Every finding on record at Lineville Health and Rehabilitation, LLC

Based on observations, interviews and review of policy titled, Hand Hygiene, the facility failed to ensure a licensed staff member sanitized her hands after administering medication to Resident Identifier (RI ) #63 and before entering the medication cart to retrieve additional medications. This deficient practice affected RI #63, one of seven residents observed during medication administration. Findings include: A review of the facility policy titled, Hand Hygiene, with an effective date of (MONTH) 01, 2009, revealed the following: . PURPOSE: To provide guidelines to employees for proper and appropriate hand washing techniques that will aid in the prevention of the transmission of infections. II. Hand Sanitizer If hands are not visibly soiled, use an alcohol-based hand sanitizer for routinely decontaminating hands . RI #63 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. On 6/12/19 at 5:09 p.m., during medication administration, the surveyor observed Licensed Practical Nurse (LPN), Employer Identifier (EI) #3, take medications into RI #63's room and give him/her the medicine cup. RI #63 asked for a PRN (as needed) medication. RI #63 gave the medication cup back to EI #3 with the medication still in it. EI #3 returned to the medication cart and entered it to obtain the additional medication requested by RI #63 without sanitizing her hands. On 6/12/19 at 6:16 p.m., the surveyor conducted an interview with EI #3. The surveyor asked EI #3 why should hand sanitizer be used. EI #3 said for germs. The surveyor asked EI #3 when should hand sanitizer be used after giving medications. EI #3 said before going back into the medication cart. EI #3 said if hands were not sanitized, something (germs) could be spread from one person to another. On 6/13/19 at 10:51 a.m., the surveyor conducted an interview with EI #4, Registered Nurse (RN) Unit Manager and Infection Control Nurse. The surveyor asked what were the procedures for handwashing after giving a medication. EI #4 said wash hands prior to going into the room, depending on what medication was given and when coming out of the room. The surveyor asked EI #4 what were the procedures for handwashing when a nurse entered the resident's room with the medications, then left the room with the medications after a resident touched the medication cup, returned to the medication cart and opened it up to retrieve a medication. EI #4 said what she wished the nurse had done was allowed the resident to take the medications, then returned to the medication cart empty handed to retrieve the requested medication. EI #4 said the nurse was not to go back to the medication cart with something the resident touched and place it on the cart. The surveyor asked EI #4 when should hands have been sanitized. EI #4 said they should have been washed before going into the room, after leaving the room and before going into the medication cart. The surveyor asked EI #4 what were the concerns with this. EI #4 said if she touched anything in the medication cart, her hands were not clean and if the resident touched the cup, EI #3 should have sanitized her hands before entering the medication cart. The surveyor asked EI #4 would this be a way of spreading germs or an infection. EI #4 said it did have that potential.

Based on observations, interview, and review of the facility's policy titled Food Preparation Guidelines, the facility failed to ensure: 1) packaged lettuce was not stored past the manufacturers best by date; and 2) milk was not held at room temperature throughout meal service, resulting in a temperature exceeding 41 degrees F at the time it was served to residents. This had the potential to affect all 99 of 99 residents receiving meals in the facility. Findings include: 1) On 7/01/18 at 8:24 AM, an opened bag of lettuce stamped with a manufacturer's date of: Best if Used By 06/27/18 was observed in the walk-in cooler. Some of the lettuce leaves appeared wilted with a slight brown discoloration. A second unopened bag with the same date was also observed in the cooler. During an interview with Employee Identifier (EI) #4, the Dietary Manager (DM), on 07/03/2018 at 7:46 AM, EI #4 was asked what the facility's policy was in regard's to the manufacturer's best by dates. EI #4 said staff should be going by those dates and once exceeded discard them. EI #4 said the staff member that finds an item that exceeds the best by date would be responsible for discarding it. When asked what potential harm could occur if lettuce was stored past the best by date on the packaging, EI #4 said it would not taste good, look good, and could make some of the residents sick. 2) Review of the facility's policy titled Food Preparation Guideline, effective 08/15/2009, revealed the following: . PR[NAME]ESS: . g. Food should be protected from contamination, while being stored, prepared and served to residents. To prevent growth of pathogenic organisms: . 1. Refrigerated at or below 41 (degrees) F (Fahrenheit) . On 07/02/2018 at 11:02 AM, it was noted cartons of milk were out on trays (at room temperature) without any ice during meal service. At 11:40 AM, a carton of milk on the counter measured 50 degrees F at the time of service. The DM verified the temperature of the milk, but continued to allow the dietary staff to serve it. Staff began plating the last cart at 11:50 AM and the last resident was served at 11:52 AM. At that time, EI #4 checked the milk temperature again, which measured 58 degrees F. During an interview with Employee Identifier (EI) #4, the Dietary Manager (DM), on 07/03/2018 at 7:46 AM, EI #4 said milk should be at a temperature of 41 degrees F or below at the time of meal service. When questioned about the milk sitting on the counter-top throughout meal service at room temperature, that measured 58 degrees while serving the last residents, EI #4 said drinking bad milk might make someone sick if it were to sour. EI #4 also said she would probably not want to drink milk at that temperature. When asked why they keep the milk out at room temperature throughout the meal service, EI #4 said they normally only pull out a tray at a time and put the milks over bags of ice, but they failed to do that.

Based on record review and interviews, the facility failed to ensure Resident Indentifer (RI) #30's care plan approach to keep the lift chair remote out of reach was implemented on 6/13/18. This affected one of 16 residents for whom care plans were reviewed. Findings include: RI #30 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Resident Incident Report, dated 12/15/2017, indicated RI #30 was found on the floor in front of his/her lift chair. Review of RI #30's fall care plan, with a start date of 12/14/2016, revealed a new intervention was added to the care plan on 12/17/2017 to keep the lift chair remote out of the resident's reach to help prevent dumping him/herself onto the floor. Review of an undated document titled CERTIFIED NURSING ASSISTANT INFORMATION also revealed a care approach dated 12/17/2017 to keep the lift chair remote out of the resident's reach to help prevent dumping him/herself onto the floor. A second Resident Incident Report for RI #30, dated 06/13/2018, documented RI #30 was found on the floor in front of his/her lift chair. Departmental Notes included with the facility's fall investigation documented the following: . 6/13/2018 . RESIDENT WAS FOUND LYING ON THE FLOOR IN FRONT OF (his/her) RECLINER. REMOTE TO RECLINER IN CHAIR. Employee Identifier (EI) #1, Certified Nursing Assistant (CNA) was interviewed on 07/03/2018 at 8:41 AM. EI #1 recalled finding RI #30 on the floor in his/her room in (MONTH) (YEAR). EI #1 said RI #30 had been in his/her recliner, but when she found RI #30, he/she was on the floor in front of the recliner with the remote control (to the lift chair) in his/her hand playing with it. According to EI #1, the recliner was tilted up and the resident slid out of it. When asked how CNAs know what care to provide to residents, such as keeping the chair remote out of the resident's reach, EI #1 said they have guides (CERTIFIED NURSING ASSISTANT INFORMATION) taped inside each resident's closet. When asked how long CNAs had been required to keep the remote away from RI #30 when in the recliner, EI #1 said she did not know the exact time frame, but pretty much since the resident had the recliner. EI #1 said that was already in place prior to the 6/2018 fall. EI #1 said it was important to follow the care guides for the safety of the residents. On 07/03/18 at 9:32 AM, EI #2, the Care Plan Coordinator was interviewed. When asked when the intervention to keep the lift chair remote out of resident's reach added to the care plan for RI #30, EI #2 stated 12/17/17. She stated the approach was added to the care plan after the resident sustained [REDACTED].#2 explained staff should keep the remote out of the resident's reach. On 07/03/18 at 9:49 AM, EI #3, Registered Nurse (RN) Unit Manger, said she had updated RI #30's care plan after the 12/2017 fall to include an approach to keep the lift chair remote out of the resident's reach. EI #3 said RI #30 was forgetful and liked to play with the remote, and in reviewing the fall, it was determined the cause of the fall in (MONTH) (YEAR) was that he/she lifted the chair too high and fell out of it. After reviewing the information for the 6/2018 fall, EI #3 said the fall occurred because RI # 30 raised the chair up with the remote and slid out of it. Based on information provided to EI #3, she determined the resident had the lift chair remote in his/her hand at the time he/she was found on the floor. EI #3 said if the CNA had reviewed the guide in the closet, she would have known to keep the remote out of the resident's reach, but that was not done. When asked why it was important for staff to follow the care plan/care guide, EI #3 said to make sure they know what they are doing; it is an instruction sheet for providing care to the resident.

Based on record review and interviews, the facility failed to ensure Resident Identifier (RI) #30 did not sustain an avoidable fall on 6/13/18 when staff placed his/her lift chair remote in reach. This affected one of four residents reviewed for falls. Findings include: RI #30 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Resident Incident Report, dated 12/15/2017, indicated RI #30 was found on the floor in front of his/her lift chair. Departmental Notes included with the facility's fall investigation documented the following: . 12/15/2017 . RESIDENT IN FLOOR IN FRONT OF RECLINER ON (his/her) BACK WITH ELECTRIC CHAIR IN THE RAISED POSITION . Review of RI #30's fall care plan, with a start date of 12/14/2016, revealed a new intervention was added to the care plan on 12/17/2017 to keep the lift chair remote out of the resident's reach to help prevent dumping him/herself onto the floor. Review of an undated document titled CERTIFIED NURSING ASSISTANT INFORMATION also revealed a care approach dated 12/17/2017 to keep the lift chair remote out of the resident's reach to help prevent dumping him/herself onto the floor. A second Resident Incident Report for RI #30, dated 06/13/2018, documented RI #30 was found on the floor in front of his/her lift chair. Departmental Notes included with the facility's fall investigation documented the following: . 6/13/2018 . RESIDENT WAS FOUND LYING ON THE FLOOR IN FRONT OF (his/her) RECLINER. REMOTE TO RECLINER IN CHAIR. Employee Identifier (EI) #1, Certified Nursing Assistant (CNA) was interviewed on 07/03/2018 at 8:41 AM. EI #1 recalled finding RI #30 on the floor in his/her room in (MONTH) (YEAR). EI #1 said RI #30 had been in his/her recliner, but when she found RI #30, he/she was on the floor in front of the recliner with the remote control (to the lift chair) in his/her hand playing with it. According to EI #1, the recliner was tilted up and the resident slid out of it. When asked how CNAs know what care to provide to residents, such as keeping the chair remote out of the resident's reach, EI #1 said they have guides (CERTIFIED NURSING ASSISTANT INFORMATION) taped inside each resident's closet. When asked how long CNAs have been required to keep the remote away from RI #30 when in the recliner, EI #1 said she did not know the exact time frame, but pretty much since the resident had the recliner. EI #1 said that was already in place prior to the 6/2018 fall. EI #1 said it was important to follow the care guides for the safety of the residents. On 07/03/18 at 9:49 AM, EI #3, Registered Nurse (RN) Unit Manger, said she had updated RI #30's care plan after the 12/2017 fall to include an approach to keep the lift chair remote out of the resident's reach. EI #3 said RI #30 was forgetful and liked to play with the remote, and in reviewing the fall, it was determined the cause of the fall in (MONTH) (YEAR) was that he/she lifted the chair too high and fell out of it. After reviewing the information for the 6/2018 fall, EI #3 said the fall occurred because RI # 30 raised the chair up with the remote and slid out of it. Based on information provided to EI #3, she determined the resident had the lift chair remote in his/her hand at the time he/she was found on the floor. EI #3 said if the CNA had reviewed the guide in the closet, she would have known to keep the remote out of the resident's reach, but that was not done. When asked if this fall could have been avoided, EI #3 said yes, it could have been avoided by staff reading the sheet that was provided to to them and providing the care the resident required. When asked why it was important for staff to follow the care plan/care guide, EI #3 said to make sure they know what they are doing; it is an instruction sheet for providing care to the resident.

Based on observation, review of the facility's policy titled Food Taste Test, and concerns voiced by the resident's at the Resident Council Meeting on 07/02/2018, the facility failed to ensure grilled cheese sandwiches were not hard. This affected 6 of 9 residents who attended resident council meeting on 07/02/2018. Findings include: Review of the facility policy titled Food Taste Test, effective 02/01/2002, revealed the following: . PURPOSE: Foods with a distinctively good taste and appearance help promote the resident's dietary intake. . PR[NAME]ESS: . c. Check the food for: . Texture . During the Resident Council meeting held on 07/02/2018 at 9:00 AM, there were nine residents in attendance. One resident stated the grilled cheese sandwiches were too hard and the bread was stale sometimes. Six residents agreed. On 07/02/2018 at 11:54, a test tray was plated (including a grilled cheese). The cart left the kitchen at 11:55 AM. arrived on the hall at 11:56 AM. After the last resident was served, Employee Identifier (EI) #4, the Dietary Manager, began testing the tray. The grilled cheese sandwich was served wrapped in foil. One side was nicely browned, but the other side was not. EI #4 tasted the grilled cheese and said it was a little chewy. The surveyor also tasted it, and was in agreement that the sandwich was chewy. EI #4, the Dietary Manager, was interviewed on 07/03/18 at 7:46 AM. EI #4 said it was important to ensure food was palatable because the residents will not eat it if it is not palatable. When asked why the grilled cheese sandwiches were chewy, EI #4 said they put them in foil to keep them warm, but the bread sweats and makes it chewy.

Based on observation, interviews and review of the facility's policies titled, Hand-washing Guidelines, Cleaning of Miscellaneous Equipment and Utensils and Food Receipt and Storage, the facility failed to ensure: 1. meat and vegetables were stored in separate containers, 2. food in the freezer was securely closed and had an open date, 3. the oven and grill were free from grease and food particles, 4. staff did not use bare hands to turn off the faucet after washing their hands, 5. staff washed their hands after touching the garbage can lid, and after removing their gloves before returning to their duties, 6. staff did not touch residents' food with bare hands, 7. staff did not touch their glasses, hair and uniform with their gloved hands and resume their duties and 8. opened items in the walk in refrigerator had an open date. This was observed on two of three days of the survey and had the potential to affect 98 residents receiving meals from the kitchen. Findings Include: A review of a policy titled, Hand-washing Guidelines dated February 1, 2002 documented: .PROCESS: I. Frequency of Hand-washing: Hands should be washed in the following situations: . After hands have touched anything unsanitary . II. Hand-washing Procedure: .g. Dry hands and turn water off with paper towels h. Dispose of paper towels in a pedal opening trash can(do not touch the trash can lid with clean hands) A review of a policy titled, Cleaning of Miscellaneous Equipment and Utensils dated March 17, 2016 documented: .PROCESS: .28. Ovens: (weekly and as needed) .29. Range and Grill: (daily) . A review of a policy titled, Food Receipt and Storage dated August 21, 2013 documented: .PROCESS: .k. Open food items should be covered, labeled, and dated . On 08/15/2017 at 5:50 p.m. during the initial tour of the kitchen the following items were observed: 1) On the shelf in the walk in freezer, an open box containing bags of corn was noted with a sirloin roast in the box on top of the corn, 2) a bag containing curly fries was open to air, 3) a gallon jar of mayonnaise was open in the refrigerator without an open date, 4) the oven was noted to have a thick brown substance on the racks, window and the bottom of the oven and 5) the grill was observed to have pools of grease and particles of food. On 08/16/2017 at 8:00 a.m., the following observations were made: 1) Employee Identifier (EI) #6, Kitchen Staff, after wiping off the preparation counter, removed her gloves and without washing her hands, started preparing the pureed food, 2) EI #7, Kitchen Staff, washed her hands, turned the water off with her bare hands and applied gloves. With her gloved hands, EI #7 lifted the trash can lid, disposed of trash, and started slicing cake for the noon meal, 3) EI#8, a Dietary Worker, entered the kitchen from the outside, washed her hands and turned off the water with her bare hands, 4) EI#8, Dietary Worker, left the kitchen, returned and applied gloves without handwashing, 5) EI #3, the Dietary Manager, removed the basket from the coffee maker, lifted the garbage can lid, emptied the coffee grounds and without washing hands or putting on gloves, started the coffee. EI #3 then washed her hands and turned the water off with her bare hands, 6) EI #5, the Cook, lifted the garbage can lid with her bare hands and disposed of aluminum foil and did not wash her hands or apply gloves. EI #5 tore off a sheet of aluminum foil and placed it over a pan of food. EI #5 continued to a preparation table and placed sliced tomatoes into a bowl. That bowl of tomatoes was placed on the cart for the residents, and 7) while standing in the kitchen, EI #7, Dietary Worker, touched her glasses, her hair and her uniform with gloved hands before obtaining a divided plate for the tray line. On 08/17/2017 at 10:15 a.m., EI #6 was asked if water should be turned off with bare hands after washing. EI #6 stated she cut the water off with her bare hands and should have used a paper towel. EI #5 was interviewed on 08/17/2017 at 10:20 a.m. EI #5 was asked how should staff turn the water off after washing their hands. EI #5 stated with the back of the hand. EI #5 was asked what was the concern with turning the water off with bare hands. EI #5 stated staff could re-contaminate their hands. EI #5 was asked why should staff not touch a resident's food with their bare hands. EI #5 stated it was cross contamination. An interview was conducted with EI #7 on 8/17/2017 at 10:25 a.m. EI #7 was asked what should be done after touching the garbage can lid. EI #7 stated hands should be washed and gloves applied because there were germs on the lid. The Dietary Manager, EI #3, was interviewed on 08/17/2017 at 10:35 a.m. EI #3 was asked what was the harm in lifting the garbage can lid and returning to her duties without washing her hands. EI #3 stated it was cross contamination. When asked how often the grill and oven was cleaned, EI # 3 stated it was cleaned once a week and wiped off every day. EI #3 was asked should a roast be stored in the box on top of bags of corn. EI #3 stated probably not because of contamination. EI # 3 was asked if food should be left in the freezer open to air. EI # 3 responded no. EI # 3 was asked should food items have an open date. EI # 3 responded yes.

Based on observation, interviews, medical record review, review of POTTER and PERRY, FUNDAMENTALS OF NURSING, NINTH EDITION and review of a facility policy titled, Medication Administration - General Guidelines, the facility failed to ensure a licensed nurse did not leave medication unattended on Resident Identifier (RI) #6's overbed table. This was observed on 08/16/2017 and affected RI #6, one of 12 sampled residents. Findings Include: Review of POTTER and PERRY, FUNDAMENTALS OF NURSING, NINTH EDITION, Unit V, Foundations for Nursing Practice, Chapter 32, Medication Administration, Skill 32-1, Administering Oral Medication, pp. 655-658, documented: .DELEGATION CONSIDERATIONS . l. Do not leave medications unattended. Nurse is responsible for safekeeping of drugs . A review of a facility policy titled, Medication Administration - General Guidelines with a date of 03/11 revealed the following: 6.2: MEDICATION ADMINISTRATION - GENERAL GUIDELINES . Procedures .3. Medications are administered at the time they are prepared. Medications are not pre-poured. 4. The person who prepares the dose for administration is the person who administers the dose 13. The resident is always observed after administration to ensure that the dose was completely ingested. If only a partial dose is ingested, this is noted on the MAR (Medication Administration Record), and action is taken as appropriate . RI #6 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 08/16/2017 at 7:46 a.m., the surveyor observed RI #6's breakfast tray sitting on the overbed table in RI #6's room. A medication cup with a tongue blade sticking into a brown substance in the cup was observed lying on the tray beside the resident's plate. The surveyor stepped back into the hallway and observed RI #6 sitting in a Broda chair down the hall. Employee Identifier (EI) #1, a Certified Nursing Assistant (CNA), approached RI #6 and assisted RI #6 into the room and pushed the overbed table in front of the resident's chair. The surveyor asked EI #1, what was in the medication cup. EI #1 replied, that was her/his medicines that we (facility staff) mix with her/his food so she/he will take them. The surveyor asked EI #2, LPN (Licensed Practical Nurse) to come to RI #6's room. EI #2 was asked to identify what was in the medication cup. EI #2 replied, there were several medicines, so she would have to go and see. EI #2 returned to the medication cart and read off the medications she had previously crushed and placed in the medication cup for RI #6. On 08/16/2017 at 2:00 p.m., an interview was conducted with EI #2. EI #2 was asked, how did RI #6 take her/his medications. EI #2 stated, Crushed and usually mixed with her/his food in the morning time. EI #2 was asked, what brown substance were the medications added to after they were crushed. EI #2 answered, Pudding. The surveyor asked, what time did she leave RI #6's medications in her/his room. EI #2 said, I can't remember . EI #2 was asked, should the medications have been left in RI #6's room unattended. EI #2 replied, No Ma'am, they should not have been . EI #2 was asked, what was the potential harm in leaving medications in the room unattended. EI #2 answered, Someone else could take them and it could be detrimental to them.

Based on observation, interviews, review of POTTER and PERRY, FUNDAMENTALS OF NURSING, NINTH EDITION, review of facility policies titled, Hand Hygiene and Using Gloves, the facility failed to ensure: 1) Certified Nursing Assistants (CNA's) washed their hands before applying gloves and after removing gloves, during incontinence care for Resident Identifier (RI) #7 and RI #7's leg did not touch an open garbage bag of soiled wipes and gloves after incontinence care was performed and 2) a Licensed Practical Nurse (LPN) washed her hands before applying gloves to administer eye drops to RI #21. This was observed on 08/16/2017, during an observation of incontinence care and on 08/17/2017, during the medication pass observation. This affected one of two incontinence care observations, one of three nurses observed during medication pass and RI #21, one of one residents receiving eye drops during the medication pass observation. Findings Include: Review of POTTER and PERRY, FUNDAMENTALS OF NURSING, NINTH EDITION Chapter 29, Infection Prevention and Control p. 459 revealed: .TABLE 29-6 Centers for Disease Control and Prevention Isolation Guidelines Standard Precautions (Tier One) for Use with All Patients Perform hand hygiene before, after, and between direct contact with patients. (Examples of between-contact activities are cleaning hands after a patient care activity, moving to a non-patient care activity, and cleaning hands again before returning to perform patient contact.) Perform hand hygiene after contact with blood, body fluids, . and immediately after gloves are removed. Wear gloves when touching blood, body fluids, secretions, excretions, nonintact skin, mucous membranes, or contaminated items or surfaces is likely. Remove gloves and perform hand hygiene between patient care encounters and when going from a contaminated to a clean body site. A review of a facility policy titled, Hand Hygiene with an effective date of December 1, 2009, documented: . STANDARD: Hand washing should be performed between procedures with residents based upon the principle that all blood, body fluids, secretions, excretions . may contain transmissible infectious agents. A review of a facility policy titled, Using Gloves with an effective date of December 1, 2009, revealed: . STANDARD: Gloves should be worn when contact with feces or possibly infectious materials are anticipated. 1) RI #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 08/16/17 at 11:02 a.m., the surveyor observed four CNA's, EI (Employee Identifier) #9, #10, #11 and #12, enter RI #7's room to provide incontinence care. The surveyor observed all four CNA's apply gloves after entering the room without washing their hands. RI #7 was transferred from a Geri chair to the bed and positioned to check for incontinence. RI #7's brief was observed soiled with stool. After providing incontinence care, RI #7's soiled brief was rolled out from under him/her and placed in a plastic bag at the end of the bed. EI #9 removed her dirty gloves and placed them in the garbage bag. The clean brief was positioned under RI #7 and he/she was rolled onto his/her side causing RI #7's right leg to roll onto the open garbage bag filled with the soiled brief, soiled wipes and soiled gloves. After RI #7's pants were positioned on his/her hips, EI #10, #11, and #12 removed their gloves and placed them in the garbage bag and without washing their hands, assisted EI #9 in putting RI #7 back into the Geri chair. EI #9 entered RI #7's bathroom to wash her hands and EI #10, #11 and #12 poured hand gel into their hands. On 08/16/17 at 2:49 p.m., an interview was conducted with EI #10. EI #10 was asked, when was she supposed to wash her hands. EI #10 replied, Before going in the room and before and after you take your gloves on/off. EI #10 was asked, did she wash her hands before helping with RI #7 that morning. EI #10 answered, . not before, I put my gloves on in the room. EI #10 was asked, did she wash her hands after she took off her gloves before putting RI #7 in the chair. EI #10 said, No. The surveyor asked, did RI #7 lay on the bedspread without a brief on or anything under him/her. EI #10 stated, Yes, when we were rolling him/her. EI #10 was asked, did RI #7's leg touch the open garbage bag with the soiled brief, soiled wipes and soiled gloves in it. EI #10 replied, I know he/she touched the bag, but not what else he/she touched. EI #10 was asked, did she consider those things infection control issues. EI #10 responded, Yes. On 08/16/17 at 3:00 p.m., an interview was conducted with EI #11. EI #11 was asked, when she was supposed to wash her hands. EI #11 stated, When you enter the room and before you start on the resident. The surveyor asked, did she wash her hands before helping with RI #7 that morning. EI #11 replied, No Ma'am, I didn't. EI #11 was asked, did she wash her hands after taking off her gloves and before putting RI #7 into the chair. EI #11 said, No Ma'am, I didn't. EI #11 was asked, did RI #7 lay on the bedspread without a brief or pad under him/her. EI #11 answered, Yes Ma'am, he/she did. The surveyor asked, did RI #7's legs touch the garbage bag with the soiled wipes and soiled gloves in it. EI #11 said, Yes Ma'am, they did. EI #11 was asked, did she consider those things infection control issues. EI #11 replied, Yes Ma'am. On 08/16/17 at 3:06 p.m., an interview was conducted with EI #9. EI #9 was asked, when she was supposed to wash her hands. EI #9 said, When I go in a room and when I take my gloves off. EI #9 was asked, did she wash her hands before helping with RI #7 that morning. EI #9 replied, Not when I went in the room, no. The surveyor asked, did she wash her hands after taking her gloves off and before putting him/her in the chair. EI #9 answered, No. EI #9 was asked, did RI #7 lay on the bedspread without a brief or pad under him/her. EI #9 said, Yes Ma'am, but I went back and changed the comforter later. EI #9 was asked if RI #7's legs touched the open garbage bag with the soiled wipes and gloves in it. EI #9 answered, Yes. EI #9 was asked, did she consider those things infection control issues. EI #9 replied, Yes. On 08/16/17 at 3:15 p.m., an interview was conducted with EI #12. EI #12 was asked, when she was supposed to wash her hands. EI #12 answered, You knock on the door, enter the room, tell the resident what you're there to do and then go wash your hands and wash them after you take your gloves off. EI #12 was asked, did she wash her hands before helping with RI #7 that morning. EI #12 said, No Ma'am. The surveyor asked, did she wash her hands after taking her gloves off and before putting him/her in the chair. EI #12 responded, No Ma'am. EI #12 was asked, did RI #7 lay on the bedspread without a pad or brief under him/her. EI #12 said, Yes. EI #12 was asked, did RI #7's legs touch the open garbage bag with the soiled wipes and soiled gloves in it. EI #12 replied, Yes. EI #12 was asked, did she consider those things infection control issues. EI #12 answered, Yes. 2) On 08/17/17 at 8:07 a.m., the surveyor observed EI #13, a LPN, apply gloves without washing her hands to administer eye drops for RI #21. On 08/17/17 at 1:35 p.m., an interview was conducted with EI #13. The surveyor asked, when she was supposed to wash her hands. EI #13 answered, Before and after every patient contact and in between, if you're changing procedures. EI #13 was asked, did she wash her hands prior to putting on her gloves to administer RI #21's eye drops. EI #13 replied, No Ma'am. EI #13 was asked, was that an infection control issue. EI #13 said, Yes, it is.

Based on observations, interviews, and record reviews, the facility failed to ensure: 1) Staff did not wear stud earrings uncovered; maintenance staff did not have facial hair uncovered while in the kitchen; and a repair man was not observed in the dish washing room without a hair restraint. This was observed on one of three survey days. 2) Mighty Shakes and Ready Care Nutritional Treat cups had a thaw date on them on two of three survey days. Also, the Mighty Shakes and Nutritional Ready Care Treat cups were not served on the tray line without a thaw date on one of three survey days. 3) Food items were not stored in a broken reach in freezer with a temperature of 44 degrees on two of three survey days. 4) Food items in the walk in refrigerator, the reach in refrigerator, and freezer were dated, labeled and sealed, on two of three survey days. 5) Dietary workers did not continue to work serving food on the tray line after picking items up off the floor on one of three survey days. 6) The dishwasher was at a correct temperature, of 140 degrees or above, for washing dishes on one of three survey days. 7) There was a Julian Calendar available to check expiration dates for the Ready Care Nutritional Treat cups. This had the potential to affect 99 residents that received meals from the kitchen. Findings Include: A review the facility's document titled, Job Description for Dietary Assistant, with a review date of 06/30/03, revealed, General-purpose:) To provide assistance in all dietary functions as directed and instructed in accordance with establish(ed) Federal, State, and local dietary regulations, policies and procedures. Essential Job Functions A. Dietary Functions . 6. Ensure proper storage of raw and leftover foods. 8. Perform all daily tasks in accordance with established Universal Precautions and sanitary, safety infection control policies and procedures. D. Safety and Equipment Functions 1. Ensure that the department and all food storage and work areas are maintained in a clean and safe manner and that necessary equipment and supplies are properly maintained and arranged. 2. Maintain habits of good personal hygiene. 3. Dispose of food and waste in accordance with established policies and procedures. 1) A review of a Policy and Procedure titled, Employee Personal Health and Hygiene, with an Effective Date: April 29, 2015, revealed, PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses. STANDARD: Employees must maintain a clean, neat and well groomed appearance at all times. Uniforms must be worn and all sanitation/personal hygiene policies will be followed. PROCESS: . d. Hairnets - Hair must be neatly styled and completely covered with an appropriate hair covering. Facial hair must be covered with proper restraint. g. Jewelry should be minimized. Food service employees may not wear jewelry on their arms and hands(with the exception of a plain band). Earrings if worn must be small and non-dangling. Artificial eyelashes are not allowed. FOOD CODE U.S. Public Health Service FDA 2013 A review of the Food Code revealed: 2-3 PERSONAL CLEANLINESS Subparts 2-303 Jewelry Jewelry 2-303.11 Prohibition (page 50) Except for a plain ring such a wedding band, while preparing FOOD, FOOD EMPLOYEES may not wear jewelry . 2-4 HYGIENE PRACTICES Subparts 2-402 Hair Restraints Hair Restraints 2-402.11 Effectiveness (page 51) (A) Except as provided in paragraph (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, . During the tour of the kitchen on 8/17/2015 at 5:52 PM, EI (Employee Identifier) #4, an Assistant Cook, was observed with stud earrings on and not covered by a hair restraint. On 8/19/2015 at 1:28 PM, a Maintenance Worker was observed in the dish washing area without a beard restraint on and a repair man was observed in the dish washing area without a hair restraint to cover his facial hair. On 8/19/2015 at 1:28 PM, the maintenance worker said he did not have to worry about covering his head because he had no hair. The surveyor asked him about covering his facial hair and he replied that he could shave it off. An interview was conducted on 8/19/2015 at 2:49 PM, with EI #4, an Assistant Cook. EI #4 was asked what jewelry was allowed to be worn while working in the kitchen. EI #4 replied, Jewelry allowed to be worn is like a wedding band. I am not sure about anything else. I do know you can't wear dangling earrings or watches. EI #4 was asked what about wearing stud earrings in the kitchen. EI #4 replied, That's what I wear and my supervisor told me to take them out. EI #4 was asked if she had on uncovered stud earrings on 8/17/2015 during the initial tour of the kitchen. EI #4 replied, Yes I did and they were not covered. EI #4 was asked if stud earrings should be covered if worn in the kitchen. EI #4 replied, Yes ma'am. EI #4 was asked if all people should wear hair restraints when entering the kitchen area. EI #4 replied, Yes ma'am, everybody. An interview was conducted on 8/19/2015 at 4:45 PM, with EI #6, the Dietary Manager. EI #6 was asked what jewelry was allowed to be worn while working in the kitchen. EI #6 replied, Plain wedding band and stud earrings if covered by hair restraint. EI #6 was asked what the facility's policy indicated regarding wearing jewelry in the kitchen. EI #6 replied, Plain wedding band and stud earrings if covered. EI #6 was asked if all people should wear hair restraints when entering the kitchen area. EI #6 replied, They should if in production area, if going through the dish room and not in production area no hair restraint is required. An interview was conducted on 8/20/2015 at 12:00 PM, with EI #1, the Consultant Dietitian. EI #1 was asked what jewelry was allowed to be worn while working in the kitchen. EI #1 replied, A wedding band, that's what policy says. EI #1 was asked if stud earrings should be covered if worn in the kitchen. EI #1 replied, Our policy does not specifically say that they have to be covered, just no dangling earrings. EI #1 was asked if all people should wear hair restraints when entering the kitchen area. EI #1 replied, If going to be in the kitchen in food production area or working around food a hair restraint is required. 2) A review of a facility Policy and Procedure titled, Leftover Food Storage and Use, with an Effective Date: August 15, 2009, revealed, PURPOSE: To assure that food borne illnesses are avoided. A review to an attachment to the above policy titled, SHELF LIFE OF FOODS and BEVERAGES, revealed, · 3 Days for refrigerated items once removed from container · If original container, observe the use by date . · 6 months for items in original container in freezer, unopened · 3 months for items re-packaged in container in freezer . · 6 months for Magic Cup unopened in freezer · 10 days for Magic Cup after opened (date box) . · 10 days for Mighty Shake after opened, in cooler (date box) . A review of an undated Manufacturer's document for Ready Care Nutritional products titled, Unintended Weight Loss Frozen Nutritional Treats, revealed, (Name of Company) Ready Care Frozen Nutritional Treats are the perfect snack supplement to help with shake supplement fatigue. High calorie and high protein, this creamy nutritional treat is like ice cream when served from the freezer, but melts to a pudding consistency as it thaws. Perfect for residents for dysphagia. Available in 5 flavors to enhance supplement consumption. Packaging Specifications(:) Case Pack 48/4 oz (ounce); Case Dimensions 12 ½ X 12 ½ X 6 ¼; Case Cube 0.56; Cases/Layer 10; Cases Pallet 120. Shelf Life: · Frozen: 1 year from production date · Refrigerated: 5 days once thawed Production code date is a four digit code. The very last digit (reading from left to right) designates the year. The first three digits (reading right to left) indicate the numerical day of the year in Julian Code. Example: 7008 January 7, 2008. Storage and Handling: · To serve frozen: Pull from freezer and place on tray. As product thaws it turns into pudding consistency. · To serve as a pudding type product: Thaw in refrigerator overnight, then serve. An observation was made on the initial tour of the kitchen, on 8/17/2015 at 5:52 PM. In the walk-in cooler, the surveyor observed 26 Mighty Shakes on a serving tray un-dated and un-labeled and none of the Mighty Shake cartons were labeled with a thaw date. An additional observation in the walk-in cooler was of one box, half empty, of strawberry Mighty Shakes (total of 55) frozen. The box and the Mighty Shakes were not labeled with a thaw date. It was observed that there was no thaw date on any of these 13 cups of Ready Care Frozen Nutritional Treats. An observation was made on 8/18/2015 at 11:00 AM, during the tray line observation. Mighty Shakes and Ready Care Nutritional treats were being served without thaw dates on the cartons. An interview was conducted with EI #4, an Assistant Cook, on 8/19/2015 at 2:49 PM. EI # 4 was asked who was responsible for checking for expired food product and how often was food checked for expiration. EI #4 replied, Everyone is responsible to check every day. EI #4 was asked how were Mighty Shakes managed related to thawing and serving them to residents. EI #4 replied, We prep them, when on the line I get them out of the freezer and let them thaw and date them. EI #4 was asked if she ever obtained Mighty Shakes from the refrigerator that were already thawed. EI #4 replied, Yes ma'am but I check the thaw date to see if they are still good. EI #4 was asked why there were so many Mighty Shakes found during the initial tour on 8/17/2015 that were undated. EI #4 replied, Because some people use other peoples stuff and some people just don't date them. EI #4 was asked if Mighty Shakes should be labeled with a thaw date. EI #4 replied, Yes ma'am, in case someone else needs to use them. EI #4 was asked what was required for the use of the Ready Care Frozen Nutritional Treat served frozen and what was required if served thawed in a pudding consistency. EI #4 replied, I don't date them if (they are) frozen, I look at the label on the box. An interview was conducted with EI #5, a Dietary Assistant, on 8/19/2015 at 3:49 PM. EI #5 was asked who was responsible for checking for expired food products and how often was food checked for expiration. EI #5 replied, Sometimes me and then the cook, checked everyday. EI #5 was asked how were Mighty Shakes managed related to thawing and serving them to residents. EI #5 replied, When unthawed they can't be left out too long because they will spoil. I take out what I need for the day and thaw in the refrigerator. EI #5 was asked what does she do if she does not use all of the Mighty Shakes she took out. EI #5 replied, I throw them away. EI #5 was asked if Mighty Shakes should be labeled with a thaw date and what should the thaw date be. EI #5 replied, Yes ma'am, because when you get the Mighty Shake it should have a thaw date. EI #5 was asked what was required for the use of the Ready Care Frozen Nutritional Treat served frozen and what was required if served thawed in a pudding consistency. EI #5 replied, Nothing frozen, expiration date is on the lid, if not used throw them away. They have to have a thaw date good for only one day. An interview was conducted with EI #6, the Dietary Manager, on 8/19/2015 at 4:45 PM. EI #6 was asked who was responsible for checking for expired food products and how often was food checked for expiration. EI #6 replied, Me, the Dietary Manger. Most of the time daily. EI #6 was asked how were Mighty Shakes maintained related to thawing and serving them to residents. EI #6 replied, When placed in the refrigerator they should be dated (when they come out of the freezer) before we send them out on the hall re-date them with a use-by date. EI #6 was informed on the initial tour of the kitchen on 8/17/2015 Mighty Shakes were found in the walk in refrigerator un-dated and EI #6 was asked if this was correct. EI #6 replied, No, they should have been dated. EI #6 was asked if Mighty Shakes should be labeled with a thaw date and why. EI #6 replied, Yes they should be, so everyone will know how old they are. EI #6 was asked what was required for the use of the Ready Care Frozen Nutritional Treat served frozen and what was required if served thawed in a pudding consistency. EI #6 replied, Frozen state they are like ice cream. EI #6 was asked were they suppose to be dated. EI #6 replied, I don't know, I will have to ask the Consultant Dietitian. EI #6 was asked if the Ready Care Nutritional Treats that were served thawed in a pudding consistency required any type of dating. EI #6 replied, I don't know, I'll have to ask the Consultant Dietitian. An interview was conducted with EI #3, an Assistant Cook, on 8/20/2015 at 10:26 AM. EI #3 was asked who was responsible for checking for expired food product and how often was food checked for expiration. EI #3 replied, Everybody, probably the supervisor, use first in first out, and leftovers are checked every two days. EI #3 was asked how were Mighty Shakes managed related to thawing and serving them to residents. EI #3 replied, Take out of freezer, has a date on it, then we re-date them before served with a ten day expiration date. EI #3 was asked if Mighty Shakes should be labeled with a thaw date and what should the thaw date be. EI #3 replied, Take them (Mighty Shakes) out of freezer, has a date on them, then we date them before severed with a 10 day expiration date. EI #3 was asked what was required for the use of the Ready Care Frozen Nutritional Treat served frozen and what was required if served thawed in a pudding consistency. EI #3 replied, Should be at 41 degrees or below to be served at a frozen state. EI #3 was asked how long were the Ready Care Nutritional Treats useable while frozen. EI #3 replied, I don't know, I really don't, thawed they are not served that way. They are thrown out. EI #3 was asked if she knew what a Julian Calendar was and how to use it. EI #3 replied, No ma'am. An interview was conducted with EI #1, the Consultant Dietitian, on 8/20/2015 at 12:00 PM. EI #1 was asked who was responsible for checking for expired food product and how often was food checked for expiration. EI #1 replied, Everyone, all dietary employees, it is an ongoing task. EI #1 was asked how were Mighty Shakes managed related to thawing and serving them to residents. EI #1 replied, The box should be dated with the thaw date and if the carton is removed from the box the carton should be dated. EI #1 was asked if Mighty Shakes should be labeled with a thaw date and what should the thaw date be. EI #1 replied, Yes with a thaw date on the box, carton re-dated with a sticker with a use-by date, so we know when the expiration date is. EI #1 was asked what was required for the use of the Ready Care Frozen Nutritional Treat served frozen and what was required if served thawed in a pudding consistency. EI #1 replied, We serve them frozen, no other requirements. Thawed is fine they can be served thawed in a pudding consistency. EI #1 was asked what was the use-by date of the Ready Care Nutritional Treat if served in a pudding consistency. EI #1 did not know there was suppose to be a use-by date of five days if served in a pudding consistency. 3) A review of the Policy and Procedure titled, Food Storage Temperature Logs, with an Effective Date: April 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: a. The Dietary Manager, or designee, should check food storage temperatures twice daily; at the open and close of the kitchen. b. Action should be taken and noted, if temperatures are not in the recommended ranges: · Dry Storage Area 50-80 degrees F (Fahrenheit) · Refrigerators 33-40 degrees F · Freezers 0 degrees F or less A sample temperature log is attached as form DS.IV-16a. FOOD CODE U.S. Public Health Service FDA 2013 A review of the Food Code revealed: 3-5 LIMITATION OF GROWTH OF ORGANISMS OF PUBLIC HEALTH CONCERN Subparts 3-501 Temperature and Time Control (page 88) Temperature and Time Control 3-501.11 Frozen Food Stored frozen FOODS shall be maintained frozen 3-501.12 Time/Temperature Control for Safety Food. Slacking Frozen Time/Temperature Control; For Safety Food that is slacked to moderate the temperature shall be held: (A) Under refrigeration that maintains the food temperature at 5 degrees C (Celsius) (41 degrees F (Fahrenheit); or less (B) At any temperature if the FOOD remains frozen. 3-501.13 Thawing Except as specified in paragraph (D) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be thawed: (A) Under refrigeration that maintains the FOOD temperature at 5 degrees C (41 degrees F) or less; or . During the tour of the kitchen on 8/17/2015 at 5:52 PM, the surveyor observed in the reach-in freezer the temperature was 44 degrees. The surveyor was told that it was broken and not being used as a freezer per EI #4. There were 13 cups of Ready Care Nutritional Treats in this freezer. All 13 cups were soft to touch with the lids popping off when squeezed and the surveyor was able to puncture the side of the cup with her thumb while squeezing it. On 8/18/2015 at 11:00 AM, while observing tray line, it was observed milk, Mighty Shakes, and Ready Care Nutritional Treats from the reach-in freezer were being served on the tray line to residents from the reach-in freezer. The temperature of the reach-in freezer was 44 degrees. The Mighty Shakes had no use-by date on them and the Ready Care Nutritional Treats were soft to touch and when squeezed the lids popped off and the side of the container was punctured with the thumb of the surveyor. In the reach in refrigerator there was a tray of Mighty Shakes on the bottom shelf with no use-by date on any of the cartons and no date was observed on the tray. These Mighty Shakes were being served on the tray line to residents. An interview was conducted on 8/19/2015 at 2:49 PM with EI #4. EI #4 was asked what the temperature of the freezer and refrigerator should be. EI #4 replied, Our supervisor usually checks it if there is a problem she calls maintenance. EI #4 was asked about the reach in freezer being at 44 degrees and if this was an appropriate temperature to store refrigerated foods, why or why not. EI #4 replied, I think so, to keep foods from spoiling. An interview was conducted on 8/19/2015 at 3:49 PM with EI #5. EI #5 was asked what the temperature of the freezer and refrigerator should be. EI #5 replied, I think, I do not know. We do not check those temps. EI #5 was asked about the reach-in freezer being at 44 degrees and if this was an appropriate temperature to store refrigerated foods why or why not. EI #5 replied, I do not know. Yes I would have used them and served them. 44 degrees is okay. An interview was conducted on 8/19/2015 at 4:45 PM with EI #6 . EI #6 was asked what the temperature of the freezer and refrigerator should be. EI #6 replied, 0 degrees or below and 33-40 degrees for the refrigerator. EI #6 was asked about the reach in freezer being at 44 degrees and if this was an appropriate temperature to store refrigerated foods. EI #6 replied, No, because it should be 40 degrees or below. An interview was conducted on 8/20/2015 at 12:00 PM with EI #1. EI #1 was asked what the temperature of the freezer and refrigerator should be. EI #1 replied, 0 degrees or below for freezer and refrigerator is 33-40 degrees. EI #1 was asked about the reach in freezer being at 44 degrees and if this was an appropriate temperature to store refrigerated foods. EI #1 replied, No, should be 40 degrees or below. EI #1 was asked if all dietary staff should know the temperatures for the freezer and refrigerator. EI #1 replied, Yes, should all know it. 4) A review of a facility Policy and Procedure titled, Leftover Food Storage and Use, with an Effective Date: August 15, 2009, revealed, PURPOSE: To assure that food borne illnesses are avoided. STANDARD: Leftover foods should be stored under the same conditions as other foods. PROCESS: a. Leftover foods should be refrigerated promptly, in approved storage containers of appropriate size and depth, to allow prompt cooling. b. Leftover foods should be covered, labeled and dated. c. Refrigerated leftover foods should be used within 72 hours (three days). If not used within 72 hours, refrigerated foods should be discarded. These foods should be monitored for proper cooling with times and temperature recorded on a cooling log. A review of an attachment to the above policy titled, SHELF LIFE OF FOODS and BEVERAGES, revealed, · 3 Days for refrigerated items once removed from container · If original container, observe the use by date . · 6 months for items in original container in freezer, unopened · 3 months for items re-packaged in container in freezer . · 6 months for Magic Cup unopened in freezer · 10 days for Magic Cup after opened (date box) . · 10 days for Mighty Shake after opened, in cooler (date box) . FOOD CODE U.S. Public Health Service FDA 2013 A review of the Food Code revealed: Chapter 3 Food Parts . 3-2 SOURCES, SPECIFICATIONS, AND ORIGINAL CONTAINER AND RECORDS Subparts . 3-202.15 Package Integrity FOOD packages shall be in good condition and protect the integrity of the contents so that the FOOD is not exposed to ADULTERATION or potential contaminants. During the initial tour of the kitchen on 8/17/2015 at 5:52 PM and on 8/18/ at 11:00 AM, the following observations were made related to storage of food in the walk-in cooler, the walk-in freezer, the reach-in freezer and the reach-in refrigerator. In the walk-in cooler the surveyor observed on 8/17/2015: a) An open box of thawed bacon unsealed and no open date b) An open box of patty type sausage unsealed and no open date c) Four individual covered cups of pineapple nibbles. One was dated 8/11/2015 and no date on the other 3 containers and the cups were not labeled. d) Mighty Shakes were observed with no thaw date on the cartons. In the walk-in freezer the surveyor observed on 8/17/2015: a) Two boxes of Western Beef Steak Fritters which were open and the bag inside was not sealed and there was no open date on the box. b) A box of frozen mixed vegetables was open, the bag inside was unsealed and there was no open date on the box. c) A box of frozen cinnamon rolls was open and unsealed without an open date on the box. d) There was a box of Brussels Sprouts sealed in individual bags with loose whole kernel corn in the bottom of the bag unsealed without an open date. In the reach-in freezer the surveyor observed on 8/17/2015: a) At a temperature of 44 degrees, 13 cups of Ready Care Nutritional Treats. In the reach-in refrigerator, the surveyor observed on 8/17/2015: a) A large container half full of a soup type substance, undated and not labeled. b) Four individual size serving bowls covered, undated and not labeled. During the observation of the reach-in refrigerator, on 8/17/2015, EI #4 was asked how she would know if these items were good to be served to a resident. EI #4 replied she would use the sniff test. When EI #4 was asked what the sniff test was, EI #4 replied, I would smell it to see if it was still good. Observations made on 8/18/2015 of the walk-in freezer: a) All boxed items which had been opened on 8/17/2015 were now closed using a crisscross method. However, the boxes were still not sealed and the bags inside of the boxes were open. b) The reach-in freezer at 44 degrees had Ready Care Nutritional Treats, Mighty Shakes and milk in it. An interview was conducted on 8/19/2015 at 2:49 PM with EI #4 . EI #4 was asked who was responsible for dating food items when opened. EI #4 replied, Whoever opens it, they should know to put a date and label on it. EI #4 was asked should she use an open date and a use-by date when food was opened. EI #4 replied, If you open it up and don't use it all you put the use by date on it. EI #4 was asked should she use an open date and a use-by date on food opened. EI #4 replied, You should use both. EI #4 was asked should all opened food be placed in a sealed container if all the food was not used at one time. EI #4 replied, Yes, if you open it out of a can you want to put it in a sealed container, make sure it is dated and labeled. But if it is in a box you can reseal the box. EI #4 was asked if she had to date the box when it was opened. EI #4 replied, Yes ma'am. EI #4 was asked how would she seal the box. EI #4 replied, If there is a bag inside the box make sure you seal the bag and the box. EI #4 was asked if a large container of soup and bowls of soup in the refrigerator should be labeled, dated and why. EI #4 replied, Yes ma'am, because the next person using the soup would know if it is out of date. EI #4 was asked if an opened box of Western Beef Fritters, Mixed Vegetables, cinnamon rolls, bacon and sausage patties in the original box in a plastic bag be left opened, unsealed and undated. EI #4 replied, No ma'am. It should have been sealed and dated. An interview was conducted on 8/20 /2015 at 12:00 PM with EI #1. EI #1 was asked who was responsible for dating food when opened. EI #1 replied, Whoever puts into storage. EI #1 was asked what date should food product be dated. EI #1 replied, The date opened and dated to be used by. EI #1 was asked should staff use an open date and use-by date on food products. EI #1 replied, Yes. EI #1 was asked if not using a use by date how does staff know when to discard food product. EI #1 replied, If it was a leftover it would have to be labeled, they would not know. EI #1 was asked what was the facility's policy regarding dating opened foods. EI #1 replied, Our policy requires an open date and a discard date. EI #1 was asked if a large container of soup and bowls of soup were in the refrigerator should they be labeled, dated and why. EI #1 replied, Yes, so you can identify the use by date and content. EI #1 was asked if an opened box of Western Beef Fritters, Mixed Vegetables, Cinnamon Rolls, bacon and sausage patties in the original box in a plastic bag should be left opened, unsealed and undated in the refrigerator or freezer. EI #1 replied, All should be properly sealed, dated and labeled. This done to assure quality of the product and expiration of the product. 5) A review of a facility Policy and Procedure titled, Hand-washing Guidelines, with an Effective Date: February 1, 2002 revealed, 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. (in example), garbage, soiled utensils or equipment, dirty dishes, etc. FOOD CODE U.S. Public Health Service FDA 2013 A review of the Food Code revealed: 2-3 PERSONAL CLEANLINESS Subparts 2-301 Hands and Arms . Hands and Arms . 2-301.14 When to wash FOOD EMPLOYEES shall clean their hands . immediately before engaging in FOOD preparation including . and: . E) After handling soiled EQUIPMENT or UTENSILS; . I) After engaging in other activities that contaminate the hands. On 8/18/2015 at 11:00 AM, an observation was made of the following by the surveyor: a) A dietary worker picked up a package of eating utensils after they fell on the floor. The dietary work placed the packaged utensils on a clean shelf used for tray line serving. The dietary worker returned to packaging clean eating utensils without washing her hands. b) A dietary worker dropped a plate cover on the floor during the serving of the lunch time meal. The dietary worker picked up the plate cover and placed it on a clean surface. The dietary worker then returned to work covering food plates without washing her hands. c) A dietary worker dropped a plastic lid on the floor which was to be used to cover a soup bowl for the tray line. The dietary worker picked up the plastic lid from the floor and placed it on a clean table next to the microwave. The dietary work then obtained another lid, touching the inside of the lid, and place it on the soup bowl. The dietary worker did not wash her hands after picking up the plastic lid from the floor. On 8/19/15 at 2:40 PM, an interview was conducted with EI #4, Assistant Cook. EI #4 was asked what should occur if silverware or plastic lids were dropped on the floor or plate covers. EI #4 stated, Pick it up wash it and dry it, and wash their hands and put gloves on. EI #4 stated, Dropped lid (should) take to dish room, wash hands, (don) gloves and get on the line. EI #4 was asked what the worker that picked the item up should have done. EI #4 stated, Should have trashed it in (the) trash can, wash (their) hands, (don) gloves, and go back to line. On 8/19/15 at 3:49 PM, an interview was conducted with EI #5, Dietary Assistant. EI #5 was asked what should occur if silverware or plastic lids were dropped on the floor or plate covers were dropped. EI #5 stated, When dropped on the floor should go to where dirty dishes are, remove gloves, wash hands, and return to work. EI #5 was asked what should the worker do that picked items up from the floor. EI #5 stated, Should put lid in trash can, wash hands, and come back to work. On 8/19/15 at 4:45 PM, an interview was conducted with EI #6, Dietary Manager. EI #6 was asked what should occur if silverware or plastic lids were dropped on the floor, or plate covers. EI #6 stated, Silverware not appropriate, fell in floor, should have taken to dish room, changed gloves and washed hands. EI #6 also stated, Food covers should have (been) taken to dish room, washed hands, and changed gloves. EI #6 stated, Food bowl cover lid should have gone in (the) trash, wash hands, and change gloves. On 8/20/15 at 10:26 AM, an interview was conducted with EI #3, Assistant Cook. EI #3 was asked what should occur if silverware or plastic lids were dropped on the floor, or plate covers. EI #3 stated, No ma'am, take gloves off, wash hands, and (apply clean gloves). Silverware should go back to dish room. EI #3 was asked what the worker should do that picked the item up from the floor. EI #3 stated, No ma'am, give lid to someone to get it out of the way, wash hands and (don) gloves. On 8/20/15 at 12:00 PM, an interview was conducted with EI #1, Consultant Dietitian. EI #1 was asked what should occur if silverware or plastic lids were dropped on the floor, or plate covers. EI #1 stated, She should have washed her hands before returning to (the) task 6) A review of a facility document titled, DISH MACHINE TEMPERATURE LOG Form DS.V-26a. Month/Year dated August 2015 There were three columns stating, Record Temperatures, with a Legend: W (wash), R (rinse) S (sanitizer)* The columns were labeled Breakfast, Lunch, Dinner. On this form there were dates down the side representing the day of the month. Three columns under the headings of Breakfast, Lunch and Dinner. Each of these columns was labeled W, R, S. Each of these columns had entries for every day of t

Based on observations, interviews, and record reviews, the facility failed to ensure: 1) An LPN (Licensed Practical Nurse) did not administer insulin with her bare hands to RI (Resident Identifier) #11. 2) An LPN sanitized the top of the eye drop bottle after it a rolled off of a clean surface onto the bedside table for RI #18 3) The LPN did not use her contaminated gloved finger to mix medication with water prior to administering the medication through a Gastrostomy tube for RI #11. This affected RI #11 and RI #18, two of eighteen sampled residents in the facility. Findings include: 1) A review of Potter - Perry Fundamentals of Nursing, 7th Edition, Chapter 35, page 745, Skill 35-5 Administering Injections, revealed, STEPS For All Injections . 8. Take medication to client at right time, and perform hand hygiene. 13. Apply clean gloves. A review of RI #11's medical record revealed RI #11 was readmitted to the facility with [DIAGNOSES REDACTED]. On 8/18/15 at 10:55 AM, EI (Employee Identifier) #8 (LPN) was observed during medication pass for RI #11. EI #8 administered Insulin to RI #11 but failed to don gloves prior to administering the Insulin. On 8/20/15 at 9:15 AM, a phone interview was conducted with EI #8. The surveyor explained to EI #8 that she was observed preparing the insulin for administration for RI #11 and then administering the insulin without donning gloves. The surveyor asked EI #8 what the concern was for administering the insulin without donning gloves. EI #8 stated she guessed contamination. 2) A review of RI #18's medical record revealed RI #18 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of physician's orders [REDACTED]. On 8/18/15 at 12:55 PM, EI #15 (LPN) was observed during medication pass for RI #18. EI #15 removed the top of an eye drop bottle and placed the top on a paper towel on the bedside table. EI #15 administered the eye drop to RI #18, removed gloves and washed his hands. The top for the eye drop bottle rolled off of the paper towel onto the bedside table. EI #15 replaced the top on the eye drop bottle, but failed to sanitize the top prior to replacing it on the eye drop bottle. On 8/20/15 at 10:05 AM, an interview was conducted with EI #7 (Registered Nurse/Infection Control Nurse). EI #7 was asked what a Nurse should do when the top from an eye drop bottle rolled off of the clean surface. EI #7 stated, the Nurse should at least, at a minimum, wipe the top of the bottle with an alcohol wipe. The surveyor explained the observation to EI #7 of the Nurse replacing the top of the eye drop bottle after the top had rolled from the clean surface, a paper towel, onto the bedside table. The surveyor asked EI #7 what the concern was regarding this observation. EI #7 stated, if the top was contaminated and the Nurse placed the top on the bottle, the next time the eye drops were used the Nurse could potentially introduce bacteria to that resident. EI #7 was informed of the observation made of the Nurse administering Insulin without donning gloves. EI #7 stated, the Nurses should be wearing gloves during the administration of Insulin. EI #7 stated, the Nurses should not give an injection without wearing gloves. On 8/20/15 at 10:05 AM, an interview was conducted with EI #14 (DON - Director of Nursing). EI #14 was asked what the concern was when the top of the eye drop bottle rolled from the clean surface, a paper towel, onto the bedside table prior to placing it back onto the bottle. EI #14 stated the top should be cleaned. 3) A review of the medical record revealed that RI #11 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of an Annual MDS, with an ARD of 08/19/2015, revealed RI #11 had a (BIMS) Brief Interview for Mental Status score of four. This indicated RI #11 was severely impaired for daily decision making skills. RI #11 was coded as always being incontinent of bowel and bladder. On 8/18/2015 at 1:00 PM, an observation was made of a medication pass on RI #11. An LPN, EI #8, knocked and entered RI #11's room. EI #8 placed a medication cup with powdered medication in it on the bedside table. EI #8 donned gloves. EI #8 walked to the bathroom and opened the bathroom door with her right gloved hand, obtained a paper towel and then returned to RI #11's bedside. EI #8 checked gastrostomy tube for correct placement and residual. EI #8 poured water into the medication cup with the powdered medication in it, then held the cup with her right hand, placed her contaminated, gloved, index finger into the cup and stirred the medication and the water to dissolve the medication. EI #8 then administered the medication through RI #11's gastrostomy tube. On 8/20/2015 at 9:50 AM, an interview was conducted with EI #8, an LPN. EI #8 was asked when should gloves be changed during medication pass. EI #8 stated she had changed gloves when she went into RI #11's room. EI #8 was asked how a medication was dissolved prior to administering through a gastrostomy tube. EI #8 stated water was used and then stirred. EI #8 stated she had forgotten the stick to stir with and she had opened the bathroom door to get a towel. EI #8 was asked what the potential negative effect would be for a resident receiving a medication that was not mixed properly. EI #8 stated contamination and infection. On 8/20/2015 at 9:55 AM an interview was conducted with EI #7, RN (Registered Nurse)/Infection Control Nurse. EI #7 was asked when should gloves be changed during medication pass. EI #7 stated if anything was touched prior to touching a resident, hands should be washed and gloves changed. EI #7 was asked how a medication was dissolved prior to administration through a gastrostomy tube. EI #7 stated that water was put with the medication to dissolve or it can be stirred with a stick (obtained from the medication cart.) EI #7 was asked what the potential negative effect would be for a resident receiving medication that was not mixed properly. EI #7 stated introduce bacteria.

Based on observations, interviews, and record review, the facility failed to ensure RI (Resident Identifier) #6's wheelchair was kept in good repair. This had the potential to affect one of ten residents sampled with wheelchairs. A review of RI #6's current medical record revealed, RI #6 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a readmission Minimum Data Set with an Assessment Reference Date of 08/19/2015, indicated RI #6 was coded as severely impaired of vision. RI #6 had a BIMS (Brief Interview for Mental Status) score of 14 out of a possible 15, which indicated RI #6 was cognitively intact. RI #6 required extensive assistance with dressing, transferring, eating, toileting and hygiene. RI #6 ambulated per wheelchair and walker. On 8/18/2015 at 9:31 AM, RI #6 was observed sitting in the wheelchair. The arms of RI #6's wheelchair were worn. RI #6's wheelchair had areas worn on both arms of the wheelchair. The outer area of the left arm of the wheelchair had approximately a 4 inch area that was worn and on the right side there was approximately a 2 inch area on the outside of the arm that was worn. The surveyor noted a 6 inch area on the inside of the right arm that was worn. On 8/18/2015 at 11:13 AM, RI #6 was observed on the bedside commode. RI #6's wheelchair was observed with wear to the left and right arms of the wheelchair as observed earlier. On 8/19/2015 at 8:15 AM, RI #6 was observed up in the wheelchair. RI #6's wheelchair was observed with no changes. RI #6's wheelchair was observed with wear to the left and right arms of the wheelchair. On 8/19/2015 at 2:19 PM, an interview was conducted with EI (Employee Identifier) #9, a CNA (Certified Nursing Assistant). EI #9 was asked who was responsible for maintenance on medical equipment used by residents. EI #9 replied that EI #12 (Maintenance Director) was responsible. EI #9 was asked what was the potential for harm of not keeping up resident medical equipment. EI #9 responded, Wheels could fall off and the resident fall out. It could hurt a resident. EI #9 was asked if an observation had been made of RI #6's wheelchair. EI #9 stated, No. EI #9 was asked what was the potential harm to RI #6 with wear to the arms of the wheelchair. EI #9 said, It could cut (RI #6's) arms or skin tear. On 8/19/2015 at 2:28 PM, an interview was conducted with EI #10, a CNA. EI #10 was asked who was responsible for maintenance on medical equipment used by residents. EI #10 replied that EI #12 was responsible. EI #10 was asked what was the potential harm of not keeping up resident medical equipment. EI #10 responded, Brakes might be out and they might have problems safely transferring. EI #10 was asked if an observation had been made of RI #6's wheelchair. EI #10 stated, No ma'am. EI #10 was asked what was the potential harm to RI #6 with wear to the arms of (RI #6's) wheelchair. EI #10 said, Skin tears. On 8/19/2015 at 2:34 PM, an interview was conducted with EI #11, a Registered Nurse/Unit Manager. EI #11 was asked who was responsible for maintenance on medical equipment used by residents. EI #11 replied, I let them know but as replacement I would think that would be the rehabilitation nurse or EI #12. EI #11 was asked what was the potential harm of not keeping up resident medical equipment. EI #11 responded, Injury to the resident. EI #11 was asked if an observation had been made of RI #6's wheelchair. EI #11 stated, I have not. EI #11 was asked what was the potential harm to RI #6 with wear to the arms of the wheelchair. EI #11 said, Injury to (RI #6's) skin. On 8/19/2015 at 2:50 PM, an interview was conducted with EI #12. EI #12 was asked who was responsible for maintenance on medical equipment used by residents. EI #12 replied, Me. EI #12 was asked what was the potential harm of not keeping up resident medical equipment. EI #12 responded, Health risk. EI #12 was asked if an observation had been made of RI #6's wheelchair. EI #12 stated, No. EI #12 was asked what was the potential harm to RI #6 with wear to the arms of the wheelchair. EI #12 said,Skin tears.

Based on an observation, interviews, and record reviews, the facility failed to ensure: 1) A CNA (Certified Nursing Assistant) washed hands prior to providing incontinence care. The CNA multi-tasked with gloved hands prior to providing incontinence care. 2) A CNA changed the position of the wash cloth during incontinence care for RI (Resident Identifier) #2. 3) A CNA cleaned the back of RI #2's perineal area in a manner to prevent the potential for cross contamination during incontinence care. This affected RI #2, one of two residents observed for incontinence care. Findings include: A review of POTTER & PERRY. Fundamentals of Nursing.7th Edition, revealed: .page 655.Chapter 34 Infection Prevention and Control. The CDC (Center for Disease Control Prevention) (2002 b) recommends the following: . 2. If hands are not visibly soiled, use an alcohol-based waterless antiseptic agent for routinely decontaminating hands in all other clinical situations: . c. After contact with body fluids or excretions, mucous membranes, . d. When moving from a contaminated body site to a clean body site during client care. h. After removing gloves. A review of POTTER & PERRY. Fundamentals of Nursing.7th Edition.reprint 2009, revealed: .page- 878 and 879.39-2.Perineal Care. 3. Apply clean gloves, and assess genitalia for signs of inflammation, skin breakdown, or infection.Discard gloves. Perform hand hygiene. 11. If gloves are soiled, perform hand hygiene and then apply new pair of gloves. 15. Provide Perineal care. B. Male perineal care. (3) Gently raise penis, and place bath towel underneath. Gently grasp shaft of penis. If client is uncircumcised, retract foreskin . (4) Wash tip of penis at urethral meatus first. Using circular motion. Cleanse from meatus outward.Discard washcloth, and repeat with clean cloth until penis is clean. Rinse and dry gently. (5) Return foreskin to its natural position. (6) Wash shaft of penis with gentle but firm downward [MEDICAL CONDITION]. (7) Gently cleanse scrotum. 17. Remove clean gloves, dispose in proper receptacle, and perform hand hygiene. The facility's Policy entitled, Perineal Care, with the effective date of October 1, 2010 revealed: PURPOSE: Good perineal care helps prevent infection, irritation and skin breakdown. III. Male Resident a) Wash the penis from the urethra opening or tip of the penis and then wash the scrotum. Take care to wash, rinse, and dry between ant (the) skin folds. b) B) Turn resident onto side. Wash, rinse, and dry the anal area, moving upward toward the back. A review of the medical record revealed RI #2 was admitted on [DATE], with [DIAGNOSES REDACTED]. RI #2 was care planned for incontinent episodes of bowel and bladder. The most recent Quarterly MDS (Minimum Data Set) for RI #2, with an ARD (Assessment Reference Date) of 8/11/15, revealed RI #2 was severely impaired for daily decision making skills. This MDS also indicated RI #2 required extensive to total assistance with all of the ADLs (Activities of Daily Living.) RI #2 was coded as always incontinent of bowel and bladder. On 8/19/15 at 10:30 AM, an observation was made of incontinence care for RI #2. The incontinence care was performed by EI (Employee Identifier) #13, a CNA. EI #13 transferred RI #2 from the wheelchair and removed RI #2's pants and adult brief. EI #13 did not wash her hands or change her gloves prior to performing incontinence care for RI #2. EI #13 started incontinence and was observed to wipe across the top of the perineal area twice without changing the position of the disposable wipe. EI #13 wiped from front to back twice on the right side of the perineal area without changing the position of the disposable wipe. EI #13 wiped the top of the penis with a disposable wipe. EI #13 then wiped underneath the penis twice without changing the position of the wipe. EI #13 wiped the top of the penis then wiped down the shaft of the penis without changing the position of the disposable wipe. EI #13 wiped underneath the scrotum twice without changing the position of the disposable wipe. RI #2 was turned to the left side. EI #2 wiped the right buttocks from back to front twice without changing the position of the disposable wipe. EI #13 wiped the left buttocks from back to front changed position of the disposable wipe and wiped back to front. EI #13 cleaned the buttocks fold from back to front twice without changing the position of the disposable wipe. EI #13 cleaned the top of the buttocks twice without changing the position of the disposable wipe. On 8/19/15 at 2:45 PM, an interview was conducted with EI #13. EI #13 was asked when did she change gloves and wash her hands while providing incontinence care for RI #2. EI #13 stated when she had finished providing the peri-care. EI #13 was asked had she changed her gloves and washed her hands after handling the Broda chair and removing RI #2's pants. EI #13 stated, Yes. The surveyor then shared the observation made of the incontinence care for RI #2. EI #13 was asked what the concern was when gloves were not changed after handling the chair then performing incontinence care. EI #13 stated, Spreading germs. EI #13 was asked how she was taught to provide incontinence care for a male resident. EI #13 stated, I was taught to wipe the sides of the perineal area first. Wipe one side of the penis down then the other side down. Then clean the front side and then pull the top part (the head of the penis) down and clean it. Then clean the buttocks, wipe down on both sides. I then wipe the middle of the buttocks. The surveyor asked EI #13 how she cleaned RI #2 during the incontinence care observation. EI #13 stated she cleaned RI #2 as stated above. The surveyor asked EI #13 when did she change the position of the disposable wipe while cleaning RI #2. EI #13 stated, When I wiped and cleaned RI #2's penis. I did wipe a couple of times when I cleaned the back sides. The surveyor asked EI #13 what direction did she wipe while cleaning RI #2's bottom. EI #13 stated, Front to back. The surveyor asked EI #13 to demonstrate the direction she wiped during the above care. EI #13 demonstrated that she wiped back to front. EI #13 agreed with the observation of the incontinence for RI #2. The surveyor asked EI #13 what the concern was when a resident was cleaned without changing the position of the disposable wipe and the resident's bottom was cleaned from back to front. EI #13 stated, They are not cleaned the way they are supposed to be cleaned. On 8/20/15 at 10:05 AM, an interview was conducted with EI #7, the Infection Control Nurse. EI #7 was asked when staff members should wash their hands and change their gloves during incontinence care. EI #7 stated the staff should wash their hands upon entering the room, don gloves, and only touch the resident after gloves applied. The staff should then provide incontinence care and assist to adjust the resident's covers. EI #7 stated the staff should then wash their hands and change gloves before coming back to touch any linen or the resident. EI #7 was asked what the concern was regarding staff members handling equipment, for example a wheelchair, then transferring the resident, and then providing incontinence care without changing gloves or washing their hands. EI #7 stated if the staff came in contact with bacteria on any of those surfaces and then touched the resident they could (potentially) transfer the bacteria to the resident. EI #7 was asked how were staff members trained to provide incontinence care for a male resident. EI #7 stated staff were in-serviced quarterly, upon hire and intermittently. EI #7 further stated staff were trained to wipe front to back, with one wipe per disposable wipe. EI #7 was asked what the concern was when a resident was wiped twice without changing the position of the disposable wipe. EI #7 stated, moving bacteria from one area to the other.

Based on observations, interviews and record review, the facility failed to ensure Resident Identifier (RI) #6 was turned every one (1) hour as care planned. On 09/10/14, RI #6 was observed lying on the right side from 10:15 a.m. to 1:25 p.m. without being turned or repositioned by facility staff members. This affected RI #6, one (1) of 16 residents whose plan of care was reviewed. Findings Include: RI #6 was admitted to the facility on [DATE] and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #6's Actual Skin Breakdown care plan, with a problem onset date of 05/23/11, documented: "...Turn & (and) reposition per resident's individual turning schedule/Q (every) 1 HOUR ..." A Quarterly MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 08/28/14, identified RI #6 as scoring a 3 on the BIMS (Brief Interview for Mental Status) indicating severely impaired cognition. RI #6 was also assessed as being totally dependent on staff for bed mobility and incontinent of bowel and bladder. On 09/10/14 from 10:15 a.m. through 1:15 p.m., for a period of three hours, RI #6 was observed lying in bed on the right side with a wedge to the resident's left back. RI #6 was not turned or repositioned during these three hours. On 09/10/14 at 4:51 p.m., the surveyor conducted a phone interview with Employee Identifier (EI) #9, the CNA (Certified Nursing Assistant) assigned to care for RI #6 on the 7-3 shift on 09/10/14. The surveyor asked EI #9 how often RI #6 was care planned to be turned. EI #9 replied every hour. The surveyor asked EI #9 if RI #6 was turned every one hour on her shift. EI #9 said no. The surveyor asked EI #9 why RI #6 was not turned every one hour that morning on her shift. EI #9 replied she was trying to catch up with other things, but that was not an excuse. On 09/11/14 at 12:43 p.m., the surveyor conducted an interview with EI #8, the RN (Registered Nurse) Unit Manager on the unit RI #6 resides. The surveyor asked EI #8 how often RI #6 was care planned to be turned. EI #8 replied, "Every hour." The surveyor asked EI #8 why was RI #6 to be turned every one hour. EI #8 replied RI #6 had a decubitus on his body (coccyx) that the facility was trying to heal.

Based on interview and record review, the facility failed to ensure RI (Resident Identifier) #18 and RI #19's discharge summaries included a recapitulation (recap) of the residents' stay as well as a final summary of their status at the time of discharge. This affected two of three closed records reviewed. Findings include: RI #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #18's "Discharge Summary" (dated 08/06/14) included "DISCHARGE NOTES" which revealed: "Discharge home tomorrow with current meds (medications) and Clay County Home Care to eval (evaluate) and treat." The discharge summary did not include a recap of the resident's stay or a summary of the resident's status at the time of discharge. RI #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #19's "Discharge Summary" (dated 08/27/14) included "DISCHARGE NOTES" which revealed: "Discharge home today with current meds." The discharge summary did not include a recap of the resident's stay or a summary of the resident's status at the time of discharge. On 09/11/14 at 8:47 AM, the Director of Nursing, EI (Employee Identifier) #1, was asked who was responsible for making sure the discharge summary was completed for a resident who has a planned discharge. She said social services does the planning and makes sure the resident has everything they need, but the RN (Registered Nurse) Unit Manager is responsible for completing the discharge summary. On 09/11/14 at 12:40 PM, the RN Unit Manager (EI #6) was asked if she was the Unit Manager for RI #18 and RI #19. She replied, "Yes." EI #6 was asked if she completed their Discharge Summaries. EI #6 looked on her computer and said she completed RI #19's discharge summary, but RI #18's was not closed yet. EI #6 was asked if there was a recap of the residents' stay on the discharge summaries. She said what was on the discharge summary was all they had. EI #6 was asked who was responsible for making sure the discharge summaries were completed. She stated, "I am." EI #6 was asked why RI #18's was not completed. She said she did not realize it was not closed out. EI #6 was asked if she was aware that the regulations specify that the discharge summary must include the resident's status at time of discharge and a recap of the resident's stay. She responded, "No. I was not." On 09/11/14 at 1:12 PM, the Director of Nursing (EI #1) was asked if there was a facility policy or procedure regarding discharge summaries. She said there was not; they just fill out their form and send it. EI #1 was asked if she was aware that the discharge summary must include a recap of the resident's stay and their status at time of discharge. She said she did not know they were supposed to include that.

Based on observations, interviews and record review, the facility failed to ensure the oxygen (O2) humidifier water bottle was dated when the bottle was placed on Resident Identifier (RI) #9's oxygen concentrator and the resident's nasal cannula tubing was stored in a plastic bag when not in use. On three of three days of the survey the O2 humidifier water bottle was observed without a date on it and the nasal cannula tubing was not stored in a plastic bag. This affected RI #9, one (1) of four (4) sampled residents receiving oxygen therapy. Findings Included: A facility policy titled "Oxygen Administration", with an effective date of December 8, 2005, documented: "... PROCESS: ... 11. Cannulas and masks should be changed weekly ... 14. O2 cannuala (cannula)/mask should be stored in a plastic bag when not in use." RI #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Quarterly MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 09/02/14, identified RI #9 as scoring a 15 on the BIMS (Brief Interview for Mental Status) indicating no impaired cognition. RI #9's September 2014 Physician order [REDACTED]. "... O2 AT 2L (liters) VIA (by way of) NASAL CANNULA PRN (as needed) ..." On 09/09/14 at 3:55 p.m., RI #6 was observed sitting in a lounge chair in the resident's room. An O2 nasal cannula was observed hanging across the trapeze bar attached to the head of RI #9's bed. The nasal cannula was not stored in a plastic bag. The surveyor observed an oxygen concentrator located behind the resident's lounge chair. There was a humidifier water bottle on the concentrator and there was no date on the humidifier water bottle. On 09/10/14 at 8:50 a.m., RI #9's humidifier water bottle remained undated. The surveyor also observed the nasal cannula tubing lying across the trapeze bar. On 09/11/14 at 8:35 a.m., RI #9's humidifier water bottle remained on the 02 concentrator. The humidifier water bottle remained undated. RI #9's nasal cannula tubing was observed lying on the floor. The nasal cannula tubing was again observed without a plastic bag covering it. On 09/11/14 at 8:36 a.m., a staff member picked up the nasal cannula tubing and placed it on RI #9's bed. 09/11/14 at 12:35 p.m., the nasal cannula tubing remained on RI #9's bed. On 09/11/14 at 12:43 p.m., the surveyor conducted an interview with EI #8, the RN (Registered Nurse) Unit Manager on the unit RI #9 resides. The surveyor asked EI #8 how often were the humidifier water bottles on the concentrators changed. EI #8 replied they were changed as soon as they were used up or when they were observed to be low. The surveyor asked EI #8 what procedure the facility had in place to identify when a humidifier water bottle was first initiated. EI #8 said the humidifier water bottle should be dated when it is put on. EI #8 said RI #9 had asked for oxygen about a week ago, 09/02/14, because RI #9 said he was having trouble breathing at night. The surveyor asked EI #8 when O2 cannulas were changed. EI #8 replied, "The cannula is changed every week when the O2 bottle is changed." The surveyor asked EI #8 where O2 cannula's were kept. EI #8 said O2 cannulas were kept in a plastic bag when they are not in use. On 09/11/14 at 3:16 p.m., the surveyor conducted an interview with EI #1, the DON (Director of Nursing). The surveyor asked EI #1 what should the licensed nurse do when placing O2 (water humidifier bottles) or nasal cannula tubing on a concentrator. EI #1 replied, "It should have a date on it."

Based on observations, interviews and record review, the facility failed to ensure: 1) a Certified Nursing Assistant (CNA) changed her contaminated gloves before picking up a clean adult brief after providing incontinent care for Resident Identifier (RI) #6 on 09/10/14; and 2) a Licensed medication nurse washed or sanitized her hands between residents when administering medications on 09/10/14 during the morning Medication Pass Observation. This affected RI #6, one (1) of one (1) resident observed for incontinent care, and one (1) of four (4) nurses observed during the Medication Pass Observation. Findings Include: 1.) RI #6 was admitted to the facility on [DATE] and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Quarterly MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 08/28/14 identified RI #6 as scoring a 3 on the BIMS (Brief Interview for Mental Status) indicating severely impaired cognition. RI #6 was also assessed as being totally dependent on staff for bed mobility and incontinent of bowel and bladder. On 09/10/14 at 1:25 p.m., the surveyor observed Employee Identifier (EI) #7 (CNA), and two other CNA's (EI #10 and EI #11) provide incontinent care to RI #6. RI #6 was positioned to the left side by the CNA's. The surveyor asked EI #7 how she would describe the amount of urine on RI #6's adult incontinent brief. EI #7 replied it was a moderate amount. EI #11 handed EI #7 an adult washcloth and EI #7 wiped RI #6's inner buttocks twice using different areas on the washcloth. As the incontinent care continued, EI #7 wiped RI #6's right then left buttocks. EI #7 rolled the dirty adult brief beneath RI #6's left back then, with the contaminated gloves still on, picked up a clean adult brief and pushed the clean adult brief beneath RI #6. On 09/10/14 at 4:51 p.m., the surveyor conducted a phone interview with EI #7, the CNA assigned to care for RI #6 on the 7-3 shift on 09/10/14. The surveyor read the observation of the CNA's providing care to RI #6 on 09/10/14 at 1:25 p.m. The surveyor asked EI #7 what she should have done before picking up the clean adult brief after providing incontinent care to RI #6. EI #7 replied she should have changed her gloves. The surveyor asked EI #7 what were some of the problems that could occur when gloves are not changed when going from a dirty area to a clean area. EI #7 said infection control could occur. On 09/11/14 at 12:43 p.m., the surveyor conducted an interview with EI #8, the RN (Registered Nurse) Unit Manager on the unit RI #6 resides. The surveyor asked EI #8 when should CNA's change their gloves when providing incontinent care. EI #8 replied, "Anytime they need to especially when they are removing something dirty and touching something clean." The surveyor asked EI #8 what would going from dirty to clean be considered. EI #8 said contamination. On 09/11/14 at 3:16 p.m., the surveyor conducted an interview with EI #1, the DON (Director of Nursing). The surveyor asked EI #1 what she expected the CNA's to do with contaminated gloves before touching anything clean. EI #1 replied, "They should be changed if they are contaminated. They should be taken off." 2) A facility policy dated 03/11, titled "Medication Administration - General Guidelines" documented: " ... Procedures ... 6. Cleanse hands with soap and water before handling medication and before and after direct contact with resident ..." On 9/10/14 at 8:52 a.m., EI #2, an LPN (Licensed Practical Nurse) medication nurse was observed to punch out from a bubble/blister pack medications for RI #21. EI #2 had another LPN, EI #3 (an orientee) who was going through the facility's orientation process for medication pass observing EI #2. EI #2 entered RI #21's room, EI #2 gave RI #21 the cup of medications. EI #3 stood at the door while EI #2 administered the medications to RI #21 from a souffle' cup. RI #21 took her PO (by mouth) medications and EI #2 returned to the medication cart and signed the E MAR (Electronic Medication Administration Record). Then EI #2 proceeded to punch out medications for the next resident RI #22. EI #2 did not wash her hands nor did she use a hand sanitizer gel. At 9:05 a.m., the surveyor observed EI #2, LPN, pour the following medications in a souffle cup for RI #22 (which came from the physician's orders [REDACTED].? TAB (tablet) to EQUAL 0.125 MG, ASPIRIN EC ([MEDICATION NAME] coated) 81 MG one TABLET, [MEDICATION NAME] 12.5 MG TABLET, [MEDICATION NAME] SULFATE 325 MG one TABLET, CLARTIN 10 MG one TABLET, [MEDICATION NAME] 40 MG one TABLET, POTASSIUM CL (CHLORIDE) ER (EXTENDED RELEASE) 10 MEQ (milliequivalent) 1 CAPSULE GIVE, [MEDICATION NAME] 3 MG one CAPSULE, [MEDICATION NAME] ([MEDICATION NAME]) 0.5 MG one TAB, CALCIUM 600 + VIT (vitamin) D one TABLET, and [MEDICATION NAME] 15 MG one TABLET. EI #2 did not wash or sanitize her hands after administering medications to RI #21 and before administering medications to RI #22. After EI #2 administered medications to RI #22, EI #2 returned to the medical cart and sanitized her hands with alcohol gel and signed the E-MAR. On 9/10/14 at 11:55 a.m. during an interview with EI #2, the surveyor asked EI #2 how does she prevent cross-contamination between each resident. EI #2 said, use hand sanitizer and wash hands. The surveyor asked EI #2 if she washed her hands between the two residents. EI #2 said no. EI #2 said she used hand sanitizer. The surveyor shared with EI #2 he did not observe her wash her hands nor use a hand sanitizer between the residents. The surveyor showed EI #2 on the Medication Observation Form where it was documented "hands not washed between residents or sanitized with alcohol gel." EI #3 was also present and did not voice any concerns at this time related to EI #2's failure to wash her hand or sanitize her hands. On 9/10/14 at 5:25 p.m., the surveyor conducted an interview with EI #5, a Registered Nurse (RN), the Infection Control Nurse. The surveyor asked EI #5 what should the medication nurse do between giving medications to two residents and going from room to room. EI #5 said wash their hands. The surveyor asked EI #5 how do the medication nurses prevent cross-contamination during medication pass and what is this called. EI #6 said use hand sanitizer or wash their hands and this is called infection control. The surveyor asked EI #5 if it is alright if a nurse goes directly from one resident to another one after giving medications. EI #5 stated, "Not unless they sanitize their hands; never."

Based on observation, interview and record review the facility failed to ensure a Certified Nursing Assistant (CNA) did not pull Resident Identifier (RI) #13, backwards in her geri-chair at the 08/21/13 supper meal. The facility further failed to ensure RI #14 was served her lunch meal and fed at the same time as the other two residents at the table. This affected RI #13 and RI #14, 2 of 14 sampled residents for meal observations. Findings include: In the facility "Resident Handbook," dated June 1, 2008, page 7, documented: "...III. YOUR RIGHTS AS A RESIDENT ...The Facility strives to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect, in full recognition of his or her individuality. ..." 1. RI #13 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #13's Significant Change Minimum Data Set ((MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 2 out of 15. This indicated RI #13 was severely impaired in cognitive skills for daily decision making abilities. RI #13 was usually understood, but with difficulty communicating some words or finishing thoughts. RI #13 sometimes understood and could respond adequately to simple direct communication. RI #13 was totally dependent on staff for being transported on and off the unit in her geri-chair. On 08/21/13 at 4:50 PM, RI #13 was observed to be pulled backwards in her geri-chair from the dining room door, through the dining room and positioned at the table where she ate, by the CNA, Employee Identifier (EI) #2. On 08/21/13 at 5:05 PM, the CNA (EI #2) was asked why she pulled RI #13 in the dining room backwards. EI #2 replied the geri-chair would not always push easy and would veer off to the side. EI #2 was asked had she told anybody that the chair was hard to push. EI #2 she had not told anybody and did not know if anyone else had. EI #2 was asked why she had not reported the chair being hard to push. EI #2 replied she normally worked the first shift and did not see RI #13 at the supper meal. EI #2 further commented she did not ask anyone else about RI #13's chair. On 08/22/13 at 9:15 AM, EI #3, Licensed Practical Nurse/Staff Development, was asked how were CNAs trained to transport residents who are in wheelchairs/geri-chairs. EI #3 replied they would demonstrate how, such if there is a footrest to make sure the footrest was down and the resident's feet were on the footrest. We instruct to push forward and only if a resident is care planned can they be pulled backwards. EI #3 was asked if a resident's chair is not pushing forward properly what should be done. EI #3 replied the CNA should report it to the Charge Nurse so she could report it to maintenance. EI #3 was asked what would be the concern of a resident being pulled backwards. EI #3 replied the CNA would not be watching the resident. EI #3 was asked what would be the concern of a resident being pulled backwards because the chair was not pushing right. EI #3 replied, dignity. On 08/22/13 at 3:10 PM, EI #4, Maintenance Director, was asked who should report a geri-chair if it was not pushing forward correctly. EI #4 replied anyone who pushed the chair could fill out a maintenance slip and put it on the clipboard. EI #4 further commented he checked the clipboard daily. EI #4 was asked when a chair should be reported if it is not pushing correctly. EI #4 replied when it was first noticed. The facility policy titled, "Tray Distribution," dated February I, 2002, documented: "Purpose: To facilitate the rapid and accurate distribution of trays to residents ...." The Facility policy titled, "Feeding the Impaired Resident," dated October I, 2010, documented: "PURPOSE: Residents are assisted, as needed, to consume each meal so adequate nutrition is provided. STANDARD: Residents should eat in the location of their preference, and should be provided with a pleasant dining environment, regardless of the location ..." The Facility policy titled, "Tray Sequencing," dated February I, 2002, documented: "... PURPOSE: Tray sequencing may be used in a facility so that residents in similar settings are served at the same time. STANDARD: Residents eating at the same table should receive their trays at the same time... PROCESS: All residents at a dining room table should be served at the same time, before another table..." 2. On 08/21/13 at 11:55 AM, the following observation was made in the dining room at the lunch meal: Three residents were seated at a table, who required to be fed by staff. All other residents in the dining room had received their trays and were either feeding themselves or being fed by staff. The three residents were not served their trays; there were six CNAs feeding other residents. At 12 noon, one of these three residents began scooting backwards in her chair. At this time, a CNA came from feeding another resident, placed this resident's tray in front of her and pushed her back up to the table. The CNA then got one of the other residents' trays and placed it in front of her. This CNA then sat between those two residents and began to feed them. The third resident remained at the table without her tray, nor was she being fed while she watched the other residents eat their lunch. On 08/21/13 at 5:35 PM, RI #14 was observed in the dining room, seated at a table with two other residents who required to be fed by staff. The other two residents were served their trays. At 5:40 PM, the other two residents at the table with RI #14 were either eating or being fed. RI #14 did not receive her supper tray until 5:55 PM (15 minutes later). On 08/21/13 at 5:55 PM, RI #14 was asked did it bother her that she had to wait to be fed while the other residents at the table were being fed. RI #14 replied, sometimes. RI #14 was asked how that made her feel. RI #14 replied, like she was not important. RI #14 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #14's Annual Minimum Data Set ((MDS) dated [DATE] documented she was usually understood with some difficulty communicating but was able if prompted or given time. She usually understood missing some part of message but comprehended most conversation. RI #14 required extensive to total assistance from staff for all activities of daily living skills, and total dependence on staff for eating. A Care Plan for RI #14 with a "Problem Onset" date of 03/18/2009, documented: "Potential for weight loss ... with one approach listed as, "... Feed if necessary ..." On 08/22/13 at 3:30 PM, Employee Identifier (EI) #3, the Staff Development/ Licensed Practical Nurse, was asked what the CNAs were trained to do about tray sequencing. EI #3 replied everyone has to be eating or be fed at the same time.

Based on observation, interview and record review, the facility failed to ensure residents' everyday used wheelchairs, geri-chairs and wheelchair cushions, were free of dust, dirt, other debris; wheelchair arm rests were not torn and jagged; and a wheelchair cushion was not torn, exposing the inner foam. This affected Room Locators (RL) #s: 1-7. Findings include: According to the facility "3-11 Wheelchair/Geri-chair Cleaning Schedule," all wheelchairs and geri-chairs were to be cleaned once a week, on the 3-11 shift. During the initial tour on 08/20/13 at 3:25 PM, the following observations were made: Room Locators (RL) 1) RL #1- the wheelchair spokes, frame brake handle and foot rests had more than a day's build-up of dust, dirt and dried debris. 2) RL #2- the wheelchair brake handle had a build-up of a dried brown substance. 3) RL #3- inside the geri-chair seat area, each side had a build-up of dried debris. The plastic covering of the right arm rest was torn and jagged. 4) RL #4- the wheelchair spokes and frame had a build-up of dirt and dust; the seat pad was torn on one side, exposing the inner foam. 5) RL #5- the wheelchair spokes and frame had a build-up of dirt and dust; the sides of the wheelchair had a dried substance and the underneath of the seat pad had a dried substance. 6) RL #6- the right and left wheelchair arm rests were cracked and jagged, rough to the touch. 7) RL #7- the padding on the sides of the Broda chair, in the front, was jagged and torn. On 08/22/13 at 3:10 PM, Employee Identifier (EI) #5, Certified Nursing Assistant, CNA, was asked who was responsible to clean the residents' wheelchairs and geri-chairs. EI #5 replied it was scheduled for the 3-11 (second) shift. EI #5 further commented, they had a schedule but if the wheelchairs/geri-chairs needed to be cleaned they would clean them. EI #5 was asked if a resident eats their meals while seated in a wheelchair or geri-chair and spilt foods or liquids, what should the CNA do after each meal. EI #5 replied, check for food in the chair and under the seat pad.

Based on observation, record review and interviews with staff, the facility failed to turn and reposition Resident Identifier (RI) #10 every hour, as planned. This affected one of 12 sampled residents for whom care plans were reviewed. Findings included: RI #10 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. These wounds were described as Deep Tissue Injuries or pressure sores in the 04/23/13 "Ulcer Record." RI #10's care plan dated 04/23/13 (with a review date of 07/25/13) specified: "Turn & reposition per resident's individual turning schedule." On 08/21/13 at 10:17 AM and throughout the survey, a one hour turn schedule was posted on the wall beside RI #10's bed, designating the bed position of the resident each hour. The 04/24/13, 9:53 AM "Departmental Notes" designated RI #10 was to be "turned and repositioned per staff q (every) 1 hr (hour) and prn (as needed) for pressure relief." The Quarterly Review Minimum Data Set Assessment (MDS) with an Assessment Reference Date of 07/31/13, identified RI #10 as in need of extensive assistance (two staff) with bed mobility, and with Stage I or higher pressure sores, including five unstaged slough/eschar wounds. The MDS designated no venous and/or arterial ulcers were present. On 08/21/13 from 2:50 PM to 5:30 PM, survey staff continuously watched the room of RI #10. Over a period of 2 hours and 40 minutes, RI #10 was not repositioned in his bed. At 5:30 PM, two Certified Nursing Assistants (CNAs) entered the room and repositioned RI #10 from his right side onto his back, elevating the head of the bed to prepare him for the supper meal. On 08/21/13 at 4:30 PM, the Treatment Nurse (Employee Identifier/EI #6) was asked if RI #10 could move himself. EI #6 responded he could not move himself in the bed. On 08/21/13 at 5:30 PM, the CNA (Employee Identifier/EI #7) assigned to the care of RI #10 was asked why she had not checked on or turned the resident over the past several hours. EI #7 explained she had been busy. When asked what the potential was of not repositioning RI #10 as scheduled, EI #7 stated he could get worse. On 08/22/13 at 2:22 PM, the Registered Nurse Unit Manager (EI #7) was asked why RI #10 had been placed on a one hour turn schedule. EI #7 explained the resident had returned to the facility with multiple pressure sores on his feet and his bottom was red/excoriated. This approach was to help with healing, and was the facility's protocol. On 08/22/13 at 3:30 PM, the resident was scheduled to be positioned on his back in the bed. Instead, RI #10 was lying in his right side.

Based on observation, interview, and record review, the facility failed to ensure licensed staff cleaned the wounds of Resident Identifier (RI) #10 from inner to outer and did not use the same area of the 4 x (by) 4 to clean the wound more than once. This affected one of one wound care observation. Findings Include: The facility's advanced care policy and procedure for "Dressings - Clean," dated 01/15/10, included the following: "... Purpose To provide guidelines for the care of wounds and soiled dressings, to decrease the potential for nosocomial infection. Each wound site should be treated individually. ... Process: ... 11. Cleanse the wound as ordered; pick up moistened sponges and wipe the area, cleaning one wound at a time do not contaminate other skin surfaces, ..." RI #10 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. These wounds were described as deep tissue injuries (DTI) or pressure sores in the 04/23/13 "Ulcer Record." The Quarterly Review Minimum Data Set Assessment (MDS), with an Assessment Reference Date of 07/31/13, identified RI #10 as in need of extensive assistance from two staff with bed mobility and transfers, and totally dependent upon staff for eating, toileting and personal hygiene. The resident was coded as totally incontinent of bowel, but not rated for urinary continence due to the presence of a catheter. RI #10 was coded as having Stage I or higher pressure sores, including five unstaged slough/eschar wounds. The MDS designated no venous and/or arterial ulcers were present. The "Ulcer Record," dated 08/21/13, identified the presence of the following pressure sores (length by width by depth in centimeters/cm): Mid left inner foot: Slough, 2.0 x 1.8 Left inner foot: Slough, 2.2 x 2.5 x 0.2 Left outer heel: Eschar, 2.0 x 2.7 Right inner heel: Slough, 1.5 x 2.0 x 0.4 Right outer heel: Slough, 1.8 x 3.0 x 0.2 Tip of right great toe: deep tissue injury, 0.4 x 0.4 On 8/21/13 at 11:10 AM, the following was observed during wound care to RI #10: Employee Identifier (EI) #6 (Licensed Practical Nurse/LPN and Treatment Nurse) obtained separate 4x4 gauze pads to clean the wounds of RI #10's left lateral foot, right heel, right inner foot, and left inner foot. EI #6 cleaned each wound bed inner to outer and then from side to side without changing the position of the 4x4 gauze. The nurse cleaned each of the four wounds using each 4x4 gauze in the same manner, without changing position of the 4x4. On 8/21/13 at 12:07 PM, the surveyor asked the nurse in which direction should a wound be cleaned. EI #6 said inner to outer. EI #11 (the LPN assisting EI #6) was asked if this was what EI #6 did. EI #11 said EI #6 did not clean from inner to outer, but instead wiped out to in. The surveyor asked EI #6 how many times should the same area of the 4x4 be used. EI #6 said one. When asked if she remembered cleaning the wound from inner to outer and then back into the wound without changing position of the 4x4, EI #6 said yes, she did. EI #6 was asked what was the potential for harm. EI #6 said causing infection by spreading germs.