Every finding on record at Shands Jacksonville Medical Center

Based on the kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness. The facility failed to ensure that the dietary staff was trained and knowledgeable about the proper procedures for hand hygiene, disposable glove use, food storage, and proper sanitation practices in the kitchen. Specific instruction on hand hygiene, food handling, and sanitation is important in health care settings serving nursing home residents due to the risk of serious complications from foodborne illness as a result of their compromised health status. Unsafe food handling practices represent a potential source of pathogen exposure. Findings include: During the initial kitchen tour on [DATE] from 10:33 AM until 11:25 AM with the Patient Services Manager (PSM) and the Quality Assurance (QA) Specialist, the hand sink nearest to the door did not have paper towels in the dispenser or a garbage can to dispose of paper towels. Employee C, a food preparation cook, was observed at 10:35 AM to doff one of his disposable gloves, take his phone out of his pocket with his bare hand, use the phone and return it to his pocket, take off his other glove and discard it, and don a new pair of gloves without washing his hands. He was observed again at approximately 10:43 AM to doff his gloves and don a new pair of gloves without washing his hands. Employee D was observed at 10:39 AM to open a bag of sliced bread and remove six slices of bread with her bare hands. She laid them out on the cutting board, went to the dish room to retrieve a spreader, went out of the kitchen to the retail section of the cafeteria and fill a quart size cup with chicken salad and return to the cutting board. She did not have gloves on, and she then went to wash her hands. After washing her hands and taking the paper towel to dry them, she turned the water off with her bare hand, thereby recontaminating her hand. She dried her hands, disposed of the paper towels, and donned a pair of disposable gloves. She then went back to the cutting board. She did not discard the bread slices but continued to make the sandwiches using the bread. The three door reach-in cooler had standing water in the bottom of the unit. No internal thermometer was found inside the unit. The salad bar cooler had no internal thermometer. The daily prep cooler had a bag of raw chicken pieces submerged in juice lying on a shelf with no tray under it to guard against leakage (Photographic evidence obtained). No internal thermometer was found. The walk in cooler had no internal thermometer. The walk in freezer had no internal thermometer. Food was observed on the floor (Photographic evidence obtained). In the ware washing area of the kitchen, stainless steel mixing bowls and baking pans were found to be wet nesting, stacked on top of each other with no chance to air dry. Flies were observed in the kitchen. Observation of the dish room and dish washing processes revealed Employee F working in the dish room by himself. He loaded the dirty dishes on the conveyor belt and then went to the other end of the machine and unloaded the clean dishes without doffing his contaminated gloves, washing his hands, and donning new gloves. He continued to do this without changing gloves or washing his hand during the whole observation from 10:33 AM until 11:25 AM. The hand washing sink in the dish room was blocked by several carts stored in the area. Flies were observed in the dish room. During a follow-up tour and lunch meal service observation on [DATE] from 11:35 AM until 1:37 PM, the hand sink nearest to the door had no trash can to dispose of paper towel. The three door reach-in cooler still had standing water in the bottom and no internal thermometer. The QA Specialist moved a cardboard box that was sitting in the water. She stated she was not sure where the water was coming from. Stainless steel bowls were observed on the shelves in the ware washing area wet nesting. The QA Specialist stated they would have to get more shelving to allow for proper air drying of the pots and pans. The QA Specialist acknowledged that the missing internal thermometers did not just happen recently, and that the coolers had probably been without an internal thermometer for some time now. She did not know how long. One of the reach-in coolers near the tray line had an external digital thermometer display that was covered by a piece of tape. The QA Specialist laughed and pulled the tape off to indicate the thermometer was working. She stated, I keep it covered because I don't want the staff to rely on the external thermometer reading only. I want them to check the internal thermometer. The cooler did not have an internal thermometer. Standing water was observed on the floor of the kitchen under the prep sink and the counter. Employee F was instructed by the QA Specialist to mop up the floor. Water was observed on the floor under a shelving unit in the ware washing area of the kitchen. Flies were again observed in the kitchen. The food mixers in the bakery prep room were both dirty with crusted on food. The large mixer's mixing mechanism had rust and the outer seal was peeling off into the mixing bowl (Photographic evidence obtained). During an interview with the QA Specialist and the Chef at 1:29 pm, the Chef stated that the mixers were recently brought over from the main hospital and they have not been used. During the lunch meal service observation from 11:55 AM until 12:40 PM, Employee E, Culinary Supervisor, was observed to be plating food on the tray line. She did not change gloves when they became contaminated. QA Specialist, Employee I, Patient Services Supervisor, and Employee C all opened the door to the food warmer behind the tray line at different times during the meal tray preparations. After they touched the latch to the food warmer, Employee E then opened the door by touching the latch. After she touched the latch, she did not change her gloves. She went to the tray line and continued to plate the food with the same gloves. She then opened a bag of hamburger buns and took one bun out of the bag and put in on a plate with her contaminated gloves. She prepared a hamburger. She then went to the warmer, opened the door, and plated French fries on the plate with the hamburger. After putting the plate on cart for service, she went back to the tray line and kept plating food without changing her gloves or washing her hands. During an interview with Employee D on [DATE] at 12:45 PM, she stated that she was not aware that she did not have gloves on when she took the bread out of the bread bag on [DATE]. She stated she should have had gloves on while making sandwiches. She did not remember shutting the faucet off with her bare hand after washing her hands. She has received training on hand hygiene and glove use. When asked what she should have done after touching the bread with her bare hands, she stated, I should have thrown it away. During an interview with Employee C on [DATE] at 1:05 PM, he stated he remembered he used his phone on [DATE], and that he keeps it in his back pocket while working. He did not remember whether or not he washed his hands after using the phone and prior to donning new disposable gloves. He stated he knew he should do that and has had training on hand hygiene and glove use. During an interview with the QA Specialist on [DATE] at 1:10 PM, she confirmed that there is not a hand washing sink in the area of the tray line. She indicated the nearest hand washing sink 20 feet from the tray line located in the prep area of the kitchen. She confirmed that it was not located close enough for accessibility by Employee E while plating the food, and it is not convenient for her to change gloves and wash her hands often enough. She stated that she was aware of the flies in the kitchen, and she knew the pest control company had come in the last month to treat for them. She stated she thought the problem was due to a drain in the kitchen and water backing up into the kitchen, but that had been fixed. A second observation of the dish room from 1:15 PM until 1:37 PM revealed Employee F rinsed the dirty lunch dishes, loaded the dish machine, and started the conveyor belt. He did not doff his disposable gloves or wash his hands and don clean gloves before he went to the other end of the dish machine and removed the clean dishes from the machine, thereby recontaminating the dishes. Water was observed on the floor of the dish room under the sink used to rinse the dishes prior to loading them into the dish machine. A swarm of flies was observed in the dish room near the standing water on the floor. Food debris was stuck on the stainless steel chute under the rinse sink in the dish room. During an interview with Employee F on [DATE] at 1:30 PM, he stated there is a hand wash sink in the dish room and indicated the hand sink that was blocked by the stored carts. He stated he does not use it. He stated he washes his hands in one of the sinks in the kitchen. The nearest sink to the dish room in the kitchen was observed to be 35 to 40 yards from the rinse sink in the dish room. He confirmed he had not changed his gloves when he went from the dirty side of the dish room to the clean side. He stated he had been trained to change his gloves and wash his hands prior to unloading the clean dishes. He confirmed that there has been a problem for some time now in the dish room with flies swarming near the rinse sink and water standing on the floor of the dish room. During an interview with the contracted pest control company representative on [DATE] at 1:35 PM, he stated that he had been in the facility kitchen on [DATE], but was not made aware of the swarming flies in the dish room. He bent down and took his flashlight and showed this surveyor the stuck on food debris on the wall and the stainless steel chute under the rinse sink. He stated that is a good food source for the flies. He stated the standing water is also a big problem because the flies are attracted to it. During an observation of the Transitional Care South Unit nutrition room, seventeen individual nutritional supplements were found to be expired (Photographic evidence obtained). One carton expired [DATE]. During an interview with Employee G, Certified Nursing Assistant, on [DATE] at 1:35 pm, she looked at the expiration dates on the cartons and stated that the dietary staff are responsible for the rotation of the nutritional supplements. She did not know why the expired cartons were still available for use in the nutrition room. Review of the employee training entitled Infection Prevention and Control: Protect Yourself, Protect Others, dated ,[DATE], revealed Employees C and E were not on the sign-in list indicating they had not received the training. No other training sign in sheets were provided. Review of the facility policy and procedure entitled Hand Hygiene, #F007, last revised on ,[DATE] revealed it read: In the Food & Nutrition Services Department: All associates associated with the handling of food shall wash hands. Hands are washed with soap and water at the following times: Before handling food or clean utensils/dishes/equipment. Before putting on gloves. After handling soiled silverware/utensils. After removing gloves. After any other activity that may contaminate the hands. All hand wash sinks should be easily accessible with nothing blocking their access in food production, food service and dishwashing areas. Hand wash sinks should be clean and stocked with soap, paper towels and a covered waste receptacle. Use a paper towel to turn off the faucet to avoid contact with faucet germs (Copy obtained). Review of the facility policy and procedure entitled Disposable Glove Use, #F021, last revised on ,[DATE] revealed it read: Disposable, non-latex gloves must be worn at the following times: When handling ready to eat foods. When handling clean utensils/dishes/equipment. When handling soiled dishware. Procedures: Hands must be washed before putting on and after removing disposable gloves when working in the kitchen. Disposable gloves must be changed, and hands washed when the gloves are dirty or ripped and when moving from one task to another, such as moving from handling dirty dishes to handling clean dishes (Copy obtained).

Based on observations, staff interviews, and facility document review, the facility failed to ensure the pest control service was effective. Failure to maintain a pest free kitchen allows the possibility of the spread of disease by pests and infection of the residents. The findings include: During the initial kitchen tour on 09/28/2020 from 10:33 AM until 11:25 AM, flies were observed in the kitchen and the dish room. During a follow-up tour and lunch meal service observation on 09/29/2020 from 11:35 AM until 1:37 PM, flies were again observed in the kitchen and the dish room. During an interview with the QA Specialist on 09/29/2020 at 1:10 PM, she stated that she was aware of the flies in the kitchen and she knew the pest control company had come in the last month to treat for them. She stated she thought the problem was due to a drain in the kitchen and water backing up into the kitchen, but that had been fixed. During an interview with Employee F, dish washer, on 09/29/2020 at 1:15 PM, he stated that there are many flies under the rinse sink in the dish room and it has been that way for some time now. Flies were observed to be swarming under the rinse sink in the dish room. During an interview with the contracted pest control company representative on 09/29/2020 at 1:35 PM, he stated that he had been in the facility kitchen on 09/28/2020, but was not made aware of the swarming flies in the dish room. He bent down and took his flashlight and showed this surveyor the stuck on food debris on the wall and the stainless steel chute under the rinse sink. He stated that is a good food source for the flies. He stated the standing water is also a big problem because the flies are attracted to it. Review of the facility Inspection Report dated 09/26/2020 revealed the contracted pest control company treated the facility for rats but not flies in the kitchen (Copy obtained). Review of the facility Inspection Report dated 09/25/2020 revealed the contracted pest control company noted no pest activity. The facility was treated for [REDACTED]. Review of the facility Inspection Report dated 08/31/2020 revealed the contracted pest control company noted exclusion old walk-in door. Recommended exclusionary measure to inhibit pest entry. Recommended door sweep be replaced. Exposed food: Alternative food sources were noted during the inspection process. Actions: clear debris. Removal will help eliminate conductive conditions for pest activity. No pest activity noted. Cabinets under soda fountain still need to be cleaned out (Copy obtained). Review of the facility Inspection Report dated 08/28/2020 revealed the contracted pest control company noted no pest activity (Copy obtained).

Based on observations and staff interviews, the facility failed to maintain a comfortable water temperature within the range for hot water of 105-115 degrees for five rooms (Rooms #385, #342, #343, #351, and #374), out of 27 resident rooms located on the North and South units. The findings include: 1) An observation on 8/16/2016 at 3:18 PM of Room #343's water temperature revealed the water was lukewarm. A temperature was obtained at that time with a calibrated thermometer, and showed a temperature of 85 degrees Fahrenheit. An interview was conducted with Resident #146 on 8/16/2016 at 3:19 PM, and he complained the water was too cold. 2) An observation was conducted on 8/16/2016 at 03:20 PM of the water temperature for Room #351, and it was lukewarm. A water temperature was obtained on 8/18/2016 at 3:50 PM, along with Employee M, Maintenance Supervisor, and Employee N, Director of Facilities, for Room #351. The temperature was obtained with the facility's digital infrared thermometer, and a reading of 76 degrees was obtained. 3) A water temperature was obtained on 8/18/2016 at 3:30PM, along with Employee M and Employee N, for Room #385. The water temperature was obtained with the facility's digital infrared thermometer, and a reading of 115.6 degrees was obtained. An interview on 8/18/2016 at 3:31 PM with Employee N confirmed the facility did not check residents' rooms individually for appropriate ranges for water temperatures. 4) A water temperature was obtained on 8/18/2016 at 3:40 PM with Employee M and Employee N for Room #374. The water temperature was obtained with the facility's digital infrared thermometer, and a reading of 72 degrees was obtained. An interview was conducted with Resident #150 who resided in Room #374, and he complained his water was cold frequently and never warmed up, even if it ran for a long time. 5) A water temperature was obtained on 8/18/2016 at 3:55 with Employee M and Employee N, for Room #342. The water temperature was obtained with the facility's digital infrared thermometer, and a reading of 73 degrees was obtained. An interview was conducted with the PCA (Patient Care Assistant) on 8/18/2016 at 4:00 PM, who confirmed the South Unit's water had not been hot for a few weeks. She was asked how she got hot water for her residents, and she stated, I will go into the nurse's room and get water from there and walk it back to the resident's room. We have a shower room that the residents can go in for a shower, and the water is hot in there. An interview with the Patient Care Assistant (PCA) on 8/18/2016 at 4:03 PM confirmed the South Wing had no hot water, and that she had been getting water from Room #348. She stated, The water in there gets hot pretty quick, and that's what I use. An interview was conducted on 8/18/2016 at 4:27 PM with Employee G, Division Director, who confirmed she was not aware that the water in the South Unit was not reaching the appropriate temperature. She stated the facility would get it fixed.

Based on observations, record reviews, and staff interviews, the facility failed to maintain a safe and sanitary environment during wound care for 3 of 3 residents sampled for pressure ulcers (Resident #114, Resident #67, and Resident #121), and failed to ensure the use of personal protective equipment (PPE) and handwashing in 2 of 7 resident rooms designated with contact precautions (rooms [ROOM NUMBERS]). The facility failed to provide and maintain environmental infection control and prevention for 3 of 11 resident rooms (Rooms #305, #342, and #386) with active isolation precautions. The findings include: 1. An observation of the lunch tray delivery was conducted on the Expansion Unit on 8/15/16 at 12:00 pm. All meals were delivered on trays via rolling thermal carts, and delivered into each individual resident's room. Employee J, Catering Associate, arrived to room [ROOM NUMBER] at 12:10 pm, and dressed in personal protective equipment (disposable gown and gloves) prior to entering the room. She delivered the tray by placing it on the resident's over-bed table, then removed the gown and gloves prior to exiting the room. Employee J did not wash her hands after removing the gloves, and before delivering the remainder of the lunch trays to the remaining resident rooms. An interview was conducted with Employee O, Registered Nurse (RN), on 8/15/16 at approximately 12:15 pm. She stated the resident in room [ROOM NUMBER] was on contact precautions for a wound on his ear that had become infected with Methicillin-Resistant Staphylococcus Aureus (MRSA, an antibiotic resistant bacterial infection). During a tour of the South Unit on 8/15/16 at approximately 12:20 pm, Employee P, RN, stated the resident in room [ROOM NUMBER] was on contact precautions for a history of clostridium difficile (an antibiotic-resistant bacterial infection of the colon). On 8/17/16 at 10:45 am on the South Unit, room [ROOM NUMBER] was visited. There was a sign on the door to stop prior to entering, and a cart with personal protective equipment was located outside the room. Employee I, Case Manager, was inside the room at the foot of the resident's bed. She was speaking with the resident, and was dressed in a lab coat. Employee I did not wear the disposable gown or gloves provided for safe entry into room [ROOM NUMBER]. 2. An observation was conducted on 8/17/2016 at 2:18 PM of wound care being performed for Resident #114 by Employee H, Registered Nurse (RN). The employee was observed cleaning the wound for Resident #114, and did not remove her gloves or perform hand hygiene afterward. The nurse then proceeded to place a clean 2x2 gauze pad inside of the resident's wound using her fingers. Employee H finished the wound care, removed her gloves and PPE, left the room, and used hand sanitizer from the outside wall of the resident's room. She never washed her hands. A record review for Resident #114 revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Physician orders, dated 8/17/2016, stated, Cleanse wound and peri-wound then pat dry. No-sting barrier to peri-skin, apply a thick coat of Santyl to a 2x2 gauze and lightly pack into wound bed daily and as needed, and cover with a foam dressing. An interview was conducted on 8/17/2016 at 2:37 PM with Employee H, RN, who confirmed she did not change her gloves or perform hand hygiene after cleaning Resident #114's wound per facility procedure. The employee was asked when she should wash her hands, and she replied, Before we start, after we remove the dressing, and at the end. Employee H confirmed she used her hands to insert gauze into the wound, and all of the supplies she was touching were now contaminated. An interview on 8/18/2016 at 9:51 AM with Employee G, RN, confirmed the facility's procedure for handwashing was anytime the employee was visibly soiled, we expect them to wash their hands. An interview on 8/18/2016 at 11:16 AM with Employee E, RN, and Employee F, RN, confirmed staff were to perform hand hygiene when hands were visibly soiled, and should remove gloves and perform hand hygiene after cleaning a wound, and after leaving a room. Employee R confirmed the staff should use a sterile cotton applicator to insert packing into a wound and not their fingers. A review of the Policies and Procedures (P&P), dated 4/2016, for Isolation Precautions and Infection Control Practices read, It may be necessary to perform hand hygiene between tasks and procedures on the same patient to prevent cross-contamination. (Photographic evidence obtained.) A review of the P&P for Clinical Skills for Dry and Moist to dry dressing change, (not dated), read, Clean wound and dry, apply antiseptic ointment with cotton tipped applicator or gauze, remove gloves, and perform hand hygiene. Apply new clean gloves and apply dressing. (Photographic evidence obtained.) 3. On 8/15/2016 at 11:26:40 AM, an observation was conducted during the facility tour. Employee Q was observed exiting room [ROOM NUMBER] carrying red bagged waste with ungloved hands. On 8-15-16 at 11:55 AM, an observation was conducted during the lunch tray pass. Employee D was observed entering a Clostridium difficile (C-diff) isolation room with Resident #67's lunch tray. Employee D donned PPE prior to entry, but failed to wash hands with soap and water after removing the gown and gloves before exiting the isolation room. Employee D used alcohol foam for sanitizing hands. Employee D stated she forgot to wash her hands before exiting. On 8-17-16 at 5:30 PM, an interview with the facility's Housekeeping Manager (HKM) was conducted. The HKM was asked about the current disinfection products used for cleaning and disinfection of floors, resident rooms, and common areas within the facility. The HKM stated that the facility used A-456 II cleaner for daily general purpose resident room cleaning. The HKM stated that the product was pre-mixed according the manufacturer's specifications. The housekeeping staff used labeled spray bottle application of the disinfectant solution. She stated that the wet kill time for most organisms listed was 10 minutes visibly wet. The HKM stated that resident rooms were cleaned and disinfected daily. On 8-18-2016 at 11:25:31 AM, an interview with the facility's Infection Control Manager, Employee F, was conducted. Employee F was asked about the proper procedure for transporting red bagged waste, and she stated that staff handling red bag soiled material should have at least one gloved hand dedicated when transporting red bagged waste. Employee F stated that she was not familiar with the use of a glove pinched over the red bag for transport and that the procedure would not be an acceptable infection control practice in handling red bagged waste. Employee F was asked about the facility's policy for hand hygiene when exiting[DIAGNOSES REDACTED] isolation rooms, and she stated that the facility's policy would require that employees would wash hands with soap and water after removal of gown and gloves, before exiting the[DIAGNOSES REDACTED] isolation room. She stated that the alcohol foam was not sufficient hand sanitizing following encounters with residents on isolation precautions for[DIAGNOSES REDACTED]. Employee F was asked what type of disinfectant was used to disinfect against the[DIAGNOSES REDACTED] organism in isolation rooms, and she stated that bleach wipes were used in the disinfection of[DIAGNOSES REDACTED] isolation rooms on all surfaces, with exception of the floors. University of Health Jacksonville (Shands) Policy #IC-02-011, dated October 2015, 6 pages. Review of this document revealed that Section III, Infection Control Practices under letter A stated, All patients and staff will be managed to protect against blood born infections by using personal protective equipment (PPE) as outlined in the Isolation Precautions policy IV-01-001. Also, listed under 1. Daily room cleaning procedures: a., b., c., d., e., f. daily mopping of floors. 2. Environmental Services (EVS) personnel will be responsible for the daily cleaning of the isolation rooms using daily cleaning procedures, with the addition of the following listed below (page 2 of 6): a. Employees must wear the proper PPE for the type of isolation (refer to policy IC-01-001) and use the appropriate disinfectant (germicidal and/or bleach solution) based on the type of isolation. See list below. Follow sequence when donning PPE. Use proper hand hygiene (refer to policy IC-01-007). e. Use damp mop to gather debris and to mop floor. l. Remove isolation clothing following the sequence for removing PPE. m. Thoroughly wash your hands. Page 5 of 6 listed Environmental Cleaning Product and Usage for Patient Room Cleaning: Chemical name used on and location A-456 II Disinfectant Cleaner Patient rooms, Exam rooms, Floors (All surfaces) Sani-Cloth Bleach Germicidal Wipe surfaces, including but not limited to, bed rails, phones, door knobs, bathrooms, etc. in[DIAGNOSES REDACTED] and Rotavirus isolation patient rooms and exam rooms (All high touch). Isolation Precautions per Hospital Infection Control Practice Advisory Committee (HICPAC)IC-01-001. A. Hand Hygiene: Perform hand hygiene after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn. Hand hygiene should be performed immediately after gloves are removed, between patient contacts, and when otherwise indicated to avoid transfer of microorganisms to other persons or environments. It may be necessary to perform hand hygiene between tasks and procedures on the same patient to prevent cross-contamination of different body sites. (refer to Policy IC-01-007) Facility provided letter for clarification, dated 8-18-16, stating TCU-SNF operates under the umbrella of the Infection Prevention and Control global policies recognized by the Clinical Center of UF Health Jacksonville.

Based on observations and staff interviews, the facility failed to maintain a comfortable water temperature within the range for hot water of 105-115 degrees for five rooms (Rooms #385, #342, #343, #351, and #374), out of 27 resident rooms located on the North and South units. The findings include: 1) An observation on 8/16/2016 at 3:18 PM of Room #343's water temperature revealed the water was lukewarm. A temperature was obtained at that time with a calibrated thermometer, and showed a temperature of 85 degrees Fahrenheit. An interview was conducted with Resident #146 on 8/16/2016 at 3:19 PM, and he complained the water was too cold. 2) An observation was conducted on 8/16/2016 at 03:20 PM of the water temperature for Room #351, and it was lukewarm. A water temperature was obtained on 8/18/2016 at 3:50 PM, along with Employee M, Maintenance Supervisor, and Employee N, Director of Facilities, for Room #351. The temperature was obtained with the facility's digital infrared thermometer, and a reading of 76 degrees was obtained. 3) A water temperature was obtained on 8/18/2016 at 3:30PM, along with Employee M and Employee N, for Room #385. The water temperature was obtained with the facility's digital infrared thermometer, and a reading of 115.6 degrees was obtained. An interview on 8/18/2016 at 3:31 PM with Employee N confirmed the facility did not check residents' rooms individually for appropriate ranges for water temperatures. 4) A water temperature was obtained on 8/18/2016 at 3:40 PM with Employee M and Employee N for Room #374. The water temperature was obtained with the facility's digital infrared thermometer, and a reading of 72 degrees was obtained. An interview was conducted with Resident #150 who resided in Room #374, and he complained his water was cold frequently and never warmed up, even if it ran for a long time. 5) A water temperature was obtained on 8/18/2016 at 3:55 with Employee M and Employee N, for Room #342. The water temperature was obtained with the facility's digital infrared thermometer, and a reading of 73 degrees was obtained. An interview was conducted with the PCA (Patient Care Assistant) on 8/18/2016 at 4:00 PM, who confirmed the South Unit's water had not been hot for a few weeks. She was asked how she got hot water for her residents, and she stated, I will go into the nurse's room and get water from there and walk it back to the resident's room. We have a shower room that the residents can go in for a shower, and the water is hot in there. An interview with the Patient Care Assistant (PCA) on 8/18/2016 at 4:03 PM confirmed the South Wing had no hot water, and that she had been getting water from Room #348. She stated, The water in there gets hot pretty quick, and that's what I use. An interview was conducted on 8/18/2016 at 4:27 PM with Employee G, Division Director, who confirmed she was not aware that the water in the South Unit was not reaching the appropriate temperature. She stated the facility would get it fixed.

Based on observations, record reviews, and staff interviews, the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity, evidenced by the failure to cover indwelling Foley catheters with a dignity bag for two residents (Resident #114 and Resident #146), out of a total of 25 residents sampled. The findings include: 1. An observation was conducted on 8/17/2016 at 11:51 AM of Resident #114 sitting in his wheelchair in the therapy department. His indwelling urinary catheter bag was clipped to the right side of the wheelchair, and it was not covered by a dignity bag. A brief interview with Resident #114 on 8/17/2016 at 11:52 AM revealed that he had not been offered a dignity bag to cover his indwelling urinary catheter bag until the previous day, 8/16/16. An observation was conducted on 8/17/2016 at 2:49 PM of Resident #114 with his catheter bag clipped to the left side of the bed and visible to visitors. It was not covered by a dignity bag. An observation on 8/18/2016 at 8:48 AM was conducted of Resident #114 lying in bed with his indwelling urinary catheter and bag clipped to the left side of his bed and visible to visitors. It was not covered by a dignity bag. On 8/18/2016 at 10:47:09 AM, an interview with Employee A, Registered Nurse (RN), was conducted regarding urinary catheter bag covers, and she stated that all residents with urinary catheter bags should have dignity covers, especially when the resident was out of their room in public view. 2. On 8/15/2016 at 12:15:28 PM, an observation was conducted in the physical therapy treatment room. Resident #146 was observed in a wheelchair with a urine collection bag hanging on the side of the wheelchair. There was no dignity cover for the exposed urine collection bag. On 8/16/2016 at 2:50 PM, an observation and interview was conducted with Resident #146. The resident's urine collection bag was hung on the right side of the resident's bed, out of view from the open door, and did not have a dignity cover. The resident stated that the bag had never been covered. The resident stated he did not know that there was such a thing and that it would be nice to have the bag covered. On 8/17/2016 at 11:42:28 AM, Resident #146 was observed in the therapy treatment room; there was no dignity cover used for his urine collection bag. The urine bag was still exposed. On 8/18/2016 at 10:15:56 AM, an interview with Employee B, RN, was conducted on the South Wing. The employee was asked about the care provided for residents with urinary catheters with collection bags. Employee B stated that any resident with a catheter bag should have the bag kept up off ground, the bag should be hung on the side of the bed and/or on the side of the wheelchair, and that each bag should have a dignity cover. Employee B stated the facility did have urinary catheter dignity bags.

Based on observations, record reviews, and staff interviews, the facility failed to provide reasonable accommodation of individual needs and preferences for 1 of 30 sampled residents (Resident #142), whose rooms were observed. The findings include: On 8/17/2016 at 3:28 PM, an observation was conducted of Resident #142's call light wrapped and clipped to the wall behind the resident's bed. (Photographic evidence obtained.) A family interview was conducted with Resident #142's mother on 8/17/2016 at 2:30 PM, and she was asked how the resident asked for help since her call light was out of reach. The mother replied, Oh, she will let them know if she needs something; she yells out for them to come in the room. An observation was conducted on 8/18/2016 8:43 AM of the call light for Resident #142 tied and clipped to the wall behind the resident's bed and out of reach of the resident. An observation was conducted on 08/18/2016 at 10:37 AM of the call light for Resident #142 out of her reach. A brief interview with the resident was conducted at this time, and she was asked if she had a call light, and could she use it. She replied, Yes. An interview was conducted on 8/18/2016 at 10:40 AM with Employee C, Certified Nursing Assistant (CNA), who was assigned to care for Resident #142. The CNA verified the call light for the resident was out of her reach, and not able to be used if she needed to call for assistance. An interview was conducted on 8/18/2016 at 10:57 AM with Employee A, Registered Nurse (RN), who confirmed the call light for Resident #142 was out of the resident's reach and was not connected. Employee A also confirmed the call light being used was not appropriate for the resident, since she had bilateral hand contractures and would need a touch pad. Employee A was then observed switching out the currently used call light/TV remote with an appropriate touch pad call light which Resident #142 could use. A record review for Resident #142 was conducted which revealed [DIAGNOSES REDACTED]. A review of the care plan for Resident #142, dated 7/29/2016, revealed the resident was at risk for injury, with interventions including keep call light in reach, resident is unlikely to use, but will remain within easy reach, and educate resident and family on fall precautions and use of call bell. A review of a Admission Minimum Data Set (MDS), dated [DATE], revealed the resident required total dependence with a 2-person physical assist for all activities of daily living.

Based on record review and employee interview the facility failed to ensure that three of three sampled residents for Liability Notice & Beneficiary Appeal Rights Review, out of 18 total Stage II residents were informed in advance of the end date for their skilled services. The findings include: Review of the Notice of Medicare Non-Coverage form for Resident #17 revealed she was given notice on 03/27/2015 that her the coverage for her skilled services was going to end on 03/27/2015. Review of the Notice of Medicare Non-Coverage form for Resident #11 revealed he was given notice on 05/27/2015 that his the coverage for his skilled services was going to end on 05/27/2015. Review of the Notice of Medicare Non-Coverage form for Resident #36 revealed she was given notice on 05/15/2015 that her the coverage for her skilled services was going to end on 05/15/2015. During an interview with the Director of Nursing on 06/30/2015 at 2:20 pm she stated she was not aware that the Notices of Medicare Non-Coverage had been given to Residents #17, #11 and #36 on the same day the coverage would end. She stated that she did not know that they should be given in advance in order to give the resident time to file an appeal. It was explained to her that it is a resident right. She stated that the case manager assigned to these residents is responsible for making sure the notices are given in a timely manner. During an interview with the Director of Case Management on 07/01/2015 at 1:06 pm she stated she was not aware that the Notice of Medicare Non-Coverage was not given to Residents #17, #11 and #36 in advance of the day their skilled services would end. She stated that her expectation is that the case manager should give them to the residents at least 48 hours or more prior to their skilled services ending.

Based on record review and interviews with facility staff and residents, the facility failed to meet residents' choices about aspects of their lives in the facility that are significant to the resident related to provision of snacks for 2 residents (Residents #217 and #226), who were on consistent carbohydrate diets and received [MEDICAL TREATMENT] services outside the facility three times per week, out of 2 residents sampled for [MEDICAL TREATMENT] services. The findings include: 1) A review of the electronic medical record for Resident #217 revealed that he was admitted to the facility on [DATE] with a history of end stage [MEDICAL CONDITION]. In an interview with Resident #217 on 8/1/2014 at 1:23 PM he stated that he went to [MEDICAL TREATMENT] three times a week, on Tuesdays, Thursdays and Saturdays in the afternoon. He stated that he left about 2:00 pm and generally returned to the facility between 7:00 p.m. and 9:00 p.m. on [MEDICAL TREATMENT] days. He said that the facility did not give him any food or snacks to take with him on [MEDICAL TREATMENT] days. A review of Resident #217's Minimum Data Set (MDS) assessment, with a reference date of 7/27/2014, revealed that Resident #217 was alert and oriented to person, place, time and situation. There were no visual, auditory or communication deficits noted. There were no mood or behavioral issues noted. It was documented that the resident felt it was very important that he have snacks available between meals. MDS documentation revealed that the resident was receiving a mechanically altered, therapeutic diet. A review of Resident #217's current diet order indicated that he was receiving a renal diabetic diet. A review of Resident #217's Medical Nutritional Therapy note dated 7/23/2014 revealed that the resident's diet was renal, diabetic, carbohydrate consistent, with a Nephro supplement three times daily. A review of the care plans for Resident #217 revealed that he was care planned for the following: [MEDICAL TREATMENT], Altered Renal Function and Nutrition. None of these care plans addressed sending a snack or a bagged lunch with Resident #217 to [MEDICAL TREATMENT]. The nutritional care plan mentioned a goal detail, "HD TTHS" ([MEDICAL TREATMENT] Tuesday, Thursday, Saturday) An interview with the Food Manager on 8/1/2014 at 3:17 p.m. revealed that Resident #217 "Usually takes a brown bag lunch, an apple, a sandwich and a water or 4 oz apple juice. It is per patient request." (This resident is on a mechanically altered diet.) The Food Manager said that she did not always know what the reason was for a resident leaving the facility. She said she did not know specifically what days a patient went out to [MEDICAL TREATMENT]. She said the nursing staff would request a bagged meal if they knew a resident was going to an appointment, and they were going to miss their meal. 2) A review of the electronic medical record for Resident #226 revealed that she was admitted to the facility on [DATE], and had a history of [REDACTED]. A review of Resident #226's Medical Nutritional Therapy note dated 7/31/2014 revealed that the resident's diet was renal, diabetic, carbohydrate consistent with a Nephro supplement at lunch time. A review of the care plans for Resident #226 revealed that she was care planned for the following: [MEDICAL TREATMENT] and Nutrition. Neither of these care plans addressed sending a snack or a bagged lunch with the resident to [MEDICAL TREATMENT]. The nutritional care plan mentioned a goal detail, "[MEDICAL CONDITION] HD TTHS" ([MEDICAL CONDITION], [MEDICAL TREATMENT] Tuesday, Thursday, Saturday). A review of Resident #226's MDS assessment with a reference date of 7/7/2014 revealed that the resident was alert and oriented to person, place, time and situation. There were no visual, auditory or communication deficits noted. There were no mood or behavioral issues noted. It was documented that resident #226 felt it was very important that she have snacks available between meals. MDS documentation revealed that the resident received a therapeutic diet. An 8/1/2014 interview with Resident #226 at 12:56 p.m. revealed the following: She said she went to [MEDICAL TREATMENT] on Tuesdays, Thursdays and Saturdays between 2:30 p.m. and 3:00 p.m., and that she returned at approximately 7:00 p.m. - 9:00 p.m. She said that when she left to go to [MEDICAL TREATMENT], the facility did not give her any food to take with her. She said, "They don't give me anything but water at the [MEDICAL TREATMENT] center." .

Based on record review and interviews with facility staff and residents, the facility failed to distribute and serve food under sanitary conditions for 2 of 2 residents sampled for [MEDICAL TREATMENT] services. (Residents #217 and #226) The findings include: 1) A review of the electronic medical record for Resident #217 revealed that he was admitted to the facility on [DATE] with a history of end stage [MEDICAL CONDITION]. A review of Resident #217's Minimum Data Set (MDS) assessment with a reference date of 7/27/2014 revealed that the resident was alert and oriented to person, place, time and situation. There were no visual, auditory or communication deficits noted. There were no mood or behavioral issues noted. It was documented that Resident #217 felt it was very important that he have snacks available between meals. It was documented that the resident received a mechanically altered, therapeutic diet. In an interview with Resident #217 on 8/1/2014 at 1:23 PM he stated that he went to [MEDICAL TREATMENT] three times a week, on Tuesdays, Thursdays and Saturdays in the afternoon. He said that the facility did not give him any food or snacks to take with him on [MEDICAL TREATMENT] days. A review of Resident #217's current diet order indicated that he was receiving a renal diabetic diet. A review of Resident #217's Medical Nutritional Therapy note dated 7/23/2014 revealed that Resident #217's diet was renal, diabetic, carbohydrate consistent, with a Nephro supplement three times daily. An 8/1/2014 interview with Resident #217 at 3:37 PM revealed the following: Resident #217 stated that when he returned from [MEDICAL TREATMENT], his dinner was in his room. He said the staff warmed it up for him because it was cold. He stated that he generally returned to the facility between 7:00 p.m. and 9:00 p.m. on [MEDICAL TREATMENT] days. An 8/1/2014 interview with Employee #12 at 3:42 p.m. revealed the following: "When a resident is out to [MEDICAL TREATMENT] we hold the dinner meal. We keep it in their room until they return." An interview with the Food Manager on 8/1/2014 at 3:17 p.m. revealed that if a resident is not back from [MEDICAL TREATMENT] by the time dinner is served, the caterer would communicate with the nurse, and ask when the resident was expected to return. She said if the resident was expected to return soon, they would leave the meal tray in the resident's room. However, if it was going to be a while, then they would take the tray. She said that it was not acceptable for a tray to remain in a resident's room for 2-3 hours. 2) A review of the electronic medical record for Resident #226 revealed that she was admitted to the facility on [DATE], and had a history of [REDACTED]. A review of Resident #226's Medical Nutritional Therapy note dated 7/31/2014 revealed that the resident's diet was renal, diabetic, carbohydrate consistent with a Nephro supplement at lunch time. A review of Resident #226's MDS assessment with a reference date of 7/7/2014 revealed that the resident was alert and oriented to person, place, time and situation. There were no visual, auditory or communication deficits noted. There were no mood or behavioral issues noted. It was documented that the resident was receiving a therapeutic diet. An 8/1/2014 interview with Resident #226 at 12:56 p.m. revealed the following: She said she went to [MEDICAL TREATMENT] on Tuesdays, Thursdays and Saturdays between 2:30 p.m. and 3:00 p.m., and that she returned at approximately 7:00 p.m. - 9:00 p.m. She said that when she left to go to [MEDICAL TREATMENT], the facility did not give her any food to take with her. An 8/1/2014 interview with Resident #226 at 2:36 p.m. revealed that her dinner was left in her room on [MEDICAL TREATMENT] days. She said that it was cold when she returned from [MEDICAL TREATMENT] and staff had to warm it up for her. .

Based on observations and staff interview, the facility failed to ensure that two refrigerators used during the tray line service were maintained in safe operating condition. The findings include: On 5/12/2014 at 11:56 AM, the two reach-in refrigerators located at the tray line were observed at 54 degrees F. (Fahrenheit) and 44 degrees F. respectively. The food service manager stated that the high temperature was because the doors were left open during the entire food service period. A carton of milk that was in the refrigerator was observed at 42.9 degrees F. at 11:58 AM. The manager instructed the aides to shut the refrigerator doors. On 5/14/2014 at 12:05 PM the same two refrigerators were observed at 46 degrees F. and 44 degrees F. respectively. The manager instructed staff to shut the door of the refrigerator observed at 46 degrees F. The refrigerator observed at 44 degrees F. was already closed. The dietary manager stated at 12:20 PM on 5/14/14 that she would report the issue to maintenance, because with the doors shut the refrigerator did not rebound to 41 degrees F. Milk and juices were kept in these refrigerators.

Based on record review and interviews with facility staff and residents, the facility failed to meet residents' choices about aspects of their lives in the facility that are significant to the resident related to provision of snacks for 2 residents (Residents #217 and #226), who were on consistent carbohydrate diets and received [MEDICAL TREATMENT] services outside the facility three times per week, out of 2 residents sampled for [MEDICAL TREATMENT] services. The findings include: 1) A review of the electronic medical record for Resident #217 revealed that he was admitted to the facility on [DATE] with a history of end stage [MEDICAL CONDITION]. In an interview with Resident #217 on 8/1/2014 at 1:23 PM he stated that he went to [MEDICAL TREATMENT] three times a week, on Tuesdays, Thursdays and Saturdays in the afternoon. He stated that he left about 2:00 pm and generally returned to the facility between 7:00 p.m. and 9:00 p.m. on [MEDICAL TREATMENT] days. He said that the facility did not give him any food or snacks to take with him on [MEDICAL TREATMENT] days. A review of Resident #217's Minimum Data Set (MDS) assessment, with a reference date of 7/27/2014, revealed that Resident #217 was alert and oriented to person, place, time and situation. There were no visual, auditory or communication deficits noted. There were no mood or behavioral issues noted. It was documented that the resident felt it was very important that he have snacks available between meals. MDS documentation revealed that the resident was receiving a mechanically altered, therapeutic diet. A review of Resident #217's current diet order indicated that he was receiving a renal diabetic diet. A review of Resident #217's Medical Nutritional Therapy note dated 7/23/2014 revealed that the resident's diet was renal, diabetic, carbohydrate consistent, with a Nephro supplement three times daily. A review of the care plans for Resident #217 revealed that he was care planned for the following: [MEDICAL TREATMENT], Altered Renal Function and Nutrition. None of these care plans addressed sending a snack or a bagged lunch with Resident #217 to [MEDICAL TREATMENT]. The nutritional care plan mentioned a goal detail, HD TTHS ([MEDICAL TREATMENT] Tuesday, Thursday, Saturday) An interview with the Food Manager on 8/1/2014 at 3:17 p.m. revealed that Resident #217 Usually takes a brown bag lunch, an apple, a sandwich and a water or 4 oz apple juice. It is per patient request. (This resident is on a mechanically altered diet.) The Food Manager said that she did not always know what the reason was for a resident leaving the facility. She said she did not know specifically what days a patient went out to [MEDICAL TREATMENT]. She said the nursing staff would request a bagged meal if they knew a resident was going to an appointment, and they were going to miss their meal. 2) A review of the electronic medical record for Resident #226 revealed that she was admitted to the facility on [DATE], and had a history of [REDACTED]. A review of Resident #226's Medical Nutritional Therapy note dated 7/31/2014 revealed that the resident's diet was renal, diabetic, carbohydrate consistent with a Nephro supplement at lunch time. A review of the care plans for Resident #226 revealed that she was care planned for the following: [MEDICAL TREATMENT] and Nutrition. Neither of these care plans addressed sending a snack or a bagged lunch with the resident to [MEDICAL TREATMENT]. The nutritional care plan mentioned a goal detail, [MEDICAL CONDITION] HD TTHS ([MEDICAL CONDITION], [MEDICAL TREATMENT] Tuesday, Thursday, Saturday). A review of Resident #226's MDS assessment with a reference date of 7/7/2014 revealed that the resident was alert and oriented to person, place, time and situation. There were no visual, auditory or communication deficits noted. There were no mood or behavioral issues noted. It was documented that resident #226 felt it was very important that she have snacks available between meals. MDS documentation revealed that the resident received a therapeutic diet. An 8/1/2014 interview with Resident #226 at 12:56 p.m. revealed the following: She said she went to [MEDICAL TREATMENT] on Tuesdays, Thursdays and Saturdays between 2:30 p.m. and 3:00 p.m., and that she returned at approximately 7:00 p.m. - 9:00 p.m. She said that when she left to go to [MEDICAL TREATMENT], the facility did not give her any food to take with her. She said, They don't give me anything but water at the [MEDICAL TREATMENT] center.

Based on observation, record review and staff interviews, the facility failed to accurately assess a resident's [MEDICAL CONDITION] capacity (Resident # 127), out of 30 sampled residents. The findings include: Review of the medical record for Resident #127 revealed he was admitted to the facility on [DATE] following a stroke. Review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed the resident was coded as being always continent of bowel and bladder. Review of the MDS assessment dated [DATE] revealed the resident was always incontinent of bowel and bladder. Observation of Resident #127 on 5/14/14 revealed him to be lying supine in bed with his eyes closed. When asked a question he opened his eyes but was not able to communicate. Review of the care plan dated 1/28/14 revealed an added problem of altered urinary elimination, identified on 2/22/14. The goal was listed as maintaining effective urinary elimination. The interventions included: assess causes of altered urinary function, bladder scan as needed, and labs as ordered. No other interventions were noted to address assessment or care for an incontinent resident. Interview with Employee M on 5/14/14 at 11:10 AM revealed she has never known Resident #127 to be continent. She stated Resident #127 was put in diapers and he is able to tell us when he is wet. After reviewing the medical record she did not find any documentation for assessing the new onset of urinary incontinence. She stated she has never seen a resident placed on a bladder retraining program. Interview with Employee C on 5/14/14 at 11:52 AM revealed she got her information from the nurse's admission assessment, which stated that the resident's [MEDICAL CONDITION] function was within normal limits. Records revealed that 1/27/14 was the first time the resident was listed as incontinent. Employee C stated that if the resident was incontinent the nurse would have entered that information, but it wasn't noted until 1/27/14. Interview with Employee L on 5/14/14 at 12:05 PM revealed the facility does not have a policy and procedure for bladder incontinence assessment or bladder retraining program. Interview with Employee N on 5/15/14 at 9:00 AM revealed she has been caring for Resident #127 since admission. She stated he is incontinent sometimes at night, but during the day he will use his call light and let you know if he has to go to the bathroom or if he is wet. She stated when he was admitted he was totally incontinent, but he is better now. When asked how she receives information on residents' care needs, she stated she talks to the patient care assistant (PCA) who is going off duty. When asked if the PCAs have a care cardex or care plan for the residents, she stated only the nurses have access to that information. .

Based on observations, record review, and interview the facility failed to develop a plan of care with measurable objectives and timetables for one resident receiving [MEDICAL TREATMENT] treatment (Resident #201), out of 30 sampled residents. The findings include: Review of the electronic medical record for Resident #201 revealed that he had a history of [REDACTED]. He received [MEDICAL TREATMENT] on Monday, Wednesday, and Friday mornings. In an interview on 5/13/14 at 2:19 pm with the Assistant Nurse Manager, she stated that the facility sends out current vitals and a copy of the most recent lab results each time the resident goes out for [MEDICAL TREATMENT]. Review of the [MEDICAL TREATMENT] communication records for Resident #201 revealed no documentation. Review of the care plan dated 5/2/14 revealed a problem identified with altered renal function. The listed goal was to maintain hemodynamic stability, with the following interventions: CVVH (continuous veno-venous [MEDICAL TREATMENT]) as ordered (prn, as needed); monitor trends in lab data (prn); clarify, per orders, medications to hold prior to [MEDICAL TREATMENT] (none listed); monitor [MEDICAL TREATMENT] access for patency and security (prn); monitor I&O (intake and output, prn); and evaluate effectiveness of [MEDICAL TREATMENT]. No measurable objectives or timetables were specified in the care plan. The Assistant Nurse Manager stated on 5/13/14 at 2:25 pm that the [MEDICAL TREATMENT] care plan entered for Resident #201 was not the correct care plan for the facility. When the policy and procedure for [MEDICAL TREATMENT] residents was requested on 5/14/14 at 11:50 am, the Director of Nursing stated they don't have a policy and procedure, they just follow the care plan. .

Based on record review and staff interview, the facility failed to develop and revise resident care plans with measurable objectives and timetables to meet the residents' needs for 3 of 5 sampled residents (Residents #8, #127 and #226). The facility was out of compliance on 5/15/14, and remains out of compliance on 8/1/14. The findings include: A review of Resident #226's electronic medical record revealed a care plan dated 7/29/2014 for Potential for Complications Secondary to [MEDICAL TREATMENT]. The listed goal was not to develop signs or symptoms of complications from [MEDICAL TREATMENT]. No end date or review date was listed. Some of the interventions listed were as follows: Assess vascular site for thrill/bruit,systemic redness and pain. There was no timetable set for when to perform this intervention. Assess lab values and report significant changes to MD. There was no timetable set for this intervention, or specific labs identified. Dietitian to assess. There was no timetable set for this intervention, and no measurable objectives. Assess [MEDICAL TREATMENT] catheter, change dressing PRN (as needed). There was no timetable set for this intervention, and no measurable objectives. Obtain orders to assess for blood draws. There was no timetable set for this intervention. Clarify, per orders, meds (medications) to hold prior to [MEDICAL TREATMENT]. There were no medications listed with this intervention. A review of Resident #127's electronic medical record revealed a care plan dated 5/8/2014 for Incontinence of Bowel/Bladder. The first listed goal was to maintain skin integrity. No end date or review date was listed. The interventions were as follows: Assess skin integrity. There was no timetable set for implementing this intervention. Provide skin care. There was no timetable set for this intervention, or specifics for implementation. The second listed goal was to regain effective bowel elimination. The end date was listed as 6/30/2014. The "goal detail" stated, "Patient still having periods of incontinence as of 7/8/2014. Will continue to offer toileting every 2 hours while awake. There were no other interventions for this goal. There were no changes made or interventions added when the goal was not reached. The third listed goal was to regain effective urinary elimination. The end date was listed as 6/30/2014. The "goal detail" stated, "Patient still having periods of incontinence as of 7/8/2014. Will continue to offer toileting every 2 hours while awake." There was one intervention listed under this goal. It was to offer toileting every 2 hours while awake. There was no start date listed for this intervention. There were no other interventions added when the goal was not reached. A review of Resident #8's electronic medical record revealed a care plan dated 9/22/2013 for Incontinence of Bowel/Bladder. The listed goal was to regain effective bowel elimination. No end date or review date was listed. The interventions were as follows: Assess causes of bowel incontinence PRN (as needed). Establish bowel regimen PRN (as needed). The second listed goal was to regain effective urinary elimination. No end date or review date was listed. The interventions were as follows: Assess causes of incontinence PRN. Assess frequency of incontinence PRN. Evaluate med (medication) profile for urinary side effects PRN. There were no timetables set for implementing these interventions. In an interview with Employee #4 on 8/1/2014 at 4:50 p.m. she stated that all incontinent residents were on the same toileting plan, which was to be toileted every 2 hours while awake. When asked where residents' toileting plans were documented, Employee #4 stated that they were documented on the care plans. "Toilet every 2 hours while awake." .

Based on observations, record review and interviews with facility staff and the resident, the facility failed to monitor and evaluate 1 resident's condition related to end stage [MEDICAL CONDITION], and response to [MEDICAL TREATMENT] and related services (Resident #201), out of 30 sampled residents. The findings include: Review of the electronic medical record for Resident #201 revealed that he had a history of [REDACTED]. He received [MEDICAL TREATMENT] on Monday, Wednesday, and Friday mornings. In an interview on 5/13/14 at 2:19 pm with the Assistant Nurse Manager, she stated that the facility sends out current vitals and a copy of the last lab results each time the resident goes out for [MEDICAL TREATMENT]. Review of the [MEDICAL TREATMENT] communication book for Resident #201 revealed no documentation. Review of the care plan dated 5/2/14 revealed a problem identified with altered renal function. The listed goal was to maintain hemodynamic stability with the following interventions: CVVH (continuous veno-venous [MEDICAL TREATMENT]) as ordered (prn, as needed); monitor trends in lab data (prn); clarify, per orders, medications to hold prior to [MEDICAL TREATMENT] (none specified); monitor [MEDICAL TREATMENT] access for patency and security (prn); monitor I&O (intake and output, prn); and evaluate effectiveness of [MEDICAL TREATMENT]. No measurable objectives or timetables were specified. Further review of the electronic medical record revealed no documentation of intake and output being measured, and no documentation of assessments of the vascular site being completed. An interview with the Assistant Nurse Manager on 5/13/14 at 2:25 pm revealed I&O's are not being measured because the resident is not currently on any fluid restriction. She also stated there was no documentation in the electronic medical record of vascular site assessments. The Unit Manager also attempted to locate documentation of vascular site assessments and could not find any. The Assistant Nurse Manager stated that the [MEDICAL TREATMENT] care plan entered for Resident #201 was not the correct care plan for the facility. On 5/14/14 at 10:52 am it was noted that Resident #201 was out of the facility at [MEDICAL TREATMENT]. The resident's [MEDICAL TREATMENT] communication notebook was noted to be in the chart case along with his hard copy medical record. The communication notebook was empty except for the resident's personal information document dated 5/2/14. The front of the notebook was labeled, "Please send black notebook with history and physical, recent labs, etc." When the policy and procedure for [MEDICAL TREATMENT] residents was requested on 5/14/14 at 11:50 am, the Director of Nursing stated that they don't have a policy and procedure, they just follow the care plan. Review of the nutritional therapy note dated 5/5/14 revealed Resident #201 was to have Nepro (a supplement) with each meal. He was to be provided with a big snack to take to [MEDICAL TREATMENT] that included a turkey sandwich, applesauce, graham crackers, and 1 can of Nepro. An interview with Resident #201 on 5/14/14 at 11:05 am revealed he has been on [MEDICAL TREATMENT] for 2 years. The resident had just returned from [MEDICAL TREATMENT] and he stated there was no paperwork sent back from the [MEDICAL TREATMENT] center. He also revealed he did not take his notebook (communication book) with him to [MEDICAL TREATMENT] today. He stated sometimes it goes with him and sometimes it doesn't. When asked if he consumed his snack at [MEDICAL TREATMENT], he revealed he wasn't given a snack to take with him today or on Monday. The LPN entered the resident's room on 5/14/14 at 11:10 am and assisted him from the wheelchair into a chair. She did not perform an assessment of the resident's vascular site, or take his vital signs. Employee E entered the room at 11:28 am and brought the snack that had been made for the resident to take to [MEDICAL TREATMENT]. She reminded the resident that he needed to ask for the snack when he was ready to leave for [MEDICAL TREATMENT] on Friday morning. .

Based on observation, medical record review and staff interview, the facility failed to ensure that 1 resident who was continent on admission did not lose bladder function (Resident #127) , out of 2 sampled residents. The findings include: Review of the medical record for Resident #127 revealed he was admitted to the facility on [DATE] following a stroke. Review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed the resident was coded as being always continent of bowel and bladder. Review of the MDS assessment dated [DATE] revealed the resident was always incontinent of bowel and bladder. Observation of Resident #127 on 5/14/14 revealed him to be lying supine in bed with his eyes closed. When asked a question he opened his eyes but was not able to communicate. Review of the care plan dated 1/28/14 revealed an added problem of altered urinary elimination, identified on 2/22/14. The goal was listed as maintaining effective urinary elimination. The interventions included: assess causes of altered urinary function, bladder scan as needed, and labs as ordered. No other interventions were noted to address assessment or care for an incontinent resident. Interview with Employee M on 5/14/14 at 11:10 AM revealed she has never known Resident #127 to be continent. She stated Resident #127 was put in diapers and he is able to tell us when he is wet. After reviewing the medical record she did not find any documentation for assessing the new onset of urinary incontinence. She stated she has never seen a resident placed on a bladder retraining program. Interview with Employee C on 5/14/14 at 11:52 AM revealed she got her information from the nurse's admission assessment, which stated that the resident's [MEDICAL CONDITION] function was within normal limits. Records revealed that 1/27/14 was the first time the resident was listed as incontinent. Employee C stated that if the resident was incontinent the nurse would have entered that information, but it wasn't noted until 1/27/14. Interview with Employee L on 5/14/14 at 12:05 PM revealed the facility does not have a policy and procedure for bladder incontinence assessment or bladder retraining program. Interview with Employee N on 5/15/14 at 9:00 AM revealed she has been caring for Resident #127 since admission. She stated he is incontinent sometimes at night, but during the day he will use his call light and let you know if he has to go to the bathroom or if he is wet. She stated when he was admitted he was totally incontinent, but he is better now. When asked how she receives information on residents' care needs, she stated she talks to the patient care assistant (PCA) who is going off duty. When asked if the PCAs have a care cardex or care plan for the residents, she stated only the nurses have access to that information. .

Based on medical record review and staff interview, the facility failed to ensure that residents who were incontinent of bladder received appropriate treatment and services to restore as much normal bladder function as possible for 2 of 3 sampled residents with bladder incontinence. (Residents #8 and #127). The facility was out of compliance on 5/15/14, and remains out of compliance on 8/1/14. The findings include: 1. A review of the electronic medical record for Resident #127 revealed he was admitted to the facility on [DATE] following a stroke. A Significant Change in Status Minimum Data Set (MDS) assessment for Resident #127, with a reference date of 7/15/2014, coded the resident as frequently incontinent of bowel and bladder. MDS documentation indicated that this resident was on a toileting program, and required extensive assistance from one staff member for toileting. A review of Resident #127's electronic medical record revealed an Incontinence of Bowel/Bladder care plan dated 5/8/2014. A listed goal was to regain effective urinary elimination. The end date was listed as 6/30/2014. The "goal detail" stated, "Patient still having periods of incontinence as of 7/8/2014. Will continue to offer toileting every 2 hours while awake. There was one intervention listed under this goal, to offer toileting every 2 hours while awake. There were no other interventions added when the goal was not reached. A review of the facility's guideline for "What to do when a Patient is Incontinent" revealed that staff were to obtain the care plan template, and select goals and interventions applicable to the patient (resident). The staff was to "Start bladder training, which is simply offering toileting every two hours while awake." They were to document this care in the Daily Care flow sheets. They were also to document every time a resident was incontinent. An 8/1/2014 interview with Employee #4 at 4:50 p.m. revealed the following: When asked whether an assessment was used to determine whether a resident was appropriate for a toileting plan or bladder training, Employee #4 stated that [MEDICAL CONDITION] Assessment was completed whenever a resident was found to be newly incontinent or when there was a decline in a resident's incontinence. The assessment was designed to capture the resident's voiding pattern, including excessive urine, no urine output, pain on urination, or minimal urine output. Employee #4 confirmed that the [MEDICAL CONDITION] Assessment was not documented in Resident #127's record. Employee #4 confirmed that a 3-day bowel and bladder observation/assessment was not being completed to discover the resident's usual voiding/elimination pattern prior to initiating a toileting plan. Employee #4 confirmed that all incontinent residents were on the same toileting plan, which was to be toileted every 2 hours while awake. There was no documentation in the record indicating whether the resident's type of incontinence was assessed, the resident was appropriate for bladder training, or responding to prompts to void. 2. A review of Resident #8's electronic medical record revealed an Incontinence of Bowel/Bladder care plan dated 9/22/2013. A listed goal was to regain effective urinary elimination. No end date or review date was listed. The interventions were as follows: Assess causes of incontinence PRN. Assess frequency of incontinence PRN. Evaluate med (medication) profile for urinary side effects PRN. Offer toileting every 2 hours while awake. No measurable objectives or timetables were specified in the care plan. A review of the quarterly MDS assessment for Resident #8, with assessment reference date of 6/13/14, revealed that he was non-ambulatory and a total assist of one staff member for all ADLs. He was coded as always incontinent of bowel and bladder with no toileting plan. [DIAGNOSES REDACTED]. An 8/1/2014 interview with Employee #5 at 4:25 p.m. revealed that Resident #8 was incontinent of both bowel and bladder. Employee #5 stated that the resident always placed his call light on when he needed assistance. She stated that the resident used briefs and pads on his bed, and he was checked and changed every 2 hours. There was no evidence in the record to indicate whether the cause of Resident #8's incontinence was assessed, the resident was appropriate for bladder training, or the resident was responding to prompts to void. .

Based on record review and staff interview the facility failed to provide documentation of pneumococcal vaccine education for 1 of 5 sampled residents (Resident #24). The findings include: Record review of Resident # 24 revealed she refused the pneumococcal vaccine on 11/19/2014. On 5/14/2014 at 2:30 PM an interview with Employee #D revealed she was not able to locate documentation of education given to Resident #24. Review of the facility policy and procedure for Transitional Care Unit (TCU) Adult Influenza and Pneumococcal Immunization Protocol, dated May 3, 2013, revealed all TCU patients who have not received the influenza vaccination and pneumococcal vaccination (year round) will be given the CDC Vaccination Information Statement (VIS) for review prior to offering the vaccine. The nurse documents in the computer and or flowsheets that the VIS document copy was given to the patient/representative. .

Based on record review and interviews with facility staff and residents, the facility failed to distribute and serve food under sanitary conditions for 2 of 2 residents sampled for [MEDICAL TREATMENT] services. (Residents #217 and #226) The findings include: 1) A review of the electronic medical record for Resident #217 revealed that he was admitted to the facility on [DATE] with a history of end stage [MEDICAL CONDITION]. A review of Resident #217's Minimum Data Set (MDS) assessment with a reference date of 7/27/2014 revealed that the resident was alert and oriented to person, place, time and situation. There were no visual, auditory or communication deficits noted. There were no mood or behavioral issues noted. It was documented that Resident #217 felt it was very important that he have snacks available between meals. It was documented that the resident received a mechanically altered, therapeutic diet. In an interview with Resident #217 on 8/1/2014 at 1:23 PM he stated that he went to [MEDICAL TREATMENT] three times a week, on Tuesdays, Thursdays and Saturdays in the afternoon. He said that the facility did not give him any food or snacks to take with him on [MEDICAL TREATMENT] days. A review of Resident #217's current diet order indicated that he was receiving a renal diabetic diet. A review of Resident #217's Medical Nutritional Therapy note dated 7/23/2014 revealed that Resident #217's diet was renal, diabetic, carbohydrate consistent, with a Nephro supplement three times daily. An 8/1/2014 interview with Resident #217 at 3:37 PM revealed the following: Resident #217 stated that when he returned from [MEDICAL TREATMENT], his dinner was in his room. He said the staff warmed it up for him because it was cold. He stated that he generally returned to the facility between 7:00 p.m. and 9:00 p.m. on [MEDICAL TREATMENT] days. An 8/1/2014 interview with Employee #12 at 3:42 p.m. revealed the following: When a resident is out to [MEDICAL TREATMENT] we hold the dinner meal. We keep it in their room until they return. An interview with the Food Manager on 8/1/2014 at 3:17 p.m. revealed that if a resident is not back from [MEDICAL TREATMENT] by the time dinner is served, the caterer would communicate with the nurse, and ask when the resident was expected to return. She said if the resident was expected to return soon, they would leave the meal tray in the resident's room. However, if it was going to be a while, then they would take the tray. She said that it was not acceptable for a tray to remain in a resident's room for 2-3 hours. 2) A review of the electronic medical record for Resident #226 revealed that she was admitted to the facility on [DATE], and had a history of [REDACTED]. A review of Resident #226's Medical Nutritional Therapy note dated 7/31/2014 revealed that the resident's diet was renal, diabetic, carbohydrate consistent with a Nephro supplement at lunch time. A review of Resident #226's MDS assessment with a reference date of 7/7/2014 revealed that the resident was alert and oriented to person, place, time and situation. There were no visual, auditory or communication deficits noted. There were no mood or behavioral issues noted. It was documented that the resident was receiving a therapeutic diet. An 8/1/2014 interview with Resident #226 at 12:56 p.m. revealed the following: She said she went to [MEDICAL TREATMENT] on Tuesdays, Thursdays and Saturdays between 2:30 p.m. and 3:00 p.m., and that she returned at approximately 7:00 p.m. - 9:00 p.m. She said that when she left to go to [MEDICAL TREATMENT], the facility did not give her any food to take with her. An 8/1/2014 interview with Resident #226 at 2:36 p.m. revealed that her dinner was left in her room on [MEDICAL TREATMENT] days. She said that it was cold when she returned from [MEDICAL TREATMENT] and staff had to warm it up for her.