Every finding on record at Madison Health and Rehabilitation Center

Based on observations and interviews, the facility failed to maintain the laundry room area in a clean and sanitary [NAME] and failed to maintain laundry equipment in proper working condition. The findings include: A tour of the laundry room was conducted with Staff J, a Laundry Services Aide, on 08/15/24 at 8:35 AM. Upon entering the laundry room, the surveyor observed 2 washing machines and 2 dryers present in the same room. When asked if all the machines were working properly, Staff J stated the first washing machine had been leaking for a while and they had to use a garbage can to catch the water leaking from the door of the machine. The surveyor observed a piece of fabric wrapped around a plastic pipe which went from the side of the washing machine to the door of the washing machine. Further observation revealed water was leaking from this pipe and down the door of the machine despite the machine not being turned on. Closer observation revealed there was no floor drain in the room, which could result in a slipping hazard for the staff. Staff J stated the water would fill the whole floor of the room if the garbage can was not present to catch it. She further stated they had to empty the garbage can multiple times per day as it would fill up with water from the machine. When asked to clarify how long this washing machine had been leaking, Staff J stated it had been 6 to 8 months. She further stated the facility was aware of this issue but that she had been told that parts were not available to fix this washing machine because of its age. Continued observation revealed both washing machines had buckets located behind them which contained numerous foreign objects, including coins, pens, straws, lint, gloves, bandages, and other unidentified matter. When asked how often these buckets are cleaned out, Staff J stated she did not know. Further observation in the laundry room revealed a large number of uncovered pillows which were stacked on a counter next to the washing machines and adjacent to the handwashing sink. This could result in contamination to the pillows from the washing machines or the sink. When asked why these pillows were in the laundry room, Staff J stated the pillows used to be kept in the resident's rooms, but the previous laundry manager told the staff the pillows had to be kept in the laundry room in plastic bags to keep them clean for resident use. The surveyor also observed linens stacked on a shelf next to the handwashing sink which were uncovered. This could result in contamination to the linens from the sink. Two cardboard boxes were located under the sink which could be a tripping hazard for the staff. In the clean linen area, the surveyor observed there were clear shower curtain liners being used to cover the linens on the shelves. There was one area of the shelving which was uncovered. The surveyor observed there were mop heads being stored above the uncovered clean linen area. Staff J told the surveyor that the shower curtain liners often became ripped by the staff or fell off because they were only held on by tape and that they had to be replaced often. An interview was conducted with the facility's Administrator on 08/15/24 at 9:00 AM. The administrator stated he was aware that the washing machines were leaking. He stated he was aware that the staff was using a garbage can to collect the water from the washing machine. When asked why the washing machine was not fixed for 6 to 8 months, he stated he would call to his supplier to see if parts were available. The surveyor explained the concern was that the facility was aware that the machine leaking caused a hazard to the staff and that nothing was done until the surveyor intervened.

Based on observations, interviews, record review, and facility policy review, the facility failed to implement a care plan for 1 of 1 resident reviewed for respiratory care. (Resident #7) The findings include: On 8/13/24, an observation of Resident #7 revealed oxygen equipment next to her bed including an oxygen concentrator, an undated nasal cannula, and a humidifier. On 8/13/24 at 1:18 PM, an interview was conducted with Resident #7. She revealed using oxygen at night. She further stated staff would assist her with donning and doffing the nasal cannula every day. A review of Resident #7's medical record was conducted. The resident was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD). A review of all current and active physician's orders did not include oxygen. A review of the resident's Treatment Administration Record (TAR) revealed no documentation for oxygen care and services. A review of the care plan revealed an intervention that included oxygen settings: oxygen via nasal cannula per physician's orders. On 8/15/24 at 10:42 AM, an interview was conducted with Staff B, a Certified Nurse Assistant (CNA). He stated he had been assisting Resident #7 doffing nasal cannula every morning. On 8/15/24 at 10:46 AM, an interview was conducted with Staff D, a Licensed Practical Nurse (LPN) and Minimal Data Set (MDS) coordinator. She reviewed Resident #7's care plan and stated the resident should have a physician's order for oxygen and confirms the care plan had not been implemented. She further stated she probably went to the hospital and when she came back they missed the oxygen orders. A review of facility policy Nursing: oxygen administration was conducted. The policy stated the purpose of this procedure was to provide guidelines for oxygen administration. Bullet 9 stated turn on the oxygen. Start the flow of oxygen at the prescribed rate. A review of facility policy Person Centered care planning was conducted. Policy stated: When admitted , each resident will have physician orders, dietary needs, medications, treatments, and preliminary discharge plans reviewed by the IDT and will have an interim care plan developed within 24 hours of admission, along with input from the resident and/or representative. Resident assessments are initiated on the first day of admission and completed no later than the 14th day after admission. A comprehensive care plan is completed within 7 days of completing the resident assessment. Daily review of the preceding day's physician orders is one was to continually be aware of any changes in a resident's condition. Care plans are reviewed, at a minimum, quarterly.

Based on observation, interview and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment for 6 of 43 residents observed (Residents #14, #23, #32, #33, #35 and #37). The findings include: On 1/19/2021 during the initial tour of the B Hall, the following observations were made: At 11:40 AM, Resident #33 was observed receiving oxygen via nasal cannula. Observation of the oxygen concentrator revealed the vent grate was covered with a thick layer of dust. Further observation revealed a hole in the wall behind the bed which was approximately the size of a softball as well as a bed remote control that was visibly soiled. Observation of the roommate, Resident #35, revealed her oxygen concentrator was running while the oxygen tubing was laying on the floor. The oxygen concentrator's vent grate was covered with a thick layer of dust. (Photographic evidence obtained) At 12:48 PM, Resident #14's bed remote control was observed to be visibly soiled. Further observation revealed that the roommate's (Resident #32) call light was also visibly soiled. (Photographic evidence obtained) At 2:44 PM, Resident #23 was observed receiving oxygen via nasal cannula. Further observation revealed the oxygen concentrator's vent grate was covered with a thick layer of dust. (Photographic evidence obtained) On 1/19/2021 at 12:40 PM, an interview was conducted with Staff D, a Licensed Practical Nurse (LPN). The surveyor asked who's responsible for the maintenance of oxygen concentrators. She stated that it's typically the company who leases the equipment, but sometimes if there's an issue with a machine, they may take a look at the filter to see if that might be the source of the problem. She further stated that she'd have to ask if there's a cleaning or maintenance schedule. On 1/20/2021, the second day of survey, the oxygen supply company was observed in the facility. On 1/21/2021 at approximately 3:30 PM, a follow-up observation was made of Residents #14, #23, #32, #33 and #35. The medical equipment and environment for each resident remained in the same condition as 1/19/2021. On 1/21/2021 at 3:38 PM, the surveyor asked the facility's Risk Manager for a list of rooms serviced by the oxygen company on 1/20/21. On 1/21/2021 at 4:39 PM, a joint tour of the B Hall was conducted with the Nursing Home Administrator (NHA) and Housekeeping Manager. The NHA and Housekeeping Manager confirmed that Residents' #33 and #35 oxygen concentrator vent grates were dusty. The NHA and Housekeeping Manager confirmed the Resident #23's oxygen concentrator vent grate was dusty. The NHA wiped her index finger along the grate which left behind a visible streak of dust on her finger. The NHA and Housekeeping Manager confirmed the soiled condition of Resident #14's bed remote control and Resident #32's call light. At the end of the tour the surveyor informed them that the items observed had been in that condition since survey entrance two days earlier. On 1/21/2021 at 4:50 PM, an interview was conducted with the NHA. The surveyor asked what services the oxygen supply company had provided on 1/20/21 to the resident's oxygen concentrators. She replied that she believed they used a calibrator to check the oxygen concentration. On 1/21/2021 at 4:52 PM, an interview was conducted with the Housekeeping Manager. The surveyor asked if his staff clean resident equipment such as intravenous poles, wheelchairs, walkers, oxygen concentrators, etc. He stated that his staff wipe down wheelchairs and walkers, but not oxygen tanks/concentrators. On 1/21/2021 a record review of the facility's policy titled Environmental/Maintenance Service-Oxygen Concentrator Safety Checks effective May 2017 revealed that the facility shall conduct and document quarterly and annual Safety Checks on all Oxygen Concentrators being used. Procedure - Quarterly Maintenance & Cleaning: 1. Unplug the device before performing any cleaning. 2. Remove oxygen tubing, cannula, and humidifier bottle and discard. 3. Wipe, using a damp cloth, or replace the humidifier tubing, if used. 4. Wipe, using a damp cloth, or replace the cabinet air filter. 5. Clean the concentrator cabinet. 6. Check the oxygen concentration and flow. If the unit performs within manufacturer's specification, the filter does not need to be replaced. Routine/Annual Safety Checks 1. Check oxygen concentration with calibrated oxygen analyzer to verify concentration is greater than 87%. 2. Verify audible alarm and indicator lights. 3. Inspect filters and replace as necessary. On 1/21/2021 a record review of the facility's policy titled Cleaning and Disinfection Residents' Rooms revised August 2013 revealed the purpose of this procedure is to provide guidelines for cleaning and disinfecting residents' rooms. Further review revealed general guidelines which included: 1. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. 2. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled. On 1/21/2021 a record review of the facility's policy titled Environmental Services - Safe Environment effective February 2018 revealed the facility will provide a safe, clean, comfortable and homelike environment. Review of the procedure revealed under section 1(e.) Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. On 1/20/2021 at 12:35 PM, an observation was made of wound care on Resident #37. While in the room observing wound care, an additional observation was made of black biological growth on the ceiling tiles above the closet door. On 1/20/2021 at 1:30 PM, an interview was conducted with the NHA. The surveyor reported the finding of black biological growth on the ceiling tiles in Resident #37's room to the NHA. She stated that some roofers had done some work over on the C Hall recently, but she wasn't aware of any issues in Resident #37's room.

Based on observations and interview the facility failed to maintain kitchen equipment in a clean manner related to the area around the dishwashing machine and the tables used for air drying dishware and trays. The findings include: On January 20, 2021 at 1:00 PM, a tour of the dishwashing room in the kitchen was conducted with the Certified Dietary Manager (CMD). The ceiling above the room was noted to have rust-like debris and flaking ceiling tiles. The adjacent ceramic tile wall was also observed to have dark dust-like debris on the majority of the surface and a table below the wall noted to contain clean dishware and trays drying. (Photographic evidence obtained) On January 20. 2021 at 1:30 PM, the dishwasher area was again visited with the facility Administrator. She stated the kitchen had recently been painted but they must have missed this room.

Based on observation, record review and interview, the facility failed to maintain an infection prevention and control program by failing to put into place identified measures to prevent the transmission of Carbapenem Resistant [MEDICATION NAME] (CRE). Findings include: On 5/28/19 at approximately 11:00 AM, an observation was made of room [ROOM NUMBER] in which a plastic three drawer bin was noted sitting outside the room and a staff member was observed sitting in a chair in the doorway. At this time the Unit Manager was asked why the staff member was sitting outside the resident room he replied that the resident was on isolation for CRE and needed one on one (1:1) care as she had a history of [REDACTED]. On 5/29/19 a review of the Infection Control QAPI (Quality Assurance Performance Improvement) Report for (MONTH) 2019 was conducted which revealed that the facility had 6 residents on contact isolation for CRE, which had increased from 4 residents in (MONTH) of 2019. CRE is a nosocomial invasive infection that is highly resistant to many antibiotics and has been associated with mortality rates as high as 50% in long term care facilities. On 5/29/19 at approximately 3:22 PM, an interview was conducted with the Director of Nursing (DON) in which she stated that the facility was currently working with the Center for Disease Control (CDC), Florida Department of Health (DOH) and the Madison County Health Department (MCHD) in an effort to contain a CRE infection first identified on (MONTH) 2, 2019 in resident #55. She stated that despite their efforts CRE has been identified in 8 residents in the facility (#55, 52, 25, 48, 6, 34, 13, 54). She further stated that resident #55 had been in the hospital in (MONTH) and after she was discharged the hospital sent a result of a urine culture which identified [DIAGNOSES REDACTED] pneumonia Carbapenemase (KPC), a form of CRE, however it also identified E-coli in the resident's urine therefore the facility treated the e-coli as it was more prevalent. She stated the facility was not aware of the importance or the grave nature of the KPC/CRE until it was identified as a concern on the lab result received from the facility's lab on (MONTH) 5, 2019. The DON notified the MCHD on 3/5/19, the day the result was received. She stated that after speaking with the local MCHD she was referred to the CDC and DOH. As a result of the CRE infections the facility has offered re-education to staff on hand hygiene, Personal Protection Equipment (PPE) use and disinfection of rooms. She further stated that the in-services were not mandatory and that not all of Physical Therapy (PT) had not been included in the in-services. She stated that the Director of PT had attended one of the in-services and that the Risk Manager had reviewed the requirements with other PT staff separately. She also stated that the Director of House-keeping had provided in-services to the housekeeping staff. She further stated that the residents who have tested positive were placed on contact isolation but despite these efforts the CRE had been identified in additional residents. When asked how the infections were being tracked she stated that she keeps a record in the infection control binder of residents who are currently on antibiotics which also identifies who is on isolation. She stated that she tracks the infections by hall and not by room number as the facility is so small she is able to remember which rooms the residents were assigned to. She further stated the residents who had tested positive were cohorted together which required some room changes but was unable to identify which rooms the resident were transferred from. The DON then provided this surveyor with a copy of a letter from the Epidemiologist from the Florida Department of Health dated (MONTH) 29, 2019, which included findings and recommendations from an Infection Control and Response (ICAR) Assessment conducted in the facility on (MONTH) 26, 2019. The ICAR identified gaps in the facilities current infection control policies and made the following recommendations; train all staff on proper hand hygiene practices for standard and precaution rooms, donning and doffing of PPE; replace the furniture polish Shine-Up with an EPA (Environmental Protection Agency) registered disinfectant: provide disposable toilet brushes to be used in the isolation rooms or assign one toilet brush to only be used in each isolation room; and train EVS (Environmental services staff) staff on contact times for all products. On 5/29/19 at approximately 4:00 PM, an interview was conducted with the RM in which she stated she did not have formal in-services with the PT staff on infection control, however she would approach the staff as she saw them in the hallway. She stated she could not identify which PT staff she had spoken with nor was the education documented. On 05/30/19 at approximately 12:14 PM, an interview was conducted with staff member A, a housekeeper during which she stated that she uses Shine Up lemon furniture polishes on furniture, dresser tops, tray tables and the lamp light. She further stated that when there is a room that has isolation precautions she uses the bleach wipes on bed rails, door knobs, sinks, commodes and she uses the polish only on tray tables and bedside tables. She stated that she uses one toilet brush in all rooms, even isolation rooms but keeps it in a disinfection solution on her cart. She then pulled a white plastic container from her cleaning cart that housed a single toilet brush soaking in a hazy light colored solution. She also showed the surveyor the cleaning products she used in the rooms that included the furniture polish. Photographic evidence obtained.

Based on record review and staff interview the facility failed to adequately monitor vital signs and appropriately administer scheduled hypertensive medications for 1 of 5 sampled residents reviewed for unnecessary medications. (Resident #23) The findings include: Review of resident #23's clinical record revealed a pertinent [DIAGNOSES REDACTED]. Review of the Vital Sign Flow Sheets for March-May 2019 revealed the facility failed to monitor and document vital signs for resident #23 on 19 occasions during that timeframe: 3/3, 3/5, 3/18, 3/19, 3/20, 3/22, 3/23, 3/24, 3/26, 3/27, 4/14, 4/18, 4/22, 5/1, 5/7, 5/8, 5/11, 5/22, and 5/29. Review of the March-May 2019 Medication Administration Records (MAR) revealed that the medication was administered 31 of 31 days in March, 30 of 30 days in April, and 30 of 30 days in (MONTH) as of 5/30/19. Further review of resident #23's physician's orders [REDACTED]. Review of the Vital Sign Flow Sheet for (MONTH) revealed the resident had a BP less than 100 on 5/13 and 5/25. A review of the MAR for (MONTH) 2019 revealed the medication was administered on both days when it should've been held due to vital signs being outside of the physician ordered parameters. Review of the Vital Sign Flow Sheet for (MONTH) revealed the resident had a pulse less than 60 on 4/19 and 4/20. A review of the MAR for (MONTH) revealed the medication was administered on both of those occasions as well. An interview was conducted with the Director of Nursing (DON) on 5/30/19 at 2:57 PM. The DON confirmed that the Vital Sign Flow Sheet is where the vital signs are supposed to be recorded and that vital signs were missing for those 19 days from March-May. She also confirmed that the two days in (MONTH) and two days in (MONTH) that the medication should have been held based on parameters.

Based on record review and interview, the facility failed to provide information and education regarding the benefits and potential side effects of the influenza vaccine prior to the administration of the influenza vaccine. Findings include: On 5/30/19 Influenza Immunization Informed Consent forms were reviewed for resident's #5, 45 and 27 which revealed the residents had not been provided education on the influenza vaccine for the (YEAR)-2019 season. On 05/30/19 at approximately 03:12 PM, an interview with the Unit Manager in which he stated that education is provided on the flu and pneumococcal vaccine on admission when consents are obtained. He stated that if the resident refuses the vaccine at the annual administration time they are given education however they are not offered re-education annual if they receive it. A review of the facility policy Influenza Vaccine revealed the following Prior to the vaccination, the resident (or resident's legal representative) or employee will be provided information and education regarding the benefits and potential side effects of the influenza vaccine.

Based on observation, interview and record review the facility nurse failed to maintain clean technique when providing wound care for 1 of 2 residents observed for pressure injury care (#66). The findings are: Wound care was observed for resident #66 on 5/17/2017 at 10:30 AM being performed by Licensed Practical Nurse (LPN) A. The nurse was observed to gather supplies for the wound treatment using her ungloved hands. She reached into the medication cart and removed the dressing needed for the wound. After obtaining the dressing, she handled the wound treatment book on the cart. She then proceeded to pick up the scissors off the cart and cut the silver alginate dressing that was intended to go into the wound with her ungloved hands, and placed it on the back of an incontinence pad. She then transported the dressing into the resident's room with her ungloved hands and placed it on a barrier she had established for supplies. The nurse donned gloves and removed the old dressing. She then changed her gloves, and cleansed the wound as ordered. As she was about to place the contaminated silver alginate dressing in the wound, the surveyor requested she stop. An interview was immediately conducted with LPN A, and she confirmed she had contaminated the silver alginate that was intended to be placed into the resident's wound. Review of facility staff training showed that LPN A had received prior training on the appropriate procedure for wound care, and had been required to return demonstration of the skill with successful completion An interview was conducted with the Corporate Nursing Consult on 5/18/2017 at approximately 10:00 AM. She stated there was a wound care manual that indicated how dressing changes and treatments should be performed located on each nursing station for use at any time by staff.

Based on record review and interview the facility failed to ensure that physician ordered cultures were completed for 1 of 1 resident sampled for pressure injury (resident #66). The findings are: Review of the medical record for resident #66 revealed a physician's orders [REDACTED]. Review of the facility laboratory log book showed a faxed receipt indicating the culture had been sent to the laboratory for processing on 05/06/2017, but there was no documentation on the lab tracking form to indicate that the facility had ever received the results of the ordered culture. An interview was conducted with the Director of Nursing (DON) on 05/16/2017 at 2:15pm. She stated that she remembered the culture being sent out, and that normally culture results are obtained within 3 days, but she could find no documentation of results in the medical record or lab tracking book. The DON then called the laboratory, where the specimen had been sent, but the culture nor the results could be located by laboratory personnel.

Based on observation, interview, and record review, the facility failed to ensure an effective infection control program related to the necessary care and treatment of [REDACTED].#66). Findings include: According to documentation in the medical record of resident #66, he was admitted to the facility from the hospital on [DATE] with a documented stage 3 pressure injury (PI) to his coccyx. Measurements taken of the PI by facility staff on 3/13/17 showed the area to be 6 centimeters (cm) x 2 cm x 1 cm. Review of the physician orders [REDACTED].#66 antibiotic [MEDICATION NAME] 20mg twice daily for 10 days, to culture the coccyx wound, and to increase the resident's dressing changes to twice daily due to infection. On 5/12/2017 there was an additional order written to include the addition of antibiotic [MEDICATION NAME] 500 milligrams (mg) to the wound bed with a silver alginate pad. (According to Medscape, [MEDICATION NAME] is a broad spectrum antibiotic used to treat multiple infections including sepsis and skin and soft tissue infections. Traditionally, [MEDICATION NAME] is used to manage chronic non-surgical wound odors.) Continued review of the resident's medical record showed no results from the physician's orders [REDACTED]. An interview was conducted with the Director of Nursing (DON) on 5/16/2017 at 2:15pm. She stated she remembered the culture being obtained by the staff and being sent to the lab. She stated the facility usually gets the results back within 3 days. She confirmed she could find no results of the culture within the resident's medical record. The DON further stated a log book is kept of all labs sent out of the facility. The log book was reviewed and revealed on 5/6/2017, the culture was obtained and sent to lab, but the culture was never followed up on by the nursing staff for a result. The DON called the lab; however, they were also unable to find any results for the culture. A subsequent interview was conducted with the Director of Nursing (DON) who was the person responsible for overseeing the infection control program within the facility on 5/17/2017 at 8:18 AM. She stated whenever a resident had an infection, the ordering nurse on the unit should fill out an infection control worksheet. Review of the worksheet showed that it captured resident demographics including the name of the resident, date of symptom onset, [DIAGNOSES REDACTED]. She confirmed that the worksheet itself was not kept in the resident chart, but instead in a binder in her office. She stated that she did not keep track of the labs that were ordered, but did confirm that the facility kept a laboratory (lab) log book that captured what was obtained, including sputum, blood, and wound cultures. She stated that once the labs returned with a positive finding of infection, that is when it would have been captured by the infection control program. She decribed the lab process, stating: the process is to write on the lab log the resident name and the test that was ordered. The lab tech (technician) comes in during the early morning hours to collect the listed labs, and they sign off on the log what was collected. She stated that once they obtained the results of the test, the unit manager was to sign the log indicating the results were received. She clarified that when the unit manager received the results, they were also to look at the antibiotic, if any, the resident was currently taking, and then contact the physician to either get a new antibiotic order or to let the physician know the antibiotics the resident was on were appropriate.

Based on observation, interview, and record review the facility failed to provide proper wound care, and obtain results of ordered labs to promote healing of a pressure injury for 1 of 2 residents observed for pressure injury care (resident #66) Findings include: According to documentation in the medical record of resident #66, he was admitted to the facility from the hospital on [DATE] with a documented stage 3 pressure injury (PI) to his coccyx. Measurements taken of the PI by facility staff on 3/13/17 showed the area to be 6 centimeters (cm) x 2 cm x 1 cm. Review of the physician orders [REDACTED]. On 5/5/2017 there was a subsequent order to give resident #66 antibiotic [MEDICATION NAME] 20mg twice daily for 10 days, to culture the coccyx wound, and to increase the resident's dressing changes to twice daily due to infection. On 5/12/2017 there was an additional order written to include the addition of antibiotic [MEDICATION NAME] 500 milligrams (mg) to the wound bed with a silver alginate pad. (According to Medscape, [MEDICATION NAME] is a broad spectrum antibiotic used to treat multiple infections [MEDICAL CONDITION] and skin and soft tissue infections. Traditionally, [MEDICATION NAME] is used to manage chronic non-surgical wound odors.) Continued review of the resident's medical record showed no results from the physician's orders [REDACTED]. An interview was conducted with the Director of Nursing (DON) on 5/16/2017 at 2:15pm. She stated she remembered the culture being obtained by the staff and being sent to the lab. She stated the facility usually gets the results back within 3 days. She confirmed she could find no results of the culture within the resident's medical record. The DON further stated a log book is kept of all labs sent out of the facility. The log book was reviewed and revealed on 5/6/2017, the culture was obtained and sent to lab, but the culture was never followed up on by the nursing staff for a result. The DON called the lab; however, they were also unable to find any results for the culture. Wound care was observed for resident #66 on 5/17/2017 at 10:30 AM being performed by Licensed Practical Nurse (LPN) A. The nurse was observed to gather supplies for the wound treatment using her ungloved hands. She reached into the medication cart and removed the dressing needed for the wound. After obtaining the dressing, she handled the wound treatment book on the cart. She then proceeded to pick up the scissors off the cart and cut the silver alginate dressing that was intended to go into the wound with her ungloved hands, and placed it on the back of an incontinence pad. She then transported the dressing into the resident's room with her ungloved hands and placed it on a barrier she had established for supplies. The nurse donned gloves and removed the old dressing. She then changed her gloves, and cleansed the wound as ordered. As she was about to place the contaminated silver alginate dressing in the wound, the surveyor requested she stop. An interview was immediately conducted with LPN A, and she confirmed she had contaminated the silver alginate that was intended to be placed into the resident's wound.

Based on observation, staff interview and review of policy and procedure the facility failed to handle, clean and store dishes in a sanitary manner. The findings are: On 4/2/15 at approximately 8:45am, staff member A was cleaning dirty dishes and was observed wearing gloves. She placed the dirty dishes in the dish washer and without changing gloves she removed the clean dishes from the dish washer. This process occurred a total of three times. While wearing the same gloves she started removing the clean dishes and placing them on the clean trays for storage. On 4/2/15 at approximately 9:00am an interview was conducted with the staff member "A" who stated that she had not changed her gloves since she came in and started washing dishes. When asked, she stated that she was not aware that she should change gloves after handling dirty dishes and before handling clean dishes. An interview with the Dietary Manager on 4/2/15 at 9:05am revealed that the proper procedure was for the employee to wash their hands and change their gloves when moving from the handling of dirty dishes to clean dishes. A review of the policy for hand washing dated 2008 revealed that the employees should wash their hands following occurrences where they are touching un-sanitized equipment, work surfaces or wash cloths.

Based on observation, staff interview, and review of the facility's policy and procedure the facility failed to ensure the proper handling of linen in a manner that prevents the spread of infection during observation of incontinent care for 1 of 3 residents with a catheter (#45). The findings are: On 4/1/15 at 2:10pm an observation of staff providing incontinent care to resident #45 was conducted. Employee "B" began the procedure by placing two clean wash cloths into a basin of clean water. She then extracted on of the wash cloths and used it to clean the perineal area of the resident. When she finished cleaning, employee "B" was observed to place the visibly soiled cloth back into the basin of clean water where the other clean cloth was. She then used another clean cloth to rinse the resident's perineal area. Employee "B" then began to retrieve the second rag out of the pan of water where she had placed the dirty rag to continue cleaning the resident. She proceeded to ring out the rag and went to the resident to continue washing but was stopped befopre she was able to use the contaminated wash cloth on the resident. An subsequent interview conducted with employee "B" on 4/1/15 at approximately 2:30pm. Employee "B" stated that she should not have put the dirty wash cloth into the clean water and confirmed that it was her intention to continue cleaning with the soiled cloth if she had not been stopped. An interview was conducted with the Director of Nursing on 4/2/15 at approximately 10:00am revealed that her expectation was for the employee to put soiled linens in a bag, remove her soiled gloves, wash her hands and apply clean gloves, before continuing with care. A review of the policy and procedure entitled "Laundry and Bedding, Soiled" dated August 2009 revealed that staff should place contaminated laundry in a bag or container at the location where it is used and not sort or rinse the linen at the location of use.

Based on observation, interview and record review, the facility failed to ensure a medication administration error rate of 5% or below for 2 of 26 opportunities (resident #37) resulting in a facility error rate of 7.7%. The findings include: On 04/01/2015 at 9:44 am, medication administration was observed with staff nurse "C". Resident #37 received a 50mg tablet of [MEDICATION NAME] (antidepressant), along with two 90mg tablets of [MEDICATION NAME]. The total number of pills dispensed was confirmed with the staff nurse "C" to be "3". Nurse "C" then crushed the medications and mixed them in pudding. She also removed a bottle of eye drops from the medication cart and one 18mcg capsule of [MEDICATION NAME], which was inserted into a hand held inhaler device for the resident's use. The nurse entered the room of resident #37, identified and repositioned the resident and administered the resident's eye drops, followed by her crushed medication. Staff nurse "C" then administered the resident's [MEDICATION NAME] by holding the hand held inhaler to the resident's mouth and instructing him to take a deep breath. Once administration had been completed, the nurse asked the resident if he wanted to drink some more thickened liquids or if he wanted some cold water. The resident indicated he wanted some cold water and the nurse stated that she would have to retrieve that from the refrigerator. Medication pass was completed and confirmed with the nurse. A record review for resident #37 revealed a physician order [REDACTED]. On 04/01/2015 at approximately 10:50am a review of the resident's current medication administration record (MAR) was conducted with staff nurse "C", and she was asked to review the order for the resident's [MEDICATION NAME]. Staff nurse "C" identified that the resident should have received three of the 50mg tablets to equal the 150mg ordered dose. The MAR and medication packaging indicated to give "[MEDICATION NAME] tab 50mg three (3) tablets (150mg) by mouth once daily." The nurse was also asked if residents who receive inhalers are normally instructed to rinse out their mouth after administration. She stated that sh would normally have a resident rinse out their mouth after they receive Spriva or [MEDICATION NAME]. A review of the facility's policy and procedure on oral inhalation administration indicated that after each treatment, have the resident rinse their mouth with water or mouthwash.

Based on staff interview and record review the facility failed to follow their policy in relation to abuse investigation, abuse reporting, and protection of residents following an abuse allegation for 3 of 4 reviewed allegations of abuse. The findings include: Review of facility policy for Abuse, Neglect, Exploitation and Misappropriation effective 2/2006 and revised 01/2010 noted "it is the policy of this facility to take appropriate steps to prevent abuse (be it verbal, sexual, physical, or mental), neglect, exploitation and misappropriation. The abuse coordinator/designee shall immediately report any alleged violation of abuse, neglect, exploitation, misappropriation or injury of unknown source that meet the reporting criteria to the Agency for Healthcare Administration, the Adult Protective Services, and the local law enforcement if they feel a crime has occurred." It goes on to read: " a thorough investigation will be conducted to include interview of witnesses, caregivers, and roommates and facility will obtain signed statement from alleged perpetrator, if possible. " The policy stated "if the suspected perpetrator is an employee, the Administrator or their designee shall place the employee on immediate suspension, pending the outcome of the investigation." During review of the facility grievance log for the year of 2013, three allegations of abuse were revealed as follows: Allegation #1 occurred on 3/4/13 and complainant stated that a resident was observed by staff to run his wheelchair into another resident causing pain to the victim resident's right arm. Statement provided by staff member B stated that she observed the incident and it appeared to be a deliberate act. She stated that the victim resident immediately demonstrated pain behaviors after being hit by the wheelchair and grabbed his arm, placed it in his lap and began rocking back and forth. Documented investigation revealed statements from three staff members present at time of incident but there was no documentation that showed any attempts to interview the residents involved. Corrective action was to counsel the resident responsible for incident and look for alternative placement for this resident. No documentation noted that this incident was reported to state agency. On 1/16/14 at approximately 1:18pm an interview with the Social Services Director (SSD) confirmed that this incident was never reported to the State authorities. The SSD also stated that witness statement of the incident revealed that the witness believed the act to be deliberate and the victim resident did suffer pain in relation to the incident. The SSD also confirmed that no documentation of interviews with involved residents was present in the investigation and stated that looking back, she did think this incident should have been discussed more and should have been called into the abuse hotline but stated that she did not call it in because the resident responsible for the incident had a [MEDICAL CONDITION]. Allegation #2 occurred on 5/4/13 and complainant stated that staff member D was observed to curse at a resident and was aggressive with the resident when changing the resident's soiled brief. The complaint was filed by victim resident's roommate who also stated that staff member D was in a hurry because it was close to shift change and came in the room and said "oh[***] and then was rough with the victim resident. Investigation documents interview of the victim resident who stated staff member D was rough and in a hurry but she did not hear the her curse. Victim resident also stated that staff member D did cause her discomfort while changing her. On 1/16/14 at approximately 1:18pm an interview with the SSD confirmed that this incident was never reported to the State authorities. She also confirmed that the investigation does not show any interview of the accused or interview of any other staff members that were on shift at time of incident. She stated that staff member D accused had been written up and counseled. Allegation #3 occurred on 7/5/13 and complaint was made by a staff member on 7/10/13 who stated she was present in the dining room at the time of the incident. The complaint stated that staff member C was overheard cursing at a resident who spilled her coffee on the floor. Reporter stated that it upset one resident so badly that she started crying. The documented investigation revealed that employees working at time of the incident were interviewed as well as two residents present in dining room at time of incident. All statements obtained deny knowledge of staff member C cursing at any of the residents. The incident was not reported to state agency. On 1/16/14 at approximately 1:18pm an interview with the SSD and the Administrator which confirmed that this incident was never reported to the State authorities. She stated that she did interview staff and residents but was unable to substantiate the allegation. She confirmed that no documented interview of the accused was present with the investigation and also confirmed that the incident occurred on 7/5/13, was reported on 7/10/13 and the investigation ended on 7/15/14. The Administrator stated that part of the investigation was also to suspend the accused staff until the investigation is complete but risk manager stated that she could not remember if the nurse was suspended during the investigation or not but stated that she would retrieve a copy of the staff schedule for that month. Shortly after interview, the risk manager returned with a copy of the staff schedule that noted staff member C worked for three consecutive days (7/12/13, 7/13/13 and 7/14/13) after the complaint was made on 7/10/13 and before the investigation was completed on 7/15/13.

Based on interview and record review the facility failed to follow requirements for reporting and investigation of alleged abuse for 3 of 4 reviewed allegations. The findings include: During review of the facility grievance log for the year of 2013, three allegations of abuse were revealed as follows: Allegation #1 occurred on 3/4/13 and complainant stated that a resident was observed by staff to run his wheelchair into another resident causing pain to the victim resident's right arm. Statement provided by staff member B stated that she observed the incident and it appeared to be a deliberate act. She stated that the victim resident immediately demonstrated pain behaviors after being hit by the wheelchair and grabbed his arm, placed it in his lap and began rocking back and forth. Documented investigation revealed statements from three staff members present at time of incident but there was no documentation that showed any attempts to interview the residents involved. Corrective action was to counsel the resident responsible for incident and look for alternative placement for this resident. No documentation noted that this incident was reported to state agency. On 1/16/14 at approximately 1:18pm an interview with the Social Services Director (SSD) confirmed that this incident was never reported to the State authorities. The SSD also stated that witness statement of the incident revealed that the witness believed the act to be deliberate and the victim resident did suffer pain in relation to the incident. The SSD also confirmed that no documentation of interviews with involved residents was present in the investigation and stated that looking back, she did think this incident should have been discussed more and should have been called into the abuse hotline but stated that she did not call it in because the resident responsible for the incident had a [MEDICAL CONDITION]. Allegation #2 occurred on 5/4/13 and complainant stated that a staff member D was observed to curse at a resident and was aggressive with the resident when changing the resident's soiled brief. The complaint was filed by victim resident's roommate who also stated that staff member D was in a hurry because it was close to shift change and came in the room and said "oh[***] and then was rough with the victim resident. Investigation documents interview of the victim resident who stated staff member D was rough and in a hurry but she did not hear her curse. Victim resident also stated that staff member D did cause her discomfort while changing her. On 1/16/14 at approximately 1:18pm an interview with the SSD confirmed that this incident was never reported to the State authorities. She also confirmed that the investigation does not show any interview of the accused or interview of any other staff members that were on shift at time of incident. She stated that staff member D accused had been written up and counseled. Allegation #3 occurred on 7/5/13 and complaint was made by a staff member on 7/10/13 who stated she was present in the dining room at the time of the incident. The complaint stated that staff member C was overheard cursing at a resident who spilled her coffee on the floor. Reporter stated that it upset one resident so badly that she started crying. The documented investigation revealed that employees working at time of the incident were interviewed as well as two residents present in dining room at time of incident. All statements obtained deny knowledge of staff member C cursing at any of the residents. The incident was not reported to state agency. On 1/16/14 at approximately 1:18pm an interview with the SSD and the Administrator which confirmed that this incident was never reported to the State authorities. She stated that she did interview staff and residents but was unable to substantiate the allegation. She confirmed that no documented interview of the accused was present with the investigation and also confirmed that the incident occurred on 7/5/13, was reported on 7/10/13 and the investigation ended on 7/15/14. The Administrator stated that part of the investigation was also to suspend the accused staff until the investigation is complete but risk manager stated that she could not remember if the nurse was suspended during the investigation or not but stated that she would retrieve a copy of the staff schedule for that month. Shortly after interview, the risk manager returned with a copy of the staff schedule that noted staff member C worked for three consecutive days (7/12/13, 7/13/13 and 7/14/13) after the complaint was made on 7/10/13 and before the investigation was completed on 7/15/13.

Based on observation and interview, mechanical equipment was not maintained in safe operating condition, in that the interior walk-in refrigerator floor was rusted. This walk-in refrigerator stored refrigerated food intended for the nursing home residents' consumption. The findings include: On 12/10/12 at 9:47 a.m., during the initial kitchen tour, the entire walk-in refrigerator floor was observed to be completely rusted. The color of the metal floor was rust and there were large flakes of rusted metal observed on the floor. The floor surface could not longer be adequately cleaned. The walk-in refrigerator unit was in use and fully stocked with refrigerated food items intended for the nursing home resident's consumption. These findings were reviewed with the FSD on 12/13/12 at 12:35 p.m.

Based on observation and interview, the facility failed to store, prepare, and serve food under sanitary conditions, as evidenced by the following: -Food was not stored in a manner to prevent contamination -Equipment was not properly cleaned, sanitized, and maintained to be easily cleanable -Sanitized equipment was not protected from contamination -Food was not stored at proper temperatures; food service employees did not use proper technique when using thermometers to take food temperatures; food service employees were not aware of critical control point food temperatures and proper thermometer calibration. This has a potential to affect 43 out of 51 residents who eat food orally. Findings include: Food was not stored in a manner to prevent contamination: On 12/10/12 at 9:47 a.m., during the initial kitchen tour, the walk-in refrigerator walls and ceiling had multiple black spots over the entire surface that looked like mold. There was a black mold-like substance around the condenser fan cages. At 9:58 a.m. the bulk pasta, rice containers located in one of the dry food storerooms, had old adhesive label residue on the lids. In the canned food storeroom, the green paint on the shelves was wearing off on multiple shelves. On 12/12/12 at 2:06 p.m., during a follow up kitchen visit, there were three bulk food containers, labeled meal, flour, and sugar. The lids are sticky to touch and have visible food residue on them. Equipment was not properly cleaned, sanitized, and maintained to be easily cleanable. On 12/10/12 at 10:05 a.m., during the initial kitchen tour, one of the Traulsen double door reach-in refrigerators had blue plastic film on inside of doors, which is used during shipping to protect the stainless steel surface from being scratched. There was a black mold-like substance observed underneath the blue plastic film on the right door. At the time the Food Service Director indicated that this refrigerator unit was several years old and that the blue film was never removed. She directed one of her staff to remove the film. Additionally, the red liquid filled thermometer located in the unit was not working properly. The red liquid in the thermometer tube was reading from 60?F and above, rather than from 0 ?F and above. At 10:14 am., the bottom shelf of cook's preparation table was rusted on the exposed metal surfaces in which the gray paint was wearing and chipping off. There were several sanitized pots stored on the shelf. The FSD said it has been in this condition for awhile. On 12/12/12 at 11:58 a.m., there was some old food residue around the base of the can-opener where it attaches to the preparation table. The countertop mixer had old food residue around the attachment hub. On 12/12/12 at 2:06 p.m., during a follow up kitchen visit, the white handle of a sanitized offset spatula was melted and soiled. There was a sanitized clear plastic pitcher has old label residue on the exterior in 3 spots stored with other food preparation equipment. There were 2 sanitized ladles which had gray handles that were melted and soiled. These were stored on counter for air drying. There were 3 sanitized sheet pans with old carbon and grease buildup on the exterior stored on a counter and there was 1 sanitized sheet pan with old carbon and grease buildup on the exterior stored on shelf below table where the slicer is located. The cook's table to the right of the bottom shelf of the prep sink had gray paint that was wearing and chipping off. The exposed metal surfaces of the shelf were rusted. There was sanitized equipment stored on this shelf. At 2:20 p.m., there was a sticky adhesive substance on the exterior of the metal pellet warmer. The FSD stated this was cleaned daily. There were 5 sanitized full steam table pans and 3 sanitized half steam table pans which had old carbon buildup around exterior rims. These were stored under the steam table. At 2:23 p.m., there were 2 clear plastic pitchers stored on table shelf near the pass through window from dining room to kitchen which had tan-colored adhesive residue on the exterior. The FSD asked one of the staff to discard them. Sanitized equipment was not protected from contamination. On 12/12/12 at 2:06 p.m., during a follow up kitchen visit, there were multiple ladles stored hanging from a rack located over the three compartment sink. These were not stored to protect them from splash. Food was not stored at proper temperatures; food service employees did not use proper technique when using thermometers to take food temperatures; food service employees were not aware of critical control point food temperatures and proper thermometer calibration. On 12/12/12 at 12:03 p.m., Dietary Aide A took the temperature of a fish fillet held on the steam table but inserted the thermometer incorrectly. She did not penetrate the fillet from probe tip to the end of the sensor. She also inserted the thermometer probe incorrectly into a corn dog. The bimetallic bayonet-style thermometer was not suitable for accurately measuring the temperature of thin foods because of the large diameter of the probe and the inability to accurately sense the temperature at the tip of the probe. A few minutes later, the FSD inserted the bimetallic thermometer in the corn dog incorrectly, which was held on the steam table. She did not penetrate the corn dog from probe tip to the end of the sensor. She was advised by the surveyor of the correct technique. The corn dog holding temperature on steam table was 106?F, rather than at the minimum hot holding temperature of 135?F. The pan of corn dogs were removed from the steam table and put into the oven to reheat. At 12:40 p.m., Dietary Aide B removed the pan of corn dogs from the oven and placed them back into the steam table. She was taking the temperature of the corn dog with a different thermometer using improper technique again. She did not penetrate the corn dog from probe tip to the end of the sensor. Then the FSD took the temperature of a corn dog and it was 160?F, rather than being reheated to 165 F. The FSD was advised of this by the surveyor and the Dietary Aide put the corn dogs back into the oven to continue heating. At 12:47 p.m., the corn dogs were removed from the oven again and placed in the steam table again. The FSD took the temperature of the corn dogs correctly and the temperature was observed at 166?F and she indicated the temperature was 162?F. She was going to put them in the deep fryer. The surveyor asked her to take the temperature of another corn dog and it was found to be 170 ?F and rising and she said the temperature was 165 ?F. At 12:30 p.m., the FSD was asked her how she calibrates the bimetallic thermometer and she indicated she used the ice water method. She was asked what the minimum temperature should be when calibrating her thermometer with the ice water method, and she said "below 40 ?F". She was asked to calibrate her thermometer. At 12:36 p.m., the thermometer was placed in ice water in a cup for a few minutes and it read about 40?F. The FSD was asked what temperature she is looking for and she said "35?F", rather than 32?F. The thermometer read 28 ?F in the ice water. These findings were reviewed with the FSD on On 12/13/12 at 12:35 p.m.

Based on staff interviews and record reviews the facility failed to accurately administer routine medications by not acquiring the medications through pharmaceutical services to meet the needs of 2 of 10 sampled residents # 62 , # 35 The findings include: A staff interview conducted with Unit manager RN N on 12/12/2012 at approximately 9:50 am revealed the main pharmacy they use is Guardian pharmacy and it makes two runs a day to the facility to bring medications. She also stated they will make extra deliveries for emergency medications if needed. She stated they work Saturday but are off on Sunday, but we have two local pharmacies that cover then so we should be able to get anything we need seven days a week. Several staff interviews conducted with the DON on 12/12/2012 at approximately 2:30 pm through 4:00 pm, and 12/13/2012 at approximately 8:30 am revealed that the facility did not give Risperdal (an Antipsychotic medication) as ordered by the physician due to lack of enough medications available from the pharmacy. She stated there was a pharmacy change and the new pharmacy Medco stated they were giving too many 0.25 mg Risperdals and would not pay for more, but could provide no documentation from the pharmacy. She also stated that the reason for the delay in giving the medications from the order dated 10/02/2012 until it was first given on 10/07/2012 was because there was a drug interaction with Paxil ( an Antidepressant) and the Pharmacy would not send it until the physician cleared it. There was no nurses note, telephone order, or pharmacy or physician note to start the drug on 10/07/2012. DON revealed she did not know where the documentation was for the approval to give with the drug interaction. The DON also revealed that the nurses did not correct the incorrect and missing doses sent from pharmacy until the third week it was sent incorrectly leading to the many missed doses of medications, and she did not know why they did not. Record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Record review of the MAR for resident # 35 revealed there was 3 missed doses of medications in October and 3 missed doses of medication in November noted as unavailable from the Pharmacy, with one dose each month being Fosamax (a drug for Osteopenia or weak bones) a drug given once a week where the resident went two weeks between doses each month.

Based on observation, interview, and record review the facility failed to ensure that frozen Health Shakes were dated upon thawing and that Food Service staff were washing hands as needed while operating the dishmachine. This had the potential to affect all residents at the facility who were taking their food orally. Findings Include: Health shakes are a frozen product received by the facility from their primary supplier in a frozen form. Two thawed Health shakes were observed during the initial inspection of the main kitchen--on 10/31/11 begun at about 8:00 a.m.--in a box in the walk-in cooler. Neither of these shakes were labeled with the date of their thawing. The manufacturer provided on the individual cartons each of these shakes information that they were to be discarded 14 days after thawing and an area was provided on the side of each shake carton for dating them with their thawing date. A short time later one thawed Healthshake was observed in the Nourishment Room on the nursing unit. This shake was available for resident use--per interview with the Unit Manager at this time--and it was not dated with its thawing date. The Unit Manager was asked how she knew when that shake had been thawed, and how old that shake was. She stated that she did not know when the shake had been thawed and how old it was and she discarded the shake at this time. Also during the initial tour of the main kitchen-at about 8:15 a.m.--an observation of a staff member about to start washing breakfast dishes in the dishmachine was made. When asked how this staff member was going to wash her hands while performing this activity, the Food Service Director (FSD) stated that the staff was going to dip her hands in detergent in a bucket and then dip her hands in a quaternary ammonium sanitizer bucket filled to volume with that sanitizer. At this time it was explained to the FSD that while this is a method approved for washing and sanitizing nonporous surfaces it is not a method approved for sanitizing hands. The FSD and the staff member were unaware that the only approved method for cleaning hands in a foodservice setting is to wash them at a hand washing sink with soap and water.