Every finding on record at St Elizabeth Ft Thomas SNF

Based on observation, interview, record review, review of the facility's training, and review of the facility's policies, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent and control the development and transmission of communicable diseases and infections. This deficient practice affected two (2) of fourteen (14) sampled residents, Resident #112 and #160. Observation of State Registered Nurse Aide (SRNA) #1, on 08/03/2022 at 5:00 PM, revealed she took extra supplies, in a plastic sealed bag, between resident rooms, to perform finger sticks for blood glucose levels. One (1) room was non-isolation, and one (1) room was identified as Airborne and Contact Precautions isolation, which was designated per signage on the door. Observation of Physician #1, on 08/02/2022 at 11:55 AM, revealed the physician exiting room [ROOM NUMBER] with gloves on then doffing gloves and placing in the garbage can outside room [ROOM NUMBER], identified as Airborne and Contact Isolation per signage on the door. The findings include: Review of the facility's policy titled, Standard and Transmission-Based Precautions, origination date 12/01/2020, revealed Standard Precautions meant to treat all patients' blood or body fluids as infectious material. Per the policy, under Contact Isolation, gloves were to be removed before leaving the resident care area to prevent possible contamination of the environment outside the residents' rooms. Further instructions revealed gloves and gown were to be removed before leaving the room. Review of the facility's policy titled, Personal Protective Equipment (PPE), Inf-Cntrl-P-01, revision date 12/01/2020, revealed employees received training, during orientation, on the proper selection, use, and indicators for PPE. Continued review revealed PPE must be removed prior to leaving the work area or clinical areas. Review of the facility's Computer Based Learning (CBL) training titled, Infection Control Update, All Clinical Associates, revision date 09/2021, under Transmission-Based Precautions, revealed, for all isolation types, to use dedicated or disposable equipment when available and take only necessary supplies into a resident's room. Further review revealed to remove all PPE before exiting the resident's room. Review of SRNA #1's training records revealed the SRNA received training for Infection Control and NOVA StatStrip glucose meter (glucometer, medical device that was used to measure blood glucose levels) on 03/23/2022. 1. Observation of Physician #1, on 08/02/2022 at 11:55 AM, revealed the physician exited Resident #160's room, room [ROOM NUMBER], an Airborne and Contact Precautions Isolation room, with gloves on. Physician #1 then doffed (removed) the gloves and placed them in the garbage can outside the room. Interview with Physician #1, on 08/02/2022 at 11:55 AM, revealed the physician had received training from the facility for donning (putting on) and doffing PPE, but it had been some time ago. 2. Observation of SRNA #1, on 08/03/2022 at 5:00 PM, revealed she entered the room of Resident #112 to obtain a blood glucose level. She had, in her hand, a plastic bag, which could be sealed at the top, and contained lancets, alcohol pads, glucose monitoring strips, and 2 x 2 gauze pads. She also carried the glucometer in her hand. Per the observation, SRNA #1 placed a paper towel on the overbed table, and then placed the glucometer and the needed supplies from the plastic bag on the paper towel. The first attempt to get a drop of blood from Resident #112 yielded an amount that was insufficient for a blood glucose level reading, but the second attempt was successful. Per the observation, SRNA #1 properly disposed of supplies, properly performed hand hygiene, disinfected the plastic bag and the glucometer with sanitizing wipes, and left the room. Continued observation of SRNA #1, on 08/03/2022 at 5:15 PM, revealed she donned PPE, took the glucometer, including the plastic bag with supplies, and entered room [ROOM NUMBER], Resident #160's room. which was an Airborne and Contact Precautions Isolation room. Additional observation revealed, upon exiting room [ROOM NUMBER], she began donning PPE to enter room [ROOM NUMBER], which was an Airborne and Contact Precautions Isolation room with the plastic bag of supplies and the glucometer. At this point, SRNA #1 was stopped and interviewed by the State Survey Agency (SSA) Surveyor about entering different resident rooms with the same plastic bag of extra supplies. Interview with SRNA #1, on 08/03/2022 at 5:15 PM, revealed she knew the policy of taking only needed supplies into resident rooms which would decrease possible cross contamination of residents and knew better than to take the same plastic bag with numerous supplies into each room. Additional interview with SRNA #1, on 08/02/2022 at 2:20 PM, revealed she had worked at the facility since March 2022 and had received new orientation training upon hire at that time which included isolation training for PPE and training for usage of glucometers. She stated there were two (2) glucometers for the unit, and they were cleaned with sanitizing wipes after use for the isolation rooms but not always for the non-isolation rooms. Interview with SRNA #2, on 08/04/2022 at 11:40 AM, revealed, for blood glucose monitoring, he placed the glucometer on a barrier, performed hand hygiene, and put on new gloves. Additionally, he stated he never took the bag of supplies into a room and would never reach in the bag or place supplies in his pockets. He also stated the glucose strip was scanned prior to entering the resident's room. Interview with Licensed Practical Nurse (LPN) #1, on 08/03/2022 at 4:00 PM, revealed her job duties included medication administration, assessments, drawing labs, and contacting the physician as needed. She stated the PPE supply was plentiful. She stated she would don PPE prior to entering the resident's room and doff PPE prior to exiting the room. LPN #1 also stated glucometers were to be cleaned after each use with sanitizing wipes for all rooms, including non-isolation rooms, and wipes were inside each room. Interview with the Infection Preventionist (IP) Manager, Registered Nurse (RN) # 4, on 08/04/2022 at 10:00 AM, revealed she had been the IP at this facility for three (3) years and was covering for the IP nurse at this time. She stated doffing (removing) PPE, including gloves, should occur inside isolation rooms. The IP Manager stated only needed supplies should be taken into residents' rooms. She stated the plan for the facility was to begin audits for PPE use, but the audits had not begun yet. Interview with the Director of Nursing (DON) and Unit Manager, on 08/04/2022 at 1:50 PM, revealed her expectations were for staff to abide by PPE use and glucometer checks for residents according to guidelines and regulations by taking gown and gloves off in the room. Per the interview, the DON said scanning of supplies should take place before entering the room and only (2) lancets and strips should be taken inside the room; the strip bottle should be left outside the room. She stated 2 x 2 gauze pads and alcohol pads were in the room, and supplies not used should be thrown away inside the room. The DON stated training for staff occurred annually, with hands on training for glucometer use, donning and doffing of PPE, and infection control videos. Interview with the Assistant [NAME] President of Post-Acute Services, on 08/04/2022 at 3:15 PM, revealed she had been in this role for four (4) months but had been the Administrator for the facility since December 2021. She stated her expectations for staff was to know and follow policies and to maintain training. She stated training for staff was conducted in person as well as with CBL, and she also expected staff to follow current practice concerning any medical equipment.

Based on interview, record review, and review of the facility's Discharge and Transfer policy, it was determined the facility failed to ensure Resident #13 was permitted to remain at the facility and not discharged . Review of a facility Discharge Summary, dated 07/21/19, revealed Resident #13 was discharged from the facility and admitted to an Acute Care Hospital because he/she had behaviors and required twenty-four (24) hour monitoring. However, there was no documented evidence the transfer/discharge was necessary. The findings include: Review of a facility policy and procedure titled, Admission/Transfer/Discharge, last revised 05/01/17, revealed the facility would comply with federal regulations to permit each resident to remain in the facility and not transfer or discharge the resident unless the resident's needs could not be met and the safety of individuals in the facility was endangered. Record review revealed Resident #13 was admitted to the facility on [DATE] from an acute care hospital with [DIAGNOSES REDACTED]. Review of a Nurse's Note, dated 07/17/19 at 10:32 PM, revealed Resident #13 had been confused and restless and made several attempts to get out of bed unassisted. Continued review revealed the staff placed Resident #13 in a recliner where she continued to attempt to get up multiple times without assistance. Additional review revealed Resident #13 was eventually placed back in his/her bed with no further attempts to get up unassisted documented. Review of a Nurse's Note, dated 07/18/19 at 10:13 PM, revealed Resident #13 would not stay in his/her bed or his/her recliner and attempted to get up unassisted. Continued review revealed Resident #13 was placed in a wheel chair. Further review of the Nurse's Note revealed while Resident #13 was in his/her wheel chair he/she wheeled him/herself around the nurse's station. Additional review revealed Resident #13 was eventually placed back in his/her bed with no further attempts to get out of bed unassisted documented. Review of a Nurse's Note, dated 07/19/19 at 5:18 PM, revealed Resident #13 was agitated, yelled at staff, and attempted to smack a nurse aide. Continued review revealed Resident #13 was toileted, given a snack and assisted to bed. Resident #13 made no attempts to get out of bed unassisted and no further issues were documented. Review of a Nurse's Note, dated 07/21/19 at 3:45 PM, revealed Resident #13 had been up in his/her wheelchair and had been saying he/she wanted to go home. In addition, the Nurse's Note stated Resident #13 was attempting to get on the elevators; however, the note stated the resident was easily redirected by staff. Further review of the nurse's note revealed Resident #13's family members were notified and came in to the facility to sit with him/her. Review of a Nurse's Note, dated 07/21/19 revealed at 4:41 PM, revealed Resident's family member was propelling Resident #13 up and down the hall in his/her wheel chair. Further review revealed Resident # 13 was noted to be calm and happy. Continued review of the Nurse's Note revealed the family was asked about the need for Resident #13 to have twenty-four hour a day seven day a week (24/7) care from his/her family for his/her safety. Review of a Nurse's Note, dated 07/21/19 at 5:11 PM, revealed the family stated they were not prepared to provide 24/7 care for the Resident at the facility. Continued review revealed the family agreed to have Resident #13 moved to the acute care hospital for a net bed or to figure out medications. Further review revealed the nursing supervisor and the physician were notified. Review of a Nurse's Note, dated 07/21/19, revealed Resident #13 was discharged from the facility and admitted to the acute care hospital. Review of a Discharge Summary, dated 07/21/19, revealed Resident #13 had behaviors while at the facility and on the day of discharge the resident was combative toward staff, tried to leave the floor on the elevator and tried to ambulate without assistance. Continued review revealed the staff in the facility did not have enough man power to provide the resident twenty-four (24) hour monitoring and unfortunately his/her family was unable to stay at the facility 24/7. Continued review revealed it was determined to transfer Resident #13 back to the acute care hospital where he/she could be more closely monitored. However, continued record review revealed no documented evidence the facility could not meet the needs of the resident. Interview with the Administrator, on 09/21/19 at 2:24 PM, revealed the Administrator stated the staff reported that the resident's level of care was out of their comfort zone. In addition, the Administrator stated, the facility felt like they had exhausted all efforts to care for Resident #13. However, the Administrator stated she did not expect that a resident should be discharged due to the need for one (1) on one (1) supervision.

Based on observation, interview, and review of the facility's Policy, it was determined the facility failed to prepare, distribute, and serve food in a sanitary manner and in accordance with professional standards for food service safety. Observation on 01/23/18, revealed the stove, flat top grill, fry station, pasta station, and flooring under and behind the stove/grill/fry station had greasy soil and debris buildup. The findings include: Review of the facility's Nutritional Services Infection Control Policy revised 01/15/15, revealed the purpose of the policy was to prevent and control contamination of foodstuffs and foodborne bacteria, and to prevent the spread of infection within the department and medical center. Per Policy, the department should be clean and free from visible soil; all work surfaces and equipment would be cleaned thoroughly after each use; and floors would be swept and mopped using approved disinfectant daily after each meal. Review of the Cook's Unit Daily Closing Duties List, undated, revealed the stoves, flat top grill, and char grill, would be cleaned at the end of each AM (morning) and PM (night) Cook shift. Per interview, on 01/23/18 at 12:04 PM, with the Dietary Manager, the cleaning duties also included cleaning the pasta station, and sweeping and mopping the floors around, under, and behind the equipment after each meal. Review of the Contract Deep Cleaning Company Invoice, dated 08/30/17, revealed the facility had deep cleaning completed to the tile, and tile grout as well as sealing. Observation on 01/23/18 at 11:45 AM, during tray line service, revealed the gas stove, the flat top grill, the deep fry station, and the pasta station had thick grease buildup on the top surface, sides, and front of the cooking equipment. Further observation revealed the tile flooring under, around, and behind the stove/grill/fry stations had thick greasy soil buildup and debris. Interview on 01/23/18 at 12:04 PM, with the Dietary Manager, who toured with the State Survey Representative, revealed each kitchen staff member was responsible for cleaning the floors between equipment, under the equipment and around the equipment in their work area every day at the end of each meal. Per interview, the facility also had a contracted company that came quarterly to deep clean the entire kitchen area. Continued interview revealed there was a daily cleaning schedule for staff for cleaning at the end of each meal service; however, she did not keep a tracking log or checklist to ensure staff were cleaning the cooking equipment after each meal service. Per interview, she relied on the Dietary Supervisor to oversee the operations of the kitchen and she expected her to do a walk through every day to ensure the kitchen was clean and sanitary. Interview on 01/24/18 at 1:15 PM, with the Food Line Worker, revealed dietary staff was responsible for cleaning their work station at the end of their shift and that included washing down the surface area, and restocking and rotating stock in the work area. Continued interview revealed she thought night shift was responsible for sweeping and mopping at the end of the last meal service. Per interview, each work area had a task list that told staff what tasks they were responsible for in their assigned work area. Further interview revealed there was no sign off sheet to complete at the end of the shift to let the manager know staff had completed all their assigned tasks in the work areas. Interview on 01/24/18 at 1:20 PM, with the Nutrition Assistant, revealed the cooks and the nutrition assistants were responsible for wiping down the stoves, fryers, and pasta station. She further stated they were also responsible for rotating stock, sweeping, mopping, and cleaning other areas in the cook station at shift change. Continued interview revealed there was a cleaning list and all the tasks were divided up between the cook staff working on the shift. Per interview, he did have a sign off sheet and he was supposed to sign off that he had completed his task, but he stated the staff had not been doing that for a long time. Interview on 01/24/18 at 1: 30 PM, with the Dietary Supervisor, revealed whoever used the equipment in the work station was responsible for cleaning the equipment and the surrounding area every day. Continued interview revealed the facility had a contract company that was to come quarterly to deep clean all the tile flooring in the kitchen, and the stove vents and hoods. Per interview, she would prefer to have deep cleaning be done weekly, but the facility would not agree because of the high cost. Further interview revealed she used to have a cleaning crew who was responsible for cleaning every day, but the kitchen staff were now responsible for all the food service and cleaning. Additional interview revealed there was a lead person who was assigned to do a walk through at the end of each meal to ensure cleaning was done and she expected the lead person to do the walk through at the end of the shift before staff left for the day to ensure the cleaning had been done. Interview on 01/24/18 at 4:30 PM, with the Administrator, revealed she expected the kitchen supervisory staff to educate all the food service staff on the cleaning policy and procedures, implement a cleaning schedule, track the cleaning, and adjust the schedule as needed to ensure the kitchen remained as free of soil and debris as possible, She further stated she expected the Dietary Manager to ensure all the kitchen staff followed the facility's policy to maintain a clean and sanitary kitchen environment.

Based on observation, interview, and review of the Kentucky Administrative Regulations, it was determined the facility failed to maintain water heating equipment to ensure water temperatures were within the appropriate temperature range for four (4) of eighteen (18) resident rooms (rooms # 5110, 5112, 5115, and 5117). Observation, during the environmental tour on 02/01/17, revealed hot water temperatures were above required range of one hundred (100) to one hundred ten (110) degrees Fahrenheit (F). The findings include: Interview, on 02/02/17 at 11:50 AM, with the facility Administrator, revealed the facility did not have any policy(s) related to water temperatures; however, the facility followed 902 KAR 20:310. Review of Kentucky Administrative Regulation 902 KAR 20:310 (Nursing Facility Specifications), Section 16.(5)(g) under water supply system, revealed the plumbing fixtures which required hot water and which were intended for patient use shall be supplied with water which was controlled to provide a maximum water temperature of 110 degrees (F) at the fixture. Observation during the environmental tour, on 02/01/17 at 11:20 AM, revealed resident room #5110 had a hot water temperature at the fixture of 117 degrees (F). Continued observation revealed resident rooms #5112, #5115, and #5117 had a hot water temperature at the fixture of 113 degrees (F). Interview, on 02/02/17 at 11:20 AM, with the Assistant Director of Maintenance, revealed there was not a system in place to monitor hot water temperatures in resident areas other than when a complaint was reported. Continued interview revealed going forward there would be a system in place. The Assistant Director of Maintenance stated it was important for the facility to maintain water temperatures between 100 degrees (F) and 110 degrees (F) for the safety of the residents. Interview, on 02/02/17 at 11:30 AM, with the acting Director of Maintenance, revealed there was no system in place to monitor hot water at the point of use in residential areas. Continued interview revealed he did not know why there was no system in place, but there needed to be a system to monitor hot water temperatures going forward. The Director of Maintenance further stated it was his expectation hot water temperatures were maintained in the temperature range as spelled out in the state regulatory requirements and this was important to prevent injury such as scalding or burning of residents' skin. Interview, on 02/02/17 at 11:50 AM, with the facility Administrator, revealed it was her expectation resident's hot water temperatures were maintained between 100 degrees (F) and 110 degrees (F) per state regulation. Continued interview revealed there was not a system or process in place to monitor hot water temperatures at the point of use in resident areas; however, the temperature was monitored and adjusted as appropriate when a resident voiced concern. The Administrator stated it was important resident's water temperatures be maintained per state regulation for resident safety, to prevent possible injury and also for resident comfort.

Based on observation, interview and review of the facility's policy, the facility failed to store, prepare and serve food under sanitary conditions. Observation of the kitchen revealed: dented cans stored available for use; and a dietary aide removing clean dishes from the dishwasher who took a pan placed it to soak in the three-compartment sink filled with soapy water, got her gloved hand wet which she wiped dry with a paper towel, then continued to unload clean dishes to put away. The findings include: 1. Review of the facility's policy titled, "Storage of Foodstuffs" revised 05/31/12, revealed "any leaky, rusty or dented cans" would be "removed from stock, marked unacceptable, and stored in the assigned damaged goods location until destroyed". Observation, on 01/27/15 at 6:50 PM, during initial tour of the kitchen, revealed three (3) cans of Pizza Sauce, two (2) cans Pinto Beans, four (4) cans Pears and one (1) can sliced Beets which were dented; however, stored on the for use stock rack, and available for staff to utilize. Interview with Dietary Supervisor #5 on 01/27/15 at 7:20 PM, revealed the facility did have a designated area for dented cans to be stored. She stated the facility had "a boy" who put all the stock up who should be checking the cans for dents before placing them on the racks for use. Per interview, dietary staff would put the dented cans observed on the dented can rack back by the dishroom where they should be. Dietary Supervisor #5 stated residents could get sick if one of those dented cans was spoiled and staff used it. Interview with Receiving Clerk #4 on 01/29/15 at 2:20 PM, revealed the process for dented cans was to place the dented cans on the dented can rack. Per interview, then he talked with the supplier of the product to get credit, then disposed of the dented cans. He stated if the cooks found dented cans on the racks they usually put them on his desk. Receiving Clerk #4 stated he knew dented cans were not to be used because they could be contaminated and if used could make everyone sick. Further interview revealed he "missed" seeing the cans were dented when he put them up, or was in a hurry and "just missed them". Interview with the Dietary Manager on 01/29/15 at 3:03 PM, revealed the facility's procedure the receiving clerk was to follow, was when canned food supplies were received to check all cans for dents, and if observed to be dented the can should be placed on the dented can rack by the dish room. Per interview, the receiving clerk had not followed the facility's policy for storage of food. 2. Review of the facility's policy titled, "Infection Control Guidelines", reviewed 01/15/13, under Section N-d revealed nutrition services department employees were to thoroughly their wash hands before handling clean dishes to prevent contamination. However, observation of the dish room on 01/28/15 at 9:20 AM revealed Dietary Aide #2 to leave the area where dirty dishes were, wash her hands, apply gloves and enter the clean side of the dishwasher area. Continued observation revealed Dietary Aide #2 started removing clean dishes from the dishwasher and storing them. Dietary Aide #2 was then observed to remove a pan which had some food stuck on it, take it to the three (3) compartment sink and place it in the soapy water getting her right hand wet. Further observation revealed she then obtained paper towels and dried her gloved right hand and returned to the clean side of the dishwasher to continue putting dishes away. Interview with Dietary Aide #2 on 01/28/15 at 9:40 AM, revealed she should have washed her hands and applied new gloves when her gloved hand got wet from the soapy water. She stated however, she was nervous, but knew that was a cross contamination issue. Interview with the Dietary Manager on 01/29/15 at 2:05 PM, revealed Dietary Aide #2 had not followed the facility's policy and the procedures; however, should have. Per interview, this matter had been discussed with Dietary Aide #2 and inservicing of dietary staff would be done.

Based on observation and interview, it was determined the facility failed to provide a safe and sanitary environment and to help prevent the development and transmission of disease and infection. Observation of nursing staff on 01/29/15, revealed staff placed dirty linens on the floor of a resident's room, and after picking the linen up transported the dirty linen held against their clothing. The findings include: Observation, on 01/29/15 at 10:20 AM , revealed State Registered Nursing Assistant (SRNA) #1 removed dirty linen from a resident's bed and placed it on the floor. Further observation revealed SRNA #1 picked the dirty linen up off the floor and transported it by holding the dirty linen against her clothing. Interview with SRNA #1 on 01/29/15 at 10:25 AM, revealed she did not remember if she had been trained not to put dirty linens on the floor or on how to transport dirty linens. Per interview, she stated she guessed this could spread infections though. Interview with the Assistant Nurse Manager (ANM) on 01/29/15 at 3:15 PM, revealed SRNA's were trained in orientation and on the unit on how to handle linen, clean and dirty. Per interview, she expected linens to be handled per policy, not to be on the floor and not carried touching staff's clothing. Interview with the Administrator on 01/29/15 at 4:30 PM, revealed the facility did not have a policy for linen and how to handle it. She stated however, she expected staff to put dirty linen in a bag or in the linen cart, and not carry dirty linen against their clothing related to infection control issues.

Based on observation, interview and review of the facility's policies, it was determined the facility failed to store, prepare, distribute, and serve food under sanitary conditions. Observation during initial tour revealed food items were stored on a shelf, open and unsealed, including a bag of corn meal, a bag of cinnamon sugar, a bag of almonds, a bag of brown sugar, and a bag of dry yeast. In addition, spices were stored on a shelf with the bottle lids open including [MEDICATION NAME] leaves, cinnamon, nutmeg, ground ginger, white powder, and black pepper. Also, a bottle of Dawn dishwashing detergent was noted to be sitting on top of the food prep table. Additionally, observation during tray line revealed the cook obtained food temperatures and was using the same alcohol pad to clean the thermometer probe for each food item. The findings include: Review of the facility's "Storage of Foodstuffs Policy", dated 10/11/11, revealed all supplies were to be stored properly to maintain quality and ensure food safety. Cleaning materials were to be stored separately from food and paper products. Review of the facility's "Nutrition Services Infection Control Guidelines", undated, revealed thermometers used for testing food temperatures were to be cleaned and sanitized prior to use. Observation during initial tour of the kitchen, on 04/24/12 at 12:45 PM, revealed items on the dry goods shelf which were open and unsealed including a bag of corn meal, a bag of cinnamon sugar, a bag of almonds, a bag of brown sugar, and a bag of dry yeast. Also, a shelf in the kitchen contained spices with the lids flipped open including [MEDICATION NAME] leaves, cinnamon, nutmeg, ground ginger, white powder, and black pepper. Interview with the Dietary Manager at the time of the observations revealed the corn meal should have been wrapped with plastic wrap after opening, and the cinnamon sugar, almonds, brown sugar, and dry yeast should have been closed and sealed after opening. She further stated the spice lids should have been closed and she would need to re-educate staff. Further observation, on 04/24/12 at 12:50 PM, during initial tour, revealed a bottle of Dawn dishwashing detergent was on top of the food prep table. Interview with the Dietary Manager at the time of the observation revealed cleaning supplies were not to be stored where food was being prepared. Observation on 04/24/12 at 4:45 PM, revealed Cook #1 wiped the thermometer probe with an alcohol swab and temped the tomato soup. He then used the same alcohol swab to clean the thermometer probe and then dry the probe with a dry dish cloth prior to temping the vegetable soup. The cook continued the same process using the same alcohol wipe and the same dry cloth to clean the same thermometer probe to temp the potato soup, green beans, macaroni an cheese, mashed potatoes, corn, pasta noodles, and carrots. Interview at the time of the observation with the Dietary Manager, who was also watching tray line, revealed it was policy to use a different alcohol wipe to clean the thermometer probe after each food item and she had not noticed the cook using the same alcohol wipe. Interview, on 04/24/12 at 5:30 PM with Cook #1, revealed he was unaware of the need to use a different alcohol pad to clean the thermometer probe between each food item, and was unaware he was not to use a dish cloth to dry the probe after each use. After further questioning, he stated he could see how this could be a problem if residents had food allergies and also for the possible contamination of food items. Further interview, on 04/26/12 at 11:30 AM, with the Dietary Manager when requesting a policy related to temping food items, revealed there was nothing in the facility policy related to using a different alcohol swab prior to temp each food item, and she had never instructed the cooks to do this.

Based on observation, interview and review of the facility's policy, it was determined the facility failed to ensure all medication vials were labeled in accordance with current professional standards. The facility failed to ensure a multi-dose vial of Tuberculin skin test serum was dated upon opening. The findings include: Review of the facility's policy titled "Medication Storage - Single and Multi Dose Vials", (undated), revealed the maximum expiration date for any properly stored, opened multiple-dose containers was twenty-eight (28) days. Observation, on [DATE] at 11:50 AM, revealed an opened (uncapped) vial of Tuberculin skin test serum was stored in the refrigerator in the medication room. Interview with Registered Nurse #8, at that time, revealed multidose medication vials should be dated when opened and expired twenty-eight (28) days after opening. She confirmed the vial had not been dated when opened and stated there was no way to determine when the medication had or would, expire. Interview with the Administrator, on [DATE] at 12:30 PM, revealed all multi-dose medication vials were to be dated upon opening. She stated she was not sure when the medication would expire, but thought it was twenty-eight (28) days after opening.

Based on observation, interview, and record review, it was determined the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection for one (1) of eight (8) sampled residents (Resident #4). Resident #4 was in contact isolation related to a penile wound with Methicillin Resistant Staphylococcus Aureus (MRSA) organism. Observation revealed a Licensed Practical Nurse (LPN) examined Resident #4's penile wound site/Foley catheter site, and removed the soiled gloves. The nurse then donned new gloves without washing her hands and applied lotion to the resident's feet. Also, observation revealed a Certified Nursing Assistant (CNA) removed the isolation gown by untying the gown around the neck with soiled gloves. The findings include: 1. Review of the "Mosby's Nursing Skills Isolation Precautions Quicksheet", dated 11/09, used by the facility, revealed when leaving the isolation room, the order of removal of protective barriers depends on what the nurse wears in the room. Further review revealed, remove one glove by grasping cuff and pulling glove inside out over hand. Hold removed glove in gloved hand. Slide fingers of ungloved hand under remaining glove at wrist. Peel glove off over first glove. Discard gloved in proper container. Perform hand hygiene. Untie neck strings of gown, and then untie back strings of gown. Allow gown to fall from shoulders; touch inside of gown only. Remove hands from sleeves without touching outside of gown. Hold gown inside at shoulder seams, and fold inside out into a bundle; discard in laundry bag. Review of Resident #4's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the laboratory data revealed a wound culture of the penis was collected on 04/16/12. Review of the physician's orders [REDACTED]. The final report received on 04/20/12 indicated MRSA which the culture and susceptibility showed resistant to [MEDICATION NAME]/[MEDICATION NAME] (antibiotic medication). Review of the Care Plan, dated 04/23/12, revealed a problem of a chronic indwelling catheter for Benign Prostatic Hyperplasia (BPH-enlarged prostate), status/post TURP with complication of Hematuria. Further review revealed the resident was diagnosed with [REDACTED]. Observation, on 04/25/12 at 9:30 AM, revealed there was an isolation cart outside the resident's door containing gloves, masks, and gowns and a sign by the resident's door which stated contact precautions. Observation of a skin assessment, on 04/25/12 at 3:00 PM, revealed Licensed Practical Nurse (LPN) #1 touched Resident #4's penile wound and Foley catheter and stated the resident had MRSA in the wound. She then removed the soiled gloves, and donned new gloves without washing her hands. LPN #1 proceeded to touch her glasses, and then lotion the resident's feet. Interview, on 04/25/12 at 3:30 PM, with LPN #1 revealed she should have washed her hands prior to donning new gloves, and she had not realized she touched her own glasses with the gloves on. 2. Further observation, on 04/25/12 at 5:00 PM, revealed Certified Nursing Assistant (CNA) #2 repositioned Resident #4 in the bed and then weighed the resident by pushing a button on the side rail of the bed. The CNA then untied the tie at the neck of her gown while still wearing soiled gloves and then removed her gown and placed it in the laundry hamper. She then removed her soiled gloves. Interview with CNA #2 after she exited the resident's room, revealed she should have removed her gloves, and then her gown, however, may have been nervous due to being observed. Interview, on 04/25/12 at 4:20 PM and 5:15 PM, with the Infection Control Nurse, revealed CNA #2 should have removed her soiled gloves prior to removing her gown in order to keep from contaminating her hair and neck area. She stated the proper procedure was to remove the gloves, then gown, roll the gown in a ball, and place the gown in a hamper.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure the resident environment remains as free of accident hazards as is possible for one (1) of eight (8) sampled residents (Resident #2). Observation during the initial tour on 04/24/12 revealed an electric heater, which was close to a wooden chair leg, was turned on and being utilized in Resident #2's room . The findings include: Review of the facility's "Safety Policy/Procedure", dated 01/24/12, revealed space heaters carry a much greater risk of causing fire than central heating, and present a greater potential for human error such as leaving them too close to combustible materials. The policy further stated that space heaters were not permitted in areas where patients were housed or treated. Observation, on 04/24/12 at 1:15 PM, revealed there was an electric heater plugged in and turned on in Resident #2's room and the heater was positioned close to a wooden chair leg. Further observation, on 04/24/12 at 4:00 PM, revealed the electric heater was not observed to be in the room. Interview, on 04/25/12 at 9:45 AM, with Resident #2 revealed she/he had an electric heater in the room; however, staff had removed it. Interview, on 04/25/12 at 2:00 PM, with the Administrator revealed the electric heater was given to the unit by maintenance and it had been approved for use. She stated it had been removed from the resident's room on 04/24/12 because there was some concern with the style of the electric heater. She indicated she was unaware portable electric heaters were not to be utilized in residents' rooms. Interview, on 04/25/12 at 2:05 PM, with the Director of Plant Engineering, revealed "per policy, heaters were not to be used in patient rooms".

Based on observation and interview, it was determined the facility failed to prominently display information regarding how to apply for and use Medicare and Medicaid benefits. The findings include: Observation, on 04/25/12 at 3:15 PM, revealed there was no signage posted for Medicare and Medicaid and how to apply for these services and benefits. Interview, on 04/26/12 at 9:25 AM, with the Administrator, revealed the signage used to be on the bulletin board in the hall. She indicated she was unaware the signage had been removed.

Based on interview and record review, it was determined that Immediate Jeopardy (IJ), identified during the standard survey (03/24/11) had been removed; however, non-compliance continued to exist related to administration regarding the infection control process. The facility had not completed staff in-servicing regarding contact isolation precautions nor had the facility's Quality Assessment and Assurance Program completed the monitoring, analysis of information in order to develop and implement the Performance Improvement Plan to ensure the deficient practice had been corrected and to prevent recurrence. The findings include: Record review of the Contact isolation Precautions Tracking Record revealed the facility had not completed training for two (2) Direct Care Staff (CNA). Interview, on 04/11/11 at 12:45pm, with the Administrator and Associate Nurse Manager revealed that while observations of staff demonstrating proper glucometer use and cleaning, and isolation precautions had been completed daily the facility had not implemented all aspects of their plan to correct the deficient practice. The facility needed to continue to monitor for eight (8) weeks the contact isolation procedures. At which time the Quality Assessment and Assurance Program will develop a Performance Improvement Plan (PIP) based on the analysis of the data from the observation logs. The PIP will be developed with specific objectives to meet the needs of the skilled unit.

Based on interview and record review, it was determined that Immediate Jeopardy identified during the standard survey (03/24/11) had been removed; however, non-compliance continued to exist as the facility had not completed Contact Isolation Precautions in-servicing for two (2) certified nursing assistants (CNA). Additionally, the facility had not completed the Quality Assessment and Assurance (QAA) initiative related to staff monitoring, analysis of monitoring results, and the development and implementation of the Performance Improvement Plan. The findings include: Record review of the Contact isolation Precautions Tracking Record revealed two (2) Direct Care Staff (CNA) had not completed the training. Interview, on 04/11/11 at 12:45pm, with the Administrator and Associate Nurse Manager revealed the facility had not implemented all aspects of their plan to correct the deficient practice. She stated the facility needed to continue to monitor contact isolation procedures for up to eight (8) weeks. Once the monitoring is complete, the Quality Assessment and Assurance Program will coordinate an analysis of the information in order to develop a Performance Improvement Plan with specific objectives to meet the needs of the skilled unit.

Based on observation, interview, record review, and literature review of The Centers for Disease Control, the facility failed to ensure effective Infection Control procedures to prevent cross-contamination were implemented. The facility identified nine residents of a census of thirteen (13) on 03/24/11, requiring contact isolation precautions, to prevent the spread of infection, of which four residents required blood glucose monitoring. The facility failed to ensure all facility infection control policies and procedures were revised to reflect facility wide changes and failed to ensure staff was knowledgeable and competent with regard to infection control practices. On 03/15/11, facility staff failed to clean and disinfect a glucometer (blood glucose monitoring device) after Resident #11's use, who the facility identified as requiring contact isolation precautions due to the [DIAGNOSES REDACTED]. This failure led to another staff (CNA #9) using the same glucometer to perform the blood glucose testing on Resident #12 (having a stapled incision to the left hip) later on that date without ensuring the device was cleaned and disinfected prior to it's use. CNA #9 did not recall disinfecting the glucometer prior blood glucose testing on Resident #12. This failure to ensure effective cleaning and disinfection after each use placed Resident #12 at risk for exposure to a pathogen. Additionally, facility staff was observed placing used isolation gowns on stored clean gowns ready for staff use in contact isolation rooms and placing used gowns on hooks in residents rooms to be reused. The facility's failure to ensure disinfection of blood glucose monitoring devices after each use placed other residents requiring blood glucose monitoring at risk for serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 03/15/11 at F441 "K" and F490 "K". The findings include: 1. Review of the Centers for Disease Control and Prevention (CDC) website page regarding glucometer care, last updated on 02/23/11, revealed the "CDC is alerting all persons who assist others with blood glucose monitoring and/or insulin administration of the following infection control requirements: ...whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared." Review of the Quick Reference Guide for the Accucheck Inform manufacturer guidelines for cleaning the glucometer, stated it should be cleaned with a dampened cloth or pre-moistened wipe with one of the following: water, soap, 70% (or less) [MEDICATION NAME] alcohol, 1:10 dilution of sodium hypochlorite, or ammonium chloride. There was no recommendation by the manufacturer for frequency of cleaning the glucometer. Interview with the Health Care Professionals department of Roche Diagnostics (manufacturer of the Accucheck Inform), on 03/24/11 at 2:40pm, revealed the Accucheck Inform is a glucometer intended for multi-person use. The representative stated the manufacturer recommends how to clean the device only, and stated they do not recommend how or with what product to disinfect the unit or the frequency of disinfection. The representative detailed the disinfection process would be determined by the facility and it's infection control practices. Review of the Infection Control Quick Guide in the facility's Infection Control Manual revealed that all equipment is to be decontaminated before use on another patient. Review of the Patient Care Services Policies and Procedures Manual and Whole Blood Glucose Monitoring: Accu-Check Inform with effective date January 2009, revealed the glucometer should be wiped with Gluco-chlor wipes, alcohol wipes, or ammonium chloride wipes, and stated "Frequency is as needed." Record review and observation of the facility revealed the facility had identified nine residents requiring contact isolation requirements of which four residents required blood glucose monitoring. Record review revealed the facility admitted Resident #11 on 03/14/11 with multiple [DIAGNOSES REDACTED]. The facility had initiated, per physician order [REDACTED]. MRSA is defined as any strain of Staphylococcus aureus that has developed antibiotic resistance to beta-lactam antibiotics which include the [MEDICATION NAME], (methicillin Methicillin, [MEDICATION NAME]/[MEDICATION NAME]/[MEDICATION NAME]/[MEDICATION NAME], etc.) and the cephalosporins. Patients/Residents with open wounds, invasive devices and weakened immune systems are at greater risk of infection/Nosocomial infection than the general public. (source:Wikipedia)) Record review of training provided to CNA #4 revealed a hire date of 12/06/10 and training during hospital orientation included Bloodborne Pathogens, Infection Control, and Isolation Update, all provided on 12/07/10. Point of Care Testing dated 12/08/10, revealed CNA #4 completed training, and provided return demonstration of blood glucose monitoring, witnessed by a Hospital Education Specialist. Initial skill/equipment competency checklist revealed glood glucose monitoring training was provided on 12/09/11 and initialed as completed by a Hospital Education Specialist. Nurse Assistant Skill Demonstration on 12/10/11 did not include assessment of Infection Control procedures. CNA #4 was provided Unit Clinical Orientation during the period of 12/13/10 through 01/14/11. CNA #4 demonstrated use of the blood glucose monitor, and verbalized and demonstrated Contact Precautions on 01/04/11, which was acknowledged and signed by the Associate Nurse Manager on 01/21/11. Observation on 03/15/11 at 12:20pm, revealed CNA #4 wore gloves and a gown into the contact isolation room of Resident #11 and carried the glucometer, stored inside the case with glucometer supplies, into the room. CNA #4 placed the glucometer case and the glucometer on the bed, obtained the glucometer test result, then returned the glucometer to the case. CNA #4 entered the resident's bathroom, placed the glucometer case on the sink, removed the gloves and washed her hands. CNA #4 walked to the doorway, placed the glucometer case on a cart outside the resident's door, removed the isolation gown, and returned the used gown to the bin within the cart, placing the used gown on top of the clean gowns on the cart. CNA #4 carried the glucometer case to the nursing station, and placed the glucometer case inside a locked cabinet, then returned to serve a lunch tray to Resident #11. During this observation, the CNA did not clean or disinfect the glucometer after Resident #11's use, prior to placing the glucometer in the case or putting the glucometer case in the locked cabinet. Interview, on 03/15/11 at 12:25pm with CNA #4, revealed that she stated it would be acceptable to sit the glucometer and case on the bed in Resident #11's room because she is assigned to the care of this resident and since she changed the bed, it was considered clean. CNA #4 acknowledged that neither the glucometer nor the glucometer case was disinfected before they were returned to the locked cabinet. She further revealed that she did not know if she had been trained to clean the glucometer after removing it from a contact isolation room. Review of the memory report for glucometer #12, on 03/15/11 at 1:45pm accessed by CNA #8, revealed a glucometer check was performed for Resident #11 on 03/15/11 at 11:23am, followed by a glucometer check for Resident #12 on 03/15/11 at 11:35am. (CNA #8 stated that the glucometer's time settings had not been changed to reflect daylight saving time which went into effect on 03/13/11.) Interview on 03/23/11 at 10:45am with CNA #9, revealed CNA #9 conducted the blood glucose check for Resident #12 on 03/15/11 at 11:35am. CNA #9 did not remember if she cleaned the glucometer prior to performing the glucometer check on Resident #12. CNA #9 stated it should have been cleaned after the previous glucometer check. Record review revealed on 03/10/11 Resident #12 had a surgical repair of a left hip fracture. Observation revealed Resident #12 had a stapled incision to the left hip on 03/15/11. Interview with the facility's Infection Preventionist, on 03/15/11 at 2:20pm, revealed that all equipment, including the glucometer, should be disinfected between resident use with Sani-wipes. She stated when blood glucose monitoring is performed, only the glucometer should be taken into the room, leaving the case with the lancets and other supplies on the cart outside of the resident room. While the Infection Preventions detailed that the glucometer syould be disinfected between resident use the Patient Care Services Policies and Procedures Manual and Whole Blood Glucose Monitoring: Accu-Check Inform policies did not detail when or the frequency for which the glucometer should be wiped with Gluco-chlor wipes, alcohol wipes, or ammonium chloride wipes. Interview with three (3) Education Specialists, who are all responsible for nursing facility orientation and training of newly hired staff, by conference call on 03/24/11 at 4:00pm, revealed that staff are trained to gather supplies needed to perform a glucometer check before entering an isolation room. The staff are trained to leave the glucometer case outside of the room, and wear a gown and gloves into the contact isolation room. The isolation gown should be placed in the soiled linen bag upon exit from the room. Staff are required to disinfect the glucometer between residents with Sani-wipes which were provided on the carts next to each isolation room. However, observations revealed that while the Sani-wipes were provided on the carts, CNA #4 did not use them. Interview with the Associate Nurse Manager (ANM), on 03/15/11 at 2:25pm, revealed staff are trained to disinfect the glucometer after each use with Sani-Wipes which are germicidal. The ANM said all staff are trained during a three (3) day period after corporate orientation that provided more specific training on the unit which includes use of the glucometer. The ANM stated she worked with CNA #4 on 03/17/11 and told the Administrator that CNA #4 did not seem to understand what had been taught regarding infection control and glucometer policy and procedures. 2. Review of Centers for Disease Control website revealed, '2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings' which advised: Contact Precautions are intended to prevent transmission of infectious agents, including epidemiologically important organisms, which are spread by direct or indirect contact with the patient or the patient's environment. When Contact Precautions are used, donning of both gown and gloves upon room entry is indicated to address unintentional contact with contaminated environmental surfaces." It was also recommended the gown be removed before leaving the patient care area in a manner that prevents contamination of clothing or skin with the outer, contaminated side of the gown, which should be turned inward and rolled into a bundle, then discarded into a receptacle for contaminated linen. Review of the Infection Control Quick Guide in the facility's Infection Control Manual revealed gloves were to be worn when entering a contact isolation room to provide direct patient care. Interview with the Associate Nurse Manager (ANM), on 03/17/11 at 12:00pm, revealed that direct care is defined as care which requires touching of the resident. Review of the facility's Contact Precautions Policy revealed that gloves are required when entering contact isolation and that gowns are worn when providing direct patient care. The policy stated individuals may reuse the gown during a shift if not soiled with blood or body fluids, and stored on hooks in the room. The soiled gowns are to be placed in soiled linen bags within the isolation room. Observation, on 03/15/11 at 12:10pm, revealed that CNA #4 wore gloves and a gown into the contact isolation room of an unsampled resident to deliver the lunch tray. CNA #4 removed the gown at the doorway upon exit of the isolation room, then folded the used gown and placed it in the open bin on top of the clean gowns on the cart near the resident room. Observation, on 03/15/11 at 12:20pm, revealed CNA #4 wore gloves and a gown into the contact isolation room of Resident #11. Upon finishing in the contact isolation room, CNA #4 removed the isolation gown, and returned the used gown to the bin, placing it on the clean gowns stored on the cart. Interview with CNA #4, on 03/15/11 at 12:15pm, revealed that she was trained to always wear gown and gloves when entering a contact isolation room. CNA #4 stated that it was an acceptable practice to place the used gown in the clean bin near the door, unless contact with the resident occurred, then the gown should be placed in the linen hamper in the soiled utility room. Continued interview with the ANM revealed that only gloves are required in contact isolation unless direct care is provided, then a gown would be required. The ANM said isolation gowns should be disposed in the dirty linen after each use and are not intended for reuse. However, interview with CNA #11, on 03/23/11 at 4:20pm, revealed that an Infection Control Inservice was provided by the Hospital Infection Preventionist on 03/18/11 which covered the same information as presented in the training last summer in hospital orientation which detailed the Contact Precautions Policy. Interview with CNA #10, on 03/23/11 at 4:10pm, revealed that the Hospital Infection Preventionist provided training regarding Isolation Policy and Procedures on 03/21/11 for the Skilled Nursing Unit. CNA #10 stated the focus was Contact Precautions and she had been provided a copy of and reviewed the Contact Precautions Policy, dated 02/18/10. Review of the Contact Precautions Policy which CNA #11 and #10 referenced as the training material used on 03/18/11 and 03/23/11 detailed that individuals may reuse the gown during a shift if not soiled, and store the gown on hooks in the room. Interview with three (3) Education Specialists by conference call on 03/24/11 at 4:00pm, who are all responsible for nursing facility orientation and training of newly hired staff, revealed the staff are trained to wear a gown and gloves into the contact isolation room. The isolation gown should be placed in the soiled linen bag upon exit from the room. The Education Specialists agreed it would be acceptable to hang the isolation gown on the hook in the resident room if it was not soiled with blood or body fluids, used only for single staff use, and discarded at the end of the shift. The Education Specialists did not think reusing the isolation gown would result in staff contamination. Interview with the Hospital Infection Preventionist (HIP), on 03/24/11 at 3:40pm, revealed that the hospital trains employees in accordance with the Contact Precautions Policy, dated 02/18/10. The HIP stated that it is acceptable for staff to reuse gowns if they are not soiled with blood or body fluids, and hang them on a hook provided in the resident room, and are for single staff use, and must be discarded in the soiled linen at the end of each shift. The HIP was not aware that the Skilled Nursing Unit had been training staff to discard the isolation gowns after each use, but said that it was a more cautious practice than the policy required, and said, "the reuse of isolation gowns is a nursing judgment." The HIP did not agree that the reuse of isolation gowns would result in staff contamination. Further interview with the ANM revealed they were told it was acceptable to reuse gowns and hang them on a hook in the room, but later told it was best not to reuse them. The ANM expected staff to dispose of the isolation gowns after each use. However, observation of Resident Rooms 5322-02 and 5323-01, on 03/24/11 at 5:20pm, revealed both rooms were identified by the facility as requiring contact isolation precautions. At the time of this observation both rooms each had an isolation gown hanging on a hook located behind the door to the room. Further interview with the ANM revealed all staff are trained during a three (3) day period after corporate orientation which provided more specific training on each individual unit including the use of equipment including the glucometer. The ANM said when a staff member is observed functioning outside the facility policy and procedures, the ANM provides immediate one on one retraining. The ANM said recent issues addressed with staff on a one to one basis included appropriate removal of gown, and handwashing encouragement, which involved review of the policy regarding isolation gowns and handwashing.

Based on observations, interview, and record review, it was determined the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions. The facility failed to follow their Floor Care, Infection Control Guidelines for Nutrition Services, Storage of Foodstuffs and Maintenance of Equipment for Nutrition Services policies. The Kitchen floors were observed unclean and with standing water. Appliancies (i.e. mixers, bowls) were soiled with dired sticky substances. Employees were not wearing required full hair covering. Frozen food items were stored on the floor in the freezer. Dry goods items were not sealed and covered and stored in a manner in accordance with infection cntrol. The walk in refrigerators and freezers had peeling paint on the ceilings. The findings include: 1. Policy review of the Floor Care policy with revision date of 11/09 revealed all spills (food, liquids, grease) are immediately cleaned up by appropriate staff person. Floor care policy states mop heads are placed in soiled laundry and mop equipment is stored in the appropriate area, and wet floor signs are placed on wet floors until dry, with all associates responsible to report wet or slippery floors to Supervisors. Observation, on 03/15/11 at 10:00am, during a tour of the kitchen revealed the kitchen floor had standing water near large boilers directly under the hood where condensation dripped constantly on the floor. Two (2) large boilers had continuous boiling water. Puddles of water were contained by using multiple mop heads placed on the floor to absorb the water. Lettuce salad was spilled on the floor near the cold prep area. In the dry goods storage area, flour was spilled on the floor. Interview, on 03/15/11 at 10:00am, with the Manager of Food Service (FSM) revealed that condensation drips from the range hood where new boilers and equipment were installed during 2010 in order to provide a new meal delivery format. The FSM said, the staff useed mop heads to absorb the condensation from the range hood, which pools on the floor. The FSM acknowledged the spills should be cleaned when they occur, and the lettuce salad and flour should have been cleaned off the floor immediately. 2. Policy review of Infection Control Guidelines for Nutrition Services, with revision date 11/09 reveal all equipment shall be disassembled, cleaned, sanitized, dried, and reassembled after each use, and states 'clean' means free of visible soil. The Infection Control Guidelines also stated that kitchen personnel shall keep clean hair covered with a hairnet, all foods that have been prepared for service shall be covered, dated, and discarded after three days, and food shall be served with clean tongs, scoops, forks, spoons, spatulas or other suitable implements to avoid manual contact whenever possible. Observation on 03/16/11 at 11:45am during tray line preparation found the Cook wearing a checked cap with hair outside of the cap. The Prep-cook and Server/Cashier both wore a bouffant head cover on the back part of the head with the front of the head/hair exposed. The staff at the Starter Station wore a bouffant head cover in a manner which left hair exposed at the forehead and back of the neck. Observation on 03/17/11 at 9:10am, during the sanitation tour, revealed the Kitchen Aide counter mixer, can opener, and Hobart stand mixer were not clean and ready for use, as there were dried particles on the equipment. Continued interview with the FSM revealed the FSM said the Kitchen Aide mixer, the Hobart stand mixer, and the can opener were not cleaned properly and should have been cleaned after use. The FSM did not have a cleaning log for the cleaning of appliances and the kitchen work area. The FSM said she was not aware that kitchen staff were not wearing complete head coverings, and said that no hair should be exposed when the head covering was worn properly. 3. Policy review of Storage of Foodstuffs, with a revision date of 11/09, revealed food items are to be stored six inches off the floor, and all leftovers will be placed in shallow pans, covered, labeled, and dated before refrigeration, with mandatory prompt cooling of leftovers. Continued observation during the kitchen tour revealed the Walk-in refrigerator #2 had a container of tomato soup, artichoke strips, and blueberry muffin batter in baking tins uncovered on a cart. The tomato soup and artichoke strips were stored in open containers on the top shelf of a second cart, within three (3) feet of cracked and peeling paint on the ceiling. The third cart had a tray of scalloped potatoes which were too hot to touch and directly placed under a covered tray with tomatoes, sauce, and cheese. The prep walk-in refrigerator revealed containers of carrots, corn, green beans, and asparagus, which were stored on the top shelf of a rolling cart, unsealed and open to air. Observation of Walk-In freezer #3 revealed three (3) boxes of frozen mashed potatoes were stacked and stored directly on the floor. Continued interview the FSM was unaware of the open dry goods and said she would identify a container in which to seal and store the breadcrumbs and lentils. The FSM said staff have been trained during orientation to review kitchen policies, and not to leave scoops in a container/bins. The FSM acknowledged that all refrigerated containers of prepared foods should be covered and the items on the top of the rolling cart were in close proximity to the cracked and peeling paint, which created a risk of food contamination. The FSM stated, the storage of a tray of hot scalloped potatoes on a cart within the walk-in refrigerator was acceptable because the food was stored in a large flat tray which would cool quickly. He/she said hot food would not affect the tray of prepared cold food directly above it or raise the temperature of the refrigerator. The FSM acknowledged boxes of frozen food should not be stored on the freezer floor. 4. Policy review of Maintenance of Equipment for Nutrition Services, with revision date 11/09, stated all corrective maintenance is conducted consistent with procedures outlined by Plant Engineering. Both walk-in refrigerator #1 and #2 were found to have cracked and peeling paint from the ceilings and walls. Walk-in freezer #3 revealed ice droplets on the ceiling and ice on the freezer vent; ice was heavy on the upper right side. Continued interview revealed the FSM was not aware of the cracked and peeling paint in walk-in refrigerators #1 and #2, but said the peeling paint, "needs to be taken care of." . The FSM further stated the ice on the ceiling and vent of walk-in freezer #3 was not unusual. This freezer was out of service in January, 2011. The FSM said the freezer was old and required service frequently by facility Plant Engineering. Interview on 03/17/11 at 9:10am with the FSM revealed that she initiated a work order to report the cracked and peeling paint in walk-in refrigerators #1 and #2, as well as the collection of ice droplets on the ceiling and vent of walk-in freezer #3. The FSM said she addressed concerns with the hospital's Project Manager about the condensation of the floor since the new equipment was installed in October, 2010, and said he/she sent an e-mail on the date of the survey, 03/17/11, requesting assistance. Interview on 03/17/11 at 10:00am with the Supervisor of Plant Engineering (SPE) revealed that the frozen condensation in walk-in freezer #3 was not an unusual occurrence because it was a very old appliance. The SPE said the defrost mode is automatically activated three (3) times daily and runs for thirty (30) minutes to defrost the buildup. The SPE had no response to explain if the defrost mode was functioning properly, or why the frozen condensation remained in place as observed consecutively for two days. The SPE stated when the request was received to paint the inside of walk-in refrigerators #1 and #2, he objected and explained that the interior surface of both units was aluminum, which should not be painted. The SPE said last year the engineering staff scraped the paint off of the interior of walk-in freezer #3 which also aluminum, had been painted earlier and the paint was cracking and peeling. The SPE said, "I guess we will have to scrape the other refrigerators now."