Every finding on record at The Transitional Care Center of Owensboro

Based on observation, interview, and facility policy review, it was determined the facility failed to store food in accordance with professional standards for food service safety. This had the potential to affect sixteen (16) of sixteen (16) residents residing in the facility. Observations, during initial tour of the kitchen on [DATE], revealed three (3) food items which were not labeled or dated after being removed from their original container; a five (5) pound bag of okra, a five (5) pound bag of chicken, and a five (5) pound bag of potato wedges. The findings include: Review of the facility's policy, Food and Supply Storage, last revised ,d+[DATE], revealed all food items were to be stored in a manner to maintain the safety and wholesomeness of the food for human consumption. Continued review of the policy revealed staff were to cover, label and date unused portions and open packages. Observation, on [DATE] at 12:57 PM, during the kitchen tour revealed a 5 pound bag of Okra that had been received as part of a box of four (4) 5 pound bags on [DATE], a 5 pound bag of chicken was received in a box of two (2) 5 pound bags on [DATE], and a 5 pound bag of potato wedges received in a box of six (6) five pound bags on [DATE]. However, the food items were not dated when removed from their original package. In an interview with the Executive Chef on [DATE] at 12:52 PM, he stated when freezer items were removed from their original package, items were to be labeled, dated, and discarded if not used within three months. In an interview on [DATE] at 9:00 AM with the Interim Director Food Service (IDFS), she stated all three identified food items were outside of their original containers. She stated if a food item was pulled from it's original box, it needed to stay with the box, or was to be labeled indicating an expiration date. The IDFS stated she expected any unused food portions to be labeled on returned to the freezer with identifying information with a use by date. She stated it was important to identify an expiration date on food items, as the danger would be items could be pulled after their expiration date. In an interview with the Administrator on [DATE] at 10:16 AM, she stated she expected all food items to be dated with an expiration date and an opened date. She stated she would expect that everything have a date, and staff to routinely go through those items and discard expired items. The Administrator further stated not knowing if a food item is expired could present a danger.

Based on observation, interview, review of the facility's policy, and review of the Centers for Disease Control and Prevention (CDC) Guidelines, 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 the development and transmission of communicable diseases, including Coronavirus Disease (COVID-19). Upon arriving to the Transitional Care Unit, on 06/14/2022 at 6:15 AM, Certified Nursing Assistant (CNA) #1 opened the door, and failed to screen three (3) State Surveyors prior to the Surveyors entering the unit. Observation at the time, revealed a visitor log at the entrance and signage posted stating the unit followed CDC guidelines and all visitors must be screened. Further, Life Safety Code (LSC) Surveyors were not screened upon arriving to the Transitional Care Unit entrance on 06/14/2022 at 10:30 AM. The findings include: Review of the memo titled, The Transitional Care Center Notice to Residents' Representatives and Family Members, revealed the facility was following guidance from the Centers for Disease Control (CDC) and Center for Medicare and Medicaid Services (CMS) to reduce the spread and impact of COVID-19, such as: Screening residents, staff, and visitors for symptoms. Review of the Transitional Care Center Visitor Screening form, dated 03/29/2020, revealed visitors were to complete the form and answer several questions related to signs and symptoms of COVID-19. Observation on 06/14/2022 at 6:15 AM, upon arrival to the Transitional Care Unit, revealed Certified Nursing Assistant (CNA) #1 opened the door, and failed to screen three (3) State Surveyors prior to the Surveyors entering the unit. Further observation upon entering the unit, revealed a visitor log at the entrance and signage posted stating the unit followed CDC guidelines and all visitors must be screened. Observation on 06/14/2022 at 10:30 AM, by the Life Safety Code Surveyors, revealed upon arrival to the Transitional Care Unit, they were not screened at the unit entrance. LSC Surveyor #1 revealed Guest Relations (Greeter) #1 informed him state surveyors did not have to be screened. Interview with Greeter #1, on 06/14/2022 at 10:39 AM, revealed all visitors were to be screened when visiting the unit. Per interview, visitors filled out a symptom sheet and had their temperatures taken. However, Greeter #1 confirmed she did inform Life Safety Surveyors the state surveyors did not have to be screened. Interview with Greeter #2, on 06/14/2022 at 10:42 AM, revealed everyone was to be screened upon entering the unit. She further revealed state surveyors should have been screened upon entering. Interview with Certified Nursing Assistant (CNA) #1, on 06/15/2022 at 9:50 AM, revealed visitors should be screened by staff when entering the unit. She stated, on 06/14/2022 she failed to screen surveyors upon entry to the unit. She stated failure to screen visitors could lead to COVID positive staff or residents. Interview with Licensed Practical Nurse (LPN) #1, on 06/15/2022 ay 9:07 AM, revealed staff and visitors were to be screened prior to entering the unit. She stated different forms were used for staff and visitors to complete and anyone entering the unit had to have their temperature taken. Interview with Registered Nurse (RN) #1, on 06/15/2022 at 10:05 AM, revealed all staff and visitors were to be screened when entering the unit. She stated staff and visitors were to review and sign a questionnaire form and have their temperatures taken. Interview with Manager of Nursing #1/Director of Nursing (DON), and Manager of Nursing #2, who was in training, on 06/16/2022 at 10:30 AM, revealed it was their expectation that all staff and visitors entering the unit be screened by the Greeter or a staff member. They revealed failure to screen could lead to residents or staff being exposed to COVID 19. Further interview revealed the Infection Preventionist for the Transitional Care Unit had resigned and therefore was unavailable for interview.

Based on observation, interview, and facility policy review, it was determined the facility failed to prepare and distribute food under sanitary conditions. Review of the facility Census and Condition, dated 04/10/17, fifteen (15) of fifteen (15) residents received their meals from the kitchen. Observations on 04/10/17 revealed the sanitizer in the cleaning cloth bucket was not at the appropriate level; food was not sealed and was open to air in the walk in freezer; one (1) dietary staff did not change gloves and wash their hands after contaminating gloved hands; and foods were left uncovered on the tray line. The findings include: 1. Review of the facility's policy titled, Sanitizing Food Contact Surfaces, last revised 03/01/17, revealed the red bucket's were to have a preferred effective solution sanitizing range of 200-400 Parts Per Million (PPM.), but per manufacturer a sanitizing solution range of 150-400 PPM is acceptable. Further review of the policy, revealed the red bucket's were to have the sanitizer solution replaced every two (2) to four (4) hours and whenever visibily dirty. Observation of the red sanitizer bucket at the grill line, on 04/10/17 at 6:35 PM, revealed the water was visibly soiled and brown in color and the sanitizer test strip was not showing any sanitizer agent in the bucket. 2. Review of facility's policy titled, Sanitation Safety/Hand Washing, last revised 04/29/16, revealed the purpose of this policy is to prevent the transmission of infectious and / or contagious diseases, employees observe procedures for hand washing for prevention of contamination of food and food-related equipment and employees are to thoroughly and frequently perform handwashing. Further review of the policy, revealed employees are to wash their hands after their hands have become soiled and dirty. Observation of Dietary Aide #1, on 04/10/17 at 6:45 PM, revealed he was preparing a plate of food and he dropped a meal ticket on the floor and then picked it up and continued preparing the plate of food. Further observation revealed the aide then dropped a tomato slice and picked it up off the floor; then as he attempted to throw it in the trash can it went back on the floor and the aide picked it up a second time and threw it in the trash. The aide continued to handle clean plates, handle the plate of prepared food and take the prepared plate to a delivery person. The aide did not change gloves or wash hands until interviewed by surveyor. Interview with Dietary Aide #1, on 04/10/17 at 6:55 PM, revealed he did not think he did anything wrong and stated he did not touch anything with the contaminated hand he used to pick stuff up off the floor with. 3. Review of facility's policy titled, Procurement-Receiving and Storage, last revised 03/29/17, revealed food items being stored in the freezer are to be in approved containers that have tight fitting lids, approved plastic bags, and food should be wrapped tightly to prevent cross contamination. Observation of walk-in freezer #1, on 04/10/17 at 6:24 PM, revealed a box of beef patties, a box of lasagna noodles and a box of pizza dough; unsealed and open to the air. Observation of tray line, on 04/10/17 at 6:10 PM and at 6:40 PM, revealed a plate of several pieces of meatloaf sitting out and uncovered; a pan of pork chops uncovered; a container of corn, gravy and macaroni /cheese uncovered. Interview with tray line Cook #1, on 04/10/17 at 6:48 PM, revealed she stated she should not have left the food on the tray line open and uncovered. She stated she does not normally leave food uncovered and stated she was unsure why she had done so this time. Interview with Dietary Manager #1, on 04/11/17 at 3:20 PM, revealed he expected all food items in the freezer to be sealed completely and not exposed to air; all sanitary buckets to be checked every two (2) hours and changed as needed when visibly soiled; foods on the tray line should be covered and not left open; and he expects all staff to always change their gloves and wash their hands if their hands have been contaminated. Interview with the evening Dietary Supervisor #1, on 04/10/17 at 6:50 PM revealed foods should be sealed completely when being stored in the freezer and foods on the tray line should be covered and not left open/uncovered. Dietary Supervisor #1 stated the sanitization water in the sanitary buckets should be changed when visibly dirty and periodically, and staff should wash their hands and change gloves when their hands have been contaminated. She stated she expects staff to follow facility policy and procedure. Interview with the Associate Director of Dietary Services, on 04/11/17 at 9:10 AM, revealed all food items in the freezer are to be sealed completely and not exposed to air; sanitary buckets are to be checked every two (2) hours and changed as needed when visibly soiled; foods on the tray line should be covered; and staff are expected to change gloves and wash their hands anytime their hands have been contaminated. He stated he expected staff to follow the facility's policies and procedures.

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) 3.0 Manual, it was determined the facility failed to ensure care plans were developed with an individualized plan of care that included the minimum healthcare information necessary to properly care for three (3) of eight (8) sampled residents (Residents #1, #2, and #8). The facility failed to ensure Resident #1's care plan was individualized for nutrition, mobility, and [MEDICAL CONDITION] medication to ensure proper care; Resident #2's care plan was individualized for bowel, urinary, restraint, and skin; and, Resident #8's care plan was individualized for Activities of Daily Living (ADL), anticoagulants, bowel, mobility, and nutrition. The findings include: Review of the RAI 3.0 Manual, dated October 2015, revealed the RAI helps nursing staff to gather information on resident's strengths, which must be addressed in developing an individualized care plan. Further review revealed the care planning process is to include a plan to move the resident toward resident specific goals using the resident's individual strengths and interdisciplinary expertise. Therefore, crafting the how of a resident's care. In turn, implementing that information with specific goals and interventions through individualized care planning by staff knowledgeable about the resident care goals and approaches; carrying out the how and when of the resident's care. 1. Record review revealed the facility admitted Resident #1 on 02/12/17 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 03/06/17, revealed the resident was not assessed for a Brief Interview Mental Status (BIMS) during the assessment period however, a BIMS on 02/27/17 revealed a BIMS score of thirteen (13). Review of the Comprehensive Care Plan, last reviewed on 04/11/17 at 12:15 AM, revealed to review the plan of care each shift and update the plan of care and document reviewed by clicking the reviewed button at the top of the care plan activity. Review of the Nutrition Care Plan, dated 03/14/17, revealed to drink (specify) % of dietary supplement and to lose no more than (specify) pounds dated 04/03/17. Review of the Anticoagulant Care Plan, dated 03/09/17, revealed to read potential complication of bleeding due to anticoagulation medication (specify). In addition, review of the [MEDICAL CONDITION] Medication Care Plan, dated 03/09/17, revealed potential alteration in (specify) due to [MEDICAL CONDITION] drug use and review of the Mobility Care Plan, dated 03/09/17, revealed to use assistive device of (specify). Each place that said specify was not filled in with the specific for Resident #1. 2. Record review revealed the facility admitted Resident #2 on 04/05/17 with [DIAGNOSES REDACTED]. Resident did not have a completed MDS at time of survey. Review of the care plan last reviewed on 04/06/17 at 8:15 AM revealed to review the plan of care each shift and update and document reviewed by clicking the reviewed button at the top of the care plan activity. Review of the Bowel and Bladder Care Plan, dated 04/05/17, revealed toileting schedule-offer assistance (specify) schedule. Review of the bowel elimination care plan, dated 04/05/17, revealed no episodes of diarrhea by (specify) and administer anti-diarrheal (specify). Review of the Alteration in Urinary Elimination, dated 04/11/17, revealed no sign of Urinary Tract Infection by (specify) as well as change catheter (specify). Review of the Physical Restraint Care Plan of two (2) upper rails, dated 04/06/17, revealed will make an informed choice regarding restraint use by (specify). In addition, review of Skin Integrity Care Plan, dated 04/06/17, revealed show presence of granulation tissue by (specify) and wound care (specify) and special bed (specify) dated 04/11/17. Each place that said specify was not filled in with the specific for Resident #2. 3. Record review revealed the facility admitted Resident #8 on 04/02/17 with [DIAGNOSES REDACTED]. Resident did not have an MDS completed at time of survey. Review of the last care plan review dated 04/07/17 at 9:39 AM revealed to review the plan of care each shift. Update the plan of care and document reviewed by clicking the reviewed button at the top of the care plan activity. Review of the Bowel Elimination Care Plan, dated 04/02/17, revealed no episodes of diarrhea by (specify) and stool specimen as ordered (specify). Review of Activities of Daily Living (ADL) Care Plan, dated 04/02/17, revealed the resident will be able to perform ADLs (specify) by (specify). In addition, review of the Anticoagulation Care Plan, dated 04/02/17, revealed potential bleeding complications of bleeding due to anticoagulation medication (specify). Furthermore, review of Alteration in Mobility Care Plan, dated 04/02/17, revealed assistive device of (specify). Review of the Nutrition Care Plan, dated 04/08/17, revealed provide modified diet (specify diet). Each place that said specify was not filled in with the specific for Resident #3. Interview with the MDS Coordinator #1, on 04/11/17 at 10:00 AM, revealed they use the RAI Manual 3.0 as reference for care planning. She stated the Dietician performs the nutrition part of the care plan and the MDS Coordinator performs the nursing section of the MDS. She stated she was not for sure why the nutrition care plan was vague as that part of the care plan was performed by the Dietician. She further stated the comprehensive care plan was not as specific with staff assistance with ADLS. She revealed on 04/12/17 at 1:55 PM that she was beginning to inservice the nurses on a complete care plan with specific goals and interventions as was her expectations. Interview with the Registered Dietician, on 04/11/17 at 10:30 AM, revealed the intern Dietician put the care plan in the computer for Resident #1and will need to modify the care plan to be specific. She stated the care plan should be resident specific and she will educate on individualized care plans for residents. Interview with the Nursing Manager, on 04/12/17 at 2:10 PM, revealed the problem with care plans not being individualized was discovered as an issue on a mock survey throughout the hospital, but the Transitional Care Unit was not surveyed during that time. She stated she figured they had the same issue. She revealed the care plan was difficult with the changes in the computer system. She stated she expected the care plans to reflect the resident and be individualized according to resident's needs and goals.

Based on interview, record review, and review of the Resident Assessment Instrument {RAI} 3.0 User Manual, it was determined the facility failed to accurately reflect the resident's status, for two (2) of two (2) sampled residents (Residents #1 and #4) who had Comprehensive Minimum Data Sets (MDS) assessments completed, in the selected sample of eight (8) residents. The facility failed to accurately code Resident #1's Comprehensive MDS assessment related to cognition, pain, and mood and failed to accurately code Resident #4's comprehensive MDS assessment related to pain. The findings include: Further review of the RAI Manual revealed one of the regulatory requirements included that the assessment must accurately reflect the resident's status. 1. Review of the RAI 3.0 User Manual, dated October 2015, revealed Section C, cognition items are crucial factors in many care planning decisions. The RAI Manual revealed to assess the resident's short term memory during the seven (7) day look back period. In addition, section D, determines the mood of a resident and D0100 should be answered to determine if the resident is able to complete the interview and continue to staff or resident interview. Furthermore, the manual revealed to attempt to conduct mood assessments on all residents and to assess the resident's mood unless the resident is rarely or never understood during a fourteen (14) day look back period. In addition, conduct the interview preferably the day before or the day of the Assessment Reference Date (ARD). Further review under Section J, revealed the assessment of pain uses an interview with the resident or staff if the resident is unable to participate. A pain assessment should be completed unless the resident is rarely or never understood in the five (5) day look back period. If the resident is understood or at least sometimes understood the interviewer should attempt to complete the interview. Record review revealed the facility admitted Resident #1 on 02/27/17 with [DIAGNOSES REDACTED]. Review of the Brief Interview for Mental Status (BIMS) assessment, dated 02/27/17, revealed the resident had a BIMS score of thirteen (13) on admission; however, review of the Comprehensive Admission MDS Assessment, dated 03/09/17, revealed Sections C cognition, Section D mood, and Section J pain were not assessed. Interview with MDS Nurse #1, on 04/11/17 at 10:00 AM, revealed Resident #1 should have had a BIMS score with a cognitive assessment as well as a mood assessment unless the resident refused to answer the questions. She stated the nurse performed the mood and cognitive assessment on admission. She revealed the mood was blank with no information and the cognitive assessment was performed outside of the reference period and another one was not completed during the assessment reference period. She further stated the nurse did perform the psychosocial assessment on Resident #1 so she was not sure why the mood assessment was not completed. She stated the MDS nurse usually looks over the information while inputting the MDS to ensure completeness and she would check into why the resident was not assessed for mood and the MDS was documented in section D as not assessed/no information. Further interview with MDS Nurse #1 on 04/12/17 at 10:46 AM revealed due to the computer system when the nurse was performing the initial assessment on Resident #1 she did not realize she had to click on the mood tab for the mood assessment to appear for questions to appear. Interview with Registered Nurse (RN) #2 on 04/12/17 at 11:30 AM revealed she was fairly new and was learning when Resident #1 was admitted and did not know there was a drop down box in the computer to answer the mood questions. Interview with the Nursing Manager on 04/12/17 at 2:10 PM revealed there was nothing in the computer to flag the nurses to do another BIMS or mood assessment. Furthermore, there was not a good process in place for situations like this. Interview with MDS Nurse #2, on 04/12/17 at 11:00 AM, revealed usually when there are blanks on the assessments we call the nurse who performs the assessments for any clarification, however she did not recall Resident #1 MDS and if she called the nurse when she did not have all the information needed for a complete MDS. She stated she also reviewed the manual and Resident #1 should have had another BIMS score and the cognitive assessment should have been completed during the seven (7) day look back period. 2. Record review revealed the facility admitted Resident #4 on 03/23/17 with [DIAGNOSES REDACTED]. Review of the fourteen (14) day Admission MDS Assessment, dated 04/05/17 revealed the resident was interviewable with a BIMS score of fifteen (15); however, review of Section J Pain was not assessed as a resident interview and was assessed by staff even though the resident was interviewable. Interview with MDS Nurse #1, on 04/11/17 at 2:05 PM, revealed Resident #4 did not have a pain assessment asking the pain questions with a resident interview as indicated on the MDS Section J. She stated the staff asked the resident pain questions every shift and that was why she had placed under staff interview instead of resident interview. Further interview with MDS Nurse #2, on 04/12/17 at 11:00 AM, revealed she had reviewed the RAI Manual this morning and now understands how to correctly code pain as was the case for Resident #4.

Based on observation, interview, and review of the facility's New Employee Handbook, it was determined the facility failed to ensure food was stored and served under sanitary conditions. Review of the facility Census and Condition, dated 04/30/14, revealed there were sixteen (16) residents residing in the building with one (1) resident requiring tube feeding. The findings include: Review of the New Employee Handbook, undated, revealed eating and drinking was only permitted in designated break rooms, dining rooms, and offices. Personal belongings should not be stored with you at your workstation. Observation in the kitchen, on 04/29/14 at 6:15 PM and on 04/30/14 at 10:15 AM, revealed a handwashing station by the tray line with no accessible trash can. Additional observation, on 04/29/14 at 6:15 PM, revealed one (1) personal drink cup of ice with a lid and straw, located in the freezer. Further review of the New Employee Handbook, undated, revealed to always use the food thermometer correctly and sanitize it before each use. Observation of food temperatures, on 04/30/14 at 10:30 AM, revealed Cook #1 used the thermometer probe to obtain a temperature of the mashed potatoes; however, did not clean the probe afterwards. He then obtained a temperature of the low potassium mashed potatoes, but did not clean the probe before obtaining a temperature of the potato soup. Cook #1 then obtained a temperature of green beans with onions, green beans without onions, and carrots without cleaning the probe between items. He re-used an alcohol swab to clean the probe after the carrots, then obtained a temperature of the brown gravy. Interview with the Food Service Director, on 04/30/14 at 10:50 AM, revealed there should be a trash can available by each handwashing station; however, the one by the tray line had been removed for cleaning. She revealed staff should not store personal drinks in the freezer. She further revealed staff should clean the food thermometer probe with a new alcohol swab after each food item.

Based on observation and interview, it was determined the facility failed to ensure each resident accessible bathroom was equipped to receive resident calls through a communication system. Two bathrooms located in the facility were unlocked and resident accessible; however, did not have a call system in place. The findings include: Observation, on 04/30/14 at 3:00 PM, revealed one (1) bathroom across from the mechanical room and one (1) bathroom across from the dining/recreation room was unlocked with no call system in place. Interview with the Manager of Nursing, on 05/02/14 at 10:15 AM, revealed the hallway bathrooms were accessible to residents; however, she was not aware of the need for a call system. She revealed there was no facility policy related to the call system.

Based on observation, interview and facility policy and procedure review it was determined the facility failed to ensure food was stored and prepared under sanitary conditions. A broom and dust pan was observed sitting on the floor in a food prep area. Additionally, opened milk was observed in walk in refrigerator without the proper label to indicate opened date. Findings include: Review of a facility policy titled, "Miscellaneous Food Service Policies-Sanitation Safety", last revised 12/10/12, revealed there was no information related to storage of brooms and dustpans. Interview with the Registered Dietician, on 07/03/13 at 10:30 AM, revealed she was not sure if there was a specific policy related to labeling of food items or storage of brooms and dustpans. An initial tour of the facility kitchen, on 07/01/13 at 11:30 AM, revealed: 1. an opened, partly empty, container of milk without a label to indicate what date the milk had been opened in the walk in refrigerator. 2. a broom and dust pan on the floor, propped against the wall in the food preparation area of the kitchen. An interview with the Food Services Director, on 07/01/13 at the time of the observations revealed opened containers of food and beverages should always be labeled to reflect the date opened. She stated it would be impossible to determine how long the partly used container of milk had been opened. Additionally, the Food Services Director stated brooms, mops and dust pans should never be stored in food preparation areas and should be stored in the cleaning closet hung on the appropriate hangers to keep them off the floor.

Based on observation and interview it was determined the facility failed to provide basic personal laundry services which are included in the Medicare or Medicaid payment. Observation of the interior of the facility, on 07/01/13, revealed there was no laundry services available for resident's basic personal clothing and linens. Findings include: Observations during a tour of the facility, on 07/01/13, revealed there was no laundry services available for resident's basic personal clothing and linens however, a washer and dryer were located in the laundry department. Interview with Registered Nurse (RN) #1, on 07/02/13 at 2:00 PM, revealed a washer and dryer were located in the therapy department but were not installed for use. She additionally stated there was no projected date for the installation of the washer and dryer. Interviews with Occupational Therapy Assistant (OTA) #1 and #2 and Physical Therapy Assistant (PTA) #1, on 07/02/13 at 3:00 PM, revealed a washer and dryer were located in the therapy department for working with residents for motion of loading and unloading, as therapy. The washer and dryer were non-functional as far as actually laundering clothing. They stated someone had been up to look and see if the dryer could be vented according to code but they were unaware of any plans to install the washer and dryer to actually function. An interview with the Administrator, on 07/02/13 at 10:00 AM, revealed there was no laundry service installed in the new Transitional Care Unit when the building was recently constructed. The Administrator stated the families took resident's basic personal laundry home for laundering.

Based on observation, interview, record review, and review of the facility's policy/procedure it was determined the facility ensure the Infection Control Program was implemented to provide a safe, sanitary, and comfortable environment for two (2) residents (#3 and #7) in the selected sample of eight (8) residents and one (1) resident (#9) not in the selected sample. The facility failed to date and label an intravenous line (IV) dressing on the initiation of the site for Resident #3 and IV tubing for fluids and/or medications for Residents #7 and #9. Findings include: A review of the facility's "Central Line and Blood Sampling Policy", dated 12/13/12, revealed "all dressings should be clearly labeled with the date and initials of nurse". 1. A record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of Central line dressing on the right chest of Resident #3 which was covered with a transparent dressing, on 07/01/13 at approximately 12:35 PM, revealed there was no date or initials of the nurse initiating the dressing. Interview with Assistant Director of Nursing (ADON), on 07/03/13 at 11:00 AM, revealed the IV team was responsible to ensure the dressing on a central line was dated and labeled by the clinician initiating the IV access according to the facility's policy/procedure. A review of the facility's IV Patient Management Protocol, dated 11/13/12, revealed the primary and secondary IV tubing should be changed every 72 hours and immediately upon suspected contamination or when the integrity of the product or system has been compromised, Intermittent IV tubing shall be changed every 24 hours (example saline lock receiving intermittent IV infusions) and immediately upon suspected contamination or the integrity of the product of system has been compromised. All tubings shall be changed using aseptic technique and observing Standard Precautions. Label tubing with date and time and nurse's initials. 2. A record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #7's physician's orders [REDACTED]. IVPB should have been administered once a day for 5 days with the last dose on 6/26/13. Observation of Resident #7, on 07/01/13 at 1:32 PM, revealed an empty Intravenous Piggy Back (IVPB) bag of [MEDICATION NAME] (antibiotic) 500 milligrams (mg.), with a date of 06/26/13, hanging on an IV pole with the IV tubing threaded through the infusion pump without a dated label on the tubing. 3. A record review revealed Resident 39 was admitted to the facility on [DATE]. A review of Resident #9's Physician order, dated 06/28/13, revealed 0.9% Normal Saline (NS) IV to infuse until 06/30/13. Observation of Resident #9, on 07/01/13 at 1:44 PM, revealed the IV tubing was not dated or labeled. Interview with the ADON, on 07/03/13 at 11:00 AM, revealed the IV tubing labeling and dating was an important infection control issue in the Transitional Care Area and he was aware staff were not dating or labeling the tubing.

Based on observation, interview, and review of the facility's policies and procedures, it was determined the facility failed to ensure food was stored under sanitary conditions and cookware was properly sanitized. Findings include: 1. A review of the facility's "Procurement-Receiving and Storage" policy/procedure, revised 06/30/11, revealed each food item would be stored and handled in a safe, sanitary, and appropriate manner. All food should be stored in such a manner as to maintain the wholesomeness of the food for human consumption. The procedure for dry storage included removal of items for which the expiration date had expired. The procedure for refrigerated storage included to discard food past the use-by date. Frozen storage procedures included to wrap food tightly to prevent cross contamination. An observation of dry storage, on 05/31/12 at 11:45 AM, revealed the following: a). One plastic bag containing Couscous, opened but not dated. b). One plastic bag containing Quinoa, opened but not dated. c). A plastic bag of peanut butter chips, opened, unsealed, undated, and overflowing into the box. d). A plastic bag of butterscotch chips sitting in a box opened, unsealed, and undated. An observation of the refrigerator and freezer, on 05/31/12 at 12:15 PM, revealed the following: a). A crate of fresh sliced carrots, expiration date 05/29/12. b). A plastic bag of frozen sugar cookie dough, opened and unsealed. c). A plastic bag of frozen crescent rolls, opened and unsealed. An interview with the Director of Food Services, on 05/31/12 at 5:00 PM, revealed she expected the staff to follow the facility's policy related to food storage. 2. A review of the facility's policy/procedure, "Dish Room Ware Washing," revised 09/11/08, revealed to empty, clean, and refill the power sinks as needed. In the power soak sink, dispense the correct amount of cleaning agent into the water. Use the test kit to ensure the correct level has been dispensed (level should be 200 parts per millions (ppm) on the test kit). An observation, on 05/31/12 at 4:10 PM, revealed pans were being cleansed in the three compartment sink. The power soak sink contained pans; however, a test of the water indicated there was no cleaning agent present. An interview with the Dishwasher, on 05/31/12 at 4:10 PM, revealed she tested the water earlier in the shift, but the water had been changed. She revealed she did not test the water prior to washing the pans. An interview with the Assistant Director of Food Services, on 05/31/12 at 4:15 PM, revealed she expected the Dishwasher to test the water prior to washing the cookware to ensure proper sanitation.

Based on observation, interview, record review and review of the Glucometer and the Reusable Equipment policy, it was determined the facility failed to have an effective system to ensure infection control policies were implemented for two (2) (Residents #1 and #11) of the eleven (11) sampled residents. The glucometer was not cleaned after blood glucose levels were obtained on Resident #1 and #11. Immediate Jeopardy was determined to exist on 06/07/11 and identified on 06/08/11. The facility's failure to provide adequate cleaning of the glucometers placed residents at risk for infection and placed residents in a situation that is likely to cause serious injury, harm, impairment, or death to a resident. The facility provided an acceptable Allegation of Compliance (AOC) on 06/09/11. The state agency verified Immediate Jeopardy was removed on 06/10/11. The deficiency 483.65, F441, Infection Control was lowered to a scope and severity of an "D". The findings include: The facility policy on reusable equipment with a revision date of 02/01/11, stated patient care reusable items shall be decontaminated between each resident use with a hospital disinfectant. The facility policy on the SureStepFlexx Whole Blood Glucose Testing, with a revision date of 07/13/10, stated the glucose monitor shall be cleaned at least once every twenty four (24) hours. The monitor will be cleaned according to manufacturer's recommendation in the operator's manual. Keypoint: Use a moist cloth to wipe the machine clean. A cloth with ten percent 10% bleach solution may be used when indicated. To clean the test strip holder, remove from the machine and clean with ten percent (10%) bleach solution and cotton swab. The test strip holder should stay moist for one (1) minute. The SureStepFlexx Whole Blood Glucose Testing manual, dated 2002, stated clean the meter if dirt, blood, or lint is present, when an error message appears indicating the meter may need to be cleaned, and as defined by your institution's infection control policies. The manual stated, clean the outside of the meter with a cloth dampened with a ten percent (10%) bleach solution. Follow with a cloth moistened with water to remove residual bleach. Dry the meter thoroughly. Refer to cleaning agents listed in the manual for other solutions that can be used to clean the outside of the meter. Clinical record review for Resident #11, revealed the facility admitted the resident on 06/02/11 with the [DIAGNOSES REDACTED]. The resident was ordered Humalog Insulin per sliding scale (adjusted dose to cover elevated blood sugars). Clinical record review for Resident #1, revealed the resident was admitted by the facility on 04/08/11 with [DIAGNOSES REDACTED]. The resident was ordered Humalog Insulin via sliding scale (dose is adjusted to cover elevated blood sugars). Observation of Registered Nurse (RN #7), on 06/07/11 at 6:30am, revealed the nurse entered Resident #11's room and performed the blood glucose test. She identified the resident, scanned the meter to her badge and the resident's identification bracelet, wiped off the resident's finger with alcohol, donned gloves, did the finger stick, and placed a drop of blood onto the strip. She obtained the reading of one hundred (100) and placed the needle in the sharps container. RN #7 placed the glucometer in her uniform pocket until she entered the medication room where she placed the glucometer directly onto the charger base. Observation of RN #7, on 06/07/11 at 7:00am, revealed she entered the medication room and retrieved the glucometer. She proceeded into the room of Resident #1 and performed a blood glucose level. She then proceeded to the medication room and placed the glucometer onto the charger base. Interview with RN #7, on 06/07/11 at 7:10am, revealed she did not clean the glucometer before placing it in the charger. She stated she cleaned the glucometer between some residents, however not between each resident. The RN stated the policy of the facility was to clean the glucometer between each resident with the facility disinfectant. She acknowledged the glucometer could potentially spread infection if not cleaned properly between residents. Interview with the Unit Manager, on 06/07/11 at 7:35am, revealed her expectation would be the glucometer would be cleaned after obtaining a blood glucose level. She stated the nurse should not have placed the glucometer in her pocket after obtaining the blood glucose. The Unit Manager explained it was the facility policy to clean the glucometer after obtaining the blood glucose sample. An interview conducted with the Infection Preventionist, on 06/06/11 at 7:50am, revealed the glucometer was to be cleaned every shift unless contaminated. She admitted there was a discrepancy between the glucometer cleaning policy and the reusable equipment policy. Her expectation would be the glucometer should be cleaned after obtaining the blood glucose sample, because all residents could potentially carry an organism. She stated the reusable equipment policy indicated the equipment should be decontaminated after each resident use and the glucometer would be considered reusable equipment. The facility's AOC included the following and was verified by the state agency: 1. Review of the revised policy, dated 06/08/11, on the SureStepFlexx Whole Blood Glucose Testing included: the exterior surface shall be decontaminated between each resident use with a hospital approved disinfectant, example "Sani-Cloth Plus or Cavi Wipes" (for[DIAGNOSES REDACTED] residents, must use ten percent (10%) bleach solution example "Dispatch" towelette. Gloves shall be worn during the cleaning policy. 2. Review of the staff education records revealed all staff who perform blood glucose testing were inserviced on the revised cleaning policy, dated 06/08/11, and competency tests were completed on 06/09/11. 3. Continued review of the education records revealed staff performed a return glucometer cleaning demonstration on 06/08/11. 4. An audit tool was developed for exterior and interior glucometer cleaning to be completed using a random sample of staff. The facility completed ten (10) random observations with 100% compliance, on 06/09/11. 5. All diabetic residents were assessed from 06/07/11 through 06/09/11 for any conditions/diseases that would compromise their immune system and for any signs or symptoms of infection that may be related to non-cleaning of the glucometer. Interviews with staff on 06/09/11 revealed they were knowledgeable regarding the revised cleaning policy. The staff, which included Licensed Practical Nurse #2 and #3, Registered Nurse #4, #5, #7 and #9, and Nursing Assistant #1 and #3 stated the glucometer was to be cleaned after each resident use with Sani-wipes or Cavi cloths unless the resident has[DIAGNOSES REDACTED] which requires a ten percent (10%) bleach solution. Observations on 06/09/11 revealed staff Licensed Practical Nurse #2 and #3, Registered Nurse #4, #5, #7 and #9, and Nursing Assistant #1 and #3 did clean the glucometer after each resident use according to the new policy. The state agency reviewed the revised cleaning policy and the audit tool that was developed to ensure staff compliance. Record review revealed the facility completed ten (10) random observations with 100% compliance. Interview with the Unit Manager on 06/09/11 revealed no diabetic residents had been adversely affected by the glucometer not being cleaned. The facility provided an acceptable Allegation of Compliance (AOC) on 06/09/11. The state agency verified the Immediate Jeopardy had been removed prior to exit on 06/10/11. The deficiency 483.65, F441, Infection Control was lowered to a scope and severity of an "D" while the facility's Quality Assurance monitors glucometer testing and disinfecting.

Based on observation and interview, it was determined the facility failed to store food properly, and failed to maintain sanitary conditions when serving food and operating the dishwasher at the required temperature. The facility had expired food and food not covered properly in the refrigerator. The dietary staff did not have their hair completely covered when serving food. The dishwasher was not at the proper temperature during a washing cycle. The findings include: Observation of the kitchen, on 06/07/11 at 9:00am, revealed expired bread pudding dated 05/29/11 and expired orange fluff dated 05/26/11. The bake shop freezer contained a cake under the freezer fan that was partially covered with plastic wrap. Interview with the Dietary Supervisor, on 06/07/11 at 9:30am, revealed the kitchen bake shop staff should have removed the expired food. The cake should have been covered securely. She stated expired food could pose a health hazard. Observation, on 06/08/11 at 11:30am, revealed two (2) employees serving food on the tray line with hair not completely covered. The Assistant Dietary Manager witnessed one employee with their hair not completely covered and did not ask the employee to cover their hair. Interview with the Assistant Director of Food Services, on 06/08/11 at 11:45am, revealed staff should completely cover their hair while in the kitchen. Observation of the dishwasher, on 06/08/11 at 12:00pm, revealed the dishwasher did not reach the required temperature during the start of a washing cycle. The gauge was marked for the required temperature. Interview with the Dietary Worker, who was starting the dishwasher, on 06/08/11 at 12:00pm, revealed he was not aware the dishwasher should reach a required temperature. He stated he had been operating the dishwasher for eight (8) months and had not received training regarding the operation of the dishwasher. Interview with the Assistant Director of Food Services, on 06/08/11 at 12:00pm, revealed she did not have training records for the employee who was operating the dishwasher. She acknowledged running the dishwasher at a lower temperature could result in the dishes etc. not being properly sanitized and potentially causing food borne illnesses.

Based on observation, interview, record review and policy review regarding intake and output directions, it was determined the facility failed to ensure physician orders [REDACTED]. Resident #5's fistula drainage was not consistently recorded by the nursing staff. The findings include: The facility policy on intake and output directions with a revision date of 02/09/10, revealed intake and output is collected and reported every four (4) hours unless otherwise ordered. Example of device related intake/output include but are not limited to a feeding pump, intravenous pump, Jackson Pratt drain, Hemovac, gastrointestinal suction, chest tube, and Foley catheter. Record review for Resident #5 revealed the resident was admitted by the facility on 04/06/11 with the [DIAGNOSES REDACTED]. A physician order [REDACTED]. The resident was NPO (nothing to eat or drink) and was receiving TPN (total parental nutrition). Review of the intake/output sheet dated 05/29/11 recorded revealed two different amounts for the fistula drainage on the night shift. The intake /output sheet dated 05/31/11 and 06/02/11 did not have the fistula output recorded for the day and/or evening shift. Observation of Resident #5, on 06/07/11 at 10:30am, revealed the resident sitting in a chair with the fistula draining into a collection device. Interview with Licensed Practical Nurse (LPN), on 06/08/11 at 1:00pm, revealed the nurse was responsible for emptying and recording the fistula drainage. No explanation was provided as to why the fistula output was not recorded consistently. Interview with the Clinical Supervisor, on 06/07/11 at 3:00pm, revealed the fistula drainage was not consistently or accurately recorded. She stated the output information was important because the physician used this information to determine the intake for Resident #5. Interview with the Physician, on 06/08/11 at 1:00pm, revealed she was concerned the output of the fistula was neither recorded correctly or not at all. She stated she used the output of the fistula to calculate the compliance of the resident's NPO status. The Physician stated if the resident was not compliant, the fistula would be more difficult to heal.