Every finding on record at Marshall Manor Nursing Home

Based on observation, interview, the United States (U.S.) Food and Drug Administration (FDA) 2022 Food Code; the facility failed to prevent potential cross contamination from the food preparation sink drain pipe extending into a floor drain and also from the dishwashing machine drain pipe extending into a floor drain. This had the potential to affect 81 of 81 residents receiving meals from the kitchen. Findings include: The U.S. FDA 2022 Food Code included: . 5-402.11 Backflow Prevention. (A) . a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. On 06/20/2023 at 6:53 PM, the food preparation sink was observed. The food preparation sink drain pipe extended into the floor drain without an air gap. On 06/21/2023 at 9:28 AM, Employee Identifier (EI) #5, the Maintenance Technician, measured the distance from the floor level to the end of the food preparation sink drain pipe. EI #5 said the depth of the food preparation sink drain pipe into the floor drain was four inches. EI #5 said cross contamination would be a potential concern. EI #5 further said that we need to cut the pipe shorter. On 06/22/2023 at 9:31 AM, dishwashing was observed. The draining pipe from the dishwashing machine was observed to be extending into the floor drain. When asked the potential problem with the dishwashing machine drain pipe going down into the floor drain; EI #4, the Dietary Manager, said cross contamination. On 06/22/2023 at 9:39 AM, EI #3, the Registered Dietitian, was interviewed about the potential problems which could result from the dishwashing machine drain pipe extending into the floor drain. EI #3 said there could be a danger of backup into the dishwashing machine via the pipe, which could result in cross contamination. On 06/22/2023 at 10:05 AM, EI #5, the Maintenance Technician, looked at the drain pipe extending into the floor drain and confirmed that it was connected to the tank of the dishwashing machine. EI #5 measured 2.5 inches as the distance from floor level to the end of the dishwashing machine drain pipe inside the floor drain. EI #5 said the potential concern would be sewage backup from the floor drain into the dishwashing machine.

Based on interviews, resident record reviews, review of the facility policy titled, Comprehensive Care Plans, and review of the Minimum Data Set (MDS) Nurse's Job Description, the facility failed to ensure care plan meetings for Resident (RI) #7 and RI #25 were conducted timely. This affected RI #7 and RI #25, two of eighteen sampled residents whose care plans were reviewed. Findings include: A review of a facility policy titled, Comprehensive Care Plans with a revision date of 01/24/2023 revealed: . It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. 2. The comprehensive care plan will be developed within 7 days after the completion of the Comprehensive MDS assessment. Employee Identifier (EI) #6's job description documented: MDS NURSE JOB DESCRIPTION . Position Purpose Conducts and coordinates the completion of required Resident Assessment Instrument (RAI) and is responsible for the implementation and ongoing evaluation of each resident's comprehensive plan of care. Major Duties and Responsibilities . Implementation and ongoing evaluation of each resident's comprehensive plan of care. Scheduling and leading interdisciplinary care plan team meetings. RI #7 was admitted to the facility on [DATE] and had diagnoses to include Adjustment Disorder with Anxiety, Bipolar Disorder, and Orthopedic aftercare. RI #7's care plan sign-in sheets were reviewed. There was no care plan meeting following the annual MDS assessment dated [DATE]. RI #25 was readmitted to the facility 03/07/2022 and had diagnoses to include Infectious Gastroenteritis and Colitis, and Hypokalemia. RI #25's care plan sign-in sheets were reviewed. There was no care plan meeting following the annual MDS assessment dated [DATE] or the quarterly MDS assessment on 03/03/2023. The facility Care Plan Conference schedule dated December 2022 was reviewed. RI #25 was scheduled for a care plan conference on 12/20/2022 at 1:45 PM. The facility Care Plan Conference schedule dated March 2023 was reviewed. RI #7 was scheduled for a care plan conference on 03/14/2023 at 1:45 PM and RI #25 was scheduled for a care plan conference on 03/28/2023 at 1:30 PM. The facility was unable to provide documentation of these care plan conferences or evidence the conferences had taken place. On 06/23/23 09:29 AM an interview was conducted with EI #6, MDS Coordinator. EI #6 was asked what part she had in ensuring the care plans are addressed after MDS assessments. She answered that she notified the representative, residents and the IDT team members. EI #6 was asked when should care plan meetings be scheduled. She said around a week after the assessment was completed. EI #6 was asked why that was not done since 09/27/22 for RI #25. EI #6 said, RI #25 was in the hospital in December when it was scheduled. EI #6 was asked when was it re-scheduled. EI #6 said, she never re-scheduled it. EI #6 was asked why not, and she answered, she forgot. EI #6 was asked when the next care plan meeting have been due for RI #25. EI #6 said, in March. She said she failed to schedule it because of other duties such as working the med cart. EI #6 said the next care plan meeting for RI #25 would have been in March, but she failed to schedule it because of other duties such as working the med cart. EI #6 was asked what was the concern of residents not having a care plan review and meeting. EI #6 answered, the care plan was the basis of what the resident needs, so, it would be important to make sure their needs were met appropriately and changes identified. On 06/23/2023 at 9:39 AM EI #6 was asked about RI #7's care plan meetings. EI #6 said RI #7 should have had a care plan meeting after the annual MDS assessment that was completed in February. When EI #6 was asked why there was no care plan meeting held, she said, other duties kept her from following through, having the meeting, and reviewing the care plan with the IDT (Interdisciplinary Team). On 06/23/2023 at 10:45 AM an interview was conducted with EI #2, the Director of Nursing. EI #2 was asked when a care plan meeting should be held and care plans reviewed. She said after an MDS assessment. EI #2 was asked why care plan meetings had not been conducted for RI #25 and RI #7. EI #2 said, they should have been. EI #2 said, she did not know why they were not done. EI #2 said, the MDS coordinator had filled in on the medication cart at times. EI #2 was asked what should be done when EI #6 was on the cart to ensure the resident's care plans are being reviewed. EI #2 said, the other person in the MDS office should assist. EI #2 was asked if she should you have known that was not being done and she said yes. EI #2 was asked what the concern of residents not having a care plan review and meeting was. She said the residents and family need to be informed of the most recent assessment and their potential needs. EI #2 was asked how the IDT team met to discuss the MDS assessment if a meeting was not scheduled to discuss the residents. She said she did not have any evidence documented to show they met.

Based on interview and record review, the facility failed to ensure Resident Identifier (RI) #24's 05/21/18, Annual Minimum Status Data (MDS) assessment was not coded for the use of an anticoagulant and hypnotic medication when RI #24 was not receiving these medications. This deficient practice affected RI #24, one of 21 residents whose MDS assessments were reviewed. Findings Include: RI #24 was admitted to the facility on [DATE], and readmitted on [DATE]. A review of RI #24's 05/21/18, Annual MDS assessment revealed RI #24 was coded as receiving an anticoagulant and hypnotic medication. A review of RI #24's (MONTH) (YEAR) physician's orders [REDACTED]. On 07/12/18 at 10:50 a.m., an interview was conducted with Employee Identifier (EI) #1, a MDS/Care Plan Coordinator. The surveyor asked EI #1 if RI #24 was receiving an anticoagulant and hypnotic medication during the month of (MONTH) (YEAR). EI #1 looked at RI #1's MDS and said according to what she coded, yes. However, after EI #1 reviewed RI #24's (MONTH) (YEAR) MAR, she stated the anticoagulant and hypnotic medications should not have been coded on RI #24's 05/21/18 Annual MDS. The surveyor asked EI #1 if it was an accurate assessment. EI #1 said no.

Based on observation, record review, a review of the facility's policy titled, Perineal Care and staff interviews, the facility failed to ensure a Certified Nursing Assistant/CNA, completely removed stool from Resident Identifier (RI) #4's perineal area. This affected RI #4, one of two residents observed during incontinent care. Findings Include: A review of the facility's policy titled, Perineal Care with a revised date of October 2010, revealed the following: Purpose The purpose of this procedure are (is) to provide cleanliness and comfort to the resident, to prevent infections and skin irritation . RI #4 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #4's Quarterly Minimum Data Set assessment dated [DATE] revealed RI #4's Brief Interview for Mental Status score of 14, indicating cognition intact. The MDS documented RI #4 required limited assistance with one person for toileting. On 05/18/2017 at 9:18 a.m., the following was observed during incontinent care: Employee Identifier (EI) #5, CNA, and EI #6, Licensed Practical Nurse/LPN, washed their hands and applied gloves. RI #4 was positioned on his/her back. EI #5 obtained a wet wash cloth from a basin of water and applied perineal rinse free peri-wash. EI #5 used a separate wash cloth and a separate area of the wash cloth to wipe the perineal area. Discoloration was observed on the last wash cloth used to wiped the perineal area. RI #4 was assisted and positioned on his/her right side. EI #5 obtained a separate wash cloth sprayed with perineal rinse free-peri-wash and wiped the perineal area. Stool was observed on the wash cloths. After the observation of the incontinent care the surveyor asked EI #5 was she finished. EI #5 replied yes she had completed the care and the resident was clean. The surveyor asked was the resident's perineal area clean and did she visualize all areas of the perineum. EI #5 said yes when she wiped downward to clean the resident. EI #5 also stated after she wiped downward, she did see some yellowish stains, which could have been urine or bowel. EI #5 further stated the facility's policy and procedure stated to wipe until the resident was clean, and she thought that was what she had done. EI #5 stated she should repeat the care. On 05/18/17 at 9:56 a.m., during the repeat observation of incontinent care, after EI #5 wiped the perineal area, the surveyor observed the wash cloth and asked what was on the cloth, EI #5 stated, BM (Bowel Movement). EI #5 repeated the wiping of the perineal area three additional times and each time the surveyor asked what was on the wash cloth and EI #5 stated twice, BM and EI #6 replied once, BM. The surveyor asked EI #5 what was the potential for harm when BM is left in the perineal area. EI #5 stated Urinary Tract Infection and skin breakdown.

Based on record review, observation of medication administration and a review of the facility's policy titled, Enteral Tube Medication Administration Procedures and staff interviews, the facility failed to ensure a licensed staff did not place her bare, left index finger in a crush bag after crushing medication and pouring medication into the medication cup. This affected one of one resident and one of one nurse observed during medication administration with crush medications. Findings Include: A review of the facility's policy titled, ENTERAL TUBE MEDICATION ADMINISTRATION PROCEDURES with no date, revealed the following: POLICY: To safely and accurately administer oral medications through an enteral tube. 1. Wash hands . Put on gloves . Resident Identifier (RI) #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's Quarterly Minimum Data Set (MDS) with a Assessment Reference Date (ARD) of 02/21/2017 revealed that RI #1's Brief Interview for Mental Status (BIMS) score was 3, indicating severe cognitive impairment, and under Section K was checked for having a feeding tube. On 05/17/2017 at 4:10 p.m., during medication administration observation, Employee Identifier (EI) #3 Licensed Practical Nurse (LPN), placed her bare, left index ungloved finger in the crush pouch after crushing the medication and pouring the medication in the medication cup. On 05/17/2017 at 4:50 p.m., an interview was conducted with EI #3, LPN. EI #3 was asked when pouring the crushed medication from the crush pouch into the medication cup what did she do. EI #3 said she put her bare, left index finger inside the pouch. EI #3 was asked why she should not have placed her finger in the pouch. EI #3 said that was an infection control issue. On 05/18/2017 at 1:10 p.m., an interview was conducted with EI #4, Infection Control Nurse/Assistant Director of Nursing. EI #4 was asked why should staff not place their ungloved (bare) finger inside the crush medication pouch. EI #4 said infection. EI #4 was asked what was the potential harm when staff put their ungloved finger inside the medication pouch. EI #4 said infection and cross contamination.

Based on observation, interviews and a review of the Bread Pudding Cake recipe, the facility failed to prepare and serve a palatable dessert for the 05/17/17 lunch meal. This had the potential to affect 75 residents for whom food of a regular or soft consistency was served. Findings Include: The 05/17/17 lunch meal included a 4 ounce portion of Bread Pudding Cake. The cake had a dry appearance, with no glaze or icing. The surveyor showed a sample of the cake to Dietary Management Staff (at 12:50 p.m.) from the tray of a resident who would not eat it. On 05/17/17, two residents complained about the cake served during the lunch meal. A review of the Bread Pudding Cake Recipe revealed the inclusion of a powdered sugar glaze for the cake, however no glaze had been observed. On 05/17/17 at 4:00 p.m., the Assistant Dietary Manager, Employee Identifier (EI) #2 confirmed the baker had forgotten to make the glaze. Resident Identifier (RI) #2 and RI #13 were interviewed about the cake on 05/18/17 at 11:55 a.m. RI #2 described the cake as plain, dry, and in need of ice cream or fruit. RI #13 stated it needed a lot more sugar and some icing.

Based on observation, record review, and interview: 1. The facility failed to prevent potential cross-contamination of food by direct care staff who handled ready-to-eat food (cornbread) with their bare hands. 2. The facility failed to assure dinnerware (sectional plates) were clean to sight and touch. The above practices posed the potential for food contamination and compromised food safety. This had the potential to affect all 83 residents who received meal trays from dining services. Findings include: 1. The 2013 Food Code by the United States Public Health (USP) and the Food and Drug Administration (FDA) included the following: 3-301.11(B) Preventing Contamination from Hands. (B) . EMPLOYEES may not contact exposed ready-to-eat food with their bare hands . On 5/03/2016 at 5:25 PM, meal service in the dining room was observed. A CNA (Certified Nursing Assistant) EI (Employee Identifier) #11 was observed to spread butter on two pieces of cornbread. The CNA held the cornbread with fingers while spreading the butter on the bread with a fork. When questioning the CNA about not touching food with bare hands, EI #11 stated that she did not know. During an interview with the CNA, EI #11 on 5/5/2016 at 11:30 AM, she admitted touching the cornbread with bare hands and stated she had received multiple training's. EI #11 indicated she should have used utensils. EI #11 said she used her hand, but used a fork to spread the butter. EI #11 indicated the negative outcome for the deficient practice was spreading germs and a potential for cross-contamination. 2. The 2013 Food Code relative to: 4-601.11 .Food-Contact Surfaces .(A) .FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch . Observations of divided plates stored on the tray line were examined on 5/03/2016 at 7:50 AM. Two of five plates were badly stained and one contained food debris. At 8:10 AM, the CDM (Certified Dietary Manager) EI #3 was asked to tell what she saw. EI #3 stated, stained and with food particles. On 5/4/2016 at 10:40 AM the CDM was asked who should be accountable for the clean dinnerware problem and she responded: I think we all are. The CDM was asked about the potential outcome for the stained plates with food debris and EI #3 said there was a potential outcome for biological cross-contamination.

Based on observations, interviews, and record reviews, the facility failed to ensure a Licensed Practical Nurse (LPN) prepared wound care supplies in a manner to prevent cross contamination. The facility further failed to ensure that a dressing over a wound was secured. This affected Resident Identifier (RI) #4 during one of two observations of wound care during the survey. Findings include: A review of facility wound care guidelines titled: WoundCare MythBUSTERS Volume 4, Issue 1 with a reissued date of August 2015 revealed, Bacteria are a major concern for wound healing. Consider that gauze is permeable to bacteria even at > (greater than) 50 layers thickness .A secondary dressing with a waterproof backing can be especially useful when the wound is located on the buttock/coccyx region .Ideal Secondary Dressing: Maintain moisture content, Impermeable to bacteria . A review of a facility policy titled: Pressure Ulcer Treatment with a revised date of October 2010 revealed, .Stage III (three) Pressure Ulcer Interventions/Care Strategies: 1. Protect; 2. Fill dead space .; 3. Manage drainage; 4. Promote moist wound healing . RI #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #4's weekly wound documentation dated 5/2/2016 revealed a stage three pressure ulcer to the coccyx. On 5/4/2016 at 10:20 AM, Employee Identifier (EI) #9 performed a dressing change to the pressure ulcer on RI #4's coccyx. The surveyor watched EI #9 prepare her supplies prior to entering RI #4's room. EI #9 used a sanitary cloth to wipe both of her hands then picked up the trash can lid with her bare right hand to throw away the cloth. EI #9 then removed the wound care supplies from the cart without any further hand hygiene, after she had touched the trash can lid. EI #9 opened a package of gauze pads and removed several with her bare right hand that had touched the trash can lid. She placed the gauze pads into a plastic cup and took the wound supplies into RI #4's room. EI #9 removed the old dressing to RI #4's coccyx. The dressing only adhered to the skin on the two lateral sides and the dressing was open on the other two distal sides. RI #4 was not wearing an incontinence brief and had been lying on a wet, brown-stained pad that smelled of urine. The gauze pads placed in the plastic cup were then used to clean RI #4's stage three wound. EI #9 completed the wound care and applied a foam dressing, that had adhesive on the two lateral sides, across the open wound leaving the other two sides gapped open, not secured to the skin, and open to urine and feces. On 5/5/2016 at 10:52 AM, EI #9 was asked what the facility policy was regarding touching supplies, to be used on an open wound, with a bare hand. EI #9 answered that she would have to look, but they wash their hands before starting. The surveyor asked EI #9 why she got the gauze out of the package with her bare hand after touching the trash can lid. EI #9 confirmed she had raised the lid after her hands were cleaned. The surveyor asked EI #9 if touching the trash can lid then touching gauze would cause the gauze to become contaminated. EI #9 answered that she had touched the gauze with her bare hand, so it could have contaminated the gauze. The surveyor asked EI #9 what the potential harm to the resident was if staff touched the trash can lid, then touched supplies that were used directly on RI #4's open wound. EI #9 answered that if the gauze was contaminated it could cause infection in the wound and slow the healing process. The surveyor asked EI #9 what the purpose was of a dressing over a wound. EI #9 answered that it was to cover the wound, prevent infection, and keep medication in place. The surveyor asked EI #9 if the dressing she applied to RI #4 protected the wound. EI #9 answered that it did not. The surveyor asked EI #9 if the coccyx wound was not covered, could the incontinence harm the resident. EI #9 answered, it could cause the wound to become infected and slow the healing. EI #9 stated that RI #4's dressing had the potential to get something under it like feces or urine. On 5/5/2016 at 11:05 AM, an interview was conducted with EI #2 Registered Nurse (RN) Assistant Director of Nursing (ADON), Infection Control. The surveyor asked EI #2 if a nurse should clean hands with a sanitary wipe, touch a trash can lid with her bare hand, then touch any clean items that were to be used on a resident. EI #2 answered, No. The surveyor then asked EI #2 if a nurse should touch, with a bare hand, any wound supplies, that would be used directly on the wound. EI #9 responded, No. The surveyor asked EI #2 what the potential harm would be to a resident if a nurse touched a trash can lid then touched gauze to be used on an open wound. EI #2 stated that whatever was on her hand could go directly to the wound bed. EI #2 then said, there could be anything on the trash can such as bacteria. The surveyor asked EI #2 how a wound on a coccyx should be protected from incontinence. EI #2 answered that they would use frequent checks and closed dressings. The surveyor asked EI #2 what the potential harm to the resident would be if the coccyx wound was not protected from incontinence. EI #2 answered that the resident could become septic.

Based on observation, interview, and record review, the facility failed to ensure a Licensed Practical Nurse (LPN) did not dry a syringe used for medication administration by gastrostomy tube for Resident Identifier (RI) #18 with a dirty paper towel. The facility failed to ensure an LPN did not wipe her hands on a paper towel used to turn the faucet off after washing her hands during medication administration for RI #18. The facility further failed to ensure two Licensed Practical Nurses (LPN) thoroughly cleaned Resident Identifier (RI) #4 after an incontinent episode and that an LPN did not touch clean linen and RI #4's hand while wearing gloves that were used to clean the resident during incontinent care. This affected two of 18 sampled residents. Findings include: A review of Potter and Perry's, FUNDAMENTALS OF NURSING EIGHTH EDITION, Copy Right 2013, Chapter 28, Infection Prevention and Control, Page 411 revealed: .If hands are not visibly soiled ., use an alcohol-based waterless antiseptic agent for routinely decontaminating hands in the following clinical situations: .b. After contact with body fluids or excretions, mucous membranes, nonintact skin, or wound dressings c. When moving from a contaminated to a clean body site during patient care. d. After contact with inanimate surfaces or objects in the patient's room (e.g., (for example) over-bed table, bed linen, IV pump) . A review of Potter and Perry's, FUNDAMENTALS OF NURSING EIGHTH EDITION, Copy Right 2013, Chapter 48, Skin Integrity and Wound Care, Page 1213 revealed: .SAFETY GUIDELINES FOR NURSING SKILLS: SKILL 48-1: ASSESSMENT FOR RISK OF PRESSURE ULCER DEVELOPMENT: Delegation Considerations: .Keep the patient's skin dry and provide hygiene following incontinence of urine or stool or exposure to other body fluids . A review of a facility policy titled Perineal Care, with a revised date of October 2010, revealed: .The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation .Steps in the Procedure .10 h. Wash and rinse the rectal area thoroughly .12. Remove gloves and discard .Wash and dry your hands thoroughly. 13. Reposition bed covers. Make the resident comfortable . A review of a facility policy titled Standard Precautions with a revised date of December 2007, revealed: .Standard Precautions will be used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status .Standard precautions include the following practices: .1. Hand hygiene .b. Hands shall be washed with soap and water whenever visibly soiled with .body fluids, or after direct or indirect contact with such .2. Gloves .e. Change gloves, as necessary, during the care of a resident to prevent cross-contamination from one body site to another (when moving from a dirty site to a clean one . A review of a facility policy titled Handwashing/Hand Hygiene with a revised date of April 2012, revealed: .Policy Statement. This facility considers hand hygiene the primary means to prevent the spread of infections .Policy Interpretation and Implementation .5. r. After handling soiled or used linens . 1.) RI #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of April 24, 2016 indicated that RI #18 did have a feeding tube at the time of the assessment. On 5/03/2016 at 12:12 PM, Employee Identifier (EI) #7, an LPN, was observed to give medication to RI #18 through a gastrostomy tube. Prior to administering the medication, EI #7 went into the bathroom and washed her hands, used a paper towel to turn the faucet off, and then used that same paper towel to wipe her hands before discarding the paper towel. EI #7 then turned the faucet on to run water into a plastic cup to be used to flush the gastrostomy tube. EI #7 turned the faucet off using a paper towel and again, wiped her hands with that paper towel before discarding it. EI #7 administered RI #18's medication through a syringe inserted into the tip of the gastrostomy tube, then took the syringe into the bathroom and rinsed it with water from the faucet. EI #7 obtained a length of paper towel from the dispenser in the bathroom. The end of the paper towel was hanging down as she held it. EI #7 rested the end of the paper towel on the edge of the sink then pushed down with the hand holding the paper towel in order to push the paper towel into her hand. This caused the paper towel to come into contact with the inside surface and the edge of the bathroom sink. EI #7 then used this paper towel to dry the syringe both inside and outside and hung the syringe back on the pole by the resident's bed. On 5/05/2016 at 9:20 AM, EI #7 was asked how she cleaned and dried the tube feeding syringe after using it on RI #18. EI #7 stated she rinsed the syringe then used a paper towel to dry it and put it back in the bag. The surveyor discussed with EI #7 the observation of touching the sink with the paper towel before using it to dry the syringe. The surveyor asked EI #7 if she knew why she touched the inside of the sink with the paper towel then used that paper towel to dry the syringe. EI #7 answered that she should not have done that. The surveyor asked EI #7 how she was trained to turn the faucet off after she washed her hands. EI #7 answered that she was taught to turn the faucet off with a paper towel. The surveyor discussed with EI #7, the observation of EI #7 turning off the faucet with a paper towel then wiping her hands with that paper towel on two separate occasions. EI #7 was asked why she would have done that. EI #7 answered that she did not know why she did it, and admitted she should not have. The surveyor asked EI #7 if that would have caused her hands to become contaminated. EI #7 confirmed that it would. The surveyor asked EI #7 what the potential harm to a resident was when staff dried a tube feeding syringe with a paper towel that touched a dirty surface such as a bathroom sink. EI #7 answered that whatever was in the sink could cross contaminate the syringe. On 5/5/2016 at 11:05 AM, an interview was conducted with EI #2, Registered Nurse (RN) Assistant Director of Nursing (ADON), Infection Control. The surveyor asked EI #2 how staff was supposed to turn the faucet off when they washed their hands. EI #2 stated they were supposed to use a paper towel to turn the water off. The surveyor asked if staff should use a paper towel to turn the sink off then wipe their hands on that paper towel. EI #2 responded that they should not. The surveyor asked EI #2 if a nurse should wipe her hands on a paper towel used to turn off the faucet then handle a cup of water to be used to flush a gastrostomy tube. EI #2 answered, Probably not. The surveyor asked EI #2 what the potential harm to a resident was in this situation. EI #2 answered that there was cross contamination related to the faucet knob. The surveyor asked EI #2 how a nurse should dry a tube feeding syringe. EI #2 answered that using a paper towel is fine if the paper towel is clean and the employee's hands are clean. The surveyor asked EI #2 if a nurse should ever touch the inside and top surfaces of a bathroom sink with a paper towel then use that paper towel to dry a tube feeding syringe. EI #2 answered, No. The surveyor asked EI #2 what the potential harm to a resident was when a nurse dried a tube feeding syringe with a contaminated paper towel. EI #2 answered, what was in the syringe went directly into the resident's body, and whatever was in the sink contaminated the tube. 2.) RI #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #4's admission MDS (Minimum Data Set) with an Assessment Reference Date of 4/29/2016 revealed a BIMS (Brief Interview for Mental Status) score of 13 which indicated intact cognition. The MDS also revealed RI #4 required extensive assistance with hygiene. RI #4's weekly wound documentation dated 5/2/2016 revealed a stage three pressure ulcer to the coccyx. On 5/04/2016 beginning at 9:35 AM, two LPNs were observed providing incontinent care to RI #4. RI #4 was lying directly on an incontinence pad. The pad had a large area that was wet, brown, and smelled of urine according to Employee Identifier (EI) #8. During the provision of incontinent care, EI #8 and EI #9 assisted RI #4 to a left side-lying position. While in that position, RI #4's left hip was directly on the wet, brown-stained pad. Neither EI #8 nor EI #9 cleaned RI #4's left hip. EI #9 cleaned RI #4's penis by holding it with her left hand and wiping with her right hand. EI #9 then used her left hand to reach into a bag of clean linen and touched an inside surface of the bag in an attempt to open it wider. The linen in the bag was brought in the room to be used in RI #4's care. EI #8 then cleaned the resident's buttocks and rectal area. EI #8 then reached into the bag, picked up a clean pad from the bag containing linen and rolled it up under RI #4 with the same gloves on that she had worn to clean the resident. The dirty pad was removed from under RI #4 while EI #8 held RI #4's hand wearing the same soiled gloves. EI #8 stated the pad they removed was wet, had a dark brown stain, and a urine odor. On 5/05/2016 at 10:45 AM, an interview was conducted with EI #9. The surveyor asked EI #9 if they should have cleaned all of the resident's skin that had come in contact with urine or feces. EI #9 answered, Yes. The surveyor asked EI #9 why she and EI #8 had not cleaned RI #4's hips after the resident had been rolled onto the left hip directly on the pad that was wet, soiled, and smelled of urine. EI #9 stated that it was just an oversight. The surveyor asked EI #9 what the potential harm was of not cleaning all of RI #4's skin that had been in direct contact with the wet and soiled pad. EI #9 responded that there was an increased risk for further skin breakdown. The surveyor asked EI #9 what she was taught about keeping clean and dirty things separated during incontinent care. EI #9 stated that you should keep clean and dirty items in separate bags. The surveyor asked EI #9 if once a dirty hand is established during care, should this hand be used to obtain or touch clean supplies. EI #9 answered, No. The surveyor discussed the observation with EI #9 of her establishing her left hand as dirty then reaching into a clean bag of linen with it. EI #9 confirmed that she may have done that. The surveyor asked EI #9 why she had used her dirty hand to reach into the linen bag. EI #9 answered that she just was not thinking. The surveyor asked EI #9 what could potentially happen to the linen and then the resident because of this. EI #9 answered that she could have had feces on her hand and it was an infection control issue. The surveyor asked EI #9 when she should wash her hands when performing incontinent care. EI #9 answered, after you wash, rinse and dry the resident. The surveyor asked EI #9 if EI #8 should have washed her hands after cleaning RI #4's buttocks and before handling a clean pad that the resident laid directly on. EI #9 answered, Yes. The surveyor asked EI #9 what the potential harm to the resident was since EI #8 did not wash her hands after cleaning RI #4's buttocks and before handling the clean pad. EI #9 answered that it could expose the wound to feces or urine. On 5/05/2016 at 11:05 AM, an interview was conducted with EI #2, RN/ADON/Infection Control. The surveyor asked EI #2 when staff should wash their hands during incontinent care. EI #2 answered, they should wash before, after, and any time gloves are changed. The surveyor asked EI #2 if staff should touch any clean linen with gloves that have been in contact with a dirty surface. EI #2 answered, No. The surveyor asked EI #2 what the potential harm to a resident would be if staff did not wash their hands between handling soiled items and clean items during incontinent care. EI #2 answered, staff should have washed their hands and the risk was infection due to the staff member contaminating linen with dirty hands. The surveyor asked EI #9 what the potential harm was to a resident when staff used a dirty glove to reach inside a clean bag of linen and open it. EI #2 answered that it could contaminate all of the linen. The surveyor asked EI #2 what staff should do if any part of a resident's skin came in contact with soiled or wet linen. EI #2 answered that they should provide perineal care. The surveyor asked EI #2 what the potential harm to the resident was if the resident was positioned on a soiled, wet pad and all of the skin that was in contact with the soiled pad was not cleaned. EI #2 answered, all of the skin should have been cleaned because it could lead to more skin breakdown.

Based on record review, observation and interview, the facility failed to ensure puree Green Beans and regular Spaghetti Meat Sauce reached the proper temperature of 165 degrees when reheated. Furthermore, the facility failed to ensure silverware was dry before being placed in silverware bags. This had the potential to affect 76 of 78 residents who receives meals from the kitchen. Findings Include: A review of the facility Policy ... "Food Preparation and Service" with a revised date of December 2008 revealed the following: ... Cooking and Holding Temperatures and Time ... 6. Previous cooked food must be reheated to an internal temperature of 165 degrees for at least 15 seconds..." On 3/25/2015 at 10:50 AM, the surveyor observed EI #6 (Employee Identifier) dietary worker, taking the temperature of the foods on the steam table. EI #6 took the temperature of the Spaghetti Meat Sauce. The first temperature was 120 degrees. EI #7 (Certified Dietary Manager), pulled the meat sauce off the steam tray table and put it on the stove. After a few minutes, the meat sauce was placed back on the steam tray table. EI #6 took the temperature again. The Spaghetti Meat Sauce reached the temperature of 155 degrees and the food was served. EI #6 took the temperature of the Puree Green Beans. The first temperature of the Puree Green Beans was 100 degrees. The Certified Dietary Manager pulled the Puree Green Beans off the steam tray table and placed them on the stove. After reheating the green beans for a few minutes, they were placed back on the steam tray table. EI #6 took the temperature of the green beans again. The temperature of the green beans were 140 degrees and were served. On 3-26-2015 at 9:15 A.M., an interview was conducted with EI #6. EI # 6 was asked who was responsible for reheating foods. EI #6 replied my runner if she need them or whoever was in the dish room. EI #6 was asked what was the facility policy on reheating food. EI #6 replied put it back on the stove to reheat to 165 degrees or above. EI #6 was asked when should food be reheated. EI #6 replied when you take your first temperature, if it was not up to the temperature, you reheat. EI #6 was asked who wrote down the temperatures of the Puree Green Beans and Spaghetti Meat Sauce on 3/25/2015 while the worker was taking food temperatures on the steam table. EI #6 replied no one. EI #6 was asked what was the temperature of the Spaghetti Meat Sauce after it was reheated. EI #6 said 155 degrees. EI #6 was asked what was the temperature of the Puree Green Beans when they were reheated. EI #6 replied 150 degrees. EI #6 was asked what should the temperature be when reheating foods. EI #6 replied 165 degrees. EI #6 was asked why should food be reheated. EI #6 replied because it was not up to the temperature it should be reheated. EI #6 was asked what was the potential harm when food was reheated and do not reach the correct temperature of 165 degrees. EI #6 replied the food can get bacteria and E-Coli if it was not fully cooked. On 3-26-2015 at 9:30 A.M., EI #4 Dietary Manager/Supervisor was asked who wrote down the temperatures of the Puree Green Beans and Spaghetti Meat Sauce on 3/25/2015 while the worker was taking temperature of foods on the steam tray table. EI #4 replied no body. EI #4 was asked what should the temperature be when reheating foods. EI #4 replied 165 degrees or above. EI #4 was asked why should food be reheated. EI #4 replied to hold temperature to keep it from getting bacteria in it. EI #4 was asked what was the potential harm when food is reheated and it do not reach the correct temperature of 165 degrees. EI #4 replied bacteria starts to grow. A review of the facility Policy "Sanitizing Flatware" with no revised date revealed the following: " ... PROCEDURE: ... 4. After washing and allowing to air dry, place a clean empty cylinder over the mouthpieces and insert the cylinder so that the handle point up. ..." On 3/25/2015 at 11:40 A.M., the surveyor observed spoons, forks and knives being taken out of a cylinder, placed in a silverware bag and then placed onto the residents tray. The surveyor checked seven bags of silverware and observed some to be wet. On 3-26-2015 at 1:00 P.M., an interview was conducted with EI #4. EI #4 was asked who was responsible for washing the silverware. EI #4 replied dishwashers. EI #4 was asked what was the facility policy on washing silverware. EI #4 replied put in soak, put the silverware in a flat container and run through the dishwasher. Place the knives, forks and spoons upside down in a rack and run through the dish washer three times and set the silverware to the side to air dry. EI #4 was asked was the silverware in the cylinder and silverware bags wet on 3/25/2015. EI #4 replied yes, there was spots and water on the silverware. EI #4 was asked what was the potential harm when silverware in a cylinder and silverware bag were wet. EI #4 said germs and bacteria. EI #4 was asked how long should silverware be allowed to air dry. EI #4 replied one hour. EI #4 was asked was the silverware dry before placing them in the silverware bags. EI #4 replied no. On 3/26/2015 at 1:15 P.M., a telephone interview was conducted with EI #5, a dietary worker. EI #5 was asked who was responsible for washing silverware. EI #5 replied dishwashers. EI #5 was asked what was the facility policy on washing silverware. EI #5 replied run them through the dishwasher three times and place in a cylinder to air dry. EI #5 was asked was the silverware in the silverware bag wet. EI #5 replied yes ma'am. EI #5 was asked what was the potential harm when silverware was place in a cylinder and silverware bags. EI #5 replied contamination. EI #5 was asked how should silverware be allowed to dry. EI #5 replied air dry. EI #5 was asked how long should silverware air dry. EI #5 replied 15 to 20 minutes. EI #5 was asked was the silverware dry before placing them in the silverware bags. EI #5 replied no ma'am

Based on observation, interviews, and review of a facility policy titled "CONTROLLED MEDICATION STORAGE", the facility failed to store the controlled medications, Marinol and Ativan, in a permanently affixed locked compartment inside the refrigerator. This deficient practice affected Resident Identifier (RI) #17, one (1) of one (1) resident who received Marinol, and one (1) of two (2) medication rooms with refrigerators in the facility that store controlled medications. Findings Included: A facility policy titled "CONTROLLED MEDICATION STORAGE" with an effective date of July 1, 2009, documented: "Policy Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations. Procedures ...B. Schedule III-V medications and other medications subject to abuse are stored in a permanently affixed compartment separate from all other medications ..." An article from the AP (Associated Press) Headlines dated Friday July 2 (no year) at 8:15 PM ET (Eastern Time) documented: "... The Drug Enforcement Administration reclassified Marinol from a "Schedule 2'' drug to the less restricted "Schedule 3'' category. This essentially means that instead of being classified with drugs like morphine, Marinol is now classified with more widely used drugs like Codeine ..." RI #17 was originally admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of RI #17's medical record revealed physician orders [REDACTED]. "... Marinol Capsule 2.5 MG (milligram) (Dronabinol) Give one capsule by mouth two times a day related to ANOREXIA." On 3/26/15 at 8:05 a.m., the surveyor conducted an observation of the medication room with the Administrator, Employee Identifier (EI) #1, the Assistant Director Of Nursing (ADON), EI #2 and the Unit Manager EI #3. The surveyor asked EI #2 if there were any controlled medications in the refrigerator. EI #2 said yes, Ativan. Observation of the inside of the refrigerator revealed there were stored medications in the refrigerator. The surveyor asked EI #2 what were the medications. EI #2 identified the contents in the two packs lying on the rack inside the refrigerator as Marniol. EI #2 identified RI #17 as the resident who the Marinol was prescribed for. The surveyor, along with EI #1 and EI #2, also observed 1 vial of a 2 mg stocked (Injectable) Ativan lying in the rack inside the refrigerator. On 3/26/15 at 8:30 a.m., the surveyor conducted an interview with EI #2, the ADON. The surveyor asked EI #2 did the facility store narcotics in the refrigerator. EI #2 stated, "In a lock box that's permanently affixed." The surveyor asked EI #2 was the Marniol and Ativan observed on 3/26/15 at 8:05 a.m. stored in a locked box that was permanently affixed inside the refrigerator. EI #2 stated, "No sir, it was in the refrigerator with just a pad lock." The surveyor asked EI #2 did the facility's policy and procedure say how narcotics that are refrigerated should be stored. EI #2 said she was not sure and she needed to review the policy and procedure. EI #2 reviewed the facility's policy and procedure and stated, "Medication subject to abuse are stored in a permanently affixed compartment separate from all other medications."

Based on interview and review of a facility policy titled "Discarding and Destroying Medications", the facility failed to ensure: (1) three of five medication destruction sheets titled "Record Of Medication Destruction (for) Non-Controlled" for the month of July 2014 contained the required number of signatures according to the facility's policy titled "Discarding and Destroying Medications" with a revision date of April 2013 and; (2) two of two medication destruction sheets titled "Record Of Medication Destruction (for) Non-Controlled" for the month of October 2014 contained the required number of signatures according to the facility's policy titled "Discarding and Destroying Medications" with a revision date of April 2013. This was found in two (2) of 12 months of "Non-Controlled" destruction sheets reviewed from March 2014 to March 2015. Finding Included: A facility policy titled "Discarding and Destroying Medications", with a Revision date of April 2013 documented: " ... Policy Interpretation and Implementation ... 2. Non controlled ... will be disposed of in accordance with state regulations and federal guidelines regarding disposition of non-hazardous medications ... 4. ... c. ... (5) Document the disposal on the medication disposition. record. (6) Include the signature(s) of at least two witnesses." On 3/26/15 at 11:45 a.m., the surveyor reviewed 12 months of narcotic and non controlled Record of Medication Destruction sheets from March 2014 to March 2015. A review of the July 2014 "Record Of Medication Destruction" sheets revealed there was only the consultant pharmacist signature for each of the two sheets reviewed for non controlled medication. A review of the October 2014 "Record Of Medication Destruction" sheets revealed there was only the consultant pharmacist signature on three of five of the sheets reviewed for non controlled medication. On 3/26/15 at 12:00 noon, the surveyor conducted an interview with Employee Identifier (EI) #1, the Administrator. The surveyor asked EI #1 who was responsible for signing the drug destruction record for non-controlled medications. EI #1 stated, "The pharmacist, plus one person licensed." The surveyor asked EI #1 how many signatures were on the July 2014 and October 2014 non-controlled "Record Of Medication Destruction" sheets. EI #1 stated, "One signature." The surveyor asked EI #1 how many signatures according to the facility's policy and procedure were required for non controlled medication destruction. EI #1 stated, "Two for non control."

Based on observation, interview and record review the facility failed to label three left over items in the walk in cooler to indicate what they were. This had the potential to affect 12 of 70 residents receiving Regular and Mechanical Soft diets. Findings include: Review of ServSafe Starters Employee Guide, Fifth Edition, copy right 2008, page 19 revealed: "How to Label Food for Storage ...All ready-to-eat food that is prepped in -house must have a label that includes the following information. Name of the food ..." Review of the policy provided by the facility (no date) titled "SANITATION/INFECTION CONTROL" documented the following "... SANITATION F340 ... 2. Steps in the sanitary preparation of food include, but are not limited to the following:.. i. Leftover foods are placed in shallow containers, dated, labeled..." During the initial tour of the kitchen on 3/12/13 at 1:06 P.M. three food items each in a 10 inch by 7 inch stainless steel pans observed to be less than half full. The containers had a clear plastic cover labeled with dates however; the label did not identify what the food items were. The surveyor was accompanied by ( Employee Identifier ) EI # 1, Dietary Manager who identified the food in the containers as chicken noodle soup, beef stew, and meat used for sloppy joes. A review of the "OptimaSolutions Diet Master...Print Date: Tuesday, March 12, 2013" documented 49 residents received a Regular diet from the kitchen and 21 residents received a Mechanical Soft Diet from the kitchen. An interview was conducted with EI #1 on 3/13/13 at 8:10 A.M. The surveyor asked EI #1 if the food items ( chicken noodle soup, beef stew and meat used for sloppy joes) should have been labeled. EI #1 stated "Yes". EI# 1 further stated that she inserviced her staff regarding dating and labeling foods. The surveyor then asked EI #1 what could happen from the food items not being labeled. EI #1 stated if the food could not be recognized it would have to be thrown out. An interview was conducted with EI #1 on 3/13/13 at 7:38 P.M. The surveyor asked EI #1 which residents would receive chicken noodle soup, beef stew and meat for sloppy joes. EI #1 stated the food would have been served to residents receiving Mechanical Soft or regular diets. The surveyor then asked how many serving were available per pan for serving. EI #1 replied four servings in each pan.

Based on observation, interview and record review the facility failed to ensure 1) the glucometer was sanitized in a manner to prevent cross contamination for Resident Identifier (RI) #18 and RI #19. This affected one of six nurses observed using a glucometer to perform Finger Stick Blood Sugar (FSBS). 2) The facility further failed to ensure RI #2's overbed table was sanitized prior to wound care. This affected one of two observations of wound care. Findings include: 1) RI #18 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of RI #18's most recent physician's orders [REDACTED]. RI #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of RI #19's most recent physician's orders [REDACTED]. Further review of a document titled "Physician order [REDACTED].#19 were to receive finger stick blood sugar checks 4 times daily. An observation was conducted on 03/13/2013 at 11:20 AM of Employee Identifer (EI) #2, Licensed Practical Nurse performing Finger Stick Blood Sugar. After completing RI #18's Finger Stick Blood Sugar, EI #2 was observed to clean the glucometer with an alcohol pad. EI #2 then proceeded and obtained RI #19's FSBS. EI #2 used another alcohol pad to clean the glucometer after obtaining RI #19's FSBS. The machine was then returned to the medication cart. EI #2 stated she was done with FSBS until 4:00 PM. Review of an undated facility policy titled "PROCEDURES FOR CLEANING GLUCOMETERS" revealed "...clean the glucometer with the Germicidal disposable wipe...If blood is visibly present on the meter two wipes must be used; one to clean the glucometer and a second wipe to disinfect the glucometer." On 3/14/13 at 8:30 AM an interview was conducted with EI #2. EI #2 was asked if she had been trained on sanitizing the glucometer. EI #2 indicated that she had. EI #2 was also asked why an alcohol pad was used to clean the glucometer. EI #2 stated that some germicidal wipes were prepackaged like the alcohol pad and that she was nervous and grabbed the alcohol. EI #2 was also asked what potential harm could occur if the glucometer was not cleaned properly with a sanitizing agent. EI #2 indicated that it was an infection control problem and that the alcohol would not properly sanitize the machine. 2) Resident Identifier (RI) #2 was readmitted to the facility 4/10/10 with [DIAGNOSES REDACTED]. An observation of RI #2's wound care was conducted on 03/13/13 at 10:01 AM. Employee Identifier (EI) #3, Licensed Practical Nurse, was observed removing RI #2's personal belongings from the overbed table. EI #3 did not clean or sanitize the overbed table and placed a clean towel down to form a barrier for the wound care supplies. Review of a facility policy titled "Dressings, Dry/Clean" with a revision Date of April 2010 revealed "Clean bedside stand. Establish a clean field." An interview was conducted with EI #3 on 3/15/13 at 8:01 AM. EI #3 was asked how a clean field should be prepared before providing wound care. EI #3 stated "Use a germicidal wipe to sanitize the overbed table and put a clean towel down". EI #3 was then asked why a germicidal wipe should be used. EI #3 indicated that it sanitized. EI #3 was asked if that is how she prepared the clean field prior to performing RI #2's wound care. EI #3 indicated that it was not. EI #3 was asked what potential harm could occur from not sanitizing the overbed table prior to preparing a clean field. EI #3 stated "Germs and bacteria could be transferred onto the clean supplies that I am going to be working with."

Based on record review, observation and staff interviews, the facility failed to ensure RI (Resident Identifier) #2's foley catheter tubing was anchored to prevent potential infection and/or injury of the bladder wall and urethra. This affected RI #2, one of two sampled residents with catheters. Findings include: RI #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/06/2011, identified RI #2 with severely impaired cognition. She was coded as always incontinent of bowel, had an indwelling catheter and was totally dependent on staff for ADLs (Activities of Daily Living). A review of RI #2's care plan dated 02/15/2012 and updated 03/02/2012, documented an approach, "Provide leg strap to prevent tension on catheter tubing." On 03/07/2012 at 9:00 AM, RI #2 was provided catheter care by Employee Identifier (EI) #2, a Certified Nurse Assistant (CNA). The catheter tubing was not anchored with a leg band or tape to prevent excessive tension. The catheter drainage bag was secured to the bed frame on RI #2's right side. Upon completion of the catheter care, EI #2 positioned RI #2 on her back. EI #2 then left the room without anchoring the catheter tubing in place. An observation was made of EI #6, Licensed Practical Nurse (LPN) Wound Care Nurse, providing wound care on 03/07/2012 at 9:45 AM. RI #2 did not have a leg strap or device to anchor the foley catheter tubing in place. A subsequent observation of EI #2's foley catheter tubing was made on 03/07/2012 at 4:00 PM with EI #3, a CNA. There was no device to anchor the foley catheter tubing in place. An interview was conducted with EI #3, CNA, on 03/07/2012 at 4:10 PM. EI #3 was asked if she had observed a leg strap or device to anchor RI #2's catheter tubing and she said no. EI #3 was asked if the catheter tubing should have been secured and she replied yes. EI #3 was asked why should the catheter tubing be secured. EI #3 replied to keep it from pulling out, to keep it from getting kinked and to be more comfortable for the resident. EI #3 was asked what could happen if there is tension on the catheter tubing. EI #3 replied trauma to the urethra and the tubing could not drain correctly and cause infection. EI #3 was asked if she had been trained in catheter care. She replied yes, and that she had been trained to ensure leg bands were in place to secure the foley tubing. An interview was conducted with EI #2, CNA on 03/08/2012 at 9:25 AM. EI #2 was asked when she provided Activities of Daily Living (ADL) care on 03/07/2012 did she secure RI #2's foley catheter tubing. EI #2 said no and further stated that she was too nervous and didn't think about it. EI #2 was asked should she have secured RI #2's catheter tubing. EI #2 said yes. EI #2 was asked what could happen if the catheter tubing is not secured. EI #2 replied that the foley could be pulled out and cause trauma to the urethra. EI #2 was asked if she had been trained to secure foley catheter tubing and she replied yes. An interview was conducted with EI #1, the Director of Nurses (DON) on 03/08/2012 at 10:00 AM. EI #1 was asked what RI #2's care plan instructed the staff to do to stabilize the resident's foley catheter tubing. EI #1 said to apply a leg band. EI #1 was asked who is responsible to ensure the foley catheter tubing is secured. EI #1 replied the CNAs and nursing staff. The DON was asked what could happen if a foley catheter tubing is not secured. EI #1 replied it can cause tension on the catheter, cause trauma and it could be pulled out.

Based on observation and interviews, the facility failed to ensure infection control practices were followed during medication administration. During medication pass a nurse was observed touching the inside of a medication cup and the inside of a beverage cup with ungloved hands. Subsequently, the medication cup and the beverage cup were used for medication administration. This affected unsampled resident #1 and unsampled resident #2, one of two nurses observed during medication administration. Findings include: On 03/06/12 at 4:20 PM, Employee Identifier (EI) #4, a Licensed Practical Nurse (LPN), was observed removing a medicine cup from a stack of medication cups by placing her ungloved index finger inside the cup. She then placed six pills in the medication cup. EI #4 was then observed administering the medication from the cup to unsampled resident #1. At 4:40 PM, EI #4 was observed removing a beverage cup from a stack of cups by placing her ungloved index finger inside the beverage cup. EI #4 then proceeded to mix [MEDICATION NAME] and four ounces of liquid in the beverage cup. EI #4 was then observed administering the medication to unsampled resident #2. During an interview on 03/08/2012 at 10:30 AM, EI #4 was asked what potential problem does placing an ungloved finger inside a resident's medicine cup and a resident's beverage cup pose. EI #4 replied that there is a potential for cross contamination because the resident is being exposed to another person's normal flora. During a interview on 03/08/2012 at 11:15 AM, EI #5, the Infection Control Coordinator, was asked what potential problem could touching the inside of a resident's medicine cup and beverage cup pose. EI #5 stated that touching the inside of the medicine cup or the inside of the resident's beverage cup should not not happen because there is a potential for cross contamination. A review of Potter Perry's, Fundamentals of Nursing, 6th Edition (pages 776 and 786) from "Infection Control" revealed the following: " ...the major mode of transmission of microorganisms is the hands of the health care worker...The nurse's efforts to minimize the onset and spread of infection are based on the principles of aseptic technique...Aseptic technique refers to practices that keep a client as free from pathogens as possible."

Based on observation, interview and record review, one (Employee Identifier Number (EI#) 6) of five nurses observed performing a med pass failed to follow physician's orders [REDACTED]. Resident Identifier (RI) #13 did not receive the medication ICAR-C as ordered. This affected RI # 13, one of seven residents observed during the administration of medications (med pass) on 02/15/11 and 02/16/11. The findings include: RI #13 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. RI #13's most recent Minimum Data Set ((MDS) dated [DATE], assesses the resident as having severely impaired cognitive ability and requiring assistance with Activities of Daily Living (ADL's). A review of the Physician Orders, for the month of February 2011, included the following orders: ICAR-C TABLET- GIVE ONE TAB(tablet) PO (by mouth) Q (every) DAY. The time code was documented as 9:00 AM. A review of RI #13's MAR(Medication Administration Record) for the month of February 2011, documented the following medication: ICAR-C Tablet. Give one tab PO Q Day. Start Date: 4/29/09. The time of administration was documented as 9:00 AM On 2/15/11 at 9:35 AM, the Registered Nurse (RN) EI # 6 was observed administering medications on Private Hall for the 9:00 AM scheduled medications. EI # 6 began medication pass starting with RI #13. As EI # 6 read the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. EI # 6 looked at the MAR indicated [REDACTED]. EI # 6 removed a bottle of pills from the top drawer of the medication cart. The bottle was labeled, "Calcium 600mg with Vitamin D 400 IU (International Units)". EI # 6 said that the medication in that pill bottle was ICAR-C and removed a pill from the bottle and placed it into the plastic medication cup. EI # 6 then walked into RI #13's room and put the cup to RI #13's mouth and RI #13 swallowed the pills. An interview was conducted on 02/15/11 at 2:05 PM with EI # 6, who was observed to administer medications to RI # 13. EI # 6 was asked if she administered ICAR-C to RI #13 at 9:35 AM, during medication pass. EI # 6 acknowledged that she had not given ICAR-C, but she had given Calcium with Vitamin D to RI #13 instead. An interview was conducted on 2/17/11 at 5:05 PM with EI # 7, the Director of Nursing (DON.) She was asked if RI #13 had a doctor's order for the Calcium with Vitamin D when the resident received the medication on 2/15/11 at 9:35 AM. EI # 7said that RI #13 did not have a doctor's order for that medication and that EI # 6 had mistakenly given the Calcium with Vitamin D for ICAR-C. When asked why it is important for nursing staff to follow doctor's orders, EI # 7 replied for the safety of the patient and not to create medication errors. EI # 7 was asked what steps a nurse should take before giving a medication. The DON said that nurses should check the medication label against the Medication Record (MAR) to prevent medication errors. A review of the facility's policy for "Medication Pass/Medication Administration," no date, documents the following: "POLICY: The facility's nursing personnel (RN/LPN (Licensed Practical Nurse) will use the following guidelines to administer medication in a safe manner and in accordance with the physician's orders [REDACTED]...5. The nurse (RN/LPN) verifies the correct resident, correct medication and correct dosage for each medication for each resident." A review of Fundamentals of Nursing, 7th Edition, Potter-Perry, Page 704, documents the following: "...Steps to Take to Prevent Medication Errors: Follow the six rights of medication administration. Be sure to read labels at least three times (comparing Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"

Based on observation, interview and record review the facility failed to ensure that food dislikes were not served on Resident Identifier (RI) # 6's breakfast tray. This affected RI # 6, one of fifteen sampled residents. Findings include: RI # 6 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The Initial MDS (Minimum Data Set) with an assessment reference date of 1/11/11, documented RI #6 as having moderately impaired cognitive functioning and requiring assistance with eating. RI # 6's admission height and weight are documented as 72 inches tall and weighing 126 pounds. A review of RI #6's Care Plan documented as follows: "Problem/Need, 01/24/2011, Resident is at risk for altered nutritional status due to Dx (diagnosis) of dysphagia, decreased vision and requires assist with meals...approaches included "honor resident's food preferences within diet ordered..." A review of "physician's orders [REDACTED]. RI #6 was observed in his room on 2/15/11 at 8:30 AM. The resident was observed eating breakfast. A serving of pureed eggs was observed, uneaten on his plate . A diet card next to his breakfast plate documented RI #6's name, diet, beverages and food likes. The tray card documented "INSTRUCTIONS: NO STRAWS, no eggs and gravy..." On 2/16/11 at 8:05 AM, RI #6 was observed in his room having completed his breakfast. The tray was observed to have a serving of uneaten pureed eggs. When the surveyor asked RI #6 why he hadn't eaten his eggs, he replied that he was served eggs everyday and he just didn't like them. RI #6's diet card dated 2/16/11 was observed on his breakfast tray. The tray card documented, "INSTRUCTIONS: NO STRAWS, no eggs and gravy..." On 2/16/11 at 8:20 AM, the Assistant Director of Nursing (ADON) EI #4 was asked by the surveyor to come to RI #6's room to observe his breakfast plate. When EI #4 was asked what was on his plate she said eggs, oatmeal, sausage and applesauce. EI #4 was then asked to review RI #6's diet card. When asked what food dislikes were documented on his diet card she said eggs and gravy. EI # 4 was asked how food dislikes were determined for residents. EI #4 replied that the Dietary Manager (EI #5) determines food likes and dislikes within 24 hours of admission through resident interviews and she then puts them in the computer. When asked why it was important to adhere to resident likes and dislikes, EI #4 said the the staff wants residents to get all the nourishment they can and if residents were served dislikes they wouldn't eat them. On 2/16/11 at 8:45 AM an interview was conducted with the Dietary Manager (EI #5) in RI #6's room with observance of his breakfast plate. EI #5 was asked what tool she used to determine resident food likes and dislikes and she replied the Food Preference Guide. EI #5 showed the surveyor a Food Preference Guide with RI #6's name on it. When asked why the document was not dated, EI #5 replied that she had completed the guide on the day RI #6 was admitted but forgot to date it. When asked what foods were documented as dislikes for RI #6, EI #5 said eggs and gravy. EI #5 was then asked what foods were on RI #6's breakfast plate and she replied sausage, oatmeal, eggs and applesauce. When asked why it was important to adhere to resident food likes and dislikes, EI #5 said that when residents come from home the facility was a whole different world and they may not eat as much.

Based upon observation, interviews, record reviews, and review of the facility's policies and procedures, the facility failed to ensure that staff members performed proper hand hygiene techniques by using gloves appropriately during incontinence care to prevent possible cross-contamination. This affected 1 of 4 residents observed during incontinence care on 1 of 4 halls. Findings include: Resident Identifier (RI) #8 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set ((MDS) dated [DATE], reveals that RI #8 is dependent on staff for assistance with Activities of Daily Living (ADL). RI #8 is continent of bowel and occasionally incontinent of bladder. A review of the General Infection Control Practices policy dated 2001, pages, 53-55 reveals... "Change gloves, as necessary, during the care of a resident to prevent cross-contamination from one body site to another (when moving from a "dirty" site to a "clean" one)... "Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident and wash hands immediately to avoid transfer of microorganisms to other residents or environments" .... Review of the CDC (Centers for Disease Control) and Prevention (2002b) guidelines as cited in Potter and Perry Fundamentals of Nursing 7th ed. (2009) pg. 655, recommends...."If hands are not visibly soiled, use an alcohol-based waterless antiseptic agent for routinely decontaminating hands in all other clinical situations ...when moving from a contaminated body site to a clean body site during client care; after contact with inanimate objects (including medical equipment) in the immediate area of the client;...after removing gloves"... Review of the Perineal Care policy dated July 2004 revealed the following: "CONSIDERATIONS... I. Remove gloves when soiled and replace before proceeding to the next step. J. Avoid contaminating clean surfaces with soiled gloves"... "PROCEDURES... S. Rinse the rectal area with a clean washcloth. Stroke from front to back. T. Pat the area dry with a towel. U. Remove and dispose of soiled gloves. V. Reglove and apply moisture barrier as indicated. W. Remove and dispose of gloves. X. Assist resident into a comfortable position per turn schedule as indicated. Cover with top linens. Y. Raise side rail and lower bed. Place call light within reach. Tidy room, Open curtains. Z. Wash hands " ... During a pericare observation on 2/16/2011 at 8:44 AM, Employee Identifier (EI) #1, a Certified Nursing Assistant, was observed to clean RI #8's perineal area, dry the area, remove her soiled gloves, and put on new gloves. After applying the clean gloves, EI #1 raised EI #8's right leg to remove the pillows. EI #1 did not sanitize or wash her hands before applying clean gloves. After turning RI #8 to the left side, EI #1 cleaned RI #8's gluteal area; applied Periguard, removed soiled gloves, and applied new gloves. EI #1 did not sanitize her hands after removing her gloves. The used cloth bed pad was then rolled up and placed in a plastic bag and a clean pad was applied. RI #8 was repositioned in the bed to the left side and pillows were placed beneath her lower extremities. EI #1 and EI #2 (CNA) removed their gloves and opened the bathroom door. An interview was conducted with EI #4, the Assistant Director of Nursing on 2/16/2011 at 11:35 AM. The surveyor asked EI #4 what are staff members taught about the proper use of gloves during patient care? EI #4 stated wash your hands; put your gloves on, then do your procedure; then throw them in the resident's bathroom garbage, and then wash your hands. EI #4 was asked by the surveyor if staff members are taught to wash their hands between changing gloves? EI #4 answered yes. EI #4 was asked if the facility follows the Center's for Disease Control and Prevention guidelines? EI #4 stated, yes. EI #4 said with pericare, after they get through with the front and the back, then they change gloves, reglove, and then apply barrier cream. If there is a bowel movement, they can change their gloves to prevent urinary tract infections. EI #4 was asked if staff members are taught to clean off the over-bed-table? EI #4 stated yes. They should have a barrier. The surveyor asked, if with a barrier, should they (the staff) wipe off the over-bed-table? EI #4 stated, yes. EI #4 was asked if staff members are taught to change their gloves throughout the procedure (pericare) and then wash their hands? EI #4 stated, yes, that's our policy. On 2/17/2011 at 12:27 PM, EI #4 was asked how was the pericare check off training conducted? EI #4 stated one-on-one. EI #4 was asked what was covered in this training and she stated the handwashing policy was reviewed prior to check off. During an interview with EI #1 on 2/17/2011 at 2:30 PM, the surveyor asked EI #1 if she was taught to wash her hands between changing gloves? EI #1 stated, no; even the glove changes are not in the policy. The surveyor asked EI #1, how were you taught to change your gloves during pericare? EI #1 said that she learned it through state. She (a state surveyor) asked me if I was going to change my gloves. So, since then I've always done it ... I knew if I went from clean to dirty I should change my gloves. During an interview on 2/17/2011 at 2:55 PM with EI #3, a CNA, the surveyor asked were you taught to wash your hands after removing gloves? EI #3 said if we need to between glove changes. There's not a policy here saying we have to wash our hands when changing gloves.