Every finding on record at Piedmont Health Care Center

Based on observation, interview and a policy titled, Personal Hygiene Training, the facility failed to ensure dietary workers' hair was contained inside of hair restraints while working in the kitchen. This was observed on two of three days in the kitchen, and had the potential to affect all 83 residents who were served meals from the kitchen. According to the RESIDENT CENSUS AND CONDITIONS OF RESIDENTS form,the census was 84. Findings Include: A review of a undated policy, titled, Personal Hygiene Training, revealed: .4. Keep hair neat and clean. Wear a hair restraint when around exposed foods, in the kitchen or food service areas including dining areas. On 02/13/18 at 2:38 p.m., an observation of EI (Employee Identifier) #3, the Dietary Manager, was made with hair unrestrained about 1/4 inch wide and three inches long at the ear and at the neckline with some pieces of hair hanging out from underneath the hair restraint. On 02/14/18 at 11:19 a.m., an observation was made of EI #1, a Dietary Worker. EI #1 had hair exposed at the neckline, about 1 and 1/2 inches, with no hair restraint covering it. At this time EI #2, a Dietary Worker, was observed with hair all along the edge of the hair restraint, around the ears showing and hanging down outside of the hair restraint. Another observation was made at the same time of EI #3 with hair in clusters hanging out all around at the edges of the hair restraint . On 02/15/18 at 12:42 p.m., an interview was conducted with EI #1. EI #1 was asked, when should hair restraints be worn. EI #1 stated, anytime staff was in the kitchen. EI #1 was asked, how should hair restraints be worn. EI #1 said, to cover any hair on the head and face. EI #1 was asked, why should hair restraints be worn in the kitchen. EI #1 said to keep hair out of whatever food he was preparing or serving. An observation of a staff member with their hair restraint exposing the back neckline (1 and 1/2 inch of the hair) was shared with EI #1. EI #1 was asked if that was an appropriate way to wear a hair restraint. EI #1 stated, no. An observation made of a dietary staff member with their hair hanging in strands around the outside of the hair restraint was shared with EI #1. EI #1 was asked if that was the proper way to wear a restraint. EI #1 stated, no it was not. An observation made of a dietary worker with hair hanging out around the edges of the hair restraint was shared with EI #1. EI #1 was asked if that was an appropriate way to wear the hair restraint. EI #1 stated, no ma'am. EI #1 was asked when should hair restraints be worn inside of the kitchen. EI #1 stated, anytime. EI #1 was asked what was the facility policy on wearing hair restraints. EI #1 stated, anytime staff was in the kitchen, all hair should be covered. EI #1 was asked what was the potential negative outcome of not correctly wearing a hair restraint in the kitchen. EI #1 stated, hair in the product. On 02/15/18 12:55 p.m., an interview was conducted with EI #2. EI #2 was asked when should hair restraints be worn. EI #2 stated, before she came in the kitchen. EI #2 was asked why should hair restraints be worn in the kitchen. EI #2 stated, to keep hair from getting in the food or on the plate. EI #2 was asked how should hair restraints be worn. EI #2 stated, to cover the whole head and facial hair if the person had it, including side burns. An observation made of a staff member with their hair restraint exposing the back neckline of hair was shared with EI #2. EI #2 was asked if that was an appropriate way to wear a hair restraint. EI #2 stated, no ma'am. An observation made of a dietary staff member with their hair hanging in strands around the outside of the hair restraint was shared with EI #2. EI #2 was asked if that was a proper way to wear a hair restraint. EI #2 stated, no ma'am. EI #2 was asked when should hair restraints be worn inside of the kitchen. EI #2 replied, before entering the kitchen. EI #2 was asked, what was the facility policy on wearing hair restraints. EI #2 replied, wear the hairnet at all times (in the kitchen). EI #2 was asked what was the potential negative outcome of not wearing a hair restraint in the kitchen. EI #2 stated, hair might fall in the food and the possibility a resident might not want to eat the food. On 02/15/18 at 1:09 p.m., an interview was conducted with EI #3. EI #3 was asked when should hair restraints be worn. EI #3 stated, when they (staff) enter the kitchen. EI #3 was asked why should hair restraints be worn in the kitchen. EI #3 stated, to keep hair out of food. An observation made of a staff member with the hair restraint exposing the back neckline was shared with EI #3. EI #3 was asked if that was an appropriate way to wear a hair restraint. EI #3 stated, no. An observation made of a dietary staff member with their hair hanging in strands around the outside of the hair restraint was shared with EI #3. EI #3 was asked if that was the proper way to wear a hair restraint. EI #3 stated, no. EI #3 was asked when should hair restraints be worn inside of the kitchen. EI #3 stated, whenever staff was in the kitchen. EI #3 was asked what was the facility policy on wearing hair restraints. EI #3 stated, to wear a hair restraint when around exposed food. EI #3 was asked what was the potential negative outcome of not wearing a hair restraint in the kitchen. EI #3 stated, someone could find a hair in the food.

Based on observation, interview and the Food Code U.S. Public Health Service and FDA (Food and Drug Administration)2013, the facility failed to ensure that the grease trap grill was free from excessive debris and trash, which had the potential to attract rodents and pests. This was observed on one of three days and had the potential to affect all 84 residents who reside in the facility. Findings Include: A review of an undated facility policy titled, POLICY FOR USED COOKING OIL, revealed: ALL DISCARDED COOKING OIL WILL BE MAINTAINED IN OUTSIDE CONTAINER FOR PICKUP BY DESIGNATED COMPANY, . .MAINTENANCE WILL KEEP AREA AROUND FREE OF DEBRI (DEBRIS) . A review of a contract with the designated waste company revealed: .b. Remove and replace containers of cooking oil from Client's premises on a regular schedule agreed upon by the parties or upon notification . A review of the Food Code U.S. Public Health Service and FDA (Food and Drug Administration) 2013 revealed: . 5-501.115 Maintaining Refuse Areas and Enclosures. A storage area and enclosure for REFUSE, recyclables, or returnables shall be maintained free of unnecessary items, .and clean . 5-501.116 Cleaning Receptacles .(B) Soiled receptacles and waste handling units for REFUSE, recyclables, and returnables shall be cleaned at a frequency necessary to prevent them from developing a buildup of soil or becoming attractants for insects and rodents . On 02/13/18 2:50 p.m., an observation was made of the grease trap. The grease trap had a mound about nine inches high of fried, cooked debris on top of the grease trap grill. On 02/15/18 1:09 p.m., an interview was conducted with EI (Employee Identifier) #3, Dietary Manager. EI #3 was asked how often did the facility have the grease trap cleaned out. EI #3 stated, monthly. EI #3 was asked when was the last time the facility grease trap was cleaned. EI #3 stated, January. EI #3 was informed of the observation on 2/13/18, of the grease trap with about a nine inch mound of a fried substance on the grill of the grease trap. EI #3 was asked if that was appropriate. EI #3 stated, she did not know. EI #3 was asked who was responsible for cleaning the grease trap. EI #3 stated, maintenance. EI #3 was asked what was the facility policy on disposing of grease into the grease trap and cleaning it. EI #3 stated, they just poured the used grease in the bin and the company disposed of it. EI #3 was asked, what was the potential negative outcome of allowing debris to build up on the grease trap and not be cleaned off. EI #3 stated, she did not know. On 02/15/18 1:38 p.m., an interview was conducted with EI #4, the Maintenance Director. EI #4 was asked how often did the facility have the grease trap cleaned out. EI #4 stated, quarterly, but they were having trouble finding someone to do it. EI #4 said no one cleaned the grill in between. EI #4 said a company pumped it out but maintenance did nothing in between.

Based on record review, interview, a document titled, CODE OF ALABAMA 1975 .ALABAMA STATE BOARD OF PHARMACY and review of a facility policy titled, Medication-Destruction Controlled Drugs, the facility failed to ensure three required signatures were obtained for controlled drug destruction for (MONTH) (YEAR). This affected one of thirteen months of medication destruction records reviewed. Findings Include: Review of CODE OF ALABAMA 1975 .Practice of Pharmacy Act 205 Legislature 1966 ALABAMA STATE BOARD OF PHARMACY revealed the following: .7. For destruction of controlled substances, there shall be a third witness who may be a law enforcement official, management or supervisory personnel, i.e.(for example), administrator, LPN (Licensed Practical Nurse) charge nurse, etc (and so on) . A review of a policy with a revised date of 1/31/2009, titled, Medication-Destruction Controlled Drugs, revealed: Subject: Storage and Destruction of Discontinued Narcotics .Destroying of Controlled Drugs: *Destruction of controlled drugs must be done by Pharmacist, DON (Director of Nursing) (or designee) and other Licenses (licensed) Nurse . On 02/15/2018 at 1:50 PM, the surveyor reviewed thirteen months of drug destruction records for controlled medications. These thirteen months of drug destruction were from (MONTH) (YEAR) through (MONTH) (YEAR). The controlled record of destruction required three signatures; a registered nurse, the pharmacist and a witness. The (MONTH) record, with signatures made on 7/3/2017, only showed two signatures. No witness signature was made on the two documents for this month. On 2/15/2018 at 2:30 PM, an interview with EI (Employee Identifier) #5, the Director of Nursing, was conducted. EI #5 was asked, who was responsible for medication destruction at the facility. EI #5 replied, that would be her. EI #5 was asked, how often were the controlled medications destroyed. EI #5 replied, typically once per month but there could be a month with none. EI #5 was asked, how many signatures were required for medication destruction for controlled drugs. EI #5 replied, three. EI #5 was asked, from whom should these signatures be obtained. EI #5 replied, Pharmacist, RN (Registered Nurse) and a witness. EI #5 was asked, on the record of medication destruction dated 7/3/2017, were three required signatures obtained. EI #5 replied, no. EI #5 was asked, what was the potential negative outcome from not obtaining three required signatures for records of medication destruction for controlled medication. EI #5 replied, a potential negative outcome could be that drugs were not destroyed properly.

Based on observation, interviews, and record review the facility failed to ensure Employee Identifier (EI) #1, an LPN (Licensed Practical Nurse), washed her hands before putting on her gloves and after removing her gloves during medication administration to Resident Identifier (RI) #12 on 01/04/2017. This affected RI #12, one of five residents observed during medication administration and one of four nurses observed during medication observations. Findings include: Review of a facility document titled, Medication - Drops, Nose with a revision date of 12/03/2008 revealed: . PROCEDURE: . B. Wash hands. Put on gloves. RI #12 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED].#12 had a physician's orders [REDACTED]. On 01/04/2017 at 08:40 a.m., the surveyor observed EI #1 administering medications to RI #12. EI #1 gathered her medications and went to RI #12's room. EI #1 put on gloves. (Without washing her hands prior to putting on the gloves.) She administered RI #12's [MEDICATION NAME] nasal spray and removed her gloves. EI #1 went to the medication cart and put the nasal spray into the cart. EI #1 did not wash her hands after removing her gloves. On 01/04/2017 at 08:50 a.m., the surveyor interviewed EI #1 about the medication administration to RI #12. EI #1 stated hands should be washed every time gloves are changed, before putting on gloves and after removing gloves. She further stated she had not washed her hands prior to putting on her gloves or after removing her gloves during the administration of RI #12's nasal spray. EI #1 stated it was important to wash hands before putting on gloves and after removing gloves to prevent the spread of germs. On 01/05/2017 at 10:30 a.m., the surveyor interviewed EI #2, Assistant Director of Nurses/Infection Control Nurse. EI #2 was asked when hands should be washed during medication administration. EI #2 stated upon entering the room, before putting on gloves and after removing gloves. EI #2 further stated it was important to wash hands prior to putting on gloves for infection control. She also stated that after removing gloves hands should be washed for infection control. EI #2 stated it was important to wash hands prior to gloving and after removing gloves to prevent contamination and the spread of germs.

Based on record review and interview the facility failed to ensure the most current Minimum Data Set (MDS) with an Assessment Reference Date of 10-11-15 documented RI (Resident Identifier) # 3 as receiving Hospice Services. This affected 1 of 2 residents sampled for Hospice Care. Findings Include: RI # 3 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI # 3's most recent Physician order [REDACTED].HOSPICE SERVICES ELECTED DX (Diagnoses) CHRONIC ISCHEMIC [MEDICAL CONDITION] . A review of RI # 3's most recent Quarterly MDS with an ARD of 10/11/15 did not show that RI # 3 was receiving Hospice Services. An interview was conducted with EI (Employee Identifier) # 1, RN (Registered Nurse) on 12/2/15 at 3:15PM. EI # 1 was asked if RI # 3 was on Hospice. EI # 1 stated yes the resident was admitted in July 2015. EI # 1 was asked if the Quarterly MDS dated [DATE] documented RI # 3 as receiving Hospice Services. EI # 1 stated no it is not checked on this MDS. EI # 1 was asked if it should be checked and she sated yes, it should be. EI # 1 was asked if she would consider this an accurate assessment for RI # 3. EI # 1 stated no, it should be marked showing the resident receiving Hospice Services.

Based on observation, record review and interview the facility failed to ensure RI (Resident Indentifer) # 3 a resident with a history of weight loss received an ordered supplement for lunch and supper. This was observed on 12/1/15 at the supper and on 12/2/15 at the lunch meal. This affected 1 of 5 residents sampled for weight concerns. Findings Include: A review of an undated facility policy titled Nourishments and Supplements documented the following: Policy: The food service manager will assure that individuals receive the nourishments/supplements that have been ordered by the physician and/or recommended by the registered dietitian or designee. Nursing staff will deliver the nourishments/supplements . RI # 3 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI # 3's most recent Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/11/15 documented the following: .K0300 Weight Loss 2 Yes, not on physician-prescribed weight -loss regimen . A review of A Physician order [REDACTED]. A review of RI # 3's most recent Physician Order's dated December 2015 documented the following: .ADD ICREAM W(WITH)/LUNCH &SUPPER . A review of a document titled CHANGE OF DIET documented the following: .8-26-15 .Add Ice Cream .Lunch + Supper Tray . A review of RI # 3's diet card for lunch on 12/2/15 did not document ice cream with lunch and supper. A review of a document titled Dietitian Progress Notes documented the following: .10-16-15 .ice cream L (lunch) + S (Supper) . A review of RI # 3's weight record documented the following: .8-17-15 157.2, 8-24-15 149.8, 9-21-15 136.8, 10-12-15 137.9 and 11-16-15 147.1 . A review of Nutrition Facts for 4 oz (ounce) Ice Cream documented the following .Serv (serving size) 1 Unit .Calories 110 . Meal Observations: On 12-1-15 from 5:10PM to 5:30PM RI # 3 was observed eating Supper in the Dining Room. The following items were placed on the Tray. Hot Dog, Onion Rings, Pie, Sour Kraut, Juice, tea and water. The Surveyor did not observe ice cream on RI # 3's tray during the supper meal observation. On 12-2-15 from 12:30PM to 1:00PM RI # 3 was observed eating Lunch in the room. The Lunch tray was delivered and set up by staff. The resident was fed by staff. The following items were observed on the lunch tray. Turkey, Dressing, Green Beans, Roll, Tomato Soup, Juice, tea and water. The Surveyor did not observe ice cream on RI # 3's tray during the lunch meal observation. The Surveyor interviewed EI # 3, Certified Nursing Assistant (CNA) on 12-2-15 at 1:05PM. EI # 1 was asked if RI # 3 got anything else on the tray and she stated no. An interview was conducted with EI # 2, Dietary Manger on 12/2/15 at 3:30PM. EI # 2 was asked if a resident was ordered to receive ice cream with a meal would the kitchen staff place the ice cream on the tray and she stated yes. EI # 2 was asked how you would know if someone should receive ice cream with meals. EI # 2 stated we get an order from nursing. EI # 2 was asked if RI # 3 received ice cream with lunch and supper. EI # 2 stated its not on the card, if its an order it should be on the diet card. EI # 2 was asked if RI # 3 was a weight loss. EI # 2 stated the resident has been in the past but is picking back up now. EI # 2 was asked if RI # 3's current physician's orders [REDACTED]. EI # 2 stated yes, it was written in September. EI # 2 further stated RI # 3 had a change of diet for ice cream with lunch and supper dated 8/26/15. EI # 2 was asked what is the possible harm of not receiving an ordered supplement such as ice cream. EI # 2 stated weight loss. EI # 2 was asked why RI # 3 did not receive the ice cream with lunch and supper on 12/1/15 and 12/2/15. EI # 2 stated it wasn't on the meal card and staff are taught to read the meal cards.

Based on observation, interview and review of the facility's policy, the facility failed to ensure the lids on the popcorn and rice were sealed and bread was stored at least six inches from the floor. This deficient practice had the potential to affect all residents receiving food from the kitchen. Findings include: The facility's policy titled "Food Storage" with a copyright date of 2013 documented " ... Procedure: ... 4. Plastic containers with tight fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetables, and broken lots of bulk foods ... 11. Food is stored a minimum of 6 inches above the floor ... ." During the initial tour of the kitchen with Employee Identifier (EI) #1, the Dietary Manager (DM), on 01/27/2015 at 10:20 AM, the lids did not fit on the popcorn and rice. Also, bread was not stored at least six inches off the floor. In an interview on 01/29/2015 at 09:55 AM, EI #1, the DM acknowledged the lids on the popcorn and rice did not fit properly, leaving an one to two inch gap. EI #1 also acknowledged the bread was only stored three inches from the floor. When asked what was the potential harm in having dried foods stored in bins that were not sealed, EI #1 stated, "Bugs and rodents could get into the food." When asked what was the harm in having food stored less than six inches off the floor, EI #1 stated, "Not able to clean underneath without getting anything onto the food."

Based on observation, interview, and record review the facility failed to maintain O2 (Oxygen) concentrator filters free of dust accumulation for RI (Resident Identifier) #6, #8, and #10. This was observed on three of three days of the survey. This affected three of five residents observed for O2 therapy during the survey. Findings include: A review of the Manufacturer's manual titled, "...(Name of Company) Oxygen Concentrator Service and Maintenance Log" (not dated) documented, "...Patient/Caregiver Maintenance...2. Cabinet air filter-clean weekly..." A review of the facility's Maintenance policy (not dated) documented, "...Remove the filter and clean at least once a week depending on environmental conditions..." 1) RI #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #6's most recent five day admission MDS (Minimum Data Set) assessment dated [DATE], revealed a BIMS (Brief Interview for Mental Status) score of 12, indicating moderately impaired cognitive skills for daily decision making. The MDS further revealed RI #6 received O2 therapy. A review of RI #6's March 2014 MAR (Medication Administration Record) revealed "...CLEAN EXTERIOR CONCENTRATOR FILTERS...Q (every) 2 WEEKS..." The MAR further revealed that the last scheduled cleaning of the filters was to be done on 3/31/2014. On 4/1/2014 at 4:11 PM during the initial tour, an observation was made of RI #6 receiving O2. The filter on the back of RI #6's O2 concentrator was covered with an accumulation of gray dust-like substance. On 4/2/2014 at 8:25 AM, an observation was made of RI #6 receiving O2. The filter on the back of RI #6's O2 concentrator was covered with an accumulation of gray dust-like substance. On 4/2/2014 at 3:55 PM, an observation was made of RI #6 receiving O2. The filter on the back of RI #6's O2 concentrator was covered with a gray dust-like substance. On 4/3/2014 at 10:18 AM, an observation was made of RI #6 receiving O2. The filter on the back of RI #6's O2 concentrator was covered with a gray dust-like substance. On 4/3/14 at 10:25 AM, Employee Identifier (EI) #5 RN/ADON, (Registered Nurse/Assistant Director of Nursing) was asked who was responsible for cleaning resident's oxygen concentrator filters. EI #5 said the nurses were. EI #5 was asked how often they were cleaned. EI #5 said every two weeks. EI #5 was asked if RI #6 was dependent on oxygen at all times and she said she was. EI #5 (along with the surveyor) went to look at RI #6's concentrator as she was sitting in the day area. EI #5 was asked what was on RI #6's filter. EI #5 said, "Dust." EI #5 was asked if she was responsible for making sure the filters were cleaned. EI #5 said the LPN (Licensed Practical Nurse) was since they signed the MAR. EI #5 was asked who was responsible for the LPN's on the unit. EI #5 replied, "I am." EI #5 was asked what would be the potential harm to the resident if they received oxygen and the filters were not clean. EI #5 said, "I don't know." EI #5 also said the filters were put on the units wet so it may contribute to the dust on them. EI #5 was asked what was the manufacturer's recommendation for cleaning. EI #5 said, "I can get it from maintenance, I don't know." 2.) RI #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. [MEDICAL CONDITION], Acute [MEDICAL CONDITION], Hypertension, Diabetes Mellitus and Shortness of Breath. A review of RI #8's most recent initial Admission MDS dated [DATE] documented RI #8 scored a 15 out of 15 on the BIMS indicating she was cognitively intact for daily decision making. The MDS also revealed RI #8 received O2 therapy. A review of RI #8's MAR for March 2014 revealed, "...CLEAN EXTERIOR CONCENTRATOR FILTERS...Q (every) 2 weeks..." On 4/1/14 at 5:55 PM RI #8 was observed to be receiving O2 at 2 liters per minute per nasal cannula. The filter on the back of RI #8's concentrator was observed to have an accumulation of gray dust-like substance on it. On 4/2/14 at 9:05 AM, RI #8 was receiving O2 at 2 liters per minute per nasal cannula. The concentrator filter was observed to have an accumulation of gray dust-like substance on it. On 4/3/14 at 10:10 AM, RI #8's concentrator was observed sitting in her room. The filter on the back of the unit contained an accumulation of gray dust like substance. On 4/3/14 at 10:25 AM, Employee Identifier (EI) #5 RN/ADON, (Registered Nurse/Assistant Director of Nursing) was asked who was responsible for cleaning resident's oxygen concentrator filters. EI #5 said the nurses were. EI #5 was asked how often they were cleaned. EI #5 said every two weeks. EI #5 was asked if RI #8 was dependent on oxygen at all times and she said she was. EI #5 (along with the surveyor) went to look at RI #8's concentrator. EI #5 was asked what did RI #8's filter look like to her. EI #5 said, "Like it needs to be cleaned." EI #5 was asked what was on RI #8's filter. EI #5 said, "Dust." EI #5 was asked how long it took to accumulate and she said she did not know. EI #5 was asked what would be the potential harm to the resident if they received oxygen and the filters were not clean. EI #5 said, "I don't know." EI #5 also said the filters were put on the units wet so it may contribute to the dust on them. EI #5 was asked what was the manufacturer's recommendation for cleaning. EI #5 said, "I can get it from maintenance, I don't know." 3) RI #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #10's most recent Annual MDS dated [DATE] revealed that RI #10 had severely impaired cognitive skills for daily decision making. The MDS further revealed RI #10 received O2 therapy. A review of RI #10's MAR indicated [REDACTED]. On 4/1/2014 at 3:35 PM during the initial tour, an observation was made of RI #10 receiving O2 at three liters per minute by nasal cannula. The filter on the back of RI #10's O2 concentrator was covered with an accumulation of gray dust-like substance. On 4/2/2014 at 12:50 PM, an observation was made of RI #10 receiving O2 at three liters per minute by nasal cannula. The filter on the back of RI #10's O2 concentrator was covered with an accumulation of gray dust like substance. On 4/3/2014 at 10:25 AM, an observation was made of RI #10 receiving O2 at three liters per minute by nasal cannula. The filter on the back of RI #10's O2 concentrator was covered with an accumulation of gray dust-like substance. An interview was conducted with EI #3, RN/Unit Manager on 4/3/2014 at 10:30 AM. EI #3 was asked when were O2 concentrator filters cleaned. EI #3 said it was on the MARs and was done every two weeks on the third shift. EI #3 was asked when was RI #10's O2 filter cleaned. EI #3 said it was cleaned on 3/27/2014. EI #3 was asked to describe RI #10's O2 concentrator; she said, "It has dust." EI #3 was asked to describe the amount of dust build-up on RI #10's O2 concentrator filter. "It is a little bit of dust. When they wash it, it comes off." EI #3 was asked how long it would take for that amount of dust to accumulate. She said it would not take long. EI #3 was asked what would be the harm in a resident receiving O2 with a concentrator filter with this amount of dust accumulation. EI #3 stated that it (O2) is filtered and it doesn't come through. An interview was conducted with EI #4, RN, DON (Director of Nursing) on 4/3/2014 at 11:05 AM. EI #4 was asked if she was aware of residents' O2 concentrators having an accumulation of dust, visible on the filters. EI #4 said yes, she was. EI #4 was asked how often should O2 filters be cleaned. She stated every two weeks, and as needed. EI #4 was asked who was responsible for cleaning the O2 concentrator filters. She said Licensed Practical Nurses (LPNs); that it shows up on the computer. EI #4 was asked how much dust accumulation she would expect to be on oxygen filters in two weeks; she did not know. EI #4 was asked what would she expect for nurses to do if dust accumulation was noted on O2 filters. She said, "I would look at the inside of the filter to make sure that dust was not going through."

Based on observation, interview, and record review, the facility failed to ensure that a CNA (Certified Nursing Assistant) washed her hands and changed gloves in a manner to prevent cross-contamination during incontinent care for RI (Resident Identifier) #6. This affected one of two observations of incontinent care. Findings Include: Chapter 28 titled, "Infection Prevention and Control", page 411 of "Potter and Perry's Fundamentals of Nursing, 8th Edition" with copyright date of 2013, documented: "...when hands are...soiled with...body fluids...wash hands with water and...soap..." A review of the facility policy and procedure titled, "Handwashing" revised 11/05/2008 revealed "...Objective: To remove microorganisms and contaminants from the hands and nails and to prevent transmission of transient bacteria to resident receiving care..." A review of the facility policy and procedure titled: "Incontinence (Male and Female)--Perineal Care" (revised 11/10/2008) revealed: "...Considerations: ...I. Remove gloves when soiled and replace before proceeding to the next step. J. Avoid contaminating clean surfaces with soiled gloves..." RI #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #6's most recent 30 day Minimum Data Set ((MDS) dated [DATE], revealed RI #6 had a BIMS (Brief Interview for Mental Status) score of five, indicating severe impairment of cognitive skills for daily decision making. RI #6's MDS also revealed RI #6 required extensive assistance with Activities of Daily Living and was frequently incontinent of bowel and bladder. On 4/02/2014 at 10:20 AM, a CNA (EI/Employee Identifier) #1 provided incontinent care to RI #6, assisted by CNA (EI) #2. EI #1 cleaned RI #6's perineal area then EI #2 dried RI #6's perineum. EI #2 continued assisting with care for RI #6 with out changing her gloves or washing her hands. EI #1 removed a saturated, yellow-stained brief from RI #6 and proceeded to apply a new clean brief on RI #6 without changing soiled gloves or washing her hands. While wearing the same soiled gloves EI #1 pulled covers up around RI #6's upper body and repositioned RI #6 in bed. EI #1 then raised the head of the bed and repositioned the bedside table using the same soiled gloves. On 4/02/2014 at 10:50 AM, EI #2 was asked when did she change her gloves during perineal care for RI #6. EI #2 stated, "Not at all." EI #2 was asked why she did not change her soiled gloves. EI #2 stated, "I was just not thinking. I know what to do, but I was nervous with people standing over me." EI #2 was asked what was the potential harm in not changing soiled gloves during incontinent care. EI #2 stated, "Causes contamination." On 4/02/2014 at 11:00 AM, EI #1 was asked how should she have provided perineal care for RI #6. EI #1 stated that she would cleanse the front of RI #6 and then turn the resident to the side and remove the soiled brief. EI #1 stated that she would then remove her soiled gloves and wash her hands. EI #1 was asked when providing incontinent care for RI #6 when did she change her gloves. EI #1 stated, "We didn't." EI #1 was asked why she did not remove her soiled gloves and wash her hands. EI #1 stated she was nervous and forgot. EI #1 was asked what potential harm could be caused by not changing her soiled gloves and washing her hands. She stated, "Cross-contamination."

Based on observations, record review and interview: FOOD TEMPERATURES 1) The facility failed to assure hot foods were maintained at 135 degrees F (Farenheit) or above when served from the tray line. MACHINE DISHWASHING 2) The facility failed to assure dishes and utensils were effectively sanitized to destroy potential food borne organisms. (Food Code) 4-501.112 3) PREVENT POTENTIAL CROSS-CONTAMINATION A. Meal Tray Delivery Carts B. Staff failed to assure meal tray delivery carts were effectively disinfected between use for return of soiled trays and delivery of meal trays. The above practices posed the potential for food contamination and compromised food safety. This had the potential to affect all 78 residents who received meal trays from dining services. Findings include: FOOD TEMPERATURES 1) On 1/15/13 at 12:10 PM, the trayline was observed for temperature monitoring. The temperature of Baked Chicken was measure to be 127 degree F. This item was pulled from the steamtable and reheated. MACHINE DISHWASHING 2) According to the Food Code U.S. Public Health Services, dated 2001, page 107, documents, "... section 4-501.112. Mechanical Warewashing Equipment, Hot Water Sanitization Temperature ... (2) For all other machines, 82 (degrees) C (celsius) (180 (degrees) F (Farenheit)). ..." On 1/15/13 at 2:05 PM, the Dishroom Temperature Log for January 1 through 15 was monitored. Two problem areas were identified: A. On January 01, 2013 the supper temperature recorded the final rinse (sanitizing) temperature as 157 degrees Fahrenheit (F). The standard final rinse temperature should be 180 degrees F. It was determined Employee Identifier (EI) # 9 was responsible for the temperature monitoring/documentation. On 1/16/2013 at 3:20 PM, EI #9 was interviewed. He was asked to tell me about the 157 degree F. temperature documented on the log (for January 1, 2013). His response was: "I just messed up, only thing I can think of." What should the temperature be? His response: "Between 155 and 180, I'm (I am) an idiot, as far as I know, I am supposed to go tell someone (if temperatures are sub-standard). I get nervous very easy." B. The second problem area was the recording of the supper dishmachine temperature on the log at 2:05 PM. This was 3+ hours prior to the delivery of the supper meal. The posting was no initialed, and the Dietary Manager stated she was unable to determine which employee made the entry. A review of the facility untitled policy documented, "POLICY Dishwashing staff will monitor and record dish machine temperature to assure proper sanitizing of Dishes. PROCEDURE: ...4. "The dietary manager will spot check this log to assure temperatures are appropriate , and staff is actually monitoring, dish machine temperatures. 5. Dishwashing staff will be trained to report any problem with the dishmachine to the Dietary Supervisor as soon as they occur. ..." EI #8 failed to report the temperature on 1/02/13 as sub-standard as evidenced by no corrective action taken/recorded on the log and he stated he did not report the infraction. There was no evidence to substantiate this procedure had occurred of reporting the infraction. On 1/16/13 at 7:15 PM, the dishmachine operator, EI #9 was observed to assemble 2 rows of plate covers (16) in one rack. This positioning failed to allow water to reach all surfaces. The Dietary Manager instructed the operator to reduce the volume to 1/2 (8). 3) PREVENT POTENTIAL CROSS-CONTAMINATION A. Meal Tray Delivery Carts On 1/16/13 at 7:00 PM the dishroom and cleaning of meal carts were observed. Staff sprayed a chemical on cart and wiped off the liquid immediately. The chemical used for disinfecting was a Quaternary sanitizer. Multi-Quat Sanitizer ... Directions for use: non porous nonfood contact surface. Apply sanitizer use-solution with a cloth, mop sponge, sprayer or by immersion ... treated surfaces must remain wet for 60 seconds. Wipe dry with a sponge, mop or cloth or allow to air dry. The liquid solution was tested at 7:10 PM. The test strip indicated the solution was 100 ppm (parts/per million). For effective sanitizing, the strength of Quat should be 200 ppm. The facility policy titled "CLEANING FOOD CARTS," undated documented, "CLEANING FOOD CARTS POLICY: Food carts will be cleaned and sanitized immediately after each use. PROCEDURE: 1. Each day, inside and outside of carts will be sanitized and wiped down. 2. Wheels on the food carts should be cleaned as often as needed. 3. The outside of the food carts may be polished with stainless steel polish on occasion if applicable." The facility policy for cleaning food carts failed to be specific by identifying the chemical to use, dilution and contact time. B. HAND WASHING/GLOVE USE Staff failed to utilize proper hand washing between handling of soiled and clean dishes. On 1/16/13 at 7:00 PM the dishmachine operator on the clean side failed to wash her hands and put on clean gloves after touching cart handles. The operator was asked: Did you wash your hands and change gloves prior to coming to the clean side? Her response was: "No, Ma'am, I did not."

Based on interviews, record review and review of a facility policy titled "Change of Condition", the facility staff failed to notify Resident Identifier (RI) #1's sponsor when there was a change in the resident's condition. In October 2012, RI #1 had improvements in the areas of Activities of Daily Living (ADL's) and he had a pressure sore that healed on his buttocks during this assessment period. The facility failed to notify RI #1's sponsor of the resident's areas of improvements and failed to invite RI #1's sponsor to the care plan meeting. RI #1, one (1) of 17 sampled residents was affected by this deficient practice. Findings Included: The facility's policy titled "Change of Condition" dated Sept. 2007, documented: "Policy Resident change in condition will be assessed promptly and follow-up activity will occur as appropriate and in a timely fashion. Procedures ... D. Notification of physicians and/or responsible parties (families) shall be documented in the clinical record and a significant change in status report completed and given to the Nursing Supervisor... E. ... Significant change is defined as a major improvement or decline in the resident's physical, mental or psychosocial status. ..." RI #1 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of RI #1's medical record revealed a Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 10/28/2012, which identified RI #1 to have a (BIMS) Brief Interview Mental Status of 15, indicating no cognitive impairment. RI#1 was assessed as needing extensive assistance with bed mobility, transfers, walk in room, dressing, toilet use, personal hygiene and bathing, independent with eating, had an indwelling catheter and was always continent of bowel. Under Section I 800; Additional active diagnoses, the [DIAGNOSES REDACTED]. Section M, for Skin Conditions, identified RI #1 had a stage II pressure sore. RI #1's care plan with a "Problem/Need," dated 11/12/2012 documented, "There has been a significant change in status related in improvements in ADL's..." "Approaches Post activity calendar in resident's room, encourage resident to attend group activities of interest such as food/singing socials, religious activities, etc." On 1/16/13 at 6:45 p.m., the surveyor conducted an interview with Employee Identifier (EI) (number) #3, the facility's Social Service Director. The surveyor asked EI #3 how often does she invite the residents sponsors to care plan meeting. EI #3 said whenever one is scheduled and that's quarterly, annually and for a significant change assessment. The surveyor asked EI #3 if she invited RI #1's sponsor to the care plan meeting and informed her about the Significant changes in RI #1's ADL's and the healing of his stage II pressure sore. EI #3 said in October 2012, but the sponsor did not attend. The surveyor asked why. EI #3 said she was not sure, but she did send a letter to the sponsor and she keeps a copy of the letter. EI #3 stated that is how she knows who will be attending the care plan meeting. EI #3 stated the sponsors will respond to the letter. The surveyor requested a copy of the letter. On 1/16/13 at 7:00 p.m., the surveyor conducted an interview with RI #1's sponsor. The surveyor asked RI #1's sponsor how often is she invited to the care plan meeting. RI #1's sponsor stated they do not invite her to the care plan meeting anymore. RI #1's sponsor stated she use to come, but it's been over 6-8 months since she had been invited to a care plan meeting. RI #1's sponsor said the EI #3 would send out letters but she had not received one. RI #1's sponsor stated the care plan meeting would have been a good time to tell the staff not to send him (RI #1) gravy. He does not like gravy and he wanted his food seasoned. The surveyor asked RI #1's sponsor if she had been made aware of the changes in RI #1's ADL's. RI #1's sponsor stated she had not. Further review of the medical record revealed the facility staff failed to provide evidence that sponsor/family member was notified in regards to the significant changes of improvements in RI #1 ADL's and the healing of his stage II pressure sore on RI #1's buttocks.

Based on observations, interviews and record review, the facility: 1) failed to have a system in place to monitor, track and evaluate the effectiveness of a care plan for between meal supplements for Resident Identifer (RI) # 6, a resident identified with a problem of significant weight loss. This deficient practice affected RI #6 and had the potential to effect the 17 residents with planned or prescribed between meal supplements. 2) The facility failed to develop a care plan for RI #5 and RI #2, residents observed with Foley catheters. This deficient practice affected RI #5 and #2, two of 4 sampled residents with foley catheters. Findings include: 1) RI #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #6's care plan with a "Problem/Need," dated 12/6/2012 documented, "Potential for nutritional deficient/dehydration r/t (related/to) diabetes,[MEDICAL CONDITION](Hypertension), dementia, uti (Urinary Tract Infection). Goal & (and) Target date (no date) Will attempt to prevent weight loss (5% 30 days, 10% 180 days) Will show no s/s (signs and symptoms) dehydration daily by next review Approaches Send diet as ordered by MD (Medical Doctor) Offer substitute if meal not eaten Honor meal requests as much as possible Administer medications as ordered and supplements if order ... Supply fluids needs as determined by RD (Registered Dietitian)." RI #6's form titled "Nutritional Evaluation & Assessment" dated 1/9/13, documented, "... Summary of nutritional assessment: ... Inadequate oral intakes ... sig (significant) weight (arrow down) loss after one month...." On 1/17/13 at 6:37 PM, the surveyor conducted an interview with Employee Identifier (EI) #1, the RN (Registered Nurse) Unit Manager for Unit II. The surveyor asked EI #1 if RI #6 was receiving a snack at 10 AM and 2 PM. EI #1 stated yes. The surveyor asked EI #1 was the direct care staff documenting that snacks were provided at 10 AM and 2 PM. EI #1 said, yes, but not consistently. The surveyor asked EI #1 to quantify the January data. EI #1 said documentation was provided twice (2) on 24 opportunities. On 1/17/13 at 6:40 PM, the surveyor conducted an interview with EI #8, a RN (Registered Nurse) on the same unit. The surveyor asked EI #8 why was is documentation / monitoring important (for the prescribed diets and care planned snacks). EI #8 said, to determined the effectiveness of the plan of care. 2) RI #5 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. and Benign Prostate Hypertrophy without Urinary Obstruction. RI #5's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/25/2012 has RI #5 as requiring limited assistance of one with bed mobility, locomotion on the unit, dressing, toileting, and personal hygiene. RI #5 was assessed as being occasionally incontinent of bowel and as having an indwelling (Foley) catheter in place for bladder. Additional information in section I. and Benign Prostate Hypertrophy without Urinary Obstruction. RI #5's January 2013 "Physician Orders" has documented an order dated 12/05/2012, "CHANGE CATH (Catheter) BAG QM (every month) ON THE 1ST & (and) 15 TH ON 7-3 SHIFT, CHANGE FOLEY CATH # (number) 16 FR (French) W(with) /30 CC (cubic centimeters) BULB QM & PRN (as needed) " On 1/15/2013 at 12:12 pm, during the initial tour with EI #1, EI #1 stated that RI #5 had a Foley catheter and was scheduled for surgery on 1/16/2013 to try and remove the catheter. RI #5 was not in the facility at the present time. On 1/15/2013 at 1:40 pm, RI #5 was observed at the nurse's station in a wheelchair. The surveyor observed a catheter bag in a privacy bag underneath his chair. On 1/15/2013 at 5:45 pm, the surveyor conducted an interview with RI #5 in his room. RI #5 was observed to be in bed with the catheter bag attached to the bed in a privacy bag. The surveyor observed RI #5 to have clear yellow urine in the bag. On 1/16/2013 at 8:00 am, RI #5's medical record was reviewed by the surveyor. The surveyor was unable to locate a care plan for RI #5's catheter. On 1/17/2013 at 8:35 am, an interview was conducted by the surveyor with EI #1, the facility's Unit 2 Manager and Assistant Director of Nursing (ADON). EI #1 was asked what are her responsibility in the development of care plans. EI #1 stated she reviewed care plans weekly during the MDS (Minimum Data Set) process and when incidents occurred on the unit. EI #1 was asked if a resident with a Foley catheter required a care plan. EI #1 stated yes. EI #1 was asked how would she know a care plan was needed. EI #1 stated that an assessment would be done. EI #1 stated that if a catheter was inserted between the assessment periods then she would notify the MDS Coordinator. EI #1 was asked if RI #5 had a catheter. EI #1 stated yes. EI #1 was given RI #5's care plans to review by the surveyor. EI #1 was asked if RI #5 had a care plan for a catheter. EI #1 stated no. EI #1 could not explain why RI #5 did not have a care plan for a catheter. On 1/17/2013 at 9:30 am, EI #2, the MDS Coordinator was interviewed by the surveyor. EI #2 was asked to review RI #5's MDS. EI #2 was asked what did the bowel and bladder section document for RI #5. EI #2 stated indwelling catheter and incontinent of bowel. EI #2 was asked if a care plan would have been generated. EI #2 stated it should have been. EI #2 was given RI #5's care plans and asked to locate the care plan. EI #2 stated there was not a care plan. EI #2 could not explain why a care plan was not generated. EI #2 stated that it just got missed. EI #2 was asked what was included in the care plan for catheters. EI #2 stated the potential for infection, the goals for no infections, the care of the catheter, when the catheter should be changed and what size (of the catheter). 3) RI #2 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #2's physician's orders [REDACTED]. "(1) Foley Cath #18 w /10 cc bulb ..." RI #2's Quarterly MDS with an ARD of 12/13/12, identified RI #2 to have a BIMS of 15, indicating no cognitive impairment. RI #2 was assessed as needing extensive assistance with bed mobility, transfers, locomotion on the unit, dressing, toilet use, personal hygiene and bathing, independent with eating, had an indwelling catheter and was always continent of bowel. Under Section I 800; Additional active diagnoses, the [DIAGNOSES REDACTED]. On 01/15/13 at 5:55 PM, the surveyor observed RI #2 in bed. The surveyor observed RI #2's Foley Catheter in a blue covering attached to the right lower bed frame. On 01/17/13 at 9:00 AM, the surveyor conducted an interview with EI #2, the facility's MDS/Care Plan Coordinator. The surveyor asked EI #2 what was the reason for RI #2's Foley Catheter. EI #2 stated RI #2 has a lot of problems with [MEDICAL CONDITION]. EI #2 stated the Foley Catheter was put back in on 09/27/12. When asked if RI #2 had a care plan for the Foley Catheter, EI #2 stated she did not see one. The surveyor asked EI #2 should there be a care plan for the Foley Catheter. EI #2 stated, "Yes." EI #2 stated the purpose of RI #2 having a care plan would be to make sure staff was aware that RI #2 was at risk for infection due to the indwelling Catheter. The surveyor asked EI #2 whose responsibility would it have been to initiate a care plan for the Foley Catheter. EI #2 stated the care plan should have started on the floor (started when the Foley Catheter was inserted) and then it should be communicated to her.

Based on an observation, interviews, medical record review and review of a facility policy titled "Medication - Administration via (by way of) Feeding Tube", the facility failed to ensure EI (Employee Identifier) #5 adhered to standards of practice by not administering a 200 cc (cubic centimeters) water flush to RI (Resident Identifier) #7 as ordered by the physician. This deficient practice affected RI #7, one of (twelve) 12 residents observed during medication pass observations. Findings Include: A facility policy titled "Medication - Administration via Feeding Tube" with a Revised date of 07/21/2008, documents: "... I Procedure: ... N. Flush amount will be indicated per physician orders [REDACTED]. According to Potter & Perry, FUNDAMENTALS OF NURSING, Stocker-Hall, eighth edition, 2009, pp. 305, documents, "... Health Care Provider's Orders ... Nurses follow health care providers' orders unless they believe the orders are in error or harm patients ..." RI #7 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #7's physician's orders [REDACTED]. "... Flush g (gastrostomy) - tube with 200 cc H2O (water) q (every) 4 hrs (hours). " RI #7's care plan with a "Problem/Need "Potential for complications or injury r/t (related to) feeding tube" with a Problem Onset date of 09/21/2012, documented: "... Approaches ... *Provide ... flushes as per MD (Medical Doctor) orders." RI #7's care plan with a "Problem/Need "Potential for weight loss & dehydration, fluid volume deficit placement of feeding tube ..." with a Problem Onset date of 09/21/2012, documented: "... Approaches ... *Provide water flushes as prdereed (ordered) and recommended by dietiticain (Dietitian) ... " Review of a facility form titled "Care Plan Update" dated 11/17/11, documented: "... 200 ml (milliliters) H2O flush Q (Every) 4 H (Hours) ...". RI #7's January 2013 MAR (Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] "... Flush [DEVICE] with 200 cc H2O q 4 hrs ..." RI #7's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/09/2012, identified RI #7 to have short and long memory problems and severely impaired cognitive skills for daily decision making. RI #7 was assessed as being totally dependent on staff for bed mobility, transfers, locomotion on the unit, dressing, eating, toilet use, personal hygiene and bathing, and was always incontinent of bowel and bladder. Section K, under K0510. Nutritional Approaches, RI #5 was coded as having a feeding tube. On 01/16/13 at 8:08 AM, during the morning medication pass observation, EI #5 was observed to pour 200 cc's of water into a cup. EI #5 informed the surveyor the water was for RI #7's every 4 hour H2O flush. EI #5 used the water to give the initial flush (15 cc's), to mix with the crushed medications (4 medications/40 cc's) and to give the in between water flushes (45 cc's). EI #7 used the remaining 100 cc water to flush RI #7's feeding tube. On 01/16/13 at 3:20 PM, the surveyor conducted an interview with EI #5, the LPN (Licensed Practical Nurse) administering the water flush to RI #7 on 01/16/13, during the morning medication pass. The surveyor asked EI #5 what was RI #7's H2O flush order. EI #5 stated 200 cc's every 4 hours. The surveyor asked EI #5 why did she use some of the 200 cc H2O flush to mix with RI #7's crushed medications and for the in between water flushes. EI #5 stated that was the way that she had always done it. The surveyor asked EI #5 what did the facility's policy say concerning administering H2O flushes. EI #5 stated she didn't know if the policy specified that the flushes should be given alone. On 01/16/13 at 6:15 PM, the surveyor conducted an interview with EI #4, the RN (Registered Nurse) Unit Manager of Unit One. The surveyor asked EI #4, when an H2O flush order is written, when is the flush administered. EI #4 stated, "After the meds (medications) are given." The surveyor asked EI #4 could the H2O flush be given with the crushed meds and the in between flushes. EI #4 stated it should not be.

Based on observations, record review and interview, the facility failed to assure dietary personnel had knowledge, were properly trained and were competent to assure proper sanitary techniques were utilized in the preparation and distribution of food as evidence by: 1) There was a lack of evidence that all the staff had received orientation to job performance tasks. 2) Observations of food storage, preparation and distribution on two of three days of the survey, which resulted in deficient practices cited under F 371 (Store, prepare and serve food under sanitary conditions). Discrepancies were documented in 3 areas of concern. This deficient practice affect Employee Identifier (EI) #9 and EI #10 two of the 10 dietary staff members reviewed for competence. Findings include: The facility policy titled "CLEANING FOOD CARTS," undated documented, "CLEANING FOOD CARTS POLICY: Food carts will be cleaned and sanitized immediately after each use. PROCEDURE: 1. Each day, inside and outside of carts will be sanitized and wiped down. 2. Wheels on the food carts should be cleaned as often as needed. 3. The outside of the food carts may be polished with stainless steel polish on occasion if applicable." This policy does not instruct the staff member on what is to be used to clean and sanitize the food carts. On 1/15/13 at 2:05 PM, the "Dishroom Temp (Temperature) Log" for January 1 through 15 was monitored. Two problem areas were identified: A. On January 01, 2013 the supper temperature recorded the final rinse (sanitizing) temperature as 157 degrees Fahrenheit (F). The standard final rinse temperature should be 180 degrees F. It was determined EI # 9 was responsible for the temperature monitoring/documentation. On 1/16/2013 at 3:20 PM, EI #9, a facility dietary aide, was interviewed. EI #9 was asked to tell the surveyor about the 157 degree F. temperature documented on the log (for January 1, 2013). EI #9 response was "I just messed up, only thing I can think of." The surveyor asked EI #9 what should the temperature be? EI #9 response "Between 155 and 180, I'm (I am) an idiot, as far as I know, I am supposed to go tell someone (if temperatures are sub-standard). I get nervous very easy." On 1/16/2012, EI #7, the facility's Dietary Manager, provided the surveyor with a form titled "DIETARY INSERVICES 2012." The form documents in July 2012 the staff was in-serviced on Maintaining and Cleaning Equipment. EI #7 was unable to provide evidence that staff was instructed on how and what to use to sanitize or clean equipment or what equipment was discussed. EI #9's, a facility Dietary Aide, "DIETARY SKILLS EVALUATION" form was reviewed. The form documents that EI #9 was trained on "Use/ cleaning of dish machine/how to take temps (temperatures)./ppm (parts per million)." This entry was initialed by EI #9 on 5/28/11 and by EI #7 on 6/7/12. On 1/17/13 at 9:15 AM, an interview was conducted by the surveyor with EI #7. EI #7 was asked if she completed the form. EI #7 stated she did. EI #7 was asked if she observed EI #9 on "Use/cleaning of dish machine/how to take temps (temperatures)./ppm." EI #7 stated she did not. EI #7 was asked how did she know EI #9 was competent. EI #7 stated she did not. There was no evidence the skills evaluation utilized the teach-back technique. The process that involves asking the trainee to explain or demonstrate what he/she had learned. A review of the Consultant Dietitian Reports revealed that she had reviewed the logs. There was no dishmachine temperature completed for the 6/04/12 supper meal. According to the Food Code U.S. Public Health Services, dated 2001, page 107, documents, "... section 4-501.112. Mechanical Warewashing Equipment, Hot Water Sanitization Temperature ... (2) For all other machines, 82 (degrees) C (celsius) (180 (degrees) F (Farenheit)). ..." B. On 1/15/2013 during the review of the dietary documentation the surveyor observed the recording of the supper dishmachine temperature on the log at 2:05 PM. This was 3+ hours prior to the delivery of the supper meal. The posting was not initialed, and the Dietary Manager stated she was unable to determine which employee made the entry. A review of the facility untitled policy documented,' POLICY Dishwashing staff will monitor and record dish machine temperature to assure proper sanitizing of Dishes. PROCEDURE: ...4. "The dietary manager will spot check this log to assure temperatures are appropriate , and staff is actually monitoring, dish machine temperatures. 5. Dishwashing staff will be trained to report any problem with the dishmachine to the Dietary Supervisor as soon as they occur. ..." 1/16/2013 at 3:20 pm, EI #9 acknowledged he failed to report the temperature on 1/02/13. The was no evidence of corrective action taken/recorded on the log. The facility was unable to provide evidence this procedure had occurred. On 1/16/13 at 7:15 PM the dishmachine operator, EI #9 was observed to assembled 2 rows of plate covers (16) in one rack. This positioning failed to allow water to reach all surfaces. The Dietary Manager instructed the operator to reduce the volume to 1/2 (8).

Based on observations, interviews and review of a facility policy titled "Medication Administration - General", the facility failed to ensure loose pills were not in the drawers of one of the two medication carts on Unit II. This deficient practice affected one of five medication carts in the facility. Finding Include: A facility policy and procedure titled "Medication Administration - General" dated 03/11, documented: " ... Procedures ... 25. Once removed from the package or container, unused doses should be disposed of appropriately." On 01/16/13 at 5:50 PM, the surveyor observed 8 (eight) loose pills in one of the medication carts on Unit II. EI (Employee Identifier) #6, the LPN (Licensed Practical Nurse) assigned to the cart where the loose pills were discovered, identified the pills for the surveyor. There were 2 (two) oblong grey pills, identified as Namenda 10 mg (milligram), 2 (two) oblong white pills identified as Celexa 40 mg, 1 (one) small pink oval pill, identified as Lisinopril 5 mg, 1 (one) medium white pill, identified as Diltiazem 30 mg and 2 (two) small round white pills which EI #6 could not identify. The surveyor asked EI #6 how did she think the pills came out of the "bubble pack." EI #6 stated sometimes when you hit the corner of the pack (bubble pack) the pills may pop out. The surveyor asked EI #6 how often were the medication carts cleaned. EI #6 stated she tried to go through the cart on the nights she worked to look for loose pills. The surveyor asked EI #6 when loose pills are found on the medication cart, what would she do with the pills. EI #6 stated she would put them in the sharps container or crush them and put them in the sink. The surveyor observed EI #6 place the 8 (eight) loose pills in the sharp's contained affixed to the side of the medication cart. On 01/17/13 at 8:30 AM, the surveyor conducted an interview with EI #1, the RN (Registered Nurse) Unit Manager for Unit II. The surveyor asked EI #1 how often did the nurses clean the medication carts. EI #1 stated after the end of each shift. The surveyor asked EI #1 what were the nurses looking for when they cleaned the inside of the medication carts. EI #1 stated, "Loose pills, spills, dirty bottles ..." The surveyor asked EI #1 whose responsibility would it have been to identify that loose pills were in the medication cart. EI #1 stated, "The nurses on the cart."

Based on observations, interviews and review of a facility policy titled "Oxygen (O2) Administration", the facility failed to ensure Licensed staff labeled the humidifier bottle of RI (Resident Identifier) #7 with the date the bottle was placed on the O2 concentrator. This deficient practice affected RI #5, one of 4 (four)residents sampled for Oxygen usage. Findings Include: A facility policy titled "Oxygen (O2) Administration", with a Revised date of 03/27/2008, documents: "... Policy: The facility's nursing personnel (RN (Registered Nurse) / LPN (Licensed Practical Nurse) will use the following guidelines to administer oxygen. Procedure: ... Humidifier bottles will be changed PRN (as needed). The humidifiers will be labeled ..." RI #7 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #7's care plan with a "Problem/Need "Continuous and/or PRN (as needed) O2 use r/t related to" COPD (Chronic Obstructive Pulmonary Disease), SOB (Shortness Of Breath)" with a Problem Onset date of 09/21/2012, documented: "... Approaches ... *Change O2 tubing, and humidifier per policy and procedure ..." RI #7's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/09/12, identified RI #7 to have short and long memory problems and severely impaired cognitive skills for daily decision making. RI #7 was assessed as being totally dependent on staff for bed mobility, transfers, locomotion on the unit, dressing, eating, toilet use, personal hygiene and bathing, and was always incontinent of bowel and bladder. On 01/15/13 at 5:45 PM, the surveyor observed the humidifier bottle on RI #7's O2 concentrator. There was no date on the bottle. On 01/16/13 at 8:00 AM, the surveyor again observed the humidifier bottle on RI #7's O2 concentrator to be without a date. On 01/16/13 at 3:20 PM, the surveyor conducted an interview with EI #5, the LPN assigned to care for RI #7 on the 7 AM - 3 PM shift. The surveyor asked EI #5 when were the humidifier bottles to be changed. EI #5 stated the bottles were changed PRN. The surveyor asked EI #5 what should be placed on the humidifier bottle when placing a new one on the O2 concentrator. EI #5 stated the date. EI #5 stated she usually put her initials on the bottle also. The surveyor asked EI #5 how would you know if the humidifier bottle had been changed. EI #5 stated by the date on the humidified bottle. On 01/16/13 at 6:15 PM, the surveyor conducted an interview with EI #4, the RN (Registered Nurse) Unit Manager of Unit One. The surveyor asked EI #4 when are the humidified bottles changed. EI #4 stated the humidified bottles were changed PRN. The surveyor asked EI #4 what she would expect her staff to do when they changed the O2 humidified bottles. EI #4 stated, "I would expect them to date it ..."