Every finding on record at Manor at Carpenters, The

Based on observations, interviews and record review, the facility failed to ensure infection prevention and control practices were followed for the handling and storage of respiratory equipment for one resident (#72) out of four residents sampled and during three out of three medication administration opportunities with Staff A, Licensed Practical Nurse (LPN), and during the handling of soiled laundry in one out of one laundry rooms. These failures created a risk of cross contamination. Findings included: On 06/08/2026 at 10:30 a.m., an oxygen concentrator was observed in Resident #72's room. A long clear tube with a nasal cannula attached was hanging from the concentrator uncovered and unprotected from environmental contamination. A suction machine with a clear canister approximately one quarter full of a clear, thick liquid was also present, along with a disposable oral suction tube that was uncovered and unprotected. On 06/09/2026 at 11:43 a.m., the same oxygen concentrator in Resident #72's room again had a clear tube with a nasal cannula hanging uncovered. The suction machine canister remained filled approximately one quarter full with a clear, thick liquid, and the oral suction tube was still uncovered and unprotected. On 06/10/2026 at 9:10 a.m., Resident #72's oxygen concentrator was observed with a long clear tube and nasal cannula hanging uncovered. The suction machine canister remained one quarter full with a clear, thick liquid, and the disposable suction tube remained uncovered and unprotected from environmental contamination. During an interview on 06/10/2026 at 9:30 a.m., Staff F, Certified Nursing Assistant (CNA), stated the nasal cannula should be in a bag when not in use. She stated the suction canister should be cleaned after each use, adding I see a clear liquid in there, so it looks like it has not been cleaned, and reported that the suction tube should also be bagged. During an interview on 06/10/2026 at 10:01 a.m., Staff E, Registered Nurse( RN), stated that oxygen cannulas, nebulizer masks, and suction equipment must be cleaned daily and placed in a protective barrier after each use. 2. On 06/08/2026 at 10:07 a.m., during the initial tour, Staff A, LPN, was observed at the medication cart in the Rabbit hallway pushing medication tablets through their blister packages into his cupped bare hand and then placing the tablets into a medication cup. This practice was observed on three separate occasions during the tour. 3. On 06/10/2026 at 12:38 p.m., an observation was conducted in the soiled laundry receiving area. Staff B, laundry aide, demonstrated how she transferred soiled linen from the designated bins into the washing machines. Staff B reported she wears gloves while performing the task. She did not identify or demonstrate the use of a designated apron or other protective covering for her clothing. Staff B stated the laundry staff used to have white disposable aprons for clothing protection. On 06/10/2026 at 5:00 p.m., the Director of Nursing (DON) and the Assistant Director of Nursing (ADON)/Infection Control Preventionist (ICP) were interviewed. The ADON/ICP reported she provides ongoing infection control education and would re-educate any staff not following infection control practices. The ADON/ICP stated that additional staff education was needed and provided a binder of infection control training conducted daily, weekly, monthly, and annually. A review of the facility's policy titled Infection Control Prevention and Control Program, implemented 05/10/2023 and revised 01/01/2026, showed:This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.Section 13(a) showed:Laundry and direct care staff shall handle, store, process and transport linens to prevent spread of infection. A review of the facility's policy titled Infection Control – Medication Administration, revised 01/01/2026, showed:Hand hygiene is performed prior to handling any medications.andIf the sterility of a medication is compromised, or suspected of being compromised, the medication is discarded. (Photographic Evidence Obtained)

Based on interview and record review, the facility did not ensure the Preadmission Screening for Resident Review (PASRRs) were completed accurately for four residents (#1, #7, #18, and #39) out of four residents reviewed. Findings included: A review of Resident #39's admission summary showed an admission date of 11/01/24, with diagnosis to include paranoid schizophrenia (onset 2/18/25), major depressive disorder, recurrent, moderate (onset 3/19/25), other specified persistent mood disorders (onset 3/18/25), unspecified dementia, unspecified severity, without behaviors/psychological/ mood, anxiety (onset 10/06/25), and generalized anxiety disorder (onset 10/21/25). A review of Resident #39's Preadmission Screening for Resident Review (PASRR) level I, dated 10/22/25, Section A. Mental Illness (MI) or suspected MI showed the following checked under mental illness: anxiety disorder, depressive disorder, schizophrenia, and other: mood disorder, dementia. Review of question 6- Does the resident have a secondary diagnosis of dementia, related neurocognitive disorder (including Alzheimer's disease) and the primary diagnosis is a Serious Mental Illness or Intellectual disability? Question 6 was checked as no. The review showed Resident #39 was not referred for a Level II screening following qualifying diagnosis. A review of Resident #1's Detailed Summary showed an admission date of 3/10/2026 and diagnoses to include but not limited to unspecified dementia unspecified severity, without behavior, psychosis, mood and anxiety. other specified persistent mood disorders, brief psychosis disorder and major depressive disorder, recurrent, moderate. A review of Resident #1's Level I PASRR dated 5/01/2026, Section A. MI (mental illness) or suspected MI showed the following diagnoses checked as a mental illness: depressive disorder, Other (specify): Parkinson's disease, mood disorder, dementia and brief psychotic disorder. Review of question 6 of the Level I PASRR showed - Does the resident have a secondary diagnosis of dementia, related neurocognitive disorder (including Alzheimer's disease) and the primary diagnosis is a Serious Mental Illness or Intellectual disability? Question 6 was checked as no. The review showed Resident #1 was not referred for a Level II screening following qualifying diagnosis. A review of Resident #7's Detailed Summary showed an admission date of 02/18/2026 and diagnoses to include but not limited to unspecified dementia unspecified severity, without behavior, psychosis, mood and anxiety and depression, unspecified. A review of Resident #7's Level I PASRR dated 02/19/2026, Section A. MI (mental illness) or suspected MI showed the following diagnoses checked as a mental illness: depressive disorder and Other (specify): dementia. Review of question 6 showed- Does the resident have a secondary diagnosis of dementia, related neurocognitive disorder (including Alzheimer's disease) and the primary diagnosis is a Serious Mental Illness or Intellectual disability? Question 6 was checked as no. The review showed Resident #7 was not referred for a Level II screening following qualifying diagnosis. A review of Resident #18's Detailed Summary showed an admission date of 3/11/2026 and diagnoses to include: mood disorder due to known physiological conditions, unspecified, bipolar disorder, current episode mixed, moderate, major depressive disorder, recurrent, moderate and unspecified dementia, unspecified severity, with other behavioral disturbances. A review of Resident #18's level I PASRR dated 3/24/2026, Section A. MI (mental illness) or suspected MI showed the following diagnoses were checked as a mental illness: bipolar disorder, depressive disorder and Other (specify): dementia and schizoaffective disorder. Review of question 6 showed - Does the resident have a secondary diagnosis of dementia, related neurocognitive disorder (including Alzheimer's disease) and the primary diagnosis is a Serious Mental Illness or Intellectual disability? Question 6 was checked as no. The review showed Resident #18 was not referred for a Level II screening following qualifying diagnosis. On 6/11/2026 at 10:50 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated the initial screening process for PASSRs was screened by the Social Service Director (SSD) initially, and a second screen would be completed by herself. The DON stated the PASSRs will be adjusted at the time of any initial concerns upon new admissions. The DON stated PASSRs will be updated if there is a new medication change or a new diagnosis is added or changed. The DON stated, in addition to daily clinical meetings, she will meet weekly with the psychiatry provider for all residents currently under their care. The DON stated she would update PASSRs after these weekly meetings if needed. The DON reviewed the current PASSRs for Residents #1, 7, 18, and 39 specifically related to question #6. The DON stated the question was an inadvertent mistake and corrections will be updated. The DON stated the PASSRs will be updated and if further PASSRs should be presented for a Level 2 PASSR she will submit to the appropriate service. A review of the facility's policy titled: Coordination-Pre-admission Screening and Resident Review (PASRR) program, revised on 01/01/2026 showed the following intent statement:It is the policy of the facility to assure that all residents admitted to the facility receive a Pre-admission Screening and Resident Review, in accordance with State and Federal Regulations.Procedure:1. The facility will coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicating testing and effort.2.Coordination includes:a.Incorporating he recommendations form the PASARR level 1 determination and the PASRR evaluation report into a resident's assessment, care planning, and transition to care.b.Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment.

Based on interviews and record review, the facility did not ensure the development of comprehensive person-centered care plans related to the use of high risk medications for five residents (#1, #5, #7, #18 and #37) out of five residents reviewed. Findings included: A review of Resident #18's Detailed Summary showed an admission date of 3/11/2026 and diagnoses that included mood disorder due to known physiological conditions, unspecified; bipolar disorder, current episode mixed, moderate; major depressive disorder, recurrent, moderate; and unspecified dementia, unspecified severity, with other behavioral disturbances. A review of Resident #18's Minimum Data Set (MDS), Section C, Cognitive Patterns, dated 3/18/2026, showed in Section N, Medications High Risk Drug Classes: Use and Indication, that the item was checked yes, indicating Resident #18 had received an antipsychotic during the last seven days or since admission, entry, or reentry. A review of Resident #18's physician orders showed the following: behavioral monitoring for antipsychotic medication every shift, ordered 3/11/2026; risperidone 0.5 mg tablet, one tablet by mouth twice a day for schizoaffective disorder, ordered 3/11/2026; trazodone 50 mg tablet, 1.5 tablets (total dose 75 mg) by mouth at bedtime for depression, ordered 4/22/2026; behavioral monitoring for antidepressant medication every shift, ordered 3/11/2026; and an antipsychotic nursing alert every shift, ordered 3/11/2026. A review of Resident #18's care plan showed there was no focus area related to behaviors or the use of psychotropic medications. A review of Resident #1's Detailed Summary showed an admission date of 3/10/2026 and diagnoses including unspecified dementia, unspecified severity, without behavior, psychosis, mood, or anxiety; other specified persistent mood disorders; brief psychotic disorder; and major depressive disorder, recurrent, moderate. A review of Resident #1's MDS, dated [DATE], showed in Section N, Medications High Risk Drug Classes: Use and Indication, that the item was checked yes, indicating Resident #1 had received an antipsychotic during the last seven days or since admission, entry, or reentry. A review of Resident #1's physician orders showed the following: behavioral monitoring for antipsychotic medication every shift, ordered 3/25/2026; Seroquel 25 mg tablet, one tablet by mouth twice daily for brief psychotic disorder, ordered 3/31/2026; mirtazapine 7.5 mg tablet, one tablet by mouth at bedtime for depression, ordered 5/01/2026; Depakote 125 mg delayed release tablets, two tablets by mouth twice daily for mood disorder, ordered 3/10/2026; and an antipsychotic nurse alert every shift, ordered 3/31/2026. A review of Resident #1's care plan showed there was no focus area related to the resident's use of psychotropic medications. A review of Resident #7's Detailed Summary showed an admission date of 2/18/2026 and diagnoses including unspecified dementia, unspecified severity, without behavior, psychosis, mood, or anxiety, and depression, unspecified. A review of Resident #7's MDS, dated [DATE], showed in Section N, Medications High Risk Drug Classes: Use and Indication, that the item was checked yes, indicating Resident #7 had received an antipsychotic during the last seven days or since admission, entry, or reentry. A review of Resident #7's physician orders showed sertraline 100 mg tablet, one tablet by mouth once daily for depression, ordered 3/31/2026, and trazodone 50 mg tablet, one tablet by mouth at bedtime for depression, ordered 2/18/2026. A review of Resident #7's care plan showed there was no focus area related to the resident's use of psychotropic medications. A review of Resident #37's admission record revealed an initial admission date of 1/10/2024 with diagnoses of major depressive disorder, seizures, and anxiety disorder. A review of Resident #37's MDS, dated [DATE], revealed in Section N that antianxiety, antidepressant, anticoagulant, opioid, and anticonvulsant medications were used in the last seven days. A review of Resident #37's care plan revealed there was no focus, goal, or interventions related to the use of antipsychotic, opioid, or anticoagulant medications. A review of Resident #5's admission record revealed an admission date of 4/11/2026. Resident #5 was admitted with diagnoses of dementia, major depressive disorder, and anxiety. A review of Resident #5's MDS, dated [DATE], revealed in Section N that antidepressant, anticoagulant, diuretic, and anticonvulsant medications were used in the last seven days. A review of Resident #5's care plan revealed there was no focus, goal, or interventions related to the use of antidepressants, anticoagulants, diuretics, or anticonvulsants. During an interview on 6/10/2026 at 3:45 p.m., the MDS Coordinator stated that everything goes on the care plan so it can be transferred to the Kardex (a quick reference system of essential care needs used by nursing staff) for staff to review. The MDS Coordinator stated that psychotropic medication care plans should include antipsychotics and other medications requiring monitoring, such as antidepressants, anticoagulants, diuretics, and anticonvulsants. During an interview on 6/11/2026 at 9:50 a.m., the Director of Nursing (DON) stated that everything should be on the care plan, including how residents transfer and their activities of daily living. The DON stated, I have not seen medications on the care plan; I would need to check with our MDS Coordinator. A review of the facility policy titled Comprehensive Resident Centered Care Plans, dated 11/2026, revealed the intent of the policy was for the facility to provide care and services related to comprehensive resident centered care plans in accordance with state and federal regulations. The procedure section included baseline care plan requirements; development and implementation of the comprehensive care plan; care plan timing and revision; services provided meeting professional standards; qualified persons; discharge planning process; and discharge summary.

Based on observations, record review and interviews the facility failed to provide activities of daily living, related to trimming toenails for one resident (#68) out of 15 residents sampled. Findings Included: During an interview and observation on 06/10/2026 at 1:23 p.m., Resident #68 stated, My toe nails are so long I have a hard time walking. I told everyone and nothing has been done. I used to see the podiatrist, but I cannot remember when I saw them last. The resident said, I am a walker, and my nails being this long makes it hard for me to walk. Resident #68 removed her shoes and revealed 1/4 inch long, yellow colored nail on her first toe and the rest of the nails that were curved into the skin of her second, and third toes. (Photographic Evidence Obtained) Review of Resident #68's admission record revealed an admission date of 12/31/2021 with diagnoses of history of falling, need for assistance with personal care, unsteadiness on feet, and polyneuropathy. Review of Resident #68's quarterly minimum data set (MDS) dated [DATE] revealed, section C. Cognitive Patterns a brief interview mental status (BIMS) of 15 out 15 showing intact cognition. Review of Section GG- Functional Abilities revealed, Resident #68 required partial moderate assistance, meaning the helper does less than half the effort. Helper lifts, hold, or support trunk or limbs, but provides less than half the effort for self-care. Review of Resident #68's progress notes revealed there were no notes regarding podiatry visit. During an interview on 06/10/2026 at 1:10 p.m., Staff D, Registered Nurse (RN), stated the nurses do a full head to toe skin assessment, we look at everything. Staff D stated if residents had long toenails they would let social services know so they can add the resident to the list for podiatry to see. During an interview on 06/10/2026 at 1:15 p.m., Staff E, RN stated when she does a skin check she is looking at their head, neck, scalp, behind the ears, their arms, back, buttocks, legs and feet. She said if I see any residents with long toenails I would report it to my higher up and then they would tell social services to add them to the list for podiatry. Staff E said, I have seen Resident #68's toes, I believe she is seeing the podiatrist. Staff E stated Resident #68 likes to refuse care, but she had not talked to her about wanting her toes trimmed. During an interview on 06/10/2026 at 1:30 p.m., the Social Services Director (SSD), stated podiatry comes in every other month. She stated residents are added to the list on admission or as needed. The SSD said the nurses or staff usually tell her who needs to be seen. She reviewed Resident #68's electronic medical record and stated I am not able to find when Resident #68 was seen last by podiatry. I don't see any podiatry notes in her chart. I will add her now, so she is seen next week when they come in. During an interview and observation on 06/10/2026 at 2:00 p.m., the Director of Nursing (DON), looked at Resident #68's toenails and stated, Oh my those are long. She asked Resident #68 , have you told anyone that you needed your nails cut?. Resident #68 responded, Yes, I have told everyone. The DON stated nurses do a skin sweep on residents and are expected to report any new skin conditions to herself. She stated if they see long toenails, it would be expected of them to let someone know or ensure the resident is on the list to see podiatry. The DON stated Resident #68 had not said anything to her and she sees her daily. The DON stated it was very surprising of Resident #68 not tell her she needed her toenails trimmed. Review of the facility policy titled, Activities of Daily Living/Maintain Abilities, with a review date of 1/1/2026, revealed intent: it is the policy of the facility to specify the responsibility to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring all staff, across all shifts and departments, understand the principles of quality of life, and honor and support these principles for each resident; and that the care and services provided are person centered, and honor and support each residence preferences, choices, values and beliefs.2. The facility will ensure a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living.4. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; .

Based on observations, interviews, and record reviews, the facility failed to ensure adequate equipment was provided to allow residents to call for staff assistance through a communication system that relays the call directly to staff or to a centralized staff work area for one resident ( #64) out of one sampled for properly functioning call lights.Findings included: On 06/11/2026 at 11:00 AM, an interview was conducted with Resident #64, who was sitting in a recliner in the room. Resident #64 stated that the call light had been broken for a while and reported that this has been an ongoing problem. The resident stated the facility can't seem to figure out why it keeps going out. Resident #64 reported being provided with a horn; however, if the room door is closed, staff are not able to hear the resident most of the time.Review of Resident #64's admission record revealed an original admission date of 12/24/2024 . A Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition.Review of an outside maintenance company invoices revealed multiple service calls related to Resident #64's call light not functioning. A work note dated 04/24/2026 documented that a technician met with the Assistant Director of Maintenance (ADOM) regarding the call light. The station in Resident #64's room had blinking lights and could not be reset. The technician reset the station, which temporarily resolved the issue, but the master station continued to show a fault.A work note dated 05/06/2026 revealed the technician reported that an old configuration loaded during a prior visit caused the bed station to fault. The technician updated and downloaded the corrected configuration. The ADOM and the technician tested the station and verified it was working.A work note dated 05/20/2026 revealed Resident #64's bed station, which had been functioning during the last visit, was again malfunctioning. The technician informed staff that the issue continued to recur and recommended replacing the zone dome light. A work note dated 06/09/2026 documented that the technician replaced the dome light for Resident #64's room but when the technician tested the system, the light did not activate when the call button was pressed. On 06/10/2026 at 1:50 PM, an interview was conducted with Staff D, Registered Nurse (RN). During the interview, a constant ringing noise was heard. Staff D stated, That is a call light that keeps ringing. Staff D stated the call light had been worked on the previous day but continued to malfunction. Staff D stated Resident #64's call light was the only one not working and reported that the resident's horn was louder than the call light, but still not reliably heard. Staff D stated the call light had not been working for approximately one to one and a half months.On 06/10/2026 at 1:44 PM, an observation was conducted of Resident #64's room call light, which was ringing constantly, with a timer reading 280 minutes, meaning the issue was unresolved.On 06/11/2026 at 11:23 AM, an observation was conducted of Resident #64's room call light, which was ringing constantly with a top timer reading 1003 minutes and a bottom timer reading 1247 minutes, meaning the issue was unresolved.On 06/10/2026 at 2:56 PM, an interview was conducted with the Director of Maintenance (DOM) who stated they knew very little about Resident #64's call light issue. The DOM reported understanding that the problem was related to programming and that the outside company had reprogrammed and rewired the system and replaced a part. The DOM stated that when nursing reports a call light issue, maintenance contacts the outside company, which then responds within its required four hour window. The DOM stated he planned to call the outside company again.Review of the facility's Call Light Monitoring policy dated 01/01/2026 revealed the facility ensures each resident has access to a functioning call light system at all times and staff respond promptly to all requests for assistance. Policy #2 states that routine calls must be answered within 5 minutes.

Based on staff interviews, record review and policy and procedure review, the facility failed to protect one (Resident#1) of five residents right to be free from physical abuse (slap) by facility staff. Findings included: Review of the record for Resident #1 revealed she was admitted to the facility on [DATE]. Diagnoses included depression, senile degeneration of the brain, cerebral atherosclerosis, major depressive disorder, and dementia without behaviors. Review of a quarterly Minimum Data Set (MDS) assessment completed 12/13/24 revealed Resident #1 was rarely/never understood and was dependent on staff for upper body dressing, oral care, toileting, bathing, personal hygiene, and lower body dressing. The assessment revealed Resident #1 was dependent on staff for transfers. Review of a facility report dated 3/12/25 indicated Staff A, Certified Nursing Assistant (CNA) physically abused Resident #1 on 3/12/25 when Resident #1 became combative during care. A telephone interview was conducted on 3/17/25 at 4:35 p.m. with Staff B, CNA, who was a witness to Staff A, CNA physically abusing Resident #. Staff B, CNA stated while she and Staff A, CNA were assisting Resident #1, the resident pulled her arm back away from Staff A, CNA and Staff A, CNA grabbed Resident #1's arm and put her arm into her shirt. Resident #1 slapped Staff A, CNA and Staff A, CNA reacted by slapping Resident #1 back. Staff B, CNA stated she could clearly hear the slap in addition to seeing it. Review of the facility policy titled Abuse Neglect Exploitation and Misappropriation of Property Prevention, last reviewed 1/1/24, revealed: Intent: The facility will develop operational policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property, to include the use of physical and or chemical restraints. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences.

Based on resident record review, staff interview, personnel record review, and review of facility policies and procedures, the facility did not ensure abuse policies and procedures related to screening of potential employees were followed. The facility did not attempt to obtain information from previous or current employers for one staff member (Staff A, Certified Nursing Assistant) out of five staff members reviewed, resulting in harm to Resident #1. Findings included: Review of the record for Resident #1 revealed she was admitted to the facility on [DATE]. Diagnoses included depression, senile degeneration of the brain, cerebral atherosclerosis, major depressive disorder, and dementia without behaviors. Review of a quarterly Minimum Data Set (MDS) assessment completed 12/13/24 revealed Resident #1 was rarely/never understood and was dependent on staff for upper body dressing, oral care, toileting, bathing, personal hygiene, and lower body dressing. The assessment revealed Resident #1 was dependent on staff for transfers. Review of a facility report dated 3/12/25 indicated Staff A, Certified Nursing Assistant (CNA) physically abused Resident #1 on 3/12/25 when Resident #1 became combative during care. An interview was conducted with the Administrator at 1:35 p.m. on 3/17/25. The Administrator stated she found out from other staff while conducting the investigation involving Resident #1, Staff A, CNA, was fired from another nursing facility recently for abusing a resident. The Administrator stated Staff A, CNA, told them it was her first job as a CNA. Review of the personnel record for Staff A, CNA revealed she completed an employment application on 2/24/25 where she listed her previous employment at two fast food restaurants and both fast food restaurants were contacted by human resources for references. Review of a Level II background screen result dated 2/24/25 and requested by the facility's human resource department, revealed prior employment at a local nursing home from 1/21/25 to 2/19/25. There was no documentation in the personnel record indicating a reference check was conducted at this facility. This was the facility where Staff A, CNA had a prior incident of physically abusing a resident. An interview was conducted with the Human Resources Director on 3/17/25 at 1:35 p.m. She stated they check the references the potential employee gives on the application and they don't cross reference with the Level II background screen. A follow up interview with the Administrator on 3/17/25 at 2:00 p.m. revealed Human Resources was checking the employment history on the application and checking those references but not checking the Level II background screen that was obtained when Staff A, CNA applied to verify other recent employment that was not listed on the application. An interview was conducted with the Administrator on 3/17/25 at 4: 00 p.m., who stated Human Resources should have at least questioned Staff A, CNA as to why she did not put her prior employment at another nursing facility on her application as it was clearly on her Level II background screen. She stated if that reference was checked they might have found out about her termination and the reason for termination at the prior facility. A telephone interview was conducted on 3/17/25 at 4:35 p.m. with Staff B, CNA, who was a witness to Staff A, CNA physically abusing Resident #. Staff B, CNA stated while she and Staff A, CNA were assisting Resident #1, the resident pulled her arm back away from Staff A, CNA and Staff A, CNA grabbed Resident #1's arm and put her arm into her shirt. Resident #1 slapped Staff A, CNA and Staff A, CNA reacted by slapping Resident #1 back. Staff B, CNA stated she could clearly hear the slap in addition to seeing it. Review of the facility policy titled Abuse Neglect Exploitation and Misappropriation of Property Prevention, last reviewed 1/1/24, revealed: Intent: The facility will develop operational policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property, to include the use of physical and or chemical restraints. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences. Procedure: I. Screening: Screen potential employees for a history of abuse, neglect or mistreating residents. This includes attempting to obtain information from previous employers and /or current employers and checking with the appropriate licensing boards and registries.

Based on observations, interviews, and record review, the facility failed to ensure one (#40) out of twenty-one sampled residents were assessed for the self-administration of a topical pain patch dated for the day before the observation and left at bedside. Findings included: An observation was made on 1/16/24 at 10:31 a.m., of a topical patch dated 1/15/23, 3 p.m. - 11 p.m. shift by a Licensed Practical Nurse (LPN) laying on the dresser of Resident #40. During the observation the resident stated the nurse gave her the patch at night to put on her back. (Photographic evidence obtained) During an interview on 1/16/24 at 10:48 a.m., the Unit Manager (UM) stated no residents were allowed to self-administer medications. The UM stated on 1/16/24 there was one resident in the facility allowed to self-administer antacid tablets. During an interview on 1/17/24 at 1:15 p.m., the Director of Nursing (DON) stated only one resident was allowed to self-administer medications and Resident #40 was not the resident. During an interview on 1/17/24 at 2:28 p.m., Staff A, Registered Nurse (RN) stated Resident #40 was not able to self-administer medications. During an interview on 1/17/24 at 2:50 p.m., the Director of Nursing observed the photo taken of Resident #40's Lidoderm patch lying on the dresser and confirmed the patch had not been applied (due to the shape of the patch). Review of Resident #40's physician orders showed an order for Lidoderm Patch to Ribs 5% - Once daily apply to lower back. On (at) 8:00 p.m. and Off (at) 8:00 a.m. for lower back pain topical, ordered on 12/31/21. Review of Resident #40's Medication (Administration) Record dated January 2024 showed a Lidoderm patch had been applied to the resident's back as scheduled at 8:00 p.m. on 1/15/24 and had as scheduled at 8:00 a.m. been removed from the residents ribs on 1/16/24. Review of Resident #40's Minimum Data Set (MDS) showed a Brief Interview of Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment. A request was made of the facility to provide Resident #40's Self-Administration (of medication) Assessment, which was not received. Review of the care plan for Resident #40 did not identify a focus related to self administration of the pain patch by Resident #40. The policy - Self-Administration of Medication Program, reviewed on 11/22/23, revealed it is the policy of the facility to allow the resident and or legal representative of the resident the right to self-administer medication when it has been deemed by the interdisciplinary team that it is clinically appropriate. A continued review of the policy showed: - 4. If a resident requests to self-administer drugs, it is the responsibility of the Interdisciplinary team (IDT) to determine that it is safe for the resident to self-administer drugs, before the resident may exercise that right. - 5n. The resident's ability to ensure that medication is stored safely and securely. - 6. Once the resident has been deemed safe by the IDT an order will be obtained from the resident's physician or physician or physician extender listing the medication(s) that may be self-administered, where the medications will be stored, who will be responsible for documentation and the location of administration. - 10. The decision that a resident has the ability to self-administer medication(s) is subject to periodic re-evaluation based on change in the resident's status. - 11. The resident will be re-evaluated on their ability to continue to self-administer medications in conjunction with the resident assessment instrument.

Based on record reviews, and interviews, the facility failed to confirm the accuracy of the Pre-Admission Screening and Resident Review (PASRR) and to correct the document for five (#3, #13, #40, #41, and #207) out of twenty-one residents sampled. Findings included: 1. Review of Resident #3's Admission Record revealed the resident was admitted on [DATE]. The record included the resident diagnosis of unspecified single episode of major depressive disorder with onset dates of 1/19/20, 5/18/20, 6/19/20, 10/16/20, and 10/10/22, and unspecified anxiety disorder with an onset date of 1/19/20. Review of Resident #3's PASRR, dated 5/18/20, did not reveal the resident had a Mental Illness (MI), a suspected MI, or an Intellectual Disability (ID). The PASRR showed the resident did not require a Level II PASRR screening. 2. Review of Resident #13's Admission Record revealed the resident was admitted on [DATE]. The record revealed the resident's primary diagnosis on 12/5/18 was unspecified Cerebral Palsy and included the diagnoses of unspecified single episode major depressive disorder and unspecified anxiety disorder dated 11/27/18. The record revealed the diagnosis of Cerebral Palsy was recognized on 11/6/20 and 1/9/21 and the diagnoses of major depressive and anxiety disorders were documented on 11/27/18, 11/6/20, and 1/9/21. A review of Resident #13's PASRR, completed on 11/22/18 did not show the resident had a MI, suspected MI, or the related Intellectual Disability (ID) related condition of Cerebral Palsy. The resident's PASRR showed the resident did not require a Level II PASRR evaluation. 3. Review of Resident #40's Admission Record revealed the resident was admitted on [DATE]. The record included diagnosis of moderate recurrent major depressive disorder with an onset date of 12/7/21. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] showed Resident #40 had a diagnosis of non-Alzheimer's dementia. A review of Resident #40's PASRR completed at an acute care facility on 12/7/21 showed the resident did not have a MI, suspected MI, or ID and did not require a Level II PASRR evaluation. 48223 4. Review of the Admission Record showed Resident #41 was admitted on [DATE] and readmitted on [DATE] with a diagnosis of Major Depressive Disorder, and other co-morbidities. Review of Resident #41's PASRR Level I Assessment, dated 07/25/2022 did not reveal a qualifying mental health diagnosis marked in section I A. Resident #41 was readmitted on [DATE] with a new diagnosis of Major Depressive Disorder. 5. Review of the Admission Record showed Resident #207 was admitted on [DATE] with diagnoses of psychotic disorder, Alzheimer's Disease, Dementia with behavioral disturbance, mood disorder, and other co-morbidities. Review of Resident #207's PASRR Level I Assessment, dated 01/02/2024 did not reveal a qualifying mental health diagnosis marked in section I A. and had a primary diagnosis of dementia. Section II, (7) was marked yes for having validating documentation to support the dementia or related neurocognitive disorder (including Alzheimer's disease). During an interview on 01/17/24 at 01:59 PM, the Social Service Director (SSD) confirmed: Resident #3's PASRR does not reflect the diagnosis for MDD. The SSD confirmed the PASRR should have be corrected and submitted for a Level II screening. Resident #13's PASRR, completed on 11/22/18 did not show the resident had a MI, suspected MI, or the related Intellectual Disability (ID) related condition of Cerebral Palsy. The SSD confirmed the PASRR should have be corrected and submitted for a Level II screening. Resident #40's PASRR dated 12/07/21 did not show the resident had a MI, suspected MI, or ID and did not require a Level II PASRR evaluation. The SSD confirmed the diagnoses should be on the PASRR. This PASRR needs to be accurately completed and submitted for a Level II screening. Resident #41 was readmitted on [DATE]. A new PASRR was not completed. The SSD confirmed that a new PASRR would need to be completed to include the new diagnosis of Major Depressive Disorder and resubmitted for a Level II screening. The SSD confirmed Resident #207's PASRR is incorrect and needs to be redone and submitted for a Level II screening. Review of the facilities policy and procedures titled Coordination - Pre-Admission Screening and Resident Review (PASRR) program, with a last review date of 11/22/2023 showed: Intent: it is the policy of the facility to assure that all residents admitted to the facility receive a PASRR, in accordance with the State and Federal regulations. Procedures: . 2. b. Referring all Level II residents and all residents with newly evident or possible serious mental disorders, intellectual disabilities, or related condition for Level II resident review upon a significant change in status assessment. 5. A nursing facility must notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in mental or physical condition of a resident who has mental illness or intellectual disability for resident review.

Based on observations, record reviews, and interviews, the facility failed to assess and obtain physician orders for the two wounds for one (#40) out of four resident sampled for skin conditions. Findings included: An observation was made on 1/16/24 at 10:35 a.m., of an undated large brown-colored adhesive bandage, applied to Resident #40's left wrist and a white 3x3 centimeter (cm) bordered dressing dated 1/15 on the outer aspect of the resident's right leg. During the observation on 1/16/24 at 10:35 a.m. Resident #40 stated (regarding left wrist) it happened a week ago, scraped it, and skin was hanging. The Resident stated the Band-Aid was changed over the weekend. An observation and interview was conducted on 1/17/24 at 2:24 p.m. with Resident #40. A white bordered dressing dated 1/15/24 continued to be observed on the resident's right lower leg. The resident reported rubbing the leg against the over bed table (pointing at it) last week. A large brown-colored undated adhesive dressing had been applied to the resident's left wrist. The resident reported tripping into the dresser and the nurse had applied the adhesive dressing this weekend. An interview and observation was conducted on 1/17/24 at 2:28 p.m. with Staff A, Registered Nurse (RN). The staff member stated Resident #40 did not have any skin conditions. The staff member stated if there was a dressing on the resident's lower leg it had not been applied by him. Staff A observed the white dressing on Resident #40's right lower extremity (RLE), confirming it was dated 1/15/24 and the adhesive dressing on right wrist. The resident reported to the staff member of scrapping it (leg) on the over bed table. Immediately following the observation, Staff A reviewed the electronic record of the resident and confirmed there was no report or treatment order for either injury. On 1/17/24 at 5:05 p.m., during an interview, the Infection Preventionist (IP) reported observing the skin tears of Resident #40 and both areas were old. The IP reported both areas should have had orders for treatments. A review of the facility report log dated 11/11/23 to 1/16/24 did not reveal Resident #40 had suffered any injury. Review of Resident #40's physician orders included an order for Weekly skin assessment to be completed in [electronic record] on Sunday 3-11 shift every week, to start on 6/8/23. A review on 1/17/24 at 1:45 p.m., revealed the last Interdisciplinary (ID) nursing note written on 9/5/23 was regarding the request by the Resident #40's Power of Attorney to discontinue the fentanyl patch. The ID notes did not include any information regarding the left wrist or right leg injury suffered by the resident. Review of Resident #40's January 2024 Treatment Administration Record (TAR) revealed no wound care orders until 1/17/24 and wound care had not been provided to the resident's right lower extremity or left wrist. A review of the Skin Evaluations revealed a skin assessment had last been completed on 12/24/23 on Resident #40. The facility did not provide any further weekly skin evaluations for 12/31/23, 1/7/24, and 1/14/24. On 1/17/24 at 2:50 p.m., during an interview, the Director of Nursing stated if it (an incident) happens during the day, wound care can see it, if not staff are to notify the physician and obtain any order for treatment. She stated if is a skin tear or pressure injury an incident report is required. The DON stated usually there was a nursing note generated in the incident report. She reviewed and confirmed there were no treatment orders for either skin injury. A policy titled - Charting and Documentation, undated, revealed All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. The policy showed: - All observations, medications administered, services performed, etcera (etc), must be documented in the resident's clinical record. - All incidents, accidents, or changes in the resident's condition must be recorded. A policy titled - Wound Prevention, reviewed 11/23/21, revealed the purpose was to assist the facility in the care, services, and documentation related to the occurrence, treatment, and prevention of pressure as well as, non-pressure related wounds. The process showed Weekly skin checks will be conducted by the license nurse. This will be documented in the resident's Electronic Medical Record (EMR). The policy titled - Change in Condition Process, reviewed 11/23/21, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notify, consistent with his or her authority, resident's representative when there is a change requiring notification.

Based on observations, record review, and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen. Findings included: On [DATE] starting at 10:00 a.m., an initial tour of the kitchen was conducted with the Director of Dining and the chef. Rust was observed on the ceiling tiles in the dishwashing area. The Director of Dining stated they were in the process of remodeling, and it should take place within the next six months. There were two male staff members running dishes through the dish machine. One of the male staff members had an excessive amount of facial hair sticking out from around his surgical mask. He was not wearing a beard guard. Three gallons of expired milk dated ,d+[DATE], ,d+[DATE], and ,d+[DATE] was observed in walk in cooler number one. The following was observed in walked in cooler number two: *a case of raw thawed ground pork stored on the shelf above a case of fully cooked meatballs; *a case of raw thawed tenderloin stored on the shelf above a case of fully cooked meatballs; and *black buildup was observed on the ceiling and on the fan in the back of the walk-in cooler. A staff member was observed touching the trash can lid with her hand to throw trash away and then put the oven mitt on her hand with no hand hygiene until the Director of Dining interfered. On [DATE] starting at 10:37 a.m., a follow up tour of the kitchen was conducted. A personal phone was observed on the food prep table. The Director of Dining removed the phone after the surveyor asked who did the phone belong to. On [DATE] at 10:45 a.m., the Director of Dining confirmed the male staff member should have been wearing a beard guard. He stated the truck came on the day the expired milk was observed in the walk-in cooler and the person responsible for ensuring there were no expired foods in the walk-in cooler did not get to pull it out. He stated they receive deliveries almost daily. The Director of Dining stated the food code indicated that raw foods could be stored over ready to eat foods and they use the food code for their policy. He reported that maintenance replaced the rusty tiles and cleaned the fan in the walk-in cooler yesterday and maintenance would have to use a sand blaster to clean the ceiling. On [DATE] at 12:40 p.m., the Director of Dining stated they use the food code for all their policies. An online form had to be submitted for maintenance requests to submit work orders, but maintenance comes around ,d+[DATE] days to check for maintenance issues. Hand hygiene should be performed anytime you go from dirty to clean or changing tasks. They have hand washing signs posted throughout the facility. No personal items can be in the food preparation area.

Based on record reviews and interviews, the facility failed to ensure treatment was provided timely for one resident (Resident #39) out of the sampled two residents related to a Urinary Tract Infection ([CONDITION(S)]) and [CONDITION(S)]-Resistant Staphylococcus Aureus ([CONDITION(S)]). Findings included: A review of the Profile Face Sheet revealed Resident #39's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Physician's Orders for 02/10/22 revealed the following order: Urinalysis Culture and Sensitivity (UA C&S) with a start date of 02/02/22. A review of the lab results, dated 02/05/22, revealed a collection date and an order date of 2/02/22. The urine culture revealed Resident #39 had [CONDITION(S)]-Resistant Staphylococcus Aureus ([CONDITION(S)]). The urinalysis showed the blood, protein, [MEDICATION(S)], and leukocytes were abnormal. The microscopic urinalysis showed the white blood cells, red blood cells, and bacteria were abnormal. The Interdisciplinary Notes dated 02/07/22 revealed the Physician Assistant saw the resident and a new order was received for [MEDICATION(S)] for [CONDITION(S)]. A review of the Physician's Orders for 02/11/22 revealed the following order: [MEDICATION(S)] 600 mg (milligram) tablet by mouth every 12 hours for [CONDITION(S)] (urinary tract infection) for 7 days with a start date of 02/08/22 and a stop date of 02/15/22. There was no physician order related to isolation. The Medication Record for 02/2022 reflected the [MEDICATION(S)] was administered as ordered starting on 02/08/22. The care plan related to infections revealed a category for [CONDITION(S)] initiated on 02/07/22. The approaches included but were not limited to apply infection control precautions and procedures as needed. Several observations on 02/08/22 and 02/09/22 revealed a caddy with personal protective equipment (PPE) was not on or outside of Resident #39's room door. There was no signage that indicated staff had to wear PPE when providing care. On 02/10/22 at 12:59 p.m., Staff C, Licensed Practical Nurse (LPN), reported the caddy in the resident's room was put on the bathroom door today because he had [CONDITION(S)] in the urine and a [CONDITION(S)]. Anyone that touches the resident and helps with activities of daily living (ADL) care must use personal protective equipment (PPE) reported Staff C, LPN. She reported staff knew they had to wear PPE because of the yellow caddy hanging on the bathroom door. On 02/11/22 at 10:50 a.m., the Infection Control Preventionist (ICP) reported she had not done any tracking for Resident #39 yet. They had a physician notebook the nurses use to write any symptoms or problems the residents are having. The ICP reported she looks through the book daily and looks at new orders every morning. She gets with the physician if the resident was symptomatic to order a UA and she was responsible for checking the results of the labs. She reported the turnaround time was not good for receiving UA results and it could take anywhere from 2-4 days. The UA for Resident #39 was ordered on 02/02. The results were received 02/05/22 per the labs, but she could not promise 02/05 was the date the facility received the results. After further review of Resident #39's electronic medical record, the Infection Preventionist stated they received the results on 02/07 at 11:21 in the a.m. She stated the doctor was called, and he said to put it in the book for tomorrow and the next morning he would write the orders. She confirmed they could call the labs for results. She confirmed the antibiotics for Resident #39 were started on the 8th. She stated a week was too long for waiting for lab results. The ICP reported she had not done a document or tracing on the infection. She tries to complete the infection report on Mondays. She agreed one week was a long time to wait before a resident gets treatment. She confirmed the nurses were allowed to initiate contact precautions. She confirmed there was no order for precautions. The ICP reported the nurses would put the order in and get the Certified Nursing Assistants (CNAs) to hang the caddy on the door. She reported nurses have the ability to initiate orders for isolation, but they have to notify her. The policy provided by the facility titled, Diagnostic Services, dated 10/22/20 revealed the following: Intent: It is the policy of this facility to ensure that laboratory, radiology, and other diagnostic services meet the needs of residents, that results are reported promptly to the ordering provider to address potential concerns and for disease prevention, provide for resident assessment, diagnosis, and treatment, and that the facility has established policies and procedures, and is responsible for the quality and timeliness of services whether services are provided by the facility or an outside resource. Procedure: 1. The facility will provide or obtain laboratory services to meet the needs of its residents and will be responsible for the quality and timeliness of the services.

Based on observations, record review, and interviews the facility failed to ensure as needed (PRN) orders for [CONDITION(S)] drugs were limited to 14 days for one (Resident #33) of seven residents investigated for unnecessary medications. Findings included: On 2/08/22 at 12:18 p.m. Resident #33 was observed lying in his bed fully dressed. A personal caregiver was present in the room. The resident appeared clean, dry and had no odors. The resident was unable to answer questions about his care and he appeared calm and cooperative. A review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including: cognitive impairment, dementia, anxiety disorder, and mood disorder. A review of the Physician's Order set, dated 2/11/22, revealed an active order for [MEDICATION(S)] 0.25 milligrams (mg) one by mouth every 6 hours as needed for anxiety started 11/2/21 with no stop date (last dose 12/8/21). A review of the comprehensive care plan for Resident #33 revealed the following focus area: [CONDITION(S)] drugs: [Resident #33] is on psychotropics due to depression, anxiety, and [CONDITION(S)] (start date 10/15/21). Goal: Will be free of depressive/anxious//[CONDITION(S)] behaviors and adverse effects of medication through the review date (goal date 5/9/22). Interventions included: Monitor and document all behaviors related to depression/anxiety/hypnotic such as episodes of tearfulness, withdrawal from friends/family. Monitor and document side effects of antidepressant, hypnotic, and antianxiety medications. Monitor for lowest possible dose. A review of the Medication Records from 12/2021 through 2/10/2022 revealed no documented behaviors for anxiety and only one dose of [MEDICATION(S)] given on 12/8/2021. A review of the Medication Regimen Reviews (MRR) conducted by the Consulting Pharmacist (CP) indicated on 10/23/2021 a recommendation was sent to the physician to evaluate the resident for the appropriateness of [MEDICATION(S)] 0.25 mg every 6 hours as needed. There was no response documented on the recommendation from the provider. On 2/11/22 at 11:10 a.m. an interview was conducted with the Director of Nursing (DON). The DON stated the policy is not to have PRN medications for more than 14 days for [CONDITION(S)] medications. She stated they review all residents on these medications monthly in their psychiatric meetings. She stated the CP and nursing, all review residents for any gradual dose reductions to identify changes that need to be made. On 2/11/22 at 11:13 a.m. a telephone interview was conducted with the Consulting Pharmacist. She stated she had sent a recommendation on October 23rd, after her MRR for Resident #33 to address the PRN status of the [MEDICATION(S)]. She stated she did not see that a change on the medication had been made. She stated she did prepare notes for the January meeting related to Resident #33. She stated another member of the pharmacy attended the meeting, so she was not aware of the outcome. She stated PRN psychotropics are something she would let the provider know about and the medications should not be continued without further explanations. She stated she would recommend if needed the medication be changed to a routine medication. A review of the policy titled, Pharmacy Services-Drug Regimen Free From Unnecessary Drugs, updated on 10/22/20, indicated the following: Intent: the intent of this policy is each resident's entire drug/medication regiment is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial wellbeing; the facility implements gradual dose reductions and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing [CONDITION(S)] medications; and PRN orders for [CONDITION(S)] medications are only used when the medication is necessary and PRN use is limited. 1 Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used: a. In excessive dose b. For excessive duration c. Without adequate monitoring d. Without adequate indications for its use e. In the presence of adverse consequences which indicate the dose should be reduced or discontinued f. Any combinations of the reasons stated 2 A [CONDITION(S)] drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: a. Anti-psychotic b. Anti-depressant c. Anti-anxiety d. Hypnotic 3. Based on a comprehensive assessment of a resident, the facility will ensure that: c. Residents do not receive [CONDITION(S)] drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. d. PRN orders for [CONDITION(S)] drugs are limited to 14 days. Except, if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

Based on observations, record reviews, and interviews, the facility failed to ensure isolation precautions were initiated in a timely manner for one resident (Resident #39) and failed to ensure appropriate hand hygiene was performed during wound care for one resident (Resident #4) out of the sampled three residents. Findings included: 1. A review of the Profile Face Sheet revealed Resident #39's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Physician's Orders for [DATE] revealed the following order: Urinalysis Culture and Sensitivity (UA C&S) with a start date of [DATE]. A review of the lab results, dated [DATE], revealed a collection date and an order date of [DATE]. The urine culture revealed Resident #39 had [CONDITION(S)]-Resistant Staphylococcus Aureus ([CONDITION(S)]). The urinalysis showed the blood, protein, [MEDICATION(S)], and leukocytes were abnormal. The microscopic urinalysis showed the white blood cells, red blood cells, and bacteria were abnormal. A review of the Physician's Orders for [DATE] revealed the following order: [MEDICATION(S)] 600 mg (milligram) tablet by mouth every 12 hours for [CONDITION(S)] (urinary tract infection) for 7 days with a start date of [DATE] and a stop date of [DATE]. There was no physician order related to isolation. The Medication Record for ,d+[DATE] reflected the [MEDICATION(S)] was administered as ordered starting on [DATE]. The care plan related to infections revealed a category for [CONDITION(S)] initiated on [DATE]. The approaches included but were not limited to apply infection control precautions and procedures as needed. Several observations on [DATE] and [DATE] revealed a caddy with personal protective equipment (PPE) was not on or outside of Resident #39's room door. There was no signage that indicated staff had to wear PPE when providing care. On [DATE] at 12:59 p.m., Staff C, Licensed Practical Nurse (LPN), reported the caddy in the resident's room was put on the bathroom door today because he had [CONDITION(S)] in the urine and a [CONDITION(S)]. Anyone that touches the resident and helps with activities of daily living (ADL) care must use personal protective equipment (PPE) reported Staff C, LPN. She reported staff knew they had to wear PPE because of the yellow caddy hanging on the bathroom door. On [DATE] at 10:50 a.m., the Infection Control Preventionist (ICP) reported she had not done any tracking for Resident #39 yet. The UA for Resident #39 was ordered on ,d+[DATE]. The results were received [DATE] per the labs, but she could not promise ,d+[DATE] was the date the facility received the results. After further review of Resident #39's electronic medical record, the ICP stated they received the results on ,d+[DATE] at 11:21 in the a.m. She confirmed the antibiotics were started on the 8th. The ICP reported she had not done a document or tracing on the infection. She tries to complete the infection report on Mondays. She confirmed the nurses were allowed to initiate contact precautions. She confirmed there was no order for precautions. The ICPreported she did not know when the caddy was put on the door. Normally the nurses would put the order in and get the Certified Nursing Assistants (CNAs) to hang the caddy on the door. She reported nurses have the ability to initiate orders for isolation, but they have to notify her. On [DATE] at 11:30 a.m., a policy related to isolation for [CONDITION(S)] was requested and not provided. A review of the Centers for Disease Control and Prevention document titled, [CONDITION(S)]-Resistant Staphylococcus Aureus ([CONDITION(S)]) General Information Patient found at https://www.cdc.gov/[CONDITION(S)]/community/patients.html revealed: To prevent [CONDITION(S)] infections, healthcare personnel: Clean their hands with soap and water or an alcohol-based hand sanitizer before and after caring for every patient. Carefully clean hospital rooms and medical equipment. Use Contact Precautions when caring for patients with [CONDITION(S)] (colonized, or carrying, and infected). Contact Precautions mean: o Whenever possible, patients with [CONDITION(S)] will have a single room or will share a room only with someone else who also has [CONDITION(S)]. o Healthcare providers will put on gloves and wear a gown over their clothing while taking care of patients with [CONDITION(S)]. 2. A review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician's Order set dated [DATE] indicated an active order for wound care, with a start date of [DATE], as: cleanse wound on sacrum with normal saline, pat dry, apply [MEDICATION(S)] Blue to wound bed, cover with Allevyn dressing daily. A review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed, under Section M--Skin Conditions, Resident #4 had a Stage 4 pressure ulcer, not present on admission. A review of the Comprehensive Care Plan for Resident #4 indicated the following focus area started on [DATE]: Pressure Ulcers: [Resident #4] has potential for impaired skin integrity, at risk due to weakness, dementia, [CONDITION(S)]. Goal: Will prevent resident from developing a pressure ulcer unless resident's clinical condition demonstrates that they were unavoidable. Skin will be kept as clean and dry as possible on a daily basis. Interventions included: obtain physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the wound care notes revealed the following measurements: Stage 4 Coccyx date opened [DATE], [DATE]--2.7 x 0.5 x 0.4, [DATE]--3.0 x 0.6 x 0.4, [DATE]--4.0 x 0.9 x 0.2, [DATE]--7.5 x 4.0 x 0.2. On [DATE] at 10:49 a.m. Resident #4 was observed lying in his bed. The resident was friendly and appeared confused. Staff A, Registered Nurse (RN), Unit Manager and Staff B, Certified Nursing Assistant (CNA), were preparing to do wound care for the resident. The resident had been previously medicated and had been informed about the procedure. Resident #4 was confused and making jokes during the procedure. The nurse stated the resident has had the wound for a while and the wound care physician comes once a week to assess and measure the wound. The nurse stated the physician does all the measurements and provides any changes in orders as needed. Staff A, RN cleaned the overbed table with bleach wipes and let the table dry over two minutes. A drape was placed on the table. Both staff members cleaned their hands and put on gloves. Supplies for the procedure were placed on the table by the RN. The resident was prepared for the procedure by the CNA. The RN stated the dressing was already removed during care by a CNA due to soilage. The RN proceeded to examine the wound with her gloved hands and expose the area to be cleansed. The nurse removed her gloves, cleansed her hands, and put on a new pair of gloves. Staff A, RN then cleaned the wound with normal saline and four by four sponges from inside of the wound to the outside of the wound using five wiping motions. No hand hygiene or change of gloves was noted after the dirty wound was cleaned. The nurse then applied skin prep to the peri wound area. The nurse then applied the [MEDICATION(S)] Blue to the inside of the wound. The nurse then applied the Allevyn dressing over the wound and secured it to the skin. The nurse then assisted to reposition the resident and replace the brief. No hand hygiene or change of gloves was noted prior to repositioning the resident after the procedure. The nurse removed her gloves, washed her hands, and placed a new pair of gloves on. The nurse then disposed of the garbage and cleaned the scissors and the table tray with bleach wipes. The nurse then removed her gloves, washed her hands, and left the room. An interview was conducted with Staff A, RN immediately after the wound care observation. The nurse confirmed she had not changed her gloves and washed her hands in between the cleaning of the wound and the application of the new dressing. The nurse stated she should have done so. A review of the policy titled, Clean Dressing Change, date last reviewed: [DATE] revealed the following: Intent: It is the policy of the facility to ensure change dressings in accordance with State and Federal Regulations, and national guidelines. Procedure: 11. Put on clean gloves 12. Remove dressings and place in the resident' trash can 13. Remove gloves and perform hand hygiene 14. Put on clean gloves 15. Cleanse wound with gauze and prescribed cleaning solution using single outward stokes. Use separate gauze for each cleansings wipe 16. Use dry gauze to pat the wound dry. 17. Remove gloves and perform hand hygiene 18. Put on clean gloves 19. Apply clean dressing as ordered and ensure the dressing is dated. 20. Remove gloves and perform hand hygiene 21. Reposition the resident and ensure the call light is in place. 22. Discard all disposable items into the appropriate receptacle 23. Clean the bedside stand/table with germicidal disposable cloth 24. Remove trash from resident' room 25. Wash and dry hands thoroughly 26. Document the completion of dressing change on the treatment record. On [DATE] at 10:38 a.m. an interview was conducted with the Director of Nursing (DON). She stated the nurse needed to wash her hands and change her gloves after cleaning the dirty wound and before placing the dressings. On [DATE] at 10:51 a.m. an interview was conducted with the Infection Control Preventionist. She stated she was informed about the error that occurred during wound care and confirmed hand hygiene and glove change should be performed after cleaning the dirty wound and before the nurse placed the clean dressings.

Based on interviews and record reviews, the facility failed to conduct ongoing COVID-19 outbreak testing in accordance with testing frequency parameters for one staff member (D) of three sampled staff members for COVID-19 testing. Findings included: An interview was conducted on 02/11/2022 at 11:24 a.m. with the facility's Infection Control Preventionist (ICP) and Nursing Home Administrator (NHA). The ICP confirmed the facility was in outbreak status that started on 12/11/21 and the last positive result for a resident was on 2/1/22 and for a staff member was 2/3/22. The ICP stated all staff in the facility were tested on ce weekly, and the NHA stated testing frequency was based off of the current guidelines. A request was made on 02/11/2022 at 12:02 p.m. for review of Staff D, Dietary's previous three COVID-19 testing results from the NHA. A review of Staff D, Dietary's COVID-19 testing results, dated 01/14/2022, revealed Staff D, Dietary tested negative for COVID-19. No other COVID-19 test results for Staff D, Dietary were provided by the NHA. An interview was conducted on 02/11/2022 at 12:21 p.m. with the NHA. The NHA stated Staff D, Dietary was recently hired on 01/07/2022 and addressed there was only one COVID-19 test result available. The NHA also stated he would check to see when the last time Staff D, Dietary worked and would follow up to see if any other results were available. A follow up interview was conducted on 02/11/2022 at 1:01 p.m. with the NHA. The NHA stated Staff D, Dietary last worked in the facility on 02/10/2022 and no other COVID-19 testing results were able to be found for Staff D, Dietary. A review of the facility policy titled, Testing Policy for COVID-19, last revised 05/21/2021, revealed under the section titled Staff Testing that staff members of the facility will be tested according to regulatory guidance. If a staff member is unable or unwilling to be tested , the individual will be removed from the schedule until test results can be provided.

Based on observations, interviews and record reviews the facility failed to ensure resident rights to privacy were maintained for 1 (#5) resident out of 2 residents observed for wound care related to failure to close the room door or privacy curtain while performing wound care to the resident's coccyx area. Findings included: Review of Resident #5's medical record showed that he was admitted most recently on 8/31/2020 with [DIAGNOSES REDACTED]. A wound care observation was conducted on 12/03/2020 at approximately 2:00 p.m. The resident's roommate, Resident #900 was in the room sitting on the side of his bed facing Resident #5. Resident #900 said, Wound care again. I should not have to watch this. I am getting out of here. Resident #900 transferred himself to his wheelchair and left the room. Staff D, Registered Nurse (RN) assembled the wound care supplies on top of barrier on a clean bed side table. Staff D and Staff E, Licensed Practical Nurse (LPN), both washed their hands and donned new gloves. Staff E, LPN using the controls located on the foot of the bed raised the resident's bed then assisted the resident onto his right side. Neither Staff D nor Staff E closed the room door or pulled the privacy curtain before starting the dressing change. Staff E changed the dressing to the resident's coccyx area and then with his gloves on assisted the resident back on to his back and pulled the sheet over the resident. Staff I, Certified Nurse's Aide (CAN) entered Resident #5's room with Resident #900 rolling himself to his side of the room. Staff I said, Why did you guys not shut his door or at least pull the privacy curtain? Staff D, RN then picked up the used supplies/wrappers from the bedside table and put them in the trash can. Staff D and Staff E both removed their gloves and washed their hands. Staff D then pulled the trash bag out of the trash can and walked out of the resident's room. Upon completion of the would care Staff D confirmed she should have closed the resident's door and pulled the privacy curtain before starting his wound care. A request for the facility policy for dignity was made to the Assistant Director of Nursing (ADON). A copy of the Bill of Rights for residents of nursing homes from their admission pack was provided. A review of the Bill of Rights for residents of nursing homes revealed: You, as a long-term care resident, have the right to: Be treated courteously, fairly, and with the fullest measure of dignity right to privacy in receiving treatment and in caring for personal needs . An interview was conducted on 12/04/2020 at 4:11 p.m., the ADON said, It is my expectation that during resident care that the door and privacy curtain if needed are closed to provide privacy for the residents.

Based on observations, interviews and record reviews, the facility failed to perform pressure ulcer care in a manner to promote healing and prevent infection related to not performing dressing changes according to standards of practice and to provide pressure relieving devices for 2 (#5, #20) residents out of 2 sampled for wound care. Findings included: 1.An observation was conducted on 12/01/2020 at approximately 10:48 a.m., Resident #5 was in his room, eyes closed, in bed with a hospital gown on. The resident was positioned on his back. An observation was conducted on 12/03/2020 at approximately 10:18 a.m., Resident #5 was in his room in bed positioned on his back. Review of Resident #5's medical record showed that he was admitted most recently on 8/31/2020 with [DIAGNOSES REDACTED]. Review of the Wound Care physician's visit report note dated 11/23/2020 showed the following: Focused Wound Exam Site 1: Stage 3 Pressure Wound with a duration of greater than 69 days. Wound size. 2.6 x 1.6 x 0.3 cm; Surface area 4.16 cm; Exudate: Moderate Serosanguineous; Slough 5%; Granulation tissue: This wound is in an [MEDICAL CONDITION] stage and is unable to progress to a healing phase because of the presence of a biofilm. Dressing treatment plan: [REDACTED]. Secondary dressing (s) foam silicone border and faced apply once daily for 16 days . Plan of Care reviewed and addressed: Recommendations: Off-loaf wound; Reposition per facility protocol; Low air loss mattress; Multivitamin once daily PO (by mouth); Vitamin C 500 mg twice daily PO. An interview was conducted on 12/03/2020 at 8:45 a.m., the Physician Assistant (PA) stated, If the physician ordered an air mattress then the facility needs to put one on. I am not familiar with Resident #20. You will need to check with her physician. The resident's current physician orders for wound care with an order date of 11/18/2020 and a start date of 11/19/2020 to cleanse the coccyx wound with sterile normal saline (SNS), pat dry, apply collagen sheet with Ag (alginate), calcium alginate, cover with (brand name) dressing once daily. A review of the physician orders and the treatment administration record (TAR) for 11/2020- to 12/02/2020 revealed there was not an order for [REDACTED].>An order dated 9/01/2020 with out a stop date documented, Restorative nursing to perform bilateral upper extremity active range of motion 2 x 10 reps at all joints and bed mobility with care giver assistance daily 6 x a week. A review of the care plan for Resident #5 documented under Category 16: Resident #20 has the potential for impaired skin integrity, at risk due to thin fragile skin with a Start Date of 11/21/2020. Resident has a pressure ulcer present coccyx: With a goal that the pressure ulcer will reduce to a smaller size within 90 days. Interventions included: Treatment as ordered, pressure relieving device in wheelchair cushion and pressure reducing mattress air, and alternating air mattress and to monitor site for infection-redness, swelling, drainage, foul smell, decline in function, reduced mobility. Report signs and symptoms of infection to the physician, all with a start date of 11/21/2020. A wound care observation was conducted on 12/03/2020 at approximately 2:00 p.m. Staff D, Registered Nurse (RN) assembled the wound care supplies on top of barrier on a clean bed side table. Staff D and Staff E, Licensed Practical Nurse (LPN), both washed their hands and donned new gloves. Staff E, LPN using the controls located on the foot of the bed raised the resident bed then assisted the resident onto his right side. Staff D, RN picked up the residents catheter and un-hooked it from the side of the bed and put it up on the bed. Staff E said, No this is not an air mattress. Staff D, RN removed the soiled dressing, placed it in a clear bag, removed her gloves, washed her hands, applied new gloves, cleaned the wound four times with SNS solution and a gauze 4x4 cleaning from the outside of the wound, wiping through the wound and up near the gluteal fold and did not change gloves after they were contaminated during the cleaning of the wound. Staff D after completion of the cleaning of the wound, removed her gloves, washed her hands, donned clean gloves, applied the prescribed calcium alginate and covered the wound with a foam bordered dressing. Staff E with his gloves on assisted the resident back on his back and pulled the sheet over the resident. Staff D, RN then picked up the unused supplies/wrappers from the bedside table and put them in the trash. Staff D and Staff E both removed their gloves and washed their hands. Staff D walked out of the resident room and said, I will have to call the physician to get an order for [REDACTED].>At approximately 2:30 p.m., on 12/03/2020 Staff D, RN was informed of the breaks in infection control that were observed during wound care. Staff D, RN said I understand what you are saying. You clean the wound from the inside out. I should have changed my gloves more often. At approximately 2:40 p.m., on 12/03/2020 the Assistant Director of Nursing (ADON) was informed of the breaks in infection control observed during wound care. She said that the nurses had been trained to do wound care. An interview was conducted on 12/ 0 at 9:20 a.m., Staff G, RN said, The beds we purchased have built in mattresses that can be turned into an air mattress, but a tube needs to be connected to it. No, the buttons on the foot of the bed only control the movement of the bed. Something needs to be attached to the bed to make it an air mattress. An interview was conducted on 12/04/2020 at 3:18 p.m., the ADON said, We put an air mattress on Resident #5's bed last night. I am not sure why there was not one on his bed. There was an order and he was care planned for one. At 17:07 p.m., on 12/04/2020 a copy of the physician orders for Resident #5 was provided by the Nursing Home Administrator (NHA) that revealed an order with a Start Date of 12/03/2020 for Air Mattress for pressure injury. 2. An observation was conducted on 12/03/2020 at 12:25 with Staff D, RN and Staff Resident #20 was in her room in bed lying on her back. The resident's caregiver was sitting at the bedside with a surgical mask on. The caregiver spoke up and said that the resident had just fallen asleep and asked that we come back later to change her dressing. The caregiver said, No she does not have an air mattress on her bed. An interview was conducted on 12/03/2020 at 12:28 p.m., Staff D, RN said, Resident #20's wound was like just a small opening. Then she returned form the hospital and now it is huge. It is on both sides of her coccyx. A review of the physician orders revealed an order dated 12/02/2020 for restorative nursing to perform bed mobility and transfers with CGA (care giver assistance) daily 6x/a week. A review of the care plan for Resident #20 documented under Category 16: Resident #20 has the potential for impaired skin integrity, at risk due to thin fragile skin with a Start Date of 12/01/2020. Resident has a pressure ulcer present coccyx: With a goal that the pressure ulcer will reduce to a smaller size within 90 days. Interventions included: Treatment as ordered, pressure relieving device in wheelchair cushion and pressure reducing mattress air, and alternating air mattress and to monitor site for infection-redness, swelling, drainage, foul smell, decline in function, reduced mobility. Report signs and symptoms of infection to the physician, All with a start date of 12/01/2020. A review of the current wound care orders for Resident #20 was conducted with Staff H, RN, who stated the order was for Santyl ointment 250 unit/gram topical ointment, Treatment Topical apply once daily to bilateral sacrum wound for open area. Cleanse area with Sterile normal saline (SNS), apply Santyl inside wound bed, apply gauze and cover with (brand name) for open area on sacrum. I do not see any wound measurements in the system yet. Maybe she has not been seen by wound care yet. A wound care observation was conducted on 12/04/2020 at 12:46 p.m., Staff H, RN cleaned the bedside table and assembled the wound care supplies and placed them on top of barrier on a clean bed side table. Observed on the foot of the resident's bed was an air mattress pump that was on and connected to the resident's mattress. A caregiver for the resident was sitting in a chair at the foot of the resident's bed. Staff H closed the door to the resident room and pulled the privacy curtain. Staff H, RN washed her hands and donned new gloves. Staff D rolled the resident onto her right side and removed the soiled dressing, placed it in a clear bag and removed her gloves. Staff H confirmed that the resident did not have an air mattress. The resident's coccyx area was red. Staff H removed her gloves and went into the resident bathroom to wash her hands. The caregiver said, I have wondered why she did not have an air mattress before since she has a wound. I guess they put it on her bed last night. Staff H then donned new gloves and cleaned the wound with sterile normal saline solution saturated 4x4 gauze. Staff H cleaned the wound 4 separate times, with clean gauze cleaning from the outside of the wound, wiping through the wound and up near the gluteal fold. Staff D, RN removed her gloves, washed her hands, donned clean gloves, applied the prescribed Santyl ointment and covered the wound with gauze and covered with (brand name). Staff H with her gloves still on positioned the resident back on her back and pulled the sheet up over the resident. Staff H removed her gloves, washed her hands. At approximately 1:10 p.m., on 12/04/2020 Staff H, RN was informed of the breaks in infection control that were observed during wound care. Staff H, RN said You're right, the wound should be cleaned from the inside out. Review of Resident #20's medical record showed that she was admitted most recently on 12/01/2020 with [DIAGNOSES REDACTED]. An interview was conducted on 12/04/2020 at 3:18 p.m., the ADON said, We put an air mattress on Resident #20's bed last night. I am not sure why there was not one on her bed. There was an order and she is care planned for one. An interview was conducted on 12/04/2020 at 5:37 p.m., the Medical Director said, If the physician ordered the air mattress then the facility should have provided one. An air mattress, it would help off load the pressure of the wounds. On 12/03/2020 at 1:59 p.m., the ADON confirmed that neither Resident #5 nor Resident #20's controls located on the foot of the bed for the air mattresses were on. I checked with the IP who went in and checked each of the resident's beds and confirmed neither of them were on. (photographic evidence was obtained). Review of the facility's procedure for Clean Dressing Changes revised 10/30/2019 showed Steps in the Procedure: 2. Perform hand hygiene and assemble equipment and supplies needed for dressing change. 5. Put on gloves. Adjust bedside stand/table to waist level. Clean bedside stand/table with germicidal disposable cloth. Establish a clean field. 7. Remove gloves and perform hand hygiene. 8. Set up supplies on barrier. 9. Position the resident for comfort. 10. Perform hand hygiene. 11. Put on clean gloves. 12. Remove dressing and place in the resident's trash can. 13. Remove gloves and perform hand hygiene. 14. Put on clean gloves. 15. Cleanse wound with gauze and prescribed cleaning solution using single outward [MEDICAL CONDITION]. Use separate gauze for each cleaning wipe. 16. Use dry gauze to pat the wound dry. 17. Remove gloves and perform hand hygiene. 18. Put on clean gloves 19. Apply clean dressing as ordered and ensure the dressing is dated. 20. Remove gloves and perform hand hygiene. 21. Reposition the resident and ensure the call light is in place. 22. Discard all disposable items into the appropriate receptacle. 23. Clean the bedside stand/table with germicidal disposable cloth. 24. Remove trash can from resident's room. 25. Wash and dry hands thoroughly . A review of the facility policy and procedure titled Infection Control-Hand Hygiene with a reviewed date of 10/30/2020 revealed: #3. The Centers for Medicare and Medicaid service operations manual indicates that hand hygiene should be performed: a. When coming on duty; b. Before and after performing any invasive procedure (e.g., finger stick blood sampling); c. Before and after entering isolation precautions settings; . d. Before and after assisting a resident with meals; e. Before and after assisting a resident with personal care; f. Before and after handling peripheral vascular catheters and other invasive devices; . g. Before and after inserting indwelling catheter; h. Before and after changing a dressing i. Upon and after coming in contact with the resident's intact skin (e.g. when taking a pulse or blood pressure, and lifting a resident); j. Before and after assisting a resident with toileting; k. After blowing or wiping nose; l. After contact with resident's mucous membranes and body fluids or excretions; m. After handling soiled or used linens, dressing, bed pants, catheters , an urinals semi colons after handling soiled equipment or utensils; n. After removing gloves or aprons; o. After completing duty.

Based on Observations, record review and interview the facility failed to 1) ensure that oxygen was administered according to the physician orders for one (43) of 3 sampled residents and 2) failed to ensure respiratory equipment used for inhalation therapy was maintained in a clean and sanitary manner for 4 (12/01/2020, 12/02/2020, 12/03/2020, 12/04/2020) out of 4 days for 1 (#42) resident out of 3 residents with inhalation therapy observed. Findings included: 1. Observations on 12/1/20 at 11:01 AM of Resident #43's room revealed that the residents oxygen tubing was noted to be wrapped around the oxygen concentrator . Closer observations revealed that the oxygen tubing was unlabeled and un-bagged. Observations of the residents room on 12/1/20 at 1:28 PM revealed that the oxygen nasal canella was attached to the oxygen concentrator with the excess oxygen tubing noted to be on the floor. It was noted that the oxygen tubing was unlabeled and un-bagged. Closer observation of the oxygen concentrator at this time revealed that the oxygen concentrator was set at 4 liters. Observation of resident #43 on 12/3/20 at 11:50 AM revealed that the resident was receiving oxygen from his oxygen concentrator which was observed to be set between 4.5 and 5. liters. Interview with the resident at this time revealed that he received continuous oxygen and that staff set up his concentrator. He reported that if he leaves his room then he uses the oxygen tank which staff also set up for him. At this time the excess oxygen tubing was noted to be lying on the floor. (Photographic evidence obtained) Review of the residence record revealed that the resident had a current physicians order for O2 at 3 LPM via NC Continuous every shift. Review of the residents care plan revealed that the interventions indicated the resident was to receive 2 liters of oxygen per minute. Observation of resident number #43 on 12/3/20 at 12:00 PM revealed that the resident was sitting in his room and he was receiving oxygen from his oxygen concentrator. Closer observations of the oxygen concentrator revealed that it was set between 4.5 and 5.0 liters per minute. Interview on 12/3/20 at 12:03 PM with the Assistant Director of Nursing (ADON) after reviewing the residents physician order revealed that the resident was to receive oxygen at 3 liters per minute. Interview on 12/3/20 at 12:05 PM with Staff A, RN revealed that the resident was to receive 3 liters of oxygen. Observations on 12/3/20 at 12:07 PM of the residents oxygen concentrator while in use by the resident with Staff A, RN and the ADON present in the room, the ADON inspected the oxygen concentrator and reported that the oxygen concentrator was running at almost 5 Liters She reported that it would be checked and changed to reflect the current physician orders. Interview on 12/3/20 at 12:10 PM with Staff A, RN revealed that the resident is on continues oxygen, and that she has worked with the resident for the past 2 days. She reported that the resident uses his oxygen tank when he is out of his room and that she checks the residents oxygen tank when he changes to it, but that she has not checked his concentrator. She stated that it is to be checked at least each shift. Interview on 12/3/20 at 12:11 PM with the ADON revealed that the expectation for the provision of oxygen is that the nurses are to follow physicians orders. Interview on 12/3/20 at 12:33 PM with the MDS Coordinator revealed that the care plan is based on physician orders and that the current care plan indicates 2 Liters. At this time the MDS Coordinator reviewed the resident's current physician orders and confirmed that the resident is currently on 3 Liters of oxygen and reported that she will update the residents care plan now to reflect his current order. 2. An observation was conducted on 12/01/2020 at 11:16 a.m., Resident #42 was in her room in bed. Observed the resident's nebulizer equipment for inhalation therapy stored in the top drawer of her night stand uncovered next to her brush and other personal items. (photographic evidence was obtained). The resident said, That is where the nurse's put it after they are done. An interview was conducted on 12/01/2020 at 2:48 p.m., The Infection Preventionist (IP) who said, Neb/pipes and respiratory equipment used for inhalation therapy, the nurses are supposed to clean them after use and put them in a plastic bag. The bags are supposed to be changed weekly. A review of the medical record for Resident #42 revealed a recent admission date of [DATE] with a pertinent [DIAGNOSES REDACTED]. The physician orders revealed a current order dated 10/19/2020 for [MEDICATION NAME] sulfate 0.63% mg/3 ml solution for nebulization vial inhalation as needed every 4 hours for shortness of breath. An observation was conducted on 12/02/2020 at approximately 11:30 a.m., Resident #42 was in her room up in her wheelchair. Observed the resident's nebulizer equipment for inhalation therapy stored in the top drawer of her night stand uncovered next to her brush and other personal items. (photographic evidence was obtained). An observation was conducted on 12/03/2020 at approximately 8:40 a.m., Resident #42 was in bed with her oxygen on. Observed the resident's nebulizer equipment for inhalation therapy stored in the top drawer of her night stand uncovered next to her brush and other personal items. (photographic evidence was obtained). An interview was conducted on 12/04/2020 at 8:33 a.m., with Staff H, Registered Nurse (RN) who said, After the resident completes a respiratory treatment the nurses are supposed to clean out the equipment, dry it off and put it back in the plastic bag that should be kept at the bedside. An observation was conducted on 12/04/2020 at approximately 12:50 p.m., Resident #42 was up in her wheelchair sitting next to her bed. Observed the resident's nebulizer equipment for inhalation therapy stored in the top drawer of her night stand uncovered next to her brush and other personal items. (photographic evidence was obtained). An interview was conducted on 12/04/2020 at 5:28 p.m., The ADON said, All nebulizer and oxygen equipment is to be stored in a bag. I am not sure when the last time it was used but it should not matter. We have a company that comes in and takes care of our respiratory equipment. A review of the facility policy titled Infection Control-Cleaning and Disinfection/Non-Critical care and shared equipment last reviewed on 10/30/2019 revealed, Intent: It is the policy of the facility to ensure that appropriate infection prevention and control measures are taken to provide a safe, sanitary, and comfortable environment to prevent the spread of infection in accordance with State and Federal Regulations and National guidelines.

Based on observations, interviews and record reviews, the facility did not accommodate dietary preferences and intolerances for one (Resident #40) out of five sampled residents. Findings included: Resident #40 was admitted to the facility with a [DIAGNOSES REDACTED]. A review of Resident #40's quarterly minimum data set ((MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 9 signifying moderately impaired cognition. Section K on Swallowing and nutritional status showed diet orders of Regular diet, Lactose free. On 12/03/20 at 8:30 a.m., Resident #40 was observed in her room eating breakfast, her cereal bowl was full however she was not eating the cereal. Resident #40 stated, they gave me the wrong milk. I don't drink that. A regular milk carton was observed on her tray. On 12/03/20 at 12:18 p.m., another observation was made of Resident #40 being assisted with her meal by Staff C, Certified Nurse's Aide (CNA). Staff C, CNA told resident #40 that she did not receive milk with her tray. A review of Resident #40's meal ticket dated 12/03/20 revealed the following statement, sorry, out of lactose milk, waiting on delivery. The meal ticket also confirmed that Resident #40's diet included a lactose free diet. A review of physician's orders [REDACTED].#40 was Lactose intolerant. Resident #40's Care Plan dated 07/23/19 under nutrition showed a goal to maintain nutritional status at optimal level possible with an approach to honor food preferences as applicable. The plan further confirmed a lactose free diet was ordered. A review of the dietary pre-interview screen dated, 11/25/19 under food allergies [REDACTED].#40 was lactose intolerant. On 12/03/20 9:32 a.m., an interview was conducted with the Registered Dietician (RD). She confirmed that the resident was lactose intolerant and should not have been served regular milk. An interview with the Minimum Data Set (MDS) Coordinator conducted on 12/03/20 at 09:59 a.m. also confirmed that Resident # 40 should be served a lactose free diet. A follow-up interview was conducted on 12/03/20 at 12:12 p.m. with the Certified Dietary Manager (CDM). CDM reported that the truck delivery arrived this morning and the lactose milk was back ordered. When asked if there was a plan to meet the resident's needs in circumstances like those, CDM stated that they would go to the grocery store and get a gallon of milk. On 12/04/20 12:37 p.m. another interview was conducted with the RD who reported that Resident # 40 was not served lactose free milk this morning again because the truck still had not come. A review of the facility's policy titled, Food and Nutrition Services dated 10/22/20, states that the facility will provide each resident a nourishing diet that meets special dietary needs including preferences.

Based on observations, interviews and record reviews, the facility did not provide assistive devices to ordered maintain independence during meals for one (Resident #40) out of five sampled residents. Findings included: Resident #40 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A review of Resident #40's quarterly minimum data set ((MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 9 indicating moderate cognitive impairment. A review of Resident # 40's Care Plan with a start date of 7/23/19 revealed a nutritional risk related to certification of terminal illness, therapeutic diet, and a history of weight loss. The goal is noted to maintain nutritional status at most optimal levels. Approach number 12 states to offer a lipped plate. During an initial tour of hallway 112-128 on 12/01/20 at 9:50 a.m., an observation was made of resident #40 in her room eating breakfast, served in a regular plate. Her meal plate was noted to be full. On a subsequent visit on 12/01/20 at 11:14 a.m., Resident #40 was observed sitting in bed, breakfast tray in front of her and the meal not touched. An interview with the resident revealed that Resident #40 did not know if she needed assistance with meals or what specialized equipment was prescribed in her care plan. On 12/02/20 08:49 a.m., Resident #40 was observed sitting in bed, eating breakfast without a lipped plate and with regular silverware, photographic evidence obtained. On 12/03/20 at 09:32 a.m., an interview was conducted with the Registered Dietician (RD) who confirmed that Resident #40 should have been served with a lipped plate and that a lipped plate was ordered for all meals. A follow-up interview was conducted with the Rehabilitation Director on 12/03/20 at 09:39 a.m. who stated that the lipped plate was ordered on every meal effective 10/16/20 for Resident #40. On 12/03/20 at 09:59 a.m., an interview with the Minimum Data Set (MDS) Coordinator was conducted. MDS stated that Resident #40 should have a lipped plate all the time. A review of Resident's 40's meal ticket order dated, 12/03/20 under equipment showed to provide a lipped plate. A review of the physician's orders [REDACTED].#40 is to be provided a lipped plate with all meals. A review of the facility's policy titled, Food and Nutrition Services dated 10/22/20, states that the facility will provide special eating equipment and utensils for residents who need them.

Based on observation, interview, and record review, the facility failed to clean and sanitize the facility's multi-use dishes and utensils, by both mechanical dishwashing and manual washing dishwashing. This practice effected 62 residents who consumed the facility's food, out of 63 residents residing in the facility, from 8/10/14 to 9/25/14 at 5:14 p.m. The facility's failure to sanitize the dishes and utensils posed the likelihood of serious and immediate threat to the health of the residents. Nursing home residents are highly susceptible to acquiring foodborne illness, according to the Food and Drug Administration (FDA), Food Code. Foodborne illness may cause serious illness, such as gastrointestinal infection, resulting in vomiting and diarrhea: invasion of the bloodstream with virulent bacteria and toxins: and subsequent [DIAGNOSES REDACTED] disorders, and death. The nursing home failed to identify that the facility's hot water sanitizing dish machine was not properly sanitizing their multi-use dishes to ensure that microorganisms on the dish surface are reduced to levels considered safe for the consumer. Additionally, the facility failed to provide managerial oversight to ensure that the staff responsible for the dishwashing process were following proper procedures for washing and sanitizing multi-use dishes. The facility failed to ensure facility staff were using their alternate method properly for hand sanitizing multi-use dishes, after they discovered their dish machine was not properly sanitizing the resident's dishes on 9/22/14. The residents who consumed food from multi-use dishes from these unsanitized dishes could have potentially acquired foodborne illness, from microorganisms such as Salmonella species, Staphylococcus aureus, and [MEDICATION NAME] bacterium, which can cause serious illness and/or death. Additionally, the facility failed to properly manually sanitize pots and pans in the three compartment sink and the facility failed to change soiled gloves before handling clean dishes which contaminated the clean dishes. This systems failure created an immediate and serious threat to residents, which required immediate corrective action on the part of the facility. The immediate jeopardy beginning on 8/10/14; was identified on 9/23/14 and was removed on 9/25/14 as a result of corrective action taken by the facility. Additionally, the facility failed to serve food in a sanitary manner, in that the facility staff used bare hand contact with ready to eat foods. The facility failed to ensure exposed food and clean equipment and utensils were protected from contamination from leaking soiled ceiling vents and failed to protect clean dessert dishes from contamination from a curtain. The facility failed to clean the exterior surfaces of a walk-in-freezer. Record review revealed that there are no residents with organ transplants. No residents receive [MEDICAL CONDITION] or [MEDICAL CONDITION]. The ADON provided a listing indicating: 11 residents receive antibiotics; 8 residents have [DIAGNOSES REDACTED]. The Nursing Home Administrator (NHA) was notified on 9/23/14 at 1:58 p.m., the facility had ongoing immediate jeopardy (IJ) related to the dishwasher temperatures dating back to 8/10/14. The findings include: During the initial kitchen tour on 9/22/14 at 10:00 a.m. the following was observed: A black substance residue covered 4 vents located above the facility ' s dish washer and three compartment sink area. The vents were leaking water- like substance on top of the clean dishes. Pans and pots were not fully submerged into the sanitzer solution in the three compartment sink. Staff P, dish room worker, was asked how long he was supposed to place plates and dishes in the chemical solution. Staff P stated on 9/22/14 at 10:12 a.m., " 20 Seconds. I have been working here for 3 weeks. (Staff G ' s name) trained me to do the dishes. " The Director of Dining Services, on 9/22/14 at 10:15 a.m., said that the Maintenance Director was aware of the issues with the vents and he was supposed to come and clean everything this coming Thursday. Staff G was observed operating the dish washer on 09/22/14 at 10:25 a.m. She stated on 9/22/14 at 10:25 a.m. " I was unaware that vents were leaking water to the clean dishes. " During an observation of the dish machine on 9/22/14 at 10:28 a.m., the rinse temperature was 161 degrees Fahrenheit (?F) and the wash was 155 ?F. The second tray went through the dish machine and the wash was 155 ?F and the rinse was 172 ?F. The minimum dishwashing temperatures for the final rinse should be 180 degrees F. The Director of Dining Services stated during the observation on 9/22/14 at 10:28 a.m., " this is a high temperature machine." "We do not use chemicals. " Conflicting information was observed due to the sticker on the lower part of the dishwasher which indicated: ? Wash Tank temperature 140 ?F final. ? Final rinse temperature 140 ?F final ? Flow pressure 20 + - 5 PSI ? Minimum chlorine required 50 parts per million (PPM) And per instructions posted on the wall on a poster: ? For low temperature 120/140. degrees F ? High temp wash:150-160 ?F ? High temp final rinse: 180-190 ?F The Executive Chef stated on 9/22/14 at 10:36 a.m., " I noticed the issue on Friday (9/22/14) and told the staff to do the dishes twice. I made a call on Friday. Someone was to come here to check it. I told the supervisors over the weekend to check on it. I do not remember their names. I will tell them to hand wash the dishes until the tech comes in. " The practice of washing the dishes twice through the dishmachine will not sanitize them, if the rinse temperature does not reach 180 degrees F. Staff G, the dishwasher, was asked on 9/22/14 at 10:39 a.m., if anyone had told her to wash the dishes twice. She stated on 9/22/14 at 10:39 a.m., " No one told me to do the dishes twice. " During an observation on 9/22/14 at 10:46 a.m. the kitchen staff was running dishes in the dishwasher after surveyors were told they would be hand washed. The Director of Dining Services stated on 9/22/14 at 10:46 a.m., " That does not make any sense it is better to hand wash them. " During an observation on 9/22/14 at 10:46 a.m., a dusty curtain was on top of the clean dessert plates. During an interview on 9/22/14 at 11:10 a.m., the Certified Dietary Manager (CDM) said if anyone is in isolation they use disposable trays and dishes. During an observation on 9/22/14 at 11:30 a.m. there was a black residue on the freezer ' s exterior, behind the rack of clean pans and pots. The dishwasher company technician arrived on 9/22/14 at 12:26 p.m. for dishwasher maintenance. He stated on 9-22-14 at 12:26 p.m.; " I got a call an hour ago and here I am. I come here every month. This is a high temperature machine. The wash (temperature) is at least 150 ?F and the incoming water was 140 ?F and that affected the overall temperature. It is fixed now. Two weeks ago the Executive Chef called me. I walked him through the process to reset the equipment. It was because of a bad storm we had here. The data posted on the sticker on the dish machine is incorrect. I brought that one because the other one was worn off. They were supposed to use the one posted on the wall. This has been a high temp machine since August 2011. " The technician then removed the incorrect data sticker and a non-readable plate was present on the dish machine. A request was made for work orders and services reports related to the dish machine for the last 6 months to be provided for review. The following documentation was provided by the facility for review identifying the following issue at time of service: Service date: 9/22/14 - Wash 163 ?F and rinse 185 ?F. Pressure was 30 and it was adjusted to 25. The three compartment sinks was PPM 200. During an interview with the Director of Dining Services he stated on 9/22/14 at 12:29 p.m., " We do not have any min-max thermometers (irreversible registering thermometer) or other thermometers to troubleshoot. " The facility indicated that they did not have a process or system in place to troubleshoot temperature issues. Record review of Temperature Logs of the dish machine temperature and pressures with recordings of temperatures taken at non-specific times and referred to on the log as AM, Noon and PM from January 2014 to September 22, 2014 revealed these issues: 8/10/14 Final rinse 136 degrees F in the A.M. Final rinse 136 degrees F at noon, and 136 degrees F in the P.M. 8/24/14 final rinse 175 degrees F at noon, and 179 degrees F in P.M. 8/25/14 Final rinse 136 degrees F in A.M., 140 degrees F at noon, and 140 degrees F in P.M. 8/26/14 Final rinse 142 degrees F in A.M., and 138 degrees F at noon, and 150 degrees F in P.M. 8/27/14 Final rinse 139 degrees F in A.M. 8/28/14 Final rinse 136 degrees F in A.M., 138 degrees F at noon 8/31/14 Final rinse 136 degrees F at noon and 138 degrees F in P.M. 9/1/14 Final rinse 137 degrees F in A.M., 132 degrees F at noon, 140 degrees F in P.M. 9/2/14 Final rinse 142 degrees F in A.M., 136 degrees F at noon, 140 degrees F in P.M. 9/3/14 Final rinse 139 degrees F in A.M. 140 degrees F in P.M. 9/4/14 Wash 140 degrees F at noon, wash 140 degrees F in P.M.: final rinse 145 degrees F in A.M., 135 degrees F at noon, 138 degrees F in P.M. 9/5/14 Wash 138 degrees F in A.M., 140 degrees F at noon, 138 degrees F in P.M.: Final rinse 140 degrees F in A.M., 140 degrees F at noon, 140 degrees F in P.M. 9/6/14 Wash 139 degrees F in A.M.: Final rinse 142 degrees F in A.M., 140 degrees F at noon, 140 degrees F in P.M. 9/7/14 Final rinse 138 degrees F in A.M., 140 degrees F at noon, 140 degrees F in P.M. 9/8/14 Wash 148 degrees F in A.M., 138 degrees F at noon, 139 degrees F in P.M.: Final rinse 132 degrees F in A.M., 139 degrees F at noon, 142 degrees F in P.M. 9/9/14 Final rinse 126 degrees F in A.M., 126 degrees F at noon, 130 degrees F in P.M. 9/10/14 Final rinse 138 degrees F in A.M., 138 degrees F at noon 9/11/14 Final rinse 144 degrees F in A.M., 140 degrees F at noon, 140 degrees F in P.M. 9/12/14 Final rinse 140 degrees F in A.M., 142 degrees F at noon, 140 degrees F in P.M. 9/13/14 Final rinse 140 degrees F in A.M., 142 degrees F at noon, 140 degrees F in P.M. 9/14/14 Final rinse 138 degrees F in A.M., 140 degrees F at noon, 135 degrees F in P.M. 9/15/14 Final rinse 138 degrees F in A.M., 158 F degrees at noon, 152 degrees F in P.M. 9/16/14 Final rinse 148 degrees F in A.M., 142 degrees F at noon, 158 degrees F in P.M. 9/17/14 Final rinse 168 degrees F in A.M., 158 degrees F at noon, 155 degrees F in P.M. 9/18/14 Final rinse 157 degrees F in A.M., 152 degrees F at noon, 155 degrees F in P.M. 9/19/14 Final rinse 168 degrees in A.M., 162 degrees at noon, 165 degrees in P.M. 9/20/14 Final rinse 162 degrees F in A.M., 155 degrees F at noon, 160 degrees F in P.M. 9/21/14 Final rinse 158 degrees F in A, M., 160 degrees F at noon, 159 degrees F in P.M. 9/22/14 Final rinse 158 degrees F in A.M. A request was made on 9/22/14 at 12:25 p.m., for the facility ' s policies and procedures for mechanical dishwashing and hand washing dishes. A request was made at the same time for the job descriptions and in- service trainings for all the dish room workers. On 9/22/14 at 12:31 p.m. a leak was observed beneath the sanitizing compartment, near the drain pipe, of the three compartment sink. The pipe was broken and water was flooding the floor. Boxes of delivered food products were observed stored on the floor in the water. On 9/22/14 at 12:33 p.m., the Director of Dining Services and Executive Chef said that the leak had begun this morning. The Director of Dining Services stated on 9/22/14 at 12:34 p.m., " the Chef and supervisor are to check the (dishwashing temperature) log 3 times a day; they are to check for accuracy. On the weekend we had two supervisors since the Chef and me we do not work on weekends. It is (Staff H ' s name) and (Staff I ' s name). " During an interview on 9/22/14 at 12:35 p.m., the dining supervisor, Staff I, stated " I never was told to check the temps. I have been here for 2 years. I don ' t even know how to do that. " During an interview on 9/22/14 at 12:40 p.m., the dishwasher, Staff G, stated " this is not my department. (Staff K ' s name) is the one who does that, not me. I think is (Staff K and J ' s names). " During an interview on 9/22/14 at 12:49 p.m., Staff K stated " I am here and see it twice a day. It is the responsibility of whoever is in the kitchen. If they have issues they have to go to their supervisor. I worked on the weekend. (Staff J and I ' s names) checked it at: 7:30 a.m., 3:30 p.m., and 8:30 p.m. You are supposed to leave everything to sanitize 5-6 minutes. That is the contact time. " The Assistant Director of Nursing (ADON) on 9/22/14 at 2:08 p.m. was requested to provide information related to infections tracking and trending for month of August and September 2014. She stated that she would return with a book. On 9/22/14 at 2:36 p.m. the nursing home administrator (NHA) asked " what specific information do we need? " The surveyor explained what was needed. The NHA stated " I will put something together for you. " The ADON provided the requested documentation on 9/22/14 at 2:44 p.m.; No Gastrointestinal (GI) issues were documented. It was identified that the report indicated no respiratory infections for the month of August 2014. There was a resident that had pneumonia and had received antibiotics in August 2014. The ADON said on 9/22/14 at 2:45 p.m. that her computer had been out of order since last Thursday and no one in the building had access to the software she utilized to monitor infections. On 9/22/14 at 4:38 p.m., during an interview with the facility ' s controller ( who was responsible for the financial management of the entire Continuing Care Retirement Community Campus, and was the former Nursing Home Administrator) he stated " It ' s impossible to get this kind of temperatures with such a drastic difference unless the machine was broken. But it is not broken; it works as it was intended. As far as using the machine the kitchen supervisor is training the staff and he will do it himself and he will show them (staff) how to use the machine. The dishwasher is responsible of taking the temperatures 3 times a day. However the staff were trained is not correct. We do not have a written policy or training. When someone gets hired we have a general kitchen supervisor or a senior employee that will take about 2 hours to train them. After a day someone in that position is capable to operate the machine by themselves. It is the same process for the three compartment sink. No specific in-service is available for you to review. All staff are trained in infection control in their general orientation. We have no training, no in-services, no policies and procedures they have to follow. The Director of Dining Services and the Certified Dietary Manager (CDM) are responsible. If something happens on the weekend they talk to shift supervisors. They call someone like the Chef if it ' s needed. (Staff I and J ' names) worked over the weekend. The log was supposed to be looked at by the supervisor. QA&A (Quality Assessment and Assurance) is a month behind. It would have been caught in that meeting but should have been caught as it happened. We need to do an internal training. " During an interview on 9/22/14 at 4:55 p.m., the nursing home administrator (NHA) said he was not aware of the temperatures of the dish machine after lunch, but the dishwasher service tech said there was nothing wrong. He said the dishes were washed at the proper temperature. The NHA said he was assuming the temperatures were fine at lunch because the tech said there was nothing wrong. The NHA became aware of the low temperatures this morning when the Director of Dining Services approached him. The NHA said the plan was to hand wash dishes after he found out there was a problem. He stated that this has not been an issue prior and has not been through QA&A. The NHA was asked to provide in- services where staff was educated that they needed to wash the dishes by hand. The NHA said he has to get with the Director of Dining Services on that. The NHA said he had not observed that the dishes were being washed by hand or staff was in-serviced or any other over sight of the issue. He stated " No GI (gastrointestinal) problems to my knowledge " . We go through that in QA&A. In August I do not believe we had any GI problems. The NHAs expectation of staff for a problem with the dish machine was, first address the situation, get the equipment fixed, implement any interventions to prevent infection which would be to hand wash the dishes. The kitchen supervisor would instruct staff. The NHA should be notified immediately. The NHA was not notified on Friday that there was a problem with the dish machine temps. The NHA was not aware if the kitchen supervisor had ever educated the staff on sanitizing dishes by hand. The NHA stated that the Director of Dining Services was new. The former Director of Dining Services left on a Thursday and the new Director of Dining Services started the following Monday. During an observation on 9/22/14 at 5:15 p.m., a basket was full of dirty linens next to clean plates. The Executive Chef stated at the time of the observation, " It was brought here. These are the linens from the independent living. I do not know why they brought and left them here instead of the laundry. " During an interview on 9/22/14 at 5:16 p.m. with the Director of Dining Services he stated: " I oversee everything. I became aware of the problem today. I spoke to the Chef, he was aware Friday that there was a problem with the pressure. On Saturday the Chef noted that there was a problem with the temperatures. He told the house supervisor. Today, I instructed staff to wash the dishes by hand at approximately 10:00 a.m. There was no in-service sheet. We have a sanitation sheet. Theoretically, we should go behind the others (staff) and be sure that they are checking the sanitation in the three compartment sink. Everything should be fully submerged. Breakfast dishes were washed by the dish machine. The dishes were washed again by the dish machine. I cannot answer if all the staff were trained on the dishwashing machine or sanitizing or going to paper products. We always have paper products available but I ' m not sure of the quantity. " During an observation on 9/22/14 at 5:19 p.m., dripping water was coming down from the ceiling vents that were covered with black residue. The water was going onto the clean plates that were placed in a rack. During an interview on 9/22/14 at 5:20 p.m., the dishwasher, Staff L, stated " I have been working here for 3 months. (Staff Q ' s name) trained me to do this job. No I did not get any other in-services since I got hired. " Staff M was observed working in the three compartment sink on 9/22/14 at 5:20 p.m. He stated, " I leave everything in to get sanitized 3 minutes. (Staff N ' s name) trained me. No, they (facility) did not provide any additional training since then. " Staff N stated on 9/22/14 at 5:22 p.m., " I have worked here a year give and take. I leave everything to get sanitized 3-4- minutes. I do not remember who trained me. " During an interview on 9/22/14 at 5:23 p.m., the Director of Dining Services stated " It is supposed to only be 20-30 Seconds sanitation. (The minimum required contact time for dishes using chemical sanitatizer solution is 30 seconds). I did not do any additional in-service today. The new dish machine data plate with the specifications was on its way and should be here by Wednesday (9/24/14). Everything should be fully submerged. All dishes were washed in the dishwasher since the tech fixed the issue. We have paper products available, I am not sure of the quantity since I am new here. Friday we called for the pressure. I know the Executive Chef passed by the facility on Saturday. He told whoever was here (did not know whom) that the tech will be here at 10:00 a.m. (Staff Q and K ' s names) got an in-service after the fact today. " Staff Q was asked if he was responsible of taking temperatures. Staff Q stated on 9/22/14 at 5:40 p.m., " I have never done that. Just the PPM (sanitizer solution in the three compartment sink) and utilities. I have never been trained for observation in the kitchen. I am responsible for the utilities, changing soap, etc. " On 9/22/14 at 5:45 p.m., during a random dining observation in the Royal Palm Dining Room, Staff Y buttered the bread for a resident with her bare hands. On 9/22/14 at approximately 6:01 p.m. Staff Y confirmed that this was her usual practice for buttering rolls for the residents. Staff Y then picked up the bread with her bare hands and fed the resident the roll with her bare hands. During an observation on 9/23/14 at 7:57 a.m., the kitchen ceiling vents continued to be dirty. No water was observed leaking at time of observation. On 9/23/ 14 at 11:57 a.m., during an interview the maintenance director stated he does not know how to check the dish machine temperatures and if there were any problems with the machine the contractor was called because the machine was leased. During an observation on 9/23/14 12:00 p.m., Staff L was working at the dishwasher. Staff L said he was trained by (Staff Q ' s name) in July 2014. Staff L said that training in July was the only training he had received on the dish machine and dish machine temperatures. Staff L was asked what he would do if he were checking dish machine temperatures and a temperature was out of range or there was an irregularity. He stated he would call his supervisor and report it. Staff L was asked if he has been assigned to check the temperatures in September or August. He stated he had not been assigned until today, 9/23/14, to check the dish machine temperature. During an interview on 9/23/14 at 12:07 p.m., the Executive Chef said that he talked to them (staff) last night and this morning. The Chef said that he did not have documentation of the education he had provided yesterday or today and that the staff did not sign- in. During a telephone interview on 9/23/14 at 12:20 p.m., the dishwasher service technician stated, " The incoming temp was kind of low close to 125 ?F to 130?F. The incoming supply to the booster heater that was required was kind of low so it was adjusted so it would go up to 190 ?F. I got an appropriate reading. Two weeks ago the facility called in for the booster heater. It needed to be reset. It was because of an electrical storm. I just asked the Chef to reset it. Yesterday I left at 3:30 p.m. I placed an order for [REDACTED]. It ' s a high temperature dish machine and the matching appropriate wash is 150 ?F and 180 ?F for final rinse. The machine at one time was low temperature machine sanitized with chlorine. Since August 1, 2011 the dish machine has been a high temperature machine. I had to fix the water pressure because it was running kind of high, it was 29-30 pounds per square inch (PSI). I adjusted it to 25. I arrived at the facility around noon. I received the service and maintenance call on 9/23/14 at 10:02 a.m. On 9/22/14 at 2:07 p.m. the wash reading was 163 ?F, the rinse reading was 185 ?F, and the pressure was 30 and ppm 200. The last prior visit to the facility was on 8/4/14 and the readings were within normal range. " The facility has a rental agreement for the facility dish machine with the leasing company dated 10/30/07. Equipment specification review revealed that the minimum wash temperature should be 106 degrees F and the minimum rinse temperature should be 180 degrees F. Flow pressure (PSI) indicated as 20 + or - 5 PSI. During an interview on 9/23/14 at 1:49 p.m., the NHA said there is no Department of Health (DOH) (The Florida State agency responsible for food safety inspections in community residential facilities) inspection for the kitchen since 2010. During an observation on 9/23/14 at 4:47 p.m., Staff O was wearing gloves. He was observed rinsing down dirty plates with his gloves on. He placed the dishes in a rack and he ran the dishes through the dish machine. The Executive Chef was present at time of observation. The Chef stated " 6 times a day the dishwashers (staff) will take the temperatures. Then the supervisor will be here and they will write down the temperatures. They will have to initial the form. Everyone has begun to be educated about everything. " Staff O was observed on 9/23/14 at 4:50 p.m., using the same gloves he had been wearing to rinse the dirty plates as he took the clean plates from the dishwasher and placed them on trays. Staff O was asked " how often do you change gloves? " He stated, " When I go to the other side. He pointed to the three compartment sink. Staff O was asked " Do you use the same gloves when you rinse the dirty plates and take the clean plates off the machine? " Staff O stated " yes I just wash my hands " and he proceeded to wash his hands with the dirty gloves on. During an interview on 9/23/14 at 5:05 p.m., the Director of Dining Services stated " I do not understand why he said that (Staff O). The process is that they have to use gloves. They have to change when they go from clean to dirty dishes and the other way around. " During the interview a request was made for the in-service training in proper glove usage for all staff working in the dish room. The food services director stated " I am new here, I do not know. They (facility) must have it. " During an interview on 9-24-14 at 9:36 a.m., the Director of Dining Services stated " Staff was supposed to use water proof thermometer ( not specifically an irreversible registering thermometer which is required to measure the highest temperature) or the thermal strips that we have on order and that are on their way; after we identified the issue yesterday I re-educated the P.M. staff for proper use of gloves. We also modified the dish machine log to include the pressure. " Staff G said on 9/24/14 at 9:43 a.m. she has be reeducated on both dish washer and appropriate use of gloves and gave appropriate answers when she was asked what proper temp for wash and rinse was. She was observed changing gloves when she went from rinsing dirty plates to taking the clean plates out of the dishwasher. During an interview on 9/24/14 at 12:47 p.m., the Medical Director was asked if anyone had called him or told him if they had any issues related to low temperatures in the dishwasher. He stated " This will be part of our QA&A, but I do not recall any issues of that kind. I am here every week and one of my staff comes here as well. If there was something going on they would have told me. " Interviews were conducted with the CDM and registered dietitian (RD) on 9/24/14 at 1:52 p.m. The RD said that she is the substitute dietitian. She said she had started working here in January 2014 and had come back in September 2014. The CDM stated that she participates in the QA&A meetings. She stated on 9/24/14 at 1:52 p.m., " I do not recall any issues with the temperatures. " The RD did not recall any issues either. The RD stated that when she comes to the facility she goes to the kitchen to get a feeling of how things run. She did not see anything out of the ordinary. The RD stated that we had no issues with GI, vomiting, diarrhea, weight loss that she could recall. The CDM said the Executive Chef was responsible for training the new employees. The previous director before him was responsible for training the new employees. The CDM stated that she was responsible for the tray lines and the clinical. The executive chef was a CDM ( CDM are Certified Food Protection Professionals (CFPPs), who are trained in food safety- www.cdmcareer.info) and he was responsible for the training and the kitchen aspect. " I do the in-services for the tray delivery for my department only. I have a sign- in log. If the Chef was not here the food service director should have the information needed. If someone was on isolation we would use disposable dishes. No one was in isolation at the moment. No one had a [DIAGNOSES REDACTED]. " During an observation on 9/24/14 at 5:49 p.m., Staff M said he had been re-educated and knew the appropriate temperatures when he was asked. The Director of Dining Services stated on 9/24/14 at 5:52 p.m., " We got the strips (heat sensitive stickers) so we can get the temperature test strip run. " During an interview on 9/24/14 at 5:59 p.m., the Executive Chef stated that he was responsible for all training and he stated, " Usually I have a senior employee training them for 3 shifts before they go on the floor. We don ' t have documentation of training or a check list. This is my 3rd director in a year and a half. They take everything when they leave. From now own I will make copies. " During the Quality Assurance survey process interview on 9/27/14 at 8:30 a.m., the NHA stated: ? " How current action plans are being implemented. Today the CDM brought an issue with dirty linen and a stain and it wasn't caught when they were changing tablecloths. She is in-serving staff and writing a performance improvement plan. The CDM is also working on room tray cart timing. We are tracking the improvement in timing. The CDM identified the issue when she was doing her audit. As a management team we identified an issue with an outdated call-light system. We had put a halt on it due to our survey window. Since it is delayed we do a call light functionality test daily. The CNAs team up and one stands outside and the other checks the light. It is normally associated with bathing and they will do it then. I can't think of any others at this time. There is an action plan for the kitchen. We are going to continue the monthly servicing. We are expanding the training from dishwashers to all kitchen staff, how to read the gauges, what to do in an emergency, the proper methods of the three compartment sinks, washing pots and pans and the proper use of gloves. That training is for all appropriate dining services staff and they cannot work until trained. The temperatures are checked 3 times per day. The immediate supervisor must verify the temps to continue to use the machine. The Medical Director was here Thursday and informed. I don't know if he had issues or concerns. I saw him at the tail end of the discussion. The NHA is responsible for the oversight due to being the quality assurance officer. ? Issues taken through the committee which have improved: ? Room tray time. We reduced the time to deliver trays. It has improved to an average to ten minutes which was our goal; we are continuing to monitor to keep the 10 minute delivery time consistent. ? We did a mock QIS survey this month. We only got through stage 1. We were in the process when you guys came in. We do the mock survey ourselves; we do not use the consultants. The RD consultant dietician did a walk through this month and showed me what to look for. We did not identify the issues with the dish machine logs. The RD comes to the facility weekly and once per month she does an in-depth walk through of the kitchen. Resident choices were ongoing but there was no current action plan. " According to the Centers for Disease Control (CDC) using 2012 data, there were 4,563 hospitalization s and 68 deaths among infections with pathogens that are commonly transmitted through food. Among those affected, those aged [AGE] years and older were hospitalized the most frequently and had the highest death rate among the other age groups. (http://www.cdc.gov>). The Food and Drug Administration found that salmonella, a common food borne infectious organism, may cause acute symptoms of nausea, vomiting, abdominal cramps, diarrhea, fever and headache. Other complications included chronic symptoms which may commence approximately four weeks after infection and are arthritic like changes, and acute [MEDICATION NAME]-like symptoms in which the mortality rate for some strains is up to 15 percent. It further reported that symptoms are most severe in the elderly. (http://www.fda.gov>). The top five disease-causing microorganisms contributing to foodborne illness in the US are (in descending o

Based on observation, interview of the kitchen staff and facility Administration, record review, and review of administration job duties, the Administrator failed to ensure facility staff followed procedures to ensure resident safety when the facility staff systematically failed to recognize, report, and act upon the serious threat to the residents. The facility failed to clean and sanitize the facility's multi-use dishes and utensils, by both mechanical dishwashing and manual washing dishwashing. This practice effected 62 residents who consumed the facility's food, out of 63 residents residing in the facility, from 8/10/14 to 9/25/14 at 5:14 p.m. The facility's failure to sanitize the dishes and utensils posed the likelihood of serious and immediate threat to the health of the residents. Nursing home residents are highly susceptible to acquiring foodborne illness, according to the Food and Drug Administration (FDA), Food Code. Foodborne illness may cause serious illness, such as gastrointestinal infection, resulting in vomiting and diarrhea: invasion of the bloodstream with virulent bacteria and toxins: and subsequent [DIAGNOSES REDACTED] disorders, and death. The systemic system failure to properly sanitize the facility ' s dishes with both the high temperature dishwashing machine which had rinse reading temperatures below acceptable levels on the log dating back to 8/10/14 and, with the hand washing of dishes in the three compartment sink method of sanitation, where pots and pans were observed to be not completely submerged and the staff were unaware of the proper procedure for sanitizing dishes by hand washing and use of the three compartment sink. The facility staff failed to change soiled gloves before handling clean dishes, contaminating the clean dishes. The facility staff used bare hand contact with ready to eat foods. The administration failed to manage in a manner that enabled it to use its resources effectively to ensure that the facility maintained the highest practicable physical well-being of the facility ' s residents and that their health status was not jeopardized. The system failed from; identification of the temperature log issue, to the reporting of the temperature log issue, to the staff lack of knowledge of proper operation and temperatures for sanitation using the dish machine, to proper labeling of the high temperature dish machine, to the staff ' s lack of knowledge in hand washing dish sanitation in the 3 compartment sink, to the maintenance and cleaning of the ceiling vents, to the storing of clean dishes appropriately so that they were ' t re-contaminated, to staff training on proper procedures to be used for dish sanitation, to the Administrative (including QA&A committee) identification of the system failure, including day to day managerial oversight of all of these quality issues found by the survey team in the kitchen. The Administration did not assure that the direct functions and operations of the facility were in accordance with current regulations governing long term care facilities. On 9/22/14 at 10:28AM in an observation of the dish machine which used heat as a sanitizer, a wash temperature of 155 degrees F and rinse temperature of 161 degrees F were observed. An immediate second observation revealed a wash temperature of 155 and rinse temperature of 172 degrees F. A review of the facility dish machine temperature and pressure logs revealed that rinse temperatures had been recorded as too low on multiple occasions since August 10th, 2014, including every day in the month of September 2014. In September 2014 there were also wash temperatures recorded which were too low. Record review revealed that there are no residents with organ transplants. No residents receive [MEDICAL CONDITION] or [MEDICAL CONDITION]. The ADON provided a listing indicating: 11 residents receive antibiotics; 8 residents have [DIAGNOSES REDACTED]. The facility Administration ' s failure to oversee and effectively manage day to day operations placed residents at risk for more than minimal harm and resulted in Immediate Jeopardy existing in the facility as of 8/10/14. The Immediate Jeopardy was removed as of 9/25/14 at 5:14 p.m. and the scope and severity was reduced to " F " . The findings included: A request to the Administrator for the Administrator ' s job description revealed that the Administrator works for the management company and his job is described in the contract for management between the facility and the management company and that there was no other job description. A review of the management agreement titled Second Amended Management Agreement and its amendment titled First Amendment to Second Amended Management Agreement revealed that the management company will " provide a qualified and licensed Nursing Home Administrator ...who will be an employee of (the management company ' s name) and who shall assume the management of the daily operations of the skilled nursing facility and assisted living facility. (management company name) shall assist the Administrator in recruiting, hiring, and training at (facility ' s name) expense and as (facility name) employees, all other personnel necessary to maintain and operate the skilled nursing facility and assisted living facility; and provide such other supervision and management as may be required for the Administrator efficiently to perform his or her duties and responsibilities " that was signed by the facility and the management company on 10/25/10. This management contract confirmed the Administrator was responsible for the day to day operations of the skilled nursing facility. During an initial kitchen tour on 9/22/14 at 10:00 a.m. the following were observed: A black colored residue covered four ceiling vents in the dish wash and three compartment sink area. The vents were leaking a water- like substance on top of clean dishes. In the three compartment sink dishes were not fully submerged in the sanitation solution. On 9/22/14 at 10:12 a.m. in an interview with a nearby kitchen staff member (Staff P) he stated that he had been employed here for 3 weeks he stated that dishes and plates were placed in the sanitizing solution for 20 seconds and that Staff G trained him to do the dishes. On 9/22/14 at 10:15 a.m., the Director of Dining Services stated that the Maintenance Director was aware of the vents and he was supposed to come clean everything on Thursday. Staff G was observed operating the dish machine 9/22/14 at 10:25 a.m. She stated that she was unaware that the vents were leaking onto the clean dishes. In an observation of Staff G operating the dish machine on 9/22/14 at 10:28 a.m., dish machine temperatures of wash 155 degrees F and rinse 161 degrees F were revealed. An observation immediately following revealed a wash temperature of 155 degrees F and a rinse temperature of 171 degrees F. (The minimum dishwashing temperatures should be 150 degrees F for the wash and 180 degrees F for the final rinse. At the time of the observations the Director of Dining Services stated that it was a high temperature machine. The instructions observed posted on the machine were for a low temperature machine and were listed as wash temperature 120-140 degrees and rinse temperature 50-180 degrees. The Executive Chef stated on 9/22/14 at 10:36 a.m. that " I noticed the issue on Friday (9/19/14) and told the staff to do the dishes twice. " He stated that he made a call on Friday and someone was to come to the facility to check the dish machine. He further stated that he told the supervisors over the weekend to check on it but he can ' t recall the supervisors ' names. He then stated that he would tell the staff to hand wash the dishes until the technician comes in. On 9/22/14 at 10:39 a.m. Staff G stated that no one had told her to wash the dishes twice. ( Washing the dishes twice through the dish machine will not sanitize them, if the rinse temperature doesn't reach 180 degrees F) A further observation on 9/22/14 at 10:46 a.m. revealed staff running dishes in the dishwasher even though they had been told otherwise. The Director of Dining Services stated that " that does not make any sense it ' s better to hand wash them. " At that same time when the surveyor turned around, a dusty old curtain had been placed on top of clean dessert plates. The technician from the dish machine company arrived on 9/22/14 at 12:26 p.m. and in an interview he stated that he had received a call an hour ago and he is here. He stated he visits the facility monthly. He stated that the dish machine was a high temperature machine with a wash temperature of at least 150 degrees and that the incoming water was 140 degrees and that affected the overall temperature. He stated that it is fixed now. The technician stated that he had received a call two weeks ago from the Executive Chef and had had consulted over the telephone about how to reset the dish machine equipment due to a bad storm that had occurred in the area. He stated that the signage posted on the dish machine sticker was incorrect. He stated that he had brought it and applied it to the dish machine because the other had worn off and that was the only label he had with him at the time. He stated the staff was supposed to use the directions posted on the wall and that the dish machine had been a high temperature machine since August 2011. In an observation of a dishwasher (staff) running the dish machine on 9/22/14 at 12:29 p.m. the wash temperature was observed to be 175 degrees F and the rinse temperature was 205 degrees F. At the time of that observation the Director of Dining Services stated that they did not have any min-max thermometers (irreversible registering thermometer) or other thermometers to troubleshoot. A review of the temperature logs for the dish machine for the last 6 months revealed: 8/10/14 Final rinse 136 degrees F in the A.M. Final rinse 136 degrees F at noon, and 136 degrees F in the P.M. 8/24/14 final rinse 175 degrees F at noon, and 179 degrees F in P.M. 8/25/14 Final rinse 136 degrees F in A.M., 140 degrees F at noon, and 140 degrees F in P.M. 8/26/14 Final rinse 142 degrees F in A.M., and 138 degrees F at noon, and 150 degrees F in P.M. 8/27/14 Final rinse 139 degrees F in A.M. 8/28/14 Final rinse 136 degrees F in A.M., 138 degrees F at noon 8/31/14 Final rinse 136 degrees F at noon and 138 degrees F in P.M. 9/1/14 Final rinse 137 degrees F in A.M., 132 degrees F at noon, 140 degrees F in P.M. 9/2/14 Final rinse 142 degrees F in A.M., 136 degrees F at noon, 140 degrees F in P.M. 9/3/14 Final rinse 139 degrees F in A.M. 140 degrees F in P.M. 9/4/14 Wash 140 degrees F at noon, wash 140 degrees F in P.M.: final rinse 145 degrees F in A.M., 135 degrees F at noon, 138 degrees F in P.M. 9/5/14 Wash 138 degrees F in A.M., 140 degrees F at noon, 138 degrees F in P.M.: Final rinse140 degrees F in A.M., 140 degrees F at noon, 140 degrees F in P.M. 9/6/14 Wash 139 degrees F in A.M.: Final rinse 142 degrees F in A.M., 140 degrees F at noon, 140 degrees F in P.M. 9/7/14 Final rinse 138 degrees F in A.M., 140 degrees F at noon, 140 degrees F in P.M. 9/8/14 Wash 148 degrees F in A.M., 138 degrees F at noon, 139 degrees F in P.M.: Final rinse 132 degrees F in A.M., 139 degrees F at noon, 142 degrees F in P.M. 9/9/14 Final rinse 126 degrees F in A.M., 126 degrees F at noon, 130 degrees F in P.M. 9/10/14 Final rinse 138 degrees F in A.M., 138 degrees F at noon 9/11/14 Final rinse 144 degrees F in A.M., 140 degrees F at noon, 140 degrees F in P.M. 9/12/14 Final rinse 140 degrees F in A.M., 142 degrees F at noon, 140 degrees F in P.M. 9/13/14 Final rinse 140 degrees F in A.M., 142 degrees F at noon, 140 degrees F in P.M. 9/14/14 Final rinse 138 degrees F in A.M., 140 degrees F at noon, 135 degrees F in P.M. 9/15/14 Final rinse 138 degrees F in A.M., 158 F degrees at noon, 152 degrees F in P.M. 9/16/14 Final rinse 148 degrees F in A.M., 142 degrees F at noon, 158 degrees F in P.M. 9/17/14 Final rinse 168 degrees F in A.M., 158 degrees F at noon, 155 degrees F in P.M. 9/18/14 Final rinse 157 degrees F in A.M., 152 degrees F at noon, 155 degrees F in P.M. 9/19/14 Final rinse 168 degrees in A.M., 162 degrees at noon, 165 degrees in P.M. 9/20/14 Final rinse 162 degrees F in A.M., 155 degrees F at noon, 160 degrees F in P.M. 9/21/14 Final rinse 158 degrees F in A, M., 160 degrees F at noon, 159 degrees F in P.M. 9/22/14 Final rinse 158 degrees F in A.M. A review of the specification form labeled Section 1: SPECIFICATION INFORMATION for the PA-C4 series dish machine revealed the following water requirements: WASH TEMPERATURE (PA-C4) 160 DEGREES F RINSE TEMPERATURE 180 DEGREES F *NOTE: TEMPERATURES LISTED ARE MINIMUMS FLOW PRESSURE (PSI) 20, PLUS OR MINUS 5 PSI In an observation on 9/22/14 at 12:31p.m. a leak was observed in the sanitizing compartment of the three compartment sink near the drain pipe. A flood of water was observed on the floor and a pipe was broken. Boxes of delivered food products were observed in flooded the water. On 9/22/14 at 12:33 p.m. the Director of Dining Services and the Executive Chef stated that the leak had begun that morning. The Director of Dining Services stated that the Chef or the supervisors (staff I and staff H) were to check the dish machine temperatures on the weekends. In an interview with Staff I, a dining supervisor, on 9/22/14 at 12:35 p.m. she revealed " I never was told to check temps. I have been here for 2 years. I don ' t even know how to do that. " On 9/22/14 at 4:55 p.m. in an interview with the Administrator he stated that he was not aware of what the dish machine temperatures were today after lunch but that the technician had said there was nothing wrong. He stated he was assuming the dishes were washed at the proper temperature after lunch today because the dish machine service tech had said nothing was wrong. The Administrator stated that he had become aware of the dish machine low temperatures this morning when the Dining Services Manger approached him about it. The Administrator stated that the plan was to wash the dishes by hand. He stated this had not been an issue prior to the present time and that the issue had not been brought through the Quality Assessment and Assurance committee (QA&A committee). An in-service sign in was requested from the Administrator related to the staff being educated on the dish machine problem and the emergency plan between the dates of 9/19/14 when the problem was noted by the Executive Chef and 9/22/14 when the Administrator was made aware. The Administrator stated he would have to ask the Dining Services Manager about that. The Administrator reported that he had not personally observed the facility staff to ensure that they were washing dishes by hand, and he could not say that staff had been in-serviced, and that he had not provided any other oversight of the issue. The Administrator stated he was not aware of any gastrointestinal outbreaks (GI) in the facility. He stated that would have been mentioned in QA&A committee meeting. The Administrator stated that his expectation for a problem with the dish machine was first, that the staff address the situation, then get the equipment fixed, then implement any interventions to prevent infection such as hand washing the dishes. He would expect the Director of Dining Services to educate the staff and also that the Administrator should be notified immediately. The Administrator stated that he was not made aware of the dish machine problem on Friday September 19th. The Administrator confirmed that he was unaware if the kitchen staff had ever been in-serviced on emergency procedures such as sanitizing dishes by hand. The Administrator stated that the Dining Services Manager was new. During an observation on 9/22/14 at 5:15 p.m., a basket was full of dirty linens next to clean plates. The Executive Chef stated at time of observation, " It was brought here. These are the linens from the independent living. I do not know why they brought and left them here instead of the laundry. " In an interview with the Director of Dining Services on 9/22/14 at 5:16 p.m. he stated his job duties were to oversee everything related to dining. He stated that he became aware of the dish machine temperatures being too low today at about 10:00 a.m. He stated that he spoke to the Executive Chef who reported to him that there had been a problem on Friday with the dish machine pressures and that on Saturday the Chef had become aware of the dish machine temperature issues and had informed the supervisor. The Director of Dining Services stated that today (9/22/14) that he had informed the staff to wash the dishes by hand at approximately 10:00 a.m. He stated that there was no in-service sign in sheet related to the dish machine issues or hand washing the dishes. He stated that " theoretically we should be going behind the others and be sure they are checking the sanitation in the 3 compartment sink. " He stated that the proper procedure for sanitizing dishes in the 3 compartment sink would include submerging the dish completely. When asked if the staff have ever been trained in the proper operation and monitoring of the dish machine and the proper method of hand sanitizing dishes in the 3 compartment sink or any other emergency kitchen procedures he replied that he was not sure. He stated that after the dish machine technician left today he spoke with Staff Q and staff K and told them that they are the only staff who were allowed to check the dish machine besides himself and the Executive Chef. He stated they have both worked at the facility for a while so they were chosen. The Dining Services Manager stated that he had not provided any training to Staff Q or Staff K regarding the dish machine temperatures and how to obtain them or monitor them, and how to report any issues. He further stated that Staff Q has not had to do the dish machine but he will be good once he is trained. On 9/22/14 at 5:45p.m., during a random dining observation in the Royal Palm Dining Room, Staff Y buttered the bread for a resident with her bare hands. On 9/22/14 at approximately 6:01p.m. Staff Y confirmed that this was her usual practice for buttering rolls for the residents. Staff Y then picked up the bread with her bare hands and fed the resident the roll with her bare hands. In an interview with the Director of Maintenance on 9/23/14 at 11:57 a.m. he stated that he does not know how to check the dish machine temperatures and if there were any problems with the dish machine the contractor was called because the machine was leased. In an interview with Staff L who was operating the dish machine on 9/23/14 at 12 noon he stated that the only training he had received on the dish machine was an informal training by Staff Q back when he was hired sometime in July 2014. On 9/23/14 at 12:07 p.m. the Executive Chef stated that he had talked to all of the staff last night and this morning about the dish machine. He stated that he had no documentation of the content of the training he provided to the staff nor any sign- in sheets. During an observation on 9/23/14 at 4:47 p.m., Staff O was wearing gloves. He was observed rinsing down dirty plates with his gloves on. He placed the dishes in a rack and he ran the dishes through the dish machine. The Executive Chef was present at time of observation. The Chef stated " 6 times a day the dishwashers (staff) will take the temperatures. Then the supervisor will be here and they will write down the temperatures. They will have to initial the form. Everyone has begun to be educated about everything. " Staff O was observed on 9/23/14 at 4:50 p.m., using the same gloves he was wearing to rinse the dirty dishes when he took the clean plates from the dishwasher and placed them on trays. Staff O was asked " how often do you change gloves? " He stated, " When I go to the other side. He pointed to the three compartment sink. Staff O was asked " Do you use the same gloves when you rinse the dirty plates and take the clean plates off the machine? " Staff O stated " yes, I just wash my hands " and proceeded to wash his hands with the dirty gloves on. During an interview on 9/23/14 at 5:05 p.m., the Director of Dining Services stated " I do not understand why he said that. The process is that they have to use gloves. They have to change when they go from clean to dirty dishes and the other way around. " During the interview a request was made for the in-service training in proper glove usage for all staff working in the dish room. The Director of Dining Services stated " I am new here, I do not know. They must have it. " Interviews were conducted with the CDM and registered dietitian (RD) on 9/24/14 at 1:52 p.m. The RD said that she is the substitute dietitian. She said she had started working here in January 2014 and had come back in September 2014. The CDM stated that she participates in the QA&A meetings. She stated on 9/24/14 at 1:52 p.m., " I do not recall any issues with the temperatures. " The RD did not recall any issues either. The RD stated that when she comes to the facility she goes to the kitchen to get a feeling of how things run. She did not see anything out of the ordinary. The RD stated that we had no issues with GI, vomiting, diarrhea, weight loss that she could recall. The CDM said the executive chef was responsible for training the new employees. The previous director before him was responsible for training the new employees. The CDM stated that she was responsible for the tray lines and the clinical. The Executive Chef was a CDM (CDMs are Certified Food Protection Professionals (CFPPs), who are trained in food safety- www.cdmcareer.info) and he was responsible for the training and the kitchen aspect. " I do the in-services for the tray delivery for my department only. I have a sign- in log. If the Chef was not here the food service director should have the information needed. If someone was on isolation we would use disposable dishes. No one was in isolation at the moment. No one had a [DIAGNOSES REDACTED]. " In an interview with the Medical Director on 9/25/14 at 12:44 p.m. he stated that he had been the Medical Director at the facility for a few months and that he attended the QA committee meetings. He stated that he visits the facility at least weekly. The Medical Director stated he had not been made aware of any GI outbreaks in the facility. He stated that if there had been any they would have discussed it at the QA&A committee meeting. In an interview with the Administrator and the Controller on 9/25/14 at 2:27 p.m. the Controller stated that everyone wants to do the right thing. He stated " we completely acknowledge we had a deficient practice " but that the facility disagreed with the scope and severity. The Controller stated that the " punishment should fit the crime. " The Controller stated that he had spoken to the staff physicians and they had no reports of GI outbreaks and that the facility feels that " they have not had one bad thing happen and maybe that was just luck ... " The Administrator had no comments during the interview. On 9/27/14 at 8:30 a.m. in an interview with the Administrator he stated that the facility uses the Abaqis program and that they had gone through stage 1 of " mock survey " prior to the arrival of the survey team on 9/22/14. He stated that they were working on the issues identified at that time to prepare for their annual survey. During the " mock survey " the problems with the dish machine and the dish machine logs were not discovered. The Administrator stated that the Registered Dietician (RD) Consultant was teaching him what to look for in the kitchen in September and that they had " missed " the dish machine temperature log problem. He stated that the RD comes to the facility weekly and that she completes an in-depth kitchen review monthly, and that she participates on the QA&A committee. According to the Centers for Disease Control (CDC) using 2012 data, there were 4,563 hospitalization s and 68 deaths among infections with pathogens that are commonly transmitted through food. Among those affected, those aged [AGE] years and older were hospitalized the most frequently and had the highest death rate among the other age groups. (http://www.cdc.gov>). The Food and Drug Administration found that salmonella, a common food borne infectious organism, may cause acute symptoms of nausea, vomiting, abdominal cramps, diarrhea, fever and headache. Other complications included chronic symptoms which may commence approximately four weeks after infection and are arthritic like changes, and acute [MEDICATION NAME]-like symptoms in which the mortality rate for some strains is up to 15 percent. It further reported that symptoms are most severe in the elderly. (http://www.fda.gov>). The top five disease-causing microorganisms contributing to foodborne illness in the US are (in descending order): Norovirus, Salmonella, [MEDICATION NAME], ,[MEDICAL CONDITION]. perfigens, Campylobactor spp., and Staphylococcus aureus. Salmonella [MEDICATION NAME] is responsible for the most deaths from domestically acquired foodborne illnesses. Literia monocytogenes, Norovirus, and Campylobacter spp., are also listed in the top five disease causing microorganisms responsible for deaths from foodborne illness. CDC 2011 estimates of foodborne illness in the US (www.CDC.gov). The facility implemented the following measures that resulted in the Immediate Jeopardy being removed as of 9/25/14 at 5:14p.m. and the scope and severity was reduced to an " F " . The facility provided a plan of correction action presented to the survey team on 09/25/14 at 5:14 p.m. The plan was reviewed to verify implementation and operationalization. The plan included: " The facility has determined that the root cause of the problem was a failure of the identified kitchen staff to properly monitor and record the dishwasher temperatures and a failure of the on-duty supervisory staff to properly monitor the accurate completion of the dishwasher temperature log. It is the policy of this facility to have systems in place to prevent the spread of foodborne illness and practices which may result in food contamination or compromised food safety. When made aware of the dishwasher temperature issues, the facility executed the following: 1. The use of dishes from the kitchen was immediately put out of service and no dishes were used by residents. The dishwasher was put back in use once the equipment service provider had examined it and determined it was functioning properly. 2. The dishwashing equipment service provider was immediately contacted to inspect the correct functionality of the equipment. 3. The dishwashing equipment service provider arrived shortly thereafter and confirmed to the facility and the survey team that the dishwashing equipment was operating properly at the proper temperature ranges and all the dishes had been properly sanitized. 4. A new dishwasher temperature and pressure tracking procedure and log were created that requires both the identified kitchen staff and the on-duty supervisor to monitor the temperatures and pressure of the dishwasher. Copies of both are included as attachments. 5. All identified kitchen staff were provided in-service training on the proper operation of the dishwashing equipment to include the proper temperatures for machine wash and rinse cycles (160 degrees Fahrenheit and 180 degrees Fahrenheit), the proper PSI (water pressure) during the final rinse (15-25 PSI), the proper time to monitor the temperatures/ pressure, the proper way to record the temperatures/pressure. If the temperature/pressure is not accurate, the identified kitchen staff will immediately notify the on-duty supervisor or designee and the dishwasher will not be used until it has been determined to be at a safe temperature. Emergency procedures will be implemented if the dishwasher is not at the appropriate temperature/pressure. Any staff that was not able to receive the training as of the date of this allegation of compliance has been removed from the schedule and will not be permitted to work until they have received the appropriate training. 6. All Dining Services Supervisory staff was provided in-service training on the policy and procedures for the proper operation of the dishwashing equipment, specifically their role in ensuring that the proper temperatures/pressure is being reached. If the temperature/pressure is not accurate, the identified kitchen staff will immediately notify the on-duty supervisor or designee and the dishwasher will not be used until it is determined to be at a safe temperature/pressure. Emergency procedures will be implemented if the dishwasher is not at the appropriate temperature/pressure. Any staff that was not able to receive the training as of the date of this allegation of compliance has been removed from the schedule and will not be permitted to work until they have received the appropriate training. 7. All identified kitchen staff and supervisors were provided in-service training on the emergency procedures. Emergency procedures include the use of disposable dishware/utensils or the utilization of a three compartment sink. The in-service training provided for proper utilization of the three compartment sink is included as an attachment. 8. All identified kitchen staff and supervisors were provided in-service training on the proper use of gloves when handling dirty and clean dishes, pots and pans. " The facility will continue to have monthly preventative maintenance preformed on the dishwashing equipment. Staff will utilize the new form and track temperatures/ pressure 3 times a day. Supervisors will monitor the recorded temperatures/pressure 3 times a day along with staff. All new staff will be trained on the new policy and procedures. All new staff will be trained in the proper usage of gloves. The Director of dining services will audit the dishwasher temperature/ pressure log at least once per week. The results of the audit will be reviewed by the administrator or designee and will be included in the QA&A program to ensure ongoing compliance. The surveyor met with the Human Resources Manager on 9/26/14 at 10:59 a.m., and the personnel records for all of the staff working in the dish room and their supervisors were reviewed. All staff had signed a new job description after the issue identified on 9/22/14. The new job description included under essential functions: " staff need to monitor and document PPMs (parts per million) in the 3 component sink. Observe and record wash and final rinse temperatures in the dish wash machine. " Previous job description for all dish room workers, supervisors, executive chef and food manager did not include a requirement of checking temperatures, pressure or checking Parts per million (PPM) in the 3 components sink. All the staff personnel records included up to date Physicals and [MEDICAL CONDITION] (TB) tests. A Review of all the newly signed job descriptions and in- service trainings for all of the dish room and supervisory staff was completed on 9/26/14 at 4:00 p.m. All appropriate staff had been trained in the three compartment sink setup and process. All staff had received trainings in high temperature dishwashing and pressure checks and proper glove usage. During an observation of Staff G on 9/26/14 at 1:30 p.m., in the dish room the following readings were obtained: Final rinse temperature was 190 ?F; wash temperature was 160 ?F; and the PSI (water pressure) was 20. The readings were verified based on observation. A second observation revealed the Final rinse temperature was 189 ?F and the wash temperature was 160 ?F, and PSI (water pressure) was 20 on 9/26/14 at 1:35 p.m. The readings were verified based on observation. All kitchen staff during the course of the observation were interviewed and all replied positively about in- service trainings in proper temperatures, pressure, three compartment sink, hand washing and gloves usage. The kitchen had been cleaned and the ceiling vents were clean and no water-like liquid was observed dripping from them. (cross reference to F371 and F520)

Based on observation, interview of the kitchen staff and facility Administration, record review, and the Quality Assessment and Assurance Committee facility policy with an effective date of 1/11/10, the facility Quality Assessment and Assurance Committee (QA&A committee) failed to identify a systemic system failure and to put measures into place to ensure the facility residents received care and services to maintain their highest practicable well-being without immediate and serious threat to their well-being related to the kitchen dish machine rinse temperatures that were recorded as too low for adequate sanitation which began to appear on the dish machine temperature log on 8/10/14, and dish machine wash temperatures recorded as too low for adequate sanitation which began to appear on the dish machine temperature log on 9/4/14, and improper submerging of dishes in the sanitation compartment of the 3 compartment sink resulting in inadequate sanitation when hand washing dishes using the 3 compartment sink, and the storage of clean dishes under ceiling vents that were covered in a black substance and leaking water- like fluids onto the clean dishes. The facility staff failed to change soiled gloves before handling clean dishes, contaminating the clean dishes. The facility staff used bare hand contact with ready to eat foods. The QA&A committee failed to identify the quality concerns and to implement a plan of action related to dish sanitation, the facility failed to clean and sanitize the facility's multi-use dishes and utensils, by both mechanical dishwashing and manual washing dishwashing. This practice effected 62 residents who consumed the facility's food, out of 63 residents residing in the facility, from 8/10/14 to 9/25/14 at 5:14 p.m. The facility's failure to sanitize the dishes and utensils posed the likelihood of serious and immediate threat to the health of the residents. Nursing home residents are highly susceptible to acquiring foodborne illness, according to the Food and Drug Administration (FDA), Food Code. Foodborne illness may cause serious illness, such as gastrointestinal infection, resulting in vomiting and diarrhea: invasion of the bloodstream with virulent bacteria and toxins: and subsequent [DIAGNOSES REDACTED] disorders, and death. The QA&A committee failed to put systemic measures into place to correct the systemic system failure. The QA&A committee failed to accurately monitor the contracted services related to the leased dish machine. A review of the facility policy named: " Quality Assessment and Assurance Committee " with an effective date of 1/11/10 revealed the following policy statement: " The facility shall establish and maintain a Quality Assessment and Assurance Committee that oversees the identification and handling of quality issues. " Goals of the Committee: 2. " Oversee facility systems and processes related to improving quality of care and services. " 6. " To coordinate the development, implementation, monitoring, and evaluation of action plans to achieve specified quality goals. " 8. " To coordinate and facilitate communication regarding the delivery of quality resident care within and among departments and services, and between facility staff, residents, and family members. " The QA&A committee failed to operationalize facility policy and procedure in a manner that enabled it to use its resources effectively to ensure that the facility maintained the highest practicable physical well-being of the facility ' s residents and that their health status was not jeopardized. The QA&A committee did not assure that the dish sanitation of the facility was in accordance with current regulations governing Long Term Care Facilities and the current accepted practices to prevent food borne illnesses. On 9/22/14 at 10:28AM in an observation of the dish machine which used heat as a sanitizer, wash temperature of 155 degrees Fahrenheit (F) and rinse temperature of 161 degrees F were observed. An immediate second observation revealed wash temperature of 155 and rinse temperature of 172 degrees F. A review of the facility dish machine temperature and pressure logs revealed that rinse temperatures had been recorded as too low on multiple occasions since August 10th, 2014 including every day in the month of September 2014 up to and including September 22nd. In September 2014 there were also wash temperatures recorded which were too low. Record review revealed that there are no residents with organ transplants. No residents receive [MEDICAL CONDITION] or [MEDICAL CONDITION]. The ADON provided a listing indicating: 11 residents receive antibiotics; 8 residents have [DIAGNOSES REDACTED]. The QA&A committee ' s failure to identify the systemic system failure related to dish sanitation, implement an action plan, and monitor the action plan, placed residents at risk for more than minimal harm and resulted in Immediate Jeopardy existing in the facility as of 8/10/14. The Immediate Jeopardy was removed on 9/25/14 at 5:14pm and the scope and severity was reduced to " F " . The findings included: Cross refer to F 371 as it relates to the facility ' s failure to provide the necessary care and services to prevent the immediate and serious threat to the health of the residents related to kitchen sanitation. The facility had a total census of 63 on 9/22/14 and had a predominantly elderly population who resided on three wings. There were three dining rooms in service in the facility. A review of the facility policy and procedure titled " Quality Assessment and Assurance Committee " with an effective date of 1/11/10 revealed the following: Policy Statement The facility shall establish and maintain a Quality Assessment and Assurance Committee that oversees the identification, and handling of quality issues. Policy Interpretation and Implementation 1. The Administrator shall delegate the necessary authority for actions and processes to the Quality Assessment and Assurance Committee. Goals of the Committee 1. To monitor and evaluate the appropriateness and quality of care provided within the framework of the Quality Assessment and Assurance Plan. 2. To oversee facility systems and processes related to improving quality of care and services 3. To promote consistent facility systems and processes and appropriate practices in resident care 4. To help identify negative outcomes relative to resident care and resolve them appropriately 5. To help departments, consultants and ancillary services implement plans to correct identified issues in quality of care 6. To coordinate the development, implementation, monitoring, and evaluation of action plans to achieve specified quality goals 7. To help departments, consultants and ancillary services establish accountability for care and quality 8. To coordinate and facilitate communication regarding the delivery of quality resident care within and among departments and services, and between facility staff, residents, and family members Committee Meetings The committee will oversee the development and implementation of actions to correct quality concerns and promote overall quality of care and services in the facility. 1. Examples of actions that may be implemented to help address quality issues may include, but are not limited to: a. Educational training programs b. New or revised policies and procedures c. Staffing changes d. Equipment changes e. Adjustment in admission, transfer, and/or discharge practice f. Adjustment in employment practices In an interview with the Administrator on 9/22/14 at 8:30 a.m. he confirmed that the facility had a QA&A committee and that the committee was led by the Risk Manager. He reported that the staff members who attended were the Administrator, the DON, the Medical Director, department heads, and consultants. He stated that front line staff were not part of the committee. The committee meets monthly on the last Thursday of the month at noon, and as needed. On 9/22/14 at 10:45am the Administrator added the additional information that the Administrator leads the QA&A committee, not the Risk Manager. During an initial kitchen tour on 9/22/14 at 10:00 am the following were observed: A black colored residue covered four ceiling vents in the dish wash and three compartment sink area. The vents were leaking a water- like substance on top of clean dishes. In the three compartment sink dishes were not fully submerged in the sanitizing solution. On 9/22/14 at 10:12.a.m. in an interview with a nearby kitchen staff member (staff P) he stated that he had been employed here for 3 weeks. He stated that dishes and plates were placed in the chemical sanitation solution for 20 seconds and that Staff G had trained him to do the dishes. On 9/22/14 at 10:15 a.m. The Director of Dining Services stated that the Maintenance Director was aware of the vents and he was supposed to come clean everything on Thursday. Staff G was observed operating the dish machine 9/22/14 at 10:25 a.m. She stated that she was unaware that the vents were leaking onto the clean dishes. In an observation of Staff G operating the dish machine on 9/22/14 at 10:28 a.m., dish machine temperatures of wash 155 degrees F and final rinse of 161 degrees F were revealed. A second observation immediately following revealed a wash temperature of 155 degrees F and a rinse temperature of 171 degrees F. (The minimum dishwashing temperatures should be 150 degrees F for the wash and 180 degrees F for the final rinse) At the time of the observations the Director of Dining Services stated that the dishwasher was a high temperature machine. The instructions observed posted on the machine were for a low temperature machine and were listed as wash temperature 120-140 degrees and rinse temperature 50-180 degrees. The executive chef stated on 9/22/14 at 10:36 a.m. that " I noticed the issue on Friday (9/19/14) and told the staff to do the dishes twice. " (Washing the dishes twice through the dish machine will not sanitize them, if the rinse temperature does not reach 180 degrees F). He stated that he had made a call on Friday and someone was to come to the facility to check the dish machine. He further stated that he told the supervisors over the weekend to check on it but he that can ' t recall the supervisors ' names. He then stated that he would tell the staff to hand wash the dishes until the technician comes in. On 9/22/14 at 10:39a.m. Staff G stated that no one had had told her to wash the dishes twice. A further observation on 9/22/14 at 10:46a.m. revealed staff were running dishes in the dishwasher even though they had been told otherwise. The Director of Dining Services stated that " that does not make any sense It ' s better to hand wash them. " At that same time when the surveyor turned around, a dusty old curtain had been placed on top of clean dessert plates. The technician from the dish machine company arrived on 9/22/14 at 12:26 p.m. and in an interview he stated that he had received a call an hour ago and he was here. He stated he visits the facility monthly. He stated that the dish machine is a high temperature machine with a wash temperature of at least 150 degrees and that the incoming water was 140 degrees and that affected the overall temperature. He stated that it was fixed now. The technician stated that he had received a call two weeks ago from the Executive Chef and had consulted over the telephone about how to reset the dish machine equipment due to a bad storm that had occurred in the area. He stated that the signage posted on the dish machine sticker was incorrect. He stated that he had brought it, and applied it, to the dish machine, because the other signage had worn off, and that was the only label he had with him at the time. He stated that the staff was supposed to use the directions posted on the wall. The dish machine had been a high temperature machine since August 2011. In an observation of a dishwasher (staff) running the dish machine on 9/22/14 at 12:29 p.m. the wash temperature was observed to be 175 degrees F and the rinse temperature was 205 degrees F. At the time of that observation the Director of Dining Services stated that they did not have any min-max thermometers or other thermometers to run through the dish machine to troubleshoot dish machine problems. A review of the temperature logs for the dish machine for the last 6 months revealed: 8/10/14 Final rinse 136 degrees F in the A.M. Final rinse 136 degrees F at noon, and 136 degrees F in the P.M. 8/24/14 final rinse 175 degrees F at noon, and 179 degrees F in P.M. 8/25/14 Final rinse 136 degrees F in A.M., 140 degrees F at noon, and 140 degrees F in P.M. 8/26/14 Final rinse 142 degrees F in A.M., and 138 degrees F at noon, and 150 degrees F in P.M. 8/27/14 Final rinse 139 degrees F in A.M. 8/28/14 Final rinse 136 degrees F in A.M., 138 degrees F at noon 8/31/14 Final rinse 136 degrees F at noon and 138 degrees F in P.M. 9/1/14 Final rinse 137 degrees F in A.M., 132 degrees F at noon, 140 degrees F in P.M. 9/2/14 Final rinse 142 degrees F in A.M., 136 degrees F at noon, 140 degrees F in P.M. 9/3/14 Final rinse 139 degrees F in A.M. 140 degrees F in P.M. 9/4/14 Wash 140 degrees F at noon, wash 140 degrees F in P.M.; Final rinse 145 degrees F in A.M., 135 degrees F at noon, 138 degrees F in P.M. 9/5/14 Wash 138 degrees F in A.M., 140 degrees F at noon, 138 degrees F in P.M.; Final rinse140 degrees F in A.M., 140 degrees F at noon, 140 degrees F in P.M. 9/6/14 Wash 139 degrees F in A.M.; Final rinse 142 degrees F in A.M., 140 degrees F at noon, 140 degrees F in P.M. 9/7/14 Final rinse 138 degrees F in A.M., 140 degrees F at noon, 140 degrees F in P.M. 9/8/14 Wash 148 degrees F in A.M., 138 degrees F at noon, 139 degrees F in P.M.: Final rinse 132 degrees F in A.M., 139 degrees F at noon, 142 degrees F in P.M. 9/9/14 Final rinse 126 degrees F in A.M., 126 degrees F at noon, 130 degrees F in P.M. 9/10/14 Final rinse 138 degrees F in A.M., 138 degrees F at noon 9/11/14 Final rinse 144 degrees F in A.M., 140 degrees F at noon, 140 degrees F in P.M. 9/12/14 Final rinse 140 degrees F in A.M., 142 degrees F at noon, 140 degrees F in P.M. 9/13/14 Final rinse 140 degrees F in A.M., 142 degrees F at noon, 140 degrees F in P.M. 9/14/14 Final rinse 138 degrees F in A.M., 140 degrees F at noon, 135 degrees F in P.M. 9/15/14 Final rinse 138 degrees F in A.M., 158 F degrees at noon, 152 degrees F in P.M. 9/16/14 Final rinse 148 degrees F in A.M., 142 degrees F at noon, 158 degrees F in P.M. 9/17/14 Final rinse 168 degrees F in A.M., 158 degrees F at noon, 155 degrees F in P.M. 9/18/14 Final rinse 157 degrees F in A.M., 152 degrees F at noon, 155 degrees F in P.M. 9/19/14 Final rinse 168 degrees in A.M., 162 degrees at noon, 165 degrees in P.M. 9/20/14 Final rinse 162 degrees F in A.M., 155 degrees F at noon, 160 degrees F in P.M. 9/21/14 Final rinse 158 degrees F in A, M., 160 degrees F at noon, 159 degrees F in P.M. 9/22/14 Final rinse 158 degrees F in A.M. In a further review of the Dish Machine Temperature Logs it was revealed that the September 2014, August 2014, May 2014, April 2014, March 2014, February 2014 and January 2014 Dish machine Temperature Logs did not monitor the PSI (water pressure). The PSI is monitored on the July 2014 and June 2014 Dish machine Temperature Logs. A review of the " Clean Force Rental Agreement " dated 10/30/07 revealed that the facility is leasing a high temperature dish machine from Clean Force. A second " Clean Force Rental Agreement " signed 10/30/13 indicates that the facility is leasing a booster heater from Clean Force. A review of the specification form labeled Section 1: SPECIFICATION INFORMATION for the PA-C4 series dish machine revealed the following water requirements: WASH TEMPERATURE (PA-C4) 160 DEGREES F RINSE TEMPERATURE 180 DEGREES F *NOTE: TEMPERATURES LISTED ARE MINIMUMS FLOW PRESSURE (PSI) 20, PLUS OR MINUS 5 PSI A review of the Pure Force service detail reports for the last 5 months revealed: 9/22/14 Jackson PA-C4 Preventative Maintenance " Rinse pressure was slightly high at 30 PSI. Replaced solenoid disphram which was restricting flow at rinse assembly. Adjusted PSI down to 25 PSI. Final rinse PSI slightly high at 30, adjusted to 25. " 8/4/14 Jackson PA-C4 Preventative Maintenance No concerns recorded. 8/4/14 Emergency Service Request Facility out of rinse 7/25/14 Jackson PA-C4 Preventative Maintenance Cleaned debris from upper wash arm to improve spray pattern for better results Cleaned wrappers from pump intake screen to improve flow through the pump Replaced worn discharge hoses on the sink dispenser 6/25/14 Jackson PA-C4 Preventative Maintenance Machine interior cleaner than previous PMs, i.e. clogged wash arm nozzles 5/16/14 Jackson PA-C4 Preventative Maintenance No concerns were recorded In an observation on 9/22/14 at 12:31 p.m. a leak was observed in the sanitizing compartment of the three compartment sink. Water was observed flooded on the floor and a pipe was broken near the drain. On 9/22/14 at 12:33 p.m. the CDM and the Executive Chef stated that the leak had begun that morning. The Director of Dining Services stated that the chef or the supervisors (Staff I and Staff H) were to check the dish machine temperatures on the weekends. In an interview with Staff I, a dining supervisor, on 9/22/14 at 12:35 p.m. she revealed " I never was told to check temps. I have been here for 2 years. I don ' t even know how to do that. " On 9/22/14 at 4:55p.m. in an interview with the Administrator he stated that he was not aware of what the dish machine temperatures were today after lunch but that the technician had said there was nothing wrong. He stated he was assuming the dishes were washed at the proper temperature after lunch today because the dish machine tech had said nothing was wrong. The Administrator stated that he had become aware of the dish machine low temperatures this morning when the Dining Services Director approached him about it. The Administrator stated that the plan was to wash the dishes by hand. He stated that this has not been an issue prior to the present time and that the issue had not been brought through the Quality Assessment and Assurance committee (QA&A committee). An in-service sign in was requested from the Administrator related to the staff being educated on the dish machine problem and the emergency plan between the dates of 9/19/14 when the problem was noted by the executive chef and 9/22/14 when the administrator had been made aware. The Administrator stated that he would have to ask the Dining Services Director about that. The Administrator reported that he had not personally observed the facility staff to ensure they had washed the dishes by hand, and he could not say that the staff had been in-serviced, and that he had not provided any other oversight of the issue. The Administrator stated he was not aware of any gastrointestinal outbreaks (GI) in the facility. He stated that would have been mentioned in QA&A committee meeting. The Administrator stated that his expectation for a problem with the dish machine was first, that the staff address the situation, then get the equipment fixed, then implement any interventions to prevent infection such as hand washing the dishes. He would have expected the Director of Dining Services to educate the staff and also that the Administrator would have been notified immediately. The Administrator stated that he was not made aware of the dish machine problem on Friday September 19th. The administrator confirmed that he is unaware if the kitchen staff had ever been in-serviced on emergency procedures such as sanitizing dishes by hand. He stated that the Director of Dining Services Manager was new. During an observation on 9/22/14 at 5:15 p.m., a basket was full of dirty linens next to clean plates. The Executive Chef stated at time of observation, " It was brought here. These are the linens from the independent living. I do not know why they brought and left them here instead of the laundry. " In an interview with the Director of Dining Services on 9/22/14 at 5:16 p.m. he stated that his job duties were to oversee everything related to dining. He stated that he had become aware of the dish machine temperatures being too low today at about 10:00 a.m. He reported that he spoke to the Executive Chef who had reported to him that there had been a problem on Friday with the dish machine pressures and that on Saturday the Chef had become aware of the dish machine temperature issues and had informed the supervisor. The Director of Dining Services stated that today (9/22/14) that he had informed the staff to wash the dishes by hand at approximately 10:00a.m. He stated that there was no in-service sign in sheet related to the dish machine issues or about hand washing the dishes. He stated that " theoretically we should be going behind the others and be sure they are checking the sanitation in the three compartment sink. " He stated that the proper procedure for sanitizing dishes in the three compartment sink would have included submerging the dish completely. When asked if the staff have ever been trained in the proper operation and monitoring of the dish machine and the proper method of hand sanitizing dishes in the three compartment sink or any other emergency kitchen procedures he replied that he was not sure. He stated that after the dish machine technician left today he spoke with Staff Q and staff K and told them that they were the only staff who were allowed to check the dish machine besides himself and the Executive Chef. He stated that they had both worked at the facility for a while so that is why they were chosen. The Director of Dining Services Manager stated that he had not provided any training to Staff Q or Staff K regarding the dish machine temperatures and how to obtain them, monitor them, and how to report any issues. He further stated that Staff Q had not had to do the dish machine but he will be good once he is trained. On 9/22/14 at 5:45p.m., during a random dining observation in the Royal Palm Dining Room, Staff Y buttered the bread for a resident with her bare hands. On 9/22/14 at approximately 6:01p.m. Staff Y confirmed that this was her usual practice for buttering rolls for the residents. Staff Y then picked up the bread with her bare hands and fed the resident the roll with her bare hands. In an interview with the Director of Maintenance on 9/23/14 at 1:57am he stated that he did not know how to check the dish machine temperatures and if there were any problems with the dish machine the contractor was called because the machine was leased. In an interview with Staff L who was operating the dish machine on 9/23/14 at 12 noon he stated that the only training he had received on the dish machine was an informal training by Staff Q back when he had been hired, sometime in July 2014. On 9/23/14 at 12:07p.m. the Executive Chef stated that he had talked to all of the staff last night and this morning about the dish machine. He stated that he had no documentation of the content of the training he had provided to the staff nor any sign- in sheets. During an observation on 9/23/14 at 4:47 p.m., Staff O was wearing gloves. He was observed rinsing down dirty plates with his gloves on. He placed the dishes in a rack and he ran the dishes through the dish machine. The Executive Chef was present at time of the observation. The Chef stated " 6 times a day the dishwashers (staff) will take the temperatures. Then the supervisor will be here and they will write down the temperatures. They will have to initial the form. Everyone has begun to be educated about everything. " Staff O was observed on 9/23/14 at 4:50 p.m., using the same gloves he had on to rinse the dirty dishes when he took the clean plates from the dishwasher and placed them on trays. Staff O was asked " how often do you change gloves? " He stated, " When I go to the other side. He pointed to the three compartment sink. Staff O was asked " Do you use the same gloves when you rinse the dirty plates and take the clean plates off the machine? " Staff O stated " yes I just wash my hands " and proceeded to wash his hands with the dirty gloves on. During an interview on 9/23/14 at 5:05 p.m., the Director of Dining Services stated " I do not understand why he (Staff O) said that. The process is that they have to use gloves. They have to change when they go from clean to dirty dishes and the other way around. " During the interview a request was made for the in-service training in proper glove usage for all staff working in the dish room. The food services director stated " I am new here, I do not know. They must have it. " In an interview with the Medical Director on 9/25/14 at 12:44 p.m. he stated that he had been the Medical Director at the facility for a few months and that he attended the QA&A committee meetings. He stated that he visited the facility at least weekly. The Medical Director stated he had not been made aware of any GI outbreaks in the facility. He stated that if there had been any they would have discussed it at the QA&A committee meeting. Interviews were conducted with the CDM and registered dietitian (RD) on 9/24/14 at 1:52 p.m. The RD said that she is the substitute dietitian. She said she had started working here in January 2014 and had come back in September 2014. The CDM stated that she participates in the QA&A meetings. She stated on 9/24/14 at 1:52 p.m., " I do not recall any issues with the temperatures. " The RD did not recall any issues either. The RD stated that when she comes to the facility she goes to the kitchen to get a feeling of how things run. She did not see anything out of the ordinary. The RD stated that we had no issues with GI, vomiting, diarrhea, weight loss that she could recall. The CDM said the executive chef was responsible for training the new employees. The previous director before him was responsible for training the new employees. The CDM stated that she was responsible for the tray lines and the clinical. The executive chef was a CDM and he was responsible for the training and the kitchen aspect. " I do the in-services for the tray delivery for my department only. I have a sign- in log. If the Chef was not here the food service director should have the information needed. If someone was on isolation we would use disposable dishes. No one was in isolation at the moment. No one had a [DIAGNOSES REDACTED]. In an interview with the Administrator and the Controller (The controller is responsible for the financial management of the entire Continuing Care Retirement Community campus, and he was the former Nursing Home Administrator) on 9/25/14 at 2:27 p.m. the Controller stated that everyone wants to do the right thing. He stated " we completely acknowledge we had a deficient practice " but that the facility disagreed with the scope and severity. The Controller stated that the " punishment should fit the crime. " The controller stated that he had spoken to the staff physicians and they had no reports of GI outbreaks and that the facility feels that " they have not had one bad thing happen and maybe that was just luck ... " The Administrator had no comments during the interview. On 9/27/14 at 8:30 a.m. in an interview with a focus on QA&A with the Administrator he described that the QA&A committee was meeting monthly on the last Thursday of the month at noon, or more frequently if needed. The Administrator stated that he headed the QA&A committee. The DON, Medical Director, and all department heads that were available, attended the meetings. Each department went through their section on a power point presentation. Any trends or concerns were discussed and the committee looked for a root cause. Action plans were developed by the committee and implemented by the appropriate department head. The QA&A committee tracked and trended the progress. He stated the committee did not meet 9/25/14 due to the presence of surveyors conducting a survey in the facility. The last QA&A committee sign in page revealed a date of 8/28/14. The Administrator confirmed that this was the last time the QA&A committee had met. He stated that the Medical Director had been at the facility on 9/25/14 and the survey issues had been discussed with him by the DON but that he (Administrator) came in on the end of the meeting. The Administrator explained that the facility uses subcommittees (such as falls and weights)made up of department heads, and Abaqis (a survey- readiness program), and resident council minutes, to help the QA&A committee identify quality concern issues. Front line staff members did not attend QA&A committee meetings or subcommittee meetings. The Administrator stated that if front line staff members had issues they could have spoken to the Administrator or DON. The Administrator stated that the facility uses Abaqis which was a tool to perform " mock surveys " and that they had gone through stage 1 of mock survey prior to the arrival of the survey team on 9/22/14 and that they had been working on the issues identified at that time to prepare for their annual survey. The Administrator confirmed that the Registered Dietician consultant (RD) had not identified the systemic system failure with the dish machine Logs and dish sanitation, and that the RD and the Administrator had not identified the systemic system failure of the dish machine logs and dish sanitation during the " mock survey " stage 1 held this month and that the systemic problems with the dish machine sanitation and the dish machine logs had not been identified at all. The Administrator stated that the RD Consultant had been teaching him what to look for in the kitchen in September and that they had " missed " the dish machine temperature log problem, the 3 compartment sink sanitation problems, and the vents covered with the black substance dripping water - like liquid onto the clean dishes. The only kitchen issue that the QA&A committee had been addressing was dirty linen (a stained tablecloth had been used during a meal service) and timeliness of meal tray delivery on the units. He stated that the RD visited the facility weekly and that she had done an in-depth kitchen review monthly, and that she had participated on the QA&A committee by submitting a monthly report and that she had also participated in the weight subcommittee. According to the Centers for Disease Control (CDC) using 2012 data, there were 4,563 hospitalization s and 68 deaths among infections with pathogens that are commonly transmitted through food. Among those affected, those aged [AGE] years and older were hospitalized the most frequently and had the highest death rate among the other age groups. (http://www.cdc.gov>). The Food and Drug Administration found that salmonella, a common food borne infectious organism, may cause acute symptoms of nausea, vomiting, abdominal cramps, diarrhea, fever and headache. Other complications included chronic symptoms which may commence approximately four weeks after infection and are arthritic like changes, and acute [MEDICATION NAME]-like symptoms in which the mortality rate for some strains is up to 15 percent. It further reported that symptoms are most severe in the elderly. (http://www.fda.gov>). The top five disease-causing microorganisms contributing to foodborne illness in the US are (in descending order): Norovirus, Salmonella, [MEDICATION NAME], ,[MEDICAL CONDITION]. perfigens, Campylobactor spp., and Staphylococcus aureus. Salmonella [MEDICATION NAME] is responsible for the most deaths from domestically acquired foodborne illnesses. Literia monocytogenes, Norovirus, and Campylobacter spp., are also listed in the top five disease causing microorganisms responsible for deaths from foodborne illness. CDC 2011 estimates of foodborne illness in the US (www.CDC.gov). The facility implemented the following measures that resulted in the Immediate Jeopardy being removed as of 9/25/14 at 5:14p.m. and the scope and severity was reduced to an " F " . The facility provided a plan of correction action presented to the survey team on 09/25/14 at 5:14 p.m. The plan was reviewed to verify implementation and operationalization. The plan included: " The facility has determined that the root cause of the problem was a failure of the identified kitchen staff to properly monitor and record the dishwasher tempe