Every finding on record at Novant Health Presbyterian Medical Center-Snu

Based on observations and staff interviews, the facility failed to keep the area around the garbage compacter free of accumulated trash and debris for 1 of 1 garbage compacter observed. The findings included: A continuous observation was completed of the garbage compacter area on 8/12/2024 from 4:07 PM to 4:15 PM. The observation revealed the following items outside of the garbage compacter: 1 bag of trash, 3 to 4 used disposable gloves, 1 medium clear plastic bag with 4 exposed bread slices on the ground, 1 large cardboard box that was flat. The area was observed to be malodorous and had a lingering foul/ sour smell. There was wet, thick blackish/ brownish sludge matter observed around the area of the garbage compacter. At 4:15 PM an unknown staff member was observed operating the riser to the garbage compacter. While the riser was in motion and lifting, there was debris and black/brown sludge observed underneath the rising mechanism. There were 2 to 3 garbage bags filled with miscellaneous items observed behind the riser and in between the compacter. Soiled plastic gloves were on the ground around this area along with other unidentifiable items observed in the sludge. Flying insects were observed around the area of the garbage compacter. An interview was completed on 8/12/2024 at 4:10 PM with the Resident Regional Environmental Service Director who explained the garbage compacter area was a shared duty between environmental services and dietary. He explained Environmental Services would clean the area in the mornings and the afternoon/evenings. The area would also be spot checked throughout the day by Environmental Services. He did not provide a frequency or time for the spot checking of the area. An interview was completed on 8/12/2024 at 4:13 PM with the Environmental Services Director who stated environmental services staff should check the garbage compacter area two times daily. He further stated spot checks should also be completed throughout the day by environmental services staff. He did not provide a frequency or time for the spot checking of the area. The Environmental Services Director did state he last checked the area around 9:30 AM and observed a clear plastic bag on the ground in the garbage compacter area that remained present during the surveyor and staff observation. An interview was completed with the Director of Operations on 8/14/2024 at 3:46 PM. She revealed Environmental Services and Food/ Nutrition Services should maintain the cleanliness of the garbage compacter area. This responsibility was a shared responsibility between the two departments. Going forward this area would be cleaned monthly via an external contracture as well as an audit tool would be implemented to see clear follow up from internal staff to ensure the area remained clean. An interview with the Administrator was completed on 8/14/2024 at 3:57 PM. She revealed there should be clear communication between Environmental Services and Food/ Nutrition Services to maintain the cleanliness of the area around the garbage compacter.

Based on observations, staff interviews, and record review, the facility failed to apply signage indicating the use of oxygen outside the resident's room for 2 of 2 residents reviewed for oxygen use (Resident #9 and Resident #5). The findings included: 1. Resident #9 was admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #9 was cognitively intact and coded for the use of oxygen. A physician's order for Resident #9 dated 7/25/24 for 2 liters per minutes (LPM) oxygen continuous via nasal cannula. During an observation on 8/12/24 at 12:05 pm no signage for oxygen use was to be found anywhere near to resident's room entrance. Resident #9 was observed wearing her oxygen via a nasal canula at 2LPM. The oxygen concentrator was observed on the right side of the bed in Resident #9's room. Interview with the Accreditation and Regulatory staff member #1 on 8/12/24 at 2:00 pm stated they were not required to post No Smoking signs on the doors of the residents using oxygen as they were a smoke-free facility. The Accreditation and Regulatory staff member #1 stated they were only required to place a sign informing the public that they were a smoke-free facility in prominent areas. The Accreditation and Regulatory staff member #1 referred to the Fire Protection Association literature dated 8/12/24 which read in part: In health care facilities where smoking is prohibited and signs are prominently (strategically) placed at all major entrances, secondary signs with no smoking language shall not be required. Interview with Nurse #1 on 8/13/24 at 12:40 pm revealed that Novant Health campus was a smoke-free facility. This was inclusive of the skilled unit. Nurse #1 continued to explain per facility policy they were not required to post the no smoking signs on the resident's doors. On 8/13/24 at 3:00 pm an interview with the Director of Accreditation and Regulatory was completed who stated they were a smoke-free facility and there were general No Smoking signs in the parking lot and several entrances before entering the building. The Director of Accreditation and Regulatory continued to explain the Patient Handbook was provided which informs the patients for their health and wellness, Novant Health was a tobacco free organization. The Director of Accreditation and Regulatory also stated the same information was available on the patient's online record access. On 8/15/24 at 10:59 am an interview with the Administrator revealed the facility was in the hospital environment and there was some confusion with staff about posting no smoking signs at the resident's door. The Administrator stated the hospital followed the National Fire Prevention regulation which indicated oxygen signage was not required at the resident's room door. 2. Resident #5 was admitted to the facility on [DATE] with diagnoses of Tachypnea (crackling in the lungs). Review of the admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #5 was cognitively intact and coded for the use of oxygen. A physician's order for Resident #5 dated 7/24/24 for 2 liters per minutes (LPM) oxygen continuous via nasal cannula. During an observation on 8/12/24 at 12:37 pm, there was no signage outside Resident #5's room indicating the usage of oxygen. Resident #5 was observed wearing her oxygen via nasal cannula at 2 LPM. The oxygen concentrator was observed on the right side of the bed in Resident #5's room. Interview with the Accreditation and Regulatory staff member #1 on 8/12/24 at 2:00 pm stated they were not required to post No Smoking signs on the doors of the residents using oxygen as they were a smoke-free facility. The Accreditation and Regulatory staff member #1 stated they were only required to place a sign informing the public that they were a smoke-free facility in prominent areas. The Accreditation and Regulatory staff member #1 referred to the Fire Protection Association literature dated 8/12/24 which read in part: In health care facilities where smoking is prohibited and signs are prominently (strategically) placed at all major entrances, secondary signs with no smoking language shall not be required. Interview with Nurse #1 on 8/13/24 at 12:40 pm revealed that Novant Health campus was a smoke-free facility. This was inclusive of the skilled unit. Nurse #1 continued to explain per facility policy they were not required to post the no smoking signs on the resident's doors. On 8/13/24 at 3:00 pm an interview with the Director of Accreditation and Regulatory was completed who stated they were a smoke-free facility and there were general No Smoking signs in the parking lot and several entrances before entering the building. The Director of Accreditation and Regulatory continued to explain the Patient Handbook was provided which informs the patients for their health and wellness, Novant Health was a tobacco free organization. The Director of Accreditation and Regulatory also stated the same information was available on the patient's online record access. On 8/15/24 at 10:59 am an interview with the Administrator revealed the facility was in the hospital environment and there was some confusion with staff about posting no smoking signs at the resident's door. The Administrator stated the hospital followed the National Fire Prevention regulation which indicated oxygen signage was not required at the resident's room door.

Based on observations, record review and staff interviews, the facility failed to maintain a medication error rate of 5% or less as evidenced by 2 medication errors out of 26 opportunities. This resulted in a medication error rate of 7.69% for 1 of 3 residents (Resident #1) observed during medication administration observation. The findings included: A physician order dated 08/12/24 revealed Resident #1 was to receive tamsulosin (Flomax) capsule 0.4 milligrams (mg) daily for acute urinary retention and pantoprazole sodium (Protonix) EC (enteric coated) tablet 40mg daily for acid reflux. Administration instructions for both medications were: Do not open or crush. During the medication pass observation on 08/14/24 at 9:14 AM: 1a. Nurse #2 prepared medications for Resident #1. Nurse #2 was observed taking a pantoprazole sodium EC tablet 40mg out of a blister package and used a pill-crushing device to crush the medicine. Nurse #2 proceeded to sprinkle the medication into the apple sauce. 1b. Nurse #2 was observed to twist open a tamsulosin capsule 0.4mg and sprinkle this medication into the apple sauce. At 9:16 AM, Nurse #2 administered the pantoprazole sodium EC tablet 40mg and tamsulosin capsule 0.4mg with apple sauce to the resident. An interview with Pharmacist #1 and Pharmacist #2 on 08/14/24 at 10:25 AM revealed that pharmacy has the ability to substitute medications if they were aware. Pharmacist #1 stated the tamsulosin would have a rapid onset of action if opened and given to the resident in applesauce for consumption. Pharmacist #1 further stated the pantoprazole sodium EC should not have been crushed unless indicated by the physician. Both Pharmacist #1 and Pharmacist #2 verbalized the pharmacy did not get any requests from the skilled nursing unit to provide alternative medication substitutes for the tamsulosin and pantoprazole sodium EC or a physician's order clarifying the administration directions for the two medications to be crushed and or opened. An interview with Nurse #2 on 08/14/24 at 4:47 PM revealed administration instructions were displayed on the Electronic Medication Administration Record (eMAR) under details. Nurse #2 explained she had no particular reason why she did not read the administration instructions when preparing the medications for Resident #1. An interview with the Administrator on 08/14/24 at 4:54 PM stated that Nurse #2 should have reached out to the physician or pharmacy to determine if there were alternative medicines and not have disregarded the administration directions for the medications to not be crushed or not opened.

Based on observations and staff interviews the facility failed to remove loose garbage and debris from underneath 1 of 1 trash lift located in the back of the kitchen area with no closed door separating the kitchen and food was being prepared a short distance away. This practice had the potential to impact sanitary conditions, food served to residents and attract pests/rodents. The findings included: A continuous observation (with the Dietary Director and Lead Chef) of the kitchen occurred on 4/18/23 from 11:17 AM - 12:45 PM. The observation revealed trash and debris under the trash lift in the kitchen area which was not separated by a closed door and food was being prepared for residents a short distance away. During an interview on 4/18/23 12:50 PM, the Lead Chef indicated the kitchen was to be cleaned nightly according to the cleaning schedule and he was not aware that it had not been cleaned. A follow-up continuous observation (with the Lead Chef) of the kitchen occurred on 4/19/23 from 11:03 AM - 11:50 AM. The same trash and debris that was observed on 4/18/23 was also observed on 4/19/23, as previously described. During an interview on 4/19/23 at 11:55 AM, the Lead Chef stated he assigned the task of cleaning the trash lift area and did not follow up to make sure that the task was completed. He was not aware the task was not completed at the time of the interview. During an interview on 4/19/23 at 2:25 PM, the Dietary Director revealed he was unaware the trash lift area was not cleaned after the Surveyor first observed it on 4/18/23. His expectation was for the kitchen cleaning schedule to be followed and that his staff needed to do a better job with keeping the trash area clean. An interview with the Administrator on 4/19/23 at 2:00 PM indicated she was not aware of the trash and debris not being cleaned for 2 days. Her expectation was for the dietary staff to adhere to the cleaning schedule.

Based on observations and staff interviews, the facility failed to discard expired food items and remove grease build up on and around the fryer used to prepare food. These practices had the potential to affect food served to 7 of 7 residents. The findings included: A continuous observation (with the Dietary Director and Lead Chef) of the kitchen occurred on [DATE] from 11:17 AM - 12:45 PM. The observation revealed the following: a) One gallon container of opened blue cheese dressing in the kitchen prep area, that expired on [DATE]. b) One gallon container of olive oil salad dressing in the kitchen prep area, that expired [DATE]. c) Two large pots of uncovered frozen gravy in walk-in freezer, labeled with expiration date of [DATE]. d) Grease fryer #1 used to prepare resident foods displayed thick grease buildup on and around the grease fryer and floor. During an interview on [DATE] 12:50 PM, the Lead Chef indicated the kitchen was to be cleaned nightly according to the cleaning schedule and the food located in the dry storage room, refrigerators and freezer were supposed to be checked and discarded weekly if expired. A follow-up continuous observation (with the Lead Chef) of the kitchen occurred on [DATE] from 11:03 AM - 11:50 AM. The same grease buildup observed on [DATE] was also observed on [DATE], as previously described. During an interview on [DATE] at 11:55 AM, the Lead Chef stated he assigned the task of cleaning the fryer, to the evening staff and did not follow up to make sure that the task was completed. He was not aware the task was not completed at the time of the interview. During an interview on [DATE] at 2:25 PM, the Dietary Director revealed he was unaware the grease fryer was not cleaned after the Surveyor first observed it on [DATE]. His expectation was for the kitchen cleaning schedule to be followed and that his staff need to do a better job with discarding expired foods and cleaning. An interview with the Administrator on [DATE] at 2:00 PM indicated she was made aware of the expired salad dressings, gravy and the unkept grease fryer. Her expectation was for expired foods to be discarded on a regular basis and the kitchen cleaning schedule adhered to.

Based on record review, resident interview and staff interviews, the facility failed to have adequate indication and rationale for the use of an anti-depressant medication for 1 of 5 sampled residents reviewed for unnecessary medications (Resident #63). Findings included: Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #63's admission Minimum (MDS) data set [DATE] revealed an assessment of intact cognition. Review of Resident #63's care plan initiated on 11/19/18 revealed interventions for therapy and pain management. Review of the physician orders [REDACTED]. Review of Resident #63's Medication Administration Record [REDACTED]. During an interview on 11/29/18 at 11:18 AM with Resident#63, she indicated [MEDICATION NAME] had been taken at home to treat her anxiety. Resident #63 stated she received [MEDICATION NAME] daily basis while at the facility. An interview on 11/29/18 at 10:31 AM with the physician assistant (PA), the PA stated he completed a history and physical for Resident #63 on admission. The PA stated [MEDICATION NAME] had been prescribed prior to the admission and taken at home by Resident #63 daily. The PA stated home medications were continued for the resident on admission. The PA stated Resident #63's admission medical [DIAGNOSES REDACTED]. An interview with the attending physician on 11/29/18 at 10:54 AM, the physician reported he attested to the examination and prescribing orders by the PA for Resident #63. The physician stated home medications were typically ordered on admission unless there was a contraindication for use. The physician stated there would be a need to investigate and determine from the resident the purpose for the medication. The physician stated in his review of the electronic medical record for Resident#63, no medical [DIAGNOSES REDACTED].

Based on resident and staff interviews, and record review, the facility failed to give a written baseline care plan to 6 of 6 sampled residents (Residents #62. #63, #64. #162, #163, and #165). The findings included: 1. Resident #165 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #165's care plan initiated on 11/18/18 revealed interventions for therapy and pain management. Review of Resident #165's admission Minimum Data Set ((MDS) dated [DATE] revealed an assessment of intact cognition. Interview with the unit manager on 11/28/18 at 10:20 AM revealed residents' care plans were initiated upon admission. The unit manager reported she did not know if residents received a written copy of the care plan. Interview with Resident #165 on 11/28/18 at 11:58 AM revealed she did not receive a written copy of the care plan. Resident #165 reported staff provided information regarding her therapy and care orally. Interview with the MDS Coordinator on 11/28/18 at 12:00 PM revealed Resident #165 received a baseline care plan orally. The MDS Coordinator explained residents did not receive a written copy of the care plan. Interview with the Director of Nursing (DON) on 11/28/18 at 12:46 PM revealed the facility did not realize a written copy of the care plan was required. 2. Resident #162 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #162's care plan initiated on 11/17/18 revealed interventions for therapy and pain management. Review of Resident #162's admission MDS dated [DATE] revealed an assessment of intact cognition. Interview with Resident #162 on 11/27/18 at 10:20 AM revealed he did not receive a written copy of the baseline care plan. Interview with the unit manager on 11/28/18 at 10:20 AM revealed residents' care plans were initiated upon admission. The unit manager reported she did not know if residents received a written copy of the care plan. Interview with the MDS Coordinator on 11/28/18 at 12:00 PM revealed Resident #165 received a baseline care plan orally. The MDS Coordinator explained residents did not receive a written copy of the care plan. Interview with the Director of Nursing (DON) on 11/28/18 at 12:46 PM revealed the facility did not realize a written copy of the care plan was required. 3. Resident #163 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #163's care plan dated 11/17/18 revealed interventions for therapy and pain management. Interview with the unit manager on 11/28/18 at 10:20 AM revealed residents' care plans were initiated upon admission. The unit manager reported she did not know if residents received a written copy of the care plan. Interview with the MDS Coordinator on 11/28/18 at 12:00 PM revealed Resident #163 received a baseline care plan orally. The MDS Coordinator explained residents did not receive a written copy of the care plan. Interview with the Director of Nursing (DON) on 11/28/18 at 12:46 PM revealed the facility did not realize a written copy of the care plan was required. Based on resident and staff interviews, and record review, the facility failed to give a written baseline care plan to 6 of 6 sampled residents (Residents #62. #63, #64. #162, #163, and #165). The findings included: 4. Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #63's admission MDS dated [DATE] revealed an assessment of intact cognition. Review of Resident #63's care plan initiated on 11/19/18 revealed interventions for therapy and pain management. Interview with the unit manager on 11/28/18 at 10:20 AM revealed residents' care plans were initiated upon admission. The unit manager reported she did not know if residents received a written copy of the care plan. Interview with the MDS Coordinator on 11/28/18 at 12:00 PM revealed Resident #63 received a baseline care plan orally. The MDS Coordinator explained residents did not receive a written copy of the care plan. Interview with the Director of Nursing (DON) on 11/28/18 at 12:46 PM revealed the facility did not realize a written copy of the care plan was required. Interview with Resident #63 on 11/28/18 at 5:11 PM revealed she did not receive a written copy of the care plan. Resident #64 reported staff provided information regarding her therapy and care orally. 5. Resident #64 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #64's admission Minimum Data Set ((MDS) dated [DATE] revealed an assessment of intact cognition. Review of Resident #64's care plan dated 11/16/18 revealed interventions for therapy and pain management. Interview with the unit manager on 11/28/18 at 10:20 AM revealed residents' care plans were initiated upon admission. The unit manager reported she did not know if residents received a written copy of the care plan. Interview with the MDS Coordinator on 11/28/18 at 12:00 PM revealed Resident #64 received a baseline care plan orally. The MDS Coordinator explained residents did not receive a written copy of the care plan. Interview with the Director of Nursing (DON) on 11/28/18 at 12:46 PM revealed the facility did not realize a written copy of the care plan was required. Interview with Resident #64 on 11/28/18 at 5:05 PM revealed he did not receive a written copy of the care plan. Resident #64 reported staff provided information regarding his therapy and care orally. 6. Resident #62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #62's admission Minimum Data Set ((MDS) dated [DATE] revealed an assessment of intact cognition. Review of Resident #62's care plan initiated on 11/17/18 revealed interventions for activities of daily living and pain management. Interview with the unit manager on 11/28/18 at 10:20 AM revealed residents' care plans were initiated upon admission. The unit manager reported she did not know if residents received a written copy of the care plan. Interview with the MDS Coordinator on 11/28/18 at 12:00 PM revealed Resident #62 received a baseline care plan orally. The MDS Coordinator explained residents did not receive a written copy of the care plan. Interview with the Director of Nursing (DON) on 11/28/18 at 12:46 PM revealed the facility did not realize a written copy of the care plan was required.

Based on 3 of 4 observations, interviews with staff and a service provider and review of facility records, the facility failed to monitor the dish machine, while in use, to maintain wash/rinse cycle temperatures per manufacturer recommendations. Additionally, the facility failed to record a date of storage for potentially hazardous foods (ground turkey), remove expired foods (cucumbers) and store foods in a closed container (cheese, sausage links and bread) for 3 of 3 cold/frozen storage units observed. The findings included: 1. Manufacturer recommendations posted on the dish machine read the following, Hot water sanitizing wash temperature 160 degrees Fahrenheit, minimum. Final rinse temperature 180 degrees Fahrenheit minimum -194 degrees Fahrenheit maximum. On 12/16/15 from 10:01 AM - 10:06 AM the following concerns were observed regarding the dish machine wash/rinse cycle temperatures: a. On 12/16/15 at 10:01 AM, the dish machine was observed in use to wash insulated dome lids. The wash cycle temperature was 140 degrees Fahrenheit (F) and the final rinse cycle temperature was 171 degrees F. Dietary staff #2 stored the insulated dome lids on a storage rack to air dry. b. On 12/16/15 at 10:05 AM, the dish machine was observed in use to wash plates. The wash cycle temperature was 139 degrees F and the final rinse cycle temperature was 178 degrees F. Dietary staff #2 put the plates on a storage rack to air dry. c. On 12/16/15 at 10:06 AM, the dish machine was observed in use to wash food trays. The wash cycle temperature was 140 degrees F and the final rinse cycle temperature was 180 degrees Fahrenheit. Dietary staff #2 placed the food trays on a storage rack to air dry. During an interview on 12/16/15 at 10:25 AM, the food service director (FSD) stated that the dish machine operated with a low temperature/chemical agent for the wash cycle and high temperature/hot water sanitizing (minimum 180 degrees F) for the rinse cycle. A sign was observed posted near the dish machine which recorded staff were to monitor the dish machine for a wash cycle temperature of 150 -160 degrees F, a final rinse cycle temperature of at least 180 degrees F and to notify the supervisor of any problems. The FSD stated the wash cycle should reach at least 150 degrees F and the final rinse temperature should be at least 180 degrees F. The FSD pointed to the sign posted and stated We have a sign posted for the staff to follow. The FSD stated she was not aware that the sign posted by management recorded a different wash cycle temperature range (150 - 160 degrees F) than manufacturer recommendations (160 degrees minimum). Review of the dish machine temperature logs revealed the following dates when temperatures were recorded below manufacturer recommendations: · Wash cycle temperatures ranged 150 - 159 degrees F for the breakfast/lunch meals on December 1, 2, 3, 4, 5, 6, 7, 9, 11, 12, 13, 14, and 15, 2015. All other wash cycle and final rinse cycle temperatures for December 2015 were within manufacturer recommendations. · Wash cycle temperatures ranged 150 - 159 degrees F for the breakfast/lunch/evening meals on November 1, 3, 9, 10, 11, 14, 15, 17, 19, 21, 22, 23, 24, 27, 28, 29, and 30, 2015. A final rinse cycle temperature of 179 degrees F was noted on November 14, 2015 for the lunch meal. All other wash cycle and final rinse cycle temperatures for November 2015 were within manufacturer recommendations. · October 2015 log was not available for review. · Wash cycle temperatures ranged 157 - 159 degrees F for the breakfast meal on September 5, 10, 14, 17, 19, and 21, 2015. A final rinse cycle temperature of 178 degrees F was noted on September 27, 2015 for the lunch meal. All other wash cycle and final rinse cycle temperatures for September 2015 were within manufacturer recommendations. An interview on 12/16/2015 at 11:48 AM with the dish machine chemical route sales manager, while onsite, for the dish machine service company revealed the facility operated a high temperature dish machine (hot water sanitizing) that worked optimally when both the wash and rinse cycle temperatures were reached per manufacturer recommendations. The dish machine chemical route sales manager further stated that if the wash/rinse cycle temperatures were not met, staff should run 1 - 2 empty racks through the dish machine to allow the water to get hot enough and once the minimum temperatures were reached, proceed with dish washing. He also stated that he had just checked the dish machine moments earlier (12/16/15) and the dish machine operated per manufacturer recommendations. An interview was conducted on 12/17/2015 at 3:45 PM with dietary staff #2 and revealed that he had been instructed to monitor for a wash cycle temperature range between 150 -160 degrees F and at least 180 degrees F for the rinse cycle. He stated that if wash/rinse temperatures were less than recommended he had been instructed to send empty racks through the dish machine until the correct temperatures were reached and report any problems to the FSD or kitchen supervisor. A follow up interview occurred on 12/17/2015 at 3:48 PM with the FSD and revealed that the October 2015 dish machine log was not available for review. The FSD stated that management posted a sign regarding dish machine temperatures for staff to follow that did not meet manufacturer recommendations. She further stated that the sign was just updated (12/16/15) to include manufacturer recommendations for wash/rinse cycle temperatures. 2. An observation occurred on 12/16/2015 from 10:07 AM - 10:23 AM of cold/frozen storage units with the following concerns noted: a. Walkin refrigerator #8 was observed with a 35 pound box of random cut potatoes, a 5 pound bag of grated parmesan cheese and a 10 pound box of breakfast sausage links stored open to air. b. Walkin refrigerator #8 was observed with three 10 pound rolls of thawed ground turkey with no date of storage. c. Walkin cooler #7 was observed with 2 broken cucumbers, stored open to air, with a mushy consistency and discoloration (signs of spoilage). d. The freezer was observed with bread sticks, pita bread and cinnamon swirls stored in 5 pound boxes that were open to air. An interview with the FSD occurred on 12/17/15 at 3:48 PM and revealed that the cold/frozen storage units should be checked daily for expired foods, foods out of date and foods stored open to air. The FSD further stated that the cold/frozen storage units were checked earlier in the day (12/16/15), but some items may have been missed. The FSD also stated that staff had not been trained to label frozen foods with a storage date when moved to a refrigeration unit to thaw, but that staff would be trained to do so going forward.

Based on observations, staff interviews and facility record review the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor these interventions that the committee put into place in [DATE]. This was for one recited deficiency which was originally cited in [DATE] on a recertification survey and again on the current recertification survey. The deficiency was in the area of dietary services. The facility's continued failure to implement and maintain procedures from a QAA Committee, during two federal surveys of record, show a pattern of the facility's inability to sustain an effective Quality Assurance Program. Findings included: This tag is cross referred to: 1. F 371: Dietary services: Based on 3 of 4 observations, interviews with staff and a service provider and review of facility records, the facility failed to monitor the dish machine, while in use, to maintain wash/rinse cycle temperatures per manufacturer recommendations. Additionally, the facility failed to record a date of storage for a potentially hazardous food (ground turkey), remove expired foods (cucumbers) and store foods in a closed container (cheese, sausage links and bread) for 3 of 3 cold/frozen storage units observed. During the [DATE] recertification survey, the facility was cited for failure to label and date a potentially hazardous cold food, remove expired foods from cold storage, and store cold foods in closed containers. The facility was recited during the current recertification survey for failure to maintain wash/rinse cycle temperatures of the dish machine per manufacturer recommendations, record the date of storage for potentially hazardous cold foods, remove expired foods from cold storage and store cold foods in closed containers. An interview occurred on [DATE] at 4:37 PM with the director of nursing, clinical quality manager, operation improvement manager, nurse manager and minimum data set coordinator. During the interview, the clinical quality manager stated that as a result of the [DATE] survey, the QAA Committee developed a plan of correction, offered training with re-enforcement and required return demonstration to identify competency. The clinical quality manager also stated that the repeat deficiency in dietary services was attributed to staff turnover and a need for more audits, tighter oversight and close monitoring.

Based on staff interviews and record review, the facility failed to conduct a comprehensive assessment to identify and analyze how condition affected function and quality of life related to pressure sores for 1 of 1 sampled resident with pressure sores (Resident #3). The findings included: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's admission Minimum Data Set ((MDS) dated [DATE] revealed an assessment of intact cognition. The MDS indicated Resident #3 with one stage one pressure sore and one pressure sore which could not be staged. Both pressure sores were present upon admission. Review of Resident #3's Care Area Assessment (CAA) dated 08/26/15 revealed no documentation of findings with a description of the pressure sores, causes, contributing factors and risk factors related to pressure sores. There was no documentation of input from Resident #3. There was no documentation of an analysis of findings supporting the decision to proceed or not to proceed to the care plan. Review of Resident #3's clinical record revealed the pressure sores improved prior to discharge on 08/27/15. Interview with the MDS coordinator on 12/17/15 at 1:46 PM revealed the CAA did not contain documentation of findings and analysis regarding Resident #3's pressure sores. The MDS coordinator explained she did not realize a documented analysis was required on the CAA. Interview with the Director of Nursing (DON) on 12/17/15 at 2:33 PM revealed he expected Resident #3's comprehensive assessment to be documented. The DON explained he did not realize a documented analysis was required on the CAA.

Based on observation, staff interviews and record review, the facility failed to disinfect a glucose meter (used for blood sugar monitoring) after a finger stick blood sugar for 1 of 1 sampled resident observed for finger stick blood sugar checks (Resident #90). The findings included: Review of the label on the sanitizer wipe container on the counter of the medication room on the transitional care unit revealed direction for blood borne pathogen disinfection. The directions specified treated surfaces must remain visibly wet for a full 3 minutes. The directions included direction to use additional wipes if needed to assure continuous 3 minute wet contact. Review of the facility's undated procedure titled: "Cleaning and Disinfectant Grid" revealed direction for a "3 minutes kill time" in order to disinfect the blood glucose meter. Interview with Nurse #1 on 03/11/15 at 11:36 AM revealed residents shared a glucose meter which staff disinfected after each use. Observation on 03/11/15 at 11:39 AM revealed Nurse #1 obtained Resident #90's finger stick blood sugar with a glucose meter. After using the glucose meter, Nurse #1 removed a wipe out of the bleach wipe container and wiped the meter on all four sides. Nurse #1 placed the glucose meter into a plastic case. The top and sides of the glucose meter were not visibly wet. Interview with Nurse #1 on 01/14/15 at 11:40 AM revealed the blood glucose monitor did not require visible wetness. Nurse #1 explained her usual practice was to wipe the blood glucose monitor once and place it into the plastic case. Nurse #1 explained she received training when the facility changed the type of wipe but did not know a specific time requirement for visible wetness. Interview with the Director of Nursing (DON) on 03/11/15 at 1:00 PM revealed the glucose meter should remain visibly wet for 3 minutes. The DON reported he expected nursing staff to follow the facility's procedure which directed 3 minutes. Interview on 03/11/15 at 1:07 PM with the Clinical Quality Coordinator revealed the glucose meter required 3 minutes of visible wetness in order to sanitize and disinfect completely.

Based on observations, staff interviews and review of facility records, the facility failed to monitor potentially hazardous foods in cold storage as evidenced by 1) items stored without a label to record the date of opening, 2) items stored beyond the manufacturer's use by date or the facility's discard date 3) items stored with signs of spoilage, and 4) items stored open to air for 3 of 5 cold storage units observed. The findings included: The facility policy "Production, Purchasing, Storage", revised 01/15, recorded in part, All foods being cooled must be identified with a company's label. Protect food from contamination with covers or shield. The facility's "Food Storage Chart", undated, was posted outside the refrigeration units and recorded the following, in part. Dry Storage and Refrigerated Storage: Expiration dates printed by the manufacturer apply until the product is opened. Once opened, use these time limits unless the manufacturer's date is earlier. Add the time in this chart to the date of opening to determine expiration. After opening: · dried fruit add 2 months · deli meats whole, use within 3 days of thawing under refrigeration · bags of processed produce add three days · cheese add six days On 03/09/15 from 09:53 AM until 09:57 AM, an observation of walk-in cooler #8 occurred with the director of food and nutrition (DFN). The following concerns were noted: A. A clear plastic bag with approximately three pounds of feta cheese remaining was observed stored with no date of opening or discard date. B. Two containers of cottage cheese, five pounds each, were observed with a manufacturer's use by date stamp of 03/07/15. C. Approximately one pound of bologna was observed wrapped in plastic wrap with a facility label which recorded an open date of 02/17/15 and a discard date of 02/22/15. The bologna was noted with a sticky residue to its exterior. D. A cooked turkey breast was observed stored in a stainless steel pan and covered with aluminum foil with a facility label which recorded a preparation date of 03/05/15 and a use by date of 03/06/15. On 03/09/15 from 10:09 AM until 10:13 AM, an observation of walk-in cooler #7 occurred with the DFN and the following concerns noted: E. A previously opened, clear plastic bag with approximately three pounds of fresh broccoli florets remaining was observed stored without a label to record the date of opening or a discard date. F. A previously opened, clear plastic bag with approximately three pounds of sliced fresh carrots remaining was observed stored without a label to record the date of opening or a discard date. G. A cardboard box of Roma tomatoes was observed with visible signs of spoilage as evidenced by tomatoes with white and green discoloration and fuzzy hair like growth. H. A cardboard box of figs was observed dried and covered with white fuzzy growth. The box of figs recorded a manufacturer's expiration date stamp of 10/22/13. On 03/09/15 from 10:14 AM until 10:16 AM, an observation of the walk in freezer revealed the following concerns: I. A card board box was observed with cinnamon twirls which were open to air. J. A card board box was observed with pizza dough which was open to air. K. Two cardboard boxes were observed with hoagie rolls which were open to air. L. A clear plastic freezer storage bag was observed with frozen pineapples without a label to record a date of storage. On 03/09/15 at 10:20 AM, the DFN stated in interview that the cooks were responsible for monitoring cold storage every afternoon for expired foods, foods stored without labels or foods left open to air. The DFN stated she expected all staff to use a facility label when storing foods in refrigeration to record the product name, date of storage and a discard date using the "Food Storage Chart" posted outside of the refrigeration units for guidance on when foods should be discarded. The DFN confirmed that the figs and tomatoes observed appeared to have mold growth. On 03/11/15 at 12:25 PM dietary staff #1 (head chef) was interviewed and stated that he expected cooks to check the refrigeration units every two hours for food storage concerns. Dietary staff #1 stated that since some of the food items observed did not have a facility label on them, the cooks did not recognize the items were out of date and these items were missed. He further stated that the staff would have to do a better job of monitoring refrigeration units for concerns with food storage.

Based on observations, interviews with staff and review of facility records, the facility failed to monitor and maintain the wash/rinse cycle temperatures of the high temperature sanitizing dish machine per manufacturer recommendations for 3 of 3 observations and maintain pot, pan and dish storage racks clean. 1. The facility policy "Dish machine Temperatures", revised January 2012, recorded in part, "Dish machine wash and rinse water should be maintained at temperatures not less than those established by the Food and Drug Administration, High Temperature Machine: Wash temperature 150 degrees Fahrenheit, Final Rinse temperature 180 degrees Fahrenheit." Dietary aide (DA) #1 was observed preparing dishes for the dish machine on 10/18/12 at 7:47 AM. At 7:57 AM dietary aide #1 inserted a stationary rack of metal sheet pans into the dish machine, the wash cycle temperature was 116 degrees Fahrenheit (F) and the rinse cycle temperature was 178 degrees F. Interview with DA #1 during the observation revealed that the wash cycle temperature was too low. He stated that before he used the dish machine, his typical practice was to turn it on, allow the tank to fill, and make sure the booster switch was on. DA #1 further stated that he knew the water in the dish machine was hot enough and ready for use when the water was steamy and felt hot. He also stated that when in use, the wash cycle should be 150 degrees F and the final rinse cycle should be 160 degrees F. DA #1 stated that he informed his manager and the contractor who came to service the dish machine the prior week that the wash cycle temperature was not hot enough, but on 10/17/12, the water only reached 120-140 degrees F for the wash and between 170-180 degrees F for the rinse. When asked if he informed his manager of the wash/rinse cycle temperatures observed on 10/17/12, DA #1 stated "they know." During a second observation on 10/18/12 at 8:08 AM, stainless steel pans were washed with a wash cycle temperature of 113 degrees F and a final rinse cycle temperature of 153 degrees Fahrenheit. At 8:11 AM a third observation revealed stainless steel pans were washed with a wash cycle temperature of 112 degrees and a rinse cycle temperature of 178 degrees. These dishes were stored on racks for use and allowed to air dry. An interview on 10/18/12 at 8:18 AM with the Director of Food and Nutrition (DFN) revealed she was aware of the prior concerns with the temperature of dish machine. The DFN stated that the dish machine used hot water sanitizing with a chemical sanitizer back-up system. She described that repairs were made to the steam system the prior week because the water was not getting hot enough. She thought the dish machine worked properly since it was repaired, but she did not check the water temperature of the machine on 10/17/12 or 10/18/12. On 10/18/12 at 8:34 AM, an interview with the Maintenance Technician revealed he thought the dish machine had been working properly since it was repaired the prior week, he was not aware of current problems with the wash/rinse cycle temperatures until the DFN contacted him around 8:20 AM that morning (10/18/12). When he received a phone call about the dish machine, he checked the boiler room and noted that the steam head was loosing steam. The Maintenance Technician stated that he typically monitored this daily, but relied on dietary staff to notify him when there was a problem. On 10/18/12 at 8:45 AM, an interview with the Engineering Manager revealed that the dish machine was replaced about one year ago due to problems with water temperatures, but due to the availability of two boilers and one steam head to support all the hot water used in the facility, staff would need to continue to monitor water temperatures routinely. A telephone interview occurred on 10/18/12 at 9:15 AM, with the facility contractor for the dish machine and revealed that the heat tank for the wash cycle was not working at all if the wash cycle temperature was less than 150 degrees Fahrenheit. He confirmed that manufacture instructions for the wash cycle for a high temperature sanitizing dish machine should be 150-160 degrees F and 180 - 200 for the rinse cycle. A follow-up interview with the DFN on 10/18/12 at 9:38 AM revealed she should have monitored the dish machine wash/rinse cycle temperatures since there was a problem with temperatures last week. The DFN further stated that she expected staff to report any concerns to her regarding low dish machine temperatures and to only use the dish machine at proper temperatures. 2. On 10/17/12 at 9:56 AM, two metal storage racks were observed in the cook's prep area with a build-up of dust and debris on the each of the four shelves. The dust and debris was easily removed. The storage racks contained ready for use items that were stored directly on the shelves to include stainless steel pans, pizza pans, plastic cutting boards, steam table lids, plastic bins, and plastic trays. A follow-up observation of the same occurred on 10/18/12 at 7:40 AM. Both metal storage racks were observed again with a build-up of dust and debris with items stored ready for use. Additionally on 10/18/12 at 7:45 AM a metal storage rack with five green shelves was also observed with a build-up of white dust and debris. Stainless steel pots were observed stored directly on the shelving. On 10/18/12 at 7:58 AM, the dish machine area was observed with four storage racks that contained insulated dome lids and insulated dome bottoms stored to air dry after being washed. The storage racks had a sticky dusty film on each of the four shelves. An interview with the DFN occurred on 10/18/12 at 9:38 AM. The cleaning schedule was reviewed during the interview and the DFN stated that the storage racks were not included in the cleaning schedule. She stated that the storage racks were typically cleaned weekly, and may have been cleaned in the last week, but she was not sure. The DFN also stated that she rounded in the kitchen daily, but the storage racks may have been missed during the rounds. She confirmed that the storage racks were dirty and needed to be cleaned.