Every finding on record at Cypress Cove Care Center

Based on interviews, medical record review and a facility policy titled, Nutrition/Hydration Care and Services, the facility failed to ensure nutritional recommendations made by Employee Identifier (EI) #4, Registered Dietitian (RD) on 11/28/2022, were addressed for Resident Identifier (RI) #10. This deficient practice had the potential to affect RI #10, one of three residents sampled for dehydration. Findings Include: A facility policy titled, Nutrition/Hydration Care and Services, with an effective date of 01/01/2004 and a revision date of 02/01/2023, documented . PURPOSE To provide . framework for nutritional and hydration care and services. PRACTICE STANDARDS . 4. Review Dietitian recommendations on Nutritional Care Recommendations Form. Obtain orders per recommendations. RI #10 was admitted to the facility on [DATE] with a diagnosis that included Dysphasia, Oropharyngeal Phase and was discharged from the facility on 12/01/2022. Review of RI #10's February 2023 physician orders revealed orders dated 11/23/2023 for RI #10 to receive enteral feeding by gastrostomy tube and water flushes to be given with medication administration 30 ml (milliliters) before and after medication administration and at least 15 ml of water between each medication. A review of RI #10's Nutritional assessment dated [DATE] and completed by EI #4, RD, revealed a recommendation to increase the free water flushes to 200 ml every four hours, totaling 1200 ml per 24 hours. A review of an email from EI #4 to EI #2, Director of Nursing (DON), dated 11/28/2022 at 5:43 PM, revealed EI #2 was notified, four days prior to RI #10's discharge, of EI #4's recommendation for free water flush order of 200 ml six times a day. In an interview on 02/03/2023 at 01:50 PM, EI #4, RD, stated she assessed RI #10 on 11/28/2022 and recommended the resident receive free water flushes 200 ml every four hours that equaled 1200 ml/24 hours. EI #4 stated she calculated the resident's fluid needs at 2129. EI #4 stated the resident discharged before she could follow-up on her recommendation. EI #4 stated the concern with her recommendation not being followed was the resident's body physiology could be on the dry side. In an interview on 02/03/2023 at 11:34 AM, EI #2, DON, reported the RD was to email her when she had a recommendation to send to the doctor. EI #2 stated she was unaware of the email dated 11/28/2022 from EI #4 regarding RI #10's water flushes because she did not see the email. EI #2 stated the concern with not acting on the RD recommendation timely was it could lead up to dehydration. In an interview on 02/03/2023 at 3:50 PM, EI #5, Medical Director (MD) reported he did not receive the recommendation from the RD for RI #10. EI #5 stated if he had received the recommendation, he would have followed the recommendation. This citation was cited as a result of the investigation on complaint/report number AL00042528.

Based on interview, record reviews, and review of Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure the most recent annual Minimum Data Set (MDS) assessments were coded to accurately reflect resident's status at the time of the assessment. Resident Identifier (RI) #3's MDS assessment dated [DATE] and RI #13's MDS assessment dated [DATE] did not reflect the use of wander guard devices. This had the potential to affect two of 13 residents for whom MDS assessments were reviewed. Findings Include: A review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, dated October 2019, revealed: . P0200: Alarms . Bracelets or devices worn by or attached to the resident and/or his or her belongings that signal a door to lock when the resident approaches should be coded in P0200E Wander/elopement alarm, whether or not the device activates a sound or alerts the staff. RI #3 was admitted to the facility on [DATE] and had a diagnosis of Dementia. RI #3's January 2023 orders documented an order dated 09/13/2022 to check RI #3's wander guard device every shift for placement. RI #3 had a care plan with a focus area documented for RI #3 being at risk for elopement related to Dementia, that was initiated on 06/09/2020, with an intervention that was created on 06/09/2020 and revised on 12/28/2022 to utilize and monitor a security bracelet per protocol. RI #3's annual MDS assessment with an Assessment Reference Date (ARD) of 11/02/2022 documented a 0 for E. in Section P0200 for Alarms, which indicated a wander/elopement alarm device was not used for RI #3. RI #13 was admitted to the facility on [DATE] and had diagnoses to include: Alzheimer's Disease, Dementia, and Cognitive Communication Deficit. RI #13's January 2023 orders documented an order dated 08/18/2022 to check RI #13's wander guard device every shift for placement. RI #13 had a care plan with a focus area documented, for RI #13 being at risk for elopement related to Cognitive Loss and Dementia, that was initiated on 11/15/2021, with an intervention that was created on 11/15/2021 and revised on 08/18/2022 to utilize and monitor a security bracelet per protocol. RI #13's annual MDS assessment with an ARD of 10/31/2022 documented a 0 for E. in Section P0200 for Alarms, which indicated a wander/elopement alarm device was not used for RI #13. On 02/01/2023 at 11:56 AM, an interview was conducted with Employee Identifier (EI) #3, Clinical Reimbursement Coordinator. EI #3 reported RI #3 and RI #13 both had a wander guard but the residents' current MDS was not coded accurately for wander/elopement alarms. EI #3 stated RI #3 had an order for a wander guard dated 09/13/2022 and RI #13 had an order for a wander guard dated 08/18/2022. EI #3 stated the concern with the residents' MDS not being coded accurately for wander/elopement alarm was it did not give an accurate description of the residents or their current status. This citation was cited as a result of the investigation on complaint/report number AL00042793.

Based on observation, interviews, medical record review, and review of a facility policy titled, Hand Hygiene, the facility failed to ensure: 1) a Registered Nurse (RN), Employee Identifier (EI) #1, washed her hands or used hand sanitizer after she checked Resident Identifier (RI) #34's oxygen saturation, prior to putting on gloves to administer RI #34's oral inhaler. Further, EI #1 did not wash hands or remove her gloves, prior to administering RI #34's inhalation medication via breathing pipe; and 2) a Certified Nursing Assistant (CNA), EI #3, washed or sanitized her hands while feeding two residents, RI #26 and RI #66, at the same time during a lunch observation on 1/9/2020. This affected one of four Licensed Nurses observed during medication administration pass, one of four residents observed during medication administration pass, and one of five dining room observations. Findings include: A review of a facility policy titled, Hand Hygiene, with a Revision Date of 11/28/2017, revealed . POLICY . hand hygiene practices is maintained by all Center personnel. This includes hand washing . and use of alcohol based hand rubs for routine decontamination in clinical situations . PR[NAME]ESS 1. Perform hand hygiene . 1.4 After patient care; 1.5 after contact with the patient's environment . 1) RI #34 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/8/2020 at 8:00 a.m., the surveyor observed EI #1, a RN, during medication administration pass. EI #1 checked RI #34's oxygen saturation with a pulse oximetry with ungloved hands. EI #1 touched and and then placed the pulse oximetry on RI #34's bedside table with ungloved hands. EI #1 applied gloves to both hands, but did not wash her hands or use alcohol based hand rub prior to administering an oral inhaler to RI #34. After RI #34's oral inhaler treatment, EI #1 took RI #34's oral inhaler, with both gloved hands, and placed it on RI #34's bedside table. EI #1 did not remove her gloves, wash her hands or use alcohol based rub prior to administering RI #34's inhalation medication by the breathing pipe. On 1/8/2020 at 2:46 p.m., an interview was conducted with EI #1. EI #1 was asked what should have been done after she checked RI #34's oxygen saturation and placed the pulse oximetry on the bedside table, prior to applying gloves to administer RI #34's oral inhaler. EI #1 stated she should have sanitized with gel or washed her hands with soap and water. EI #1 was asked what would be the concern in not washing hands or using a hand sanitizer between those two tasks. EI #1 stated the resident or anyone could get an infection. [NAME] #1 was asked what should have been done after she gave RI #34's oral inhaler treatment, prior to administering RI #34's inhalation medication by the breathing pipe. EI #1 stated she should have removed her gloves and washed or sanitized her hands because the resident or anyone else could get an infection. On 1/8/2020 at 3:19 p.m., an interview was conducted with EI #2, an Infection Control Preventionist/RN. EI #2 was asked what would be the concern in not washing or sanitizing hands between checking an oxygen saturation and administering an oral inhaler to a resident. EI #2 stated it could cause cross contamination and this could cause an infection to the resident. EI #2 was asked what would be the concern in not removing your gloves and not washing or sanitizing your hands after administering an oral inhaler, prior to administering inhaled medication by the breathing pipe. EI #2 stated it could cause cross contamination and an infection to the resident. 2) On 1/9/2020 at 11:40 a.m., the surveyor observed Employee Identifier (EI) #3, CNA, sitting at a table in the dining room feeding Resident Identifier (RI) #26 and RI #66. EI #3 proceeded to feed both residents during the observation. EI #3 was observed touching the residents' eating utensils, clothes, hands and straw while feeding both residents. EI #3 did not wash or sanitize her hands between residents. EI #3 was observed removing a soiled clothing protector from RI #26 and then proceeded to feed RI #66 without washing or sanitizing her hands. An interview was conducted with EI #3 on 1/9/2020 at 12:42 p.m EI #3 was asked if she fed two residents at lunch. EI #3 stated yes, RI #26 and RI #66. EI #3 was asked if she washed or sanitized her hands between residents while feeding both residents. EI # 3 stated no, only if she got up from the table and returned. EI #3 was asked if she touched RI #26 and RI #66's clothes, hands, straw and clothing protector while feeding both residents. EI #3 stated she knew she had not washed her hands when she opened RI #26's straw. EI #3 was asked what was the potential harm of not washing or sanitizing your hands when feeding two residents. EI #3 stated germs from one resident to another resident. An interview was conducted with EI #2, RN/ Infection Control Preventionist, on 1/9/2020 at 1:00 p.m EI #2 was asked if staff should wash or sanitize their hands if they touch one resident's hands, straw, clothes, clothing protectors, or eating utensils before feeding another resident. EI #2 stated probably yes. EI #2 was asked what was the potential harm of not washing/sanitizing hands while feeding two residents a meal at the same time. EI #2 stated they could get sick or get an infection.

Based on observation, interviews and record review, the facility failed to ensure staff: 1) labeled commercially prepared milkshakes with a use-by date after thawed; 2) labeled thickened juice after opening with a use-by date, and discarded each in a timely manner; and 3) were able to accurately calibrate food thermometers prior to use. These findings had the potential to affect 82 residents who received meals and/or supplements from the facility at the time the survey. Findings Include: The facility policy regarding Labeling and Dating provides the following guidelines: All foods should be dated upon receipt before being stored. Food labels must include: The food item name The date of preparation/receipt/removal from freezer Items that are removed from a labeled case in the freezer and placed in the refrigerator for thawing should be labeled with the date of removal from the freezer. This policy then identified a refrigerated storage (40 degrees Fahrenheit) life of 14 days. 1) During the initial kitchen tour, on 03/20/18 at 2:35 PM, eight commercially prepared, four-ounce (oz) cartons of thawed milkshakes were stored in the reach-in refrigerator, with no use-by date. 2) On 03/21/18 at 9:45 AM, the Dietary Manager, Employee Identifier (EI) #4, accompanied the surveyor to the front hall nursing station's nourishment refrigerator. The refrigerator contained: a) three, four-oz commercially prepared (thawed) milkshakes in the door of the refrigerator, with no use-by date. EI #4 stated she did not know where the shakes came from, but affirmed the shakes were good for 14 days after thawed, and should be dated. b) One eight oz glass of clear, orange colored beverage, was stored uncovered, in the refrigerator. EI #4 immediately removed the beverage from the refrigerator. c) One carton of commercially prepared nectar-thickened orange juice was stored without an open date. The carton of juice was stamped as good until 4/11/18, but a date of 12/8 and DC (discard?) 12/23 was written on the side of the container. EI #4 was unsure if it was still good, and immediately discarded it. At 10:00 AM, the Consultant Licensed, Registered Dietitian (EI #5) examined the juice container at the nourishment refrigerator. EI #5 explained once opened, the instructions on the carton specified to discard the product within seven days, and pointed out the printed directions on the side of the carton. EI #5 affirmed the item was supposed to be labeled with a discard date after opened. EI #5 was not able to determine what the written dates on the side of the juice carton meant. The Dietary Manager (EI #4) explained that 12/8 was the delivery date, and 12/23 was possibly the discard date. 3) The facility's directions, and previous inservice education provided to staff on 10/04/17, regarding thermometer calibration, detailed the following: How to Calibrate a Thermometer 1. Fill a large container with crushed ice. Add clean tap water until the container is full. Stir the mixture well. 2. Put the thermometer stem or probe into the ice water . Wait 30 seconds or until the reading stays steady. 3. Adjust the thermometer so it reads 32 degrees Fahrenheit or F (0 degrees Centigrade). Hold the calibration nut securely with a wrench or other tool and rotate the head of the thermometer until it reads 32 degrees F (0 degrees C). On 03/21/18 at 3:45 PM, four thermometers were resting in a glass of ice water. The thermometers registered 60, 44, 28, and 28 degrees F. At this point the surveyor questioned the Cook/Aide, EI #6 as to the temperature she wanted each thermometer to read in the ice water (to calibrate). EI #6 explained the thermometer should read below 32 degrees. When asked why, EI #6 had no response. At this point, staff handed the Cook (EI #6) sanitizing pads. EI #6 proceeded to check the food temperatures on the tray line. On 3/21/18 at 4:05 PM, the surveyor questioned EI #6 as to what the reading of each thermometer should be when in ice water (to determine the thermometer's accuracy). EI #6 responded, 35 to 40 degrees (Fahrenheit), to kill bacteria.

Based on observations, interviews, medical record reviews and reviews of facility policies titled, Standard Precautions and Hand Hygiene, the facility failed to ensure licensed staff: 1. washed hands before applying gloves for Resident Identifier (RI) #22, 2. washed hands before applying gloves for RI #180, 3. did not turn off faucet with bare hands after handwashing for RI #46, and 4. washed hands before applying gloves during RI #62's wound care and did not return a bottle of wound cleanser to the treatment cart that was placed on RI #62's bathroom sink. These deficient practices affected RI #22, RI #46, RI #180, three of six residents observed during the medication administration observation and RI #62, one of one residents observed during wound care. Findings Include: 1.) A review of a facility policy titled, Standard Precautions with a revision date of 11/28/17, revealed: .3. Change gloves .3.1 Between tasks and procedures on the same individual and after contact with material that may contain a high concentration of microorganisms; 3.2 After contact with patient and/or surrounding environment (including medical equipment); . A review of a facility policy titled, Hand Hygiene with a revision date of 11/28/17 documented: .1. Perform hand hygiene: 1.1 Before patient care; .1.5 After contact with the patient's environment. RI #22 was admitted to the facility on [DATE] and readmitted [DATE], with [DIAGNOSES REDACTED]. On 03/21/18 at 10:12 a.m., Employee Identifier (EI) #9, Registered Nurse (RN), was observed during medication pass observation for RI #22. The surveyor observed EI #9 put sanitizer gel on her hands then go through all the drawers in the medication cart picking up medications until the topical gel was located for RI #22. EI #9 then assisted RI #22 by pushing her/his wheelchair with her bare hands and applied gloves to administer a topical gel to RI #22's knees. On 03/21/18 at 10:25 a.m., an interview was conducted with EI #9. EI #9 was asked did she wash her hands before applying gloves after she went through the medication cart drawers to locate RI #22's topical medication and pushed her/his wheelchair with her bare hands. EI #9 said no. EI #9 was asked, what was the concern with not washing her hands after touching potentially contaminated objects before applying her gloves to administer RI #22's topical gel. EI #9 replied infection control. 2.) RI #180 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. On 03/21/18 at 10:27 a.m., EI #10, RN, was observed during medication administration observation for RI #180. The surveyor observed EI #10 wash her hands and move RI #180's wheelchair to the right side of the bed using her bare hands. Then EI #10 was observed applying gloves without washing her hands to obtain RI #180's Fingerstick Blood Sugar (FSBS). On 03/21/18 at 10:42 a.m., an interview was conducted with EI #10. The surveyor asked EI #10 did she wash her hands after she pushed RI #180's wheelchair to the other side of the bed before applying her gloves to check RI #180's FSBS. EI #10 said no she did not. EI #10 was asked should she have washed her hands before putting on her gloves. EI #10 replied yes. EI #10 was asked what was the concern with not washing her hands before applying gloves. EI #10 answered infection control. 3.) RI #46 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 03/22/18 at 9:31 a.m., EI #13, Licensed Practical Nurse, was observed during medication administration observation for RI #46. EI #13 was observed washing her hands and turning off the faucet with her bare hands. On 03/22/18 at 9:37 a.m., an interview was conducted with EI #13. EI #13 was asked how she turned off the faucet after washing her hands. EI #13 said with my hand. EI #13 was asked what was the concern in turning off the faucet with her bare hand after handwashing. EI #13 answered infection control. 4.) RI #62 was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. On 03/21/18 at 2:50 p.m., EI #14, RN/Assistant Director of Nursing/Treatment Nurse was observed performing wound care for RI #62. The surveyor observed EI #14 wash her hands in the bathroom, pick up a box of gloves and place them on the overbed table, pull RI #62's privacy curtain, and touched RI #62 on the left shoulder. EI #14 was then observed applying gloves to perform wound care without washing her hands. On 03/21/18 at 3:17 p.m., an interview was conducted with EI #14. EI #14 was asked when should she wash her hands when using gloves. EI #14 said before she puts the gloves on and when she takes them off. EI #14 was asked did she wash her hands before applying gloves after she picked up a box of gloves, pulled RI #62's privacy curtain and touched the resident on the left shoulder. EI #14 replied no because she thought it was still part of setting up the field and getting ready. EI #14 was asked should she touch any potentially contaminated object after washing her hands and prior to applying gloves. EI #14 said no. EI #14 was asked did she place the bottle of wound cleanser on the back of RI #62's sink without a barrier and then take the container back out to the treatment cart and put it in a drawer without cleaning it. EI #14 answered yes she did do that and she thought when she did that she should not have done it.

Based on observation, interview and review of the Task List Report, the facility failed to ensure nail care was provided as needed for Resident Identifier (RI) #187. This affected one of 20 sampled residents, dependent upon staff for the provision of nail and hygiene care. Findings Include: RI #187 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/09/18, identified RI #187 as being in need of supervision with the support of one staff member for personal hygiene needs, including hand care. The resident was acknowledged in the 03/02/18 care plan to require assistance with or/total dependence upon staff for care in personal hygiene due to generalized weakness and dementia. On 03/20/18 at 4:50 PM, RI #187, a visually impaired resident, received the supper tray, and with the direction of a staff nurse, fed self the meal with his/her fingers. On 03/22/18 at 8:49 AM, the surveyor observed RI #187's fingernails to be long (1/4 to 1/2' in length beyond the fingertips) with a significant amount of hardened debris beneath the nails. The breakfast tray had been completed and taken from the room. On 03/22/18 at 8:59 AM, a Registered Nurse (RN) Employee Identifier (EI) #10 entered the room with RI #187's medications. At the conclusion of the medication administration, the surveyor asked EI #10 to look at RI #187's fingernails. When asked, EI #10 explained the resident's contract aide provided baths twice a week, but did not specify who was responsible for the cleaning and trimming of fingernails. The surveyor asked EI #10 how she would describe the nails and what could be done. EI #10 did not describe the nails, but explained the resident ate with his/her hands frequently. EI #10 said she would take care of the matter. The Task List Report, initiated on 03/02/18, specified the provision of personal hygiene every day, every shift: Day, Night, Evening. On 03/22/18 at 2:26 PM, the Unit Supervisor, EI #11, was questioned regarding RI #187's response to personal care. EI #11 explained RI #187 used bad language at times, but was receptive to care. When asked why the resident's nails had not been trimmed and cleaned before this morning, EI #11 did not know.

Based on observation, interview and a review of facility policies titled, Food and Nutrition Services USE BY Dating Guidelines, Cleaning Procedure WareWashing, Manual, Cleaning Schedule and the U.S. Public Health Service 2013 Food Code, the facility failed to ensure the following: 1. items in the reach in and walk in cooler were labeled to include a use by date, 2. jello in the walk in cooler was discarded after the use by date, 3. pans were not stacked together to dry after washing and 4. the kitchen floor and kitchen equipment were free of food and debris. This was observed on 5/23/17 and 5/24/17 and had the potential to affect 71 of 72 residents receiving meals from the kitchen. Findings Include: A review of a policy titled, FOOD AND NUTRITION SERVICES USE BY DATING GUIDELINES with a revised date of 12/01/15, documented the following: .Day of preparation or opening is considered Day 1 in the use by date . A review of a policy titled, Cleaning Procedure WareWashing, Manual with a revised date of 12/01/15, documented the following: .9. Place ware on drain board, inverted to drain and air dry; do not wipe dry . A review of a policy titled, Cleaning Schedule with an effective date of 07/01/98, documented the following: .PURPOSE To maintain a clean and sanitary Food and Nutrition Services Department and prevent the growth of bacteria .4 employees clean the assigned equipment/area as scheduled following the established cleaning procedures . A review of U.S. Public Health Service 2013 Food Code 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. documented the following: . (D) A date marking system that meets the criteria stated . (2) Marking the date or day of preparation, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, . or discarded . On 5/23/17 at 1:20 p.m., during the initial tour of the facility, the Surveyor made the following observations: 1. a jar of cherries in the reach in cooler with a came in date of 5/12 and open date of 5/17, 2. a box of opened lettuce and a bottle of ham base in the walk in cooler with no use by date observed, 3. a pan of green Jello with a use by date of 5/22, 4. two deep pans and three large baking pans stacked together drying and 5. dirt and debris was observed under the vegetable sink and on kitchen floor. On 5/24/17 at 11:10 a.m., the Surveyor made the following observations: 1. two pans and three baking pans were stacked together drying, 2. the plate warmer with crumbs on top near clean plates and 3. food and debris behind tray line, under sink and on kitchen floor. An interview was conducted with Employee Identifier (EI) #1, Dietary Manager, on 5/24/17 at 2:55 p.m. EI #1 was asked how the cherries in the reach in cooler should be labeled. EI #1 stated they should have an open and use by date. EI #1 stated 5/12 was the date they came in and 5/17 was the open date. EI #1 stated there was no use by date. EI #1 was asked about the ham base and lettuce observed in the walk in cooler. EI #1 stated the ham came in on 5/19 and had not been opened and the lettuce came in on 5/17. EI #1 stated the items should have a use by date. EI #1 was asked if the jello in the walk in cooler with a date of 5/16 and 5/22 was correct. EI #1 stated 5/16 was the day it was made and 5/22 was the day it should have been discarded. EI #1 further stated it should have only been kept three days. EI #1 was asked what was the potential harm of not labeling food with a use by date and keeping food past the use by date. EI #1 stated you would not want to use food past the use by date because the food could be spoiled. EI #1 was asked how pans should be dried. EI #1 replied they have to air dry. EI #1 further stated if pans were stacked together they can not air dry. EI #1 was asked what was the harm of not drying pans correctly. EI #1 replied they could be put up wet. EI #1 was asked what was the potential harm of crumbs on the plate warmer near clean plate. EI #1 replied sanitization issues. EI #1 was asked what was the problem with food and debris being on the floor in the kitchen. EI #1 replied sanitization issues.

Based on observation, a review of a dietary documents, interview and a review of facility policy titled, Food and Nutrition Services Policies and Procedures .Meal Serviceand Food and Nutrition Services Policies and Procedures .Food Handling, the facility failed to ensure residents who received a pureed diet and a regular diet with ground meat received the correct portion sizes for the lunch meal on 5/24/17. This affected 27 of 71 residents who received meals from the kitchen. Findings Include: A review of a facility policy titled, Food and Nutrition Services Policies and Procedures .Meal Service with an effective date of 07/01/98, documented: .Meals are served accurately .1.5 Serving utensils are gathered based on portion sizes that appear on the menu guides . A review of a facility policy titled, Food and Nutrition Services Policies and Procedures .Food Handling with an effective date of 7/1/98, documented: .4. Appropriate utensils are used to serve food and vary according to the type of food served (tongs, scoops, spoodles and ladles, etc.) . A review of the Week At A Glance Report documented the following: .Dys (dysphagia) Puree .WED 24 (Wednesday) Puree Chicken Filet, Bread 1 serv (serving) .Puree Seasoned Potato 1 #10 sc (scoop) .Regular Liberalized GrdMt (ground meat) WED 24 .Chicken Filet sandwich, Grd (ground) 1 each . A review of a document titled, Menu Nutrient Analysis Report documented the following: .Menu: Dys Puree Date Wed May 24, 2017 .Lunch Puree Chicken Filet,Bread 1 serving .Puree Seasoned Potato Wedges 1 #10 scoop .Menu: Regular Liberalized GrdMT Date Wed May 24, 2017 .Lunch Chicken Filet Sandwich, Grd (ground) 1 each . A review of a document titled, Puree Chicken Filet, Bread documented the following: .2 To serve, portion #12 scoop chicken a #8 scoop bread . A review of a document titled, Chicken Filet Sandwich, Grd documented the following: .2 To serve, portion #12 scoop . A review of a document titled, FOOD AND NUTRITION SERVICES SCOOP SIZES documented the following: Number 8 .Volume 4oz (ounces) .Number 10 .Volume 3 oz .Number 12 .Volume 2 3/4 oz .Number 20 .Volume 1 1/2 oz . On 5/24/17 at 11:30 a.m., the Surveyor observed the kitchen staff plating the following items: Ground Chicken using a #20 scoop Pureed Bread using a #12 scoop Pureed Mashed Potatoes using a #12 scoop Pureed Chicken using a #20 scoop. An interview was conducted with Employee Indentifer (EI) # one, Dietary Manager on 5/24/17 at 2:55 p.m. EI #1 was asked how much meat residents received if the staff used a #20 scoop to serve the pureed chicken and ground chicken at lunch on 5/24/17. EI #1 stated 1.6 oz's (ounces). EI #1 was asked how many ounces of meat should the residents receiving pureed chicken and ground chicken have received. EI #1 stated 2.67 oz using a #12 scoop. EI #1 was asked if the residents received the correct amount of food. EI #1 stated no. EI #1 was asked what scoop should have been used for the pureed bread. EI #1 stated # 8 scoop. EI #1 one was asked what was the potential harm of residents not receiving the correct amount of food. EI #1 stated weight loss.

Based on observations, interviews, and review of the facility's preplanned menu and recipes, the facility failed to ensure the 05/06/2015 breakfast meal was served as planned. Residents did not receive scrambled eggs with cheese as planned and pureed eggs and pureed bread were served with the wrong portioning utensil resulting in a smaller than planned portion size. Also, grits were not prepared in accordance with the facility's recipe to ensure the nutritive content was maintained. This had the potential to affect all 81 residents receiving meals from the kitchen. Findings include: Review of the facility's "Production Worksheet Report" for the 05/06/2015 breakfast meal revealed scrambled eggs with cheese was the planned entree. Also, residents were to receive a serving of grits. 5 residents were listed as receiving a pureed diet. The production sheet specified residents were to receive a #12 (1/3 cup) scoop of pureed scrambled eggs with cheese and a #12 (1/3 cup) scoop of pureed cinnamon bread. The facility's recipes for the pureed eggs and the pureed cinnamon bread also indicated the portion size size should be one #12 (1/3 cup) scoop. The facility provided the following recipe for the grits: "... 40 Servings Amount... Water, Hot... 1-3/4 gal (gallon) (Note: Equivalent to 7 quarts)... Cereal, Grits... 1-1/4 qt (quarts)... In a stockpot, bring water to a boil. Gradually stir in grits using a wire whip. Stir constantly until cereal thickens..." During trayline observations on 05/06/2015 beginning at 6:02 AM, the surveyor noted the eggs served to residents did not have cheese as planned for the day. Also, the surveyor noticed the grits had a very watery consistency. Employee Identifier (EI) #1, the cook, was serving both the pureed eggs and pureed bread with a #20 scoop (1/5 cup), a little more than half of the planned portion size. At 8:10 AM, after all residents were served, EI #3, the Food Service Director (FSD), referred to the menu and said they were supposed to serve cheese eggs but had done the wrong thing. Also, EI #1, the cook, told the surveyor she had not measured the water used for the grits but had instead filled a pan three quarters of the way full with water and added four cups of grits. The FSD measured and stated three quarters of the pan the cook used would be about 6 quarts of water, which was too much. EI #3, the FSD, was interviewed on 05/07/2015 beginning at 8:10 AM. EI #3 stated the pureed eggs should have been served with a #12 scoop per the production list. He also said that if a #20 scoop was used they were not portioning correctly and would not have given enough. When asked about the preparation of the grits, EI #3 stated the grits were runny because the had used about a quarter cup less grits than was needed for the amount of water used. The surveyor then asked what serving size had been planned for the pureed bread. EI #3 stated a #12, and said if a #20 scoop was used they would have been underportioning. The surveyor then specifically asked how residents receiving a pureed diet could be affected if they received a smaller portion than was planned of pureed eggs and bread and watery grits. EI #3 stated weight loss. EI #4, the facility's Registered Dietitian, was interviewed on 05/07/2015 beginning at 10:05 AM. EI #4 said the FSD told her they had served plain scrambled eggs instead of the scrambled eggs with cheese as planned. EI #4 explained the cheese would provide more nutrients because it is a good source of calcium, protein, and sodium. When asked how using the wrong amount of water to prepare the grits could affect the food, EI #4 said residents would be getting less and the nutritional density would be decreased because it was diluted. When asked what portion size should have been used for the pureed eggs and bread, EI #4 said a #12 scoop, equivalent to 1/3 cup. EI #4 said if a #20 scoop was used instead of a #12 for the pureed eggs, residents would be receiving less calories and protein. EI #4 also said if a #20 scoop was used for the pureed bread, residents would be getting less carbohydrates than planned. The surveyor then specifically asked how residents receiving a pureed diet could be affected if they received a smaller portion than was planned of pureed eggs and bread and watery grits. EI #4 explained it would decrease the amount of nourishment the residents were receiving.

Based on observations and interviews, the facility failed to ensure scrambled eggs and sausage served for the 05/06/2015 breakfast meal were at a temperature palatable to residents. The facility further failed to ensure the grits were served with a desirable flavor and consistency. This had the potential to affect all 81 residents receiving meals from the kitchen. Findings include: On 05/05/15 at 8:25 AM, during the initial tour and the breakfast meal, an unsampled resident was asked if she had tasted her eggs. She replied yes and they were cold. The roommate commented she told dietary to quit sending her eggs because they were always cold. Another unsampled resident was asked about her eggs. She commented they were not cold but not very warm either. On 05/05/15 at 3:00 PM, in a Resident Council Group Meeting, 3 out of 10 in attendance stated they had received cold eggs on several mornings. The surveyor entered the kitchen on 05/06/2015 at 6:02 AM to observe trayline proceedings. At 7:03 AM, Employee Identifier (EI) #1, the cook, opened the plate warmer but no heat was coming from the unit even though it was turned on. EI #1 stated it should heat the plates and then bumped and shook the plate warmer to get it to come on. EI #1 stated that happened sometimes. Eight minutes later, at 7:11 AM, the cook began plating trays. Dietary staff were observed utilizing insulated bases and lids; however after 13 trays were placed on the last closed cart, EI #2, a Dietary Aide, began covering the plates with plastic wrap. EI #2 stated they use the plastic when they run out of the insulated lids. At 8:08 AM, the last resident was served, and at 8:10 AM, the surveyor, along with EI #3, the Food Service Director (FSD), performed a test tray. Upon tasting the grits, EI #3 stated they were bland but warm. The surveyor agreed, but added the grits were runny. The surveyor described the scrambled eggs as lukewarm and said she would prefer them hotter. EI #3 tasted the sausage and said he would prefer it warmer. The surveyor agreed and described the sausage as cold. The temperature of the sausage was 90 degrees Fahrenheit. On 05/06/2015 at 7:45 AM, Resident Identifier (RI) #4 was observed during the breakfast meal. RI #4's grits were very watery and thin. RI #4 stated the grits looked like soup or broth, not grits. EI #3, the FSD, was interviewed on 05/07/2015 beginning at 8:10 AM. EI #1 explained the purpose of the plate warmer was to keep plates hot, which in turn kept food warmer. When asked how long prior to plating trays the warmer should be turned on, EI #3 said they turn it on about 5:30 AM when they get there for the day. EI #3 said that if the plate warmer was not working properly, the food would not stay as hot as long. EI #3 also stated the purpose of the insulated lids and bases was to keep food warm. He further stated they did not have enough because the facility had lent theirs to another facility. When asked how not having enough insulated bases and lids could affect the food, EI #3 stated the food would not stay as hot as long.

Based on observations, interviews, and review of facility policy, the facility failed to ensure: 1) items exceeding their use-by-dates (UBD) were discarded; 2) thawed commercial shakes were labeled in a manner such that the UBD was evident; 3) cookies were covered in an attempt to prevent potential contamination; 4) items in the walk-in freezer were stored to prevent potential contamination from water and ice; 5) the dish machine data plate was affixed to the machine in a manner allowing staff to easily access the operating specifications; 6) dietary staff tested the concentration of the Quaternary Ammonium in the three-compartment sink in accordance with manufacturer specifications to ensure accuracy of the results; 7) staff checked the temperature of the ground sausage prior to serving for the 05/06/2015 breakfast meal to ensure a temperature of 135 degrees Fahrenheit (F) or greater; and 8) staff did not use the same gloves to serve bacon, sausage, and toast. These failures had the potential to affect all 81 residents receiving meals from the kitchen. Findings include: 1) Review of the Food and Drug Administration, Food Code 2013, Chapter 3 Food, revealed the following: "...3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD... shall be discarded if it: (1) Exceeds the temperature and time combination specified..." During the initial tour of the kitchen on 05/05/2015 beginning at 7:45 AM, the surveyor noted the following items in the reach-in cooler exceeding their UBDs: Ham Glaze- "Pulled/opened 4/16/15... Use By 4/28/15" Hush Puppy Batter- "Pulled/opened 4/25/15... Use By 5/4/15" Refried Beans- "Pulled/opened 4/27/15... Use By 4/30/15" Honey Mustard Dressing- "Pulled/opened 4/17/15... Use By 4/28/15" Apple Crisp Batter- "Pulled/opened 4/18/15... Use By 4/25/15" Cucumber Dressing- "Pulled/opened 4/20/15... Use By 4/28/15" Balsamic Dressing- "Pulled/opened 4/1/15... Use By 5/1/15" Sandwich bag of Salami labeled "Sol 12-24" Employee Identifier (EI) #3, the Food Services Director (FSD), was interviewed on 05/07/2015 beginning at 8:10 AM. EI #3 stated it was everyone's job to check for UBDs on a daily basis. EI #3 further stated it was important to discard items exceeding their UBDs because they did not want to get anyone sick. 2) Review of a letter from the facility's commercial shake manufacturer revealed the following: "... The Frozen shakes have a one year shelf life from date of manufacture when kept frozen. Once thawed, please use within 14 days..." During the initial tour of the kitchen on 05/05/2015 beginning at 7:45 AM, the surveyor noted 2 individual thawed commercial shakes in the walk-in cooler. The shakes were not labeled with a thaw date or a UBD, only a resident's name. On 05/06/2015 at 12:42 PM, the surveyor observed 3 thawed commercial shakes in the refrigerator located on the hall. The shakes were not labeled with a thaw date or a UBD. EI #3, the FSD, was interviewed on 05/07/2015 beginning at 8:10 AM. When asked about the commercial shakes observed in the kitchen and on the hall without a thaw date or UBD, EI #3 stated he had never seen that as a problem because they label them for snacks. When asked what potential harm could occur if individual cartons of shakes were not labeled with a UBD, EI #3 stated resident safety and potentially expired items. 3) Review of the facility's policy titled "5.6 Dry Storage", revised 04/01/2014, revealed the following: "POLICY Products stored in dry storage areas are maintained in a safe and sanitary manner. PURPOSE To prevent damage, spoilage, contamination and infestation of products. PROCESS... 2. Food Storage: ...2.6 Open packages are stored in closed containers, tightly secured with ties or in food quality storage bags and includes the "use by" date..." During the initial tour of the kitchen on 05/05/2015 beginning at 7:45 AM, the surveyor observed four cookie sheets stacked in a cris-cross fashion one on top of another, containing baked cookies. The cookies were not covered and were open to air. Employee Identifier (EI) #4, the Registered Dietitian, was interviewed on 05/07/2015 beginning at 10:05 AM. EI #4 stated that if storing a cooked item, such as cookies, it would have to be covered to protect the item. 4) Review of the Food and Drug Administration, Food Code 2013, Chapter 3 Food, revealed the following: "...3-303.12 Storage or Display of Food in Contact with Water or Ice. (A) PACKAGED FOOD may not be stored in direct contact with ice or water if the FOOD is subject to the entry of water because of the nature of its packaging, wrapping, or container... 3-305.12 Food Storage, Prohibited Areas. ... (G) ... under lines on which water has condensed ... (I) Under other sources of contamination..." During the initial tour of the kitchen on 05/05/2015 beginning at 7:45 AM, the surveyor noted an accumulation of ice in the top of the walk-in freezer. There were two empty plastic bins under the vents; however, stalactites of ice were noted hanging down from the vents and hanging down below the plastic bins. Below, a cardboard box of green beans was noted with a layer of ice on the top of the box and also frozen down the side. Also, an open box containing plastic bags of broccoli contained a sheet of ice. EI #3, the FSD, was interviewed on 05/07/2015 beginning at 8:10 AM. EI #3 stated the plastic bins in the top of the walk-in freezer were supposed to catch the condensation that comes down from the vents. He stated he had seen the ice on the box of green beans but not the broccoli. EI #3 said ice and/or water should not come in contact with food stored in the freezer because if it came in contact with the food itself it would contaminate it. 5) Review of the Food and Drug Administration, Food Code 2013, Chapter 4 Equipment, Utensils, and Linens, revealed the following: "... 4-204.113 Warewashing Machine, Data Plate Operating Specifications. A WAREWASHING machine shall be provided with an easily accessible and readable data plate affixed to the machine by the manufacturer that indicates the machine's design and operation specifications..." On 05/05/2015 at 1:35 PM, the surveyor observed staff utilizing the dish machine. There was no data plate listing the specifications for usage. The surveyor asked EI #3, the FSD, if there was a data plate on the machine. EI #3 looked and said he did not see one and that the data plate should be where staff can see it. In a follow-up interview with EI #3 on 05/07/2015 at 8:10 AM, EI #3 stated he had to call the vendor for their machine to locate the data plate. EI #3 further explained the data plate was on the bottom side of the machine and said he had to bend all the way down to find it. 6) Review of the manufacturer's wall poster specifying usage for the Quaternary Ammonium revealed the following: "...Food contact surface sanitizer...Three compartment sink sanitizer... Sanitation Range Testing ... Testing solution should be at room temperature - 65°F- 75°F..." The poster depicted that the sanitizer solution should be tested in a separate cup. On 05/06/2015 at 6:10 AM, EI #3, the FSD, was observed preparing the three-compartment sink for future use. The surveyor asked him to notify her when he was ready to test it. At 6:11 AM, EI #3 said he was ready to test the concentration of the sanitizer. EI #3 placed the test strip directly into the sanitizing sink. EI #3 did not test the temperature of the water prior to testing. The surveyor tested the temperature of the water and it measured 130 degrees F. At 6:58 AM, EI #1, the cook, utilized the three-compartment sink to sanitize the scoops used to serve the breakfast meal. EI #3, the FSD, was interviewed on 05/07/2015 beginning at 8:10 AM. EI #3 said that when testing the concentration of the sanitizing solution you should put the water in a small cup and test the water to ensure it is at the proper temperature for testing. 7) Review of a facility document titled "Genesis Food and Nutrition Services October 2011" revealed hot foods should be served at a temperature of 135 degrees F or higher. During trayline observations on 05/06/2015 beginning at 6:02 AM, the surveyor observed EI #1, the cook, obtain temperatures of items on the steam table prior to serving. EI #1 did not check the temperature of the ground sausage prior to serving to residents. At 7:42 AM, the surveyor asked EI #3, the FSD if he had recorded a temperature for the ground sausage. EI #3 said he had not and asked EI #1 if she had checked it. EI #1 said she had not checked it prior to serving. EI #3 then obtained the temperature of the ground sausage, which was at 120 degrees F. EI #3, the FSD, was interviewed on 05/07/2015 beginning at 8:10 AM. EI #3 stated all hot and cold items should be checked to verify safe temperatures 15 to 30 minutes prior to serving. When asked what potential harm could occur if food was served without checking the temperature, EI #3 said that if food was not at the right temperature it did not need to be served because it could potentially cause a health hazard. 8) Review of the facility's policy titled "4.6 Hand Washing", revised 03/16/2015, revealed the following: "... PURPOSE To minimize the spread of disease. PROCESS 1. Hand washing is performed after: ...1.3 after handling any food... 1.5 After contacting any soiled utensils; 1.6 Before touching any clean utensils, plates, cups, or pans; 1.7 When moving from one task to another..." During trayline observations on 05/06/2015 beginning at 6:02 AM, the surveyor observed EI #1, the cook,serving resident trays. EI #1 was observed touching trays, plates, and the handles of all serving utensils with gloved hands. EI #1 also used the same gloved hands to serve bacon, sausage, and toast without utensils. EI #1 did not wash hands or change gloves between items. EI #3, the FSD, was interviewed on 05/07/2015 beginning at 8:10 AM. During the interview, the surveyor described the trayline observations of staff using the same gloved hands to serve bacon, sausage, and toast. EI #3 said, "I would say that is not okay." EI #3 said it could result in potential cross contamination.

Based on interviews and record review, the facility failed to ensure Employee Identifier (EI) #3, EI #4 and EI #6, all Certified Nursing Assistants (CNAs) reported alleged verbal and physical abuse immediately to the administrator. This affected RI #2, one of three residents sampled for abuse. Findings include: RI #2 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set with an assessment reference date of 6/22/14, identified RI #2 as being severely impaired in cognitive skills for daily decision making, with long and short term memory problems. On 7/9/14 at 1:00 PM, EI #3, a CNA, approached a State surveyor in the hallway and stated she was aware of resident abuse in the facility. When asked about the details, EI #3 stated EI #11, a Licensed Practical Nurse (LPN) was verbally abusive to RI #2. According to EI #3 another staff member told her that EI #11 threw RI #2 into a wall. EI #3 further stated two other LPNs were aware of the incident. In a follow-up interview on 7/9/14 at 1:30 PM, EI #3 said EI #11 is always yelling at RI #2. EI #3 stated EI #5, a LPN told her that EI #11 slammed RI #2 into the wheelchair against the wall. When asked if she reported this incident, EI #3 said no because she thought EI #5 and EI #10, both LPNs reported the incident. When asked if she ever heard EI #11 verbally abuse RI #2, EI #3 stated yes. EI #3 stated a couple of days ago at the nurses' station she heard EI #11 say to RI #2 "I am tired of this[***] I can't take this." When asked if she reported this incident to her supervisor, the Director of Nursing (DON) or Administrator, EI #3 said no. When asked why she did not report the incident, EI #3 stated she didn't feel comfortable going to the DON or Administrator. EI #3 was asked if she should have reported it and she said yes. In an interview on 7/9/14 at 1:45 PM, EI #4, a CNA stated she could not recall the exact day but she witnessed EI #11 slam RI #2 into a wall, while the resident sat in a wheelchair. When asked if she reported this to anyone, EI #4 said no. During an interview on 7/9/14 at 2:10 PM, EI #5, a LPN stated she has never witnessed EI #11 verbally or physical abuse RI #2. On 7/9/14 at 7:20 PM and 7/10/14 at 11:30 AM, EI #10, a LPN was called. On both occasions there was no answer and no voice mail was set up to leave a message. In a telephone interview on 7/9/14 at 6:00 PM, EI #3, a CNA, was asked what time of day did the incident occur. EI #3 stated it happened between 6:00 AM and 9:00 AM the weekend of June 21st (2014). When asked if there were any other witnesses who may have heard or saw EI #11 verbally or physically abuse RI #2, EI #3 stated there were two CNAs, EI #6 and EI #7. During a telephone interview on 7/9/14 at 7:00 PM, EI #7, a CNA, stated she has never witnessed EI #11 verbally or physical abuse RI #2. In an interview on 7/10/14 at 11:45 AM, EI #6, a CNA was asked if she ever observed EI #11 being physically abusive to RI #2. EI #6 said yes. EI #6 stated while RI #2 sat in the wheelchair, EI #11 slammed the wheelchair into the wall. When asked when did she observe this, EI #6 stated everyday. When asked had she reported this incident to anyone, EI #6 said no. EI #6 was asked if she considered this incident abuse and she said yes. When asked what she was supposed to do, EI #6 said report it. When asked if she followed the facility's policy, EI #6 said no. EI #6 stated she did not report it because other people on hall see it. EI #6 also stated she had witnessed EI #11 be verbally abusive to RI #2 but did not report it to the DON or Administrator. During an interview on 7/10/14 at 1:30 PM, EI #11, a LPN denied all the allegations against her. EI #11 stated she did not verbally or physically abuse RI #2. During an interview on 7/10/14 at 7:00 PM, EI #9, the Administrator, who is also the Abuse Coordinator, stated she was informed today by EI #3 and EI #4 of the alleged verbal and physical abuse of RI #2 by EI #11. When asked what was the staff expected to do when they are made aware of verbal and physical abuse, EI #9 stated the staff is suppose to report it. EI #9 stated all the employees have been placed on suspension for failure to report. This deficiency was cited as a result of the investigation of complaint/report number AL 336.

Based on observations, interview, and record reviews, the facility failed to ensure Employee Identifier (EI) #12, a Registered Nurse (RN) cleaned the bandage scissors before cutting two [MEDICATION NAME] pads and two 12-inch plain packing strips to dress Resident Identifier (RI) #5 and RI #12's open wounds. This affected RI #5 and RI #12, two of two residents observed for wound care. Findings include: The facility's policy and procedure titled "IC201 Cleaning and Disinfecting" with a revision date of 10/01/13, documented "... PURPOSE To prevent infectious spread from items or environment to patients and/or staff. PRACTICE STANDARDS ... 4. Perform routine disinfection of items used in daily care practices ... 4.2 Multi-patient equipment must also be cleaned/disinfected between patients ... ." RI #5 was admitted to the facility on [DATE]. RI #5's Significant Change Minimum Data Set (MDS) with an assessment reference date of 3/8/14, indicated the resident had two Stage II pressure ulcers. During the provision of RI #5's wound care on 7/9/14 at 4:20 PM, EI #12, a RN gathered wound care supplies from the treatment cart for a wound care dressing change. EI #12 placed the bandage scissors into a clear Ziploc bag without cleaning the scissors with a disinfectant wipe. EI #12 cut one [MEDICATION NAME] with the scissors and placed the patch on the resident's open wound. RI #12 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Significant Change MDS with an assessment reference date of 6/10/14, identified RI #12 as having one Stage II pressure ulcer. During the provision of RI #12's wound care on 7/10/14 at 12:10 PM, EI #12 obtained a clear plastic Ziploc bag that had supplies in it: scissors, a sharpie, and integrity wound cleaner and placed them on the barrier without cleaning the scissors with an disinfectant wipe. EI #12 cut two 12-inch packing strips and an [MEDICATION NAME] with the scissors and placed the packing strips into and onto the resident's open wound. In an interview on 7/10/14 at 2:15 PM, EI #12, a RN, was asked if the scissors should have been cleaned prior to wound care, EI #12 stated yes. When asked what was the potential harm in using unclean scissors for dressing changes and EI #12 stated, "Causes infection." During an interview on 7/10/14 at 2:30 PM, EI #13, the Infection Control RN, stated the scissors should be cleaned before and after the dressing is changed.

Based on observation, interview and record review, the facility failed to ensure incontinence care was provided for RI (Resident Identifier) #3 in a manner to prevent potential cross-contamination by cleaning from the rectal area to the vaginal area. This affected one of three residents observed during incontinence care. Findings include: RI #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The significant change MDS (Minimum Data Set) dated 04/24/2013 assessed RI #3 as being totally dependent on one person for toileting and personal hygiene. RI #3 was also assessed as being incontinent of bladder and bowel. A review of the "Clinical Competency Validation Perineal Care" (last revised 03/2011) revealed: "...3. If present, removes feces with toilet paper by wiping from the front of perineum toward the rectum. ... 4. Cleanses perineum with perineal cleanser by wiping from the front of the perineum to toward the rectum. ..." On 06/12/2013 at 9:40 AM, a CNA (Certified Nursing Assistant) EI (Employee Identifier) #2 was observed providing incontinence care for RI #3. EI #2 removed RI #3's brief and cleaned RI #3. EI #2 positioned RI #3 onto her side, at which time a moderate amount of bowel movement was noted on the resident's buttock, rectal area and the brief. With a clean wet wipe, EI #2 wiped RI #3 from the rectal area toward the vaginal area three times, using different wipes each time. After the observation, EI #2 was asked if she knew what she had done wrong. EI #2 stated that she had washed down to the vaginal area instead of up to the rectal area. When asked why this was important, she stated it was to prevent infections. The DON (Director of Nursing) EI #1, was interviewed on 06/13/2013 at 2:00 PM. EI #1 was asked why it was not a good plan to wipe a resident with stool from the rectal area to the front. EI #1 stated it was not the facility's policy, it could cause E Coli infection and a UTI (Urinary Tract Infection).

Based on observation, interview and record review, the facility failed to ensure medication was prepared and administered in a manner to prevent potential cross- contamination for RI (Resident Identifier) #7. The nurse failed to wash her hands, failed to put on gloves, and placed a needle cap into her mouth. This affected one of three residents observed during medication pass. Furthermore, the facility failed to ensure wound care was provided for RI #2 in a manner to prevent potential cross-contamination by not cleaning her scissors before and after using them to cut away a soiled dressing. This affected one of two residents observed for wound care. Findings include: A review of the facility's policy for administering subcutaneous injections (not dated) revealed: "...1 Perform hand hygiene. ... 7 Apply clean gloves. ... 15 Remove needle cap by pulling it straight off. ... 21 Remove gloves, and perform hand hygiene. ..." A review of the facility's policy for administering eyedrops (not dated) revealed: "...1 Perform hand hygiene, and arrange supplies at bedside; apply clean gloves. ...Reduces transmission of microorganisms; ensures a smooth, orderly procedure. ..." A review of the "Skin Integrity Care Delivery Process," dated 10/01/2010 revealed: "...Use appropriate infection control including: Standard Precautions. ..." On 06/11/2013 at 4:15 PM, a medication pass was observed on RI #18. The LPN (Licensed Practical Nurse) EI (Employee Identifier) #4, was observed to open the insulin syringe package and place the tip of the needle cap into her mouth to remove the cap. EI #4 then removed the cap from her mouth and placed the contaminated cap onto the top of the medication cart. After she drew up the insulin into the syringe, she replaced the cap onto the syringe and placed it on top of the medication cart while she prepared the other medications including another subcutaneous injection. EI #4 entered RI #18's room and placed the two syringes, medication cup and the eye drops onto the overbed table. EI #4 administered the insulin without applying gloves. Before she administered the second subcutaneous injection, she donned gloves but did not wash her hands. After administering the two injections, without washing her hands, she applied gloves and administered the eye drops. An interview with EI #18 took place immediately after the above observation at 4:30 PM. EI #18 was asked why it was not a good idea to place the needle cap in her mouth. EI #18 said it was an infection control issue. The surveyor asked why she did that. EI #18 said she just was not thinking. The surveyor asked why she should use gloves to administer an injection. EI #18 said to prevent infection, transfer of germs from her hands to the resident. Then she was asked what was the concern of lying the syringe on the medicine cart and on the resident's overbed table after it had been in her mouth. EI #18 said it contaminated the surfaces. EI #18 was asked why she did not put on gloves to administer the first injection. EI #18's reply was she just forgot. On 06/13/2013 at 2:00 PM, the Director of Nursing (DON), EI #1, was interviewed. EI #1 was asked when should a nurse wash her hands when administering medication. EI #1 stated before and after administering medications. EI #1 was asked when the nurse would wash her hands if there were two injections and eyedrops to be administered. EI #1 stated before she starts, between the injections, before the eye drops and when she finishes. EI #1 was asked what the policy was for wearing gloves during administration of injections. EI #1 stated the policy was to wash hands first, put on gloves, administer the injections, remove the gloves, and wash her hands. On 06/12/2013 at 8:45 AM, wound care was observed for RI #2. The RN (Registered Nurse) (EI #5) removed her scissors from her pocket and without cleaning them, cut the soiled dressing from RI #2's right heel, potentially contaminating the wound. After cutting the dressing away, EI #5 returned the contaminated scissors to her uniform pocket. EI #5 was interviewed on 06/12/2013 at 9:00 AM. EI #5 was asked when she should clean her scissors. EI #5 stated they should be cleaned before and after use. When asked why she had not done that she stated she forgot.

Based on observation and interview, the facility failed to ensure A/C (Air Conditioning) filters were free of dust-like residue, doors were free of scratches and gashes, and a night stand was free of stuck-on debris. This affected two of three units in the facility. Findings include: On 06/11/13 at 3:00 PM, during the initial tour of the facility, RL (Room Locator) #15's night stand had a white substance stuck all over the top of it. On 06/11/13 during the initial tour of the facility at 3:00 PM, the following was observed: RL #1 had a dusty A/C filter, fully covered with lint and dust, the bathroom door was scratched up on the inside and outside. RL #2 had a large accumulation of dust (dark gray) on the A/C filter. RL #3 had a large accumulation of dust on the A/C filter and there were large gashes and scratches in the door. RL #4 had a large accumulation of dust on the A/C filter and gashes on the inside of the bathroom doors. RL #5 had a large accumulation of dark gray dust on the A/C filter. RL #6 had a large accumulation of dark gray dust on the A/C filter. RL #7 had a large accumulation of dust on the A/C filter. RL #8 had a large accumulation of dust on the A/C filter and the bathroom doors were scratched. RL #9 had a large accumulation of dust on the A/C filter. RL #10 had a large accumulation of dust on the A/C filter. RL #11 had a dusty A/C filter and the doors were scratched. RL #12 had a dusty A/C filter and the bathroom door had a gash in it. On 06/12/13 at 7:55 AM, RL #13's A/C filter contained a large accumulation of dust-like residue. On 06/12/13 at 10:40 AM, RL #14's A/C filter contained a large accumulation of dust-like residue. On 06/12/13 at 2:50 PM, RL #15's A/C filter contained a moderate amount of dust-like residue. On 06/13/13 at 10:43 AM, the Maintenance Director, EI (Employee Identifier) #3 was asked who was responsible for cleaning or replacing the air conditioner vents/filters. He said the maintenance department was. EI #3 was asked what he does. He said he removes the filters, cleans them, then puts them back. EI #3 was asked how often he cleans them. He said about once a month. EI #3 was asked if he was aware that some of the filters were extremely dusty. He replied, "No." EI #3 was asked if he completed a routine walk-through. He said he fixes things as he sees them and as things are reported. EI #3 and the surveyor went to RL #13 and observed the A/C filter. EI #3 said they had not cleaned the filters yet for this month. EI #3 was shown RL #14's A/C filter. EI #3 said maybe they need to clean them every week. EI #3 was shown RL #3 and RL #4's scratched doors. EI #3 said he could put a kick plate on the doors to protect them from scratches and gashes.

Based on observation, interview and record review the facility failed to ensure that a tube feeding did not continue to infuse while the head of the bed was lowered to a flat position during incontinence care. The head of the bed was lowered for forty minutes on 06/15/11 while Resident Identifier (RI) # 9 was provided incontinence care. This affected RI #9, one of two sampled residents with tube feedings and one of six residents receiving tube feedings in the facility. Findings include: RI # 9 was readmitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) with an Assessment Reference Date of 02/04/11, identified that the resident had a BIMS (Brief Interview for Mental Status) score of 4. The resident is totally dependent on staff for bathing, dressing, eating, and hygiene. RI # 9 is always incontinent of bowel and bladder. RI # 9 receives more that 51 % of intake by a feeding tube. The Resident Assessment Instrument (RAI) identifies that the BIMS Score is a brief screener that aids in detecting cognitive impairment. A score of 0-7 indicates severe impairment. A review of RI # 9's care plan, with a review date of 05/20/11, documented as follows: "Focus, Tube required to assist resident in maintaining or improving nutritional status related to [MEDICAL CONDITION] dysfunction..." Interventions included "...Maintain resident in 45 degree upright position." A review of the "Active Orders for June, 2011," documented as follows: "...Two Cal (Calorie) (symbol for at) 25 cc (cubic centimeters) x (times) 22 hrs (hours). RI # 9 was observed on 06/15/11 at 9:50 AM, lying in bed with the head of the bed elevated and receiving a tube feeding of two Cal HN (High Nitrogen) at 25cc per hour by a tube feeding pump. Two CNAs (Certified Nursing Assistants), Employee (EI) # 1 and EI # 2 entered RI # 9's room and began to provide incontinence care. EI # 2 lowered the head of the bed to a flat position with the tube feeding still infusing. The head of the bed was observed to be in the lowered position for forty minutes with the tube feeding infusing while the CNAs provided incontinence care. At 10:30 AM, after completing care, the CNA, EI # 2, raised the head of the bed to an elevated position. A sign was observed to be posted on the wall by RI # 9's bed documenting "Bed must be 30-45 (symbol for degrees) at all times." An interview was conducted on 06/15/11 at 12:10 PM, with EI #2, one of the CNAs observed to provide incontinence care to RI #9. EI #2 acknowledged that she lowered the head of RI # 9's bed and the tube feeding continued to infuse while incontinence care was being provided. An interview was conducted on 06/15/11 at 12:20 PM, with EI #1, the second CNA observed providing incontinence care to RI #9. During the interview EI #1 acknowledged that the head of RI #9's bed was let all the way down and that she should have kept the head of the bed elevated. EI #1 also acknowledged that the tube feeding continued to infuse while incontinence care was being provided. An interview was conducted on 06/16/11 at 2:30 PM, with the Registered Nurse (RN), EI # 3, responsible for staff development. She was asked how CNAs are trained to provide ADL (Activities of Daily Living) care to residents with tube feedings. EI # 3 said the head of the bed should be elevated. She said if there is a reason to let the head of the bed down, the tube feeding should not be infusing because of the risk of aspiration. A review of the facility's policy, "Enteral Nutrition," not dated, documented as follows: "...Planning...Step 6. Place client in high-Fowler's position, or elevate head of bed as least 30 degrees. RATIONALE...Elevated head helps prevent aspiration."

Based upon observation, interviews, record review, review of the facility's policy and procedure, and the Center's for Disease Control and Prevention hand hygiene guidelines, the facility failed to ensure that staff utilized proper hand hygiene and gloving practices to prevent potential cross-contamination. This deficient practice affected Resident Identifier (RI) #3, 1 of 3 sampled residents. Findings include: RI #3 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS with an Assessment Reference Date (ARD) of 11/15/2010 reveals that RI #3 is rarely/never understood; modified independence regarding tasks of daily life, and dependent on staff for activities of daily living (ADL) assistance, and no skin issues. Potter, P. and Perry, A. (2009) in Fundamentals of Nursing (7th edition) references the CDC's 2002 recommendations ..."If hands are not visibly soiled, use an alcohol-based waterless antiseptic agent for routinely decontaminating hands in all other clinical situations: a. After contact with a client's intact skin (as in taking a pulse or blood pressure or lifting a client)... e. After contact with inanimate objects (including medical equipment) in the immediate area of the client... h. After removing gloves" (p. 655). Review of the CDC's guidelines as cited in Potter and Perry (2009), Fundamentals of Nursing (7th ed.), reveal that.... "gloves should be changed between tasks and procedures on the same client after contact with material that contains a high concentration of microorganisms. Remove gloves promptly after use, before touching non-contaminated items, and environmental surfaces, and before going to another client" (p. 667). Review of the facility's policy and procedure on handwashing dated (October 2009) outlines a list of some situations that require hand hygiene:...after removing gloves or aprons... Under section 2. Entitled gloves reveals.. " change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another patient, and wash hands immediately to avoid transfer of microorganisms to other patients or enivronmental surfaces " ... A wound care observation took place on 2/9/2011 at 10:02 AM for RI #3's left Stage II heel wound. Employee Identifier (EI) #5 was observed to remove the dressing from RI #3' s wound which contained serosanguinous (clear/bloody) and purulent (pus) drainage. EI #5 removed her gloves and put on clean gloves. The surveyor asked EI #5 to explain the drainage she observed. EI #5 removed the dressing from the red bag, and described the drainage as "tan/red". EI #5 removed her gloves, put on clean gloves and measured RI #3's wound. EI #5 removed the glove from her left hand and picked up the marker to write down the measurements on a gauze pad. EI #5 reapplied a clean glove to her left hand and continued to measure the wound as a 2 centimeter (cm) x 2-3.4 cm x 1.7 cm left lateral redden area. EI #5 removed her gloves bilaterally, wrote down the measurements on the gauze sponge, and reapplied clean gloves. EI #5 raised RI #5's left heel to measure the width at 4.9 cm. EI #5 removed her gloves bilaterally, wrote the measurements down, and reapplied clean gloves. EI #5 measured a new area of white slough at 1.4 cm. EI #5 stated that she would inform the physician about the area of redness and slough. EI #5 removed her gloves bilaterally, and wrote measurements down on the gauze sponge. EI #5 proceeded to lower RI #3's head with the bed controls with her ungloved hands. EI #5 applied gloves, raised up the left heel, and stated that the color of the area was better, not strawberry. EI #5 removed her gloves and went to RI #3's restroom to wash her hands. EI #5 reapplied clean gloves and placed the marker in the right pocket of her lab coat. EI #4 proceeded to spray four dressings (4 x (by) 4's) with Dermal Wound Cleanser. EI #5 cleaned the wound 3 times. EI #5 removed her gloves and reapplied new gloves without washing her hands. After applying the triple antibiotic ointment and Kerlix gauze, EI #5 removed her gloves. EI #5 picked up paper on the barrier and proceeded to apply RI #3's sock to his left foot with her ungloved hands. EI #5 applied a clean glove to her right hand and turned off the heater with her left hand. EI #5 reapplied a glove to her left hand and cleaned her scissors and removed her gloves. EI #5 lowered RI #3's head and raised his feet. EI #5 hooked the Dermal Wound cleanser bottle to her lab coat pocket and carried the red bag out with her left ungloved hand. EI #5 had to wait for someone to come and unlock the soil utility room. An interview was conducted with EI #5, the Treatment Nurse on 2/9/2011 at 4:55 PM. The surveyor asked EI #5 about the policy on using gloves. EI #5 stated that she washes her hands when she goes in, washes her hands before the dressing change, and washes her hands when she is finished. The surveyor asked EI #5 about the use of gloves. EI #5 stated that she changes her gloves when she takes off the dressing and changes them before she picks up her pen. EI #5 stated that anytime she is going to touch something that is on the clean field. If my gloves are already dirty, I would want to change them because my final pair of gloves is put on when I apply my final wrap. EI #5 was asked by the surveyor if the facility follows CDC guidelines. EI #5 stated, yes. An interview was conducted with EI #7 the RN, Infection Control Nurse and Staff Development Coordinator on 2/10/2011 at 1:35 PM. During this interview, EI #7 was asked by the surveyor, what are staff taught about the use of of gloves when providing direct patient care? EI #7 stated that anytime you are providing patient care, wash your hands, apply gloves, perform the care, remove the gloves, and wash your hands. EI #7 was asked by the surveyor, if the facility followed CDC guidelines? EI #7 stated, yes ma'am. We do. EI #7 stated that staff have been educated to wash hands anytime removing and reapplying gloves during patient care. The surveyor asked when was the last time staff were inserviced? EI #7 stated, yesterday (2/9/2011). Reveiw of the mandatory in-service training record dated 2/9/2011 reveals that an inservice was conducted on 2/9/2011 during the survey on handwashing. The content and objectives were: "Hands should be washed before and after patient contact. Hands should be washed after glove removal (when changing gloves that becomes soiled during patient care)."

Based upon interviews and record review, and review of the facility's policy and procedure on Interdisciplinary Care Plans, the facility failed to ensure that Resident Identifier (RI) #1 had a care plan initiated to address the red area assessed to her coccyx upon admission 8/17/2010. The facility also failed to ensure that target dates were documented on the impaired skin integrity careplans for RI #1 dated 11/4/2010 and RI #2 dated 1/30/2011. This deficient practice affected 2 of 3 sampled residents. Findings include: Review of the facility's policy and procedure entitled,"Care Plan-Interdisciplinary" and dated 1/08, reveals the following under "Procedure Action Steps: "1. Upon admission the Licensed Nurse initiates a care plan addressing the resident's most immediate needs. 2. The Interdisciplinary Team (IDT) develop care plans within 24 hours of admission addressing the resident's most acute problems... The care plan is comprehensive for each resident including mensurable objectives and timetables to meet resident ' s medical, nursing, and mental and psychosocial needs." RI #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of RI #1's Admission Minimum Data Set ((MDS) dated [DATE] reveals that RI #1 has short and long term memory problems; severely impaired cognitive skills for daily decision making, highly impaired vision, changes in mood, socially inappropriate/disruptive, and resists care. RI #1 is physically dependent for physical functioning and structural problems. There are no limitations in her range of motion or loss of voluntary movement of her extremities. RI #1 is incontinent of bowel and bladder functioning. RI #1's skin condition assessed as a Stage I pressure ulcer. Review of the initial nursing assessment form dated 8/18/2010 reveals that RI #1 was admitted on [DATE] from the hospital. A time was not documented on the form. Also, the Integumentary/Feet section reveals that EI #1 (Assistant Director of Nursing-ADON) indicated that RI #1 did not have any skin/wound conditions present. However, EI #1 documented that RI #1 had a "slight red area" to her coccyx. EI #1 noted,"all skin intact no broken areas noted; slight red area to coxxy" (Coccyx); arrived with Foley cath in place. Review of the initial "Medical Nutrition Therapy Assessment" dated 8/18/2010 reveals that RI #1 had a "tumor in abdomen, slight red area to coccyx." Review of RI #1's "Interdisciplinary Care Plan" with a problem onset date of 11/4/2010 for the problems/issues: Skin integrity impaired actual related to Stage II coccyx risk factors- limited mobility; incontinent of bowel and bladder and decreased [MEDICATION NAME]. The goal is wound will heal without complication or decline. There is no target date for this goal. Also, the approaches listed are: wound care as ordered per Medical Doctor; Measure wound weekly; Place low air loss mattress on bed;.... Assist to turn side-to-side only when in bed... There are no dates as to when these approaches were implemented. There was not a careplan implemented until Nov. 4, 2011 when RI #1 developed a Stage II pressure ulcer. During an interview on 2/09/2011 at 3:15 PM, the surveyor asked EI #2, the RN Unit Manager of the back hall, on her (RI #1's) initial admission, did she have a Stage I wound? EI #2 said, yes; a slight red area according to the admission assessment. EI #2 was asked by the surveyor if any interventions were implemented? EI #2 stated that we routinely use check and change every 2 hours and use a protective barrier; that's our protocol. The surveyor asked EI #2 if this would have been care planned? EI #2 stated that this would have been on her initial care plan. The surveyor asked EI #2 to locate the initial care plan for the Stage I wound. EI #2 and EI #1 the ADON was also present, were unable to locate the care plan for the Stage I wound. During an interview with EI #5, the RN treatment nurse on 2/10/2011 at 9:45 AM, EI #5 was asked by the surveyor, when was it determined that RI #1 had a Stage I pressure ulcer? EI #5 stated on 8/17/2010 it showed a slight red area. She was a small lady. We document and turn from side to side and watch it. If it resolves that night or in a couple of hours, we resolve it and no treatment is necessary. The surveyor asked EI #5 if any interventions were implemented and she stated that she did not see anything. EI #5 was asked by the surveyor if she would normally start a care plan for that stage? EI #5 stated, Yes. I would for a potential for skin breakdown and watch that area. EI #4 was asked if she normally set goals on the care plan and she stated, No; We go 2 weeks. EI #5 continued by saying that we don't set a date because no one is going to heal on a certain pattern or in the same time. What we look for as long as the wound is showing improvement and is not measuring the same... During an interview with EI #4, the Director of Nursing on 2/10/2011 at 3:05 PM, the surveyor asked EI #4 if she would expect a nursing care plan on a resident with a Stage I wound (red area)? EI #4 said yes. The surveyor asked EI #4 what type of interventions would she expect to see in place? EI #4 stated, turning and repositioning; after each incontinence episode applying the moisture barrier cream; informing the physician and dietary. EI #4 was asked if she would expect to see some target dates on the care plans? EI #4 stated, yes. 2. RI #3 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS with an Assessment Reference Date of 11/15/2010 reveals that RI #3 is rarely/never understood; modified independence regarding tasks of daily life, and dependent on staff for activities of daily living (ADL) assistance, and no skin issues. Review of the Interdisciplinary Care Plan dated 1/30/2011 and initiated by EI #5 (RN Treatment Nurse) reveals RI #3 had a problem with skin integrity impaired (actual) related to a Stage II wound on the left heel. Risk factors-limited mobility; left [MEDICAL CONDITION]; Diabetes Mellitus Type II; [MEDICAL CONDITION]; Hypertension, and Weakness. The goal for this problem is documented as "wound will heal without complication." There are no target dates set for the goals. The approaches listed include: Wound care as ordered; measure wound weekly; weekly body audits; labs as ordered; float heels as patient will allow;... A date these approaches were implemented is not documented.