Every finding on record at Nazareth Home

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to follow proper sanitation practices to prevent a possible outbreak of foodborne illness. Record review revealed the dishwasher rinse cycle failed to reach a temperature of 180 degrees Fahrenheit (F) on several occasions. In addition, the Sunset Dining Room refrigerator contained opened juices past their use by date. The findings include: 1. Review of the facility's policy, Food Service Infection Control, Safety and Sanitation, revised January 2015, revealed the temperature of the dishwasher rinse cycle was to be checked and logged before each use to ensure the rinse water was above 180 degrees Fahrenheit (F). The facility was to ensure safe and sanitary precautions were followed to safeguard the health of the residents. Review of the facility's Wash and Rinse Temperature log, dated April 2002, revealed instructions for staff to record the wash and rinse temperatures, and initial, for breakfast, lunch, and supper. The temperature should be at or above 150 - 160 degrees F for the wash, and 180 degrees F for the rinse. Promptly report any problems. Review of the Wash and Rinse Temperature Log, for July 2017, revealed the rinse temperatures were below 180 degrees F for breakfast on 07/01/17, 07/05/17, 07/06/17, 07/07/17, 07/10/17, 07/13/17, 07/15/17, 07/17/17, 07/18/17, 07/19/17, 07/21/17, 07/23/17, 07/26/17, and 07/28/17. The rinse temperatures were below 180 degrees F for lunch on 07/06/17, 07/14/17, 07/21/17, 07/22/17, 07/23/17, 07/26/17, and 07/27/17. The rinse temperatures were below 180 degrees F for supper on 07/03/17, 07/04/17, 07/05/17, 07/07/17, 07/09/17, 07/14/17, 07/15/17, 07/18/17, 07/23/17, and 07/24/17. Review of the Wash and Rinse Temperature Log, for August 2017, revealed rinse temperatures were below 180 degrees F for breakfast on 08/02/17, 08/06/17, 08/08/17, 08/09/17, 08/10/17, 08/13/17, 08/18/17, 08/27/17, 08/29/17, and 08/30/17. The rinse temperatures were below 180 degrees F for lunch on 08/17/17, 08/10/17, 08/17/17, 08/24/17, and 08/29/17. The rinse temperatures were below 180 degrees F for supper on 08/03/17, 08/04/17, 08/07/17, 08/13/17, 08/19/17, 08/20/17, 08/25/17, and 08/28/17. Review of the Wash and Rinse Temperature Log, for September 2017, revealed rinse temperatures were below 180 degrees F for breakfast on 09/03/17, 09/06/17, 09/08/17, 09/09/17, 09/10/17, 09/13/17, 09/14/17, and 09/16/17. The rinse temperatures were below 180 degrees F for lunch on 09/01/17, 09/02/17, 09/06/17, 09/08/17, 09/09/17, 09/11/17, 09/12/17, 09/14/17, 09/16/17, 09/18/17, 09/19/17, and 09/20/17. The rinse temperatures were below 180 degrees F for supper on 09/01/17, 09/04/17, 09/05/17, 09/07/17, 09/13/17, and 09/15/17. Interview with the Dishwasher, on 09/21/17 at 10:15 AM, revealed the dishwasher rinse cycle temperature should be greater than 182 degrees F. The Dishwasher stated he was supposed to notify the kitchen supervisor or maintenance when the temperature was below 182 degrees F because it could cause the residents to become sick; however, he had not notified the kitchen supervisor or maintenance when the rinse temperatures were below 182 degrees F. He stated he trained with another dishwasher for a week and completed yearly training that included sanitation and infection control for food service employees. He reveled the Food Service Director had monthly meetings that included review of infection control in the kitchen. He stated the temperature of the dishwasher rinse cycle fluctuated and the facility tried to keep it within range of 182 degree F. Interview with the Maintenance Assistant, on 09/21/17 at 10:20 AM, revealed the maintenance department had not been notified of temperatures below 180 degrees F during the rinse cycle of the dishwasher. He stated maintenance did not audit water temperatures in the kitchen for the dishwasher. He stated kitchen boiler took several dishwasher cycles to get to the appropriate temperature for the rinse cycle. Interview with the Food Service Supervisor, on 09/21/17 at 10:50 AM, revealed she did not check the temperature logs for the dishwasher to ensure proper sanitation was achieved with a rinse temperature of 180 degrees F or above because she was too busy. She stated she had been assigned to ensure proper sanitation of the dishware was achieved daily and residents could become ill if dishware was not properly sanitized. Interview with the Food Service Director, on 09/21/17 at 10:31 AM, revealed the dishwasher cycle had to be completed three (3) times before the dishwasher rinse temperature would get to 180 degree F. She stated the kitchen supervisors had been assigned to monitor the dishwasher wash and rinse cycles to ensure proper sanitation of the dishware. She stated if the dishwasher rinse cycle temperature was below 180 degree F, residents could become ill. She further stated she conducted monthly meetings for kitchen staff that included infection control and sanitation. Interview with the Director of Nursing, on 09/21/17 at 1:40 PM, revealed she did not audit sanitation of the resident's dishware. She stated infection control was included with the facilities initial education classes, which included kitchen staff. She stated residents could become sick if dishware was not cleaned correctly. Interview with the Chief Executive Officer/President, on 09/20/17 at 2:00 PM, revealed she did not audit the sanitation of the kitchen or unit dining areas. She further stated the residents could become ill if the dishwasher temperature was less than 180 degrees F during the rinse cycle. 2. Review of the facility's policy, Dating and Labeling Food Brought in from Outside/Home, reviewed January 2015, revealed beverages in the original container that was past the manufacturer's expiration date or use by date would be discarded by dietary. Dietary would monitor unit pantry and refrigeration units. Review of the facility's policy, Food Service Infection Control, Safety and Sanitation, revised January 2015, revealed food items, such as milk and left over canned fruits, would be properly stored, dated, and discarded according to the expiration dates or within one (1) week of opening. Observation of the second floor Sunset Dining Room, on 09/19/17 at 8:30 AM, revealed the resident refrigerator contained three (3) opened cartons of thickened orange juice and one (1) opened thickened cranberry juice, all were dated 08/31/17. Interview with Certified Nursing Assistant (CNA) #1, on 09/19/17 at 8:35 AM, revealed she had served the thickened juices to the residents over the weekend. She stated she did not notice the expiration date; however, she stated they appeared to be outdated as of 09/01/17. Interview with Food Service Aide #1, on 09/19/17 at 8:40 AM, revealed she served food and drinks to the residents in the Sunset Dining Room. She stated she was responsible to check the dates on all the juices daily and all opened juices should be discarded after 72 hours because there was a potential for bacteria to grow. She stated she had been trained by the former Certified Dietary Manger and in-serviced on discarding outdated foods. She stated she usually checked food/drink products for expiration dates, but she was busy and did not get to it. She confirmed the juices should have been discarded on 09/01/17. She stated the Assistant Dietary Manager monitored her work. Interview with CNA #3, on 09/19/17 at 9:25 AM, revealed one of the labels on the juices revealed when the product had been opened. She stated dietary staff checked for outdated food frequently. She stated she was not sure when opened juices should be discarded but food should be discarded after three (3) days. Interview with Assistant Dietary Manager #1, on 09/19/17 at 9:00 AM, revealed he had not checked the opened dates carefully on the juices. He stated one date on the products revealed when the facility received the product, and one date revealed when the product was opened. He stated he was not sure when the juices should have been discarded and in his experience, he had always referred to the manufacturers discard date. He stated during his orientation to the facility, he was not made aware that juice should be discarded within three (3) days after it had been opened. Interview with Relief Cook #1, on 09/20/17 at 1:00 PM, revealed it was important for all foods and drinks to be discarded after three (3) days of being opened as there was potential to make the residents ill. She stated the facility had instructed her that after three (3) days of being opened, she should discard any food or drink. Interview with the Food Service Director, 09/19/17 at 8:45 AM, revealed the thickened juices had been opened and used on 08/31/17. She stated staff had been instructed to discard any food item or drink within three (3) days after it had been opened and the Assistant Dietary Manager should have checked each resident refrigerator daily behind the Dietary Aide. She stated staff was to discard food after three (3) days of being opened to avoid any foodborne illness. Interview with the Infection Control Preventionist, on 09/20/17 at 1:50 PM, revealed she tried to do monthly rounds on all resident pantrys and refrigerators as foodborne illness was a concern to the facility. Interview with the Chief Executive Officer/President, on 09/21/17 at 4:18 PM, revealed the Dietary Manager attended all Quality Assurance meetings and had not revealed concerns with the resident refrigerators being monitored improperly for out-dated foods.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to provide services in accordance with the resident's plan of care for two (2) of twenty-three (23) sampled residents, Resident #2 and #9, related to Oxygen administration. The findings include: Review of the facility's Interdisciplinary Care Plans policy, reviewed 06/12/17, revealed the interdisciplinary plan of care would be developed per the RAI (Resident Assessment Instrument) Manual protocol and updated PRN (as needed). Review of the RAI 3.0 User's manual, dated October 2016, Chapter 4, pages 4-8 to 4-11, revealed the comprehensive care plan was an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care. Observation of Resident #2, on 09/19/17 at 8:27 AM, 12:36 PM, and 2:20 PM, and on 09/20/17 at 8:33 AM and 9:00 AM, revealed Oxygen in use for the resident at 3 liters (L) per nasal cannula. Review of Resident #2's clinical record revealed the facility admitted the resident on 04/20/17, with [DIAGNOSES REDACTED]. Review of a Physician order [REDACTED]. Review of Resident #2's Plan of Care, dated 07/26/17, revealed the resident was at risk for respiratory distress and interventions included Oxygen per physician's orders [REDACTED]. Observation of Resident #9, on 09/19/17 at 8:45 AM, 12:40 PM, and 2:15 PM, and on 09/20/17 at 8:50 AM, revealed Oxygen in use for the resident at 5 L per nasal cannula. Review of Resident #9's clinical record revealed the facility admitted the resident on 03/09/16, with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of Resident #9's Plan of Care, dated 02/20/17, revealed the resident was at risk for respiratory distress and interventions included Oxygen at 2 L per nasal cannula. Interview with Licensed Practical Nurse (LPN) #5, on 09/21/17 at 10:05 AM, revealed she looked at resident care plans to see what care to provide to the resident. She stated if a resident was on Oxygen, she checked the physician order [REDACTED]. Interview with LPN #6, on 09/21/17 at 1:32 PM, revealed care plans were in the nurses' station and she would review to see what type of equipment residents used and what the residents' [DIAGNOSES REDACTED]. She stated she checked Oxygen settings every shift. Interview with the Director of Nursing, on 09/21/17 at 2:15 PM, revealed nursing staff should review care plans with any changes in resident care and as needed. She stated staff was expected to follow the care plan to ensure appropriate care of the resident.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents received the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being for two (2) of twenty-three (23) sampled residents, Resident #2 and #9. Observations revealed the facility failed to administer Oxygen to Resident #2 and #9 per the physician's orders [REDACTED].>The findings include: Review of the facility's Physician order [REDACTED]. Observation of Resident #2, on 09/19/17 at 8:27 AM, 12:36 PM, and 2:20 PM, and on 09/20/17 at 8:33 AM and 9:00 AM, revealed Oxygen in use for the resident at 3 liters (L) per nasal cannula. Review of Resident #2's clinical record revealed the facility admitted the resident on 04/20/17, with [DIAGNOSES REDACTED]. Review of a Physician order [REDACTED]. Review of Resident #2's Treatment Record, dated 09/01/17 to 09/30/17, revealed documentation of Oxygen at 2 L per nasal cannula administered on 09/19/17 for the 11:00 PM-7:00 AM shift, 7:00 AM-3:00 PM shift, and 3:00 PM-11:00 PM shift, and on 09/20/17 for the 11:00 PM-7:00 AM shift. Interview with Licensed Practical Nurse (LPN) #2, on 09/20/17 at 9:25 AM, revealed Resident #2 had an order for [REDACTED]. Observation of Resident #9, on 09/19/17 at 8:45 AM, 12:40 PM, and 2:15 PM, and on 09/20/17 at 8:50 AM, revealed Oxygen in use for the resident at 5 L per nasal cannula. Review of Resident #9's clinical record revealed the facility admitted the resident on 03/09/16, with [DIAGNOSES REDACTED]. Review of Resident #9's quarterly Minimum Data Set, dated dated [DATE], revealed the facility assessed the resident required Oxygen administration. Review of the Physician order [REDACTED]. Review of Resident #9's Plan of Care, dated 02/20/17, revealed the resident was at risk for respiratory distress and interventions included Oxygen at 2 L per nasal cannula. Review of Resident #9's Treatment Record, dated 09/01/17 to 09/30/17, revealed documentation of Oxygen at 2 L per nasal cannula administered on 09/19/17 for the 11:00 PM-7:00 AM shift, 7:00 AM-3:00 PM shift, and 3:00 PM-11:00 PM shift, and on 09/20/17 for the 11:00 PM-7:00 AM shift. Interview with LPN #1, on 09/20/17 at 8:55 AM, revealed Resident #9 had an order for [REDACTED]. Interview with LPN #5, on 09/21/17 at 10:05 AM, revealed if a resident was on Oxygen; she checked the physician order [REDACTED]. Interview with the Director of Nursing (DON), on 09/21/17 at 2:15 PM and 2:45 PM, revealed she expected nursing staff to administer Oxygen per the physician's orders [REDACTED]. Interview with the Chief Executive Officer/President, on 09/21/17 at 4:18 PM, revealed the DON and Administrative Nursing Staff had a Quality Assurance (QA) meeting monthly with concerns reported, but she was not aware of concerns related to following physician orders.

Based on observation, interview, record review, and facility policy, it was determined the facility failed to revise the comprehensive care plan to prevent further falls for one (1) of twenty-three (23) sampled residents, Resident #1. Resident #1 sustained seven (7) falls between 01/31/16 and 06/18/16. The facility did not update the care plan after eight (6) of the seven (7) falls. The findings include: Review of the facility policy for Falls, dated November 2015, revealed the facility conducted an assessment of all residents to establish their risk of falls upon admission, quarterly, annually, and as needed. The facility initiated and implemented appropriate individualized interventions to minimize falls and injuries related to falls. Based on the findings of the assessment, the facility developed and implemented individual care plans containing the fall interventions. After a resident fall, staff completed a Resident Fall Event Report. The Falls Committee met to determine the appropriateness of new interventions put in place on the Resident Fall Event Report. The Resident Fall Even Report included a space for staff to state interventions they put into place, as well as a place to state if they updated the Comprehensive Care Plan with those interventions. The Falls Committee completed a Post Fall Analysis to determine if they needed to add additional preventative interventions. Observation of Resident #1, on 08/03/16 at 2:10 PM, 2:50 PM, 3:46 PM, 4:26 PM and on 08/04/16 at 7:42 AM, 8:25 AM, and 9:21 AM, revealed the resident in bed on his/her side with eyes closed. There were one-half (1/2) side rails in place. The resident had a foam wedge for positioning. The resident's wheelchair had a Dycem covering the seat. Review of the facility's clinical record for Resident #1, revealed the facility admitted the resident, on 01/28/16, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment for Resident #1, dated 02/03/16, revealed the resident was able to walk and transfer with limited assistance. The facility determined the resident was not interviewable. The facility conducted a Brief Interview for Mental Status (BIMS) exam and assessed the resident with a score of two (2) out of fifteen (15), determining the resident was not interviewable. Review of the Significant Change MDS assessment for Resident #1, dated 04/22/16, revealed the resident had a significant change and was no longer able to walk. The resident required extensive assistance to transfer. Review of the Significant Change MDS assessment for Resident #1, completed 07/12/16, revealed the resident required extensive assistance with transfers, eating, toileting, and bathing and total assistance with dressing and hygiene. The resident received two (2) [MEDICAL CONDITION] medications. Review of the Comprehensive Care Plan for Resident #1, dated 02/08/16, revealed Resident #1 had a risk factor of short and long-term memory impairment. The care plan interventions of reality orientation encouraged the resident to ask for assistance to stand or transfer. The facility explained to the resident why this was important. However, the facility did not modify the interventions based on the residents decreased level of understanding and awareness. Additionally, the care plan for falls revealed the resident was at risk for falls related to a history of falling. The facility placed several staff interventions on the initial care plan including completion of falls assessments, placement of bilateral half (1/2) side rails, placement of the call light within the reach of the resident, providing therapy as ordered or as needed, assuring the resident wore appropriate footwear, ensuring the proper placement of adaptive equipment, maintaining the residents room with items within the resident's reach, and assisting the resident with all transfers. On 04/27/16, the facility added an intervention of using a wheel chair with a Dycem mat. On 07/14/16, the facility added the intervention of checking and changing the resident and providing incontinent care as needed. On 07/28/16, the facility added the intervention of toileting the resident as ordered. The care plan did not include new interventions after the resident sustained [REDACTED]. Review of the Resident Fall Event Report for Resident #1, dated 02/18/16 at 8:10 PM, revealed staff found Resident #1 on the floor in the dining room. Staff did not add interventions to prevent another fall to this Resident Fall Event Report. Staff left blank the section of the report asking if the Care Plan was updated. Review of the Comprehensive Care Plan for Resident #1, dated 02/08/16, revealed the facility did not add new interventions after the fall on 02/18/16. Review of the Resident Fall Event Report for Resident #1, dated 02/19/16 at 7:45 PM, revealed staff found Resident #1 on the floor in another resident's room without injuries. Nursing staff initiated neurological checks. No new interventions were added to the Resident Fall Event Report to prevent another fall. Staff left blank the section of the report that asked if the Care Plan was updated. Review of the Quality Review Notes, dated 02/19/16, revealed the facility initiated a Physical Therapy screening to assess gait and balance. Review of the Quality Review Notes, dated 02/22/16, revealed the facility reviewed the resident's current interventions and implemented a three (3) day sleep monitor to evaluate the effectiveness of the interventions. The facility also initiated routine pain medication for Resident #1. Review of the Comprehensive Care Plan for Resident #1, dated 02/08/16, revealed the facility did not add new interventions to the care plan after the resident fell on [DATE]. Review of the Resident Fall Event Report for Resident #1, dated 03/11/16 at 2:15 AM, revealed staff found the resident on the floor next to the bed without injury. Staff documented on the interventions section of the report that they placed slip free strips next the resident's bed and initiated a three (3) day sleep monitor. Staff left blank the section of the report that asked if the Care Plan was updated. Review of the Resident Fall Event Report for Resident #1, dated 03/11/16 at 4:10 AM, revealed staff found the resident on the floor next to the bed. There were no injuries; however, staff administered medication for pain. Staff documented interventions of placing fall strips on the floor next to the resident's bed and starting a three (3) day sleep monitor. Review of the nursing notes, dated 03/11/16, revealed nursing staff initiated one to one monitoring for the remainder of the shift. Review of the Quality Review Notes, dated 03/11/16, revealed the resident sustained [REDACTED]. The facility documented all interventions remained appropriate. Review of the Comprehensive Care Plan for Resident #1, dated 02/08/16, revealed the facility did not add new interventions after the resident sustained [REDACTED]. Review of the Resident Fall Event Report, dated 03/17/16 at 1:40 PM, revealed staff witnessed Resident #1 fall backward, striking his/her head and causing a bump to the left side of the head. The documented intervention was placement of the resident in a wheelchair. Staff left blank the section of the report that asked if the Care Plan was updated. Review of the Quality Review Notes, dated 03/18/16, revealed the facility implemented the use of hipsters. The facility also implemented the use of a wheelchair or a gait belt for transfers and ambulation. Review of the Comprehensive Care Plan for Resident #1, dated 02/08/16, revealed the facility did not add new interventions after the fall on 03/17/16. On 04/27/16, the facility updated the care plan to include the use of hipsters. Review of the Resident Fall Event Report, dated 04/02/16 at 6:45 PM, revealed staff found Resident #1 on the floor in the common area with no injuries. Staff did not add interventions to prevent another fall to this Resident Fall Event Report. Staff left blank the section of the report that asked if the Care Plan was updated. Review of the Quality Review Notes, dated 04/05/16, revealed the facility documented they would continue with the current plan of care, including hipsters to mitigate injury. Review of the Comprehensive Care Plan for Resident #1, dated 02/08/16, revealed the facility did not add new interventions after the fall on 04/02/16. Review of the Resident Fall Event Report, dated 06/17/16 at 7:30 PM, revealed staff found Resident #1 on the floor of his/her room without injury. Staff did not add interventions to prevent another fall to this Resident Fall Event Report. Staff left blank the section of the report that asked if the Care Plan was updated. Review of the nursing notes, dated 06/17/16, revealed after the fall, staff assisted the resident to the dining room for ice cream per the resident's request. Review of the Resident Fall Event Report, dated 06/18/16 at 9:30 PM, revealed staff found Resident #1 on the floor outside his/her room. The resident sustained [REDACTED]. Staff placed an intervention on the report of initiating one on one monitoring. Staff left blank the section of the report that asked if the Care Plan was updated. Review of the Quality Review Notes, dated 06/20/16, revealed the facility reviewed the safety interventions. The facility received orders and increased the resident's [MEDICAL CONDITION] medications. The note further stated the facility determined all current interventions were in place and appropriate. Review of the Comprehensive Care Plan for Resident #1, dated 02/08/16, revealed the facility did not add new interventions after the fall on 06/17/16 and 06/18/16 until the facility updated the care plan on 07/14/16. Interview with Certified Nurse Assistant (CNA) #2, on 08/03/16 at 10:40 AM, revealed Resident #1 was not able to use the call light to request assistance. She stated the resident has had many falls. The resident would get out of bed and fall. She stated she received training to follow the Kardex instructions for providing care to residents. She revealed she had no input into interventions to prevent falls. Interview with Licensed Practical Nurse (LPN) #1, on 08/04/16 at 9:21 AM, revealed Resident #1 fell multiple times since admission. She stated the admitting nurse completed the initial care plan. She stated when a resident experienced a fall, the facility implemented immediate interventions to prevent further falls. Next, the Falls Team reviewed the falls daily and added other interventions if needed. She stated the Quality Review Notes were a record of the care the facility provided after a fall. Additionally, LPN #1 stated the Interdisciplinary Team made care plan updates. Interview with the Assistant Administrator, on 08/04/16 at 9:28 AM, revealed the facility reviewed each fall. Everything the facility completed in response to each fall was in the chart and reviewed. The Assistant Administrator stated the entire chart was the resident's care plan. Interview with the Director of Nursing (DON), on 08/04/16 at 2:10 PM, revealed the nurse caring for a resident who had fallen would fill out the paperwork and initiate any new interventions. However, the facility did not add the new interventions to the care plan until the assessment of the resident was complete. She stated completion of the assessment could take time. The DON stated Resident #1 caused the falls and the facility was not required to put any immediate intervention in place to prevent another fall. She stated the current care plan interventions were appropriate. Interview with the Assistant MDS Coordinator, on 08/04/16 at 2:48 PM, revealed unit nurses updated resident care plans. Interview with the Administrator, on 08/04/16 at 3:02 PM, revealed the facility did not place new interventions on a resident's care plan until the facility determined the cause of the fall. Additionally, she stated the facility did not document one (1) to one (1) supervision on the care plan.

Based on observation, interview, record review, and facility policy, it was determined the facility failed to implement interventions to prevent falls for one (1) of twenty-three (23) sampled residents. Resident #1 sustained seven (7) falls between 01/31/16 and 06/18/16. The findings include: Review of the facility policy for the Event Review Report, dated 05/2012, revealed the facility maintained a safe environment for residents. In the case of an accident, the facility used the Event Review Report and to determine if the facility comprehensively assessed the resident, if the facility identified potential risks, if the facility provided adequate supervision, and if interventions proved effective. Review of the facility policy for Falls, dated November 2015, revealed the facility conducted an assessment of all residents to establish their risk of falls upon admission, quarterly, annually, and as needed. The facility initiated and implemented appropriate individualized interventions to minimize falls and injuries related to falls. Based on the findings of the assessment, the facility developed and implemented individual care plans containing the fall interventions. After a resident fall, staff completed a Resident Fall Event Report. The Falls Committee met to determine the appropriateness of new interventions put in place on the Resident Fall Event Report. The Resident Fall Even Report included a space for staff to state interventions they put into place, as well as a place to state if they updated the Comprehensive Care Plan with those interventions. The Falls Committee completed a Post Fall Analysis to determine if they needed to add additional preventative interventions. Review of the facility's clinical record for Resident #1, revealed the facility admitted the resident on 01/18/16 with [DIAGNOSES REDACTED]. Observation of Resident #1, on 08/03/16 at 2:10 PM, 2:50 PM, 3:46 PM, 4:26 PM and on 08/04/16 at 7:42 AM, 8:25 AM, and 9:21 AM, revealed the resident in bed on his/her side with eyes closed and a foam wedge to position the resident. The resident was awake on 08/03/16 at 4:26 PM, however, the resident's speech was unclear and hard to understand. The resident appeared frail and weak. There were one-half (1/2) side rails in place and there was Dycem covering the wheelchair seat. Review of the clinical record for Resident #1, revealed the facility admitted the resident, on 01/28/16, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment for Resident #1, dated 02/03/16, revealed the resident was able to walk and transfer with limited assistance. The facility conducted a Brief Interview for Mental Status (BIMS) exam and assessed the resident with a score of two (2) out of fifteen (15), determining the resident was not interviewable. Review of the Significant Change MDS assessment for Resident #1, completed 07/12/16, revealed the resident required extensive assistance with transfers, eating, toileting, and bathing and total assistance with dressing and hygiene. The resident received two (2) psychotropic medications. Review of Resident #1's significant change Minimum Data Set (MDS) assessment, completed by the facility on 07/12/16, revealed the resident was not interviewable. The resident required extensive assistance with transfers, eating, toileting, and bathing and total assistance with dressing and hygiene. The resident received two (2) psychotropic medications. Review of the Comprehensive Care Plan for Resident #1, dated 02/08/16, revealed Resident #1 had a risk factor of short and long-term memory impairment. The care plan interventions of reality orientation encouraged the resident to ask for assistance to stand or transfer. The facility explained to the resident why this was important. However, the facility did not modify the interventions based on the residents decreased level of understanding and awareness. Additionally, the care plan for falls revealed the resident was at risk for falls related to a history of falling. The facility placed several staff interventions on the initial care plan including completion of falls assessments, placing bilateral half (1/2) side rails, placing the call light in reach of the resident, providing therapy as ordered or as needed, assuring the resident wore appropriate footwear, ensuring the proper placement of adaptive equipment, maintaining the residents room with items within the resident's reach, and assisting the resident with all transfers. On 04/27/16, the facility added an intervention of using a wheel chair with a Dycem mat. On 07/14/16, the facility added the intervention of checking and changing the resident and providing incontinent care as needed. On 07/28/16, the facility added the intervention of toileting the resident as ordered. The care plan did not include new interventions after the resident sustained [REDACTED]. Review of the Resident Fall Event Report for Resident #1, dated 01/31/16 at 2:00 PM, revealed Resident #1 was walking alone in the dining room, tripped over a chair, and fell . The resident did not sustain an injury. Review of the Resident Post Fall Report, dated 01/31/16, revealed the chairs in the dining room were too close together. The facility monitored the resident hourly for seventy-two (72) hours. Review of the Quality Review Notes, dated 02/01/16, revealed the results of the hourly monitoring revealed one (1) instance of the resident stumbling when attempting to sit in a chair. Staff assisted the resident without incident. The note stated the facility continued with the current plan of care. Review of the Resident Fall Event Report for Resident #1, dated 02/18/16 at 8:10 PM, revealed staff found Resident #1 on the floor in the dining room. Staff did not add interventions to prevent another fall to this Resident Fall Event Report. Review of the Resident Post Fall Report, dated 02/18/16, revealed the facility documented the resident attempted to sit down in a chair. Review of the Resident Fall Event Report for Resident #1, dated 02/19/16 at 7:45 PM, revealed staff found Resident #1 on the floor in another resident's room without injuries. Nursing initiated neurological checks. Review of the Resident Post Fall Report, dated 02/19/16, revealed the Resident #1 ambulated into another resident's room and fell , possibly while attempting to sit in a chair. All other documented interventions were in place at the time of the fall. Review of the Quality Review Notes, dated 02/19/16, revealed the facility requested a therapy screen to assess gait and balance. The facility determined current interventions remained appropriate. Review of the Quality Review Notes, dated 02/22/16, revealed the facility reviewed the resident's current interventions and implemented a three (3) day sleep monitor to evaluate the effectiveness of the interventions. The facility also initiated routine pain medication for Resident #1. Review of the Quality Review Notes, dated 03/02/16, revealed the resident started Physical Therapy. The facility stated the resident did not have any further falls, although the resident did continue to attempt to transfer and ambulate independently during rest periods. The facility determined the current safety interventions remained appropriate. Review of the Resident Fall Event Report for Resident #1, dated 03/11/16 at 2:15 AM, revealed staff found the resident on the floor next to the bed without injury. Staff documented on the interventions section of the report that they placed slip free strips next the resident's bed and initiated a three (3) day sleep monitor. Resident Post Fall Report, dated 03/11/16 at 2:15 AM, revealed the resident fell from bed. The report stated all listed interventions were in place. Review of the Resident Fall Event Report for Resident #1, dated 03/11/16 at 4:10 AM, revealed staff found the resident on the floor next to the bed. There were no injuries; however, staff administered medication for pain. Staff documented interventions of placing fall strips on the floor next to the resident's bed and starting a three (3) day sleep monitor. Resident Post Fall Report, dated 03/11/16 at 4:10 AM, revealed all listed interventions were in place. Review of the nursing notes, dated 03/11/16, revealed nursing staff initiated one to one monitoring for the remainder of the shift. Review of the Quality Review Notes, dated 03/11/16, revealed the resident sustained [REDACTED]. The facility documented all interventions remained appropriate. The facility initiated a three (3) day sleep monitor. Review of the Quality Review Notes, dated 03/15/16, revealed the resident did not sustain any falls during the three (3) day sleep monitor. The note stated the facility continued with the current plan of care with no concerns identified. Review of the Resident Fall Event Report, dated 03/17/16 at 1:40 PM, revealed staff witnessed Resident #1 fall backward, striking his/her head and causing a bump to the left side of the head. Staff documented and intervention of placing the resident in a wheelchair. Review of the Resident Post Fall Report, dated 03/17/16, revealed the resident fell while transferring him/herself. The resident stood up from the dining room table, lost his/her balance, and fell . The facility documented other listed interventions were in place. Review of the Quality Review Notes, dated 03/18/16, revealed the facility implemented Hipsters. The facility also implemented the use of a wheelchair or a gait belt for transfers and ambulation. Review of the Resident Fall Event Report, dated 04/02/16 at 6:45 PM, revealed staff found Resident #1 on the floor in the common area with no injuries. Staff did not add interventions to prevent another fall to this Resident Fall Event Report. Staff left blank the section of the report that asked if the Care Plan was updated. Review of the Resident Post Fall Report, dated 04/02/16, revealed the resident attempted to transfer self without assistance. Review of the nursing notes for 04/02/16, revealed monitoring was in process; however, there was no documented evidence of the monitoring. Review of the Quality Review Notes, dated 04/05/16, revealed the facility documented they would continue with the current plan of care, including Hipsters to mitigate injury. Review of the Resident Fall Event Report, dated 06/17/16 at 7:30 PM, revealed staff found Resident #1 on the floor of his/her room without injury. Review of the Resident Post Fall Report, dated 06/17/16, revealed the resident attempted to self-transfer out of bed without assistance. Review of the Nursing Notes, dated 06/17/16, revealed staff monitored the resident for an unknown period of time. Staff assisted the resident to the dining room for ice cream per the resident's request. Review of the Resident Fall Event Report, dated 06/18/16 at 9:30 PM, revealed staff found Resident #1 on the floor outside his/her room. The resident sustained [REDACTED]. Staff placed an intervention on the report of initiating one on one monitoring. Review of the Resident Post Fall Report, dated 06/18/16, revealed the resident got out of bed, walked to the hallway, and fell . Review of the nursing notes, dated 06/18/16, revealed staff seated the resident at the nursing station for monitoring. At 1:30 AM, the resident was asleep in bed. Review of the Clinical Monitoring, dated 06/18/16 to 07/01/16, revealed the facility monitored the resident hourly until 07/01/16. The resident did attempt to transfer alone during this time. Review of the Quality Review Notes, dated 06/20/16, revealed the facility reviewed the safety interventions. The facility received orders and increased the resident's psychotropic medications. The note further stated the facility determined all current interventions were in place and appropriate. Review of the Comprehensive Care Plan for Resident #1, dated 02/08/16, revealed the facility did not add new interventions after the fall on 06/17/16 and 06/18/16 until the facility updated the care plan on 07/14/16. Interview with Certified Nurse Assistant (CNA) #2, on 08/03/16 at 10:40 AM, revealed Resident #1 was not able to use the call light to request assistance. She stated the resident has had many falls. The resident would get out of bed independently and fall. CNA #2 stated the resident continued to have this behavior of attempting to transfer independently. Interview with Licensed Practical Nurse (LPN) #1, on 08/04/16 at 9:21 AM, revealed Resident #1 fell multiple times since admission. She stated the admitting nurse completed the initial care plan. She stated when a resident experienced a fall, the facility implemented immediate interventions to prevent further falls. Next, the Falls Team reviewed the falls daily and added other interventions if needed. She stated the Quality Review Notes were a record of the care the facility provided after a fall. Additionally, LPN #1 stated the Interdisciplinary Team made care plan updates. LPN #1 stated she was aware that Resident #1 was at high risk for falls. Interview with the Director of Nursing (DON), on 08/04/16 at 2:10 PM, revealed the nurse caring for a resident who had fallen would fill out the paperwork and initiate any new interventions. However, the facility did not add the new interventions to the care plan until the assessment of the resident was complete. She stated completion of the assessment could take time. The DON stated Resident #1 caused the falls and the facility was not required to put any immediate intervention in place to prevent another fall. She stated the current care plan interventions were appropriate. Interview with the Assistant Administrator, on 08/04/16 at 9:28 AM, revealed the facility reviewed each fall. Everything the facility completed in response to each fall was in the chart and reviewed. The Assistant Administrator stated the entire chart was the resident's care plan. Interview with the Administrator, on 08/04/16 at 3:02 PM, revealed the facility did not place new interventions on a resident's care plan until the facility determined the cause of the fall. Additionally, she stated the facility did not document one (1) to one (1) supervision on the care plan.

Based on observation, interview, and policy review, it was determined the facility failed to ensure food was served within the required temperature range for one (1) of five (5) dining rooms and one (1) of three (3) unsampled residents, (Unsampled Resident A). Dietary Aide #1 failed to accurately temp foods and Unsampled Resident A voiced concerns regarding cold food in the Woodside Dining room. The findings include: Review of the Food Safety Serving Temperatures Policy, reviewed January 2015, revealed prior to serving, prepared foods would remain within standard temperature ranges to assure quality and avoid potential contamination resulting in food borne illness. Hot food temperatures do not fall below one hundred and forty (140) degrees (F)ahrenheit while food was held on steam equipment, in ovens, or in other equipment. Interview with Unsampled Resident A, during the Resident Council Meeting, on 07/01/15 at 11:00 AM, revealed he/she ate in the Woodside Dining Room and found the hot food was served too cold for him/her. Observation of the lunch meal in the Woodside Dining Room, on 07/01/15 at 12:15 PM, revealed Dietary Aid #1, placed ground chicken, carrots and mashed potatoes on the steam table. She then placed three thermometers in water containing a little amount of ice. Continued observation 12:30 PM, revealed Dietary Aid #1 took the temperature of food items on the steam table. The ground chicken tempted at ninety (90) degrees (F); carrots at ninety (90) degrees (F); and, mashed potatoes at 100 degrees (F). These foof items were returned to the kitchen to be reheated. Addtional observations at 1:02 PM, revealed the ground chicken, carrots and mashed potatoes were returned from the kitchen and Dietary Aide #1 retempted the ground chicken at ninety (90) degrees (F); carrots at ninety (90) degrees (F); and, the mashed potatoes at 100 degrees (F). Observation and interview with the Team Leader during the lunch meal in the Woodside Dining Room, on 07/01/15 at 1:08 PM, revealed she stated the food had been sitting on the steam table and should be at the correct temperature. She then retemped the chicken and carrots at ninety (90) degrees (F) and the mashed potatoes were at one hundred (100) degrees (F). Dietary Aid #1 then removed all three (3) thermometers and stated she thought the food temperature was one hundred and forty (140) degrees (F) and then proceeded to serve the food. Observation of the re-calibration of the three (3) thermometers by the Team Leader, on 07/10/15 at 1:15 PM, revealed all three (3) thermometers calibrated at ten (10) and eleven (11) degrees Fahrenheit. Interview at this time with Dietary Aid #1, revealed she thought the thermometers calibrated at thirty-two (32) degrees (F). She stated if the food was served cold, the food was at risk for contamination. Interview with the Team Leader, on 07/01/15 at 1:20 PM, revealed food should not be served at one hundred (100) degrees (F). The Team Leader retempted the ground chicken at one hundred (100) degrees (F), carrots at one hundred and two (102) degrees (F) and mashed potatoes at one hundred and thirty (130) degrees (F) with a calibrated thermometer. The Team Leader stated if food was served cold it could cause food borne illness. Interview with the Dietary Manager, on 07/02/15 at 1:22 PM, revealed they tempted the food on the steam table to ensure the food temperatures were above one hundred and forty (140) degrees (F). The Dietary Manager stated she liked the food to be above one hundred and forty (140) degrees (F) so that bacteria did not get into the food. The Dietary Manager stated the thermometers were to be calibrated at thirty-two (32) degrees (F) before each meal was tempted. She stated she was not aware of any complaints from residents about the food being cold on Woodside Dining.

Based on observation, interview, and facility policy review, it was determined the facility failed to serve food under sanitary conditions in two (2) of five (5) auxiliary kitchenettes on the Second Floor Sunrise and the Woodside Dining Rooms. The findings include: Review of the facility's Food Services Department Policy and Procedure titled Food Service Infection Control and Sanitation, (Revised 09/2012), revealed personnel were to meet standards for hygiene, safe food preparation, handling, and storage to prevent food-borne illness. All equipment, counters, and tables would be sanitized before and after use, and hand washing would be done frequently and correctly by all food service personnel . A five step process for hand washing technique was outlined in the policy. Step 4 stated hands should be rinsed from finger tips to wrists. Observation, on 05/01/13 at 12:25 PM, in the second floor Sunrise Dining Room, revealed Dietary Aide #7, washed her hands at the kitchenette's sink, but touched the inside of the sink while washing her hands and vigorously shook water from her hands in such a way that water droplets landed on the counter tops around the sink bowl. Observations, on 05/04/13 at 12:30 PM, 12:45 PM, and 12:50 PM, revealed Dietary Aide #7 washed her hands in the same manner, shaking her hands vigorously while rinsing them. Observation, on 05/01/13 at 12:27 PM, revealed Dietary Aide #7 prepared a glass of ice water for calibrating the thermometers to be used for obtaining temperatures of the foods delivered from the main kitchen. Dietary Aide #7 placed the cup of ice water with thermometers in the sink where staff had been washing their hands, and then she picked up the cup of thermometers. In the process, one of the thermometers fell out of the cup and landed on the counter top beside the sink. Dietary Aide #7 did not sanitize the thermometer before putting it back in the cup of ice water, took it to the steam table, and proceded to take the temperture of the foods . The first three items were pork, sweet potatoes, and zucchini. After recording the temperatures, Dietary Aid #7 placed the thermometers briefly back in the ice water then pulled them back out to take the temperature of the creamed potatoes, tomato soup, and grilled cheese sandwiches. Dietary Aide #7 did not sanitize the thermometers between uses. A box of alcohol prep pads were on a counter top near the steam table. Interview, on 05/01/13 at 1:10 PM with Dietary Aid #7, revealed she always shook her hands when she washed them, but stated she understood shaking water from her hands, and touching the inside areas of the sink during handwashing would be unsanitary. Her last handwashing in-service occurred January 2013, but no one had corrected her technique. Dietary Aid #7 stated she had been trained to clean the thermometers with an alcohol prep pad between each food as the temperature was taken, but she thought she forgot to clean them this time because she was nervous. Dietary Aid #7 stated she should have sanitized the thermometer that fell on the counter before using it, and that the thermometers should have been wiped with the alcohol prep pads after each use to prevent any cross-contamination. Interview, on 05/02/13 at 9:35 AM, with the Dietary Manager revealed dietary staff received in-service education in sanitary procedures for meal prep and service upon hire, annually, and as needed. The Dietary Manager stated new employees had to satisfactorily demonstrate proficiency in sanitary procedures upon hire before a required checklist was completed by the dietary manager and the dietary supervisors. The Dietary Manager also stated staff should follow the steps in the dietary policy for hand washing, and that shaking water from the hands while rinsing them would increase the risk of contaminating clean kitchen surfaces. The Dietary Manager further stated food thermometers should be cleaned with alcohol if they came in contact with any unclean surfaces, and between taking temperatures of each food item on the steam table. The Dietary Manager indicated the cleaning of the thermometers would be necessary to prevent the likelihood of any type of cross-contamination during the process of serving food to the residents. Review of the facility's policy regarding Food Service Infection Control, Safety, and Sanitation, revised 09/2012, revealed all food service personnel would wash hands thoroughly and frequently before starting work, after handling soiled dishes, and anytime hands became soiled. Observation, on 05/01/13 at 12:10 PM, of the Woodside dining room and kitchenette revealed Server/Dietary Aide #1 used hand sanitizer on re-entry into the kitchenette after pouring coffee from the coffee pot located in the dining room. The Dietary Aide then proceeded to obtain food temperatures for the lunch meal. Continued observation, on 05/01/13 at 12:32 PM, revealed the Dietary Manager entered the Woodside kitchenette and sanitized her hands. Interview with Dietary Aide #1, on 05/02/13 at 9:20 AM, revealed she used sanitizer after handling the dining room coffee pot. She stated she was trained to use hand sanitizer up to three (3) times before washing her hands. The Dietary Aide stated the entire area from which she serves food from the steam table was part of the kitchenette. She stated the purpose of the half wall between the dining room and the kitchenette was to provide a barrier for the kitchen serving area. She stated using hand sanitizer in the kitchen area could make residents sick. On 05/02/13 at 10:00 AM, interview with the Dietary Manager revealed dietary staff were trained to change gloves and sanitize their hands three (3) times before they needed to wash their hands. She stated she was not aware that hand sanitizer could not be used in a food service setting. The Dietary Manager stated it was possible for sanitizer to get into the residents food and contaminate it. Review of the facility's policy regarding Food Service Infection Control, Safety, and Sanitation, revised 09/2012, revealed food service personnel should wear a hair net or hair restraint. Also, only food service personnel would be permitted in the food preparation area and all outside persons in the department would wear a hat or hair restraint. Observation, on 05/01/13 at 12:48 PM, revealed Licensed Practical Nurse (LPN) #2 was in the Woodside dining room assisting with serving residents the lunch meal. The LPN entered the Woodside kitchenette and washed her hands in the kitchenette sink without her hair restrained. Interview, on 05/02/13 at 9:10 AM, with LPN #2 revealed she would wash her hands in the kitchenette and she would not wear a hair restraint. She stated she had been trained to wash her hands in the kitchenette sink if needed. Interview with Dietary Aide #2, on 05/02/13 at 9:20 AM, revealed nurses were allowed to enter the kitchenette to wash hands if needed. She stated the half wall was a barrier between the dining room and the kitchenette and if there was was food present then everyone in the kitchenette needed to have a hair restraint. She stated hair restraints were not kept in the kitchenette for staff to use when entering the kitchenette. On 05/02/13 at 10:00 AM, interview with the Dietary Manager revealed nurses used the sink in the Woodside kitchenette to wash their hands. She stated only dietary staff used hair nets. She stated the entire area was considered a food preparation area during the process of meal service. The Dietary Manager stated without hair restrained, hair could fall into residents food and contaminate it. Review of the facility's policy regarding Food Preparation and Service Guidelines, revised 08/2004, revealed tongs or other utensils should be used in handling food whenever possible. If it was necessary to use hands, hands should be washed and gloves worn. Observation, on 05/01/13 at 12:42 PM, of the Woodside Dining Room tray line service revealed the Server/Dietary Aide #1 wore gloves for meal service. The Dietary Aide placed a meal ticket onto a tray and then, with the same soiled gloves on, tore a grilled cheese sandwich in half and served half of the sandwich on two (2) plates. After placing the sandwich on the plate, the Dietary Aide then washed her hands and put on new gloves. The Dietary Aide then placed a meal ticket on a tray, tore a grilled cheese sandwich in half, and served half the sandwich on (2) plates with the same soiled gloves. Interview, on 05/02/13 at 9:20 AM, with Dietary Aide #1 revealed she usually used tongs when serving sandwiches and had tongs to use; however, she stated she had forgotten to use them. She stated using the same gloves she used to handle the meal tickets was not sanitary and had the potential to make residents sick. On 05/02/13 at 10:00 AM, interview with the Dietary Manager revealed tongs should be used to serve sandwiches. The Manager stated she monitored dietary service with spot checks for food temperatures and if resident's were pleased with meals. She stated resident meal tickets were not sanitary and using the same gloves to handle meal tickets and then the grilled cheese sandwich's could contaminate the resident's food.

Based on observation, interview, record review and review of the facility's policy and the Center for Disease Control (CDC) Guideline for Hand Hygiene, it was determined the facility failed to follow infection control hand washing guidelines during a dressing change and during a skin assessment for one (1) of twenty-three (23) sampled residents. Staff used improper hand hand washing and gloving techniques during a dressing change and skin assessment for Resident #14. The findings include: Review of the CDC Guideline for Hand Hygiene in Health Care Setting, dated 10/25/02, revealed the following indications for handwashing and hand antisepsis: decontaminate hands before having direct contact with patients; decontaminate hands after contact with body fluids, excretions, mucous membranes, non-intact skin and wound dressings; change gloves during patient care if moving from a contaminated body site to a clean body site; and decontaminate hands after removing gloves. Review of the facility's Infection Control Policy titled Hand Hygiene revealed hand hygiene should be performed after contact with blood body fluids, excretions, mucous membranes, non-intact skin or wound dressings. Review of the facility's reference book, that was presented by the Director of Nursing (DON) during the survey, titled Smith-Temple Johnson, 6th Edition, stated to use the Center for Disease Control and Prevention Policy for Hand Hygiene infection prevention. Review of Resident #14's clinical record revealed Resident #14's stool specimen was positive for Clostridium Difficile (C-Diff) and the resident was placed in isolation related to[DIAGNOSES REDACTED]. Observation with Licensed Practical Nurse (LPN) #3 of Resident #14's skin assessment and dressing change, on 05/01/10 at 10:15 AM, revealed the resident had a Stage 2 that measured 3.5 centimeters (cm) x 4.2 cm, with a fluid-filled blister on the left heel and a 3.5 cm x 4.2 cm with a fluid filled blister on the right heel. LPN #3 removed the resident's gripper socks, the old dressing, cleansed the blister with Normal Saline using a 4 x 4 guaze, applied antibiotic ointment using a cotton tip applicator, reapplied a clean Kerlix dressing and then reapplied the residents gripper socks. The LPN proceeded to do the sample procedure with the right foot. The LPN checked the pulses in both feet wearing the same gloves. The LPN did not change gloves or wash her hand through out the entire procedure. The LPN wearing the same gloves proceeded with the skin assessment opening the resident's brief, touching the buttocks, the upper inner thighs and then touched the residents hands, arms, chest, ears and neck without washing her hands or changing the gloves. The LPN adjusted the resident's clothing, bedding and touched the resident's hands at the end of the procedure and did not perform hand hygiene or glove changes through out the entire procedure. Interview with LPN #3, on 05/01/13 at 10:45 AM, revealed she was aware that she should have washed her hands and changed her gloves after touching the gripper socks because there was a possibility the socks could have touch the floor and would be contaminated. The LPN revealed she should have washed her hands and changed gloves after touching the resident's brief, buttocks and inner thighs because she would spread the[DIAGNOSES REDACTED]. Interview with the Director of Nursing (DON), on 05/02/13 at 10:15 AM, revealed if the gripper sock had touched the floor it could contaminate a glove and was uncertain if Resident #14's gripper socks had ever touched the floor. The DON was uncertain if the resident's peri-area could have been moist and was uncertain of the specifics of the hand hygiene practice used by the facility during dressing changes and skin assessments. The DON commented she had not read the resource book the facility used for hand hygiene cover to cover and made no further comment.

Based on observation and interview, it was determined the facility failed to ensure staff were wearing hairnets appropriately during meal service involving two (2) of two (2) dietary staff. Two dietary staff did not have their hair completely contained under the hairnet. Additionally, the facility failed to ensure plates were completely dry before serving food on them for (2) of fifteen (15) wet plates. In addition, there were items in the freezers that were not dated and left open to elements. The findings include: 1. Observation, on 02/29/12 at 12:30 PM, revealed china plates on a plate warmer. These plates were observed to be dripping wet. Continued observation revealed two (2) wet plates had food placed on them before the surveyor could intervene. When Dietary Aide #1 picked up the plates, water was visible dripping from the plates. Interview with Dietary Supervisor #1, on 02/29/12 at 12:35 PM, revealed the plates had been washed in the 3 compartment sink, not allowed to dry and sent up on the plate warmer for serving line. There were a total of 15 wet plates in the plate warmer, all were very wet. Interview with Dietary Aide #1, on 03/01/12 at 10:30 AM, revealed the plates were taken to the dining room by mistake and should not have been used. She stated if they are not dry they could be contaminated. 2. Observation, on 02/29/12 at 12:30 PM, during the lunch meal revealed Dietary Aide #1 wore a hair net; however, her bangs were hanging outside the hair net and stray hair was coming out of the sides. She stated they had recently been trained on infection control and the proper use of hair nets were included. Interview with Dietary Supervisor #1, on 03/01/12 at 10:45 AM, revealed the wet plates were taken to the dining room by accident and because they were wet they could have been contaminated with soiled water. She stated they had just recently had an infection control training that included training on not using wet plates and proper use of hair nets. 3. Observation of the evening meal, on 02/29/12 at 5:15 PM, revealed dietary aide #2 had her bangs and hair around her face not contained in a hair net. The dietary aide was taking food temperature on the steam table. When she began to remove the foil from the food, the surveyor intervened. Interview with Dietary Aide #2 at the time of the observation revealed she was new and under training. She stated she had been trained to keep all hair covered when serving food. She said it was hard to contain all of her hair under the hair net. Interview with the evening shift dietary supervisor at this time (who was present during the observation) revealed all hair was suppose to be covered by a hairnet. She stated she had not noticed the trainee's hair outside of the hair net. However, observation of the supervisors's hair net revealed all hair was not contained either. Long strands of hair were observed to be hanging out of the hair net on the left side of her face. 4. Observations of the kitchen freezers, on 02/28/12 at 8:10 AM, during the initial tour revealed the following: one 30 lb. bag of frozen lima beans opened to air and not labeled with date opened; one bag of frozen carrots, not labeled with the date and open to air; one bag of individual pizzas, not dated and open to air; and one bag of frozen french fries, not labeled with open date and open to air. Interview with the Certified Dietary Manager (CDM), on 02/28/12 at 8:20 AM, revealed the items should be removed from the freezer as they should have been dated when opened and sealed tight to protect from the air. The dietary staff knows to label and seal opened items.