The dumpster is kept closed at all times except when waste is being placed in it..." At 11:02 AM on 6/11/13, during the initial tour of the facility with EI (Employee Identifier) #1 (Dietary Manager), 3 dumpsters were observed outside the facility. Two of the three dumpsters were open. EI #1 stated the dumpster located on the right end of the dumpsters belonged to dietary. The middle dumpster had 2 flap lids and one lid was flipped all the way over, leaving one side of the dumpster completely open. There were large cardboard boxes observed in the dumpster. The dumpster on the far left side had the sliding door all the way open and was half-way full of garbage bags. On 6/13/13 at 10:10 AM, EI #1 was interviewed and asked who was responsible for maintaining the dumpsters and she stated housekeeping. She was asked who ensures the dumpsters were kept closed and free of debris and she stated maintenance. EI #1 was asked what negative outcome could occur if dumpster lids/doors were not kept closed. She stated there could be bugs, flies, rats, and raccoons.

Based on observations, interviews, and record reviews, the facility failed to ensure the LPN (Licensed Practical Nurse): 1. Performed hand washing in a manner to prevent potential cross-contamination by turning off the faucet with her bare hands. 2. Did not allow the eye drop bottle to touch the eye lid of RI (Resident Identifier) # (number) 7 during medication pass. This affected 1 of 5 nurses observed during medication pass. Findings include: The facility policy entitled: "Infection control ...Hand Washing...", with a revised date of 02/15/13, revealed: "Objective: To eliminate germs and bacteria from the hands to help prevent the spread of infection... Procedure:... 3. Rub your hands together to make lather and scrub them well using a circular motion... 5. Continue rubbing your hands for at least 20 seconds... 8. Use a clean dry paper towel to turn water faucet off..." A review of "Nurses' Guide to Clinical Procedures," 5th Edition, page 159 indicated for administering eye drops, "... 6. Position client in supine or sitting position, with forehead tilted back slightly. ... 8. If using bottle with a dropper, squeeze top of medication dropper to aspirate solution into dropper tube. ... 10. Using cotton ball, gently pull lower eyelid down. 11. Instruct client to look up toward forehead. 12. Administer ordered number of drops (or quantity of ointment) into conjunctival sac of appropriate eye without letting dropper touch client... Rationale ... Places medication in conjunctival sac for absorption without contaminating dropper or ointment tip." On 6/13/13 at 7:45 AM, EI (Employee Identifier) #2, LPN medication nurse, was observed during medication pass for RI #7. EI #2 washed her hands for 7 seconds, rinsed them, then turned off the faucet with her bare hand. EI #2 proceeded to walk down the hallway, entered RI #7's room and checked her pulse. EI #2 then washed her hands and turned off the faucet with her bare hand. EI #2 proceeded to set up RI #7's medications that included 11 medications by mouth and a bottle of liquid tears. The LPN gave the medications by mouth, used alcohol gel to sanitize her hands, then applied a pair of gloves. EI #2 instilled two sets of eye drops. She allowed the eye drop bottle to touch the top of RI #7's eye lid twice while instilling the drops into RI #7's left eye. EI #2 then washed her hands and turned the faucet off with her bare hands. RI #7 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #4's significant change MDS (Minimum Data Set), dated 4/29/13, revealed the resident required extensive assistance with ADLs (Activities of Daily Living) including transfers personal hygiene and bathing. RI #7 required total assistance for mobility and dressing. The resident had a BIMS (Brief Interview for Mental Status) score of 6 out of 15 possible points which indicated RI #7 was severely impaired of cognitive skills for daily decision-making. On 6/13/13 at 10:20 AM, EI #2 was interviewed and asked how was she taught to wash her hands. She said, "Wash them for 2 minutes. I was taught in nursing school." The surveyor questioned EI #2 regarding her hand washing while administering medications to RI #7. EI #2 said she washed them before she went in after she finished. The surveyor asked what were the steps to washing her hands. EI #2 said, "Turn the water on and wash my hands, and I'm suppose to get a paper towel to turn off the faucet." When the surveyor asked if she used a paper towel to turn off the faucet during the observation, EI #2 said no. During the same interview with EI #2 on 6/13/13 at 10:20 AM, the surveyor asked EI #2 how she was taught to instill eye drops. EI #2 said to use one hand to hold the eye open and put the drops in with the opposite hand. The surveyor asked her how did she instill eye drops into RI #7's eyes. She stated she used her left hand to hold the lid open and put the drops in. The surveyor discussed the medication pass observation regarding EI #2 allowing the eye drop bottle to touch the upper left lid of RI #7 twice, while instilling the medication. EI #2 said RI #7 was usually in bed when she instilled the drops. The surveyor asked EI #2 what was the concern when incorrect hand washing and incorrect administration of the eye drops were done. EI #2 said, the risk of cross-contamination. An interview with EI #4, the RN (Registered Nurse) Risk Manager,was conducted on 6/13/13 at 2:59 PM. The surveyor asked her to explain proper hand washing. EI #4 said turn on the water, wet hands, apply soap, briskly wash fingers in palms and interlock fingers times 20 seconds at least, dry with a paper towel, and turn off the faucet with another dry paper towel. When the surveyor asked EI #4 should the faucet be turned off with bare hands, she said, no. She was asked what was the potential negative outcome if hand washing was not performed correctly, EI #4 stated the possibility of infection.

Based on observations, interviews and document review, the facility failed to prevent the potential for cross-contamination and the potential for spreading foodborne illness by the following: 1) Sanitizing buckets for wiping cloths did not have enough PPM (Parts Per Million); 2) The sanitizing side of the three compartment sink did not have an effective ppm; 3) Grease and dust were hanging from the hoods over the stove/cooking area; 4) There was an excess accumulation of grease and black substance in kitchen areas; and 5) Twelve thickened milk containers were not discarded after a use-by date of 01/07/12. This had the potential to affect all 58 of 58 residents receiving meals from the kitchen. Findings include: On 04/03/12 at 2:35 PM, the Dietary Manager, Employee Identifier (EI) #3 and the surveyor made an initial tour of the dietary department. During this tour the hoods over the cooking area were noticed to have more than a few days worth of dust and grease build-up. There was dust hanging down from hoods with grease on it. The surveyor pointed this out to the DM. EI #3 identified the commercial cleaning schedule with the last cleaning in February, 2012. When the Maintenance Director, EI #4 saw the dust and grease hanging from the hoods, he agreed there was an accumulation of grease. There were several areas of black greasy grime and dust accumulation in the dietary area: on the two fryers, three ovens, and around the cooking area. In the area from the kitchen to the dry goods area, there was at least 2 inches of grease and dust on the pipes, doors and in the general area. In one walk-in refrigerator there were 12 thawed thickened milk cartons with a use-by date of "01/07/12." On 04/04/12 at 10:35 AM, these same concerns were observed. On 04/05/12 at 8:10 AM, dishwashing service was observed. In the clean dish area, there was a rusted and greasy metal shelf. The wells in which the silverware are washed were kept on this shelf. During this time the sanitizing wash cloths were being used on a preparing table. The dish cloth sanitizing solution was tested for the effectiveness of the solution. The sanitizing bucket's solution did not register any PPMs, indicating it had no sanitizer. The sanitizing side of the three compartment sink was tested . The chemical test revealed there was no sanitizing solution in it. An interview with the Administrator, EI #1, the DM (EI #3), and the Certified Dietary Manager, EI #9 on 04/05/12 at 11:30 AM, revealed the above concerns. EI #3 said she had gone back and looked at some of the areas that the surveyor had discussed with her earlier. EI #3 said, she had not noticed the grease and grime build up because she was there every day, but now she could see it. EI #3 provided the daily cleaning assignments. On the "Daily Cleaning Assignments," each of the job tasks showed: "When you get a break from your work" do the task. EI #3 stated they needed to do some extra cleaning once a week including some pressure cleaning.

Based on observations, interviews, and record review, the facility failed to ensure RI (Resident Identifier) #3's heels were consistently floated and foot pillows applied. This affected RI #3, one of four sampled residents identified with pressure sores. Findings include: The facility policy titled, "Preventative Measures/treatment for [REDACTED]. "Policy: Residents will receive skilled nursing care and treatments necessary to heal and prevent pressure ulcers. ...3. Preventative measures will be utilized for each resident based on the "Risk Assessment" and nursing judgment ...C. Turning/repositioning program: continuous/consistent program ...O. Float heels while in bed P. Other preventative devices, heel protectors, elbow pads, etc. ...The resident's care plan will also reflect individualized treatment and preventative measures as specifically utilized; providing directions for staff for the care of each resident." RI #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #3's "Pressure Sore Risk Assessment," dated 02/21/12, revealed she was at high risk for pressure sores. A review of RI #3's "Admission Assessment" after returning from a hospital stay on 02/21/12, revealed she was admitted with a pressure ulcer described as a "purple or maroon localized area of discolored intact skin or blood filled blister (Suspected Deep Tissue Injury)" to the right heel. It was measured as 1.8 cm (centimeters) long, by 2.0 cm wide. RI #3's Significant Change MDS (Minimum Data Set) Assessment, dated 02/27/12, revealed she was severely cognitively impaired and required extensive physical assistance from two staff members for bed mobility. RI #3 was also assessed as having functional limitation in range of motion on both sides of upper and lower extremities. A review of RI #3's "Physician Orders," dated 04/01/12, revealed an order dated 02/21/12 to "Float Heels and apply booties." A review of RI #3's care plan for "Skin Breakdown at feet," dated 02/21/12, revealed: "02/21/12 Nurses ------ Observe feet to ensure heels floating and booties in place. ...Nurse Aide -- Keep pressure off heels, elevate heels bed surface. ...Nurse Aide -- Apply foot pillows to both feet in bed." A review RI #3's "CNA (Certified Nursing Assistant) Assignment Card" revealed: "02/21/12... Keep pressure off heels, elevate heels bed surface. ... Apply foot pillows to both feet in bed." On 04/04/12 at 8:35 AM, RI #3 was observed in her geri-chair with her heels resting directly on the foot rest of the chair. RI #3 had on regular socks, but no heel booties or foot pillows. On 04/04/12 at 3:30 PM, RI #3 was observed in her bed with her left heel touching the mattress, and her right heel resting on a pillow. RI #3 had on regular socks, but no heel booties or foot pillows. On 04/05/12 at 1:05 PM, RI #3 was observed in her bed in her room with both heels touching the mattress. She had on regular socks, but no heel booties or foot pillows. On 04/05/12 at 1:20 PM, EI (Employee Identifier) #11, a CNA who regularly works with RI #3, was asked what "float heels" meant. She said it meant the heels must be off the bed completely and they must not touch anything. EI #11 was asked what "foot pillows" were. She said they use regular pillows to float the heels. EI #11 was asked if RI #3's heels were supposed to be floated or wear foot pillows. She said her heels were to be floated. EI #11 explained that they applied booties to RI #3 at one time, but they had not used them since January. On 04/05/12 at 1:47 PM, EI #12, an LPN (Licensed Practical Nurse) who regularly works with RI #3, was asked what "foot pillows" were. She said they use booties or a triangular device to keep the heels floated. EI #12 was asked if RI #3 was supposed to have heel booties. She said she was. EI #12 was asked if RI #3's heels were supposed to be floated. She said they were. EI #12 was asked who was responsible for making sure CNAs do what they are supposed to. She said the LPNs. EI #12 was asked how she does that. She said she makes rounds and follows up with the residents. EI #12 was asked when the last time RI #3 had booties on. She said Tuesday (04/03/12), but someone told her they were getting washed. On 04/05/12 at 2:00 PM, EI #2, the Director of Nursing, was informed that RI #3's heels had not been consistently floated, had not had booties on her heels, and the nurse said it was because they went to the wash. EI #2 said the staff should have provided another pair of heel booties. EI #2 was asked what the potential harm was for RI #3's heels touching the mattress. She said she could get skin breakdown or the breakdown she has could get worse.

Based on document review and interview, the facility failed to ensure EI (Employee Identifier) #6, a dietary worker's background check was completed before she began working in the facility. This affected one of five personnel files reviewed. Findings include: A review of the facility policy and procedure titled, "Abuse Prevention" (not dated) revealed: "This facility will not employ individuals who have been found guilty of abusing, neglecting or mistreating residents by a court of law... This facility will ...make reasonable efforts to uncover information about any past criminal prosecution. All efforts and responses will be documented." A review of EI #6's "New Employee Checklist" revealed: "New Hire Information (required by State) immediately upon hiring ...3. Background check." A review of EI #6's "Archived Time Card Report" revealed her first day of work at the facility was 11/06/11. On 04/05/12 at 8:20 AM, a review of EI #6's personnel record revealed her background check was completed on 12/09/11, 33 days after she started working at the facility. On 04/05/12 at 10:35 AM, EI #7, the Human Resource Director, confirmed that EI #6's first background check was completed on 12/09/11. EI #7 also confirmed that EI #6 began working at the facility on 11/07/11. EI #7 was asked if she was aware EI #6's background check was not completed before she was hired. She said she was not. EI #7 explained this had never happened before. She said she was told they could hire EI #6, so she informed the Dietary Manager, then it was rescinded, but it did not come back through her (EI #7). EI #7 said she did not realize EI #6 was hired before the background check was completed. On 04/05/12 at 10:10 AM, EI #2, the Director of Nursing/Abuse Coordinator, was asked what steps are taken to screen potential employee hires for a history of reported abuse. She said they do background checks, check the CNA (Certified Nursing Assistant) registry, and check references. EI #2 was asked if she was aware that EI #6 began working in the facility before her background check was completed. She replied, "No." EI #2 was asked if EI #6 could have had contact with residents since she was working in dietary. She responded, "She could."

Based on observations and interviews, the facility failed to ensure the housekeeping and maintenance departments maintained an orderly and comfortable environment. This affected eight of 56 resident rooms in the facility. Findings include: On 04/03/12 at 3:00 PM, an initial tour of the facility was made. Room Locator (RL) #A was observed with skid strips 3 inches wide, which were not glued completely to the floor. A Registered Nurse (RN) Employee Identifier (EI) #10 was with the surveyor and told the maintenance director, EI #4 to pull the strips up immediately. There was also an over-the-toilet seat which was rusted in several areas. RL #B, C, D and E were all noted to have scratched up doors with chunks of wood out of the front door to the rooms and to the bathrooms. RL #E had unfinished painting of two colors on the walls and spackle on the walls. Under the closet doors and in several areas in the room, the floor boards were coming loose from the walls. RL #F had skid strips coming off the floor by the "B" bed. There was an area on the wall that was scratched 3 feet long by 4 feet wide and 2 inches deep. The wall paper was hanging loosely off the wall. RL #G had an over-the-toilet seat which was rusted in several areas. The door to the bathroom had several large scratches. RL #H had skid strips coming loose on the floor. The walls were scratched up and appeared to have two different colors of paint. The doors were very scratched up. On 04/05/12 at 9:30 AM, the Housekeeping Supervisor (EI #3) and the Maintenance Director (EI #4) were interviewed and observed the concerns listed above. EI #3 said the housekeepers have not been doing the details and they had fallen behind on reporting repairs to the maintenance department.

Based on observation, interview, and document review, the facility failed to: 1.) Ensure food safety for time and temperature by a. staff not knowing how to calibrate the thermometer used; b. staff not knowing how to read the thermometer used; c. staff not knowing the required minimum temperature for reheating food; d. leftover food items not labeled with the use-by date. 2.) Prevent the potential for cross-contamination by a. staff not sanitizing a countertop upon cleaning it after a task; b. picking up cups which had fallen onto the floor and putting them into service; c. stove drip-tray with accumulated residue; d. ceiling vents thick with dust over the clean dishwashing area; e. storage shelves less than six inches above the floor. This had the potential to affect all residents receiving meal trays, 71 of 77 residents. Findings include: 1.) a. The facility's policy and procedure for Calibration of Thermometers, last revised 3/30/08, included the following: "Thermometers should be calibrated weekly using the ice and water slush method. For a bi-metallic stemmed thermometer, wait until the needle stops, then use a small wrench to turn the calibration nut until the thermometer, reads 32F(0C) (32 degrees Fahrenheit (0 degrees Centigrade)). ..." Documentation of the dietary inservice for "Calibrating Thermometers" revealed it was last taught on 2/4/10. At 10:40 AM on 3/9/11, Employee Identifier (EI) #7 (the PM Cook) prepared a cup of ice water slush to calibrate the thermometer she normally used to check food temperatures. On the thermometer's dial face, the temperature range was from 50 degrees (?) Fahrenheit (F) to 550? F and the space between each measurement line was 2? F. EI #7 placed the probe of the thermometer into the ice slush and looked at the dial. When asked what temperature she was calibrating the thermometer to, EI #7 said, "Below." and pointed to 50? F on the thermometer dial. EI #7 was interviewed on 3/9/11 at 12:30 PM. EI #7 said she always calibrated the thermometer on Monday and usually used the thermometer, which ranged from 50? to 550? F. When asked what temperature the thermometer should be calibrated to, EI #7 said, "It should be below 50? F. When asked who taught her how to calibrate the thermometer, EI #7 said the RD and the Dietary Manager taught her about a year or so ago with a thermometer very similar to the one she now used. EI #7 said they taught her it should go to the very bottom, "Zero." On 3/11/11 at 9:45 AM, EI #10 (the Director of Dietary) was interviewed and asked how do you calibrate a thermometer with a dial reading marked from 50? to 550? F. EI #10 said, "Normally we use the ice water method, not the boiling method." EI #10 said she had not told staff to use the boiling point method of calibration. b. The 2009 Food Code (Recommendations of the United States Public Health Service Food and Drug Administration) included the following: "4-204.112 Temperature Measuring Devices. ... (D) Temperature Measuring Devices shall be designed to be easily readable. (E) Food Temperature Measuring Devices ... shall have a numerical scale, ... or digital readout in increments no greater than 1? C (Centigrade) or 2? F in the intended range of use. ..." At 11:00 AM on 3/9/11, EI #7 began checking the temperature of the food on the steam table with the thermometer. On the thermometer's dial face, the temperature range was from 50? F to 550? F and the space between each measurement line was 2? F. If the food temperature did not fall on a labeled measurement line, such as 150?, EI #7 was not able to discern the actual temperature reading on the thermometer dial. For example, the actual dial reading for the fried okra was 180? F, but EI #7 said it was 170? F. EI #7 was interviewed on 3/9/11 at 12:30 PM and was asked how many degrees were in-between each mark on the thermometer dial. EI #7 said 5 degrees Fahrenheit for each mark. c. Documentation of the dietary inservice for "Proper Food Temps. (Temperatures)" revealed it was last taught on 5/27/10. The inservice documentation titled "Food Temperatures: Keeping Hot Foods Hot and Cold Foods Cold" included the following: "Foods that are not cooked to, held at, or stored at the right temperature are sometimes dangerous! Many foods contain small amounts of microorganisms called bacteria that will not grow if they are stored, cooked, and held correctly. However, dangerous bacteria can grow and cause foodborne illness, often referred to as food poisoning, if foods are not handled properly. Sometimes foodborne illness is mild, but other times it is severe and even fatal in some people. ... Once foods are cooked to the right temperature, hold them at a temperature of greater than 135 degrees (?) Fahrenheit (F) to assure that they are safe. ... Minimum Temperature 165? F for 15 seconds (for) ... reheating foods ...." During the food temperature check on 3/9/11 beginning at 11:00 AM, diced beef had a temperature of 100? F and was sent back to be reheated. When the diced beef was brought back, the temperature was measured as 166? F. When asked what was the minimum temperature needed, EI #7 said 150 degrees Fahrenheit. EI #7 was interviewed on 3/9/11 at 12:30 PM and was asked to what minimum temperature did hot food need to be reheated. EI #7 said 150 degrees Fahrenheit and above. d. The 2009 Food Code (Recommendations of the United States Public Health Service Food and Drug Administration) included the following : "3-501.17 Ready-to-Eat, Potentially Hazardous Food (Time/Temperature Control for Safety Food), Date Marking. (A) ... refrigerated, Ready-To-Eat, Potentially Hazardous Food (Time/Temperature Control for Safety Food) prepared and held in a Food Establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the Food shall be consumed on the Premises, sold, or discarded ..." On 3/11/11 at 10:55 AM, leftover foods were observed in the reach-in refrigerator and labeled as follows: Diced Pickled Beets 3/9/11 Tomatoes 3/8/11 Creamed Corn 3/8/11 Peaches 3/8/11 Cranberry Sauce 3/7/11 EI #9 (the Dietary Supervisor) said the leftovers were labeled with the date the staff put it in the refrigerator. 2.) a. The 2009 Food Code (Recommendations of the United States Public Health Service Food and Drug Administration) included the following: "4-602.11 Equipment Food-Contact Surfaces and Utensils. Equipment Food-Contact Surfaces and Utensils shall be cleaned: ... (5) At any time during the operation when contamination may have occurred. ... 4-603.16 Rinsing Procedures. Washed Utensils and Equipment shall be rinsed so that ...cleaning chemicals are removed ... 4-702.10 Food-Contact Surfaces and Utensils. Equipment Food-Contact Surfaces and Utensils shall be sanitized. ..." On 3/9/11 at 9:51 AM, following the preparation of pureed chicken and dumplings, EI #8 (a Dietary Aide) was observed cleaning the base of the Robot Coupe and the countertop with a cloth soaked with soapy water. EI #8 did not rinse or sanitize the Robot Coupe base or the countertop. EI #8 was interviewed on 3/9/11 at 12:15 PM and was asked what should have been done after she washed the work area with a soapy towel. EI #8 said she normally would use 409 spray (an all-purpose cleaner) after washing the table with soapy water and then she would have wiped with a towel with warm water and then used a clean, dry towel to dry the table. When asked if she had been taught to do this, EI #8 said, "It's what I do. Everybody do different." b. The facility's policy for "Handling of Tableware," last revised June 2001, included the following: "Tableware will be handled in a manner in which there will be as little danger of contamination as possible in order to assure the health and well-being of the residents, patients, and staff. ..." On 3/9/11 at 10:59 AM, a stack of cups in an open plastic sleeve fell to the floor. The top two cups in the stack were directly exposed to the floor and made contact with it. EI #8 (a Dietary Aide) picked up the stack of cups from the floor and placed them on the counter. c. The facility's policy for "Cleaning Ranges," undated, included the following: "Policy: The cook on each shift is responsible for keeping the range as clean as possible during the preparation of the meal. The range will be cleaned after each use. ... Procedure: ... 4. Wash drip pans as needed and/or according to the cleaning schedule. ..." On 3/8/11 at 11:10 AM, the drip tray under the stove eyes had more than one day's deposit of blackened grease build-up. The Dietary Supervisor (EI #9) said the drip tray should be cleaned every night and it had not been done. d. The 2009 Food Code (Recommendations of the United States Public Health Service Food and Drug Administration) included the following under "Storing": "4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) ... cleaned Equipment and Utensils, ...shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; ..." On 3/8/11 at 11:13 AM, two ceiling vents directly above the clean table of the dishmachine were observed to be thick with accumulated dust. The Dietary Supervisor (EI #9) said the vents were taken down by Maintenance and cleaned by EVS (Environmental Services) every week on Friday. In a follow-up interview on 3/9/11 at 9:20 AM, EI #9 said those vents must have been overlooked during the weekly cleaning. e. The 2009 Food Code (Recommendations of the United States Public Health Service Food and Drug Administration) included the following under "Storing": "4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) ... Utensils, ... and Single-Service and Single-Use Articles shall be stored: ... (3) At least 15 cm (centimeters) (6 inches) above the floor." During an observation of the Dry Storage House on 3/8/11 at 11:05 AM, paper goods were observed stored on shelving that was less than six inches from the floor.

Based on observation, interview, and document review, the facility failed to follow a pre-planned menu for serving bread on Pureed diets for lunch on 3/9/11. This affected nine of nine residents receiving the Pureed Diet. Findings include: The menu used by the facility on 3/9/11 was titled "(the name of the facility) - Liberalized Geriatric Menus, Fall/Winter 2010 - Wednesday Week 1." The "Puree" menu included a footnote identifier of "(2)," which was placed to the right of the "Puree" menu title and to the right of the bread item of each meal. The menu footnote revealed the following: "2) Puree - Plain iced cake, plain cookies, bread or crackers may be served whole, pureed or soaked in slurry. Puree biscuit or cornbread or soak in slurry." The Puree lunch menu for 3/9/11 included the following: "#6 (scoop equaling 2/3 cup) Pur (Pureed) Chicken/Dumplings #8 (scoop equaling 1/2 cup) Pur Fried Okra 1 piece Cornbread (2) or 1 slice Buttered Bread (2) ..." An undated policy and procedure for "Puree Foods Preparation (name of facility)" included the following: "Policy ... All breads used for preparations for puree meals will be pureed in the meat portion of the puree meal. Procedure: The staff will use the appropriate amount of servings of bread and meat portions as specified in the portion control amount on the menu. For example if the meat portion indicates a 3 oz (ounce) serving and the bread serving indicates a 1 oz serving, then the serving size that will be used will be a 4 oz servings spoon or appropriate serving ladle. ..." During a lunch trayline observation on 3/9/11 between 11:00 AM and 11:45 AM, the items plated for the Puree Diet were a #6 scoop of pureed Chicken and Dumplings and a #8 scoop of pureed Fried Okra. No pureed bread or bread slurry was used, nor was any plain bread or buttered bread placed on the Puree Diet meal trays. Employee Identifier (EI) #6 (the AM Cook) was interviewed on 3/10/11 at 12:10 PM and the Puree menu for 3/9/11 (Fall/Winter 2010 - Wednesday Week 1) was reviewed. When asked where was the pureed bread for lunch on 3/9/11, EI #6 said, "We did not have pureed bread yesterday. We have sliced bread. We just had cornbread." EI #6 said plain cornbread was used, not pureed cornbread. EI #6 further said that was "by the menu." When asked what the "(2)" by the word "Cornbread" on the menu meant, EI #6 said, "Two pieces." When asked if bread was ever pureed in the blender, EI #6 said, "Yes. In the morning time if it calls for puree biscuit or French Toast. We do what the menu says when it comes to pureed food." When asked if bread was ever mixed with the meat or vegetable puree items at this facility, EI #6 said, "No, not here." EI #7 (the PM Cook) was interviewed on 3/10/11 at 12:30 PM. When asked who puts the bread on the Puree diets, EI #7 said, "I do, it is already in the food. Yesterday it was in the fried okra." EI #7 further said the Nourishment Person added the bread when the vegetables were pureed. When asked if those instructions were anywhere on the menu or on a recipe, EI #7 said, "No." EI #7 said the staff had just been doing that ever since she had been at the facility. EI #7 had worked at the facility for almost ten years. EI #8 (a Dietary Aide) was interviewed on 3/10/11 at 12:30 PM. EI #8 said she worked as the Nourishment Person on 3/9/11 and that she did prepare the puree vegetables. When asked what she added to the pureed vegetables, EI #8 said, "We do not add anything to the vegetables, but to the meat we add bread." EI #8 said there were nine servings of puree, so nine slices of bread were added. When asked how did she know to do this, EI #8 said she was trained to do it when she started. EI #8 had worked at the facility for seven years. EI #9 (the Dietary Supervisor) was interviewed on 3/10/11 at 5:40 PM. EI #9 was asked how bread was served to residents on Puree diets and what was the procedure. EI #9 said, "We blend it up in the meat. Each resident has a slice of bread or piece of cornbread or a roll in the meat. The reason we started mixing it in the meat was because it had to be mashed potato consistency to stand up on the plate" and the three-compartment plates were no longer to be used. EI #9 further said they started the procedure of mixing the bread in with the pureed meat about 1 1/2 years ago. When asked who told her to do that, she said, "We just did it." EI #9 said the Director of Dietary (EI #10) knew about the change. When asked if the Registered Dietitian (RD) knew about it, EI #9 said the RD might know. When asked how the pureed bread was done at breakfast, EI #9 said, "The meat. The sausage. It's always the meat. Breakfast, lunch, and dinner, it is always the meat." EI #10 (the Dietary Manager and the Director of Dietary) was interviewed on 3/11/11 at 9:45 AM and the Puree menu for 3/9/11 (Fall/Winter 2010 - Wednesday Week 1) was reviewed. EI #10 said the menus had been purchased from a company and "we modified the menu so the pureed bread is in the resident's meat." EI #10 was asked, "If bread is added, do you adjust the (serving) scoop size?" EI #10 said, "You have to increase the portion size to make sure it meets the nutritional needs for both the meat and the bread portion." It was observed that the menu required a #6 serving scoop for the pureed chicken and dumplings. EI #10 was asked how the staff would adjust the serving portion to account for the added bread in the pureed chicken and dumplings. EI #10 said, "You would need at least one ounce extra." When asked how would the staff know what serving tool to use and would it be easily understood as to what to use, EI #10 said, "No, it is not clear."

Based on observation, record review and interview, the facility failed to provide wound care in a manner to prevent the potential for cross-contamination by: 1. Having wound cleanser stored in the nurse's uniform pocket. 2. Wearing two pair of gloves, one pair over the top of another pair. This occurred during the observation of wound care for Resident Identifer (RI) #1 and incontinence care for RI #10. This affected RI #1 and RI #10, two of three residents observed during wound care and one of two residents observed during incontinence care. Findings include: A review of the "Policy and Procedure for Aseptic Dressing Changes" (not dated ) revealed: "1. The goal of aseptic cleansing of wound is to remove bacteria and debris while protecting the healthy, viable tissue: ... c. To prevent cross contamination and/or infection of an open area and prevent additional trauma to area. 2. Procedure: a. Obtain all items needed and place on clean surface. ... c. Cleanse hands and apply clean disposable gloves. d. Remove soiled dressing. ... e Remove gloves and wash hands f. Apply clean disposable gloves. ... j. Place all contaminated items in trash bag, including gloves..." The facility's policy of "Peri-Care" (not dated) revealed: "Purpose: To keep resident clean and comfortable and reduce irritation Equipment: Disposable Gloves (2) ... Procedure: ... 2. Wash hands and gather equipment that you need and take to bedside. ... 5. Wash hands and put on gloves. ... 11. Remove the gloves, raise side rail, and wash your hands. ... 12. Put on clean gloves. 13. Apply barrier cream. 14. Remove gloves. 15. Position the resident for comfort. 16. Pull up covers and side-rails if appropriate. 17. Wash hands." RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 03/09/11 at 9:45 AM, Employee Identifier (EI) #2 (the Treatment Nurse) and EI #4 (the Assistant Director of Nursing) were observed during the provision of wound care for RI # 1. EI #4 was observed to remove the soiled dressing from the left coccyx area of RI #1. However, the collagen was adhered to the wound bed. EI #4 asked for a moistened gauze to remove the collagen dressing. EI #2 obtained a spray bottle of wound cleanser from a pocket on her uniform and sprayed a 4 by 4 gauze, handing it to EI #4 to remove the collagen dressing. RI #1 was observed to have three wounds on the inner cheeks of the coccyx area. One open area on the left side and two open areas on the right side of the buttocks. EI #2 was observed to don two pair of gloves (one pair over the top of another pair). EI #2 was observed to cleanse the wound on the left side and then remove one pair of gloves from her hands. EI #2 placed a clean pair of gloves on top of the gloves already on her hands. EI #2 (with the second pair of gloves on) cleansed the two wounds on the Right side of the buttocks. At the completion of the wound care, EI #2 was observed to place the wound cleanser back into her uniform pocket. 2. RI #2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 03/10/11 at 8:40 AM, EI #2 (the Treatment Nurse) and EI #5 (a Certified Nursing Assistant) were observed providing wound care to RI #10's heel. EI #2 was observed to remove the spray bottle of wound cleanser from her uniform pocket and to spray the 4 by 4 gauze, to clean RI #10's heel. At the completion of wound care, incontinent care was provided for RI #10. EI #2 was observed to don two pair of gloves (one pair on top of another pair of gloves). After the completion of the incontinence care, EI #2 removed one pair of gloves, leaving a pair of gloves on and assisted in repositioning the resident in bed. At the completion of care, EI #2 was asked why she wore two pair of gloves. EI #2 replied, "Because, if I get my gloves soiled, I can pull off the top pair and they are clean (referring to the second pair of gloves on her hands.)" EI #2 also said something may leak through the gloves. On 03/10/11 at 12:10 PM, EI #3 (a Registered Nurse Supervisor) was asked when the policy says to wear two gloves, are you talking about two pair of gloves. EI #3 replied "No" it is saying one glove for each hand. On 03/11/11 at 11:30 AM, EI #3 was asked when would you double-glove. EI #3 replied if she had a contaminated site and was going from dirty to clean. When EI #3 was asked to tell about going from dirty to clean. EI #3 replied she would clean the site and then take the dirty gloves off. The gloves would be clean and I could continue to clean the area again if needed. EI #3 was asked if the gloves under the dirty gloves were clean. EI #3 replied, "Yes." EI #3 was asked how staff were to take wound supplies into a resident's room. EI #3 replied only supplies that are needed are to be taken into the resident's room. EI #3 was asked when would supplies be placed in the uniform pocket. EI #3 replied she would not put any supplies in her pocket. EI #3 was asked about the spray wound cleanser being put in the uniform pocket. EI #3 replied, "No" saying it might contaminate in my pocket or the wound cleanser could get contaminated in my pocket.

Based on observations, record review and interview, the facility failed to thoroughly cleanse Resident Identifier (RI) #1 when providing incontinence care. This affected one of two residents observed for incontinence care and one of nine sampled residents who were identified as incontinent. Findings include: The facility provided a copy of the policy and procedure (not dated) for"Peri-Care" as follows: "Purpose: To keep resident clean and comfortable and reduce irritation. Procedure: ... 7 Wipe in a downward motion cleaning the inner thighs using as many wipes as necessary. Also clean the upper pubic area. ... For male residents, push back foreskin. Start at top and wipe down. Turn wipe to another section and start at the top and wipe down until the entire penis is cleaned...." RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set, with the Assessment Reference Date of 01/06/11, revealed RI #1 was totally dependent on staff for all activities of daily living, requiring two person physical assist. The MDS also identified RI #1 was always incontinent of bowel and bladder with no episodes of continence. The CAAs (Care Area Assessment Summary), dated 01/12/11, for "Urinary Incontinence/Catheter" revealed the resident is on a check and change program. Staff checks every two hours and as needed to ensure the resident stays clean and dry. On 03/09/11 at 9:45 AM during an observation of wound care, RI #1 had a small bowel movement. Employee Identifier (EI) #1 (a Certified Nursing Assistant) was observed to cleanse the rectal and coccyx area before the treatment for [REDACTED].#1. The resident was observed to have a second bowel movement and (Treatment Nurse) EI #2 was observed to cleanse the resident coccyx and buttocks area. As the treatment nurse (EI #2) went to apply the boarded foam dressing, the surveyor asked EI #2 to check the top of the buttocks. A small amount of stool was observed on the upper crack of the buttocks. EI #2 cleansed this area and applied the clean dressing to RI #1's wounds. The treatment nurse (EI #2) was not observed to turn and cleansed the groin or pubic area of the resident after the buttocks and coccyx area was cleansed. EI #1 and EI #2 were observed to turn and reposition RI #1 after wound care without cleansing the groin and pubic area. On 03/11/11 at 10:50 AM, EI #1 stated that she had cleaned the resident the first time and when the resident started having the second bowel movement EI #2 (name of treatment nurse) cleansed the resident. EI #1 was asked, after the wound care was completed and the resident repositioned, was the pubic and groin area cleaned. EI #1 replied, "No" I don't think so. EI #1 was asked what should have been done. EI #1 replied the procedure should have been done over. EI #1 was asked if the groin and pubic area should have been cleaned. EI #1 replied, "Yes."