Every finding on record at Sunset Manor

Based on observation, interview, the facility's Diet Manual, the facility's policies for Menu Planning and Portion Control, and the facility's 2023 Spring/Summer Menus for Week 2, Wednesday; the facility failed to ensure the residents on Mechanical Soft and Puree diets received the portion sizes per the approved menu at lunch on Wednesday, July 26, 2023. This had the potential to affect 23 of 53 residents receiving meals from the kitchen. Findings include: The facility's Diet Manual, dated 2008, included the following: . Mechanical Soft (Dental Soft) Diet A Mechanical Soft or Dental Soft Diet is used for individuals who have difficulty chewing regular textured foods. Foods that are difficult for the individual to chew are chopped, ground, shredded and/or soft cooked to facilitate chewing and ease of swallowing. Dysphagia Puree (Level 1) Diet The Dysphagia Puree (Level 1) Diet is used only for individuals who have severe chewing and/or swallowing problems. All foods are pureed to simulate a soft food bolus, eliminating the whole chewing phase. Pureed Diet menus follow the foods on the Regular Diet as closely as possible with the main difference being food consistency . The facility's policy for Menu Planning, dated 2010, included the following: Policy: Nutritional needs of individuals will be provided in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences . through nourishing, well-balanced diets . Procedure: . 3. Regular and therapeutic menus are written by the facility's food and nutrition professional in accordance with the facility's approved diet manual. The facility's policy for Portion Control, dated 2010, included the following: Policy: Individuals will receive the appropriate portions of food as planned on the menu. Control at the point of service is necessary to assure that only the standard portion is served. Procedure: . 2. The menu should list the specific portion size for each food item. Menus should be posted at the tray line for staff to refer to for proper portioning of servings for each diet. 3. Serve the food with ladles, scoops, spoodles and spoons of standard sizes. Portions that are too small result in the individual not receiving the nutrients needed. Serving Utensils (chart for scoop [s] size conversion to cups or ounces) #8 s (equals) 1/2 cup (equals) 4 ounces (oz) #10 s (equals) 3/8 cup (equals) 3-4 ounces #12 s (equals) 1/3 cup (equals) 2.67 ounces #16 s (equals) 1/4 cup (equals) 2 ounces . The facility's 2023 Spring/Summer Menus for Week 2 at lunch on Wednesday, July 26, 2023 included the following for the Mechanical Soft Diet: . 3 oz Gr (ground) Chicken Breast . The facility's 2023 Spring/Summer Menus for Week 2 at lunch on Wednesday, July 26, 2023 included the following for the Puree diet: . 3 oz Pur (pureed) Chicken 4 oz Pur Rice Pilaf 4 oz Pur Lima Beans 2 oz Pur Bread . The tray line for the residents' lunch meal was observed on 07/26/2023. Employee Identifier (EI) #3, the AM Cook, served the hot food for the lunch meal. At 11:15 AM, the following was observed: A #16 scoop (blue handle), yielding 2 ounces, was used to portion each serving of Ground Chicken onto plates for the Mechanical Soft diets. A #8 scoop (grey handle), yielding 4 ounces, was used to portion each serving of Pureed Chicken onto plates for the Puree diets. A #12 scoop (green handle), yielding 2.67 ounces, was used to portion each serving of Pureed Rice Pilaf onto plates for the Puree diets. A #16 scoop (blue handle), yielding 2 ounces, was used to portion each serving of Pureed Lima Beans onto plates for the Puree diets. On 07/26/2023 at 12:02 PM, EI #3, the AM Cook, was interviewed. EI #3 said she checked the menu to know what to prepare for each meal. EI #3 said the menus were usually posted on the pantry door or were at the Dietary Manager's desk. EI #3 further said she usually reviewed the menu items with the Dietary Manager to ensure she was cooking the right thing. EI #3 also said this was a brand new menu from a new company and they were on Week 2. EI #3 said she had not yet seen any recipes to go with the new menus. When asked about the Pureed Chicken and Pureed Bread, EI #3 said she added the bread to the pureed meat. EI #3 said she prepared six portions of Pureed Chicken for lunch because there were 5 residents on the Puree Diet and she added a portion to be sure there was enough. EI #3 said she used frozen diced chicken to prepare the Pureed Chicken and she used a 4-ounce ladle to measure it out prior to cooking. EI #3 said she added 6 slices of white loaf bread, one slice per serving, when pureeing the chicken. EI #3 said she did not have a recipe for pureed meats. EI #3 said the menus stated how much to serve for each food item. When asked if there was a conversion chart that she could use to determine which portion scoops to use for service; EI #3 said they did have a conversion chart, but it was discarded about a year ago when the cabinets were changed. EI #3 said they had not had a conversion chart for scoops for at least a year. EI #3 used the Wednesday, July 26, 2023 menu as a reference and said, a three ounce portion should be served for Ground (Mechanical Soft) Chicken and Pureed Chicken. EI #3 said, a four ounce portion should be served for Pureed Rice Pilaf and Pureed Lima Beans. EI #3 was asked about the observed lunch service on Wednesday, July 26, 2023. EI #3 said, she thought the #16 scoop (blue handle) that was used to portion each serving of Ground Chicken onto plates, was three ounces. EI #3 said, the #12 scoop (green handle) being used for Pureed Rice Pilaf would have been three ounces. EI #3 said, the #16 scoop (blue handle) being used for Pureed Lima Beans, was about three and a half ounces if rounded, not leveled off. EI #3 then said, she really did not know because there was no (ounce to scoop conversion) chart. On 07/26/2023 at 4:32 PM, EI #2, the Dietary Manager, was interviewed. Upon being asked how did the cooks know what to prepare for each meal, how to prepare it, and how much to prepare, EI #2 said at this point, they come to me. EI #2 further said, they have a new system and new menus. EI #2 said the new recipes were currently in a file cabinet and needed to be placed in a binder. EI #2 said, for now the staff had to ask for recipes as needed. When asked if there was a recipe for pureed meats, EI #2 said there was a description for puree at the bottom of each menu sheet: Pureed: Holds shape on spoon; smooth texture; No separated liquid; not firm/sticky. Upon being asked about bread being pureed with meat, EI #2 said, that was due to past training the staff received and that the pureed bread and pureed meat should be separate. EI #2 said, the staff knew how much to serve for each food item at meals because it was listed on the daily expanded menu. When asked if there was a conversion chart available that the staff could use to determine which portion scoops to use, EI #2 said, she did not know of one, but could get one. EI #2 used the Wednesday, July 26, 2023 menu as a reference when asked about portion sizes, and said, three ounces Ground (Mechanical Soft) Chicken and Pureed Chicken should be served. EI #2 said, five to six ounces of Pureed Chicken should have been used since bread was added. EI #2 said a four ounce portion should be served for Pureed Rice Pilaf and Pureed Lima Beans. EI #2 explained the scoops as follows: A #16 scoop (blue handle) was 1/4 cup or 2 ounces. A #12 scoop (green handle) was 1/3 cup or 2.67 ounces. A #8 scoop (grey handle) was 1/2 cup or 4 ounces. EI #2 was asked about the observed lunch service on Wednesday, July 26, 2023: EI #2 said, a #16 scoop (blue handle) being used to portion each serving of Ground Chicken onto plates was not correct and it should have been at least 3 ounces. EI #2 further said a #10 scoop would have been good to use. EI #2 said, a #12 scoop (green handle) being used for Pureed Rice Pilaf was not correct, and it should have been a #8 scoop for a serving of four ounces. EI #2 said, a #16 scoop (blue handle) being used for Pureed Lima Beans was not correct and it should have been a #8 scoop for a serving of four ounces. EI #2 said, a #8 scoop (grey handle) being used to portion each serving of Pureed Chicken was not correct, because the bread was included. EI #2 was asked the concern if residents received portions less than specified on the approved menu. EI #2 answered, weight loss and a lack of nutrition.

Based on observations, interviews, resident record review, and a facility policy titled Weight Monitoring, the facility failed to ensure Resident Identifier (RI) #55 received an Ensure supplement as ordered with meals. This deficient practice affected RI #55 one of two residents sampled for nutrition. Findings include: A facility policy titled Weight Monitoring with a revised date of 04/2023 documented: . Compliance Guidelines: . 1. The facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes: . c. Developing and consistently implementing pertinent approaches . RI #55 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #55's physician orders for July 2023 documented an order dated 05/23/2023 for RI #55 to receive eight (8) ounces of Ensure supplement with all meals. RI #55 was observed during the supper meal on 07/25/2023 at 5:38 PM in RI #55's room. RI #55's meal tray was not served with eight ounces of Ensure supplement. RI #55 was observed during the lunch meal on 07/26/2023 at 11:16 AM in the dining room. RI #55's meal tray was not served with eight ounces of Ensure supplement. RI #55 was observed during the supper meal on 07/26/2023 at 05:56 PM in RI #55's room. RI #55's meal tray was not served with eight ounces of Ensure supplement. An interview was conducted on 07/26/2023 at 06:02 PM with Employee Identifier (EI) #4 CNA. EI #4 was asked if RI #55's dinner meal was served with an Ensure supplement. EI #4 said, no it was not but RI #55 was supposed to have an Ensure supplement with the meal. EI #4 was asked who was responsible for ensuring RI #55 had an Ensure supplement with each meal tray. EI #4 said, the kitchen staff was responsible for putting it on the tray. EI #4 was asked if the Ensure supplement was listed on RI #55's meal ticket. EI #4 said, no it was not listed on RI #55's meal ticket. An interview was conducted on 07/27/2023 at 8:54 AM with EI #2, Dietary Manager. EI #2 was asked about RI #55's Ensure supplement to be given with each meal. EI #2 said, RI #55 had an order for Ensure to be given with each meal. EI #2 was asked why RI #55 did not have an Ensure supplement during observed meals. EI #2 said, when the facility transferred to the new system, the resident's diet order was carried over, but the supplement was not carried over. EI #2 said, the resident's supplement order should have been carried over to the new system and listed on the meal ticket. EI #2 was asked what was the concern with RI #55 not getting Ensure supplement as ordered. EI #2 said, weight loss and lack of nutrition.

Based on observation, interview and review of a facility policy titled, Cleaning Dishes/Dish Machine, the facility failed to ensure that food dish pans were allowed to air dry prior to stacking and storing. This had the potential to affect 67 of 67 residents receiving meals from the kitchen. Findings include: A review of an undated policy Titled, Cleaning Dishes/Dish Machine revealed: .9. Allow dishes to air dry .10 .inspect for cleanliness and dryness . On 09/23/19 at 5:45 p.m., during the initial tour of the kitchen with Employee Identifier (EI) #4 Dietary Manager, an observation was made of two separate stacks of food pans stored on the shelf under the prep table. The food pans were nesting one on top of the other. The surveyor asked EI #4 to remove several pans, one at a time, from the stack. Each pan removed was noted to have clear wet substance running off. EI #4 then stated, Well, you got me. They are all wet. EI #4 removed the wet pans from the shelf and took the wet pans to the dish washing area. On 09/25/19 at 3:30 p.m., an interview with (EI) #4 was conducted. EI #4 was asked, what was the facility policy for food utensils/dish storage. EI #4 replied that the food utensils/dishes should be stored in a dry location, free from water splashes, or any other particles. EI #4 was then asked, how the food pans were stored on the shelf under the prep table on 9/23/2019. EI #4 responded that they were stacked wet. EI #4 was asked, how the food pans should have been stored after they were washed. EI #4 stated, they needed to be stacked dry, they should be allowed to air dry then stacked or put away. EI #4 was asked, what would be the potential harm in storing the pans nesting and wet. EI #4 answered, there could be contamination with mold growing. EI #4 was then asked, who was responsible for ensuring that the facility policy was followed with food utensil/dish storage and EI #4 replied, she was.

Based on observation, interview, a facility policy titled, Garbage Disposal and the (YEAR) Food Code the facility failed to ensure that the outside garbage disposal area was free of debris. This had the potential to affect all 69 residents residing in the facility Findings include: A policy titled, Garbage Disposal Revised (MONTH) (YEAR) documented: .will be observed for continued compliance by Maintenance and Housekeeping departments . A review of the (YEAR) Food Code U.S. Public Health Service documented: . 5-501.15 Outside receptacles . (B) Receptacles and waste handling units for REFUSE . shall be installed so that accumulation of debris and insects and rodent attraction and harborage are minimized and effective cleaning is facilitated around and . under the unit . On 09/25/19 at 11:46 a.m. an observation with Employee Identifier (EI) #4, Dietary Manager, was made of trash items on the ground behind the 2 dumpster's, just off of the concrete pad. Items noted were 4 blue gloves, 2 clear bottles, several paper items, and a clear plastic item. A white plastic fork and a white plastic straw were on the ground, on the concrete pad beside the dumpster's. On 09/25/19 at 3:30 p.m. an interview with EI #4 was conducted. EI #4 was asked what was the facility policy for garbage/refuse disposal. EI #4 replied that it was the facility policy to keep the doors closed, free from leaks, and the area free from debris or trash. EI #4 was then asked, what items were noted to be on the ground around the dumpster's. EI #4 replied, there were water bottles, gloves, and a straw. EI #4 was asked how the dumpster area should be maintained and EI #4 answered that it should be free from debris and dry. EI #4 was asked what would be the potential harm of garbage being on the ground around the dumpster's. EI #4 stated it could attract pest and the pest could get in the facility. EI #4 was then asked how often were the dumpster's emptied. EI #4 replied the dumpster's were emptied twice a week. EI #4 was then asked who was responsible for ensuring the dumpster area was maintained per the facility policy. EI #4 replied anyone that came out to the area should look and make sure it was clean, but maintenance and housekeeping were appointed.

Based on observation, interviews, medical review, and a facility policy titled Standard Precautions: Infection Control, the facility failed to ensure a Licensed Practical Nurse (LPN), Employee Identifier (EI) #3, washed her hands or used hand sanitizer after she removed her gloves, touched the top of the waste container on the left side of the medication cart with both hands, and prior to touching Resident Identifier (RI) #24's medication cup, on the medication tray on top of the medication cart. This affected one of two Licensed Nurses and one of three residents observed during medication pass. Findings Include: A review of a facility policy titled Standard Precautions Infection Control, with a date implemented of 11/28/2017, revealed . Policy Explanation and Compliance Guidelines: . (p. 1) e. Perform hand hygiene: . vi. After removing gloves . (p. 5) After touching . contaminated items; immediately after removing gloves . On 9/25/19 at 8:17 a.m., the surveyor observed EI #3, a LPN, apply gloves on both of her hands, crush RI #24's medication in a plastic sleeve, and put RI #24's medication in a cup. EI #3 then removed her gloves and touched the top of the waste container, on the left side of the medication cart, with both ungloved hands. EI #3 then placed the plastic sleeve in the waste container, picked up a plastic cup on top of the medication cart with both hands, and touched the lid of the waste container with both hands, to open the waste container. EI #3 did not wash her hands, or use hand sanitizer after completing tasks around the med cart. EI #3 then touched one of RI #24's medication cups on the medication tray with her ungloved hands, prior to picking up the medication tray, on top of the medication cart, with both hands. On 9/25/19 at 3:07 p.m., an interview was conducted with EI #3, LPN. EI #3 was asked what should she have done after she removed her gloves, touched the top of the waste container on the left side of the medication cart with both hands, and prior to touching RI #24's medication cup on the medication tray on top of the medication cart, during the medication pass. EI #3 stated she should have used hand sanitizer. EI #3 was asked why did she not wash her hands or use hand sanitizer after you removed your gloves and before touching a new medication cup. EI #3 stated she did not think about the lid of the waste container being contaminated at the time, but she knew that she should have used hand sanitizer prior to touching the top of the medication cup. EI #3 was asked what was the facility policy on hand hygiene after you remove your gloves. EI #3 replied the policy stated to wash your hands or use hand sanitizer after you touched contaminated items and after you removed your gloves. EI #3 was asked what would be the concern in not washing your hands or using a hand sanitizer after you removed gloves and prior to have touching a medication cup. EI #3 stated the resident could possibly contract an infection. On 9/25/19 at 3:21 p.m., an interview was conducted with EI #2, the Director of Nursing/Infection Control Preventionist. EI #2 was asked what was the facility policy on hand hygiene after you removed your gloves. EI #2 stated you should wash your hands or use hand sanitizer after you removed your gloves. EI #2 was asked what would be the concern in not washing your hands or using a hand sanitizer after you removed your gloves, touched the top of the waste container with both ungloved hands, and prior to touching RI #24's medication cup. EI #2 stated it could cause contamination and possibly cause an infection.

Based on medical records, interviews, and a facility document titled, Comprehensive Resident Assessment (Minimum Data Set), the facility failed to ensure a Significant Change in Status Minimum Data Set (MDS) was completed on three sampled residents after being admitted to hospice. This affected Resident Identifier's (RI) #2, 43 and 115, three of six facility residents on hospice. Findings Include: A review of a facility policy titled Comprehensive Resident Assessment (Minimum Data Set), with an implemented date of 10/01/1991, documented: The facility shall conduct a comprehensive, accurate .assessment of each resident's functional capacity .2. Promptly after significant change in the resident's physical or mental condition . 1. RI #2 was admitted to the facility on [DATE]. On 08/28/2018 at 11:10 a.m., a review of RI #2's Physician Order, dated 05/12/2018, revealed a new medical [DIAGNOSES REDACTED].#2 to hospice with a [DIAGNOSES REDACTED]. A review of RI #2's MDS's revealed no Significant Change in Status MDS was completed, within the fourteen day time frame, after RI #2 was admitted to hospice on 05/12/2018. On 08/29/18 at 05:30 p.m., an interview was conducted with Employee Identifier (EI) #2, Registered Nurse and MDS Coordinator. EI #2 was asked when was RI #2 was admitted to hospice. EI #2 stated that RI #2 was admitted to hospice on 05/12/2018. EI #2 was asked if there was a Significant Change in Status MDS completed on RI #2 when the resident was admitted to hospice. EI #2 replied, no. EI #2 was asked why was a Significant Change in Status MDS not completed, on RI #2, when the resident was admitted to hospice. EI #2 replied she was unsure of the new regulations, but now understood that the new regulations state that you must have a significant change within fourteen days of a resident being admitted , discharged , or changing providers of a hospice service. EI #2 was asked why should a Significant Change in Status MDS be completed on a resident when they are admitted to hospice. EI #2 stated that the Significant Change in Status MDS gives an overall picture of the resident, and this helps provide the care that the resident needs. 2.) RI #43 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #43's physician's orders [REDACTED]. .6/18/18 ADMIT TO SERVICES OF (Name of Hospice Company.) . A review of RI #43's Minimum Data Set (MDS) Significant Change in Status assessment dated [DATE], documented hospice treatment while a resident, was checked under Section O. This assessment was completed 25 days after RI #43's hospice benefits began. On 08/29/18 at 5:33 p.m., an interview was conducted with Employee Identifier (EI) #2, Registered Nurse (RN)/MDS Coordinator. EI #2 was asked when was RI #43 admitted to hospice services. EI #2 replied, 06/18/18. EI #2 was asked was there a Significant Change in Status MDS completed when RI #43 elected hospice services. EI #2 said she did one but it was completed on 07/13/18, which was after the 14 day time frame. EI #2 was asked why was a Significant Change MDS not completed before 07/13/18. EI #2 stated she was not aware of new regulations which stated that you must have a significant change within 14 days of being admitted , discharged or changing providers of hospice services. 3.) RI #115 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #115's physician's orders [REDACTED]. .8/2/18 0910 Admit to (Name of Hospice Company) . A review of RI #115's medical record revealed no Significant Change MDS after election of hospice benefits was completed. On 08/29/18 at 5:36 p.m., an interview was conducted with RI #2, RN/MDS Coordinator. EI #2 was asked when was RI #115 admitted to hospice services. EI #2 said, 08/02/18. EI #2 was asked was there a Significant Change in Status MDS completed within 14 days of RI #115 receiving hospice benefits. EI #2 said no, she was unsure of new regulations.

Based on observation, interview and review of a facility policy titled, Medications Multi-Dose Vials, the facility failed to ensure Resident Identifier (RI) #16's vial of insulin contained an opened date on the vial and package containing RI #16's insulin. This deficient practice affected RI #16, one of 7 residents observed during medication administration. Findings Include: A review of a facility policy titled, Medication Multi-Dose Vials Revised 01/29/13, revealed: .POLICY: To assure safety and infection control when multi-dose vials are utilized. PR[NAME]EDURE: 1. When a multi-dose vial (MDV) is opened initially, it should be dated. 2. There is a 28 day limitation on the use of MDV Insulins. RI #16 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 08/28/18 at 10:43 a.m. during a medication pass, Employee Identifier (EI) #4, Licensed Practical Nurse (LPN), was observed administering medications to RI #16. EI #4 took a package containing [MEDICATION NAME]from the refrigerator, took out a vial of insulin and drew up 2 units of [MEDICATION NAME] in a syringe. There was no opened date observed on the package or on the vial of insulin. On 08/29/18 at 11:05 a.m., an interview was conducted with EI #4, LPN. EI #4 was asked, what should be done when a bottle of insulin is opened. EI #4 said, it should have an opened and expiration date. It is 28 days. EI #4 was asked, did the package and/or vial of [MEDICATION NAME] for RI #16 have a opened date on it. EI #4 replied, no. EI #4 was asked, what was the concern with insulin not having an opened date. EI #4 said she would not know for sure when it was opened if it did not have an opened date on it and it should be discarded after 28 days.

Based on observations, interviews, medical record reviews and review of facility policies titled, Glove Usage and Handwashing/Hand Sanitizing, the facility failed to ensure: 1. a licensed nurse did not place gloves, a vial of medication and Resident Identifier (RI) #55's nebulizer mask on unclean surfaces during medication pass and 2. a licensed nurse washed her hands before preparing RI #59's medications and before applying her gloves to break one of RI #59's medications. These deficient practices affected RI #55 and RI #59, two of seven residents, and two of four nurses observed during medication administration. Findings Include: RI #55 was admitted to the facility on [DATE]. On 08/28/18 at 8:26 a.m. during a medication pass, the surveyor observed Employee Identifier (EI) #5, Licensed Practical Nurse (LPN), enter RI #55's room and lay a pair of gloves and a vial of nebulizer medication on RI #55's overbed table. EI #5 then entered the bathroom, washed her hands, walked back to the table and applied the gloves and picked up the vial of medication and poured it into the reservoir. After treatment, EI #5 was observed removing RI #55's nebulizer mask and placing it on the overbed table. EI #5 was then observed unplugging the nebulizer and moving it to the nightstand and lying the nebulizer mask on the nightstand, without a barrier, before picking it back up and placing it in a plastic bag. On 08/28/18 at 8:37 a.m. an interview was conducted with EI #5, LPN. EI #5 was asked should a vial of medication and gloves be placed on an unclean surface and then be used to prepare a nebulizer treatment. EI #5 said no, she knew when she did it that she should have put down a barrier. EI #5 was asked where did she place RI #55's nebulizer mask when she took it off. EI #5 stated the overbed table. EI #5 was asked where did she put the mask when she moved RI #55's nebulizer machine. EI #5 replied on RI #55's nightstand. EI #5 was asked should the mask be placed on unclean surfaces. EI #5 responded, no. EI #5 was asked what was the concern with placing items on unclean surfaces. EI #5 answered, infection control. 2.) RI #59 was readmitted to the facility on [DATE]. A review of a facility policy titled. Glove Usage with an original date 4/15/17, revealed: .Wash hands before gloves are applied and when gloves are removed. A review of a facility policy titled, Handwashing/ Hand Sanitizing with a last revised date of 4/15/2017, documented: .All personnel working in the facility are required to thoroughly clean their hands before and after resident contact . On 08/28/18 at 4:53 p.m. during a medication pass, EI #3, Registered Nurse (RN) was observed preparing RI #59's medications without washing or gelling her hands. EI #3 was then observed applying gloves without washing her hands after touching RI #59's overbed table and the bathroom door knob. EI #5 then picked up a pill from RI #59's medication cup and broke it in half wearing the gloves. On 08/29/18 at 6:17 p.m. an interview was conducted with EI #3, RN. EI #3 was asked when was she supposed to wash or gel her hands during medication administration. EI #3 replied before she applied gloves if she did any kind of eye drops, nose drops or fingerstick's before and after. EI #3 was asked did she gel or wash her hands before preparing RI #59's medications on 08/28/18. EI #3 said she did not think she did. EI #3 was asked when should she wash her hands when using gloves. EI #3 responded before putting them on and after taking them off. The surveyor asked EI #3 did she wash her hands before applying gloves that she got from RI #59's bathroom. EI #3 said no, she did not. EI #3 was asked what was the concern with not washing her hands at these times. EI #3 answered infection control. On 0829/18 at 6:27 p.m. an interview was conducted with EI #1, RN/Director of Nursing/Infection Control Coordinator. EI #1 was asked when should a nurse wash her hands during medication pass. EI #1 said before preparing medications and after contact with a resident. EI #1 was asked when should an employee wash their hands when using gloves. EI #1 replied before they glove and when they take them off wash again. EI #1 was asked should a nurse place gloves, a vial of medication and a nebulizer mask on an unclean overbed table and unclean nightstand. EI #1 stated not without a barrier down for it to be placed on.

Based on observation, interview and a facility policy titled, Garbage Disposal, the facility failed to ensure the dumpster's lid remained closed and a foul odor was not noted around the dumpster site. This affected 1 of 1 dumpster and had the potential to affect all 64 residents in the facility. Findings include: A policy titled, Garbage Disposal, last revised date Dec. 2011 revealed, Policy: This policy is to describe the disposal of garbage and waste from (name of facility) property. Policy Explanation and Compliance Guidelines: . Doors remain closed . On 08/27/18 at 04:03 PM, the dumpster was observed with the top lid completely open. Five black trash bags were observed sticking out of the top of the dumpster. On the ground beside the dumpster was one glove and two packets of pepper. A foul odor was also noted around the dumpster area. An interview was conducted with Employee Identifier (EI) #6, Dietary Manager, on 08/29/18 at 08:20 AM. EI #6 was asked what was the facility policy on the dumpster lids. EI #6 replied, they stay shut. EI #6 was asked what was the potential hazard of the lid being left open. EI #6 replied, it was a sanitation issue if it was left open.

Based on observations, interviews, a review of the medical record, the facility's policy titled, Nasogastric and Gastric: Medication Instillation and Potter and Perry's FUNDAMENTALS OF NURSING, the facility failed to ensure a licensed nurse checked RI (Resident Identifier) #16's (PEG) Percutaneous Endoscopic Gastrostomy tube placement prior to instilling medication. This affected one of seven residents observed during medication administration. Findings Include: A review of the facility's policy titled, Nasogastric and Gastric Medication Instillation with a revision date of January 24, 2006, revealed: .PROCEDURE .6. Check placement of tube. NOTE : If unable to verify placement, do not administer medication . A review of Potter and Perry, FUNDAMENTALS OF NURSING NINTH EDITION,Unit 5, Chapter 32, page 636 revealed: . 13.Verify placement . by observing gastric contents . RI #16 was readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review RI #16's physician's orders [REDACTED].ENSURE PEG PLACEMENT VIA (BY WAY OF) AUSCULTATION AND ASPIRATION WHEN USING TUBE . On 6/28/2017 at 8:30 a.m., during medication administration, Employee Identifier (EI) #1, LPN (Licensed Practical Nurse), did not check placement of RI #16's PEG tube prior to instilling medications. An interview on 6/28/2017 at 9:00 a.m., with EI #1 was conducted. EI #1 was asked what was to be done before administering medications into a G (gastrostomy) tube. EI #1 stated, Listen for bowel sounds, Aspirate stomach contents. EI #1 was asked what the potential for harm would be in not checking tube placement. EI #1 stated,It may not be in the stomach.

Based on observations, interviews, medication record review, a review of the facility's policy titled, Perineal Care for . Residents, the facility failed to ensure Employee Identifier (EI) #2, a Certified Nursing Assistant (CNA) cleaned Resident Identifier (RI) #7's front perineal area. The facility further failed to ensure EI #2 cleaned front to back during incontinence care. This affected one of one residents observed during incontinence care. Findings Include: A review of the facility's policy titled, Perineal Care for . Residents, with a revision date of 4/13/2015, revealed: . 4. Wash the pubic area first, . wash downward on each side . Wash downward the middle . Always wash downward . to prevent infection . RI #7 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. During an incontinence care observation on 6/28/2017 at 3:02 p.m., EI #2 did not clean RI #7's front perineal area. EI #2 cleaned stool from RI #7's buttocks, wiping back to front (from the top of the buttocks down to there perineal area). An interview was conducted on 6/28/2017 at 5:30 p.m. EI #2 was asked what was the correct way to wipe during incontinence care. EI #2 stated, Front to back. EI #2 was asked what was the correct way to clean the front perineal area during incontinence care. EI #2 stated, Wipe one side, change, wipe other side and then down the middle. EI #2 was asked what was the harm in not cleaning the perineal area. EI #2 said, Infection. An interview was conducted on 6/29/2017 at 1:44 p.m. with EI #3, the Director of Nursing. EI #3 was asked what was the correct way to wipe during incontinence care. EI #3 said, Front to back. EI #3 was asked what was the harm in not cleaning the perineal area correctly during incontinence care. EI #3 stated, Potential for urinary tract infection [MEDICAL CONDITION] or irritation.

Based on observations, interviews, medical record review, a review of the facility's policy titled, Perineal Care for . Residents, and Potter and Perry's FUNDAMENTALS OF NURSING, the facility failed to ensure Employee Identifier (EI) #2, a Certified Nursing Assistant (CNA): 1. washed her hands before applying gloves and after removing gloves, 2. washed her hands and changed her gloves after removing feces from RI #7's buttocks and before touching clean items and 3. wiped from perineal area to top of the buttocks during incontinence care to prevent potential infection. This affected one of one residents observed during incontinence care. Findings Include: A review of the facility's policy titled, Perineal Care . with a revision date of 4/13/2015, revealed: . 4. Wash the pubic area first . and wash downward . Always wash downward . to prevent an infection. 5. Clean each buttock . moving toward the back . 7. Remove contaminated gloves promptly after use and wash hands. Reapply clean gloves before touching Non contaminated items (ex. Clean gown, linens, etc.) . A review of Potter and Perry's FUNDAMENTALS OF NURSING NINTH EDITION, Unit V (5), page 458, reveals: . the WHO (World Health Organizations) (2009) recommend the following hand hygiene guidelines: 1. When hands are visibly . soiled . 3. Before, after, and between direct patient contact. After contact with body fluids or excretions .When moving from a contaminated to a clean body site during care . after removing gloves . RI #7 was admitted to the facility of 1/22/2015, with a [DIAGNOSES REDACTED]. On 6/28/2017 at 3:02 p.m., a CNA, EI #2 was observed touching clean items after cleaning feces from RI #7's buttocks, and not changing her gloves or washing her hands. EI #2 was further observed wiping from the back (buttocks/anus) to the front perineal area while cleaning RI #7 buttocks. An interview on 6/28/2017 at 5:30 p.m. with EI #2 was conducted. EI #2 was asked, after cleaning the buttocks and before touching clean items, what should be done. EI #2 stated, Change gloves and wash hands. EI #2 was asked what was the correct way to wipe during incontinence care. EI #2 stated, Front to back. EI #2 was asked what was supposed to be done when gloves were removed. EI #2 stated, Wash your hands or sanitize. EI #2 was asked what was the potential for harm in not changing gloves and washing hands before touching clean items. EI #2 stated, Spread of germs. An interview was conducted on 6/29/2017 at 1:44 p.m. EI #3, the Director of Nursing/Infection Control Nurse. EI #3 was asked what should be done after cleaning the buttocks and before touching clean items. EI #3 stated, Change gloves, wash hands, and reglove. EI #3 was asked what was the procedure for cleaning the front perineal area on a resident. EI #3 stated, Front to back . EI #3 was asked what was the potential for harm in not cleaning the perineal area correctly. EI #3 stated, Potential for UTI (urinary tract infection) or irritation.

Based on observations, interview and record reviews, the facility failed to ensure: 1) Two individual ice cream cups were not completely covered with ice on the top of the lids in the reach in cooler, 2) Residents' personal food in the reach in cooler contained a use by date. a) one from a fast food restaurant and b) another brought in by a family member. 3) A package of opened sliced bologna meat inside a zip lock bag was not sealed, in the reach in cooler. Findings include: On 08/16/16 at 5:00 PM, during an initial tour of the dietary department the following observations were made: 1) Two individual ice cream cups had ice on top of the lids. Food Code U. S. (United States) Public Health Service . 2013, 3-303.12 Storage or Display of Food in Contact with Water or Ice . ( page 71) (A) PACKAGED FOOD may not be stored in direct contact with ice or water if the FOOD is subject to the entry of water because of the nature of its packaging, wrapping, or container or its positioning in the ice or water . 2) a. A residents' food from a fast food restaurant was in a bag and was not labeled with a use by date, b. A residents' food in a Styrofoam to go container, brought in by a family member, was not labeled with a use by date. Food Code U. S. Public Health Service 2013, . 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety/Food, Date Marking. (page 92) (A) . READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 degree C (41 degrees F) or less for a maximum of 7 days. 3) A package of sliced bologna meat was in a Ziploc bag that was not sealed. Food Code U. S. Public Health Service 2013, . 3-501.11 Food Storage ( page 76) (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: . (2) where it is not exposed to splash, . or other contamination; . On 08/18/16 at 9:00 AM, Employee Identifier, EI #1, Dietary Manager was asked what could be the potential harm if the ice were to melt on the lids of the ice cream. EI #1 replied it could get down in the ice cream were it could cause contamination. EI #1 was asked was asked what should the residents' personal food in the reach in cooler be labeled with. EI #1 replied a use by date. EI #1 was asked what could be the potential harm of food not listed with a use by date. EI #1 replied not knowing when it was put in there, it could go bad. EI #1 was asked how should bologna meat be stored after it was opened. EI #1 replied in a sealed zip lock bag. EI #1 was asked what could be the potential harm. EI #1 replied it could spoil.

Based on observations, record review and interview: 1. The facility failed to prevent potential time/temperature abuse as evidence by monitoring, recording and maintaining hot food holding temperature on the tray line at 135 degrees Fahrenheit (F) or above. 2. The facility failed to assure utensils were properly cleaned and sanitized to destroy potential food borne organisms as evidenced by: a) failure to assure correct water temperature and chemical concentration per manufacturer's instruction by monitoring/documenting the chemical concentration and b) failed to prevent more than a days build up of bread crumbs in the toaster tray. 3. The facility failed to prevent: a) potential physical contamination by failing to utilized light bulbs (inside a refrigerator) which were shield or coated and b) potential bacterial contamination by transporting stacked (multiple) plate domes/covers touching body parts (arms etc.) The above practices posed the potential for food contamination and compromised food safety. This had the potential to affect all 59 residents receiving meal trays from dining services. Findings include: 1. The 2013 Food Code by the United States Public Health (USPHS) and the Food and Drug Administration (FDA) included the following: 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under ¶ (B) and in ¶ (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57oC (135oF) or above,. The facility policy titled Food Preparation and Handling dated 4/16/2011 under Process documented: l.b. The temperature of foods should be taken and recorded immediately at the end of cooking, . On 07/21/2015 at 11:34 AM, the trayline hot holding food plating and distribution was observed. Staff was asked what time plating had begun. The response was 10:50 AM. Nine hot items were observed and a request was made for the Certified Dietary Manager (CDM), Employee Identifier (EI) #1 to show where staff documented the monitoring. The log for Food Temp was void of any data for the noon meal. A request was made for EI #1 to monitor the temperature of the Fish and Chicken which revealed the holding temperature was substandard (below 135 degrees F. Fahrenheit). During an interview on 7/23/15 at 10:35 AM, EI #1, the Certified Dietary Manager stated the food temperatures on the tray line should be maintained at 135 degrees or higher. She further stated there were no documented temperatures for the noon meal on 7/21/15. EI #1 was asked who was responsible for documenting/monitoring food temperatures and she stated it was the cook, who had forgotten to document on 07/21/15. When asked what was the potential risk if food was not held at the required 135 degrees, she stated there was a potential for bacterial growth and the potential for food borne illnesses. 2. The 2013 Food Code by the United States Public Health (USPHS) and the Food and Drug Administration (FDA) included the following: 4-701.10 Food-Contact surfaces and Utensils. 2.a Equipment FOOD-CONTACT SURFACES and UTENSILS shall be sanitized. A record review of the facility document Dietary Dishwashing Chemical Calendar for July 2015 revealed food-contact surfaces are sanitized by the chemical Chlorine with a standard PPM (Parts Per Million) of 50/+. The record is designed for documenting at Breakfast, Lunch and Dinner. A review of the data for July 1 through 21, 2015 revealed that on July 8 (a Wednesday) and July 14 (a Tuesday) that no monitoring/documentation had occurred for any of the 6 opportunities. During an interview on 7/23/15 at 10:17 AM, EI # 1 stated the facility used a chemical dish machine for cleaning/ sanitizing dishes. She further stated the log was to be maintained at every meal. After reviewing the log, she acknowledged that staff failed to consistently document the temperature and concentration of the sanitizer. 2.b The 2013 Food Code by the United States Public Health (USPHS) and the Food and Drug Administration (FDA) included the following: 4-601.11(C) Non FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of . FOOD residue and other debris. On 7/21/2015 at 10:25 AM, the toaster crumb tray was observed to be filled with bread crumbs. During an interview with the CDM EI #1 on 7/23/15 at 10:25 AM, EI #1 stated crumbs in the toaster appeared to have been there about a week. When asked how often it should be cleaned, she stated it should be cleaned daily. She stated cleaning was important because crumbs would attract insects. 3. The 2013 Food Code by the United States Public Health (USPHS) and the Food and Drug Administration (FDA) included the following: .Functionality 6-202.11 Light Bulbs, Protective Shielding. (A) Except as specified in ¶ (B) of this section, light bulbs shall be shielded, coated, or otherwise shatter-resistant in areas where there is exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; or unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. a) On 7/21/2015 at 11:55 AM, a triple door upright refrigerator unit with stored food items was observed. One of the two light bulbs (inside the unit) was observed to not be coated/shielded. At this time, the CDM, EI #1 was asked to described the bulb. EI #1 said that one looked like it had a covering, the other one does not. EI #1 was asked what was the potential risk if the bulb was not coated/shielded. EI #1 responded shattering. b) On 7/21/2015 at 11:40 AM, a Dietary Aide, EI #2 was observed transporting clean/sanitized plate domes/covers (stacked chin high) close to the body and with an arm circled around the stack to brace them. EI #1 was asked what was the potential risk for handling domes/covers in that manner and she responded, cross contamination. When asked how should cleaned/sanitized equipment be handled, she stated with clean hands and prevent contact with any other physical contaminate. She further stated the domes/covers should, if stacked, be held away from the body and use both hands.

Based on observation, record review and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner by not removing hanging dust tags near the clean dish area and food preparation area. This was observed on 3 of 3 days of the survey and had the potential to affect all 69 residents currently receiving meals from the kitchen. Findings Include: A review of a policy titled "Contaminated/Discarded Food" dated 3/18/13 documented the following: "...PROCEDURE anytime food has had any foreign object or matter, planned or unplanned, that would be a danger to anyone ingesting, it will be discarded. This is to prevent contamination that could be detrimental to someone's health..." The following observations were made during the survey: On 7/29/14 at 4:30 PM, the surveyor observed hanging dust tags from the ceiling in the kitchen. This was located near the sink and clean dishes and near the food preparation area of the kitchen. The surveyor also observed dust and rust hanging from sprinkler head near the clean dish area. On 7/30/14 at 4:10 PM, the surveyor observed hanging dust tags from the ceiling in the kitchen. This was located near the clean dish area and food preparation area of the kitchen. The surveyor also observed dust and rust hanging from sprinkler head near the clean dish area. On 7/31/14 at 8:10 AM, the surveyor observed the same dangling dust tags from the ceiling in the kitchen. This was located near the clean dish area and food preparation area of the kitchen. The surveyor also observed dust and rust hanging from the ceiling sprinkler head, near clean dish area. On 7/31/14 at 8:15 AM, the surveyor interviewed EI (Employee Identifier) #1, Dietary Manger. EI #1 stated the ceiling in the kitchen was on a monthly cleaning schedule. EI #1 was asked to describe what was on the ceiling. EI #1 stated dust and grease, and they had tried to clean it but it needed painting. EI #1 was asked what the harm was of dust hanging from the ceiling in the kitchen. EI #1 stated the dust could contaminate food or dishes. EI #1 was asked what was hanging from the sprinkler head over the clean dishes. EI #1 explained part of the metal on the sprinkler was detached and hanging from the sprinkler. EI #1 was asked if it could fall on the clean dishes. EI #1 stated it could.

Based on observation, interviews and record review the facility failed to ensure a Certified Nursing Assistant (CNA), changed her gloves during incontinence care for Resident Identifier (RI) #7 when going from dirty to clean and further failed to ensure dirty items were not placed on a clean area. This was observed during one of two observations of incontinent care. Findings Include: A review of the facility policy titled "Handwashing" with a revised date of 12/30/05 documented the following: "...The facility must ensure proper technique is used for the prevention of transmission of infectious diseases. All personal working in the facility are required to wash their hands before and after resident contact, before and after performing any procedure, ... and when hands become obviously soiled... (a)Wash hands for approximately 15 seconds , being careful to cover every area, (i.e. between fingers, beneath nails) using friction (i.e., one hand rubbing the other). 2. Put on gloves, 7. Remove gloves and wash hands..." A review of "Fundamentals of Nursing Eighth Edition" Page 410, 411 and 419 documented the following: "...Handwashing is the act of washing with soap and water followed by rinsing under a stream of water for 15 seconds.... Contaminated hands of health care workers are a primary source of infection transmission in health care settings...Transmission of infection occurs very easily...Before, after, and between direct patient contact...c. when moving from a contaminated to a clean body site during patient care. d. after contact with inanimate surfaces or objects in the patient's room...g. after removing gloves...Remove gloves promptly after use, before touching non contaminated items and environmental surfaces, and before going to another patient. Perform hand hygiene immediately to avoid transfer of microorganisms to other patients or environments..." RI #7 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI#7's most recent significant Change MDS (Minimum Data Set), with an assessment reference date of 06/12/2014 revealed a BIMS (Brief Interview Mental Status) of 3 out of 15, indicating the resident was severely cognitively impaired. RI #7 was assessed as being totally dependent with one person assist, and was always incontinent of bowel and bladder. An observation was made 7/30/2014 at 8:10 AM. EI #2, CNA (Certified Nursing Assistant) was observed performing incontinence care on RI # 7. EI #2 put clean gloves on then removed a soiled pad and brief. EI #2 rolled the soiled pad and brief and placed at the end of the bed on top of clean linen. EI #2 than removed RI # 7's dirty gown. EI #2 did not change her gloves prior to removing the gown and then placed a clean brief and pad and gown on RI#7. EI#2 pulled clean linen over RI #7 with dirty gloves remaining on. EI #7 then removed dirty gloves and washed her hands. EI #2 was interviewed at 7/30/2014 at 8:50 AM. EI #2 was asked did you place dirty linen at the end of bed on top of clean linen. EI #2 replied yes I did. EI #2 was asked should you have placed dirty linen on the foot of the bed. EI #2 replied no. EI #2 was asked what is the potential for harm. EI #2 replied urinary tract infection or kidney infection. EI #2 was asked if gloves were changed before you put the clean brief and gown on. EI #2 replied I don't think I did.

Based on observation, interviews and record review the facility failed to ensure a Certified Nursing Assistant (CNA) Performed incontinence care for Resident Identifier (RI) # 7 in a manner to prevent cross contamination. This was observed during one of two observations of incontinent care. Findings Include: A review of the facilities policy and procedure titled, " Perineal Care for Female residents", with a revised date of 5/13/2010, revealed: "...Procedure... 4. Wash the pubic area first, moving from the pubic area to the anal area. Separate the labia and wash downward on each side of the labia using different corners of the wash cloth. If using wipes use a clean one each time. Wash downward in the middle over the urethra and vaginal openings . Always wash downward toward the anus to prevent infection. When washing outside of the perineal area one should never lap over from a clean to an unclean area with the same wipe..." RI #7 was readmitted to the to the facility on [DATE] with [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/12/2014 identified RI #7 with a BIMS (Brief Interview Mental Status) 3 out of 15 . Indicating that RI #7 was cognitively impaired. This MDS also documented RI #7 as always incontinent of bowel and bladder and totally dependent on staff for care. On 07/30/2014 at 8:10 AM the surveyor observed incontinent care for RI # 7. EI (Employee Identifier) #2, CNA was wearing gloves and used a peri wipe to wipe each side of the perineal area not separating the labia and then wiped down the middle, turned RI #7 to the right side wiped buttocks front to back then down the middle. EI #2 was interviewed on 7/30/2014 at 8:50 AM EI #2 was asked during incontinent care for RI # 7 did you separate the labia. EI #2 said that the labia was pulled up but was not separated to clean. EI #2 was asked if the labia should have been separated. EI #2 replied "yes". EI #2 was asked what is the potential for harm in not separating the labia during incontinence care. EI #2 replied not getting it as clean as it should be. EI #3, DON (Director of Nursing) was interviewed on 7/30/2014 at 9:10 AM. EI #3 was asked when performing incontinent care should the labia be separated. EI #3 replied yes. EI #3 was asked what is the potential harm in not cleaning the labia. EI #3 replied possible Urinary Tract Infection.

Based on observations, interviews, and record review, the facility failed to ensure residents were provided a private area to make personal telephone calls without being overheard. This deficient practice affected Unsampled Resident (UR) #1, #2, UR #3, UR #4 and Resident Identifier (RI) #10 and RI #13, six of 11 residents who attended the resident group meeting. Findings included: The facility's undated document titled "Resident Handbook" documented " ... TELEPHONE AND PHONE CALLS Individual room telephones are not provided ... A cell phone is available for use by residents wherever they chose to use it and is located at the Nurses' Station 1. if the cell phone is unavailable then any telephone can be used. If they wish for a private conversation, they may use any office to conduct their phone call ... ." During the resident group meeting on 6/12/13 at 10:00 AM, the surveyor asked the group if they could make a telephone call without other people overhearing their conversation. The residents said there was no telephone to use for privacy that they have to use the telephone at the desk (nurse's station). One resident, RI #10, stated the facility has a cell phone but when she has asked to use it, it was out of minutes. On 6/12/13 at 5:35 PM and 6:00 PM, RI #13 was observed asking to use the telephone at the nurses' station. The staff dialed the number RI #13 said she wanted to call; RI #13 was not offered the use of a cell phone. During an interview on 6/13/13 at 11:50 AM, Employee Identifier (EI) #1, the Resident Services Director, was asked where the residents use the telephone to make a private telephone call. EI #1 said the facility has a cell phone that residents are allowed to use at their request or they can use the telephone in his office. When asked if the residents had been made aware there is a cell phone available, EI #1 said in casual conversation the residents have been made aware. The surveyor asked EI #1 to show the surveyor where the cell phone was kept. Once a nurse retrieved the cell phone from a locked cabinet in the medication room, EI #1 tried to turn the cell phone on, but it would not come on. EI #1 stated the cell phone was not charged. In an interview on 6/13/13 at 1:25 PM, RI #13 was asked where did she make her telephone calls. RI #13 stated, "I have to come up her to the nurse's station to make my calls." When asked if she is ever offered the use of a cell phone, RI #13 replied, "No, they never have, I don't know anything about a cell phone, they will just dial the number for me and I use the phone right at the nurse's station." In an interview with UR #4 on 6/13/13 at 2:10 PM, she was asked if she was offered a cell phone to use when she made her telephone calls. UR #4 stated no that she had just been given the phone that has the cord on it. When asked if she would like to make calls in private, UR #4 replied, "Well yes, but the cord won't reach but so far." In an interview on 6/13/13 at 2:15 PM, UR #3 was asked if she had ever been told that there is a cell phone for private use if needed. UR #3 replied, "Not a cell phone, no, they let me use the telephone at the nurse station." On 6/13/13 at 2:20 PM, UR #1 was observed talking on a corded telephone at the nurse's station. At 2:35 PM, UR #1 was asked if she was offered the use of a cell phone to use and she stated, "No I wasn't." In an interview on 6/13/13 at 2:25 PM, UR #2 was asked if she was offered a cell phone to use and she stated, "Not that I can remember." When asked if she would like to have a private place to use the telephone, UR #2 said, "Yes, if I was going to call someone."

Based on observations, interviews and record review, the facility failed to ensure Resident Identifier (RI) #14's adaptive commode frame was free from a red rust like substance. This affected RI #14, one of one sampled residents with an adaptive commode frame. Findings include: During initial tour of the facility on 06/11/13 at 1:20 PM, an observation was made of RI #14's bathroom. A gray metal adaptive commode frame with four legs was situated over RI #14's porcelain commode. Each leg of the commode was secured to the frame by two metal screws for a total of eight screws. Each of the screws were coated with a red rust like substance. Two metal triangular shaped bars located under the commode seat was also coated in a red rust like substance. RI #14 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date of 03/29/13, identified RI #14 as being cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. RI #14 was assessed as requiring supervision with toilet use. An interview was conducted with RI #14 on 06/11/13 at 1:25 PM. He was asked if he uses the commode in his bathroom and he said he uses it everyday. When asked if anyone else uses the commode, he said the other person uses a bedpan. On 06/11/13 at 1:35 PM, the Licensed Practical Nurse (LPN), Employee Identifier (EI) #4, was asked by the surveyor to look at the adaptive commode frame and describe the condition of the triangular shaped bars and metal screws. EI #4 said they looked a little rusty. When asked what potential danger the rust posed, EI #4 said the frame could break or the resident could get a skin tear. An observation of RI #14's bathroom on 06/12/13 at 8:08 AM, revealed a new adaptive commode frame over his commode. On 06/13/13 at 9:58 AM, an interview was conducted with the Environmental Service Director, EI #5. She was asked who replaced the adaptive commode frame in RI #14's bathroom. EI #5 said she replaced it after EI #4 (LPN) told her it had to be replaced on 06/11/13. When asked why the commode frame was replaced, EI #5 said because the screws, the frame for the seat and the handles were rusty. She was then asked what danger the rusty equipment posed. EI #5 said the resident could have gotten a skin tear or a skin infection.

Based on observations, interview and review of the facility's procedure for labeling stored food items, the facility failed to date and label all foods stored in the reach in cooler with the contents and use by date. This had the potential to affect all 62 residents who receive their meals from the kitchen. Findings include: A review of the facility's procedure with no title or date instructed the kitchen staff to "Write the "USE BY" date on refrigerated items: (Day 1 is TODAY and discard after Day 3). These instructions were observed to be posted on the refrigerator. During the initial tour of the kitchen with Employee Identifier (EI) #4, the Dietary Manager (DM), on 04/03/2012 at 11:30 AM, a bottle of thickened tea with a date of 03/29/2012 was observed. EI #4 was asked what the date represented and she said I don't know and discarded the bottle. Four glasses covered with plastic wrap was not labeled with contents or a date. EI #4 stated that two were thickened juice and two were thickened milk and discarded all four glasses. Six trays of bacon each covered with butcher paper were not labeled with prepared or use by date. EI #4 said the bacon was prepared this morning to be cooked the next morning for breakfast. An angle food cake was wrapped in plastic and only half remaining with the current days date of 04/03/2012. EI #4 said the date was put on this morning and it definitely was not opened this morning. EI #4 discarded the cake. A plastic serving bowl with chopped bell peppers and tomatoes was observed with a resident's name on it, but no prepared and or use by date. An interview was conducted with EI #4 on 04/05/2012 at 12:00 Noon. EI #4 was asked how should food items stored in the reach in refrigerator be labeled. EI #4 replied items stored in the refrigerator or freezer should be labeled with the date prepared or opened, content and use by date. EI #4 was asked what can happen if the food is not labeled with use by dates. EI #4 replied no one would know when to throw it away and further stated it could cause food poison.