Every finding on record at Fayette Medical Center Long Term Care Unit

Based on observation and interviews, the facility failed to ensure Employee Identifier (EI) #2, a Licensed Practical Nurse (LPN) did not: 1) use gloves that she had placed on the back of the clipboard; and 2) touch a resident's glasses while wearing gloves and then instill eye drops into the resident's eyes. These deficient practices affected Resident Identifier (RI), one of four residents observed for medication administration Findings include: The facility's policy titled, Standard Precautions, revised March 2020, documented Purpose: To prevent employee exposure to blood, body fluids, or tissue . 1. Hand Hygiene: . b. During the delivery of resident care services avoid unnecessary touching of surfaces in close proximity to the resident to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surfaces . During medication pass observation on 8/19/2020 at 7:59 AM, EI #2, an LPN put on gloves that she had laid on the back of a clipboard that was located on top of the medication cart. After by mouth and nasal spray medications were administered to RI #1, EI #2 sanitized her hands and put on gloves. EI #2 then used her gloved hands to remove RI #1's glasses and place them on top of the resident's head before she administered the resident's eye drop medication. In an interview on 8/19/2020 at 12:20 PM, EI #2, an LPN was asked should gloves be used that were placed on a potentially contaminated surface. EI #2 said no. EI #2 acknowledged that she had placed the gloves on top of the clipboard on the medication cart. When asked if she placed RI #1's glasses on top of his/her head after she had sanitized her hands and put on gloves, EI #2 answered yes she did. EI #2 was asked what the concern was with touching a potentially contaminated surface then administering eye drop medication. EI #2 replied, cross contamination. During an interview on 8/19/2020 at 1:21 PM, EI #1, the Infection Control Preventionist was asked where should gloves for use during medication pass be placed prior to use. EI #1 replied, on a clean surface. When asked should a nurse place gloves on top of a clipboard on the medication cart and then use those gloves to administer nasal spray, EI #1 said no. EI #1 was asked should a nurse place a resident's glasses on top of his/her head while wearing gloves then instill eye drops into the resident's eyes. EI #1 answered, no. When asked why not, EI #1 said, contamination.

Based on observation, interview, and review of a facility policy titled, Hand Washing Guidelines- Food Service Employees, the facility failed to ensure Employee Identifier (EI) # 4, a Kitchen Assistant, washed hands and changed gloves after leaving the work area, touching a contaminated item, then returning to the meal service line. This deficiency had the potential to affect all residents receiving meals from the kitchen. Findings include: Review of the facility policy titled Hand Washing Guidelines- Food Service Employees, revised 5/2018, revealed the following: . Compliance Guidelines: . 6. Frequency of Hand Washing: Nutritional Service employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single use articles and also in the following situations: . b. After hands have touched anything unsanitary . c. After hands have touched bare human body parts other than clean hands . On 4/11/19 at 12:01 p.m., EI# 4, Kitchen Assistant, was observed wearing gloves to set up plates. She then touched her clothing and her face and answered the phone wearing those gloves. EI #4 then returned to the food service line, without washing her hands and wearing the same gloves. On 4/11/19 at 12:20 p.m., an interview was conducted with EI# 4. EI #4 was asked to explain what happened during the trayline service. EI #4 said she left the service line to answer the phone. EI# 4 was asked if she washed her hands or changed gloves after answering the phone. EI# 4 stated no. EI# 4 was asked what would be the potential harm in leaving the tray line, touching a contaminated item, then returning to food service while wearing the same gloves and not washing hands. EI# 4 stated, that there would be the potential for cross contamination or spreading germs. On 04/11/19 at 12:42 p.m., an interview with the Contracted Assistant Director of Nutritional Services was conducted. The Contracted Assistant Director of Nutritional Services was asked what would be the potential harm in leaving the tray line and answering the phone without changing gloves and/or washing hands. The Contracted Assistant Director of Nutritional Services replied that there would be the potential to spread germs to the residents.

Based on observation, interviews, medical record review, and a review of the facility's policy titled, Resident Dignity, the facility failed to ensure Resident Identifier (RI) #53 was provided privacy during the a Percutaneous Endoscopic Gastrostomy (PEG) Tube medication administration by a licensed nurse. This affected RI #53, one of one resident observed during PEG Tube medication administration, and by one of four licensed nurses observed during medication administration. Findings Include: A review of a facility policy titled, Resident Dignity, with a revised date of 11/16/2009, revealed, .Guidelines .,12. Maintain resident privacy . RI #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 04/10/19 at 5:05 p.m., Employee Identifier (EI) #1 was observed during a PEG Tube medication administration for RI #53. EI #1 exited RI #53's room to go to the medication cart to get supplies. After EI #1 came back in RI #53's room, she left the door open and RI #53's curtain was left open for public view, and visible for RI #53's roommate, who was sitting in a wheelchair across from RI #53's bed. EI #1 gelled her hands and put on gloves. EI #1 pulled back RI #53's bedcovers and gown, exposing RI #53's middle abdomen area and peg tube site for roommate and public view. The Surveyor observed one resident in the hallway carrying an oxygen tank walking up the hallway and RI #53's roommate sitting in a wheelchair across the room in front of RI #53's bed. EI #1 began administering RI #53's medication per peg tube with door left open and curtain open for roommate and public view. 04/10/19 at 6:25 p.m., the surveyor conducted an interview with Employee Identifier (EI) #1, a Licensed Practical Nurse. EI #1 was asked what should a nurse ensure is done prior to administering a medication per PEG tube to a resident. EI #1 stated you should pull the resident's curtain around the resident's bed area and close the resident's door. EI #1 was asked did you pull RI #53's curtain around the bed and close RI #53's door when administering the PEG tube medication. EI #1 stated no. EI #1 was asked why did you not pull RI #53's curtain around the bed and close RI #53's door when administering the PEG tube medication. EI #1 stated she was focused on giving the medication and she forgot. EI #1 was asked what position was the RI #53's door when administering the PEG tube medication. EI #1 stated the door was wide open for public view and the roommate was in the room sitting in a wheelchair in view of RI #53. EI #1 was asked what was exposed of RI #53 when she left the curtain and door open for public view. EI #1 stated RI #53's peg tube site area. EI #1 was asked what would be the concern with a license nurse leaving a resident's door and curtain open during a PEG tube medication administration to a resident. EI #1 stated it could expose their body parts. EI #1 further stated that this is a resident right and affects the resident's privacy.

Based on observation, interviews, and review of a facility policy titled, Hand Hygiene, the facility failed to ensure a licensed nurse washed her hands after she picked up alcohol swabs and paper off the floor, prior to putting on gloves to administer an eye drop medication to Resident Identifier (RI) #53. This affected one of four licensed nurses observed during medication administration pass and RI #53, one of four residents observed during medication administration pass. Findings Include: A review of a policy titled, Hand Hygiene, with a revised date of 12/2009 revealed, Decontaminate hands - To reduce bacterial counts on hands by performing antiseptic hand rub or antiseptic handwash . 4. Decontaminate hands before having direct patient contact . 9. Decontaminate hands after contact with inanimate objects . RI #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/10/2019 at 4:40 p.m., the surveyor observed Employee Identifier (EI) #1, a Licensed Practical Nurse (LPN), during a medication administration pass for RI #53. The surveyor observed EI #1 drop pieces of alcohol swabs and paper onto the floor, pick up the alcohol swabs and paper from the floor and put in the garbage can. Then, EI #1 did not wash or gel her hands prior to putting on gloves to administer an eye drop medication to RI #53. 04/10/19 at 6:25 p.m., the surveyor conducted an interview with EI #1. EI #1 was asked if she washed or gelled her hands after she picked the alcohol swabs and paper up off the floor, prior to putting on gloves to administer RI #53's eye drop medication. EI #1 stated no. EI #1 was asked why she had not. EI #1 stated she was concentrating on giving the medications to RI #53 and forgot. EI #1 was asked what would be the concern in not washing your hands after you picked up alcohol swabs and paper from the floor prior to putting on gloves to administer an eye drop medication. EI #1 stated it could cause contamination or infection to a resident. .

Based on observations, a review of the (YEAR) Food Code, a review of the Quat Sanitizer Technical Data Sheet, well as interviews with facility staff, the facility failed to ensure: 1. staff air dried the Robot Coupe mixer prior to storing; 2. staff cleaned the tea urn spigot every 24 hours; 3. staff took corrective action when the temperature in the dishwashing machine exceeded 194 degrees Fahrenheit; (temps higher than 194 result in ineffective sanitizing) 4. during manual dishwashing, the staff monitored the water temperature in the final rinse sink to ensure accuracy of the test strip when determining chemical concentration. This had the potential to affect all 111 residents who received meals from dining service. Findings include: 1. A review of Food Code, U.S. (United States) Public Health Service and FDA (Food and Drug Administration) (YEAR) revealed the following: .4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS; (A) Shall be air-dried . On 4/10/18 at 6:00 PM, the Robot Coupe blender was observed to be stored on a stand and covered. The blender was removed from the stand, turned on the side and water was visible beneath the blade. At this time, the Certified Dietary Manager (CDM), Employee Identifier (EI) #3, was asked, was the blender air dried. EI #3 said , No and there was a potential for mold and bacterial build-up. 2. A review of Food Code, U.S. (United States) Public Health Service and FDA (Food and Drug Administration) (YEAR) revealed the following: .Frequency 4-602.11 Equipment Food-Contact Surfaces and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be cleaned: . (E) Except when dry cleaning methods are used as specified under § 4-603.11, surfaces of UTENSILS and EQUIPMENT contacting FOOD that is not TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cleaned: . (2) At least every 24 hours for iced tea dispensers . On 4/11/18 at 9:28 AM, an observation was made of a tea urn spigot which was disassembled by the CDM, EI #3. The plunger was observed with a brown colored solid build-up. EI #3 was asked, has this been cleaned in the last 24 hours. EI #3 stated, no it did not look like it. The CDM, EI #3 was asked by the surveyor to view the cleaning schedule. None was provided. EI #3 was asked, what was the potential risk. EI #3 responded, bacteria can begin to grow on soiled equipment. 3. A review of Food Code, U.S. (United States) Public Health Service and FDA (Food and Drug Administration) (YEAR) revealed the following: .501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. (A) Except as specified in ¶ (B) of this section, in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90(degree)C(Celsius) (194(degree)F (Fahrenheit), or less than: .(2) For all other machines, 82oC (degrees Centigrade) (180oF) . An observation on 4/10/18 at 5:54 PM, of the dishmachine data plate revealed wash 150 and rinse at 180 degrees Fahrenheit. On 4/11/18 at 8:50 AM. the dishmachine temperature monitoring log was reviewed. Documented data for the evening meal on 4/07/18 was recorded as 198 for the final rinse. On 4/11/18 at 9:15 AM, the operation of the dishmachine was observed. At this time the CDM, EI #3 was asked about the 198 rinse temperature documented on 4/07/18. EI #3 said that he was unaware of the 194 requirement and further stated that the facility had no policy/procedure for corrective action to take. 4. A review of a undated document titled, Quat Sanitizer Technical Data Sheet revealed the following: . General Information: .Quat test strips should be read at room temperature (75 degrees F) Fahrenheit, higher temperatures will result in inaccurate readings. On 4/11/18 at 9:50 AM, the manual dishwashing was observed to use a chemical (Quaternary Ammonia) for sanitizing. A demonstration of monitoring by the Cook, EI #7, revealed a failure to use the test strip according to direction on product container. A review of the facility Pots/pan sink temperature log revealed the data was not monitored/documented. Staff failed to ensure the water temperature had met the standard by monitoring/recording data. A review of the current Pot and Pan Temperature Log revealed no water temperature was recorded for 33 opportunities or 11 days at three times daily. The CDM EI #3 stated that he was unaware of the need to monitor the water temperature.

Based on observation, interview, medical record review, and a review of Potter and Perry's FUNDAMENTALS OF NURSING, the facility failed to ensure physician orders [REDACTED]. Findings Include: A review of Potter and Perry FUNDAMENTALS OF NURSING Eight Edition, Chapter 23, page 305, revealed the following: Health Care Providers' Orders . Nurses follow health care providers' orders . RI #100 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #100 Care Area Triggers (CAT) dated 02/19/18 revealed the following: .Cognitive Loss/Dementia . BIMs (Brief Interview for Mental Status score) is 8 (indicating cognition was moderately impaired . ADL (Activities of Daily Living) Function/Rehabilitation Pot (Potential) . left (him/her) with right sided weakness . A review of the facility's physician's orders [REDACTED]. d/c (discontinue) divided red plate with meals . Provide regular divided plate with regular meals Date 4/2/18 11:53 am . (physician's name per (Employee Identifier (EI) #6/RD . A review of RI #100's (MONTH) (YEAR) physician's orders [REDACTED]. 4/02/18 . Start Date 4/02/18 . Orders . REGULAR MEALS AND THIN LIQUIDS WITH NO STRAWS MEALS TO BE SERVED ON REGULAR DIVIDED PLATE . A review of RI #100's dietary tray card revealed NO STRAWS and an orange sticker (per Registered Dietitian/Employee Identifier (EI) #6) indicated a regular divided plate. On 04/11/18 at 11:45 AM resident observed during lunch meal, tray card corresponded to meal, served on a regular plate. RI #100 had a straw in the tea and the water. RI #100 was observed to use the straw with the tea and the water. EI #100 consumed 100% of fluids, 100% of steak, 50% of turnip greens, 25% of yams, no % of roll, chocolate pudding-0%. Responsible party at bedside and brought resident two pork chops and resident consumed 75% of both pork chops. Sign observed above bed - NO STRAWS. RI #100 did not have a divided plate. On 04/11/18 at 5:00 PM, during supper meal observation, RI #100 was served fish, french fries, roll, cold slaw, water, tea on a regular plate. RI #100 did not have a divided plate. On 4/11/18 at 5:15 PM, during an interview with EI #6, Registered Dietitian/RD she was asked what was the order from the physician that was dated 4/2/18 at 11:53 AM. EI #6 said a regular divided plate with meals. The surveyor asked what was the difference between a red divided plate and regular divided plate. EI #6 stated,Just the color. The surveyor asked why was RI #100's plate changed. EI #6 replied this was actually an order clarification. EI #6 said Occupational Therapy/(OT), had recommended a regular divided plate to help with the resident's self-feeding. EI #6 said she did not know how red got attached to the order. The surveyor asked what was the difference with the assistance of the divided plate with a regular and/or a red plate. EI #6 said the red was used for someone who was visually impaired. The surveyor asked was RI #100 visually impaired. EI #6 stated, No, not that I've observed. On 4/12/18 at 12:40 PM, during an interview(EI) #9, Minimum Data Set Coordinator, the surveyor provided a copy of Occupational Orders for RI #100 was given for review. The surveyor asked what type of plate should RI #100 have. EI #9 stated the resident should receive a divided plate at each meal. The surveyor asked what did the orders document. EI #9 stated on 4/2/18 the divided red plate with meals was discontinued and to provide a regular divided plate with regular meals.

Based on observation of incontinent care, review of a facility policy titled, Perineal Care and staff interviews the facility failed to ensure certified staff cleaned Resident Identifier (RI) #30's buttock area from front to back. This affected one of one incontinent care observations made during the survey. Findings Include: A review of a facility's policy titled, Perineal Care with a revised date of 11/2017, documented the following: . Standard Perineal care is provided to clean the perineum and provide comfort. Procedure for a . Resident . 5. Help the resident turn onto . side. Wash, . the anal area, moving upward toward the back. RI #30 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #30's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/24/2018 revealed RI #30's Brief Interview for Mental Status score of 15, indicating cognition intact. Section H of the MDS for Bladder and Bowel, revealed RI #30 was frequently incontinent of urine and bowel and required extensive assistance with toileting. On 04/12/2018 at 8:49 a.m., an observation of incontinent care on RI #30, was made with Employee Identifier (EI) #5. RI #30 gave verbal permission for the surveyor to observe incontinent care. EI #5 wet three bath cloths with water, sanitized her hands and put gloves on. RI #30 turned to her/his left side, EI #5 removed the bedpan and placed it on the bed. EI #5 wiped a large amount of stool with a bath cloth from the right buttock. EI #5 wiped from the anal area towards the urethra in an upward motion. EI #5 then changed to a clean area of the cloth and wiped the left buttock, which was also covered in a large amount of stool. EI #5 again wiped from the anal area towards the urethra in a downward motion. EI #5 obtained a clean bath cloth and wiped downward, from the back of the buttocks to the middle of the buttocks. No redness was observed to the area. On 04/12/2018 at 8:55 a.m., an interview was conducted with EI #5 CNA. The surveyor asked EI #5 what was the facility's policy and procedure on incontinent care. EI #5 said wipe front to back. The surveyor asked EI #5 which direction did she wipe when cleaning RI #30. EI #5 said she wiped front to back at first and then she wiped back to front, and downward three times. EI #5 said RI #30 had a large amount of stool. The surveyor asked EI #5 what was the potential harm in wiping from back to front. EI #5 said infection. On 04/12/2018 at 10:55 a.m., an interview was conducted with EI #1, Registered Nurse (RN), Infection Control. The surveyor asked EI #1 what was the facility's policy and procedure on incontinent care. EI #1 said to wipe from front to back. The surveyor asked EI #1 why should staff wipe from front to back. EI #1 said risk of infection.

Based on observation, interviews, medical record review, and a review of the facility's policy titled, ENTERAL NUTRITION GUIDELINES, the facility failed to ensure licensed staff waited in between gentle pushes to unclog Resident Identifier (RI) #265's Gastrostomy Tube (GT). This affected one of one resident observed with a GT during medication administration. Findings Include: A review of the facility's policy titled, ENTERAL NUTRITION GUIDELINES without a date, revealed the following : . L. If a tube becomes clogged, instill 10 mL (milliliter) of warm water as close to the clog as possible for 1 (one) minute, and then using a back and forth motion with a 30-50 mL syringe plunger to help dislodge the clog. If the tube does not clear, clamp the tube for 5-15 minutes. Fill the syringe with 10mL of warm water and try again . RI #265 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #265's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed RI #265 was severely impaired in cognitive skills for daily decision making and had short and long term memory problems. The MDS also revealed RI #265 had a Gastrostomy Tube. A review of RI #265's care plan with a problem onset date of 10/17/17 revealed the following: . (RI #265) has potential for complications R/T (related to) PEG (percutaneous [MEDICAL CONDITION] gastrostomy) tube placement. Approaches . 3-13-18 Gentle push (with) flushes . On 04/11/18 at 12:30 PM, the following observation was made during medication administration: EI #7, Licensed Practical Nurse, prepared [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg (milligram) (1/2) tab (tablet) /(per) tube) for administration. EI #7 removed a tray from the medication cart and placed on top of the medication cart. EI #7 obtained three medications cups and placed her fingers inside each cup as she labeled the cups with a marker. EI #7 poured 30 cc (cubic centimeters) of water in each medication cup after labeling. EI #7 crushed the [MEDICATION NAME] medications and poured in a labeled medication cup. EI #7 entered the resident's room with the tray containing the medication cups with the water and the crushed medication. EI #7 checked placement and residual with a 60 cc syringe and plunger. EI #7 removed the plunger and administered the 30 cc water flush, water ran out because of the position of the stop cock on the luer lock was open. EI #7 administered the medication mixed with 5 cc of water by gravity. The medication mix did not flow by gravity. EI #7 obtained the plunger and placed in the barrel of the syringe and pushed the plunger inward. Medication did not flow. EI #7 repeated this process 3 times and the medication did not flow. EI #7 immediately pushed the plunger in and out, repeatedly 3 times, medication was administered. EI #7 removed the plunger, syringe still attached. EI #7 poured 10 cc of water into the syringe. Water did not flow in. EI #7 used the same process with the plunger 4 times, no waiting in between plunger pushes, until water administered. On 04/11/18 at 4:00 PM, during an interview with EI #8, RN Supervisor, the surveyor provided a copy of RI #265's physician's orders [REDACTED].#8 to explain gentle pressure. EI #8 demonstrated with a 60 cc syringe and said if she had a syringe on the valve and medications were not going in by gravity, she would take the plunger and apply gentle pressure and push the plunger to see if she could get the medication to go in. The surveyor asked how much pressure and how far should the plunger be inserted into the syringe. EI #8 said to start at the 60 cc, at the top of the syringe, if the syringe tip is connected to the gastrostomy tube. EI #8 said she would attempt to push 10 cc of air and if medication still did not go in, her next option would be to question if the tube was clogged, since the gentle push was not working. The surveyor asked how many times would she apply gentle pressure. EI #8 said only push with gentle pressure once, because more than that would put excessive pressure on the tube. The surveyor asked when staff repeatedly applies gentle pressure more than once, what was the potential harm. EI #8 said it could tear the tubing from where the pressure was applied, or all the way down to the end point where the tube is in the stomach. The surveyor asked when should a plunger be used in an in and out motion in a syringe connected to a GT. EI #8 said never, and that she would never do that.

Based on observations, interview, medical record reviews, and a review of the facility's policy titled, Oral Medication - Administration, the facility failed to ensure Licensed staff did not leave Resident Identifier (RI) #264's and RI #265's medications unattended and out of visual sight. This affected two of two residents observed during medication administration. Findings Include: A review of the facility's policy titled, Oral Medication -- Administration without a date, revealed the following: . Special Points: . G. Never leave medication on top of cart unless cart is in view of staff . 1. RI #264 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #264's Quarterly Minimum Data Set ((MDS) dated [DATE], revealed RI #264's Brief Interview for Mental Status score of 15, indicating cognition was intact. On 04/11/18 at 8:50 AM, the following was observed during medication administration: Employee Identifier (EI) #7 prepared the following medications for administration to RI #264: 1. [MEDICATION NAME] 20 mg (milligram) one po TID (three times a day 2. [MEDICATION NAME] 20 mg one p every morning (QAM) 3. Brimodine eye drops 0.2 (percent) 4. [MEDICATION NAME] ER (extended release) 200 mg q (every) 12 hours 5. Oxybutin CL ER 5 mg one po bid 6. [MEDICATION NAME] HCL 0.1 mg one po bid 7. Klonopine 0.5 mg (1/2) tab bid 8. [MEDICATION NAME] 5-325 mg one po bid 9. [MEDICATION NAME] 50 mg one po bid. EI #7 dispensed medications from the pill cards, placed the Klonopine and the [MEDICATION NAME] pill card back in the locked box in the medication cart and locked the medication cart. EI #7 leaves the resident's [MEDICATION NAME], ,[MEDICATION NAME], Oxybutin, [MEDICATION NAME],and the [MEDICATION NAME] medication pill cards on top of the medication cart. Staff and other residents observed on the hall way. EI #7 entered RI #264's room and closed the door. The medication cart with the pill cards are out of sight of EI #7. EI #7 administered the medications. EI #7 opened RI #264's door, exited the room and the medication pill cards were on top of the medication cart. On 04/11/18 at 9:00 AM, during an interview with EI #7, the surveyor asked what was left on the medication cart. EI #7 said medications. The surveyor asked was the medications within her sight at all times. EI #7 stated, No ma'am. The surveyor asked what was the facility's policy and procedure for leaving medications unattended and out of nurses' sight. EI #7 replied medications should always be in eyesight of the nurse or put away in the medication cart and locked. The surveyor asked what other staff and ambulatory residents were on the hall. EI #7 stated ambulatory residents and Certified Nursing Assistants were on the hall. The surveyor asked was policy and procedure followed for not leaving medications unattended and out of nurses sight. EI #7 stated, No. The surveyor asked what was the potential when medications were left unattended and out of nurses sight. EI #7 stated, Other residents or staff could get the medications and take them. 2. RI #265 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #265's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed RI #265 was severely impaired in cognitive skills for daily decision making and had short and long term memory problems. The MDS also revealed RI #265 had a Gastrostomy Tube. On 04/11/18 at 12:30 PM, the following was observed during medication administration: EI #7 prepared medication for administration to RI #265. EI #7 entered the resident's room and placed the tray, containing the residents medications on the resident's bedside table. EI #7 placed RI #265's tube feeding infusion on hold and exited the resident's room. EI #7 closed RI #265's door, leaving the resident's medication unattended and out of visual sight. EI #7 re-entered the resident's room. On 04/11/18 at 9:00 AM, during an interview with EI #7 regarding a prior medication pass, the surveyor asked what was the facility's policy and procedure for leaving medications unattended and out of nurses' sight. EI #7 replied at that time that medications should always be in eyesight of the nurse or put away in the medication cart and locked.

Based on observation, interviews, medical record review, the facility failed to ensure Resident Identifier (RI) #100 was provided a divided plate with meals. This affected one of 24 residents whose meals were observed. Findings Include: 1. RI #100 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #100 Care Area Triggers (CAT) dated 02/19/18 revealed the following: .Cognitive Loss/Dementia . BIMS (Brief Interview for Mental Status score) is 8 (indicating cognition was moderately impaired . ADL (Activities of Daily Living) Function/Rehabilitation Pot (Potential) . left (him/her) with right sided weakness . A review of RI #100's (MONTH) (YEAR) physician's orders [REDACTED]. 4/02/18 . Start Date 4/02/18 . Orders . REGULAR MEALS AND THIN LIQUIDS WITH NO STRAWS MEALS TO BE SERVED ON REGULAR DIVIDED PLATE . A review of RI #100's Occupational Therapy Orders dated 01/23/18 revealed the following: . Patient to receive divided plate (at) each meal to increase (Intake) with self-feeding tasks . A review of RI #100's care plan with a problem onset date of 02/27/18 revealed the following: . (RI #100) has ADL mobility .[MEDICAL CONDITION] with right sided weakness .Approaches . Set up meals and snacks, normally feeds self using left hand . Divided plate. A review of RI #100's dietary tray card revealed NO STRAWS and an orange sticker (per Registered Dietitian/Employee Identifier (EI) #6) indicated a regular divided plate. On 04/11/18 at 11:45 AM resident observed during lunch meal, tray card corresponded to meal, served on a regular plate. RI #100 had a straw in the tea and the water. RI #100 was observed to use the straw with the tea and the water. EI #100 consumed 100% of fluids, 100% of steak, 50% of turnip greens, 25% of yams, no % of roll, chocolate pudding-0%. Responsible party at bedside and brought resident two pork chops and resident consumed 75% of both pork chops. Sign observed above bed - NO STRAWS. RI #100 did not have a divided plate On 04/11/18 at 5:00 PM, during supper meal observation, RI #100 was served fish, french fries, roll, cold slaw, water, tea on a regular plate. RI #100 did not have a divided plate with meals. On 4/11/18 at 5:15 PM, during an interview with EI #6, the surveyor asked was the order she had received from the physician that was dated 4/2/18 at 11:53 AM. EI #6 said a regular divided plate with meals. The surveyor asked what was the difference between a red divided plate and regular divided plate. EI #6 stated,Just the color. The surveyor asked why was RI #100's plate changed. EI #6 replied it was actually an order clarification. EI #6 said Occupational Therapy/(OT), had recommended a regular divided plate to help with the resident's self-feeding. EI #6 said she did not know how red got attached to the order. The surveyor asked what was the difference with the assistance of the divided plate with a regular and/or a red plate. EI #6 said the red was used for someone who was visually impaired. The surveyor asked was RI #100 visually impaired. EI #6 stated, No, not that I've observed. On 04/12/18 at 12:40 PM, during an interview with EI #9, Minimum Data Set Coordinator/MDS, the surveyor asked what does the care plan document. EI #9 said the care plan was revised on 4/2/18 to reflect the meals were to be served on a divided plate. The surveyor informed EI #9 on 4/11/19 for the lunch and supper meal, the resident received meals on a regular plate, was the care plan followed for a divided plate for meals. EI #9 stated if the resident did not get a divided plate for meals, then the care plan was not followed. The surveyor provided a copy of RI #100's tray card and asked, where was the documentation to reflect the resident should have a divided plate with all meals. EI #9 stated she did not see anything on the tray card that stated regular divided plate. On 04/12/18 at 12:55 PM, during an interview with EI #6, RD, the surveyor provided a copy of a tray card for RI #100 and asked where was the documentation to reflect the resident was to have a regular divided plate with all meals. EI #6 said that information was on the clear sleeve of the tray card. The surveyor requested a copy of the tray card. EI #6 provided a copy of the tray card with an orange sticker that indicated RI #100 was to have a divided plate. The surveyor informed EI #6 of the observations on 04/11/18 for lunch and supper meal; and RI #100 did not have a divided plate. The surveyor asked what should RI #100 have for meals. EI #6 said per the order, a regular divided plate.

Based on observations, interviews, medical record reviews and a review of the facility's policy titled, Hand Hygiene, the failed to ensure: 1. Licensed staff did not place her fingers inside three medication cups; pour 30 cc (cubic centimeters) of water into the medication cup and then administer the water via RI #265's Gastrostomy Tube (GT); and 2. A CNA(Certified Nursing Assistant) did not store a soiled bedpan in RI #30's bathroom. This was observed 4/12/18 and had the potential to affect RI#30, a resident requiring assistance with toileting. These deficient practices affected 2 of 2 sampled residents. Findings Include: A review of the facility's policy titled, Hand Hygiene without a date, revealed the following: Purpose: to reduce the risk of transmission of pathogenic microorganisms to patients, . Definition: Decontaminate hands - To reduce bacterial counts on hands by performing antiseptic hand rub or antiseptic handwash . 10. Decontaminate hands after contact with inanimate objects (including medical equipment) . RI #265 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #265's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed RI #265 was severely impaired in cognitive skills for daily decision making and had short and long term memory problems. The MDS also revealed RI #265 had a Gastrostomy Tube. A review of RI #265's care plan with a problem onset date of 10/17/17 revealed the following: . (RI #265) has potential for complications R/T (related to) PEG (percutaneous [MEDICAL CONDITION] gastrostomy) tube placement. Approaches . 3-13-18 Gentle push (with) flushes . On 04/11/18 at 12:30 PM, the following observation was made during medication administration: EI #7, Licensed Practical Nurse prepared [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg (milligram) (1/2) tab /(per) tube) for administration. Removed a tray from the medication cart and placed on top of the medication cart. EI #7 obtained three medications cups and placed her fingers inside each cup as she labeled the cups with a marker. EI #7 poured 30 cc (cubic centimeters) of water in each medication cup after labeling. The [MEDICATION NAME] medications was crushed and poured in a labeled medication cup. EI #7 entered the resident's room with the tray containing the medication cups with the water and the crushed medication. EI #7 administered the medications and the water flush via RI #265's GT. On 04/11/18 at 12:50 PM, during an interview with EI #7, the surveyor asked when should fingers be placed inside of a medication cup. EI #7 stated never. The surveyor asked what did she do when she was labeling the medication cups for the water. EI #7 stated she did not realize that was what she had done, but she did remember placing her fingers inside of the medication as she was labeling the medication cups. The surveyor asked what could be a potential harm. EI #7 stated infection to the resident because the resident received the water that was in the medication cup, that she had touched with her fingers. The surveyor asked when she removed the tube feeding tubing from the gastrostomy tube (GT), where did she place the tubing. EI #7 stated on a towel. The surveyor asked was the towel clean, EI #7 replied it was not. EI #7 also stated after the resident received the medications, she reconnected the feeding tube to the GT and restarted the resident's infusing. EI #7 replied that could also be a cause for infection. 2. A review a facility policy titled, Policy Bedpan/Urinal with a revised date of 3/06 revealed the following: Standard: Resident's who are unable to go to the bathroom independently, are .offered the bed/pan . Process: s. Empty the bedpan .rinse pan . t. Store .bedpan in plastic bag and tie to .if resident requests .rail in bathroom . RI #30 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #30's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/24/2018 revealed RI #30's Brief Interview for Mental Status score of 15, indicating cognition intact. Section H of the MDS for Bladder and Bowel, documented RI #30 was frequently incontinent of urine and bowel. On 4/12/18 at 9:12 AM, the surveyor observed two housekeeping staff cleaning RI #30's mattress in the resident's room. One of the cleaning staff went into the resident's bathroom and found a bedside pan (bedpan) with a brown substance on the inside. The plastic bag, where the bedpan was stored, was hanging from the towel rack(rail), which was observed with a very strong odor. The cleaning staff cut the plastic bag off of the towel rack (rail) and placed it on the floor. On 04/12/18 at 9:20 AM, EI #2, the DON (Director of Nursing), was asked by the surveyor to observe the plastic bag with the brown substance, which contained the bedpan. An interview was conducted on 4/12/18 at 9:22 AM with EI #2. EI #2 was asked how were bedpans to be stored after use. EI #2 said the bedpans were to be cleaned and placed in a plastic bag and tied to a safety rail in the resident's bathroom. EI #2 was asked, when she observed the bedpan inside of the plastic bag in RI #30's bathroom, what did she observe inside the plastic bag along with the bedpan. EI #2 said the bag (on the inside) was soiled. EI #2 was asked should there have been evidence of a brown substance appearing to be bowel movement inside of a plastic bag that was used to store the bedpan. EI #2 said no. EI #2 was asked, why should bedpans be cleaned after usage especially after a bowel movement. EI #2 said, to prevent it from having bowel movement on it. EI #2 was asked, what could happen if a soiled bag with a bedpan was left hanging on a safety rail in a resident's bathroom. EI #2 explained, cross contamination and someone could get their hands soiled if they touched it. EI #2 was asked who was responsible for ensuring bedpans were cleaned thoroughly after use and stored in a clean plastic bag after resident care. EI #2 said, the CNA's or whoever assisted the resident on the bedpan. EI #2 was asked, what should have been done. EI #2 explained, after the bedpan was soiled, both should have been thrown away.

Based on observations, interviews and a review of facility polices titled, Policy and Procedure Governing Food Storage and WASHING AND DISPENSING FLATWARE, the facility failed to ensure: 1. chicken patties in the freezer were sealed properly, 2. dented cans were not in with regular food cans, and 3. spoons, forks and knives were free of water and food like substances. These deficiencies had the potential to affect 106 of 106 residents receiving meals from the kitchen. Findings Include: 1) A review of a policy titled, Policy and Procedure Governing Food Storage, with no revised date revealed: Policy: All foods, non-food items .used in food preparation shall be stored in a manner as to prevent chemical, physical and biological contamination and to assure safe food for human consumption .B. Perishable Food Storage . 5.Leftovers and unused opened foods should be covered . On 2/28/2017 at 10:35 a.m., during the initial tour, along with the dietician and the dietary manager, the surveyor observed a box in the freezer. This box had a plastic bag in it. The plastic bag was opened with about five chicken patties in the bag. The bag was not sealed and the box was not sealed. On 3/02/2017 at 8:23 a.m., an interview was conducted with (Employee Identifier) EI #2, the dietary manager. EI #2 was asked what item was exposed in the freezer and was not sealed. EI #2 replied, breaded chicken patties. EI #2 was asked what was in the box. EI #2 replied, a white card board box and inside the box was the product (chicken patties). EI #2 was asked was the plastic bag sealed inside. EI #2 replied, no. EI #2 was asked who was responsible for making sure items were sealed when putting them in the freezer. EI #2 replied, the person opening the product was responsible for making sure it was closed back. EI #2 was asked when should food items be sealed completely when putting them in the freezer. EI #2 replied, immediately after opening. EI #2 was asked how should food items be sealed once opened. EI #2 replied they should be sealed air tight with no product exposed to keep the product from getting freezer burn. EI #2 was asked why should food items be sealed properly in the freezer. EI #2 replied, it ruins the product when it is not sealed properly. EI #2 was asked what was the potential harm when items are not sealed properly in the freezer and served to the resident. EI #2 replied, it was a food quality issue. EI #2 was asked what was the facility policy regarding how food items should be sealed in the freezer. EI #2 replied, once opened, no product exposed and the box sealed. On 3/2/2017 at 9:00 a.m., the surveyor conducted an interview with EI #1, the Dietitian. EI #1 was asked what was exposed in the freezer that was not sealed. EI #1 replied, chicken patties. EI #1 was asked how should items be sealed once opened and putting back in the freezer. EI #1 replied, the bag should be tied, or taped and pressed closed. EI #1 was asked what was the potential harm when items are not properly sealed in the freezer and served to the residents. EI #1 replied, quality of food decline or freezer burns. 2) A review of a policy titled, Policy and Procedure Governing Food Storage with no revised date revealed: .II. STORAGE OF FOOD ITEMS A. Dry Storage . 5. Any damaged or leaking cans are removed to the area designated .IV. FOOD PREPARATION AND SERVICE .3. Foods coming from damaged cans or packages must not be served. On 2/28/2017 at 10:35 a.m., the surveyor and the dietician toured the dry storage area. In the regular can rack there was (one) six pound and 15 ounce can of three bean salad which was dented in the middle. On the other side of the room in dry storage, there were other cans. In this group was a one pound can of enchilada sauce and it was dented at the rim. On 3/2/2017 at 8:45 a.m., an interview was conducted with EI #1, the Dietitian. EI #1 was asked what cans in dry storage were dented on 2/28/2017. EI #1 replied, three bean salad. EI #1 was asked who was responsible for removing dented can from the regular can section. EI #1 replied, any employee who see the dented can, the people who put it up, and the service manager. EI #1 was asked where should dented cans be placed. EI #1 replied, in a separate room, there was a rack for dented cans. EI #1 was asked why should dented can be removed from the regular can section. EI #1 replied, there was a potential for spoilage or safety. EI #1 was asked what was the potential harm when dented cans are cooked. EI #1 replied, potential for comprised food safety. EI #1 was asked what was the facility policy regarding dented cans. EI #1 replied, remove them from stock and place in a separate room. On 3/2/2017 at 1:25 p.m., an interview was conducted with EI #4, a Cook. EI #4 was asked when did he/she put up stock. EI #4 replied, on Mondays and Thursdays. EI #4 was asked who was responsible for removing dented cans from the regular can section. EI #4 replied, he/she was if he/she put up the truck. EI #4 was asked why should dented cans be removed from the regular can section. EI #4 replied, dented can foods may cause bacteria to be in your food. EI #4 was asked what was the facility policy regarding dented cans. EI #4 replied, count them and put them in the chemical room. 3) A review of a policy titled, WASHING AND DISPENSING FLATWARE, with a revised date 6/05 revealed: .5. Flatware is allowed to air dry before use. On 3/1/2017 at 10:47 a.m., the surveyor observed ready to go canisters with utensils in them. These utensils were noted to have a food like substance on them, and some were observed to be wet. On 3/2/2017 at 1:14 p.m., an interview was conducted with EI #5, food service assistant. EI #5 was asked what was on some of the forks and knives. EI #5 replied, some were wet, and some with a type of particle. EI #5 was asked what was the particle. EI #5 replied, she did not know what it was. EI #5 was asked why was it there. EI #5 replied, it should have been washed a couple more times. EI #5 was asked what was the facility policy on cleaning utensils. EI #5 replied, the silverware should go through four times, and there were too many in the cups. EI #5 was asked how should utensils be allowed to dry. EI #5 replied, they should air dry. EI #5 was asked what was the potential harm when residents are given dirty utensils to eat from. EI #5 replied, severe sickness especially if the immune system is low. On 3/2/2017 at 8:55 a.m., the surveyor conducted an interview with EI #1, the Dietitian. EI #1 was asked what was on some of the forks, knives and spoons. EI #1 replied, a small white particle was on the spoons and some spoons were wet. EI #1 was asked what was the small white particle. EI #1 replied, some type of food. EI #1 was asked why was it on the utensils. EI #1 replied, because there was too much silverware in the canisters.

Based on observations, interviews and record reviews, the facility failed to ensure: 1) scoops were not stored inside of the sugar bin, flour bin, corn meal bin, thick it bin and laying on top of the product, 2) dietary staff washed their hands after touching a garbage can lid and picking up items off the floor and before continuing with their duties of preparing food and wiping off a prep table, 3) dietary staff had all hair restrained inside of a hair net/cover and 4) industrial size mixer did not have dried food like particles/substances present on the mixer. Findings Include: 1) A review of a facility policy titled, FDA (Food and Drug Administration) Food Code 2009: Chapter 3-Food, revealed the following: .3-304.12 In-Use Utensils, Between-Use Storage. During pauses in FOOD preparation or dispensing, FOOD preparation and dispensing UTENSILS shall be stored: (A) Except as specified under ¶ (B) of this section, in the FOOD with their handles above the top of the FOOD and the container; (B) In FOOD that is not POTENTIALLY HAZARDOUS (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) with their handles above the top of the FOOD within containers or EQUIPMENT that can be closed, such as bins of sugar, flour . On 2/9/2015 at 11:36 AM, during the initial tour of the kitchen, an observation was made of scoops inside of the flour bin, corn meal bin, sugar bin and thick it bin, laying on top of the products with the handles observed touching the products. On 2/11/2016, at 9:20 AM, an interview was conducted with EI (Employee Identifier) #4, Dietary Manager. EI #4 was informed of the observation made by the surveyor. EI #4 was asked what was the facility's policy and procedure for storage of scoops used to gather dry products such as sugar, flour, corn meal and Thick It. EI #4 explained scoops were to be stored in a drawer. EI #4 was asked when should scoops be stored inside of the bins containing dry products such as sugar, flour, corn meal and Thick It. EI #4 explained scoops should not be stored inside the bin with the product. EI #4 was asked why should scoops used to gather products such as sugar, flour, corn meal and Thick It be stored in a separate container. EI #4 stated to make sure the scoops were not contaminated and touching the product. EI #4 was asked should scoops be stored inside bins containing dry products. EI #4 explained no, they should not to prevent cross contamination. EI #4 was asked what was the potential harm in storing scoops inside of dry product bins, laying directly on top of the dry product. EI #4 explained that there was potential for cross contamination. 2) A review of a facility policy titled, Policy and Procedure Governing Nutritional Services Patient &(and) Staff Safety, with a revised date of 9/12/13, revealed the following: .Procedure: 1. Wash hands in the following instances .whenever you touch something that is not sanitary .trash on the floor .before you go back to .handling .food . 12. Gloves must NEVER be used in place of hand washing. Hands MUST be washed before putting on gloves and when changing to a fresh pair of gloves . On 2/10/2016 at 9:32 AM, an observation was made of a cook preparing a package of powdered potatoes. While preparing the potatoes, the cook walked to the garbage can and with an ungloved hand, pushed the lid to the side to discard part of the powdered potatoes package. When she discarded the item into the garbage can, she did not wash her hands. The cook proceeded to place a clean pair of gloves on and continued preparing the potatoes. Another observation was made on 2/10/2016 at 10:53 AM, of a gloved dietary staff member wiping the first prep table with a damp cloth, picked up a plastic cup lid off of the floor, threw it into the garbage can and proceeded to wipe the prep table without removing her gloves and washing her hands and placing new gloves. On 2/11/2016 at 9:20 AM, an interview was conducted with EI #4. EI #4 was asked what was the facility's policy and procedure for hand washing. EI #4 explained staff was to follow the food code if they touch trash, themselves or etc.(et cetera) they were to wash their hands. EI #4 was informed of the observation made by the surveyor. EI #4 was asked when should dietary staff wash their hands. EI #4 explained if staff touch trash cans or go to the bathroom or leave the kitchen and return was when they were to wash their hands. EI #4 was asked why should staff in dietary wash their hands. EI #4 explained that staff should wash their hands to remove any bacteria that could be on their hands from their touching contaminated objects before prepping food. EI #4 was asked what was the potential harm in dietary staff not washing hands when touching something that may be dirty or contaminated. EI #4 explained staff could potentially get someone sick. 3) A review of a facility policy titled, NUTRITIONAL SERVICES POLICY AND PROCEDURE Governing DRESS AND PERSONAL APPEARANCE with a revised date of 11/13 revealed the following: .POLICY: . 4. Hair shall be covered by approved hair coverings while working in the food production areas. On 2/10/2016 at 11:30 AM, an observation was made of a dietary aide working during tray-line with hair hanging from under her hair net. On 2/11/2016 at 9:20 AM, an interview was conducted with EI #4. EI #4 was asked what was the facility's policy and procedure for hair covering. EI #4 explained all hair must be covered and tucked under the hair net. EI #4 was asked what was the potential harm in not having all hair contained with a hair coverage/net. EI #4 said possible food contamination because hair could get into someone's food. 4) Further review of a facility policy titled, Food Preparation and Handling with a revised date of 1/16 revealed the following: .20. All food service equipment is cleaned, sanitized .after each use . On 2/10/2016 at 10:01 AM, a white food like substance was observed on the mixing area that holds the mixing blade of the industrial sized mixer. Both the surveyor and Dietary Manager observed the white food like substance. On 2/11/2016, at 9:20 AM, an interview was conducted with EI #4. EI #4 was asked how often was the industrial size mixer cleaned. EI #4 stated the mixer was cleaned after each use. EI #4 was asked why should the mixer be free of an accumulation of food particles. EI #4 explained that they would not want food on the machine because they would want a clean and sanitized machine. EI #4 was asked what was the potential harm in having dried food particles on parts of the mixer. EI #4 explained dry food particles could possibly get into the food that was made and it showed that the machine was not properly sanitized.

Based on observation, interview and record review, the facility failed to ensure RI (Resident Identifier) #3's care plan was followed in order to check the resident for incontinence and change every two hours. RI #3 was continuously observed from 2:50 PM to 5:50 PM without being checked for incontinence or changed. This affected one of four residents observed for checking and changing for incontinence. Findings Include: A review of a policy titled, Care Planning, with a revised date of 09/15 revealed the following: .Purpose: Plans of care are developed .to coordinate and communicate care approached and goals for the resident . A review of RI #3's Care Plan with a review date of 12/22/15 revealed the following: .Check and change every 2 hours for incontinence. RI #3 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #3's most recent quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/16/2015 revealed a BIMS (Brief Interview for Mental Status) score of 3, indicating RI #3 was severely cognitively impaired for daily decision making. Further review of RI#3's MDS revealed the resident was always incontinent of bowel and bladder and was not on a urinary or bowel toileting program. On 2/10/2016, RI #3 was continuously observed from 2:50 PM until 5:50 PM without being checked for incontinence or changed. On 2/10/2016 at 5:51 PM, an interview was conducted with EI (Employee Identifier) #1, RN (Registered Nurse) Supervisor. EI #1 was asked was she familiar with RI #3. EI #1 stated yes. EI#1 was asked what was RI #3's continence status for bowel and bladder. EI #1 stated RI #3 was incontinent. EI #1 was asked what was EI #3's cognitive status. EI #1 explained RI #3 had severe dementia and severe cognitive impairment. EI #1 was asked was RI #3 able to voice his/her needs. EI #1 explained she did not know if RI #3 was able to voice his/her needs. EI #1 was asked how often was RI #3 to be checked and changed. EI #1 stated every two hours. On 2/10/2016 at 6:00 PM, an interview was conducted with EI #2, CNA (Certified Nursing Assistant). EI #2 was asked if she was familiar with RI #3. EI #2 explained that she was not RI #3's regular aide but explained she was RI #3's aide for 2/10/2016. EI #2 was asked how often was RI #3 to be checked and changed. EI # 2 explained every two hours or if RI #3 called her. EI #2 further explained when RI #3 stated he/she needed to go she would put RI #3 on a bedpan. EI #2 was asked what was RI #3's cognitive status. EI #2 explained RI #3 had dementia. EI #2 was asked could RI #3 voice his/her needs. EI #2 stated no, but he/she could if you asked yes and no questions. On 2/11/2016 at 8:55 AM, an interview was conducted with EI #3, LPN (Licensed Practical Nurse), Restorative Nurse. EI #3 was asked was she familiar with RI #3. EI #3 stated yes. EI # was asked what was RI #3's continent status. EI #3 explained RI #3 was incontinent. EI #3 was asked what was being used for RI #3's continent status. EI #3 explained they checked and changed RI #3 because he/she could not make his/her toileting needs known. EI #3 was asked why did RI #3 not make his/her toileting needs known. EI #3 explained it was RI #3's cognition. EI #3 was asked when CNA's provided incontinent care, did they offer RI #3 a bedpan. EI #3 explained she was not sure if RI #3 would understand if asked and also RI #3's cognition and hearing were bad. EI #3 was asked was RI #3 assessed to use a bedpan. EI #3 explained no she was not assessed to use a bedpan. On 2/11/2016 at 11:05 AM, an interview was conducted with EI #1. EI #1 was asked what did RI #3's Care Plan state about his/her continent status. EI #1 explained RI #3 was to be checked and changed every two hours for incontinence. EI #1 was asked what did RI #3's Care Plan state about the use of a bedpan for toileting. EI #1 stated it did not. EI #1 was informed of the observation made by the surveyor on 2/10/2016. EI #1 was asked was RI #3's Care Plan followed. EI #1 explained RI #3's Care Plan said to check and change RI #3 every two hours so the answer was no. EI #1 was asked why should Care Plans be followed. EI #1 explained they should be followed because the Care Plan reflects how the resident should be cared for. EI #1 was asked what was the potential harm in staff not following Care Plans. EI #1 explained residents may not get the best care they could get and care they were designed specifically to receive.

Based on observation, interview and record review, the facility failed to ensure a CNA (Certified Nursing Assistant) washed or sanitized her hands after removing urine soiled gloves and before donning new gloves during the performance of incontinent care of RI (resident identifier) #6 on 02/11/2016. This affected one of one residents observed during incontinent care. Findings Include: A review of the facility's policy and procedure titled, Hand Hygiene with a review date of 12/09 revealed: Purpose: To reduce the risk of transmission of pathogenic microorganisms to patient, personnel, and visitors. Definition: Decontaminate hands - To reduce bacterial counts on hands by performing antiseptic hand rub or antiseptic handwash. 1. Hand hygiene encompasses handwashing with soap and water and the use of alcohol-based hand rubs . 8. Decontaminate hands after contact with body fluids or excretions . 11. Decontaminate hand after removing gloves . RI #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #6's Admission 5 Day MDS (Minimum Data Set) with an Assessment Reference Date of 12/17/2015 revealed the resident scored 8 out of 15 on the BIMS ( Brief Interview of Mental Status), indicating he/she had moderate cognitive impairment. RI #6 was assessed as requiring extensive assistance of one person for toileting and was always incontinent of bowel and bladder. On 02/11/2016 at 9:00 AM, RI #6 received incontinent care from a CNA, EI (employee identifier) #6. The old brief which was soaked with urine was removed from RI #6. EI #6 used soap and water to perform incontinent care. Prior to performing incontinent care EI #6 washed her hands and donned gloves. EI #6 wiped front to back down both sides of the labia, removed gloves and applied new gloves. She used soap and water to do this and rinsed with plain water. She used different corners of the bath cloth then patted dry. EI #6 removed her gloves and applied new gloves. She then separated the labia wiping front to back with soapy water. EI #6 removed her gloves, applied fresh gloves and rinsed and separated the labia with plain water. EI #6 removed her gloves and applied new ones. She turned the resident to the right side and wiped the left buttock from front to back with soapy water and then rinsed with plain water. She removed her gloves and applied new ones. She repeated the same procedure for the right buttock. She removed gloves and applied new gloves. EI #6 wiped down the rectal area with soapy water and rinsed with plain water, wiping from front to back with a different area of the wash cloth than used previously. She patted dry and removed her gloves and donned a fresh pair. EI #6 removed gloves and then went to sanitize her hands. She placed the clean brief under the resident and rolled RI #6 onto the resident's back then secured the brief. She pulled up the resident's panties and slacks. On 02/11/16 at 12:10 PM, the surveyor conducted an interview with EI #6. EI #6 was asked what she failed to do when performing incontinent care of EI #6. She said washing my hands after removing my gloves. EI #6 was asked why she did not wash or sanitize her hands after she removed her gloves. EI #6 said because she was nervous. She was asked when she was supposed to wash/sanitize her hands when providing incontinent care. She replied after removing her gloves. EI #6 was asked what the facility policy said about sanitizing the hands after removing soiled gloves. EI #6 said wash or sanitize hands. EI #6 was asked what the potential harm was when the hands were not washed/sanitized after removing gloves when providing incontinent care. She said germs. On 02/11/2016 at 12:06 PM, an interview was conducted with EI #5, Infection Control Nurse. EI #5 was asked who in the facility monitored for handwashing at appropriate times. She replied supervisors did it monthly. EI #5 was asked where this was documented and she replied the audit forms were compiled and the PI (Performance Improvement) reports. EI #5 was asked how she ensured infection control procedures were effective. She replied through monthly reports, infection and antibiotic usage and infection control audits. EI #5 was asked during incontinent care when were the staff supposed to wash /sanitize their hands. She said before washing the resident and after. EI #5 was asked when soiled gloves were removed what were the staff members supposed to do before donning clean gloves. She replied wash their hands.

Based on observations, interviews, and review of facility's policy, the facility failed to ensure food in the meat and vegetable cooler were labeled with an open and use-by date. The facility also failed to ensure food in the meat and vegetable cooler was removed from the cooler after the expiration date. This had the potential to affect 111 residents receiving meals from the kitchen. The "RESIDENT CENSUS AND CONDITIONS OF RESIDENTS (Form CMS-672) completed by Employee Identifier (EI) #3, the Director of Nursing dated 1/6/15, indicated 115 residents reside in the facility, of that number (115), four residents were fed by way of a feeding tube. Findings include: The facility's policy dated 9/9/13 titled "FAYETTE MEDICAL CENTER POLICY AND PROCEDURE GOVERNING FOOD SHELF LIFT AND STORAGE" revealed the following: "... Procedure: All food items which are to be consumed by our patrons will be handled and served within the expiration date ... All items are to be clearly labeled with both the date produced or opened and the date it is to be used by or expires ... ." During the initial tour of the kitchen on 1/6/15 beginning at 9:45 AM, the following items were observed in the meat and vegetable cooler, in a stainless steel container labeled "DISCARD AFTER" attached to the plastic wrap on top: ketchup dated 1/2/15; mandarin oranges dated 1/4/15; and pineapple slices, shredded pork, and chili, all dated 1/5/15. On 1/7/15 at 9:16 AM, the meat and vegetable cooler was re-inspected. The following items were observed in the meat and vegetable cooler, in a stainless steel container labeled "DISCARD AFTER": mandarin oranges dated 1/4/15 and pineapple slices, shredded pork, and chili, all dated 1/5/15. In an interview on 1/7/15 at 9:18 AM, EI #1, the Food Service Manager, was asked who was responsible for removing foods that have expired. EI #1 stated the staff was told that if they see an expiration date, they have the authority to throw it away. When asked if the items found in the meat and vegetable cooler had two dates, EI #1 said no. During an interview on 1/8/15 at 11:25 AM, EI #2, the Food Service Director/Registered Dietician was asked what was the potential harm of serving food that should have been discarded. EI #2 replied it could make somebody sick.

Based on observation, interview and record review, the facility failed to check temperatures of pureed foods, as well as other items served prior to the 01/15/14 lunch trayline. Facility staff also failed to ensure thermometers were calibrated for accuracy prior to use. This affected 17 residents receiving pureed food, and had the potential to affect all 114 residents for whom meals were prepared and served at the time of this survey. Findings included: The facility policy related to "Use of Thermometers to Test Food for Appropriate Temperatures" (revised 07/16/13) specifies: "A thermometer is to be used to test all food products for appropriate temps prior to food being served." The procedure specifies: "...2. Thermometers must be accurate to within +/- 2 degrees F (Fahrenheit). They must be calibrated weekly. The supervisor on duty needs to be consulted to calibrate thermometers and check for accuracy weekly." "...4. All temperatures will be recorded on appropriate temperature forms." THERMOMETER CALIBRATION On 01/15/14 at 11:10 AM, a Dietary Assistant (Employee Identifier/EI) #3 began checking the food temperatures on the lunch trayline. During the process of checking the regular food, the Surveyor asked EI #3 how often the staff calibrated the thermometers used on the trayline, and why. EI #3 explained the thermometers were calibrated "every so often" to determine accuracy. EI #3 knew the temperature should read 32 degrees Fahrenheit (F) in ice water. At the surveyor's request, EI #3 obtained a cup of ice water and checked the accuracy of the thermometer. The digital thermometer registered 38.4 degrees F (after additional ice was added to the water). EI #3 explained the thermometer could not be re-set, and continued using the thermometer to check the remaining regular textured food on the line. TRAYLINE FOOD TEMPERATURES The trayline started at 11:28 AM, prior to a temperature check of the pureed food, baked fish and milk. After the service of several pureed trays (at 11:43 AM) and the completion of the first food cart, the surveyor requested a copy of the facility menu, on which the trayline food temperatures were documented. The menu lacked documentation of the temperature of the pureed food, baked fish and milk. At 11:45 AM, the surveyor asked EI #3 who was responsible for checking the pureed food temperatures. EI #3 specified another Food Service Assistant, EI #4. The last food cart was sent out of the kitchen at 12:04 PM. At 12:25 PM, the surveyor interviewed Food Service Assistant, EI #4. EI #4 affirmed she was the person who had been responsible for checking the pureed food temperatures this day, but had checked only the desserts. When the surveyor asked why it was important to ensure the food temperatures were adequate, EI #4 explained it was to prevent food poisoning or cross-contamination.

Based on observation, interview, and record review, the facility failed to ensure meal and fluid intake documentation for the residents on Hall A was maintained in a location where non-staff members could not view it. This affected all residents on one of five halls. Findings include: The facility's "Resident Rights & Responsibilities" provided to residents upon admission (revised March 2012) revealed: "...Privacy and Confidentiality. The resident has the right to personal privacy and confidentiality of his or her personal clinical records..." On 01/15/14 at 7:40 AM, the surveyor observed multiple staff members going in and out of a room on Hall A where two residents lived. Both residents were inside the room. The staff members were going just inside the room, opening the left closet door and writing on a sheet on the inside of the closet door. Six different staff members went inside the room and wrote down information on the sheet. One of the CNAs (Certified Nursing Assistant) wrote down some information on the sheet and said it was meal consumption. At 8:05 AM, EI (Employee Identifier) #5 (CNA) wrote on the sheet. At 8:06 AM, three staff members entered the room and were inside the room at the same time. At 8:07 AM another two staff members went into the room and wrote on the sheet. At 8:08 AM another staff member entered the room and wrote on the sheet. Another two staff members entered the room, opened the closet door and wrote on the sheet. Another staff member entered the room and looked at the sheet. At 8:12 AM two staff members entered the room, opened the closet door and wrote on the sheet. At 8:15 AM, one of the residents who lived in the room (RI/Resident Identifier #18) was interviewed. According to her Annual MDS (Minimum Data Set) assessment, RI #18 scored a 15 out of 15 on her interview for mental status, indicating she was cognitively intact. RI #18 was asked if she noticed the staff members coming into her room and writing on the sheet in the closet. She said she did. RI #18 said they have to write down how much the residents eat. RI #18 was asked if that closet was her or her roommate's closet. She said it was the roommate's closet. RI #18 was asked if she had ever read it. She replied, "Yes." During this interview, two more staff members entered the resident's room to document on the meal intake sheet. On 01/15/14 at 8:28 AM, EI #5 removed the clipboard that was holding the meal intake sheet. EI #5 was asked whose names were on the sheet. EI #5 said all the residents on Hall A. EI #5 was asked how long they had been keeping the sheet in a resident's room. She said a few months. She stated, "I guess it got like a habit. It was the wrong thing to do. I apologize." EI #5 also said no one should see how much other residents eat. EI #5 was asked what the potential problem was with this practice. She said it was a privacy issue. A review of the sheet on which staff members were documenting revealed 27 total residents who lived on Hall A with all of their food percentages and fluid intake from that morning's breakfast meal. On 01/15/14 at 9:14 AM, the Station 2 RN (Registered Nurse) Supervisor (EI #6) was asked if she was aware the the documentation of the meal percentages of Hall A residents were located in a resident's room. She said she was. EI #6 was asked why it was kept there. She said it was a central location near the meal cart, so CNAs could communicate meal percentages without having to find each other. EI #6 was asked how long they had been keeping this meal intake documentation in the residents' room. She said about three or four years. EI #6 was asked if it was for all the meals or just breakfast. She said breakfast and lunch were all she knew about. EI #6 was asked what the potential problem was with all the Hall A residents' meal intakes being in a resident's room. She said the confidentiality. On 01/15/14 at 2:54 PM, the Director of Nursing (EI #2) said they did not have a specific policy regarding confidentiality, but they provide computer-based training about confidentiality. EI #2 was asked if she was aware the meal sheet was located in a resident's room. She said she was, but they would not put it in a closet of a resident who could get up and read it. On 01/16/14 at 1:47 PM, the Medical Director (EI #1) was informed that staff members were going in and out of a resident's room to document the Hall A residents' meal intake on a sheet inside the closet. He responded, "That's no good. We can't do that. We will fix that."

Based on observation, interview, and record review, the facility failed to maintain RI (Resident Identifier) #1 and RI #18's dignity by staff members freely going in and out of their room without the residents' permission. This affected two of 21 sampled residents. Findings include: A review of the facility's "Resident Rights & Responsibilities" (revised March 2012) revealed: "The resident has the right to a dignified existence, self-determination... The facility must protect and promote the rights of each resident, including each of the following rights: (A) Exercise of Rights: 1. The resident has the right (to) exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. ..." RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's Quarterly MDS (Minimum Data Set) assessment (10/30/13) revealed she had severe cognitive impairment. RI #1 required extensive to total assistance with all of her ADLs (Activities of Daily Living) except for eating. RI #1's care plan for history of [MEDICAL CONDITION] with right [MEDICAL CONDITION], memory deficit and communication deficit ([MEDICAL CONDITION]) (with a problem onset date of 08/06/13) revealed: "...Introduce self when entering room and let her know the reason for your visit... Give her time to respond. Has trouble with expressing speech at times so do not rush her. ..." On 01/15/14 at 7:40 AM, the surveyor observed multiple staff members going in and out of a room where two residents lived on Hall A. Both residents were inside their room. The staff members were going just inside the room, opening the left closet door and writing on a sheet on the inside of the closet door. Six different staff members went inside the room and wrote down information on the sheet between 7:40 AM and 8:03 AM. One of the CNAs (Certified Nursing Assistant) wrote down some information on the sheet and said it was meal consumption. At 8:05 AM, EI #5 (CNA) wrote on the sheet. At 8:06 AM, there were three staff members inside the room at the same time. Some of them did not knock or get permission before entering. At 8:07 AM, another two CNAs went in the room to write on the sheet. At 8:08 AM, another staff member entered the room without knocking and wrote on the sheet. Another two staff members entered the room without knocking, opened the closet and wrote on the sheet. Another staff member entered the room without knocking and looked at the sheet. At 8:12 AM two staff members entered the room without knocking, opened the closet door and wrote on the sheet. Each time staff members entered the room they removed one side of the magnetic mesh stop sign/gate positioned across the doorway to the room. When they exited the room each time, the magnet made a loud noise when placed back on the door frame. At 8:15 AM, the surveyor interviewed RI #18 in her room. During the interview, two staff members entered the room and wrote on the meal intake sheet. On 01/15/14 at 8:28 AM, EI #5 removed the clipboard that was holding the sheet. The surveyor asked EI #5 whose names were on the sheet. She said all the residents on Hall A. EI #5 was asked how long they had been keeping the sheet in a resident's room. She said a few months. EI #5 stated, "I guess it got like a habit. It was the wrong thing to do. I apologize." EI #5 also said no one should see how much other residents eat. EI #5 was asked what the potential problem was with this practice. She replied, "It could upset her (RI #1). If it was me it would be a privacy and dignity issue. And every time we remove the stop sign it makes a loud clicking noise and they may think we're coming in." A review of the sheet on which staff members were documenting revealed 27 total residents who lived on Hall A with all of their food percentages and fluid intake from that morning's breakfast meal. On 01/15/14 at 9:14 AM, the Station 2 RN (Registered Nurse) Supervisor (EI #6) was asked if she was aware the documentation of meal percentages of the Hall A residents were located in a resident's room. She said she was. EI #6 was asked why it was kept there. She said it was a central location near the meal cart, so CNAs could communicate meal percentages without having to find each other. EI #6 was asked how long they had been keeping this documentation in the residents' room. She said about three or four years. EI #6 was asked if it was for all the meals or just breakfast. She said breakfast and lunch was all she knew about. EI #6 was asked what the potential problem was with all the Hall A residents' meal intake being in RI #1 and RI #18's room. She said it could disturb the residents in the room. EI #6 was asked if staff members were trained to knock on residents' doors or get permission before entering their rooms. She responded, "Yes ma'am." EI #6 was asked why they knock or get permission. She said because it was like their home, asking permission to go in. EI #6 was asked if she considered stepping inside the door and opening the resident's closet as inside the room. She replied, "Yes." On 01/15/14 at 2:54 PM, the Director of Nursing (EI #2) said they did not have a specific policy regarding knocking before entering residents' rooms. EI #2 was asked if she was aware the meal sheet was located in a resident's room. She said she was, but they would not put it in a closet of a resident who could get up and read it. EI #2 was asked if she trained the staff members to knock or get permission before entering a resident's room. She said she does, but did not see this as the staff entering the room. EI #2 was asked if it was the resident's room if staff members were stepping inside the door. She said only if they were providing care. EI #2 was asked if anyone received permission from RI #1's sponsor or RI #1 to use her closet for resident documentation. She said she did not know. On 01/16/14 at 1:47 PM, the Medical Director (EI #1) was informed that staff members were going in and out of RI #1's room to document Hall A residents' meal intake on a sheet inside RI #1's closet. He responded, "That's no good. We can't do that. We will fix that."