Every finding on record at PruittHealth - Moultrie

Based on observations, staff interviews, and a review of the facility's policies titled Labeling, Dating and Storing and Foodborne Illnesses the facility failed to ensure food items in the pantry, cooler, refrigerator, and freezer were properly labeled and dated, opened food items were securely wrapped and sealed and foods were discarded when expired. The facility failed to practice safe and sanitary methods when preparing foods to prevent cross contamination and the spread of bacteria. The deficient practice had the potential to affect 60 out of 60 residents receiving an oral diet. Findings include: Review of policy titled, Labeling, Dating and Storing, reviewed [DATE], revealed under Purpose: Food and beverage items will have an identifying label as well as a received date and opened date, as applicable for items prepared onsite, a use by date will also be indicated. Review of the policy titled Foodborne Illnesses reviewed [DATE], revealed under Purpose: It is the responsibility of the Dietary Manager (DM) to see that dietary employees practice safe and sanitary methods when preparing foods to prevent cross contamination and the spread of bacteria. It is the responsibility of the DM to see that food is properly stored to reduce the chance of temperature to prevent foodborne illnesses. Thaw meats under refrigeration at or below 41 degrees Fahrenheit in a drip proof container or submerged in a solid bottom pan under cold running water. Georgia Department of Public Health Food Facility Inspection Report has an 86 B score dated [DATE]. Observation on [DATE] at 9:40 a.m. during initial tour of the kitchen revealed: In the refrigerator, a bowl of fruit cocktail/fruit salad was not labeled with content or dated with prep date or use by date. Raw chicken in a pot with ice and water covering it and plastic wrap covering the top was near the stove on a rolling cart. While in the kitchen the water was drained from the pot of raw chicken and replaced with more water, it was covered with plastic wrap and pushed into the cooler. It was dated [DATE]. In the pantry nine (9) green bowls with lids and cereal in them on a tray with no date were sitting on top of cereal bin. Interview on [DATE] at 9:40 a.m. with the DM during the initial tour of the kitchen revealed the chicken in the pot of water and ice had been defrosting in the sink and it was being cooked for lunch. Observations of the kitchen on [DATE] at 10:01 a.m. revealed: An opened bottle of barbecue sauce with a label that indicated refrigerate after opening was on a shelf in the pantry. An opened box of cranberry juice, wrapped in plastic wrap, was not labeled with an open or use by date in the cooler. An opened bag of cheese, wrapped in plastic wrap, was not labeled with an open or use by date in the freezer. A large plastic container with frozen chicken in red colored liquid was in the freezer. A large plastic zipper bag had several smaller bags of sandwich meat in it that was not labeled with an open or use by date. Interview on [DATE] 10:01 a.m. with the DM revealed the raw chicken in the freezer was left over defrosted chicken from yesterday and refrozen for future use. Interview on [DATE] at 10:25 a.m. with the Assistant Dietary Manager BB revealed dates are placed on foods when delivered. We have certain sides of the freezer that we keep meat. To thaw the meat, we put it in a pan with ice and leave it in the cooler and prep and cook it.

Based on observations, staff interview, review of the clinical record, and review of facility policy titled, Oxygen Administration, the facility failed to obtain a physician's order with a specific rate/setting for liters per minute (LPM) for oxygen therapy for, one of 12 residents (R) R #15 and failed to ensure the water humidification bottle was adequately filled for R #15. Findings include: Review of the facility policy titled, Oxygen Administration with a revision date of 8/2/2023 revealed the following: 1. Procedure: Regulate liter flow to ordered flow rate. 2. Infection Control Policy of O2 Humidifier Bottles: (1) O2 humidifier bottles should be used on all patients/residents receiving higher than 2 liters/minute of oxygen flow. (3) Humidifier bottles should be filled when water level drops below fill line marking. Record review for R#15 revealed a Brief Interview for Mental Status (BIMS) score 10 indicating minimal cognitive decline, full code status. Primary diagnoses included but not limited to, acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), major depressive disorder, and generalized anxiety disorder. Review of physician's orders included but not limited to, oxygen (O2) at 2-5 liters per minute (LPM) via nasal cannula (N/C) continuous every (q) shift, change respiratory circuit/supplies weekly q Monday. Review of the most recent comprehensive minimum data set (MDS) annual assessment dated [DATE] revealed: Section C - Cognitive Patterns-BIMS 10. Section I - Active Diagnoses-Medically Complex Conditions. Section O - Special Treatments, Procedures, and Programs-Included oxygen therapy. Review of the care plan included but not limited to, risk for shortness of breath (SOB), respiratory difficulties/distress related to chronic obstructive pulmonary disease (COPD), and history of respiratory failure. Oxygen use. Interventions included provide oxygen therapy as ordered. Observation on 9/5/2023 at 10:12 a.m., of Resident # 15 sitting up in bed, head of bed elevated, with O2 running at 4 LPM via N/C from concentrator at bedside. Observation on 9/5/2023 at 4:08 p.m. of R#15 sitting up in bed sleeping, head of bed elevated, O2 running at 4 LPM via N/C, and the humidification water bottle had a low water level. Observation on 9/6/2023 at 8:35 a.m. of R#15 sitting up in bed eating breakfast. Oxygen running at 4 LPM via N/C from concentrator at bedside, humidification water bottle empty. Observation on 9/6/2023 at 12:30 p.m. of R#15 lying in bed sleeping. Oxygen running at 4LPM via N/C from concentrator at bedside, humidification water bottle empty. Interview on 9/6/2023 at 2:23 p.m. with Licensed Practical Nurse (LPN) JJ checked the order in the clinical record and confirmed R# 15's order for oxygen was a range of 2-5 liters per minute (LPM) via nasal cannula (N/C) continuously. She revealed R#15 recently readmitted from hospital, the doctor did not give a specific oxygen setting when R#15 returned, and they did not have a specific rate. Looking at R#15's history in the clinical record, LPN JJ revealed R#15's oxygen order before going in the hospital was for 2-4 liters, and since his return on August 31st the new oxygen order was for 2-5 LPM. She revealed R#15 was the only resident that you can go on back and to on the setting, and confirmed there were no instructions for determining whether it should be set at 2 LPM versus 5 LPM. Interview further revealed they change tubing once a week, and the humidification water bottle was changed as needed. Most all residents were on 2 liters and their humidification water bottle lasts about a week, but the water bottle on R#15 was changed more frequently because he's on such a high (LPM) rate and it runs out quicker. LPN JJ also revealed the nurses look at the water in the bottle, monitor the water level, change it whenever it gets low. LPN JJ revealed that being on such a high LPM setting R#15's water runs out every 2-3 days. LPN JJ confirmed the water humidification bottle was empty, it should not be empty, and confirmed the oxygen was currently on 5 LPM. LPN JJ revealed the nurse was responsible for monitoring oxygen settings, for monitoring the humidification bottle water level, and should change it before it runs out. Interview on 9/6/2023 at 3:05 p.m. with the Director of Nursing (DON) confirmed R#15's oxygen setting order was for a range of 2-5 LPM, and revealed there should not be a range. Her expectation was that there should be an order with a specific number for the oxygen LPM rate, the water humidification water bottle should not be empty, and staff should be monitoring the water level and change it when it gets low near the fill line.

Based on observations, staff interviews and review of the facility policy titled, Medication Administration: General Guidelines, the facility failed to properly secure medications for one of two medication carts. Specifically, the facility left an insulin pen and four individually wrapped medication packages on top of the medication cart unattended. Findings include: Review of the facility policy Medication Administration: General Guidelines last revised on 4/10/2019, revealed: 16. During routine administration of medications, the medication cart is kept in the doorway of the patient/resident's room, with open drawers facing inward and all other sides closed and locked. No medications are kept on top of the cart, and all outward slides must be inaccessible to patients/residents or others passing by. Observation on 9/5/2023 at 11:35 a.m. revealed Licensed Practical Nurse (LPN) KK administering medications on the B Hall. LPN KK locked the medication cart, entered resident room B14, and closed the resident's door behind her. The medication cart was subsequently found to be locked and unattended with an insulin pen and four individually wrapped medications packages (Jardiance, probiotic, multivitamin and sennosides-docusate sodium) left on top of the cart with the drawers facing the hallway. Interview on 9/5/2023 at 11:37 a.m. with LPN KK revealed that medications should always be secured and confirmed that she had mistakenly left medications on top of the medication cart unattended. Interview on 9/6/2023 at 8:15 a.m. with LPN LL revealed that all narcotics are double locked on the medication carts and are counted each shift by the off going and oncoming nurses. She also revealed that all medication carts were to be locked when not attended. Interview on 9/6/2023 at 8:55 am with LPN GG revealed that all medications should be secured if the nurse isn't with the medication cart. She reported that they should never leave the medication cart unlocked or medications unsecured. Interview on 9/7/2023 at 1:12 p.m. with the Unit Manager revealed there were currently 14 residents residing on B Hall, one resident was able to independently ambulate, and three residents were able to independently travel the facility while seated in their wheelchairs.

Based on observations, record review, interviews, and review of facility policy 'Pressure Injury Prevention Program', the facility failed to enter wound care orders in the electronic medical record for one of one resident (R#47) reviewed for pressure ulcers. Findings include: Review of facility policy 'Pressure Injury Prevention Program' last revised 3/18/21 revealed: 'Procedure: B. Documentation 3. Documentation of the pressure injuries should be completed in the resident's EHR (electronic health record). Record review revealed R#47 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review record review revealed R#47 had pressure ulcers to the left elbow, right foot, and sacrum. R#47 also has arterial ulcer to the left foot. During observation on 2/9/22 at 2:25 p.m. with Skin Integrity Coordinator (SIC) Registered Nurse (RN) revealed treatments performed to right and left feet. The SIC did not confirm orders prior to treatment and did not sign off that the treatments were completed afterward. Review of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During interview on 2/10/22 at 11:49 a.m. with RN SIC she confirmed that she did not verify resident's orders prior to performing treatments. States she is new to working at this facility and has not received training on how to add orders to the EHR system. During interview on 2/10/22 at 3:20 p.m. with the Assistant Director of Health Services confirmed R#47's treatment orders for his right and left foot were not in the EHR until she added them on 2/9/22.

Based on record review, staff interviews and review of the facility policy titled Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property, the facility failed to notify the State Agency (SA) within the required two hours of an incident involving staff to resident physical/verbal abuse for one resident (R#1)) of five residents reviewed for abuse. Findings include: Review of the facility policy titled, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property revised on 7/29/19 Procedures: 1. Any allegation, suspicion, or identified occurrence is identified involving patient abuse, neglect, exploitation, mistreatment, and misappropriation of property, including injuries of an unknown source, should be immediately reported to the Administrator of the provider entity. 2. In accordance with applicable laws and regulations, the Administrator or his or her designee should notify the appropriate state agency (or agencies), the patient's attending physician, and the patients' designated representative of any allegation or incident described above and of the pending investigation The state survey agency and the state agency for adult protective services should be notified in accordance with state law through established procedures of any allegations of abuse, neglect exploitation or mistreatment, including injuries of an unknown source and misappropriation of patient property, within 2 hours after the allegation is made if the events upon which the allegation is based involved abuse or result in serious bodily injury, and not later than 24 hours if the events upon which the allegation is based do not involve abuse and do not result in serious bodily injury. The Ombudsman should also be notified as required by state law. The Administrator or designee should direct an investigation into the allegation or incident. Review of Facility Incident Report Form dated 2/1/2020 revealed an investigation for staff to resident abuse. It documented that on 1/5/2020 that the staff touched R#1's nose while talking to the resident. Record review revealed that although this staff to resident abuse occurred in January of 2020 it was not thoroughly investigated until February. The investigation was not investigated in January 2020 but o in the month of February of 2020. Further investigation revealed that the investigation was not thoroughly investigated and did not include the two witnesses who were also present in the dining room when the incident occurred. During an interview on 2/26/2020 at 1:32 p.m. the Director of Health Services (DHS) revealed that she became aware of the incident on Monday, 1/6/2020 when CNA BB told the DHS about the incident with CNA CC and R#1. The DHS stated that when she did her initial investigation, she was not aware of other staff being in the dining room. The DHS stated she did not report the incident when it occurred on 1/6/2020. The DHS stated that she did not think the incident had to be reported. During an interview on 2/26/0202 at 2:28 p.m. the Social Worker (SW) revealed that she found out about the incident on 2/3/2020, during the morning meeting, and sent in a state reportable for the incident. The responsible party was notified on 2/4/2020 during a visit to the facility. During an interview on 2/26/2020 at 2:41 p.m. the Administrator reveled that in speaking with CNA BB, she became aware that CNA CC had put her finger on R#1's forehead or nose (she could not remember which one). The Administrator stated that the facility's process was to send the report to the state agency within 2 hours.

Based on record review, review of the facility policy titled Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property and staff/resident interviews, the facility failed to ensure that one of five residents (R#1) reviewed were free from physical/verbal abuse. The Resident Census and Conditions of Residents Form CMS-672 dated 2/24/2020 revealed a census of 67 residents. Findings include: Review of the policy, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property revised 9/20/19 revealed Policy Statement It is the policy of (the facility) and its affiliated entities (collectively, the Organization) to actively preserve each patient's right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, exploitation, mistreatment, and misappropriation of patient property, (referred to collectively in this policy as abuse, neglect, mistreatment, and exploitation). The Organization and its partners should assure that best efforts are made to prevent any occurrences of any form of abuse, neglect and exploitation. Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain, or mental anguish. Abuse includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Abuse also includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology. 1. Review of the Resident Face Sheet revealed Resident #1 (R#1) has the following [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 9 indicating moderate impaired cognition. Review of Facility Incident Report Form dated 2/1/2020 revealed an investigation for staff to resident abuse. It documented that on 1/5/2020 that the staff touched R#1's nose while talking to the resident. Record review revealed that although this staff to resident abuse occurred in January of 2020 it was not thoroughly investigated until February. The investigation was not investigated in January 2020 but o in the month of February of 2020. During an interview on 2/24/20 at 2:53 p.m. R#1 revealed that she had witnessed Certified Nursing Assistant (CNA) CC being slapped by R#2. At the time of the incident, R#1 said something about R#2 slapping CNA CC. CNA CC then put her finger on R#1's forehead and pushed R#1's head backward and CNA CC told R#1 to shut up and mind her own business. R#1 stated the incident happened so fast that she did not know how she felt. R#1 continued to say that she did not want CNA CC to be fired and that she wanted to put the incident behind her. During an interview on 2/25/20 at 11:20 a.m. former CNA BB revealed that on 1/5/2020 she was headed toward the dining room about 5:40 p.m. and was getting ready to bring in a resident for supper and to serve coffee or tea. Former CNA BB stated that when she entered the dining area, she saw CNA AA and CNA CC standing together and there were two other dietary personnel sitting near the kitchen. Former CNA BB stated R#2 slapped CNA CC and that it was a backhanded slap. CNA BB turned around to leave but looked back and saw CNA CC standing over R#1 with her finger pointing in R#1's face and CNA CC was telling R#1 to stay out of it. Former CNA BB stated that Registered Nurse (RN) EE was standing in the lobby near the dining room. Former CNA BB stated that she reported this incident to RN EE who was on his phone texting. During an interview on 2/26/2020 at 1:32 p.m. the Director of Health Services (DHS) revealed that she became aware of the incident on Monday, 1/6/2020 when CNA BB told the DHS about the incident with CNA CC and R#1. The DHS stated that when she did her initial investigation, she was not aware of other staff being in the dining room. The DHS stated she did not report the incident when it occurred on 1/6/2020. During an interview on 2/26/2020 at 2:41 p.m. the Administrator reveled that in speaking with CNA BB, she became aware that CNA CC had put her finger on R#1's forehead or nose (she could not remember which one). The Administrator stated that as soon as she received the information for this complaint from her corporate office in February that she started an investigation and that the responsible party for R#1 was informed of the incident on 2/8/2020. The Administrator stated that CNA BB was adamant that CNA CC had put her hand in the R#1's face.

Based on observations, staff interviews, review of facility policies including Labeling, Dating, and Storage, Cleaning Procedures: Kitchen Area and Ice Machines (Handling/Scoops), Patient/Resident's Personal Food and review of the ice machine manufacturer's Installation, Use and Care Manual, the facility failed to maintain the cleanliness of the ice machine, two food prep table shelf surfaces and one electrical cord, and failed to assure that opened food items in the dry storage area and resident personal breakfast cereals in the kitchen were sealed and secured to prevent access by vermin or pests. The issues with cleaning of the ice machine and storage of food had the potential to impact 65 of the 67 residents in the facility. Findings include: During the initial kitchen tour conducted on 10/22/18 at 11:30 a.m. with the Food Service Director (FSD), the ice machine was noted to have rust colored discoloration and brown to black colored debris along the front of the machine at the top of the door (not the door itself). The FSD used a dry papertowel and was able to remove a portion of the debris. The deflector, located inside the ice machine contained a large amount of rust colored spots and discoloration. The FSD was able to wipe off a significant amount of the rust colored spots/discolortions with a damp cloth. FSD confirmed the presence of the rust appearing substance and stated that they clean the ice machine monthly by removing all of the ice and disinfecting and sanitizing the interior of the machine. Observation also revealed a prep table in front of the sanitizing sinks was noted with a large amount of rust on the lower shelf. All items sitting on the shelf (spices) are sitting on trays and not touching the rusted surface. There is an orange, heavy duty electrical extension cord attached to a leg of the prep table that is sticky to the touch and has a large amount of visible black debris on the surface. A second prep table with a lower shelf holding pots and pans was noted to have a sticky surface. Further observation revealed that the dry storage room had one opened box of dry rice mix was wrapped with a plastic wrap but not secured. The FSD confirmed the box was not secured and sealed properly and discarded the box. Continued observation revealed more than four opened boxes of cereal labeled with specific resident's names were sitting on a cart adjacent to the kitchen/dining room door. The FSD opened the boxes and it was noted that the interior bags and outer boxes were not sealed in any manner. The FSD confirmed the packages were not sealed or secured and stated she would correct the situation. She confirmed the boxes belonged to specific residents and had been brought in by resident's responsible parties. During a tour of the kitchen conducted on 10/25/18 at 8:45 a.m. the ice machine was noted to still have a small amount of rust discoloration on the surface of the metal deflector inside the machine. The FSD stated the metal deflector is not removable. Further observation at this time revealed that the prep table with the lower rusted shelf and the dirty extension cord and the second prep table with a sticky surface were all noted in the same condtion observed during the initial kitchen tour. During an interview conducted on 10/25/18 at 1:00 p.m., the Maintenance Director (MD) stated he cleans the ice machine quarterly. He provided two documents including a copy of a monthly preventative work order with a completion date of 10/2/18 that includes nine steps for the inspection of the ice machine. He also provided a copy of a quarterly maintenance work order created 10/15/18 and with an open status for the kitchen ice machine. The quarterly work order includes 10 (ten) steps for inspection of the ice machine including 5. Check for rust or corrosion, clean/repair as needed. He stated the local water has a high iron content and that there is a filter in the ice machine which he checks monthly and replaces as needed. He stated he is replacing the filter today. The MD provided a copy of an Installation, Use & Care Manual for the ice machine. He also stated that they do not use the manufacturer's recommended cleaning products on the ice machine. Further interview conducted with the Maintenance Director (MD) revealed that the dietary staff had removed items from the rusted shelf and that he will be removing the table for cleaning and repair. A review of the Installation, Use & Care Manual for the ice machine states: You are responsible for maintaining the ice machine in accordance with the instructions in this manual. Clean and sanitize the machine every six months for efficient operation. If the ice machine requires more frequent cleaning and sanitizing, consult a qualified service company to test the water quality and reommend appropriate water treatment. Manitowac Ice Machine Cleaner and Sanitizer are the only products approved for use in Manitowoc Ice machines. It also states that the Cleaning/Sanitizing Procedure is to be performed a minimum of every six months and the Preventative Maintenance Cleaning Procedure is used to clean the ice machine between the bi-yearly cleaning/sanitizing procedure. Both the cleaning/sanitizing procedure and the preventative maintenance procedures instructions emphasize the use of the manufacturer's products. The preventative maintenance procedures note that the ice machine cleaner is used to remove lime scale and mineral deposits. Review of a facility policy 10/18/17 entitled Labeling, Dating, and Storage includes but is not limited to: 2. Foods will be stored in their original containers or in an approved container or wrapped tightly with film, foil, etc. and clearly labeled with the name of the item and the use by date. Review of a facility policy dated 1/19/18 entitled Patients/Residents' Personal Food states It is the policy of PruittHealth to allow the patient/resident's family to provide personal food items for patient/resident consumption. The patient/resident's personal food items will be maintained in a clean, healthy environment to help prevent foodborne illnesses. The scope of the policy applies to nursing and dietary partners. The procedure includes but is not limited to: 3. Non-refrigerated food to be kept in a patient/resident's room should be stored in individually sealed/prepackaged containers or stored in a closed, covered container to reduce the risk of contamination. .

Based on observation, interview, and record review, it was determined the facility failed to store respiratory equipment in a sanitary manner for three (3) residents (#3, #59, and #17) from a total sample of twenty-five (25) residents. Findings include: 1. Resident #3 had a physician's orders [REDACTED]. An oxygen concentrator with tubing and nasal cannula was stored in the resident's room. However, the tubing and nasal cannula were observed to be draped over the concentrator, unbagged, on 8/22/16 at 2:52 p.m. and on 8/25/16 at 10:34 a.m. and 12:06 p.m. 2. Resident #17 had a physician's orders [REDACTED]. The treatment was completed on 8/10/16. However, a nebulizer with attached tubing an mask were stored in the resident's room. The tubing and mask were observed, unbagged, and draped over a cane on 8/22/16 at 3:32 p.m. and on 8/23/16 at 10:17 p.m. The tubing and mask were observed, unbagged, and hanging from a lever on the underside of an overbed table on 8/24/16 at 2:49 p.m. and on 8/25/16 at 10:34 a.m. and 12:06 p.m. 3. Resident #59 had a physician's orders [REDACTED]. There was also a physician's orders [REDACTED]. A nebulizer with attached tubing and mask were stored in the resident's room. However, the tubing and inhaler were observed, unbagged, and laying on the residents' bed on 8/23/16 at 12:23 p.m. and 2:20 p.m. and on 8/25/16 at 12:06 p.m. During an interview on 8/25/16 at 1:34 p.m., the Director of Nursing (DON) stated that tubing and attachments for nebulizer's and oxygen concentrators are stored in bags. After surveyor inquiry, on 8/25/16 at 1:52 p.m., the oxygen concentrator tubing and nasal cannula for resident #3 were observed bagged. The nebulizer mask for resident #59 had been removed and replaced with an inhaler, which was bagged with the tubing. The nebulizer, tubing and mask had been removed from resident #17's room.

Based on observation, resident interview and record review the facility failed to maintain food temperatures within the acceptable level (135 degrees) for hot foods and cold foods (40 degrees) during food service for two (2) meals of the three (3) meals observed during the survey. Findings include: Observation on 3/3/14 at 12:25 p.m revealed that during the food service, temperatures were acquired by the dietary manager at the request of the surveyor and were as follows: Puree sweet and sour pork was 130 degrees Fahrenheit (F) Puree stir-fry vegetables were 130 degrees F Beef tips in regular form were 130 degrees F All of these foods were being held on the steam table and the steam table was on maximum. Observation on 3/3/14 at 12:25 p.m. revealed that the milk in individual cartons was tested at 50 degrees by the dietary manager and had been sitting on a tray to be served. Observation on 3/5/14 at 12:35 p.m. revealed the facility was serving a menu that included salmon patty and creamed corn. Observation during the food service at this time revealed that food temperatures were acquired by the dietary manager of these items on the stream table for puree creamed corn and the Salmon patties were held under a heat light: Salmon patty was 112 degrees F Puree corn was 130 F An interview with the dietary manager on 3/5/14 at 1:20 p.m. revealed that she knew food temperatures should be 135 degrees or greater for hot foods. She further stated that at supper on 3/5/14 she would keep checking temperatures and if temperatures were not holding, she would move everything to the stove and serve from there. She revealed that there was no temperature log for 3/5/14 lunch meal but stated the salmon patties were 140 degrees at the beginning of service; although there was no documentation to verify this information. An interview with the dietary manager on 3/5/14 at 2:30 p.m. revealed that plates are warmed in a plate warmer and there were domed lids for the plates that were being taken to resident's rooms. In an interview with the maintenance staff on 3/5/14 at 2:40 p.m. it was learned that the steam table was in working order. During the observation of the supper food service on 3/5/14 at 4:50 p.m. it was noted the hall trays, once plated, sat on the cart uncovered until all the trays were filled. At that time, the dome covers were placed on the plates and the trays were transported via cart to the halls. It was observed that the plate warmer, while the indicator light was on, did not radiate any heat. The Registered Dietitian confirmed that the plate warmer was not functioning. There were multiple complaints during resident interviews of cold food. A review of the facility's policy determined: All hot foods served from the steam table must be held above 140 degrees All potentially hazardous cold foods must be held at 40 degrees or less Potentially hazardous cold food should be held on the line in an ice bath Food will be served at palatable temperatures 2. An interview on 3/4/14 at 8:15 a.m. resident "A" stated that he/she receives all his/her meals in room per his/her preference. The resident further stated that when the meal trays are delivered the hot foods are cold and the cold foods are hot especially the grits and the eggs. 3. Observation on 3/5/14 at 4:46 p.m. of the kitchen for food preparation for evening meal and a test tray revealed both the Register Dietitian and the Administrator assisting in the kitchen both confirmed they usually do not help out with meal delivery service. While observing set up of the test tray, on the same day at 5:15 p.m revealed that kitchen staff had started prepping plates with steam table food. Observation at 5:49 p.m. revealed that the cart with the test tray went out to the halls with the last tray delivered at 6:06 p.m.. The test tray was then checked with the Registered Dietitian revealing the following temperatures: Stewed tomatoes-101 degrees Farenheit (F), hash browns=96 degrees F, Quiche=99 degrees F, Carton of milk=48 degrees F, Fruit cocktail=70 degrees F. The hot food was cold and the cold food was warm.

Based on observation and staff interview the facility failed to properly store food to prevent foodborne illness. Findings include: Observation on 3/3/13 at 12:30 p.m. revealed the following observations were made in the dietary kitchen: 1. On the shelf under the preparation table there was one (1) bottle of lemon juice that was 3/4 full. The date written on the label was 9/2/12. Dietary manager was unable to state what the date represented,. The label clearly stated to refrigerate after opening. The sediment in the bottle was thick and coarse. 2. In the reach-in cooler in the right side there were gallon pitchers of cranberry juice(1), orange juice(1), and apple juice(1). The pitchers were dirty in appearance with a heavy build up of dried spills on the sides. The lids were in place with labels stating "use daily". There were no dates in place relevant to when the juices were opened, made or expired. There was one gallon pitcher of tea also in the cooler with dried spills and a lid in place labelled with "use daily". 3. Further observation on the left side of the cooler was found one (1) tall round plastic container with lid in place with a label stating cranberry sauce: with in 2/22 - out 2/27. In an interview on 3/6/14 at 9:35 a.m. with staff "AA" revealed that the pitchers are emptied , washed and fresh juice made daily.

Based on resident and staff interview, review of the facility Grievance Log, review of the facility Missing Items Log and review of the facility Missing Items Policy, it was determined that the facility failed to ensure that grievances of missing articles of clothing were followed up on for two (2) residents (#1 and "A") from a sample of seven (7) residents. Review of the facility's Missing Items Policy revealed that grievances involving missing items would be handled as any other grievance but would be recorded on the Missing Items Log. All actions taken would be documented on this log and all materials would be kept in the missing items book. Items that were missing and/or damaged as fault of the healthcare center would be replaced within reason. If it was clothing that was missing, the the laundry services form should be filled out and given to the laundry supervisor. When this form was returned, the results would be logged on the Missing Items Log. 1. Resident #1 was no longer at the facility. Interview with the Senior Care Partner, who was responsible for follow-up on missing items for residents, on 1/23/14 at 4:30 pm revealed that he/she had been informed by a family member in December 2013, that the resident was missing a gray sweat suit and some Khaki pants. He/she further stated that the gray sweat suit was found on the day it was reported missing. He/she stated that the Missing Items Form for the other missing articles of clothing had not been done. Therefore, there had not been any further follow-up for the other missing clothing. The Senior Care Partner further stated that he/she had been in her position for about four months and since that time, he/she had not had any other complaints of missing items. 2. Interview with Resident "A" on 1/23/14 at 5:45 pm revealed that she had missed a blue gown with her name in it a month ago. He/she stated that she had reported the missing gown, at the time it went missing, to someone in the laundry department. However, as of the date and time of the interview, the resident stated that no one in the facility had followed up with her in regards to the missing gown.

Based on record reviews and staff interviews, it was determined that the facility failed to ensure that physicians' orders were followed for notification of physicians for abnormal blood sugars for two (2) diabetic residents (#1 and #3) of five diabetic residents reviewed, from a sample of seven (7) residents. Findings include: 1. Resident #1 had a [DIAGNOSES REDACTED].=3 units; 226-300=6 units; 301-375=9 units; 376-500=12 units and 501-800=15 units, notify the physician if blood sugar is less than 50 mg/dl or more than 500mg/dl. Review of the medication record for January 2014 revealed that the resident had an elevated BS of 548mg/dl at 11:30 am on 1/9/14 and an elevated BS of 525 mg/dl at 11:30 am on 1/13/14, with ordered amounts of [MEDICATION NAME] given. However, record review and interview with the Director of Nursing on 1/23/14 at 3:30 pm revealed that the licensed staff on duty on the above dates and times failed to notify the physician of these elevated blood sugars. Also, the resident's blood sugar was elevated as "HI" (550 mg/dl or above) on the blood glucose monitoring device on 1/8/14 at 8:00 pm. It was documented that the resident was administered 25 units of [MEDICATION NAME] insulin. However, there was no evidence that the physician was notified of this elevated blood sugar. 2. Resident #3 had a [DIAGNOSES REDACTED]. The blood sugar level for the resident was 51 mg/dl on 1/5/14 at 4:00 am. Licensed staff "AA" acknowledged that the physician was not notified of this low blood sugar.

Based on observations, staff interviews and facility policy review, it was determined that the facility had failed to maintain one of three refrigerators in safe, operating condition. Findings include: Review of the facility's policy for "Work Requisitions" revealed that the Maintenance Supervisor was responsible to the Administrator for establishing and implementing a system for work requisitions which included prompt scheduling of repair and maintenance requests. Water was dripping down from the top to the bottom interior of refrigerator #1. . At least an inch of water had accumulated in the bottom left side of the refrigerator. In an interview on 6/4/12 at 2:35 a.m., dietary staff said that about three days ago she had reported the water drip to maintenance staff. During another tour of the kitchen with the Dietary Manager on 06/05/12 at 9:00 a.m., water was accumulating again in the bottom left side of the refrigerator #1. The Dietary Manager said that dietary staff had cleaned the water out of the bottom of the refrigerator, however, the water continued to drip from the top and pool in the bottom. In an interview on 6/05/12 at 4:40 p.m., the Administrator said that the refrigerator should be repaired. The Administrator said that everything had been removed from the refrigerator and a part was being ordered for its repair. Review of the Maintenance Repair Log revealed documentation on 5/28/12 and 5/29/12 that the problem of refrigerator #1 defrosting was listed but the sections "repaired by" and the "date complete" were blank.

Based on observation, staff interview and review of the facility's policy, it was determined that the facility failed to store food properly in one (1) freezer, and one (1) of three (3) refrigerators. Findings include: 1. Review of facility's policy for storing leftover food revealed that all containers would be labeled with the food item, used by date, and tightly covered. Cold food must be covered, dated and labeled. During the initial tour of the kitchen with the Dietary Manager on 06/04/12 at 2:35 p.m., there was a large tray covered with foil on the top shelf in the freezer. There was not a label on the tray. When asked about the tray's contents, staff reported that it was ham salad. There was a hole in the foil so, it was not impervious to prevent contamination or damage to the contents from frost. Staff said that the contents should have been completely covered. When staff opened the container, it contained potato salad instead of ham salad. Staff covered the tray containing the potato salad with plastic wrap and aluminum foil, labeled it and then returned it to the freezer. 2. Water was dripping down from the top to the bottom inside of refrigerator #1. At least an inch of water had accumulated in the bottom of the left side of the refrigerator. Milk was being stored in the water. When the staff was asked about it, the staff reported that the milk should not be stored in the water. After surveyor inquiry, staff moved the milk into into another refrigerator. During an interview on 6/05/12 at 4:40 p.m., the Administrator said that the potato salad had been improperly stored. She said that the milk should not have been stored in the water and the water leak in the refrigerator should be repaired. The Administrator said that everything had been removed from refrigerator #1 and a part was being ordered to repair it. See F456 for additional information regarding refrigerator #1.

Based on observation, interviews with residents and staff, and review of the facility's policy, it was determined that the facility failed to provide personal privacy during showers for five (5) residents ("A", "B", "C", "D" and "E") from a sample of 36 residents. Findings include: The facility's policy documented that nursing staff was to protect residents' privacy at all times when showering or bathing. However, nursing staff failed to provide full visual privacy during bathing for residents "A", "B", "C", "D" and "E". During an interview on 6/04/12 at 4:36 p.m., resident "D" stated that there was not any privacy in the common shower. The resident said that residents were in the shower room together. In an interview on 6/05/12 at 12 p.m., resident "B" stated that there were usually two or three female residents in the shower room during their showers. "B" said that all of those esidents saw each other nude. The resident said that it used to make her feel uncomfortable but she was used to it now. However, she said that she would have preferred to have privacy when showering. During an interview on 6/05/12 at 1 p.m., resident "A" stated that there were often two or thee other nude residents being showered at the same time. Resident "A" said that they all saw each other nude. During an interview on 6/05/12 at 5 p.m., the family member of resident "C" reported that resident "C" was often bathed in the shower room with two other residents. The family member said that staff had not pulled the privacy curtains closed so the other residents saw resident "C" nude. . Two male residents were observed in the shower room with two staff memebers on 6/06/12 at 7:15 a.m. However, staff had not pulled the privacy curtains closed to provide full visual privacy for each of those residents during their showers. In an interview on 6/06/12 at 8:36 a.m., resident "D" stated that there was "absolutely no privacy in the shower room." Resident "D" stated that there were always other residents in the shower room at the same time that he/she was getting a shower. Resident "D" said that they could see each other during their showers. During an interview on 6/06/12 at 8:44 a.m., resident "E" stated that sometimes there were two or three other residents nude and in the shower at the same time. Residnet "E" stated that there was no privacy when taking a shower. Residnet "E" said that there were usually three or four other people in the shower room at the same time. "E" said sometimes there were only two residents in the shower room but, it was not private and you could not hide from the others (seeing you). In an interview on 6/06/12 at 9 a.m., resident "A" stated that she did not like to be bathed with other reisdents. "A" stated that sometimes she tried to take a shower early in order to be alone. "A" said that if she was not the first one in the common shower room then, there were always other nude residents in the shower. During an interview on 6/06/12 at 2:45 p.m., certified nursing assistant (CNA) "AA" stated that privacy cutains were supposed to be pulled at all times when residents were in the shower but, it was not always done. In an interview on 6/06/12 at 3:10 p.m., CNA "BB" stated that, sometimes there were two and three residents in the shower room at the same time and sometimes that privacy curtains were not pulled. During an interview on 6/06/12 at 4 p.m., administrative staff stated that the privacy curtains in the shower room should have been pulled at all times when any resident was being showered to protect the resident's privacy. .

Based on staff interview and record review, it was determined that the facility failed to revise the care plan for one resident (#3) with a history of removing or disconnecting his/her gastrostomy tube from a sample two residents reviewed with gastrostomy tubes in a total sample of 17 residents. Findings include: Resident #3 had a [DIAGNOSES REDACTED]. The resident had a care plan since 2/8/10 to address his/her having a feeding tube in place as his/her only source of nutritional intake. Licensed nursing staff had documented in the nurses notes that the resident had removed or disconnected his/her feeding tube on 8/31/10, 9/24/10, 10/5/10, and 11/21/10. In an interview on 12/14/10 at 12:30 p.m., licensed nurse "RR" stated that the staff had attempted to distract the resident from pulling out his/her feeding tube by giving him/her a stuffed animal to hold, by keeping the resident's hand on top of the covers when he/she was in bed and, by taking him/her to the planned activities. However, the resident's care plan had not been revised to include the identified behavior problem of his/her removing or disconnecting his/her feeding tube. In addition, although the nurse said that interventions had been implemented to address the resident's behavior, those interventions were not included in the care plan. See F322 for additional information regarding resident #3.

Based on observation and record review, it was determined that the facility failed to ensure that the head of the bed was elevated for one resident (#7) and that one resident (#3) did not remove his feeding tube in a census of two residents with feeding tubes from a total sample of 17 residents. Findings include: 1. Resident received all of his/her nutrition by continuous tube feeding. He/She has a care plan intervention since 9/16/10 for staff to elevate the head of his/her bed according to the facility's "Tube Feeding" policy. According to that policy when a resident was been given continuous (tube) feeding, the head of his/her bed was supposed to be elevated at least 30 to 40 degrees at all times. However, during an observation of the certified nursing assistant providing range of motion exercises for the resident on 12/14/2010 from 9:25 a.m. to 9:35 a.m., the CNA lowered the head of the resident's bed to approximately 10 degrees while the feeding pump continued to infuse formula through the feeding tube. 2. Resident #3 had [DIAGNOSES REDACTED]. The resident had a physician's orders [REDACTED]. According to documentation by the licensed nursing staff, the resident have removed or disconnected his/her feeding tube numerous times. The nurses wrote in their notes that the resident had done that on 8/31/10, 9/25/10, 10/5/10 and 11/21/20. However, the facility had not revised the resident's care plan to include that identified behavioral problem. According to the 8/31/10 nurses notes, the licensed nurse had reconnected the resident's feeding tube after he/she had removed it. The nurse documented having told the resident not to pull on his/her (feeding) tube and having the resident put his/her hands on top of the bed covers to prevent him from pulling on the tube. The 9/24/10 nurses notes contained documentation about the resident having torn the tip off of the feeding tube and holding it in his her hand while [MEDICATION NAME] 1.5 (feeding tube formula) was dripping onto his/her bed. The licensed nurse wrote that he/she had reinserted the tip back into the feeding tube and had repaired the feeding tube. The nurse described in the 10/5/10 nurses note that the resident had been found holding the feeding tube clamp and tube in his/her hand. The licensed nurse documented that that she had reinserted the feeding tube tip back into the feeding tube and secured the feeding tube. The nurse noted that the tip of the feeding tube had been broken off so, it had to be trimmed in order to fit properly. The nurse documented in the 11/21/10 notes that the resident had pulled out his/her feeding tube which had been replaced with a #14 catheter tube. In and interview on 12/14/2010 at 2:30 p.m., licensed nurse "RR" said that the staff had attempted to distract the resident from pulling out his/her feeding tube by giving him/her a stuffed animal, by keeping his/her hands on top of the covers while he/she was in bed and by taking him/her to planned activities. However, none of those interventions were included in the resident's care plan. Resident #3 was observed lying in bed partially covered with the bed covers on 12/13/10 at 4:25 p.m. There was a stuffed bear at the foot of bed between the bed's mattress and frame but, the resident was not able to reach it. On 12/14/10 at 1:30 p.m. and 4:30 p.m., the resident was lying in bed partially covered by the bed covers and staring into space. The stuffed bear was still at the foot of the bed. The resident had removed his/her neck pillow and was holding it in his/her hand. The resident was seated in a geri-chair in the hallway next to a window on 12/15/10 at 10:15 a.m. He/She was pulling at the curtains on the window. He/she had not been given a stuffed animal to hold.

Based on observation, record review, and staff interview, it was determined that the facility failed follow the plan of care for one resident (#5) with a [MEDICAL TREATMENT] access device, and for one resident (#7) with a continuous tube feedings from a sample of 17 residents. Findings include: 1. Resident #5 had care plan interventions since 11/22/10 for staff to monitor and assess his/her [MEDICAL TREATMENT] for any problems with it and to ensure that it was intact, the dressing was dry and intact, to assess the site for signs and symptoms of infection, and to monitor for it for any redness, drainage and irritation. However, during an interview and review of the clinical record with the Director of Nursing on 12/13/10 at 2:55 p.m., she stated that there was not any documentation in the resident's clinical record which indicated the implementation of those interventions for the [MEDICAL TREATMENT] had been done. See F309 for additional information regarding resident #5. 2. Resident #7 had a care plan intervention since 9/16/10 for the staff to elevate the head of his/her bed according to the facility's policy. Review of the facility's 9/10 "Tube Feeding" policy revealed that the resident's head was supposed to be elevated at least 30 to 45 degrees at all times with continuous (tube) feedings. However, during an observation of the certified nursing assistant (CNA) providing range of motion exercises for the resident on 12/14/10 from 9:25 a.m. to 9:35 a.m., the CNA lowered the head of the resident's bed to approximately ten (10) degrees while the feeding pump was still infusing. See F322 for additional information regarding resident #7.

Based on record review and staff interview, it was determined that the facility failed to monitor and assess the status of the [MEDICAL TREATMENT] for one resident (#5) in a sample of three residents who were received [MEDICAL TREATMENT] services, from a total sample of 17 residents. Findings include: Resident #5 received [MEDICAL TREATMENT] services. He/she had a care plan intervention since 11/22/10 for nursing staff to monitor and assess his/her [MEDICAL TREATMENT] for any problems with it and to ensure that the access site was intact. There were interventions for nursing staff to assess the access site for any signs and symptoms of infection and to monitor it for redness, drainage and irritation. There was an intervention for the dressing to be dry and intact. However, during an interview and review of the clinical record with the Director of Nursing on 12/13/10 at 2:55 p.m., she stated that there was not any evidence from 11/22/10 to 12/13/10 to indicate that nursing staff had implemented those interventions to promote the integrity of the resident's [MEDICAL TREATMENT].