Every finding on record at Hendrix Health and Rehabilitation

Based on observations, interviews, the facility's policies for Food Receipt and Storage, Insect and Rodent Control, Hand Sanitation During Dishwashing, and Hand-washing Guidelines, the facility's Pest Elimination Services Agreement, the facility's Pest Elimination Scope of Service, the facility's pest control service reports, and the 2022 United States (U.S.) Food and Drug Administration (FDA) Food Code; the facility failed to prevent potential cross contamination by not ensuring: food was stored a minimum of six inches from the floor and a cut watermelon was covered and dated in the refrigerator, insects were not present in the kitchen and receiving harbor from cracked/missing tile and pooled water, an employee washed hands when going from handling dirty dishes to clean dishes, and an Air Gap existed between the end of the Cook's Preparation Sink drain pipe and the top of the floor drain. This had the potential to affect 101 of 101 residents receiving meals from the facility's kitchen. Findings include: 1.) The facility's policy for Food Receipt and Storage, dated 08/23/2017, included the following: . Purpose: Foods should be received and stored properly to prevent food borne illnesses. Standard: Foods should be . stored in accordance with FDA Food Code . Process: . II. Storage of Foods . c. Items in storage rooms . should be kept at least 6 inches from the floor. k. Open food items should be covered, labeled, and dated . The 2022 U.S. FDA Food Code included the following: . 3-302 Preventing food and ingredient contamination 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation. (A) FOOD shall be protected from cross contamination by: . (4) . storing the food in packages, covered containers, or wrappings; . 3-305 Preventing contamination from the premises 3-305.11 Food Storage. (A) . FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm [centimeters] (6 inches) above the floor. 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) . refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C [Centigrade/Celsius] (41 [degrees] F [Fahrenheit]) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. During the initial tour of the kitchen on 09/05/2023 at 4:05 PM, an observation of the Six-door Reach-in Refrigerator revealed half of a watermelon, which was missing some of its interior content, was not covered or dated. At 4:18 PM, an observation of the Dry Storage Room revealed a bottom storage shelf severely bent at the back; so that the canned goods, cookies, and dry rice stored on it were slanted downwards and were not six inches from the floor. On 09/07/2023 at 12:06 PM, Employee Identifier (EI) #4, the Registered Dietitian, was interviewed. EI #4 said proper cleaning cannot occur beneath food stored less than six inches from the floor. EI #4 also said the uncovered watermelon might have something spill on it and, without a date, there was no way of knowing when it had been put in the refrigerator. On 09/07/2023 at 12:30 PM, EI #1, the Administrator and acting Dietary Manager, was interviewed. EI #1 said the problem with food being stored less than six inches from the floor was that one could not clean underneath it well and there was a potential for water splattering upon it. EI #1 also said the uncovered and undated watermelon could have gotten contaminated and you don't know how long it had been in the refrigerator. 2.) The facility's policy for Insect and Rodent Control, dated 02/01/2002, included the following: . Purpose: To prevent the spread of bacteria that may cause food borne illnesses. Standard: A contract with a pest control agency, licensed to utilize pesticides, should be in place at the facility. Process: . f. Cracks in walls, floors, along baseboards or ceilings should be reported to maintenance for repair. i. Signs of insects or rodents in the dietary department should be reported to the maintenance supervisor. The 2022 U.S. FDA Food Code included the following: . 6-501.11 Repairing. PHYSICAL FACILITIES shall be maintained in good repair. 6-501.111 Controlling Pests. The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: . (B) Routinely inspecting the PREMISES for evidence of pests; (C) Using methods, if pests are found, . or other means of pest control . and (D) Eliminating harborage conditions. During the initial tour of the kitchen on 09/05/2023 at 4:06 PM, the entry to the dishwashing area was observed to be an open doorway with broken ceramic tile at the base of entry on the right side and with additional broken and cracked ceramic tile about 1.5 feet from the floor on the right side. Small insects with wings (Sewer Flies) were observed on the right-hand side of the entry wall. There were 15 winged insects resting on the wall and many more on the floor by the entry. The grout space between the floor tiles was filled with water and had hundreds of moving insects (Sewer Flies) by the entry. Water was flowing in a thin stream from the dishroom entry wall near where the flies were resting. The dishroom was missing seven floor tiles in the middle of the dishroom floor and dirty water was pooled in the missing floor tile spaces. On 09/05/2023 at 4:09 PM, EI #6, a Dietary staff member, was asked how long had the ceramic tiles been like this and the flies been present. EI #6 said, It's been a while. When asked if it had been over a month, EI #6 said, Yes. When asked if anyone had been told, EI #6 said, They know. When further questioned, EI #6 said the Administrator knew. When asked if the exterminator had been out, EI #6 said, Yes, but it has been a while. EI #6 said the situation had gotten worse over time. EI #6 further said we try to spray with bleach every few days, but that doesn't stop them. On 09/05/2023 at 4:10 PM, EI #7, a Dietary staff member, agreed the flies and tiles had gotten worse with time. EI #7 said it had been a problem for over 3 years. When asked if the Administrator knew about this, EI #7 said he knows. During a kitchen observation on 09/06/2023 at 10:17 AM, there were at least 40 small insects with wings (Sewer Flies) seen resting on the right-side of the dishroom entry wall; while a Dietary staff member was in the dishroom operating the dishwashing machine. Additional insects (Sewer Flies) were observed on the floor in the wet grout between the tiles, but there were too many to count as they were moving and crawling constantly. Dirty water was still standing in the middle of the dishroom floor where tiles were missing and the area was covered by a rubber mat. At 10:24 AM, EI #4, the Registered Dietitian, entered the kitchen. When asked about the small flies, EI #4 said they were Sewer Flies or what are sometimes called Drain Flies. EI #4 further stated, I have never seen this, this is new to me. On 09/06/2023 at 10:31 AM, EI #3, the Maintenance Director, was interviewed in the kitchen by the dishroom entry. EI #3 said the small insects with wings were called Sewer Flies and that he had not seen them here before. When asked where the flowing water was coming from, EI #3 said it was overflow from staff washing the dishes. EI #3 said the pest control company sprayed outside monthly; but they really can not do much in the kitchen, unless they call them. EI #3 also said he was aware of the broken tiles in the kitchen and that he planned to replace missing floor and wall tiles. EI #3 further said, he did not have a quote for the work to be done, because he would be doing it himself. In addition, EI #3 said, he did not have an estimate of the cost or have a planned schedule of when the work would be done. At this time, the pest control contract and any records of pest control service visits were requested for review. On 09/06/2023 at 12:09 PM, EI #5, the Environmental Services Director, was interviewed in the kitchen by the dishroom entry. EI #5 said he was not aware of the Sewer Flies. When asked the problem with Sewer Flies in the Kitchen; EI #5 said, It's way too many and they could get in the food. EI #5 was told that a review of the pest control service receipts had revealed only prevention service for cockroaches was being provided in the kitchen. EI #5 was further told the pest control service receipt review revealed the service technician (EI #9) had documented addressing cockroaches in the kitchen during visits on 08/22/2023, 06/29/2023, 05/22/2023, 03/22/2023, 02/27/2023, and 01/26/2023. When asked if the pest control service technician should be looking for other pests; EI #5 said, Yes. On 09/06/2023 at 12:21 PM, EI #5, the Environmental Services Director, was reviewing the pest control contract, dated 11/2/2016. EI #5 confirmed he did not see where Sewer Flies were addressed in the contract. Other than Large Flies, only Small (Fruit) Flies were mentioned and those (Fruit Flies) would be treated at an additional charge according to the contract. On 09/06/2023 at 12:43 PM, EI #9, the Pest Control Service Technician, was interviewed by phone. EI #9 said he usually provided service to the facility monthly or at least every other month. EI #9 said when he sprayed for cockroaches in the kitchen, he looked for rodents also. EI #9 further said, if Sewer Flies were present during the service visit, he would treat for them. When asked if he charged extra for treating Sewer Flies; EI #9 said it would depend, he would just spray if there were only a few, but he would need to notify the staff in order to charge for it if there were a lot. EI #9 said he does not remember seeing Sewer Flies here, but, if he had, he would have mentioned it on his report. EI #9 also said he would have notified the facility and treated them with permission from the facility. On 09/07/2023 at 12:06 PM, EI #4, the Registered Dietitian, was interviewed. EI #4 said the problem with Sewer Flies in the broken tile and floor grout crevices by the dishwasher machine was the potential for pest infestation in the kitchen. EI #4 further said they could wind up on the dishes. When asked the problem with missing floor tiles allowing the pooling of dirty water in the dishwasher room, EI #4 said the potential for things to live and harbor in there. On 09/07/2023 at 12:30 PM, EI #1, the Administrator and acting Dietary Manager, was interviewed. EI #1 said he was not aware of the Sewer Flies in the kitchen until this State survey. EI #1 further said the Dietary staff will be inserviced about reporting anything they may see. EI #1 said the problem with Sewer Flies harboring within broken tile in the kitchen was that they could get in the food. When asked the problem with missing floor tiles allowing the pooling of dirty water in the dishwasher room, EI #1 said it could harbor the bugs and it could also lead to mold and mildew. 3.) The facility's policy for Hand Sanitation During Dishwashing, dated 09/05/2017, included the following: . Purpose: To prevent the spread of bacteria that may cause food borne illnesses. Standard: Hands should be washed between the handling of soiled dishes and utensils, the handling of clean dishes and utensils, and when leaving the dishwashing area, and during the dishwashing procedure. The facility's policy for Hand-washing Guidelines, dated 02/01/2002, included the following: . Purpose: To prevent the spread of bacteria that may cause food borne illnesses. Process: I. Frequency of Hand-washing: Hands should be washed in the following situations: . After hands have touched anything unsanitary, i.e., garbage, soiled utensils or equipment, dirty dishes, etc, . II. Hand-washing Procedure: a. Turn on water to a comfortable warm temperature b. Moisten hands with water and apply soap to hands c. Cover hands with soap well beyond the area of contamination d. Wash well under running water for 20 - 30 seconds e. Pay attention to areas between fingers, around nail beds and under nails . f. Rinse hands well under running water . g. Dry hands and turn water off with paper towels touching faucet handles h. Dispose of paper towels in a pedal opening trash can The 2022 U.S. FDA Food Code included the following: . 2-3 Personal Cleanliness 2-301 Hands and Arms 2-301.11 Clean Condition. FOOD EMPLOYEES shall keep their hands and exposed portions of their arms clean. 2-301.12 Cleaning Procedure. (A) . FOOD EMPLOYEES shall clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands or arms for at least 20 seconds, using a cleaning compound in a HANDWASHING SINK . (B) FOOD EMPLOYEES shall use the following cleaning procedure in the order stated to clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands and arms: (1) Rinse under clean, running warm water; . (2) Apply an amount of cleaning compound recommended by the cleaning compound manufacturer; . (3) Rub together vigorously for at least 10 to 15 seconds while: (a) Paying particular attention to removing soil from underneath the fingernails during the cleaning procedure, . and (b) Creating friction on the surfaces of the hands and arms or surrogate prosthetic devices for hands and arms, finger tips, and areas between the fingers; . (4) Thoroughly rinse under clean, running warm water; . and (5) Immediately follow the cleaning procedure with thorough drying . 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under . 2-301.12 immediately before engaging in FOOD preparation including working with . clean EQUIPMENT and UTENSILS, . and: . (E) After handling soiled EQUIPMENT or UTENSILS; . During a kitchen observation on 09/06/2023 at 10:17 AM, one Dietary staff member (EI #8) was in the dishroom pre-rinsing dirty dishes and loading them into the dishwashing machine. At 10:19 AM, EI #8 was observed rinsing her hands under the running water at the hand sink and rubbing her hands together, but EI #8 did not use any soap and was not drying her hands. With bare (ungloved) hands, EI #8 was going from handling, spraying, and loading dirty dishes onto racks for entry into the dishwashing machine to unloading, handling, and stacking clean dishes without washing her hands with soap. This was observed four times. At 10:24 AM, EI #4, the Registered Dietitian, entered kitchen and was given the opportunity to observe EI #8 rinsing, but not washing her hands when going from dirty to clean dishes. At 10:26 AM, EI #8 was asked who taught her to rinse/wash her hands like that. EI #8 said, a Dietary employee, who is now retired, trained her to rub her hands under the water. When asked if she used soap; EI #8 said, sometimes a little bit, but her hands were constantly wet. EI #8 said, the purpose of washing one's hands between dirty to clean was to sanitize. On 09/07/2023 at 10:00 AM, EI #8 was observed working in the Dishroom washing breakfast dishes by herself. There was another Dietary staff person outside the pass-through window, who was breaking down the tray carts and putting dishes on the dishtable for EI #8 to pre-rinse/spray and load onto dishwashing racks. At 10:07 AM, EI #8 was observed not washing her hands with soap. EI #8 was observed merely rinsing her hands as she went from handling dirty to clean dishes. On 09/07/2023 at 12:06 PM, EI #4, the Registered Dietitian, was interviewed. EI #4 said the problem with an employee going from handling dirty dishes to handling clean dishes without proper hand washing was cross contamination. EI #4 further said soap needs to be used for proper handwashing. On 09/07/2023 at 12:30 PM, EI #1, the Administrator and acting Dietary Manager, was interviewed. EI #1 said the problem with an employee going from handling dirty dishes to clean dishes without proper hand washing was cross contamination. 4.) The 2022 U.S. FDA Food Code included the following: . 5-402.11 Backflow Prevention. (A) . a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. During a kitchen observation on 09/07/2023 at 10:13 AM, the drain pipe of the Cook's Preparation Sink was seen to be extending down into the floor drain. At 11:10 AM, EI #3, the Maintenance Director, measured the distance from the floor to the bottom of the Cook's Preparation Sink drain pipe. The Cook's Preparation Sink drain pipe extended into the floor drain by 3/4 inch. EI #3 agreed there was not an air gap to prevent the potential back-up of sewage. On 09/07/2023 at 12:06 PM, EI #4, the Registered Dietitian, was interviewed. EI #4 said there should be an air gap between the top of the floor drain and the end of the Cook's Preparation Sink drain pipe to prevent back flow.

Based on observation, interview, the facility's policy for Garbage and Refuse, a waste management invoice for the facility, and the 2022 United States (U.S.) Food and Drug Administration (FDA) Food Code; the facility failed to ensure three of three dumpsters were not filled to overflowing with plastic bags of garbage/trash, with the dumpster lids open, and with four plastic bags of garbage/trash on the pavement beside the dumpsters on 09/05/2023 at 4:23 PM. This had the potential to affect 103 of 103 residents residing in the facility. Findings include: The facility's policy for Garbage and Refuse dated 02/01/2002, included the following: Purpose: To prevent the spread of bacteria that may cause food borne illnesses. Process: . e. Refuse containers and dumpsters kept outside the facility should have tightly fitting lids and should be kept covered when not being loaded. f. Dumpsters should be emptied according to the facility contract; garbage should not accumulate or be left outside the dumpster. g. The schedule for garbage pick-up should be revised, as needed, based on the volume of refuse. The facility's waste management invoice, dated 03/31/2023, included the following: . 3 Waste Container 8 Cu (Cubic) Yd (Yards), 6 Lifts Per Week . The 2022 U.S. FDA Food Code included the following: . 5-5 Refuse, Recyclables, and Returnables 5-501 Facilities on the Premises . Operation and maintenance . 5-501.112 Outside Storage Prohibitions. (A) . unprotected plastic bags . that contain materials with FOOD residue may not be stored outside. 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE . shall be kept covered: . (B) With tight-fitting lids or doors if kept outside the FOOD ESTABLISHMENT. 5-502 Removal 5-502.11 Frequency. REFUSE . shall be removed from the PREMISES at a frequency that will minimize the development of objectionable odors and other conditions that attract or harbor insects and rodents. On 09/05/2023 at 4:23 PM, three dumpsters were observed. All three dumpsters had their lids open and were overflowing with tied plastic bags of garbage/trash. In addition, there were four plastic bags full of garbage/trash directly on the pavement beside the dumpsters. On 09/06/2023 at 10:31 AM, Employee Identifier (EI) #3, the Maintenance Director, was interviewed. EI #3 said the contracted waste management company usually does a pick-up on Monday, but last Monday was a holiday. EI #3 further said they (the dumpsters) usually are pretty full even then. EI #3 then said he thought they were going to pick up yesterday, Tuesday, but they did not. EI #3 said, the garbage could attract things that could carry diseases that might affect the residents. On 09/06/2023 at 2:28 PM, EI #5, the Environmental Services Director, provided a waste management invoice, dated 03/31/2023, which documented: three waste dumpsters with 6 Lifts Per Week. According to EI #5, there were two lifts per week for each dumpster. EI #5 further explained there were two pick-ups each week, on Monday and on Thursday, with exceptions for holidays. In an interview on 09/07/2023 at 11:23 AM, EI #5, the Environmental Services Director, was asked the problem with bags of garbage/trash piled into dumpsters without the lids being closed and with four bags of garbage/trash on the ground beside the dumpsters. EI #5 said, Animals could get into the trash. EI #5 further said animals, such as raccoons could get into the outdoor space where the residents do activities and could be a danger to the residents who might get bitten or get rabies. On 09/07/2023 at 12:06 PM, EI #4, the Registered Dietitian, was interviewed. EI #4 said the concern with the exposed bags of garbage/trash was the potential for pest infestation, such as rodents or insects. EI #4 said if pests were drawn close to the dumpsters, then they might be drawn closer to the building (facility). In an interview on 09/07/23 at 12:30 PM, EI #1, the Administrator, said it could be a safety issue to get it (bags of garbage/trash) up that high.

Based on observations, interviews, and resident record review, the facility failed to ensure staff did not stand while feeding Resident Identifier (RI) #8 the breakfast meal on 09/06/2023. This deficient practice had the potential to affect RI #8, one of one resident sampled for dignity. Findings include: RI #8 was admitted to the facility on [DATE]. RI #8's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 06/28/2023 documented RI #8 had a Brief Interview for Mental Status (BIMS) score of zero, which indicated RI #8 had severely impaired cognitive skills for daily decision making; and RI #8 required one person assistance with eating. On 09/06/2023 at 8:51 AM, RI #8 was observed being fed the breakfast meal by Employee Identifier (EI) #10, a Nursing Assistant (NA). EI #10 was standing while feeding RI #8 the breakfast meal. An interview was conducted with EI #10 on 09/06/2023 at 09:15 AM. EI #10 stated, she was standing while she fed RI #8 breakfast and said, she should have been seated. An interview was conducted with EI #2, Director of Nursing (DON) on 09/07/2023 at 5:25 PM. EI #2 stated, staff should be seated at eye level when feeding residents. EI #2 stated, her concern of staff standing while feeding a resident is them standing over the top of the resident.

Based on observations, interviews and a review of a facility policy titled, Leftover Food Storage and Use, the facility failed to ensure: 1. outdated food was not stored in the walk-in cooler, and 2. food items were labeled with a receive date or use by date prior to storage in the walk-in cooler/walk-in freezer. These failures had the potential to affect 99 residents receiving meals from the kitchen out of 103 total residents residing in the facility. Findings Include: The facility policy titled, Leftover Food Storage and Use, with an effective date of 9/12/19, included . PURPOSE: To assure that food borne illnesses are avoided . Leftover foods should be . labeled and dated . should be used within 72 hours . If not used within 72 hours . foods should be discarded . On 10/27/19 at 10:22 a.m., the surveyor observed food items in the walk-in cooler. There were two clear plastic bags of Pancakes with no received date or use by date, one container of Hamburger Steak Puree Meat prepared on 10/23/19 and labeled with a use by date of 10/25/19, one container of Sliced [NAME]atoes with no prepared date or use by date, one container of Boiled Eggs prepared on 10/24/19 and labeled with a use by date 10/26/19, and one box of Breakfast Pork [NAME]es with no received date or use by date. On 10/27/19 at 10:31 a.m., the surveyor observed food items in the walk-in freezer. There were two clear plastic bags of Diced Potatoes with no received date or use by date and one open bag of Yeast Rolls with no received date or use by date. On 10/28/19 at 03:20 p.m., the surveyor conducted an interview with EI (Employee Identifier) #3, the Lunch Cook. The surveyor asked EI #3, what does a use by date mean. EI #3 stated, it had to be used by that date or it had to be discarded. The surveyor asked EI #3 why the following items were observed in the walk-in cooler on 10/27/19 at 10:22 a.m.: in two clear plastic bags of Pancakes with no receive date or use by date, one container of Hamburger Steak Puree Meat prepared on 10/23/19 with a use by date of 10/25/19, one container of Sliced [NAME]atoes with no prepared date or use by date, one container of Boiled Eggs prepared on 10/24/19 with a use by date of 10/26/19, and one open box of Breakfast Pork [NAME]es with no received date or use by date. EI #3 stated it was overlooked by the staff. The surveyor asked EI #3 why the following items were observed in the walk-in freezer on 10/27/19: two clear plastic bags of Diced Potatoes with no received date or use by date and one open bag of yeast rolls with no received date or use by date. EI #3 stated it was overlooked by the staff. EI #3 stated you should discard food items by their use by dates. EI #3 was asked, what was the facility policy on labeling food items prior to storage. EI #3 stated the food items should be labeled and dated with a prepared date and used by date. The surveyor asked EI #3, what was the potential concern of storing foods not labeled with use by dates and storing items past their use by dates. EI #3 stated it could cause bacteria which could be harmful to the residents. On 10/29/19 at 10:21 a.m., the surveyor conducted an interview with EI #4, the Dietary Manager. The surveyor asked EI #4, who was responsible for ensuring the food items were discarded when out of date in the walk-in cooler/refrigerator/freezer. EI #4 stated, all staff were responsible. The surveyor asked EI #4, what was the potential concern of storing foods not labeled with use by dates and storing items past their use by dates. EI #4 stated, it could cause food borne illness or cross contamination.

Based on observation, interviews, record review, and a facility policy titled Respiratory Therapy, the facility failed to ensure Employee Identifier (EI) #1, a Registered Nurse (RN), rinsed with water and dried Resident Identifier (RI) #33's nebulizer facemask and attached reservoir, prior to placing it in a plastic bag on the bedside table. This deficient practice affected RI #33, one of three residents observed during the medication pass, and EI #1, one of three nurses observed during the medication pass. Findings Include: A review of a facility policy titled, Respiratory Therapy, with a date of 03/2011, revealed . Nebulizers . C. After completion of therapy: (1) Remove nebulizer container. (2) Rinse container with fresh tap water. (3) Dry appropriately . RI #33 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/28/2019 at 12:49 p.m., the surveyor observed EI #1, a RN, during the medication administration pass. During the medication pass, EI #1 removed RI #33's nebulizer facemask with the attached reservoir and placed it in the plastic bag on the bedside table, after she gave RI #33's breathing treatment. EI #1 did not rinse with water, or dry the facemask with the attached reservoir, prior to placing it in the plastic bag on the bedside table. The surveyor observed clear liquid drops on RI #33's facemask and the attached reservoir in the plastic bag on the bedside table. On 10/29/19 at 2:00 p.m., the surveyor conducted an interview with EI #2, an Infection Control Preventionist/Licensed Practical Nurse. EI #2 was asked what would be the concern if a licensed nurse placed RI #33's facemask with the attached reservoir, with clear liquid drops on both items, in the plastic bag on the bedside table, after administering RI #33's breathing treatment. EI #2 stated it could have caused bacteria from the moisture in the reservoir and facemask. EI #2 further stated this could have caused an infection to the resident. EI #2 was asked what was the facility policy on what a licensed nurse should do with the facemask and reservoir of the nebulizer after giving a resident a breathing treatment. EI #2 stated you should remove the nebulizer container, rinse the container with fresh tap water, and dry appropriately. On 10/29/2019 at 2:12 p.m., the surveyor conducted an interview with EI #1, a RN. EI #1 was asked to describe what was in RI #33's nebulizer reservoir and facemask, after she gave RI #33's breathing treatment, and placed it in the plastic bag on the bedside table. EI #1 stated there were clear liquid drops in RI #33's reservoir and facemask of the nebulizer after she gave RI #33's breathing treatment. EI #1 was asked what should she have done prior to placing RI #33's nebulizer facemask with the attached reservoir in the plastic bag on the bedside table. EI #1 stated she should have removed the nebulizer container, rinsed it with water, and dried it appropriately. EI #1 was asked why did she not rinse and dry the facemask with the attached reservoir of the nebulizer after she gave RI #33's breathing treatment, and prior to placing both in the plastic bag on the bedside table. EI #1 stated she was nervous and forgot. EI #1 was asked what was the facility policy on what a licensed nurse should do with the facemask and reservoir of the nebulizer after she gave a resident a breathing treatment. EI #1 stated the policy stated after you gave the nebulizer treatment, you should remove the nebulizer container, rinse the container with fresh tap water, and dry appropriately. EI #1 was asked was the facility policy followed. EI #1 stated no. EI #1 was asked what would be the concern if a licensed nurse did not clean and dry the reservoir and facemask, prior to placing it back in the plastic bag, with clear liquid drops on the facemask and reservoir. EI #1 stated it could cause a respiratory infection to the resident.

Based on observations, interviews, and facility policies titled, Nursing Pantry foods, and Food Storage Temperature Logs, the facility failed to ensure: 1. unit refrigerator temperatures were being monitored and 2. food items brought in from outside of the facility were dated. This effected 2 of 3 unit refrigerators. 1. A review of the facility policy titled, Food Storage Temperature Logs, with an effective date of 04/29/2015, revealed, Purpose: In order to prevent food borne illnesses, foods should be stored at proper temperatures. STANDARD: The FDA (Food and Drug Administration) Food Code guidelines should be used for the storage of food items. Temperatures should be monitored and recorded on a food temperature log. Process . Refrigerators 33-40 degrees F . An observation was made on 09/11/18 11:42 AM of the resident refrigerator on Station 2. The temperature of the refrigerator was 54 degrees. The refrigerator had several sandwiches and bottles of liquid thickener. There was a sign on the resident refrigerator that the temperature should be between 33 and 40 degrees. A second observation was made on 09/11/18 5:36 PM of the thermometer in the refrigerator on Station 2. The temperature was 43 degrees. On 9/13/18 at 9:18 AM, an interview was conducted with Employee Identifier (EI) #1, Director of Nursing (DON). EI#1 was asked, how were the temperatures of the unit refrigerators monitored. EI#1 replied, they were monitored by the nursing staff, there should be a log. EI#1 was asked, was there a log for the Station Two refrigerator. EI #1 replied, not to her knowledge. EI #1 was asked, what was the potential harm. EI #1 replied, food not being kept cool enough . 2. A review of the facility policy titled, Nursing Pantry Foods, effective date 2/1/2002, revealed, PURPOSE: Foods are made available at each nursing station for residents who may feel hungry between meals. STANDARD: The Dietary Manager, for each nursing station, should establish a par level of foods and beverages. Dietary staff should replenish nursing units to maintain the established par levels, each day. PR[NAME]ESS: c. Any temperature dependent foods should be . sealed containers, marked with the date. An observation on 09/11/18 12:06 PM was made of the Station Three's unit refrigerator. Two Tupperware containers were observed with a resident's name on them and no date. On 9/13/18 at 10:11 AM, an interview was conducted with EI #1. She was asked, how were items brought in from outside of the facility to be stored in the unit refrigerators. EI #1 replied, they were given to a staff member and they needed to have the resident's name and the date they were brought in on them. EI #1 was asked, what was the potential harm for not dating a food item. EI #1 replied, you can not tell how long it has been there, if it is past the freshness date.

Based on interview, medical record review and the Resident Assessment Instrument User Manuel Version 3.0, Chapter 4, the facility flied to ensure RI (Resident Identifier) #77, #29, and #4 attended their care plan meetings so that they were allowed to be involved with making decisions about their care and treatment. This deficient practice affected three of three sample residents whose care plan attendance form was reviewed. Findings Include: A review of a document, Resident Assessment Instrument User Manuel Version 3.0, revealed: Chapter 4: .CARE PLANNING .4.7 Care Planning .A well developed .care plan, Reflects the resident/resident representative input for goals for health care; .The overall care plan should be oriented towards .Involving resident, resident's family . On 9/11/18 at 8:36 AM, RI #77 reported to the surveyor that he/she had not been to any care plan meeting to the resident's knowledge. RI #77 was readmitted to the facility on [DATE]. The resident had a Brief Interview for Mental Status (BIMS) of 12/15, indicating the resident's cognition to be intact. A review of RI # 77's care plan attendance form revealed one documentation of the resident's attendance of a meeting for (YEAR). Resident Care Plan meetings are conducted at a minimum of one every three months. On 09/11/18 at 9:22 AM, RI #29 reported to the surveyor that he/she did not know about care plan meetings or that the resident had been to any meetings. RI #29 was admitted to the facility on [DATE]. The resident had a BIMS of 15/15, indicating cognition intact. A review of RI #29's care plan attendance form revealed no documentation of the resident's attendance to any meetings for (YEAR). RI #4 was readmitted to the facility on [DATE]. The resident had a BIMS of 15/15, indicating the resident's cognition to be intact. A review of RI #4's care plan attendance form revealed no documentation of the resident's attendance for (YEAR) care plan meetings. On 09/13/18 an interview was conducted with Employee Identifier (EI)#2, the Social Worker. EI #2 was asked if RI #4, RI #29 and RI # 77 attended his/her care plan meeting according to the attendance form. EI #2 said, No. EI #2 was asked if residents should attend his/her care plan meeting. EI #2 said, Yes. EI # 2 was asked why was it important for residents to be involved in decisions about his/her care. EI #2 said, So they can direct their care and if they have any issues the staff could re-evaluate or assess those issues.

Based on observation, interview, review of a facility policy titled, Dish Machine Sanitization, and review of the manufacturer's specifications for the facility's dish machine, the facility failed to ensure the dish machine wash temperatures and concentration of chemical sanitizer were sufficient to consistently clean and sanitize. This affected all 87 residents to whom meals were served, as identified by the facility's diet order list. Findings Include: The facility's policy titled, Dish Machine Sanitization, with an effective date of 02/01/02, specified: . Dish machines should be operated in accordance with manufacturer's instructions, in order to promote sanitation of dishes and utensils . The manufacturer's specifications for the facility's ES-2000 chemical sanitizing dish machine specified minimum operating temperatures for both wash and rinse cycles, as 120 degrees F (Fahrenheit). The data plate affixed to the side of the machine listed a minimum chlorine concentration of 50 parts per million (ppm). On 08/22/17 at 3:40 p.m., a tour of the Dietary Department was made by survey staff. The Dish Machine Temperature Log was posted. Wash temperatures were recorded as 100 degrees F for 67 of 67 breakfast, lunch and supper meals, from 08/01/17 through the breakfast meal of 08/23/17. The wash temperatures were consistently below the recommended 120 degrees F throughout the month of July 2017 as well, at 100 degrees F for 93 of 93 recorded meal cycles. On 08/23/17 at 9:15 a.m., the surveyor observed staff during the washing of the breakfast dishes. The wash temperature was observed to be 110 degrees F (inadequate), the rinse temperature was 122 degrees F (adequate) and the chlorine concentration of the final rinse water was found to be less than 50 ppm. Despite nine additional wash and rinse cycles, the chemical concentration failed to register a minimum of 50 ppm. Three previously washed racks of dishes, bowls, bases and trays were put away into storage, by staff. When questioned on 08/23/17 at 9:30 a.m., a dishroom staff member (Employee Identifier) EI #1, stated she changed the chlorine every four to five days (as needed). EI #1 stated their goal for chlorine concentration was about 75 ppm. On 08/23/17 at 11:00 a.m., the Dietary Manager, EI #2, explained the chlorine dispenser of the dish machine was clogged. On 08/24/17 at 9:05 a.m., the surveyor asked EI #2 if he was aware of the recommended wash temperatures (120 degrees F). EI #2 stated he was not.

Based on observation, record review and interview, the facility failed to ensure: 1. Pure Cocoa was sealed with an open and use by date. 2. A can of red beans was not dented and stored with regular food cans. 3. Thickened orange juice that was out of date was not stored with other orange juice. These failures had the potential to affect 105 residents receiving meals from the kitchen. Findings Include: A review of a facility's policy titled, Food Receipt and Storage with an effective date of August 21, 2013 revealed: .PROCESS I. Receiving Foods: . Cans are intact; free of dents, bulging and swelling . e. New items should be placed on the back of the shelves, with labels in view, with older items pulled to the front of the shelves for use. f. Place dented, bulging, or rusty cans, and opened or torn package in a separate area .K. Open food items should be covered, labeled, and dated; opened dry goods should be kept in tightly sealed containers. On 8/16/2016 at 2:35 p.m., the surveyor and the dietary manager observed a five pound bag of cocoa with no open date or use by date. The package was not sealed. On 8/18/2016 at 1:56 p.m., an interview was completed with EI #2, (Employee Identifier), Dietary Manager. EI #2 was asked what item was opened and was not sealed properly with no use by date or other identifying information. EI #2 replied, cocoa. EI #2 was asked why was it opened and not in a sealed container. EI #2 replied, whoever used it failed to put it away like it suppose to be. EI #2 was asked who was responsible for making sure items were sealed. EI #2 replied the person who used it. EI #2 was asked what should be done with food items once opened out of the original container. EI #2 replied, it should be dated, labeled and put in a seal container. EI #2 was asked what was the facility's policy on opened food items. EI #2 replied, date it, label it and put it in a sealed package. EI #2 was asked what was the potential harm when food items are opened and they are not sealed properly and there was no use by date on the item. EI #2 replied, something can get into it. On 8/16/2016 at 2:35 p.m., the surveyor and the dietary manager observed a can of red beans with a dent at the top of the can. The can weighted five pounds. On 8/18/2016 at 1:50 p.m. an interview was conducted with the dietary manager. EI #2 was asked what can item was dented in dry storage. EI #2 replied, she did not remember. EI #2 was asked was it dented. EI #2 replied yes ma'am. EI #2 was asked who was responsible for removing dented items from the shelf. EI #2 replied, anyone who had time to remove it. EI #2 was asked when should dented items be removed from regular can items. EI #2 replied when they are putting it away. EI #2 was asked was the dented can mixed in with regular food cans. EI #2 replied, yes ma'am it was. EI #2 was asked what was the facility's policy regarding dented cans. EI #2 replied, put the dented cans in the dented cans area. EI #2 was asked what was the potential harm when cans are dented and on the shelf with regular cans. EI #2 replied, food poisoning. On 8/16/2016 at 2:35 p.m., an observation was made along with the dietary manager. The surveyor observed a 46 fluid ounce box of thickened orange juice dated 5/09/2016. On 8/18/2016 at 2:05 p.m., an interview was conducted with EI #2. EI #2 was asked what was the expiration date on the thickened orange juice. EI #2 replied May 2016. EI #2 was asked why was it with the other thickened orange juice. EI #2 replied, they did not go through and remove anything that was out of date. EI #2 was asked who was responsible for removing out of date thickened juice off the shelf. EI #2 replied the person who use it and the person putting it away. EI #2 was asked when should expired items be removed off the shelf. EI #2 replied as soon as they see it. EI #2 was asked what do the facility policy say about expired food items mixed with regular food items. EI #2 replied, it was not suppose to be there. EI #2 was asked what was the potential harm when a resident received expired thickened orange juice. EI #2 replied, they are not suppose to get it.

Based on observation, and interview the facility failed to ensure ice crystals were not formed around the door frame in the walk in freezer, and had not accumulated from the ceiling, on the floor and boxes on the inside of the freezer on two of three days of the survey. This failure had the potential to affect all residents receiving meals from the kitchen. Findings Include: On 8/16/2016 at 2:50 p.m., along with the dietary manager the surveyor observed ice crystasl on the inside of the door, on the door frame, on the floor, and in the ceiling. On 8/17/2016 at 2:55 p.m., the surveyor observed ice crystals in the walk in freezer, on the floor, on the inside of the door, on the door frame and boxes on the left side in the freezer. On 8/18/2016 at 2:12 p.m., the surveyor conducted an interview with EI # #3, (Employee Identifier), cook. EI #3 was asked when did he observe ice on the floor and on the door. EI #3 replied, it was last year. EI #3 was asked did he report it to maintenance. EI #3 replied, we had reported it to maintenance several times. EI #3 was asked who was responsible for reporting equipment with a problem to maintenance. EI #3 replied, anyone in the kitchen. EI #3 was asked what do the facility policy say about reporting equipment that was not working properly. EI #3 replied, tell the maintenance man and he was suppose to take care of it or tell the dietary manager. EI #3 was asked what was the potential harm when equipment was not reported to maintenance and there was ice on the floor, ceiling, and the inside of the door. EI #3 replied, severe falls even death. EI #3 was asked what was the importance of reporting equipment that was not working properly immediately. EI #3 replied, there was a danger of being injury. On 8/18/2016 at 2:15 p.m., an interview was conducted with EI #4 a dietary aide. EI #4 was asked when did she observe ice on the floor and on the door of the freezer. EI #4 replied, about a month ago. EI #4 was asked did she report it to maintenance. EI #4 replied, yes. EI #4 was asked who was responsible for reporting equipment with a problem to maintenance. EI #4 replied, let the supervisor know and she will say something to maintenance. EI #4 was asked what do the facility policy say about reporting equipment that was not working properly. EI #4 replied, to report it. EI #4 was asked what was the potential harm when equipment problems were not reported to maintenance and there was ice crystals on the freezer floor, inside the door and on boxes. EI #4 replied, it was a danger and it can cause slips and falls. On 8/18/2016 at 2:21 p.m., an interview was conducted with EI #2, dietary manager. EI #2 was asked when did she observe ice on the floor on the inside of the door. EI #2 replied it had been happening over a period of six months. EI #2 was asked did she report it to maintenance. EI #2 replied yes ma'am. EI #2 was asked did maintenance fix it. EI #2 replied, it was some work done on it. EI #2 was asked who was responsible for reporting equipment with a problem to maintenance. EI #2 replied, dietary staff. EI #2 was asked what was the potential harm when the freezer was not reported to maintenance and there was ice on the floor, inside of the door and on boxes. EI #2 replied, a safety hazard. On 8/18/2016 at 2:40 p.m., an interview was conducted with EI #5, maintenance supervisor. EI #5 was asked when did you first get a work order for the kitchen freezer regarding ice. EI #5 replied, not sure we had a couple issues with ice. EI #5 was asked was it reported to him about ice on the freezer. EI #5 replied, yes. EI #5 was asked when you made rounds on the first of the month was ice on the floor. EI #5 replied, some ice was around the door and on some on the boxes.

Based on interviews and record reviews, the facility failed to ensure residents had access to petty cash of their Resident Trust Funds after normal business hours, on holidays and weekends. This affected five of eight residents who attended the group meeting on 08/17/16. This also had the potential to affect the other 69 residents who have Resident Trust Accounts. Findings include: A review of the facility's policy, with a revised date of September 2014, revealed the following: RESIDENT TRUST The purpose of resident trust is to provide residents with personal funds the ability to use these monies .Upon written authorization from the resident or their agent, the facility must hold, safeguard, manage and account for the personal funds deposited with the facility . Each Administrator will apoint a Resident Trust custodian to be soley responsible for the fund Resident Fund Petty Cash To accommodate the resident's need for cash money, the facility must maintain a resident trust petty cash box . On 08/17/16 at 10:30 am, a Resident Council Meetings was conducted. During this meetings, residents were asked if they had funds in a Resident Trust account, the residents replied, they did. When asked if they could have access to the petty cash from their Trust Fund accounts after normal business hours, weekends or holidays. Six of the residents answered, Monday through Fridays, in the business office from hours of 8 to 5 pm. The residents further explained, there use to be money on the medication (med) cart on Station 1, but unsue of what happened. On 08/17/16 at 3:50 p.m., an interview was conducted with EI (Employee Identifer) #1, a Financial Specalist. EI #1 was asked how do resdients access their petty cash funds during business hours. EI #1 replied, during business hours Monday through Friday from 8 am- 4:30 or 5 pm, residents come to the business office. EI #1 was asked are residents able to access their petty cash funds on the weekends, or holiday or after hours. EI #1 said, No they are not. EI #1 also stated, that for eight or nine months, she left petty cash on the weekends on the med cart but no one ever asked for it, so she stopped leaving petty cash for residents on the weekends.

Based on observations, record review and interviews, the facility failed to ensure oxygen tubing and masks/nasal cannula's were stored in a sanitary manner when not in use. This affected RI (Resident Identifier) #'s 21, 22, 23 and 24, four of eight resident's reviewed for oxygen use. Findings Include: Review of a facility policy titled, Oxygen Administration with an effective date of 12/08/2005 revealed the following: .PROCESS: .14. O2 (oxygen) cannula/mask should be stored in a plastic bag when not in use. On 08/16/2016 during the initial tour of the facility, RI #21's O2 tubing and mask/cannula were observed tucked into the bed, not in use and open to air. RI #22's tubing and mask/cannula were observed lying on top of table, not in use and open to air. RI #23's tubing and mask/cannula were observed lying on the humidifier bottle, not in use and open to air. RI #24's tubing and mask/cannula were observed lying in the seat of a chair, not in use and open to air. On 08/17/2016 at 8:20 a.m. RI #21's O2 tubing and nasal cannula were observed dangling from the bed and touching the floor. At 12:06 p.m. the tubing and cannula were observed in the same position. RI #21 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of RI #21' physician's orders [REDACTED].O2 @ (at) 2l (liters)/M (per minute) PER NASAL CANNULA PRN (as needed) FOR SHORTNESS OF BREATH . On 08/17/2016 at 8:25 a.m. RI #22's O2 tubing and nasal cannula were observed lying in a arm chair. RI #22 was up to a wheelchair. At 12:03 p.m. the tubing and cannula were observed in the same position. RI #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of RI #22's physician's orders [REDACTED].OXYGEN @ 2L/M PER NASAL CANNULA PRN FOR SHORTNESS OF BREATH . On 08/17/2016 at 8:30 a.m. RI #24's O2 tubing and nasal cannula were observed lying on an used draw sheet of an unmade bed. RI #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of RI #24's physician's orders [REDACTED].OXYGEN @ -2-- L/MIN PER --N/C (nasal cannula) PRN FOR SHORTNESS OF BREATH . On 08/17/2016 at 8:35 a.m. RI #23's O2 tubing and nasal cannula were observed hanging over the humidifier bottle of the O2 concentrator and dangling approximately one inch off the floor. At 12:00 p.m. the tubing and cannula were observed in the same position. RI #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of RI #23's physician's orders [REDACTED].O2 @ 2 L/MIN PER NASAL CANNULA PRN FOR SHORTNESS OF BREATH . An interview was conducted on 08/18/2016 at 2:15 p.m. with EI (Employee Identifier) #6, RN (Registered Nurse) Unit Manager. EI #6 was asked what the correct way to store O2 tubing and masks (nasal cannula). EI #6 stated that it should all be kept in a Ziploc bag so they stay clean between uses. EI #6 was asked what was the potential harm if O2 tubing and masks/cannula's were not stored properly to which she replied, infection. An interview was conducted on 08/18/2016 with EI #7, DON (Director of Nursing). EI #7 was asked what should be done with O2 tubing and masks when not in use. EI #7 stated they should be put in a plastic bag. EI #7 was asked what was the potential harm if O2 tubing and masks/cannula were not stored properly to which she replied there was the potential for infection. An interview was conducted on 08/18/2016 at 1:30 p.m. with EI #8, Infection Control Nurse. EI #8 was asked where should O2 tubing and masks/cannula be stored between use. EI #8 stated they should be stored in a plastic bag and taped to the concentrator. EI #8 was asked what was the potential harm if the tubing and masks/cannula were not stored properly to which she responded there was the potential for infection.

Based on record review and interview, the facility failed to ensure a discharge summary was completed on RI (Resident Identifer) #13, a resident who discharge was anticipated after rehabilitation stay. This affected one of three residents, whose closed records were reviewed. Findings include: The facility's policy titled, Discharge Summary and Plan of Care with an effective date of October 1, 2010, revealed the following: . PROCESS: . Upon discharge of a resident (other than in emergency to hospital or death) a discharge summary is provided to the receiving care provider. RI #13 was readmitted to the facility on [DATE]. According to the facility's discharge resident list, RI #13 was discharged home on[DATE]. A review of RI #13's medical record revealed no discharge summary. On 8/06/15 at 1:05 PM, an interview was conducted with EI (Employee Identifer) #1, the DON (Director of Nurses). EI #1 looked through RI #13's medical record, but could not locate the discharge summary. EI #1 was asked, who was responsible for ensuring discharge summaries were done. EI #1 said, the nurse who discharged the resident. EI #1 was asked, why was a discharge summary not done on RI #13. EI #1 said, I really don't know.

Based on observation, record review and interview, the facility failed to ensure a Licensed Practical Nurse (LPN) labeled an opened, multidose vial of insulin with her initials and an opened or expire date. This occurred on one of 14 residents observed for Medication Administration. Findings include: The facility policy titled, Medication Administration Procedures Vials and Ampules (Injectable Medications) dated ,[DATE] stated the following: . Procedures . 2. The initials of the first person to use the vial and the date opened are recorded on multidose vials. On [DATE] at 4:42 PM, during Medication Administration, an observation was made of Employee Identifier (EI) #3, a LPN, who removed a medication vial from a box labeled with a resident's name and dosage. The vial was open with no open date or staff initials noted on the vial. In an interview on [DATE] at 4:42 PM, EI #3 was asked what is the facility policy when opening a new bottle of insulin. EI #3 stated you are supposed to date it when it is opened and initial it. EI #3 was asked if the vial of Humalin removed from the box had a open date on it. EI #3 stated no. EI #3 was asked what would be the potential harm in not labeling an open vial of medication with an opened date. EI #3 stated the medication might be expired, because it cannot be used 28 days past the opened date. In an interview on [DATE] at 11:55 AM, EI #1, the Director of Nurses (DON) was asked what is the facility policy on labeling opened multidose vials of medication. EI #1 stated, The person who opens the vial should initial and date it when it is opened. EI #1 was asked what is the potential harm in using medication from an opened undated or unlabeled multidose vial. EI #1 stated, We don't know if it is past date and has been opened too long.

Based on record review, observations, and interview, the facility failed to ensure posted licensed nursing and Certified Nursing Assistant (CNA) daily staffing was posted at the beginning of each shift. Staffing was posted for all three shifts at the beginning of day shift. This occurred on three of three days of the survey. Findings include: The facility policy titled, NHS Nurse Staff Posting Protocol, with an effective date of 12/27/05 stated the following: . DON (Director of Nurses)/designee will fill out the NHS nurse staffing form at the beginning . day shift with the most current scheduled staff . An observation was made on 8/4/15 at 9:30 AM of the Nurse/CNA posted staffing in the main hall at the front entrance of the facility. All Nursing/CNA staffing was posted for all three shifts for the 24 hour period at that time: day shift, evening shift and night shift. An observation was made on 8/5/15 at 8:45 AM of the posted Nurse/CNA staffing. Staffing was posted for all three shifts for the 24 hour period at that time. An observation was made on 8/6/15 at 10:15 AM of the posted Nurse/CNA staffing. Staffing was posted for all three shifts for the 24 hour period at that time. In an interview on 8/6/15 at 11:55 AM, Employee Identifier (EI) #2, the Staff Development Nurse, was asked when should staffing (the public posting) be posted. EI #2 stated, First thing in the morning. EI #2 was asked how many shifts are to be posted at one time. EI #2 stated, One at a time. EI #2 was asked how many shifts are on the posted staffing at this time. EI #2 stated, Three.

Based on observations, interviews and record reviews, the facility failed to ensure staff washed their hands after removing their gloves during the provision of care. This affected Resident Identifier (RI) #10 and RI #13, two of three residents observed during incontinent care, and RI #11, one of one resident observed during wound care. Findings Include: The facility's Policy for Infection Prevention and Control Manual, for Contact Precautions, with an effective date of Dec. 1, 2009 revealed the following: "... II. GLOVES AND HAND HYGIENE Hand hygiene should be completed prior to donning gloves ... B. Gloves should be changed after having contact with infective material (... fecal material and wound drainage) C. Gloves should be removed before leaving the resident's room and hand hygiene should be performed immediately. D. After glove removal and hand hygiene, hands should not touch potentially contaminated environmental surfaces or items." 1. RI #10 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #10's Quarterly MDS dated [DATE] documented a BIMS score of zero (0) out of 15 which indicated severe impairment in cognition. RI #10 required extensive to total assistance with all Activities of Daily Living skills. RI #10 was always incontinent of bowel and bladder. On 09/18/14 at 11:20 AM, the following was observed during the provision of incontinent care: Employee Identifier (EI) #12 and EI #13 washed their hands and applied gloves. EI #14 (Registered Nurse/Unit Manager) was present for the observation. EI #12 removed RI #10's brief and the surveyor asked what type of incontinent episode and how much. EI #12 replied a moderate amount of urine. EI #12 obtained a wet wash cloth, applied perineal soap and provided incontinent care. The resident was repositioned on the side and EI #12 provided incontinent care to the buttock and the rectal area. EI #12 removed her gloves and applied clean gloves. EI #12 did not wash her hands after removing her gloves and before applying clean gloves. RI #10 was repositioned and EI #13 removed the soiled brief. EI #13 removed his gloves and applied clean gloves. EI #13 did not wash his hands after removing his gloves and before applying clean gloves. On 09/18/14 at 11:40 AM, during an interview with EI #14, the surveyor asked what does policy and procedure state regarding what should be done when gloves are removed. EI #14 replied hands should be washed. The surveyor asked what should EI #12 have done after patting the resident dry and before applying a clean brief. EI #14 stated EI #12 should have washed her hands and then applied clean gloves. On 09/18/14 at 11:41 AM, during an interview with EI #12, the surveyor asked what should be done when gloves are removed. EI #12 stated to wash hands, but that was not what she had done. On 09/18/14 at 11:43 AM, during an interview with EI #13, the surveyor asked after the soiled brief was removed, did he wash his hands after he changed gloves. EI #13 stated no he did not. 2. RI #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 09/17/14 at 2:50 PM, the following was observed during the provision of wound care: EI #15 (Licensed Practical Nurse/LPN-Treatment Nurse) and EI #16 (Registered Nurse) washed their hands and applied gloves. RI #11 was positioned on the resident's side and the surveyor asked EI #15 if the redden area to RI #11's coccyx was blancheable. EI #15 depressed the area to see if the area was blancheable. EI #15 removed her gloves and applied clean gloves. EI #15 did not wash her hands after removing her gloves and before applying clean gloves. EI #15 proceeded with the wound care. EI #16 measured the wound. After measuring the wound, EI #16 removed her gloves and applied clean gloves. EI #16 did not wash her hands after removing her gloves and before applying clean gloves. On 09/17/14 at 3:40 PM, the surveyor asked EI #16 what should be done when gloves area removed. EI #16 stated to wash hands. The surveyor asked was that what she had done after she measured the would. EI #16 replied yes. The surveyor informed EI #16 that was not what she had done. EI #16 stated she washed her hands at the beginning and at the end. EI #16 also stated she could not say if she washed her hands every time or if she didn't, but she only remembered washing her hands at the beginning of the care and at the end of the care. On 09/17/14 at 3:50 PM, the surveyor asked EI #15 what was policy and procedure regarding what should be done when gloves are removed. EI #15 stated to wash hands and that was what believed she had done. The surveyor informed EI #15 that was not what she had done. The surveyor asked EI #15 if she remembered after she depressed the redden area to see if the area was blancheable, she removed her gloves and applied clean gloves. EI #15 stated she remembered. 3. RI #13 was admitted to the facility on [DATE] and readmitted on ,[DATE] 8/14 with [DIAGNOSES REDACTED]. The Admission MDS dated [DATE]revealed a BIMS score of 3 of possible 15, indicating RI #13 was severe impairment in cognition. RI #13 was always incontinent of both bowel and bladder. On 09/17/14 at 11:45 AM, incontinence care was provided by EI #17, a Certified Nursing Assistant (CNA). Prior to beginning the incontinent care, EI #17 washed her hands and donned gloves. After cleaning each area, EI #17 changed her gloves, but did not wash her hands prior to replacing the gloves. After incontinence care was provided EI #17 adjusted the blinds and touched the curtains prior to removing her gloves and washing her hands. EI #17 only washed her hands at the beginning and after touching the blinds/curtains with contaminated gloves and prior to exiting room. On 09/18/14 at 3:00 PM, the surveyor asked EI #7 (Infection Control Nurse) during incontinent care when should hands be washed. EI #7 stated hands should be washed before starting and anytime when one goes from dirty to clean. When asked for clarification of going from dirty to clean. EI #7 replied any time you wash the rectal area and after completion of the care.

Based on interview and record reviews, the facility failed to ensure previous employer reference checks were done for four new hire employees. This affected four of six personnel records reviewed for the abuse protocol. Findings Include: A review of the facility's policy and procedure titled, "Abuse, Neglect, Misappropriation of Resident Property, Injuries of Unknown Source" dated March 26, 2014, revealed the following: "... 1. Screening of Employees a) The facility will not knowingly employ any individual who has been found guilty by a court of law of abusing, neglecting, or mistreating residents ... b) To ensure that the facility does not knowingly hire such an individual, it has established the following procedures: ... The facility will search the appropriate registries and will conduct a background investigation to determine whether a finding of abuse, neglect, mistreatment, or misappropriation has been entered against a potential employee. As a part of this background check, potential employees will be required to disclose the names of previous employers, who will be contacted to determine whether the potential employee has a history or resident abuse or neglect, or misappropriation of resident property. ..." A review of the following Employee Identifier (EI) #'s personnel files did not reveal previous employee reference checks: EI #2 (Certified Nursing Assistant/CNA/Laundry) EI #3 (Housekeeping) EI #4 (CNA) EI #5 (Nursing Assistant) On 09/18/14 at 5:10 PM, during an interview with EI #1 (Staff Development/Licensed Practical Nurse-LPN) the surveyor provided the personnel files for EI #2, EI #3, #4 and #5 and asked where were the previous employer reference checks for each employee. EI #1 reviewed the personnel files for EI #4 and stated the reference checks from EI #4's previous employer were not in the file; EI #1 reviewed EI #3's personnel file and stated EI #3 was hired by EI #8 (Environmental Director) and she did not do reference checks for EI #3's previous employer; EI #1 reviewed EI #5's personnel files and stated she (EI #1) did not do employer reference checks; EI #1 reviewed the personnel files for EI #2 and stated EI #10 (Dietary Manager/DM) did not do reference checks from EI #2's previous employer, but personal reference checks were done. The surveyor asked was it policy and procedure to only do personal reference checks and not previous employer reference checks. EI #1 replied she was not sure. The surveyor provided a copy of the facility's abuse policy and procedure and asked EI #1 to review the section for screening employees and asked what should be checked prior to hire. EI #1 reviewed the abuse policy and stated previous employer reference checks should be done. The surveyor asked who was responsible to ensure previous employer reference checks were done. EI #1 replied she was. The surveyor asked what happened. EI #1 stated she did not know employer reference checks were supposed to be done. The surveyor asked for EI #2, #3, #4 and #5, was policy and procedure followed for screening for new hires. EI #1 stated, "No."

Based on observations, interviews and record reviews, the facility failed to ensure 1) staff followed Resident Identifier (RI) #9's care plan to check and change resident per facility's check and change schedule every two hours (q2hr) and 2) RI #10's care plan not to be placed close to the handrail when up in the Broda chair. This affected two of 13 sampled residents whose care plans were reviewed. Findings Include: 1. RI #9 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of RI #9's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed RI #9's Brief Interview for Mental Status (BIMS) score was 3, indicating severe impairment in cognition. The MDS documented RI #9 required total assistance with toileting and personal hygiene and was incontinent of bowel and bladder. A review of RI #9's careplan titled, "Totally incontinent of bowel and bladder R/T (related to) OF NEED TO VOID. ..." with an onset date of 05/20/2014, revealed the following: "... ASSIST RES (RESIDENT) TO STAY CLEAN AND DRY PER ROUTINE CHECK AND CHANGE SCHEDULE." A review of the facility's "TURN SCHEDULE" without a date and with a hand written note by Employee Identifier (EI) #6 (Director of Nursing/DON) revealed a turn schedule for every two hour on the even hours, (example 2,4,6,8 10 and 12). A review of the hand written documentation revealed the following: "This is our routine check and change schedule (signed and dated by EI #1(Staff Development Nurse))." On 09/18/14 beginning at 11:00 AM continuous observation until 2:30 PM, RI #9 was not checked and changed per check and change schedule. On 09/18/14 at 1:30 PM, RI #9 was put to bed by EI #11 (CNA) and EI #12 (CNA) and positioned on the resident's right side. RI #9 was not checked for incontinence. On 09/18/14 at 2:36 PM, the following was observed: EI #11 (CNA) checked RI #9 and stated the resident was moderately wet. On 09/18/14 at 2:45 PM, the surveyor asked EI #11 was the resident incontinent of bowel and bladder. EI #11 replied yes. The surveyor asked if the resident could voice when the resident was incontinent. EI #11 stated no. The surveyor asked how often should a resident be checked for incontinence. EI #11 stated every two hours. The surveyor asked when was the last time the resident was checked for incontinence. EI #11 stated around 12, during lunch. The surveyor informed EI #11, the resident was observed continuously from eleven o'clock and the resident had not been checked nor changed. The surveyor asked at 1:30 PM, was the resident checked for incontinence. EI #11 stated no. The surveyor asked why not. EI #11 replied she had heavy wetters at the end of the hall and that's where she would start and work her way down to RI #9's room. The surveyor asked why did she not check the resident for incontinence earlier. EI #11 replied she was told the resident had gone to the bathroom, but she could not remember who told her. The surveyor asked who was responsible for this resident to ensure the resident was checked and changed every two hours. EI #11 stated she was. On 09/18/14 at 2:47 PM, the surveyor asked how many hours had gone by since the resident was checked and changed. EI #14 (Registered Nurse/Unit Manager) stated three hours. The surveyor asked what was policy and procedure for check and change time frame. EI #14 stated every two hours. The surveyor asked did EI #11 follow policy and procedure for check and change. EI #14 replied not if EI #11 did not check and change the resident when EI #11 put RI #9 to bed. 2) RI #10 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #10's Quarterly MDS dated [DATE] documented a BIMS score of zero (0) out of 15 which indicated severe impairment in cognition. RI #10 required extensive to total assistance with all Activities of Daily Living skills. A Fall care plan for RI #10 with a problem onset date of 03/23/13, documented the following approach: "... ENSURE RES. IS NOT CLOSE TO HANDRAILS WHEN IN HALLWAY. 2/27/14 ..." On 09/17/14 at 3:15 PM, RI #10 was observed in the Broda chair in the hallway. The back of RI #10's Broda chair was positioned up against the handrail. On 09/18/14 at 1:45 PM, RI #10 was observed in the Broda chair in the hallway. The back of RI #10's Broda chair was positioned up against the handrail. On 09/08/14 at 5:30 PM, in an interview with EI #18, a Licensed Practical Nurse/LPN, stated they have seen RI #10 pull on the handrails. EI #18 was asked what intervention was added to RI #10's care plan. EI #18 replied to make sure resident is not close to handrails when in the hallway." In an interview on 09/18/14 at 5:45 PM, EI #19, a LPN, stated when RI #10's chair was backed up to the handrail, RI #10 would squirm and reach around behind the chair for the handrail. EI #19 was asked if he was aware that RI #10 was not suppose to be where the handrail could be reached. EI #19 replied, "No ma'am."

Based on observation, interview and record review, the facility failed to ensure staff cleaned Resident Identifier (RI) #10's labia and vaginal opening in a manner to prevent the potential for cross contamination. This affected one of three residents observed during incontinent care. Findings include: A review of the facility's policy and procedure titled, "Perineal Care" dated October 1, 2010, revealed the following: "PURPOSE: Good perineal care helps prevent infection, irritation and skin breakdown. ... PROCESS: ... II. Female Resident a) Wash pubic area first. Separate the labia and wash downward on each side of the labia using different corners of the wash cloth. Wash downward in the middle over the urethra and vaginal openings. ..." A review of the facility's "Perineal Care Observation" without a date, revealed the following: "... FEMALE RESIDENT" ...12. Clean between the labia with a clean wipe, being certain to separate the labia ..." RI #10 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #10's Quarterly MDS dated [DATE] documented a BIMS score of zero (0) out of 15 which indicated severe impairment in cognition. RI #10 required extensive to total assistance with all Activities of Daily Living skills. On 09/18/14 at 11:20 AM, the following was observed during the provision of incontinent care: EI #12 (Certified Nursing Assistant/CNA) and EI #13 (CNA) washed their hands and applied gloves. EI #14 (Registered Nurse/Unit Manager) was present for the observation. EI #12 removed RI #10's brief and the surveyor asked what type of incontinent episode and how much. EI #12 replied a moderate amount of urine. EI #12 obtained a wet wash cloth and applied perineal soap. EI #12 wiped the groins and the lower abdomen with a separate area of the wash cloth. EI #12 obtained a wet wash cloth with perineal soap and wiped down the middle of the vaginal area twice with separate areas of the wash cloth. EI #12 did not separate the labia and wiped each labia. On 09/18/14 at 11:30 AM, the surveyor asked EI #12 what areas of the vaginal area should be wiped. EI #12 stated the labia and the clitoris. The surveyor asked how many wipes should be for that area. EI #12 stated three, and that was what she had done. The surveyor asked EI #13 was that what EI #12 had done. EI #13 replied no and the only area EI #12 had wiped was down the middle.

Based on observation, interview and record review, the facility failed to ensure licensed staff cleaned Resident Identifier (RI) #11's wound from center outward. This affected RI #11, one of one wound care observation. Findings Include: RI #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the facility's policy and procedure titled, "Wound Care Procedure for Major Wounds" dated December 1, 2009, revealed the following: "... II. PROCEDURE ... N. Clean the wound ... Clean from the center outward. ..." On 09/17/14 at 2:50 PM, the following was observed during the provision of wound care: Employee Identifier (EI) #15 (Licensed Practical Nurse/LPN-Treatment Nurse) washed her hands and applied gloves. EI #16 (Registered Nurse) was present during the provision of care. EI #15 obtained a 4 x (by) 4 with wound cleanser and wiped the wound from back to front. EI #15 obtained another 4x4 with wound cleanser and wiped the wound from back to front. On 09/17/14 at 3:40 PM, during an interview with EI #16, the surveyor asked what direction should a wound be cleaned. EI #16 stated from inner to outer so you don't contaminate the wound. On 09/17/14 at 3:50 PM, during an interview with EI #15, the surveyor asked what direction should a wound be cleaned according to policy and procedure. EI #15 stated from inner to outer. The surveyor asked was that what she had done when she wiped RI #11's wound. EI #15 stated with RI #11's wound she had wiped from top to bottom. The surveyor asked what was the potential for harm to the resident. EI #11 replied cross contamination.