Every finding on record at Highlands Health and Rehab

Based on observation, interview and review of a facility Policy Titled, Food Storage, the facility failed to ensure that expired food items and undated food items were not present in the food storage area and walk-in cooler during the initial tour of the kitchen. Further, the facility failed to ensure expired Juven was not stored in a cabinet at the nurse's station. This deficient practice had the potential to affect 45 out of 45 residents who received meals from the kitchen. Findings include: Review of a facility policy titled, Food Storage with no date, revealed the following: . 2. Stock is rotated with each delivery to ensure freshness . c.) Stock should be dated . 7. Leftover food . clearly labeled, and dated . On [DATE] at 03:08 PM during the initial tour of the kitchen, observations of the dry storage area revealed the following items: - a container of graham crumbles prepared on [DATE] with a use by date of [DATE] - 1 bag of almonds opened ,[DATE], not labeled with a use by date - 2 out of 4 bags of almonds stamped with a best by date of [DATE] - a bag of macaroni opened and tied closed in a box with no open or use by date noted on the bag or box - one open box of Juven therapeutic nutrition powder with 9 packets inside, as well as 2 full boxes of 30 packets each, all with use by dates of [DATE] - 2 additional closed cases of Juven therapeutic nutrition powder with use by date of [DATE] - eight two-packs of baby food peaches with an expiration date of [DATE], (YEAR) - 3 individual cups of baby food sweet potato with no expiration stamp on the packs - one [MEDICATION NAME] bottle (one liter) for tube feed which had a use before (MONTH) 1, 2019 date stamped on the bottle On [DATE] at 03:39 PM an observation of the walk in freezer revealed frozen sweet peas and frozen breaded cod squares were in an open, clear plastic bag in a box, with no open or use by date noted. On [DATE] at 03:45 PM an observation of the walk in cooler to the right revealed the following items: - a block of cheese opened and rewrapped with use by date of [DATE] and prepared date of [DATE], - opened bag of feta cheese, resealed with a use by date [DATE], prepared on [DATE] - an opened package of provolone sliced cheese, resealed, with a use by date of [DATE] and a prepared date of [DATE]. On [DATE] at 9:35 AM, the surveyor, along with Employee Identifier (EI) #3, Registered Nurse (RN), observed a case of Juven containing three unopened boxes of 30 packets and one opened box containing 17 packets with an expiration date of (MONTH) 2019, in a cabinet at the nurses station. On [DATE] at 05:20 PM an interview with Employee Identifier (EI) #1, Supervisor for Dietary Aides, was conducted. EI #1 was asked to look at the cheese items on the shelf and tell the surveyor if there were any concerns. EI#1 replied, yes, some were expired; they should be thrown out. EI #1 was asked what the potential harm could be in serving food that is expired, and EI #1 replied a person could get food poisoning, or it could make the residents sick. EI #1 was then asked if there should be expired items available to serve to the residents. EI#1 replied, no there should not. EI #1 was asked to look at the [MEDICATION NAME] bottle and if there was a concern. EI#1 replied that it had a date to use before (MONTH) 1, 2019. EI #1 further stated it was expired and should be removed. On [DATE] at 09:32 AM, an interview was conducted with EI #2, the Food Service Director, regarding expired food items. EI #2 was asked, who was responsible for ensuring that expired items are not available. EI #2 answered that all of the supervisors, as well as herself, were responsible. EI #2 was further asked, why there were expired items found in the dry storage and the walk-in coolers. EI#2 replied that they did not do a thorough job in their inspections. EI #2 was then asked, what would be the potential harm in having expired food items available for use. EI #2 answered that the potential harm would be to potentially make someone sick.

Based on observations, interviews, medical record reviews and review of facility policies titled, Universal Precautions and Hand Hygiene, the facility failed to ensure: 1) a licensed nurse washed her hands when removing gloves after obtaining Resident Identifier (RI) # 9's fingerstick blood sugar (FSBS) and before leaving RI #9's room to return to the medication cart. Further, the nurse failed to use a barrier when laying an insulin syringe with RI #9's insulin and alcohol wipe on the bathroom sink; and 2) a licensed nurse did not place a medication cup containing medication for RI #23 inside another medication cup containing the remainder of RI #23's medication. Further, the nurse did not use a barrier before placing RI #23's Salonpas patches and [MEDICATION NAME] on the top of the medication cart, computer and a shelf in RI #23's room. These deficient practices affected RI #9 and RI #23, two of four residents and two of three nurses observed during medication pass observations. Findings Include: 1) A review of a facility policy titled, Hand Hygiene, Last Revised: 02/2019, documented: .B. Indications for hand washing and hand antisepsis .3. Perform hand hygiene: a. before and after having direct contact with patients; b. after removing gloves; before handling an invasive device (regardless of whether or not gloves are used) for patient care; .f. after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient; . A review of a facility policy titled, Universal Precautions, Last Revised: 02/2019, revealed: .A. Hand Washing .3. Hands should be sanitized immediately after gloves are removed. B. 1. Gloves should be worn for touching blood and body fluids, . 1.) RI #9 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 06/05/19 at 5:04 p.m., the surveyor observed Employee Identifier (EI) #7, Registered Nurse (RN), during medication pass for RI #9. The surveyor observed EI #7, RN, obtain RI #9's FSBS and remove her gloves without washing her hands and returned to the medication cart to prepare RI #9's insulin injection. EI #7 was then observed entering RI #9's bathroom and laying the syringe filled with insulin and the alcohol wipes beside the bathroom sink without a barrier. On 06/05/19 at 5:17 p.m., an interview was conducted with EI #7, RN. EI #7 was asked when should she wash her hands when wearing gloves. EI #7 said she should wash them when she takes them off. EI #7 was asked did she wash her hands after obtaining RI #9's FSBS and removing her gloves before returning to the medication cart. EI #7 stated no. EI #7 was asked what should she do before laying anything down on any surface. EI #7 replied she should put down a barrier. EI #7 was asked did she put down a barrier before she laid the insulin syringe and alcohol wipe beside the sink. EI #7 stated no she did not. EI #7 was asked what was the concern with laying things down on surfaces without a barrier. EI #7 answered, it could be dirty and there could be germs. 2.) RI #23 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 06/06/19 at 8:39 a.m., EI #3, RN, was observed during medication pass for RI #23. EI #3 was observed removing two of RI #23's Salonpas patches from the packet and laying them on top of the medication cart without a barrier to initial and date them. EI #3 removed the nitro dur patch from the packet and laid it on top of the computer on the medication cart to initial and date it. EI #3 was then observed placing a medication cup containing [MEDICATION NAME] and placing it inside another medication cup containing the remainder of RI #23's pills. EI #3 entered RI #23's room and placed the items on a shelf unit inside the room without placing a barrier. On 06/06/19 at 9:21 a.m., an interview was conducted with EI #3, RN. EI #3 was asked what was the concern with placing a medication cup inside another medication cup containing medications. EI #3 said dirty stuff could be on them, infection control. EI #3 was asked what was the concern with placing Salonpas and nitro patches on the computer and on top of the medication cart to date them. EI #3 replied again, getting them dirty. EI #3 was asked did she place the Salonpas and nitro patch on her computer, top of the medication cart and on the shelving unit in RI #23's room without a barrier. EI #3 said yes. On 06/06/19 at 3:47 p.m., an interview was conducted with EI #5, RN/Director of Nursing. EI #5 was asked, when should nurses wash their hands when wearing gloves. EI #5 said as soon as the gloves come off the hands should be washed. EI #5 was asked should a medication cup containing medications be placed inside another medication cup containing medications. EI #5 replied no. EI #5 was asked should patches be placed on a shelving unit without a barrier. EI #5 stated no. EI #5 was asked what was the concern with those things. EI #5 answered infection control and cross contamination.

Based on observations, interviews, and a review of a facility policy titled, Ice Handling of Ice Scoops and the (YEAR) Food Code U.S. (United States) Public Health Service FDA (Food and Drug Administration), the facility failed to ensure: (1) the ice scoop was not stored on top of the ice machine, on three of four days of the survey; (2) a dark brown colored dust like substance was not on the pipes above the deep fryer, on three of four days of the survey; (3) dust was not on the pipes above the conventional oven, on three of four days of the survey; and (4) the meat slicer did not have food debris on it, on three of fours days of the survey. These deficient practices had the potential to affect all 44 residents receiving meals from the dietary department. Findings Include: (1) A review of an undated facility policy titled, Ice Handling/Cleaning of Ice Scoops, documented: POLICY: . Ice scoops are to be maintained in sanitary conditions in an effort to prevent the spread of infection. PR[NAME]EDURE: . 5. The ice scoop(s) in dietary shall be sanitized each day and placed next to the ice machine in a covered container . On 05/01/18 at 10:21 a.m., the surveyor observed a dietary staff member removing ice from the ice machine. The staff member was using a large blue colored ice scoop. When finished with removing ice from the cooler, the staff member placed the ice scoop on top of the ice machine. The ice scoop was not stored in any type of covering. On 05/02/18 at 8:58 a.m., the surveyor observed the large ice scoop to remain on top of the ice machine, not stored in any type of covering. On 05/03/18 at 8:27 a.m., the large ice scoop was again observed by the surveyor to be laying uncovered on top of the ice machine. On 05/03/18 at 8:28 a.m., the surveyor conducted an interview with Employee Identifier (EI) #6, the Food Service Director. The surveyor asked EI #6 how should the ice scoops be stored. EI #6 said the ice scoop should be stored up out of the bin. The surveyor asked EI #6 should the ice scoop be stored on top of the ice machine. EI #6 said, no. EI #6 said the ice scoop should be stored in a container where it could drain. The surveyor asked EI #6 what was there a potential for when the ice scoop was stored on top of the ice machine, and not in any type of covering. EI #6 replied, contamination. (2) A review of the (YEAR) FOOD CODE U.S. Public Health Service FDA, documented the following: . 4-6 CLEANING OF EQUIPMENT AND UTENSILS . 4-601.11 . Nonfood-Contact Surfaces . (C) NONFOOD-CONTACT SURFACES . shall be kept free of an accumulation of dust . On 05/01/18 at 10:39 a.m., the surveyor observed hanging dust, with a dark brown colored looking substance within the dust, on the pipes above the deep fryer. On 05/02/18 at 9:00 a.m., the hanging dust with the dark brown colored looking substance within the dust remained on the pipes above the deep fryer. On 05/03/18 at 8:22 a.m., the surveyor again observed the hanging dust, with the dark brown colored looking substance within the dust, on the pipes above the deep fryer. On 05/03/18 at 8:23 a.m., the surveyor conducted an interview with EI #6. The surveyor asked EI #6 what did the substance look like on the pipes above the deep fryer. EI #6 said she did not know what the brownish colored substance looked like. The surveyor asked EI #6 how often were the pipes cleaned. EI #6 said she did not know, and maintenance cleaned the pipes. On 05/03/18 at 8:47 a.m., the surveyor conducted an interview with EI #7, the Maintenance man. The surveyor asked EI #7 what did the brownish colored looking particles on the pipes above the deep fryer look like to him. EI #7 replied, greasy dust particles. The surveyor asked EI #7 what was there a potential for if the greasy dust particles came loose. EI #7 said the greasy dust particles could fall into whatever was beneath it. (3) On 05/01/18 at 10:53 a.m., the surveyor observed dust like looking particles on the pipes near the conventional oven as well as near the rice, flour, sugar and meal bins. On 05/02/18 at 9:04 a.m., the dust looking particles remained on the pipes near the conventional oven as well as near the rice, flour, sugar and meal bins. On 05/03/18 at 8:30 a.m., the surveyor again observed the dust like looking particles on the pipes near the conventional oven as well as near the rice, flour, sugar and meal bins. Covered bread sticks and rolls were observed in pans beneath the area where the pipes were. At this time an interview was conducted with EI #6. The surveyor asked EI #6 what was on the pipes. EI #6 said she did not know. When asked how often the pipes were cleaned, EI #6 said maintenance did that. On 05/03/18 at 8:47 a.m., the surveyor conducted an interview with EI #7. The surveyor asked EI #7 what did he see on the pipes above the conventional oven. EI #7 replied, dust. The surveyor asked EI #7 what was there a potential for if the dust would come loose. EI #7 said it could fall into what ever was beneath the pipes. When asked if his department was responsible for keeping the pipes clean, EI #7 said his department had never been given that task. (4) A review of the (YEAR) FOOD CODE U.S. Public Health Service FDA, documented the following: . 4-6 CLEANING OF EQUIPMENT AND UTENSILS . 4-601.11 Equipment, Food-Contact Surfaces . (A) EQUIPMENT FOOD-CONTACT SURFACES . shall be clean to sight and touch . On 05/01/18 at 10:32 a.m., the surveyor observed the meat slicer to have dried food debris on the slicer. On 05/02/18 at 9:02 a.m., the dried food debris remained on the meat slicer. On 05/03/18 at 8:16 a.m., the surveyor again observed the meat slicer to have dried food debris on it. On 05/03/18 at 8:17 a.m., the surveyor conducted an interview with EI #6. The surveyor asked EI #6 what did she see on the meat slicer. EI #6 replied, it kind of looked like meat. The surveyor asked EI #6 how often should the meat slicer be cleaned. EI #6 replied, after each use. When asked when was the meat slicer last used, EI #6 said three days ago. The surveyor asked EI #6 what was there a potential for when food particles were left on the meat slicer. EI #6 said it was a potential for contamination.

Based on observation and interview, the facility failed to ensure the above ground grease receptacle did not have grease and leaves on top of the receptacle, and on the ground in front of the receptacle. This was observed on 04/30/18, during the initial tour of the facility. This has the potential to affect all 45 residents residing at the facility. Findings Include: On 04/30/18 at 4:35 p.m., the surveyor observed the above ground grease receptacle. There were leaves and grease observed on top of the grease receptacle, and on the area on the ground in front of the grease receptacle. At this time, the surveyor conducted an interview with Employee Identifier (EI) #6, the Food Service Director. The surveyor asked EI #6, what did she see on the top of the grease receptacle, and on the ground in front of the grease receptacle. EI #6 said it looked like leaves and grease to her. The surveyor asked EI #6 what was there a potential for when grease and leaves were left on top of the grease receptacle, and on the ground in front of the grease receptacle. EI #6 said the grease and leaves could attract pest.

Based on observations, interview, record review and review of a facility policy titled, Care of Urinary Catheter, the facility failed to ensure Resident Identifier (RI) #29's Foley catheter bag was in a privacy bag and not visible from the hallway on 05/02/18. This deficient practice affected RI #29, one of one resident sampled with a Foley catheter. Findings Include: A review of a facility policy titled, Care of Urinary Catheter, with an effective date of 12/09/04, and a revision date of 1/12, documented: . PR[NAME]EDURE: . 10. Assure the drainage bag is placed in a privacy bag. RI #29 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #29's Foley catheter care plan, with a problem onset date of 03/10/10, documented the following approach: . * privacy bag . A Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 04/09/18, assessed RI #29 as having an indwelling catheter. RI #29's (MONTH) (YEAR) Physician order [REDACTED].> . 16 french 10 cc (cubic centimeter) foley catheter to dependent drainage. Dx. (diagnoses) [MEDICAL CONDITION] bladder s/t (secondary to) spinal cord injury . Privacy bag . On 05/01/18 at 4:15 p.m., RI #29's Foley urinary catheter bag was observed uncovered, attached to the left bed rail, and was visible from the hallway. On 05/01/18 at 5:44 p.m., RI #29's Foley urinary catheter bag remained uncovered and visible to anyone walking past RI #29's room. At this time, the surveyor conducted an interview with Employee Identifier (EI) #3, RI #29's assigned Certified Nursing Assistant (CNA). The surveyor asked EI #3 how should a resident's Foley catheter be when the resident was in bed. EI #3 said the Foley catheter should be attached to the bed frame. When asked should the Foley catheter bag be visible to any one walking past the resident's room, EI #3 said no. EI #3 said the Foley catheter bag should be on the opposite side of the door (bed) or covered. The surveyor asked EI #3 what type of concern/issue would it be considered when a resident's Foley catheter bag was not covered. EI #3 replied, it would be a dignity issue.

Based on observations, interviews, medical record review and review of facility policies titled, Medication Administration and nebulizer use, the facility failed to ensure: 1) licensed staff did not place Resident Identifier (RI) #21's container of eye drops in her pocket after instilling the drops; this was observed on 05/01/18; 2) licensed staff did not place a container of glucometer strips in her pocket, remove them to check a finger stick blood sugar for RI #146, return them to her pocket and place the container on the medication cart; this was observed on 05/01/18; and 3) RI #3's nebulizer mask was stored in a covering on two of four days of the survey. These deficient practices affected RI # 3, one of two residents observed with nebulizer masks, RI #21 one of one resident observed receiving eye drop medication; and RI #146, one of one residents observed receiving nebulizer medication. Findings Include: (1) A review of a facility policy titled Medication Administration, with an updated date of 06/12, revealed: . PR[NAME]EDURE: . 7. Return medication to medication cart and store according to the facility policy. RI #21 was readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #21's (MONTH) (YEAR) Physician order [REDACTED].> .1/29/18 ARTIFICIAL TEARS - INSTILL 2 DROPS TO EACH EYE 5 x (times)/DAY . On 05/01/18 at 10:15 a. m., Employee Identifier (EI) #4, Registered Nurse (RN) was observed administering medications to RI #21. EI #4 gave the medications by mouth then placed the eye drop bottle and the breathing treatment vial in her uniform pocket. EI #4 washed her hands, removed the eye drop bottle from her pocket and put on gloves. EI #4 instilled the eye drops then put the eye drop bottle back in her pocket after taking her gloves off. EI #4 washed her hands and removed the breathing treatment medication from her pocket, put on gloves and administered the medication. EI #4 removed her gloves and washed her hands. EI #4 returned to the medication cart and signed the medications off. EI #4 removed the eye drop bottle from her pocket and returned it to the Ziploc bag labeled for the medication and placed it in the medication cart. On 5/02/18 at 2:58 p.m., EI #4 was interviewed. EI #4 was given a recap of the observation on 5/1/18 and then asked if during the medication pass if she instilled eye drops for RI #21. EI #4 replied, yes. EI #4 was asked where should the eye drop container be stored while administering other medications or washing her hands. EI #4 replied, on the table on a barrier. EI #4 was asked what was the policy on storing the eye drop container. EI #4 replied, it should be placed on a barrier on the resident's table while in the room. EI #4 was asked if she put the eye drop container in her uniform pocket. EI #4 replied, yes. EI #4 was asked if the pocket of her uniform would be considered clean or dirty. EI #4 replied, dirty. EI #4 was asked what was the risk of storing the eye drop container in her uniform pocket. EI #4 replied, cross contamination and infection control. On 5/02/18 at 6:10 p.m., an interview was conducted with EI #2, the Director of Nursing (DON). EI #2 was asked what was the policy on where to place an eye drop container after instilling the eye drops. EI #2 replied, on a barrier if in the resident's room, then back on the cart. EI #2 was asked, when should a nurse put an eye drop container in her pocket. EI #2 replied, never. EI #2 was asked if a uniform pocket would be considered clean or dirty. EI #2 replied, dirty. EI #2 was asked what would the risk be in putting the eye drop container back on the medication cart after it was in the uniform pocket. EI #2 replied, the possibility of transferring germs. 2) RI #146 was readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. On 5/01/18 at 10:48 a.m., EI #4, a Registered Nurse (RN) was observed obtaining a glucometer check on RI #146. After obtaining the blood sample, EI #4 placed the container of glucometer strips in her uniform pocket and went in to the bathroom to wash her hands. EI #4 returned to the cart cleaned the glucometer, then removed the container of glucometer strips from her pocket and placed it on the medication cart. On 5/2/18 at 5:41 p.m., EI #4 was given a recap of the medication observation on 5/1/18 at 10:48 a.m. and an interview was conducted. EI #4 was asked if she did a glucometer check on RI # 146 before lunch. EI #4 replied, yes. EI #4 was asked what did she do with the container of glucometer strips when she finished. EI #4 replied, she put them in her pocket. EI #4 was asked what was the policy on storing the glucometer strip container. EI #4 replied, on a clean barrier on the resident's table. EI #4 was asked if the pocket of her uniform would be considered a clean area. EI #4 replied, no. EI #4 was asked, why was the pocket of her uniform not considered clean. EI #4 replied, putting your hands in and out would have germs. EI #4 was asked, what would be a risk for storing/placing a glucometer strip container in the pocket of her uniform. EI #4 replied, spreading germs, contamination and infection control issues. On 5/02/18 at 6:10 p.m., an interview was conducted with EI #2, the DON. EI #2 was asked what was the policy on where to place the glucometer strip container when in a resident's room. EI #2 replied, on a barrier on the resident's table. EI #2 was asked when should a nurse put the container of glucometer strips in their pocket. EI #2 replied, never. EI #2 was asked if the pocket of a nurse's uniform would be considered clean or dirty. EI #2 replied, dirty. EI #2 was asked what was the risks of the nurse putting the glucometer strip container in their pocket then returning it to the medication cart. EI #2 replied, possible transferring of germs. (3) RI #3 was admitted to the facility on [DATE], and readmitted on [DATE], with a [DIAGNOSES REDACTED]. A review of a facility policy titled, nebulizer use, with an effective date of 04/17, documented: . PR[NAME]EDURE . 15. Nebulizer compressor and zip lock bag of tubing and accessories to be stored at bedside . RI #3's (MONTH) (YEAR) Physician order [REDACTED].> . IPRAT-ALBUT ([MEDICATION NAME]) 0.5(2.5) MG (milligram)/3ML (milliliter) - ADMINISTER 1 VIAL PER NEBULIZER TID (three times a day) . On 05/02/18 at 8:20 a.m., the surveyor observed RI #3's nebulizer mask hanging from the nebulizer machine. The mask was not in a covering. On 05/02/18 at 3:02 p.m., RI #3's nebulizer mask remained hanging from the nebulizer machine, and not in a covering. On 05/02/18 at 6:17 p.m., the surveyor again observed RI #3's nebulizer mask hanging from the nebulizer machine. The mask remained uncovered. On 05/03/18 at 7:37 a.m., RI #3's nebulizer mask was observed uncovered and continued to hang on the nebulizer machine. On 05/03/18 at 7:43 a.m., the surveyor conducted an interview with Employee Identifier (EI) #8, a Licensed Practical Nurse assigned to care for RI #3. The surveyor asked EI #8 was RI #3 receiving nebulizer treatments. EI #8 said yes. When asked how often RI #3 received the treatments, EI #8 replied, three times a day. The surveyor asked EI #8 how should the nebulizer mask be stored. EI #8 said in a Ziploc bag. The surveyor asked EI #8, when not stored in that manner, what was that a potential for. EI #8 replied, contamination and infection.

Based on observation, interview and facility policies titled PRODUCTION, PURCHASING, STORAGE, KITCHEN HOOD CLEANING AND MECHANICAL AREA, ROOF AND GROUNDS the facility failed to ensure the following: 1. Boiled eggs were not stored in the refrigerator past the 3 day, use by date. 2. A pan of Jello was not stored past the use by date of 3-12-17. 3. Jello, oranges and pudding were not observed uncovered and undated in the refrigerator. 4. Meat balls, sloppy Joe meat and Corn on the Cobb were not stored in the freezer past the use by date. 5. Roast Beef was not stored in the freezer without a use by date. 6. Diced tomatoes, Swiss cheese and Pepper Jack cheese were not stored in the refrigerator past the use by date. 7. A pipe above the stove was free of a dust like substance. 8. A portion of the ceiling in the kitchen was free of a dark drown substance. This was observed during the initial tour of the facility on 3-14-17 and 3-15-17 and affected 49 of 49 residents receiving meals from the kitchen. Findings Include: A review of a facility policy titled PRODUCTION, PURCHASING, STORAGE with a revised date of 1/16, documented the following: POLICIES: All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption . PROCEDURES; .The words .Use-by should precede the date .foods past the use-by . date should be discarded .Cover, label and date unused portions and open packages .Frozen STORAGE .Food stored frozen should be kept no longer than 3 months for quality purposes .Discard food past the use-by or expiration date . A review of a policy titled KITCHEN HOOD CLEANING effective 1/1/99 documented the following: .Kitchen Hood Cleaning .A licensed service contractor will clean as necessary the kitchen hood system every six (6) months . A review of a facility document check titled MECHANICAL AREA, ROOF AND GROUNDS .CHECKLIST documented the following: .Check the roof monthly, Report any problems . During the initial tour of the kitchen on 3/14/17 from 2:19 p.m. - 3:00 p.m. the following observations were made in the kitchen: 1) Boiled eggs were stored in the refrigerator past 3 days once cooked. 2) Jello was observed with a use by date of 3-12-17 3) Oranges, Pudding and Jello were observed uncovered and undated. 4) Meatballs had a use by date of 3-2-17. 5) Sloppy Joe had a use by date of 3-12-17. 6) Corn on the Cobb had a use by date of 3-7-17. 7) Roast Beef did not have a use by date. 8) Diced tomatoes had a use by date of 3-13-17. 9) Swiss cheese had a use by date of 3-3-17. 10) Pepper Jack cheese had a use by date of 2-21-17. The following observations were made on 3/15/17 from 10:55 a.m. - 11:48 a.m.: 1) Dust accumulations was as on the pipes above the stove. 2) The ceiling in the kitchen was discolored. 3) The Swiss Cheese had a use by date of 3-3-17. 4) Pepper Jack cheese had a use by date of 2-21-17. An interview was conducted with Employee Identifier (EI) #8, Dietitian, on 3/15/17 at 5:00 p.m. EI #8 was asked how long boiled eggs should be kept once cooked. EI #8 replied 3 days and if kept longer there is a potential for food borne illness. EI # 8 was asked if Jello, with a use by date of 3-12-17, was observed on 3-14-17 should it be discarded. EI # 8 replied it should have been discarded. EI # 8 was asked if Jello, Oranges and Pudding should be uncovered and undated. EI #8 replied everything should be covered and have an open and use by date. EI #8 was asked if items in the freezer, such as Meat Balls and Sloppy Joe meat should be kept past the use by date. EI #8 replied no. EI #8 was asked if Roast Beef in the freezer should have a used by date. EI #8 replied yes. EI #8 was asked if items, such as diced tomatoes, Swiss Cheese and Pepper Jack cheese should be kept past the use by date. EI #8 replied no and it could cause food borne illness. EI #8 was asked about dust observed on a pipe above the stove. EI #8 replied there should be no dust near food. EI #8 further stated they have a cleaning schedule for the oven. EI #8 was asked about the stained ceiling in the kitchen. EI #8 replied its been that way a couple of months. EI #8 replied it should be fixed.

Based on observation, interview and a facility document titled MENU w (with)/DIETS the facility failed to ensure 1/2 cup of the roasted vegetables were served at lunch on 3/15/17, as indicated on the lunch menu. This affected Resident Indentifer (RI) #8, one of eight sampled residents whose meals were observed on 3/15/17 and had the potential to effect 40 of 50 residents receiving meals from the kitchen. Findings Include: Resident Identifier (RI) #8 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a facility document titled MENU w/DIETS for 3/15/17 documented .noon day 18 .ALTERNATE . REGULAR .1/2 c (cup) Roasted Vegetables .MECHANICAL SOFT .Roasted Vegetables . On 3-15-17 at 11:45 a.m., the surveyor observed kitchen staff plating food. When plating the roasted vegetables the staff used kitchen tongs to serve the Roasted Vegetables. On 3-15-17 at 12:11 p.m., during the lunch meal, RI # 8's was served roasted vegetables. On 3-15-17 at 5:00 p.m., an interview was conducted with Employee Identifier (EI) # 8. EI # 8 was asked about the roasted vegetables being served with tongs during lunch on 3-15-17 when the menu called for 1/2 cup. EI #8 replied the staff should have used a scoop or ladle and it couldn't be measured accurately using tongs.

Based on a review of a facility documents titled: MEDICATION DESTRUCTION RECORD. and interviews the facility failed to ensure there were three signatures for the drug destruction of Narcotics. This affected six of 12 drug destruction documents reviewed to include March, 2016, April, 2016 and January 2017. Findings Include: On 03/16/17, at 8:50 p.m. during a review of facility documents titled: MEDICATION DESTRUCTION RECORD . CONTROLLED SUBSTANCES the surveyor observed 2 signatures for 2 documents dated 03/16/16, 2 documents for April 2016, one with one signature, and 2 documents dated 01/16/17, with 2 signatures. An interview was conducted on 03/16/17, at 11:00 a.m. with Employee Identifier (EI) #1 Pharmacy Consultant. EI #1 was asked to review the 6 documents for the drug destruction for Narcotics and tell the surveyor how many signatures he observed for the destruction by flushing of Narcotics. EI #1 replied, 5 of the sheets dated 01/16/17 had 2 signatures, April 2016 had one document with 2 signatures and another with only one signature and 2 documents for March 2016 had only 2 signatures. EI #1 was asked how many signatures should be on each of the documents. EI #1 replied, 3 signatures. He was asked why there were 2 instead of 3. EI #1 stated, I don't know why. EI #1 was asked what the potential for harm was if 3 people were not present and destroyed Narcotics. He replied, it could be a potential for someone not destroying the medications. Drug diversion possibility. A second interview was conducted on 03/16/17, at 11:15 a.m. with EI #2 Registered Nurse. She was asked to review the 6 documents for the destruction of the Narcotics and tell the surveyor how many signatures she observed. EI #2 replied, 2 documents for January 16, 2017 had 2 signatures, 2 documents for April 2016 one included 2 signatures and one document had one signature and 2 documents for March 2016 had 2 signatures. EI #2 was asked how many signatures should be on the destruction of Narcotics. She stated, 3 Signatures. EI #2 was asked why there were one to 2 signatures on the documents for the drug destruction for Narcotics. She stated, I just can't tell you I have done this for years and haven't ever done this. EI #2 was asked what the potential for harm was if there were one to 2 signatures with the drug destruction of Narcotics. She replied, to be certain they were destroyed.

Based on observation, interview and a review of facility policy's titled: Laundry, Hand Hygiene, and Cleaning of Glucose Meter, the facility failed to ensure the following: 1) Clothing items were free of a brown substance after being washed with other resident clothing items. This affected 19 residents receiving laundry services through the facility. 2) Employee Identifier (EI) #3 Certified Nursing Assistant (CNA) removed her soiled gloves and washed her hands while providing incontinent care for Resident Identifier (RI) #4. 3) EI #7 Licensed Practical Nurse (LPN) cleaned the glucometer after checking RI #9's blood sugar. This affected one of one observation of a finger stick during the medication pass on 03/15/17. Findings Include: 1) A review of a facility policy titled, Laundry with a revised date of 05/2011 revealed the following: .Policy: Laundry will be handled in a safe manner .Procedure: .7. The department responsible for ensuring the proper handling . or cleaning of all laundry is Environmental Services. On 03/15/2017 at 9:05 a.m., an observation was made of wet/damp clothing items in a barrel with a pair of black sweat pants with a brown substance. EI #4, Environmental Service Supervisor was asked to observe the clothing item. EI #4 was asked what did the substance look like. EI #4 replied, feces. EI #4 was asked were the clothing inside of the barrel with the black sweat pants already washed. EI #4 replied yes ma'am. EI #4 was asked how were items with visible soiled areas such as feces to be handled in the laundry. EI #4 explained if laundry staff washed items with visible feces they would separate them from other resident clothing items. EI #4 was asked why should visibly soiled clothing items with feces be washed separately from other resident clothing items. EI #4 replied because it would contaminate the rest of the laundry. EI #4 was asked what was the potential harm in washing clothing items with visible substance such as feces with other resident clothing items. EI #4 replied it could cause cross contamination. On 03/16/2017 at 9:20 a.m., an interview was conducted with EI #6, Infection Control Coordinator. EI #6 was asked should a substance identified as bowel movement be observed on an item that has been washed with other clothing items. EI #6 stated,No. 2) A facility policy titled: Hand Hygiene . with an Effective Date: 5/15/2008 .7. Hand hygiene: A general term that applies to any of the following: hand washing, antiseptic hand wash, antiseptic hand rub . B. Indications for hand washing and hand antisepsis . 3. Perform hand hygiene: a. before and after having direct contact with patients . b. after removing gloves . d. after contact with body fluids or excretions, mucous membranes, intact skin, or wound dressings RI #4 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #4's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/16/17, documented RI #4 as incontinent for bowel and bladder. During an observation of incontinent care for RI #4 on 03/15/17, at 4:25 p.m. EI #3 CNA was observed repeatedly touching RI #4's bottle of peri-wash with the same gloves used to provide the incontinent care. EI #3 failed to remove the soiled gloves and wash her hands before touching RI #4's privacy curtain, and placed his/her clean brief on the bed and touched the container of barrier cream. An interview was conducted with EI #3 CNA on 03/16/17, at 11:29 a.m. She was asked what care she provided for RI #4 on 03/15/17 with the surveyors present. EI #3 replied, perineal care. She was asked if RI #4 was incontinent and of what. EI #3 replied, yes ma'am of urine. EI #3 was asked why she repeatedly picked up a bottle of peri-wash with soiled gloves. She stated, No excuse I just was not paying attention. EI #3 was asked what she should have done. She stated, I should have put the peri-wash on the cloths before I started. EI #3 was asked why she failed to remove her soiled gloves and wash her hands before she touched RI #4's clean brief, privacy curtain and barrier cream container. She stated, I knew I messed up after I got done and thought about it. EI #3 was asked what the potential for harm was if soiled gloves were used and hands were not washed before touching a residents clean brief, privacy curtain and barrier cream container. She replied, contamination of the perineal area and anything else I touch. EI #3 was asked if RI #4 had a Urinary Tract Infection. She stated, I think she has had on that I know of. An interview was conducted with EI #5 CNA on 03/16/17, at 11:50 a.m. She was asked what care she had assisted with for RI #4 on 03/15/17 with EI #3. EI #5 replied, perineal care. EI #5 was asked what the potential for harm was if soiled gloves were used to touch clean items during incontinent care. EI #5 stated, Contamination. An interview was conducted with EI #6 Infection Control Coordinator on 03/16/17 at 9:20 a.m. EI #6 was asked what should a CNA do with soiled gloves before touching a bottle of perineal wash repeatedly, a residents privacy curtain and clean brief. EI #6 stated, Gloves should be removed, hand hygiene performed and new gloves put on. EI #6 was asked what infections he was currently monitoring in the facility. He replied, to include UTI (Urinary Tract Infection). 3) A facility policy titled: Cleaning of Glucose Meter . with an effective date of 7/15/14 . POLICY This policy and procedure is to address the cleaning of Glucose Meter . CLEANING PROCEDURE 1. The meter must be cleaned between patients and prior to docking using approved disinfectant wipe. Resident Identifier (RI) #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #9's March 2017 Physician order [REDACTED]. An observation of a fingerstick blood sugar check was observed on 03/15/17, at 4:00 p.m. by EI #7 LPN. EI #7 obtained the blood sugar from RI #9 and failed to clean the glucometer before placing it in the top draw of the medication cart. An interview was conducted with EI #7 on 03/15/17, at 6:00 p.m. EI #7 was asked what was the facility's policy related to cleaning the glucometer. EI #7 stated, Clean between each resident. EI #7 was asked why she failed to clean the glucometer after she used it for RI #9. She stated, Nerves. I don't usually work on the cart we had an emergency. EI #7 was asked if she should have cleaned it after obtaining RI #9's blood sugar. She stated, Yes. EI #7 was asked what the potential for harm was if the glucometer was not cleaned after each resident. She stated, Spread of Infection. An interview was conducted with EI #6, Infection Control Coordinator on 03/06/17 at 9:20 a.m. EI #6 was asked what the potential for harm was if the glucometer was not cleaned after using it with a resident. EI # 6 stated, High potential for Hepatitis C, B and blood borne pathogens. EI #6 was asked what should a nurse to do with the glucometer after using it with a resident. EI #6 stated, Wiped down with a peroxide wipe.

Based on observation, interviews and a review of a facility policy titled: Hand Hygiene and Incontinent/Perineal Care, the facility failed to ensure incontinent care was provided for RI (Resident Indentifer) #4, a resident with a current Urinary Tract Infection in a manner to prevent cross contamination. On 03/15/17, Employee Identifier (EI) #3/staff Certified Nursing Assistant (CNA), failed to remove soiled gloves and wash her hands when providing incontinent care for RI #4. The CNA repeatedly touched the resident's bottle of peri-wash, the barrier skim cream, the privacy curtain and the residents clean brief while wearing soiled gloves. This affected RI #4, one of one sampled residents observed for incontinent care. Findings Include: A facility policy titled: Hand Hygiene . with an Effective Date: 5/15/2008 .3. Perform hand hygiene: a. before and after having direct contact with patients . A facility policy titled: INCONTINENT/PERINEAL CARE . with a revised date of 2-2016 . PURPOSE: To maintain cleanliness, promote comfort, prevent infection . RI #4 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #4's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/16/17, documented RI #4 as incontinent for bowel and bladder. A facility document titled: .URINALYSIS . with a date of 03/03/17 documented . PROTEIN 2+ H (HIGH) . BLOOD 2+ H . RBC (Red Blood Cells) 11-20 H .WBC (White Blood Cells) 20-50 H BACTERIA 4+ H . [MEDICATION NAME] DS (Double Strength) one PO (by mouth) BID (twice a day) x (times) 7. Culture. A document titled: MICROBIOLOGY . with a date of 03/06/17 . Urine Culture Final Organism 1. ESCHERICHIA COLI ESBL COLONY COUNT >100,000 colonies/ml (milliters). During an observation of incontinent care for RI #4 on 03/15/17, at 4:25 p.m., EI #3 CNA was observed repeatedly touching RI #4's bottle of peri-wash with the same gloves used to provide the incontinent care. EI #3 failed to remove the soiled gloves and wash her hands before touching RI #4's privacy curtain, placing his/her clean brief on the bed and touched the container of barrier cream. An interview was conducted with EI #3 CNA on 03/16/17, at 11:29 a.m. EI #3 was asked why she repeatedly picked up a bottle of peri-wash with soiled gloves. She stated, No excuse I just was not paying attention. EI #3 was asked what she should have done. She stated, I should have put the peri-wash on the cloths before I started. EI #3 was asked why she failed to remove her soiled gloves and wash her hands before she touched RI #4's clean brief, privacy curtain and barrier cream container. She stated, I knew I messed up after I got done and thought about it. EI #3 was asked what the potential for harm was if soiled gloves were used and hands were not washed before touching a residents clean brief, privacy curtain and barrier cream container. She replied, contamination of perineal area and anything else I touch. EI #3 was asked if RI #4 had a Urinary Tract Infection. She stated, I think she has had one that I know of. An interview was conducted with EI #6 Infection Control Coordinator on 03/16/17, at 9:20 a.m. EI #6 was asked what should a CNA do with soiled gloves before touching a bottle of perineal wash repeatedly, a resident's privacy curtain and clean brief. EI #6 stated, Gloves should be removed.

Based on observation, interview and record review, the facility failed to ensure Employee Identifier (EI) #2, a Certified Nursing Assistant (CNA) did not stand while feeding Resident Identifier (RI) #3 on 02/03/16. This affected one of seven sampled residents. Findings include: RI #3 was admitted to the facility on [DATE]. RI #3's Quarterly Minimum Data Set with an assessment reference date of 01/11/2016 revealed RI #3 required extensive assistance with feeding. On 02/03/16 at 12:00 PM, EI #2, a CNA was observed standing while feeding RI #3. On 02/03/16 at 12:05 PM, EI #2 was asked how was she feeding RI #3. EI #2 said, standing. EI #2 was asked what was the facility's protocol for feeding a resident. EI #2 said to sit down to feed a resident. EI #2 was asked, why was it important to sit down to fed a resident. EI #2 responded, that it makes the resident feel more relaxed and not hurried.

Based on observation, interview and record review, the facility failed to ensure Employee Identifier (EI) #1, a Certified Nursing Assistant (CNA) did not allow a soiled area of a cloth to come in contact with Resident Identifier (RI) #3's penis and urethra. EI #1 was also noted to wipe RI #3's catheter tubing in a downward motion repeatedly. This affected one of one residents observed for catheter care. Findings include: RI #3 was admitted [DATE] with [DIAGNOSES REDACTED]. RI #3's quarterly Minimum Data Set with an assessment reference date of 1/11/2016, identified RI #3 as being totally dependent on staff for toileting, always incontinent of bowel and having a catheter for urinary continence. On 2/3/2016 at 8:40 AM, during the observation of catheter care, EI #1 allowed a soiled area of the cloth, to come in contact with RI #1's penis and urethra. EI #1 was also observed to wipe the catheter tubing repeatedly from the urethra downward, touching the urethra opening. On 2/3/2016 at 9:15 AM, EI #1 was asked, how was she taught to provide catheter care. EI #1 stated not to use a soapy rag and to go from bottom to top and change rags (cloths). EI #1 stated, as long as you change corners, one cloth can be used. When asked, if she changed corners during the care, EI #1 replied that she did. EI #1 was asked where was the excess cloth when she changed corners and wiped down the left groin area. EI #1 replied, it was hanging down. When asked how she could ensure the part of the cloth hanging down was clean EI #1 replied, I can't. When asked, how she was taught to clean the urethra opening, EI #1 stated, Top and go down. EI #1 was asked what was the potential harm of a dirty rag trailing over the top of the urethra where the catheter was inserted. EI #1 replied, it can transfer whatever is on the rag like sweat or discharge.

Based on observations, interviews and record reviews, the facility failed to ensure Employee Identifier (EI) #1 and EI #3, both Certified Nursing Assistants (CNAs) did not wash and rinse Resident Identifier (RI) #3 using the same bath water. The facility further failed to ensure EI #1, a CNA and EI #5, a Registered Nurse (RN) washed their hands after they removed gloves. These deficient practices affected RI #1 and RI #3, two of 10 sampled residents. Findings include: 1) RI #3 was admitted [DATE]. RI #3's quarterly Minimum Data Set with an assessment reference date of 1/11/2016, identified RI #3 as being totally dependent on staff for toileting, always incontinent of bowel and having a catheter for urinary continence. During a care observation on 02/03/2016 at 8:40 AM, Employee Identifier (EI) #1 and EI #3, both Certified Nursing Assistants did not change the bath water or wash their hands after they removed gloves during the provision of care. The CNAs used the same bath water to wash and rinse the resident's body. After completing catheter care, EI #1 removed her gloves and put on clean gloves, without washing their hands. In an interview with EI #3 on 02/03/16 at 11:05 AM, EI #3 stated, No, when asked if the water in the bath basin was changed. In an interview with EI #1 on 02/03/16 at 9:15 AM, EI #1 was asked when should gloves be changed during catheter care. EI #1 stated gloves should be changed anytime gloves get soiled and before anything else is touched. When asked when should hands be washed, EI #1 stated, what we have been told is that we can use sanitizer up to three times. EI #1 was asked if she used sanitizer and she replied no. EI #1 was asked what was the potential harm in not changing gloves and performing hand hygiene during catheter care. EI #1 stated it can transfer anything you have touched. 2) The facility's policy titled Dressing Change with Aseptic Technique with an effective date of 1/30/2013, documented: . PURPOSE: The goal of cleansing a wound is to remove bacteria and debris . The goals for treating wounds are to prevent cross contamination and/or infection of an open area and to prevent additional trauma to area . 10.) Place all contaminated items in trash bag, including gloves. Remove bag from room. Perform hand hygiene . RI #1 was admitted on [DATE] with a medical history to include: Stage 3 sacral pressure ulcer. On 02/03/2016 at 4:15 PM, the surveyor observed wound care provided to RI #1 by EI #5, a Registered Nurse (RN). After wound care was completed, EI #5 removed her gloves and went to the treatment care and removed a tube of barrier cream for RI #1. EI #5 did not wash her hands. In an interview with EI # 5 on 02/03/2016 at 5:00 PM, EI #5 was asked what was the facility's policy for changing gloves and washing hands after wound care. EI #5 stated, After removing gloves and use hand sanitizer or washing hands. EI #5 was asked if she should have performed hand hygiene with completion of wound care for RI #1. EI #5 replied, yes. EI #5 was asked if she performed hand hygiene after the wound care and she replied no. EI #5 was asked if she touched the treatment cart without washing hands after completion of wound care. EI #5 stated, yes, she touched the cart and removed a tube of cream. EI #5 was asked what was the potential harm in touching that item and the treatment cart. EI #5 stated, infection control.

Based on observation, record review and interview the facility failed to ensure: 1. stove hood panels were free of dust and a grease like substance. 2. two bags of crinkle french fries, and two bags of wedge potatoes were labeled with an open date and a use by date. 3. staff washing dishes in the 3 compartment sink knew how long to leave the test strip in the sanitizer solution sink to get the correct parts per million. This had the potential to affect 46 residents who received meals form the kitchen. Findings Include: 1. Stove hood panels were free of dust and grease like substance Review of the facility policy ... "KITCHEN HOOD FIRE - EXTINGUISHING SYSTEM" with no revised date. "POLICY: KITCHEN HOOD SYSTEM: A licensed fire service contractor will test, service and clean hood, recharge as necessary the kitchen hood system every six (6) months ... On 1-27-2015 at 1:50 P.M., surveyor observed dust and grease like substance on the the stove hood panels. The deep fryer and grill is located under the stove hood. On 1-28-2015 at 3:25 P.M., surveyor observed dust and a grease like substance on the stove hood panels. On 1-29-2015 at 10:45 A.M., an interview was conducted with EI #1. (Employee Identifier) EI # 1 was asked what was the substance on the stove hood panels. EI #1 replied grease and dust. EI #1 was asked what was your policy on cleaning the stove hood panels. EI #1 replied every 6 months. EI #1 was asked when was the stove hood panels cleaned last. EI #1 replied July 1, 2014. EI #1 was asked what cooking equipment was located under the stove hood panels. EI #1 replied the stove, deep fryer and grill. EI #1 was asked what was the potential for harm when the stove hood panels had an accumulation of grease and dust on it and the grill, deep fryer and stove was located under it. EI #1 replied "Unsanitize." EI # 1 was asked does the stove hood panel need cleaning. EI #1 replied yes ma'am. On 1-29-2015 at 11:31 A.M., an interview was conducted with EI #2, the Director of Nutritional and Food Services. EI #2 was asked what was the substance in the stove hood panels. EI #2 replied grease. EI # 2 was asked what was the potential for harm when the stove hood panels has an accumulation of grease and dust on it. EI #2 replied possible grease fire. 2. Two bags of crinkle french fries and two bags of wedge potatoes was not labeled with an open by date or use by date. Findings Include: Review of the facility policy "...FOOD AND SUPPLY STORAGE PROCEDURES" with a revised date of 1/12, revealed the following: "PROCEDURES:"... Cover, label and date unused portion and open packages..." On 1-27-2015 at 1:50 P.M., surveyor observed 2 bags of crinkle french fries and 2 bags of potatoes wedges with no label of an open by date or use by date. On 1-29-2015 at 11:40 A.M., an interview was conducted with EI #2. EI #2 was asked who was responsible for labeling. EI #2 replied multiple employees. EI #2 was asked when should items be labeled. EI #2 replied after they have been opened. EI #2 was asked what was your policy on labeling. EI #2 replied it depends on the food items. We will follow our food labeling procedures guiding us to see how many days it is safe to consume. EI #2 was asked was 2 bags of crinkle french fries and 2 bags of potatoes wedges located in the freezer on 1-27-15 labeled. EI #2 replied no. EI #2 was asked what was the potential for harm when food items were not labeled. EI #2 replied you may not know what it is or misread the item. EI #2 was asked was the french fries and potatoes wedges opened. EI #2 replied yes. 3. Staff washing dishes in the 3 compartment sink did not know how long to leave the test strip in the sanitizer solution to get the correct ppm (part per million). Review of the facility policy "SANITATION AND INFECTION CONTROL Policy #F018" with a revised date of 1/14 revealed the following: "...PROCEDURES: ... -Oasis 146 Multi-Quat Sanitizer, at a concentration of 200-400 ppm, ..." On 1-28-2015 at 10:45 A.M., surveyor observed a staff member washing dishes in the 3 compartment sink. Staff member was asked to test the solution in the sanitizer sink. EI #3 put the strip in the water and pulled it out immediately. On 1-29-2015 at 11:30 A.M., a telephone interview was conducted with EI #3 (Dietary staff). EI #3 was asked who was responsible for washing the dishes in the 3 compartment sink. EI #3 replied it depends on who was working. EI #3 was asked what was your policy on washing dishes in the 3 compartment sink. EI #3 replied wash, rinse, sanitize and air dry. EI #3 was asked how often was the temperature taken in the 3 compartment sanitizer solution sink. EI #3 replied 3 times a day. EI #3 was asked what should the water temperature in the sanitizer sink be to get a ppm reading of 200. EI # 3 replied 115. EI #3 was asked what was the ppm in the sanitizer solution sink when you took it on 1-28-2015. EI #3 replied it didn't show a reading. EI #3 was asked what was the temperature of the water on 1-28-2015. EI #3 replied Don't remember. EI #3 was asked what was the potential for harm when dishes were not properly sanitized. EI #3 replied bacteria and germs. EI #3 was asked was the procedure of testing the sanitizer solution done properly on 1-28-2015. EI #3 replied no. EI #3 was asked how long should the test strip be in the water to get the correct ppm. EI #3 replied not long. It wasn't done right. On 1-29-2015 at 11:35 A.M., an interview was conducted with EI #2. EI #2 was asked who was responsible for washing dishes in the 3 compartment sink. EI #2 replied it depends on the time of day. EI #2 was asked how often was the temperature taken in the sanitizer solution sink a day. EI #2 replied 3 times a day and as needed as they change water. EI #2 was asked what was the potential for harm when dishes are not properly sanitized. EI #2 replied possible contamination. EI #2 was asked was the procedure of testing the sanitizer solution done properly on 1-28-15. EI #2 replied she did not keep it under the water long enough for the ppm to read.

Based on observations, record review and interview: 1) MANUAL DISHWASHING The facility failed to follow correct manual dishwashing procedures (i.e. (for example) 3 compartment sink) a. Assure food preparation equipment was air dried; and b. Assure/follow correct water temperature and chemical concentration for sanitation in the third compartment sink. 2) TRAY DELIVERY CARTS Staff failed to assure meal tray delivery carts were effectively disinfected between use for return of soiled trays and delivery of meal trays. 3) ROUTINE CLEANING The facility failed to perform routine cleaning of equipment removable parts as evidenced by: a. A (5 gallon tea urn) spigot when disassembled was observed with a build up of a brown residue. 4) PREVENT POTENTIAL CROSS-CONTAMINATION HYGIENIC PRACTICES. Measuring device stored in can containing Thick n Easy powder The above practices posed the potential for food contamination and compromised food safety. This had the potential to affect all 44 residents who received meal trays from dining services. Findings include: 1) MANUAL DISHWASHING The 2013 Food Code 4-901.11 documented: " Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried ..." (a) On 04/02/2014 at 9:30 AM, the Robot Coup blender was observed stored on the stand with the cover. The surveyor identified that the equipment was not air-dried and contained about a tablespoon of water. At 10:00 AM, the CDM (Certified Dietary Manager), EI #3, approached the blender and was asked by the surveyor, was there water in the blender? EI #3 responded, Yes, Ma'am, there is at least a tablespoon. On 4/3/2014 at 10:30 AM, the Registered Dietitian (RD), EI #4, was asked, what does your policy/procedure require for air drying utensils? EI #4 responded, pots/pans equipment must be air dried before being put back into use. (b) The facility failed to assure correct manual dishwashing procedures relative to assuring chemical concentration were followed, i.e. consistent monitoring/documentation of water temperature and chemical concentration. This monitoring is a critical control point. On 04/01/2014 at 2:30 PM, the manual dishwashing was observed. The chemical Oasis 146 was observed to be used for sanitizing. A Food Service Worker (FSW), EI #5, was asked about the lack of documentation/monitoring of the chemical concentration. EI #5 replied, we just got those sheets and she would sign them before she went home. A request was made to view the March documentation for the "Pot/sink Concentration Log" which revealed the chemical concentration was not documented for 3 of the 31 opportunities. On 4/03/2014 at 10:30 AM, the RD, EI #4 was asked, does staff monitor and document rinse water temperature? EI #4 responded, the staff does not monitor the temperatures in the pot/pan sink. EI #4 stated however, the thermometer is calibrated daily. The surveyor asked are the current documentation's accurate? EI #4 replied the sanitizer concentration documentation may not be accurate due to observing the temperature hotter than the manufacturers recommendations. 2) TRAY DELIVERY CARTS Staff failed to assure meal tray delivery carts were effectively disinfected between use for return of soiled trays and delivery of meal trays. The manufactures directions for the Ecolab Oasis 146, Multi-Quat Sanitizer documented: " ... Non-Food Contact Surface Sanitizing: To sanitize hard, nonporous non-food contact surface. Apply sanitizer use-solution with a cloth, mop, sponge, sprayer or by immersion ... treated surfaces must remain wet for 60 seconds. Wipe dry with a sponge, mop or cloth or allow to air dry. For spray applications, use a coarse spray device ..." On 4/3/14 at 9:15 AM, the surveyor observed a Food Service Worker (FSW) spray the meal cart with Quat Oasis 146. The FSW immediately rinsed the cart without letting the disinfecting solution remain on the surface for 60 seconds. The surveyor observed the spray was a mist and not a coarse spray. On 4/03/2014 at 10:30 AM, the RD, EI #4 was asked, why would effective disinfecting be important. EI #4 replied it was important to eliminate the transfer of any organism from a resident's room to tray to cart to employee. EI #4 said the sanitizer in use was left on the carts for an insufficient time according to the manufactures directions. 3) ROUTINE CLEANING The facility failed to perform routine cleaning of equipment removable parts as evidenced by: a. A (5 gallon tea urn) spigot when disassembled was observed with a build up of a brown residue. On 4/3/14 at 8:55 AM, the surveyor observed the tea urn spigot disassembled by the RD, EI #3. There was a brown build-up on disassembled spigot. On 4/03/2014 at 10:30 AM, the RD, EI #4 was asked, did the spigot lack routine cleaning. EI #4 said she observed visible residue on the inside of the tea urn spigot. EI #4 said it wiped away clean and she would be double checking that it was consistently cleaned. 4) PREVENT POTENTIAL CROSS-CONTAMINATION HYGIENIC PRACTICES. Measuring device stored in can containing Thick n Easy powder On 4/2/14 at 11:15 AM, the surveyor observed a blue measuring scoop stored inside the can of Thick n Easy Powder. On 4/03/2014 at 10:30 AM, the RD, EI #4 was asked, what was the standard practice for storing scoops in bulk products. EI #4 said scoops were not to be stored inside food containers. EI #4 stated she did observe the scoop stored inside the Thick n Easy container.

Based on observations, interviews and review of a facility policy titled, "Sanctions for Unauthorized Uses and Disclosures of a Patient's Protected Health Information", the facility failed to ensure 1 of 3 medication nurses observed during the "Medication Administration Observation" pass closed the privacy screen on the E-MAR (Electronic Medication Administration Record) before leaving the medication cart. This affected RI #13, RI #14, RI #15, and RI #16, four residents observed during the medication administration pass on 04/02/14. Findings Include: A facility policy titled, "Sanctions for Unauthorized Uses and Disclosures of a Patient's Protected Health Information", with a revision date of 2/20/13 documented: "...This policy is designed to give guidance and ensure compliance with all applicable laws and regulations related to sanctioning for violating (name of facility) policies and procedures ... DEFINITIONS: 1. Protected Health Information (PHI): Any information, including demographic information that may identify the patient, that relates to the past, present, or future physical or mental health or condition of an individual, the provision of health care to that individual or the past, present or future payment for the provision of health care to an individual and identifies, or could reasonably be used to identify, the individual ... PROCEDURE: The following types of conduct on the part of a member of (name of facility) workforce will result in disciplinary action against the individual engaging in this conduct: ... c. Failing to logoff or leaving a computer monitor on and unsecured; ..." 1. RI #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 04/02/14 at 8:00 a.m., surveyor #2 observed a medication cart outside of RI #13's room. On the E-MAR screen could be seen RI #13's name and medications to be administered. There was no medication nurse at the cart at this time. 2. RI #14 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. On 04/02/14 at 8:02 a.m., surveyor #1 observed EI #2, a LPN (Licensed Practical Nurse) medication nurse retrieve the following medications for RI #14 from the medication cart: a [MEDICATION NAME] 5 mg, (milligram) pill, a [MEDICATION NAME] 100 mg capsule, a [MEDICATION NAME] 20 mg pill, an [MEDICATION NAME] 9.5 mg 24 hour patch, [MEDICATION NAME] 1 gm (gram)/10 ml (milliliter) suspension 2 tsp (teaspoon) and [MEDICATION NAME] 40 mg/10 ml. After retrieving the medications, EI #2 entered RI #14's room. On 04/02/14 at 8:05 a.m., surveyor #2 observed the medication cart outside of RI #14's room. On the E-MAR screen could be seen RI #14's name and medications. There was no medication nurse at the cart at this time. 3. RI #15 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 04/02/14 at 8:10 a.m., surveyor #1 observed EI #2 prepare the following medications for RI #15: a [MEDICATION NAME] XL (extended release) 50 mg pill, a [MEDICATION NAME] 50 mg pill, and a [MEDICATION NAME] 5 mg pill. After retrieving the medications from the medication cart, EI #2 entered RI #15's room. On 04/02/14 at 8:12 a.m., surveyor #2 observed the medication cart outside of RI #15's room. On the E-MAR screen could be seen RI #15's name and medications. There was no medication nurse at the cart at this time. 4. RI #16 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. On 04/02/14 at 1:05 p.m., surveyor #1 observed EI #2 retrieving the following medication for RI #16 from the medication cart: [MEDICATION NAME] 0.1 mg/ml spray. After retrieving the medication from the medication cart, EI #2 entered RI #16's room. On 04/02/14 at 1:06 p.m., surveyor #2 observed EI #2 walking away from the medication cart without locking the E-MAR. On 04/02/14 at 1:08 p.m., surveyor #2 conducted an interview with EI #2. The surveyor asked EI #2, when you leave your medication cart, what should you do with the E-MAR. EI #2 stated it closes by itself within 5 seconds. The surveyor shared with EI #2 the observations of RI #13, RI #14, RI #15 and RI #16's E-MAR screen being left visible for anyone to view. At this time EI #2 counted for 52 seconds and the E-MAR screen did not lock by itself. EI #2 said she thought the screen would lock by itself. On 04/03/14 at 11:55 a.m., surveyor #2 conducted an interview with EI #1, the DON (Director of Nursing). The surveyor asked EI #1, after your nurses have pulled up a medication by using the E-MAR, what should they do with the screen. EI #2 stated there is a privacy button you should push. The surveyor asked EI #2 does the screen automatically close by itself. EI #2 said from her understanding you have to push it (the privacy button). The surveyor asked EI #2 what is this considered when the screen is left open with medications showing. EI #2 replied this was against HIPAA (Health Insurance Portability and Accountability Act) guidelines.

Based on observation, record review and interview, it was determined: 1) The facility failed to assure waste was contained in a properly maintained compactor. The grounds surrounding the area was littered with strewn debris, boxes, filled/tied plastic bags, plastic gloves, etc. The debris covered an area approximately one yard long and two yards wide. 2) The loading dock was cluttered with pieces of paper, plastic pieces and wood. (Food Code 5-502.11) "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 insect and rodents." This had the potential to affect all 45 residents who reside in the facility. Findings include: A facility policy titled "Grounds Care", no date, documented: "... Grounds 1. Monitored daily and all trash removed for a neat and orderly appearance." On 4/2/14 at 9:45 AM, the compactor was observed with the Certified Dietary Manager (CDM), Employee Identifier (EI) #3. The grounds near the compactor was observed to be littered with strewn debris. The CDM, EI #3 was asked to validate the findings. She responded that she agreed on the size (area of debris) and commented, everything is not dietary. When returning to the kitchen area while walking on the dock, the CDM was asked if she considered the hallway (dock) clean. The CDM responded, it definitely needs attention, no, it is not clean. The CDM was asked, would you expect it to be cleanlier? The CDM, EI #3 responded, oh yeah, people get in a rush.

Based on observation, interviews and record review, the facility failed to: 1) consistently label and discard foods by the use-by date; 2) prepare ready-to-eat food with gloved hands; and 3) serve potentially hazardous foods from the tray line at recommended safe temperatures. This had the potential to affect all 47 residents for whom meals were prepared and served at the time of this survey. Findings included: FOOD LABELING and STORAGE The facility's policy #B006, related to "Food and Supply Storage Procedures" (revised 1/2012) specifies: "All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. PROCEDURES: ...The 'use-by' date is the last date that a food can be consumed; do not sell products in retail areas or place on patient trays/resident plates past the date on the product. Foods past the 'use-by' date should be discarded. Cover, label and date unused portions and open packages. ..." During a sanitation inspection on 01/09/13 at 9:15 AM: 1) a full-size steam table pan of berry cobbler was labeled 12/06 (and later changed to 01/06), with no "use-by" date. 2) Two trays of thawed individual portions of commercial milkshakes were stored in the walk-in refrigerator with no thaw or use-by date. The Food Service Director (Employee Identifier/EI) #6 confirmed the lack of a dated label on the trays. EI #7 (the Dietary Manager)explained the staff should place a dated label on each tray after the shakes are thawed. The facility's "Food Storage Chart" (Policy #B006) specifies a "Refrigerated Storage" of 7 days for commercially prepared shakes and nutritional supplements after thawed. 3) On 01/10/13 at 10:15 AM, three containers of left-over food were stored in the walk-in refrigerator with no indication of the contents and no use-by date. EI #6 described the contents of each respectively, as: black beans, diced tomatoes, and white chicken chili. The pan of berry cobbler remained in the walk-in refrigerator with no use-by date. 4) On 01/09/13 at 9:20 AM, and again on 01/10/13 at 10:15 AM, a 5 lb. container of cottage cheese was stored beyond the stamped use-by date of 01/02/13, in the reach-in refrigerator. FOOD PREPARATION 5) On 01/09/13 at 9:45 AM, a Dietary staff member (EI #8) was observed spreading egg salad onto bread (making sandwiches) with ungloved hands for the lunch tray line. Facility policy #F021 (revised 3/2011) regarding "Disposable Glove Use" directs staff as follows: "Disposable, non-latex gloves must be worn... When handling ready-to-eat foods..." FOOD SERVICE 6) Thirteen egg salad sandwiches were stored on an unrefrigerated tray on the 01/09/13 lunch tray line, and served as the alternate. Prior to service, at 11:10 AM, EI #8 measured the internal temperature of one sandwich as 53 degrees Fahrenheit (F). At 12:05 PM, a total of five egg salad sandwiches remained on the same unrefrigerated tray, following service to residents in the long term care unit. The surveyor again requested a check of the internal temperature. EI #8 measured one sandwich with the same digital, stem-type thermometer and determined the temperature was 60 degrees F. The surveyor asked EI #8 what the initial temperature was, and EI #8 correctly responded, 52 or 53 degrees. When asked what the recommended service temperature of cold food should be, EI #8 responded, not over 40 degrees. When asked if any nursing home resident had been served an egg salad sandwich, EI #8 responded, one resident. Recommended serving temperatures from the Centers for Medicare & Medicaid Services, are 41 degrees F or below when served from the tray line (or 135 degrees F or above).

Based on observation, interview and record review, the facility failed to ensure the Licensed Practical Nurse (LPN) changed gloves after cleaning Resident Identifier (RI) #5's coccyx and left buttock wounds and before applying a clean dressing. The LPN further failed to apply the wound gel from inner to outer, using a single wipe to the wound bed. This affected one of three wound care observations. Findings Include: A review of the facility's policy and procedure titled, "Dressing Change with Aseptic Technique" with an effective date of 1-25-12, revealed the following: "...4.) ... Remove soiled dressing ... Remove gloves and perform hand hygiene. ... 5.) Apply clean disposable gloves. ..." RI #5 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of RI #5's Admission Minimum Data Set ((MDS) dated [DATE] revealed RI #5's Brief Interview for Mental Status (BIMS) score of 15, indicating independence in cognitive skills. The MDS also revealed RI #5 required limited assistance with activities of daily living except locomotion on and off unit and bathing. On 01/09/13 at 11:30 AM, the following observation was made during wound care observation: Employee Identifier (EI) #1 (Registered Nurse/RN) washed her hands and applied clean gloves. EI #1 measured and cleaned RI #5's wound to her coccyx with wound cleanser and 4 x (by) 4's. EI #1 applied hydrogel to a 4 x 4 and dabbed the wound in an in and out motion, without changing the position of the 4 x 4. EI #1 applied [MEDICATION NAME] to the wound. EI #1 repeated this process for the left buttock wound. EI #1 was not observed to change gloves after cleaning RI #5's coccyx and left buttock wounds and before applying a clean dressing. On 01/09/13 at 12:10 PM, during an interview with EI #1, the surveyor asked when did she change gloves before she cleansed or after. EI #1 stated, "I didn't, I put gel and then I changed." The surveyor asked when should she have changed her gloves. EI #1 stated after she cleaned the wound. The surveyor asked what was the potential for harm. EI #1 stated, "Cross contamination." The surveyor asked what direction should gel be applied to a wound bed. EI #1 stated, "From center to outward, in and out." The surveyor asked would it be correct to say that she (EI #1) dabbed in and out. EI #1 stated yes. The surveyor asked at all times did the 4 x 4 stay in contact with the wound bed when the gel was applied. EI #1 stated, "No, I do know inside to outer, one swoop."