Every finding on record at Traylor Retirement Community

Based on interviews, record review, and review of a facility policy titled Policy & Procedure Manual, Director of Food and Nutrition Services, the facility failed to have a qualified Dietary Manger (DM) who possessed the necessary skills and certifications for a Certified Dietary Manager and who was a clinically qualified nutrition professional, per the facility policy. This failure had the potential to affect all 71 residents receiving meals from the kitchen by compromising the safe preparation, service, and overall management of the facility's dietary program. Findings include:An undated facility policy titled Policy & Procedure Manual Director of Food and Nutrition Services documented: . Procedure:1. The director of food and nutrition services is responsible for all aspects of the food and nutrition services department including but not limited to food safety, staff safety, cost management, and meeting nutritional needs of resides/patients services .2. The director of food and nutrition services will be qualified according to the position's job description and guidelines put forth by the agency that regulates the facility. A facility that does not have a full-time dietitian (registered dietitian nutritionist or RDN) or clinically qualified nutrition professional must designate a person to serve as director of good and nutrition services. a. Is a certified dietary manager (CDM); orb. Is a certified food service manager; orc. Has a similar national certification for food service management and safety from a national certifying body; ord. Has 2 years of food service manager experience prior to October 1, 2022e. Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management from an accredited institution of higher learning; andf. In states that have established standards for food service managers or dietary managers, must meet state requirements for food service managers or dietary managers . On 12/04/2025 at 11:30 AM the Dietary Manager (DM) was asked about her certification status. The DM said she was neither a certified dietary manager nor a food service manager. The DM said she lacked any certification in food service management and safety from a recognized national certifying organization, did not hold an associate degree or higher, had less than two years of experience in food and nutrition within a nursing facility environment, and had not completed any course of study in food safety management. The DM said she had been serving as the DM for a year and a half. The DM said, the Dietician visited the facility once a week. On 12/04/2025 at 12:02 PM the Registered Dietician (RD) was asked about the certification status of the DM and was questioned regarding the type of training the DM had received. The RD said, she was unaware of any classes attended and the DM was trained on the job. The RD said the DM was not a certified dietary manager, certified food service manager, did not possess any national certifications, and to her knowledge did not hold an associate degree in food service safety and management or any higher qualification. The RD said she visited the facility twice a month. When questioned if the DM had the necessary credentials to serve as the DM according to regulations, she stated she did not know. On 12/04/2025 at 12:30 PM the Administrator (ADM) was asked about the qualifications of the DM and was questioned regarding the qualifications the DM had to fulfill the role. The ADM stated, the DM had previously worked under the former dietary manager. The ADM said the DM did not hold any certifications, had been in her position since 2023, was not a certified dietary manager, and had not participated in any classes. When asked if the DM was qualified as a dietary manager, the ADM responded that the DM was not qualified. In response to a question about the potential risks associated with the DM's lack of qualifications, she said possible issues related to the storage and preparation of food.

Based on observations, interviews, and review of facility policies titled Cleaning Instructions: Ice Machine and Equipment, Bare Hand Contact with Food and Use of Plastic Gloves, WET NESTING POLICY, Refrigerator & (and) Freezer Temperature Monitoring Policy, the facility failed to ensure:1) the ice machine was free of a pink substance in the lid;2) staff washed their hands after touching a trash can lid before returning to the tray line;3) spoons, forks, and knives were not wet nesting; and4) the temperatures of the refrigerator/freezer PM temperatures were documented on the temperature logs.These deficient practices had the potential to affect 71 of 71 residents who received meals from the kitchen. Finding include:1. Review of a facility policy titled Cleaning Instructions: Ice Machine and Equipment dated 5/2024 revealed: Policy:Ice machine and equipment . will be cleaned and sanitized on a regular basis.Procedure: . 2. Wash the interior thoroughly .3. Sanitize.On 12/01/2025 at 4:01 PM during a tour of the kitchen with Dietary Staff (DS) #9 a pink debris was observed in the lid of the ice machine.On 12/04/2025 at 8:07 AM Dietary Aide (DA) #10 said she saw a pink dark film in the ice machine up at the top and going around the rim. She stated it had not been cleaned the night before and was last cleaned on 11/28/2025. DA #10 stated the ice machine should be cleaned often so it will not be dirty, and the filter would be clean. According to DA #10 it was a potential harm to the residents when the ice machine was dirty and could make the residents sick, and she would not want dirty ice.On 12/04/2025 at 8:29 AM the Dietary Manager (DM) was asked about the ice machine. The DM said, it should be cleaned to prevent mold, mildew, and bacteria; and prevent the potential for residents to get sick.2. Review of a facility policy titled Bare Hand Contact with Food and Use of Plastic Gloves dated 04/2010 revealed: . Procedure: .6. Gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, the glove must be changed, and hands must be washed: . b. After handling garbage or garbage cans. l. Any time a contaminated surface is touched. On 12/03/2025 at 10:49 AM the surveyor observed DA #8 leave the tray line, place an item in the trash can, and touch the garbage can lid with her gloved hand. After touching the garbage can lid DA #8 did not remove her gloves or wash her hands. DA #8 then proceeded to place a pan of lasagna in the oven.On 12/04/2025 at 8:29 AM the DM was asked what she observed during the tray line. She stated the cook (DA #8) had on clean gloves, picked up some trash and walked to the trash can. The DM stated, she put the trash in the trash can, dropped the lid on the can, and proceeded back to the tray line without washing her hands. The DM said, the facility policy was to wash hands every time staff exited or entered the kitchen and if staff touch anything dirty with gloves on they must wash their hands.On 12/04/2025 at 10:02 AM an interview was conducted with the Director of Nursing (DON). She stated staff should wash their hands as soon as they get to work and when they change the trash. She said staff should wash their hands to prevent infections and food borne illnesses. She said the potential harm to the resident when staff did not wash their hands from touching the trash can lid can would be a risk of infection. She stated that touching the trash can lid at the tray line could affect all residents who receives trays from the tray line.3. Review of an undated facility policy titled, WET NESTING POLICY revealed:PurposeTo prevent bacterial growth, cross-contamination, and compromised sanitation . Policy StatementDietary staff must not stack, store, or nest any . utensils that are still wet after washing and sanitizing. All items must be thoroughly air-dried before being placed in storage or used for meal service.On 12/02/2025 at 4:00 PM the surveyor observed wet utensils, silverware spoons, forks, and knives in a crate like container placing wet utensils together in smaller containers.On 12/04/2025 at 9:00 AM the DM was asked what a staff member was doing with the silverware when she observed on 12/02/2025. The DM Th stated there was a crate full of silverware wet nesting and a staff member was placing the wet utensils in a silverware bag. The DM stated there was water on the silverware. She was asked what the facility policy said regarding wet nesting. She stated wet utensil must not be placed in a bag wet. She said staff must make sure the silverware is dry because it could cause bacteria and some illnesses. 4. Review of an undated facility policy titled Refrigerator & Freezer Temperature Monitoring Policy documented: . PolicyAll Dietary refrigerators and freezers will be monitored and recorded twice daily (AM and PM) to ensure proper operating temperatures.On 12/01/2025 at 4:01 PM during kitchen tour, the surveyor reviewed the temperature log on the refrigerator and observed missing PM shift temperatures for November dates: 24, 25, 26, 27, 28, 29, 30. The freezer temperatures for the PM shift were missing on the November dates: 27, 28, 29, and 30.On 12/04/2025 at 11:12 AM the DM was asked what the refrigerator/cooler temperatures were for November 24, 25, 26, 27, 28, 29, and 30. The DM stated blank, blank. She was asked what the November freezer temperatures were for 27, 28, 29 and 30. She stated blank, blank, and blank. The DM said, she did not know why the temperatures for the evening shift were blank. The DM stated that the cook was responsible for recording the evening temperatures. The DM said, the potential harm to the residents was when the refrigerator/freezer temperatures are not recorded the residents could get sick from food borne pathogens.

Based on observations, interviews, and review of a facility policy titled Equipment Malfunctions and Repairs, the facility failed to maintain essential equipment in safe and effective operating condition. Specifically, water was leaking from a pipe underneath the three-compartment sink and dripping into a pan placed under the sink and one of the facility's two commercial washing machines was non-functional. This was observed by the surveyor on 12/04/2025. The Laundry Supervisor (LS) said the machine had been non-functional for three weeks. The Administrator (ADM) stated the repair company had been to the facility on [DATE], and a part was ordered for the repair on 11/26/2025. Review of e-mails with the repair company revealed the machine had been non-functional since at least 11/17/2025.These failures had the potential to affect all 73 residents in the facility and to negatively impact sanitary food service operations and timely processing of linens for resident care. Findings Include: A facility policy updated on 06/2022 titled Equipment Malfunctions and Repairs documented: Policy: All equipment malfunctions and repairs will be reported to the director of food and nutrition services and/or maintenance department. Procedure: 1 When a piece of equipment malfunctions, the director of food and nutrition services should be notified. 2. The director of food and nutrition services should notify the maintenance department by phone or in writing if needed, informing them how quickly the piece of equipment is needed. 3. The administrator must approve services or purchase of parts or outside repair according to facility policy. 1.) On 12/02/2025 at 4:18 PM the surveyor observed a pipe beneath the three-compartment sink dripping water into a pan that was half full. A document titled Dietary Department District Manager Site Visit Workbook dated 06/13/2025 documented a leak under the sink. On 12/04/2025 at 9:12 AM the Dietary Manager (DM) was questioned regarding the three-compartment sink. The DM said there was a medium-sized pan located beneath the three compartment sink due to a leaking pipe. She said the pipe had been leaking since June. Furthermore, she stated that she had reported the leak and submitted a work order after it began in June. The DM said that the potential hazards of water accumulating in a pan under the sink included bacteria, frogs, roaches, and rats. She said that the pipe leaked approximately one pan full of water each day. When asked about the size of the hole in the pipe, she explained that it was leaking around the seal. When asked how many residents could be affected, she replied that all residents could potentially be impacted. On 12/04/2025 at 9:27 AM the Assistant Maintenance Supervisor (AMS) was questioned regarding the three-compartment sink in the kitchen. The AMS said there was a leak beneath the sink, which the maintenance department routinely addressed due to staff bumping the pipe, causing it to the leak. The AMS stated the Maintenance Department was responsible for the repairs of the three-compartment sink. The AMS said it was important to make repairs such as a leaking pike as soon as possible to prevent falls. The AMS said a pan of water beneath the three-compartment sink could pose a risk to residents by potentially attracting rodents. 2.) On 12/04/2025 at 10:58 AM the surveyor observed two commercial washing machines and one standard washing machine. One of the commercial machines had a sign on the door indicating it was out of order. Emails and documents from the repair company indicated that a call was placed to them on 11/17/2025, followed by an onsite visit that took place on 11/20/2025. The facility received a quote from the repair company on 11/26/2025. Additional email exchanges revealed the required part was ordered on 11/26/2025, with an estimated delivery timeframe of seven to 21 business days. On 12/04/2025 at 11:15 AM the Laundry Supervisor (LS) was questioned about the status of the commercial washing. The LS indicated that one of the commercial washing machines had not worked for three weeks. She said the facility currently had one commercial washing machine and one standard washing machine. The LS said the existing machines were insufficient to adequately manage the laundry needs. She said due to the commercial machine being out of service, the facility had relied on an offsite laundry service for linens over the past three weeks. When questioned about the timeline for the repair of the commercial washing machine, she stated she was told by the Administrator that the control board was defective, and it would take approximately three to four weeks to obtain the necessary part. On 12/04/2025 at 12:15 PM the ADM was questioned regarding the commercial washing machine. The ADM said a repair company came out on 11/20/2025 because the commercial washing machine was not working. She said the commercial washing machine had stopped working a few days before 11/20/2025 but could not remember the exact date. She said the part for the machine was ordered on 11/26/2025 and was expected to arrive within a time frame of seven to twenty-one days.

Based on interview, record review, and review of facility policies titled admission Orders and admission of a Resident, the facility failed to ensure Resident Identifier (RI) #11's physician orders included details necessary for the care and treatment of an indwelling urinary catheter upon admission on [DATE] for an existing urinary catheter. The facility obtained an order on 11/04/2025 for use of a urinary catheter and included the size of catheter RI #11 was to have, but still failed to include details such as care, treatment, changing of the urinary catheter, and any other details the physician may have wished to include, placing the resident at risk for inadequate clinical oversight and unmet care needs. This affected RI #11, one of two residents for whom closed records were reviewed. Findings include:An undated facility policy titled admission Orders documented: Policy:A physician must personally approve, in writing, a recommendation that an individual be admitted to a facility. A physician, physician assistant, nurse practitioner or clinical nurse specialist must provide written and/or verbal orders for the residents' immediate care and needs.Policy Explanation and Compliance Guidelines:1. The written and/or verbal orders should include a minimum .c. Routine care orders2. The orders should allow facility staff to provide essential care to the resident consistent with the resident's mental and physical status on admission . A policy titled admission of a resident with an implemented date of 03/05/2025 documented: Policy:The admission process is intended to obtain all possible information regarding the resident for the development of the comprehensive plan of care, and to assist the resident in becoming comfortable in the facility. Residents are admitted to the facility under orders of the attending physician. RI #11 was admitted to the facility on [DATE], discharged on 11/16/2025 and had diagnoses to include Cerebral Infarction, Malignant Neoplasm of Prostate, Acute Kidney Failure, and Obstructive Uropathy.admission notes dated 10/30/2025 for RI #11 documented Urinary catheter intact.A care plan initiated on 10/30/2025 recorded the existence of a catheter associated with the diagnosis of Urinary Retention and Prostate Cancer and interventions included checking the tubing, monitoring and documenting any pain or discomfort caused by the catheter, monitoring, recording, and reporting to the Medical Doctor (MD) any signs and symptoms of a infection, as well as positioning the catheter bag and tubing below the bladder level.admission orders for RI #11 documented an order dated 10/30/2025 for enhanced barrier precautions related to an indwelling foley (urinary) catheter but did not include details for the size, care, and treatment of the urinary catheter to be used. Record review revealed a physician telephone order was obtained on 11/04/2025 for RI #11 to have use of a 16 French size indwelling urinary catheter related to a diagnosis of Obstructive Uropathy, however the order still did not contain details to guide nurses in care, treatment, and changing of the urinary catheter.On 12/04/2025 at 1:24 PM the Director of Nursing (DON) was questioned about who was responsible for admission orders, to which she responded it was either herself, Assistant Director of Nursing (ADON), or the unit clinical coordinator. The DON said, RI #11 was admitted to the facility on [DATE]. When asked about the admission orders related to urinary catheter care for RI #11, the DON stated, she did not see any orders for urinary catheter care upon admission. The DON said, if RI #11 arrived at the facility with a catheter, orders for care should have been established during the admission assessment. The DON stated, the facility needed to do education on putting orders in and ensuring they were correct.

Based on observation, interview and a facility policy titled Safe and Homelike Environment the facility failed to maintain the exterior physical environment in safe and good repair. Specifically, on 12/3/2025 and 12/4/2025 a damaged soffit with exposed wood and hanging metal was observed on the back side of the building facing a patio area. This concern was brought up during the resident council meeting that took place on 12/03/2025, and staff indicated it had remained in that state for more than a year. Additionally, a discarded water heater was observed near the outdoor patio area where residents may gather. The deficient practices had the potential to affect all 73 residents residing in the facility.Findings Include: An undated facility policy titled Safe and Homelike Environment documented: Policy: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment .This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility, both inside and outside, maximizes resident independence and does not pose a safety risk . 3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. 9. The facility will maintain outdoor areas for the safety and access of residents and visitors by ensuring proper upkeep of grounds . 10. Routine inspections of outdoor areas for safety hazards . identified issues should be promptly addressed . During a Resident Council meeting held on 12/03/2025, at 11:15 AM, Resident Identifier (RI) #75 reported the presence of a damaged facade on the exterior of the building, with part of it hanging down. RI #75 indicated that this issue had persisted for some time, although he/she was uncertain about the exact duration. On 12/03/2025, at 11:45 AM, the surveyor observed the missing soffit, which revealed exposed wood on the exterior of the building referenced in the resident council meeting by RI #75. On 12/04/2025, at 8:48 AM, the surveyor observed a damaged soffit with exposed wood on the exterior of the building. Additionally, a discarded water heater was observed in the patio area where resident could gather. On 12/04/2025 at 9:00 AM. the Assistant Maintenance Director (AMD) was questioned about the damaged soffit located on the exterior of the building, as well as the discarded water heater observed near the patio area. In response to questions about the damaged soffit, the AMD indicated that the damage was caused by wind, which had partially torn the soffit away. The AMD further stated that a damaged soffit could potentially lead to water damage within the building. He reported some of the exposed wood had suffered damage due to weather exposure and noted this damage had existed for over a year. When asked about the discarded water heater placed near the patio, the AMD explained it had been placed there following the replacement of an old water heater, although he was uncertain about how long it had been there. The AMD was also asked whether that was an appropriate location for a discarded water heater, to which he replied he was unsure but said that it should be picked up and discarded. On 12/04/2024 at 12:40 PM the Administrator (ADM) was questioned regarding the damage to the exterior of the building. The ADM was aware of the exposed wood on the outside of the building. She said it had been in that condition for over a year. She described the damage as a missing facade, which had resulted in exposed wood that had been damaged by water. The ADM was also asked about the discarded water heater. She explained it had been placed there following the replacement of a water heater. She was uncertain how long the discarded water heater had been there. The ADM was asked if this was an appropriate location for a discarded water heater and she said it should be picked up and discarded. -

Based on observations, interview, review of the facility's policies titled, Food Storage, Cleaning Instructions: Food Preparation Appliances, and a facility document titled, Food Storage Guidelines, the facility failed to ensure: 1. a full size, two inch, baking pan of macaroni and cheese was discarded on the used by date, and 2. a dirty toaster was not stored in the Dry Goods Storage Room. These deficient practices were observed on 9/24/19, during the initial observation of the kitchen. This had the potential to affect all 106 residents in the facility. Findings Include: 1. A review of an undated facility policy titled, Food Storage, revealed: . Procedure: . 13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 3 days or discarded. 14. Refrigerated Food Storage: . f. All foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. A review of a facility document titled, Food Storage Guidelines with a revision date of 06/07/16, revealed: . Food Storage Rules Prepared In House Food Must Be Used or Discarded within 3 Days (72 hours) . During the initial tour of the kitchen on 09/24/2019 at 12:01 PM, the walk-in refrigerator contained a full size, two inch, baking pan with macaroni and cheese labeled with a prepared date of 09/14/2019 and a discard date of 09/17/2019. An interview with Employee Identifier (EI) #1, Assistant Dietary Manager (ADM) was conducted during the initial tour on 09/24/2019 at 12:01 PM. EI #1 removed the outdated dish of macaroni and cheese to be discarded. EI #1 was asked who was responsible to throw out the outdated dishes. EI #1 said that there was a new cook training and the dish may have been misdated. A follow-up interview was conducted on 09/26/2019 at 10:13 AM with EI #1. EI #1 was asked what the concern would be for the outdated macaroni and cheese in the walk-in refrigerator. EI #1 replied, a resident could get sick. 2. A review of an undated facility policy titled, Cleaning Instructions: Food Preparation Appliances revealed: Policy: Small appliances . will be cleaned and sanitized after each use. 9. Return the equipment to the appropriate area. During the initial tour of the kitchen on 09/24/2019 at 12:05 PM, which included observations in the Dry Goods Storage Room, a toaster was found stored dirty with food particles on the toaster. Upon entering the dry good storage room where paper products were stored, on 09/24/2019 at 12:09 PM, a toaster was observed sitting on top of a box on a shelf. The toaster was observed to be dirty with crumbs on the toaster. An interview was conducted during the initial tour on 09/24/2019 at 12:09 PM, with EI #1. EI #1 was asked, what was on the toaster. EI #1 replied, it was dirty. EI #1 was asked, what would be the concern of storing the dirty toaster in the dry goods room. EI #1 responded rodents or pests. EI #1 was asked, why would the toaster be stored in the dry good storage room. EI #1 replied, he did not know.

Based on observations, interview, and review of the facility's policies titled, Food-Related Garbage and Refuse Disposal and Waste Grease Disposable the facility failed to ensure: 1. the double lids on the top of the dumpster were closed and secured on 09/24/19 and 2. the lid on the oil/grease disposal container was closed and secured on 09/24/19. These deficient practices had the potential to affect all 106 residents in the facility. Findings Include: 1. A review of a facility policy titled, Food-Related Garbage and Refuse Disposal, with a revised date of (MONTH) (YEAR), revealed: Policy Statement Food-related garbage and refuse are disposed of in accordance with current state laws. Policy Interpretation and Implementation . 2. All garbage and refuse containers are provided with tight-fitting lids or covers and must be kept covered when stored or not in continuous use. . 5. Garbage and refuse containing food wastes will be stored in a manner that is inaccessible to pests. . 7. Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter . During the initial tour of the kitchen on 09/24/19 at 12:14 PM, the dumpster area was observed with Employee Identifier (EI) #1, Assistant Dietary Manager (ADM). Three dumpsters were observed. EI #1 stated the first dumpster was the kitchen's, the second was for laundry and the third was for housekeeping. The dumpsters were behind a closed fence. The first dumpster was observed to have both top lids opened. EI #1 closed the lids. An interview was conducted during the initial tour with EI #1 on 09/24/19 at 12:14 PM. EI #1 was asked, why the lids were not closed. EI #1 replied, he did not know why. EI #1 was asked, what would be a concern of having the dumpster open. EI #1 replied cats, dogs, rodents and pests. 2. A review of an undated facility policy titled, Waste Grease Disposable, revealed: Policy: Used oil/grease will be disposed of as needed. Procedure: . 3. Dispose of the oil into the outdoor waste grease container and wipe any spills as they occur. . 5. Container lids shall remain closed at all times when not in use. During the initial tour of the kitchen on 09/24/19 at 12:19 PM, the oil refuge area was observed. Three barrels for used oil disposal were observed. The second barrel was open and the lid was sitting on top of the first barrel. An interview was conducted during the initial tour with EI #1, on 09/24/19 at 12:19 PM. EI #1 was asked why the barrel was left open. EI #1 replied, he did not know but it should not have been left open. EI #1 was asked what was the concern with the oil barrel being left open. EI #1 replied, contamination, spills, fire and rodents.

Based on observation, interview, record review, and a review of the facility's policies titled, Resource: Final Cooking, Holding and Reheating Temperatures, Kitchen Cloths and Food Storage, the facility failed to ensure: 1)chicken noodle soup was reheated to a temperature of 165 degrees Fahrenheit (F); 2) Wiping cloths were placed in a sanitizing solution when not in use; and 3) food items stored in the walk-in freezer were frozen solid. This had the potential to affect all resident' receiving meals from the kitchen. Findings include: 1) The facility's policy titled, Resource: Final Cooking, Holding and Reheating Temperatures, copyright 2013, revealed: . Reheated Foods: Food that is cooked, cooled and reheated All parts of the food must reach an internal temperature of 165 (degrees) F (Fahrenheit) 15 seconds . On 8/7/18 at 11:20 a.m., during tray line, the surveyor observed the chicken noodle soup was reheated to a temperature of 158 degrees Fahrenheit. An interview was conducted on 8/8/18 at 8:38 a.m. with Employee Identifier (EI) #4, the Dietary Manager (DM). EI #4 was asked, what was the temperature of food supposed to be after being reheated. EI #4 stated, 160. EI #4 was asked, what was the temperature of the chicken noodle soup after it was reheated. EI #4 stated, 158. EI #4 was asked, what was the potential for harm. EI #4 stated, bacteria growth making people sick. 2) The facility's policy titled, Kitchen Cloths, copyright 2013, revealed: Policy: Kitchen cloths will be clean and available as needed. Procedure: . 6. Cloths that are used for cleaning purposes should be stored in sanitizing solution between uses . On 8/6/18 at 5:22 p.m. during the initial tour of the kitchen, the surveyor observed three wiping cloths on the counter of the steam table. An interview was conducted on 8/8/18 at 8:38 a.m. with EI #4, the DM. EI #4 was asked where should wiping cloths be stored when not in use. EI #4 replied, in the rinse and sanitizing bucket, the buckets contain detergent in one and quaternary ammonia in the other. 3) The facility's undated policy titled, FOOD STORAGE revealed: POLICY Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored, prepared, and transported at an appropriate temperature and by methods designed to prevent contamination. PR[NAME]EDURES . 17. Freezer Temperatures: a. Temperatures for freezer should be 0 degrees or below and must be recorded daily. d. Every freezer must be equipped with an internal thermometer, even if equipped with an external thermometer . On 8/6/18 at 5:30 p.m. the surveyor observed the walk in freezer outside thermometer register at thirty degrees Fahrenheit. The inside walk in freezer thermometer was not working. Foods that were not completely frozen included mighty shakes, magic cups, and pizza. On 8/8/18 at 8:30 a.m. the surveyor observed the outside thermometer for the walk in freezer was reading eighteen degrees Fahrenheit. The inside walk in freezer thermometer was reading twenty degrees. The mighty shakes, magic cups, diced turkey, lasagna, and pizza were not frozen solid. An interview was conducted on 8/8/18 at 8:38 a.m. with EI #4, the DM. EI #4 was asked, what should the temperature in the walk in freezer be. EI #4 stated zero. EI #4 was asked, what was the temperature in the walk in freezer on 8/8/18. EI #4 stated, eighteen outside and twenty inside. EI #4 was asked, what was the temperature in the walk in freezer during initial tour on 8/6/18. EI #4 stated, thirty outside. EI #4 was asked what was not frozen solid in the walk in freezer on 8/8/18. EI #4 stated, Magic Cups, Mighty Shakes, Pizza, Diced Turkey. EI #4 was asked, how long the walk in freezer had not been working properly. EI #4 replied, she notified EI #5, the Maintenance Director, and EI #6, the Administrator, in (MONTH) (YEAR) what the temperatures in the walk in freezer were. EI #4 was asked, what was the potential for harm. EI #4 stated, something thawing out, salmonella or some other bacteria, making everyone that eats it sick in the nursing home. An interview was conducted with EI #5, the Maintenance Director, on 8/9/18 at 3:50 p.m. EI #5 was asked if he had been notified that the walk in freezer was not functioning properly. EI #5 replied, it does this every summer, we have talked about replacing the condensing unit outside to a bigger unit. EI #5 also stated it had been discussed with the administrator. EI #5 said, a new freezer would cost $7800.00. EI #5 was asked how long had the freezer not been working properly. EI #5 stated, every summer for two to three summers. EI #5 was asked, when was the worse time for the freezer to not be working properly. EI #5 stated, the summer. EI #5 was asked, when were you notified this summer that the walk in freezer was not working properly. EI #5 replied, he had been notified by the Dietary Manager about a month ago. An interview was conducted on 8/9/18 at 4:10 p.m. with EI #6, the Administrator. EI #6 was asked, was she aware the walk in freezer wasn't working properly. EI #6 stated, that has been reported to me, not staying cold enough. EI #6 was asked, what was the concern with foods not being frozen. EI #6 stated, they could spoil.

Based on observation, interview and review of facility's policies titled, MEDICATION STORAGE IN THE FACILITY and SPECIFIC MEDICATION ADMINISTRATION PR[NAME]EDURES', the facility failed to ensure an expired vial of flu vaccine was not stored in a medication room refrigerator. This affected one of three medication rooms in the facility. Findings include: The facility's policy titled, MEDICATION STORAGE IN THE FACILITY, with an effective date of (MONTH) 1, 2009, revealed: . M. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal . The facility's policy titled, SPECIFIC MEDICATION ADMINISTRATION PR[NAME]EDURE, with an effective date of (MONTH) 1, 2009, documented: . E. Check expiration date on package/container . On 08/08/18 at 4:47 p.m., during medication room observation with Employee Identifier (EI) #12, Registered Nurse (RN)/Unit Manager (UM), the surveyor observed a box containing a vial of Flulaval Quarivalent (flu vaccine) with an expiration date of 04/2018 in the medication room refrigeration on the locked unit. EI #12 asked what was the expiration date on the flu vaccine. EI #12 said (MONTH) (YEAR). The surveyor asked what was the concern with expired medications being in the medication room. EI #12 replied medication error because someone might give it without checking the date and it might alter the effectiveness of the medication.

Based on observations, interviews, medical record reviews, review of facility's policies titled, HANDWASHING, Fingerstick Blood Sugar Testing and Glucometer Disinfection, Personal Protective Equipment - Using Gloves, Nebulizer Therapy, SPECIFIC MEDICATION ADMINISTRATION PR[NAME]EDURES, INCONTINENT CARE and review of POTTER AND PERRY'S FUNDAMENTALS OF NURSING, the facility failed to ensure: 1) a licensed nurse washed her hands prior to preparing Resident Identifier (RI) #69's medication and wore gloves during RI #69's nebulizer therapy; 2) a licensed nurse washed her hands before leaving RI #6's room after obtaining RI #6's fingerstick blood sugar (FSBS); and 3) a Certified Nursing Assistant (CNA) washed her hands after removing soiled gloves and did not touch clean items with soiled gloves or remove clean wipes from the dispenser with soiled gloves while performing incontinence care for RI #38. These deficient practices affected RI #69 and RI #6, two of seven residents observed during medication pass observations, and RI #38, one of one resident observed during incontinence care observation. Findings include: 1) The facility's policy titled, SPECIFIC MEDICATION ADMINISTRATION PR[NAME]EDURES, with an effective date of (MONTH) 1, 2009, revealed: .Procedures .H. Cleanse hands before handling medication and before contact with resident . The facility's policy titled, Nebulizer Therapy, with a revised dated of 02/2018, documented: . 1. Care of the Resident . e. Don gloves . On 08/07/18 at 11:22 a.m., during medication pass observation, Employee Identifier (EI) #13, a Licensed Practical Nurse (LPN), was observed preparing RI #69's medication without washing or her hands or using hand sanitizer. After administering RI #69's pain medication, EI #13 was observed setting up RI #69's nebulizer machine without wearing gloves. On 08/09/18 at 12:24 p.m., an interview was conducted with EI #13, a LPN. EI #13 was asked, what she should do before beginning a medication pass. EI #13 said, wash her hands. EI #13 was asked did she wash her hands before she began preparing medications for RI #69. EI #13 replied no she did not. EI #13 was asked what she should do when administering nebulizer treatments. EI #13 stated wash her hands and put gloves on. EI #13 was asked did she wear gloves when she set up RI #69's nebulizer treatment. EI #13 said no. EI #13 was asked what the concern was with not washing her hands and wearing gloves when indicated during medication pass. EI #13 said protection of the resident from transfer of bacteria. EI #13 was asked what the concern was with spreading bacteria. EI #13 answered infection control. 2) The facility's policy titled, Fingerstick Blood Sugar Testing and Glucometer Disinfection, dated 06/18, revealed: Purpose To obtain a blood sample to determine the resident's blood glucose level, ensure proper cleaning of glucometer and adherence to infection control standards . Policy .9. Remove gloves and wash hands prior to exiting room . On 08/08/18 at 4:08 p.m., during medication pass observation, EI #11, a Registered Nurse (RN), was observed not washing her hands before leaving RI #6's room after obtaining RI #6's fingerstick blood sugar (FSBS). On 08/09/18 at 2:54 p.m., an interview was conducted with EI #11, a RN. EI #11 was asked when obtaining a FSBS, when she should remove her gloves and wash her hands. EI #11 said after she finished before she left the room and after she came back and cleaned the glucometer wash them again. EI #11 was asked did she remove her gloves and wash her hands before leaving RI #6's room. EI #11 replied no she did not. EI #11 was asked what the was concern with not removing her gloves and washing her hands prior to leaving the room. EI #11 answered spreading infection. 3) The facility's policy titled, Personal Protective Equipment - Using Gloves revealed: Purpose To guide the use of gloves. Objectives 1. To prevent the spread of infection; . 3. To protect hands from potentially infectious material; . 5. Wash hands after removing gloves. (Note: Gloves do not replace handwashing.) . Resident Identifier (RI) #38 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During RI #38's incontinence care observation on 8/7/18 at 8:50 a.m., EI #1, a CNA did not wash her hands after she removed her soiled gloves. An interview was conducted on 8/7/18 at 9:15 a.m., with EI #1, a CNA. EI #1 was asked, what should be done after removing soiled gloves. EI #1 stated, wash your hands. On 8/9/18 at 10:30 a.m. and interview was conducted with EI #2, a Registered Nurse/Quality Assurance Nurse. EI #2 was asked, what should be done after cleaning stool when the CNA removes her gloves and before applying a clean pair of gloves during incontinence care. EI #2 stated, wash hands. EI #2 was asked, what should be done during incontinence care to prevent contaminating the disposable wipes container when multiple wipes are used. EI #2 stated, take out several wipes before starting when gloves are clean and lay on a clean pad to keep them clean. EI #2 was asked, what should be done before touching clean items such as the brief or the resident's clothing after wiping stool from the buttocks. EI #2 stated, she should take off gloves, clean hands, and put on clean gloves. EI #2 was asked, what the potential for harm was. EI #2 stated, infection, it being up toward the urethra, you could get a Urinary Tract Infection.

Based on observations, record reviews, interviews, and facility policies titled, Standard Precautions, the facility failed to ensure Certified Nursing Assistants (CNA) provided incontinent care in a manner to prevent cross-contamination. Resident Identifier (RI) #10 was provided incontinent care without hand hygiene or glove change before or during the care. This affected one of four sampled residents observed for incontinent care. Finding include: A facility policy titled: Standard Precautions revealed: . Standard Precautions presume that all . body fluids, secretions, and excretions . mucous membranes may contain transmissible infectious agents. Standard precautions include the following practices: 1. Hand Hygiene . Hands shall be washed with soap and water . after direct or indirect contact . d. Wash hands after removing gloves . 2. Gloves a. Wear gloves . when . direct contact with . body fluids, mucous membranes .b. when in direct contact with a resident . e. change gloves, during the care of a resident to prevent cross-contamination from one body site to another (when moving from a dirty site to a clean one). RI #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly MDS with an ARD of 4/18/2017 revealed, RI #10 required extensive assistance with personal hygiene and was always incontinent of bowel and bladder. On 7/12/2017 at 3:03 p.m. EI (Employee Identifier) #3 and EI #4, CNAs, entered RI #10's room and donned gloves, without washing their hands, to provide incontinent care. RI #10 was observed to be soiled with urine and the waterproof pad under RI #10 was noted to be soiled with urine. EI #3 and EI #4 used disposable wipes to perform the incontinent care of RI #10 and removed the soiled waterproof pad and underpad from under RI #10. While wearing the same gloves, EI #4 rolled RI #10 to the right side and EI #3 placed a clean underpad and waterproof pad under RI #10. The resident was then rolled to the left side and EI #3 straightened the underpad under RI #10. Throughout the incontinent care observation, EI #3 and EI #4 wore the same urine soiled gloves and did not wash their hands until the care was completed. On 7/12/2017 at 5:13 p.m. an interview was conducted with EI #3, CNA. EI #3 was asked what the facility's policy indicated about when gloves should have been changed and hands should have been washed during care of a resident. EI #3 said, change gloves and wash hands before touching clean items. EI #3 was asked when did she wash her hands and change her gloves. EI #3 said, after the care was done. EI #3 was asked should she have changed her gloves and washed her hands when performing incontinent care for RI #10. EI #3 said, yes. EI #3 was asked what was the potential harm to a resident when hands were not washed and gloves were not changed during incontinent care. EI #3 said, contamination. On 7/13/2017 at 9:34 a.m., an interview was conducted with EI #5, Infection Control Nurse. EI #5 was asked what did the facility's policy indicate regarding when hands should be washed and gloves changed when performing incontinent care. EI #5 said, hands should have been washed and gloves changed before care, after touching dirty, gloves should have been removed and hands washed and before touching clean items. EI #5 was asked was it an appropriate practice of that facility for a CNA to not change her gloves or wash her hands during incontinent care. EI #5 said, no. EI #5 was asked what was the potential harm to a resident when hands were not washed and gloves were not changed during incontinent care. EI #5 said, spread infection. On 7/13/2017 at 2:30 p.m., an interview was conducted with EI #4, CNA. EI #4 was asked when should hands have been washed and gloves changed when performing incontinent care. EI #4 said, before and after care. EI #4 was asked should she have washed her hands and changed her gloves during incontinent care of RI #10. EI #4 said, yes. EI #4 was asked what was the potential harm to a resident when hands were not washed and gloves were not changed during incontinent care. EI #4 said, germs.

Based on observations, record reviews, interviews, and facility policy titled, Standard Precautions, the facility failed to ensure Certified Nursing Assistants (CNA) washed their hands and changed their soiled gloves during the provision of incontinent care for Resident Identifier (RI) #'s 3, 5 and 10. This affected three of four observations of resident incontinent care and three of three residents residing on the 3rd hall in the facility. Finding include: A facility policy titled: Standard Precautions revealed: . Standard Precautions presume that all . body fluids, secretions, and excretions . mucous membranes may contain transmissible infectious agents. Standard precautions include the following practices: 1. Hand Hygiene . Hands shall be washed with soap and water . after direct or indirect contact . d. Wash hands after removing gloves . 2. Gloves a. Wear gloves . when . direct contact with . body fluids, mucous membranes .b. when in direct contact with a resident . e. change gloves, during the care of a resident to prevent cross-contamination from one body site to another (when moving from a dirty site to a clean one). 1. RI #3 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/16/2017 revealed RI #3 required limited assistance with personal hygiene and was always incontinent of bowel and bladder. On 7/11/2017 at 3:42 p.m. an observation of incontinent care was made for RI #3. Upon entering RI #3's room, EI #3, CNA and EI #4, CNA failed to wash their hands before donning gloves. RI #3 was rolled to his/her right side by EI #4 while EI #3 cleaned RI #3's buttocks area where bowel movement was observed. After cleaning the buttock area RI #3 was rolled on his/her back and EI #4 cleaned RI #3's perineal area and removed the soiled waterproof pad and underpad. RI #3 was rolled to his/her right side and a clean underpad and waterproof pad was placed under the resident. RI #3 was then rolled to his/her left side where EI #3 unrolled and straightened the underpad and waterproof pad. The waterproof pad was then pulled up between RI #3's legs. Throughout the incontinent care observation, EI #3 and EI #4 did not change their gloves or wash their hands. 2. RI #5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #5's quarterly MDS (Minimum Data Set) with an ARD of 6/13/2017 revealed RI #5 was incontinent of bowel and bladder and totally dependent on staff for toileting and hygiene. On 7/12/2017 at 9:45 a.m. EI #6, CNA provided incontinent care for RI #5. EI #6, wearing gloves, cleaned stool from RI #5's perineum. While wearing the same soiled gloves, EI #6 continued care for RI #5, applied and fastened a clean brief, touching RI #5's skin, clothes, and gastrostomy tube. 3. RI #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly MDS with an ARD of 4/18/2017 revealed, RI #10 required extensive assistance with personal hygiene and was always incontinent of bowel and bladder. On 7/12/2017 at 3:03 p.m. an observation of incontinent care was observed on RI #10. Upon entering RI #10's room, EI #3, CNA and EI #4, CNA failed to wash their hands before donning gloves. Throughout the incontinent care observation, EI #3 and EI #4 failed to change their gloves or wash their hands. On 7/12/2017 at 5:13 p.m., an interview was conducted with EI #3, CNA, EI #3 was asked what did the facility's policy indicate about when gloves should have been changed and hands washed during care of a resident. EI #3 said, change gloves and wash hands before touching clean items. EI #3 was asked when did she wash her hands and change her gloves. EI #3 said, after the care was done. EI #3 was asked should she have changed her gloves and washed her hands when performing incontinent care for RI #3 and RI #10. EI #3 said, yes. EI #3 was asked what was the potential harm to a resident when hands were not washed and gloves were not changed during incontinent care. EI #3 said, contamination. On 7/13/2017 at 9:34 a.m., an interview was conducted with EI #5, Infection Control Nurse. EI #5 was asked what did the facility's policy indicate regarding when hands should be washed and gloves changed when performing incontinent care. EI #5 said, hands should have been washed and gloves changed before care, after touching dirty, gloves should have been removed and hands washed and before touching clean items. EI #5 was asked was it an appropriate practice of that facility for a CNA to not change her gloves or wash her hands during incontinent care. EI #5 said, no. EI #5 was asked what was the potential harm to a resident when hands were not washed and gloves were not changed during incontinent care. EI #5 said, spread infection. On 7/13/2017 at 2:30 p.m., an interview was conducted with EI #4, CNA. EI #4 was asked when should hands have been washed and gloves changed when performing incontinent care. EI #4 said, before and after care. EI #4 was asked should she have washed her hands and changed her gloves during incontinent care of RI #3 and RI #10. EI #4 said, yes. EI #4 was asked what was the potential harm to a resident when hands were not washed and gloves were not changed during incontinent care. EI #4 said, germs.

Based on interview and review of the facility's record titled (Name of Facility)INSERVICE EDUCATION RECORD for Employee Identifier (EI) #s 7-9, the facility failed to ensure CNAs' (Certified Nursing Assistant), 12 hours of education per year included education related to Dementia. This affected three of five CNAs reviewed for training records. Findings Include: Review of the facility's undated record titled (Name of Facility) INSERVICE EDUCATION RECORD revealed the . Yearly Required . subjects did not include Dementia training. A review of EI #7's inservice education record revealed EI #7's hire date was 2/15/2002. EI #7's education training from 2/15/2016-2/15/2017 did not include documentation of Dementia training. A review of EI #8's inservice education record revealed EI #8's hire date was 8/16/2002. EI #8's education training record from 8/16/2015 through 8/16/2016 did not include documentation of Dementia training. A review of EI #9's inservice education record revealed EI #9's hire date was 2/16/2009. EI #9's education training record from 2/16/2016 through 2/16/2017 did not include documentation of Dementia training. On 7/13/2017 at 3:25 p.m., an interview was conducted with EI #10, Staff Development and EI #11 ADON (Assistant Director of Nursing). EI #10 reviewed the records the facility provided for EI #s 7-9 and agreed they did not have the required dementia training. EI #10 was asked which training topics were considered mandatory. EI #10 said, the subjects that were type printed on the inservice education record. EI #10 was asked why dementia training was not included on the yearly mandatory subjects. EI #6 stated, dementia was done when CNAs were first hired. When asked why it would be important to have yearly dementia training, EI #11 said, for the best quality of care.

Based on observations, record reviews, interviews, and facility policy titled, Standard Precautions, the facility failed to ensure Certified Nursing Assistants (CNA) washed their hands and changed their gloves during the provision of incontinent care for Resident Identifier (RI) #3, a resident with a history of Urinary Tract Infections. This affected one of four observation of resident incontinent care. Finding include: A facility policy titled: Standard Precautions revealed: . Standard Precautions presume that all . body fluids, secretions, and excretions . mucous membranes may contain transmissible infectious agents. Standard precautions include the following practices: 1. Hand Hygiene . Hands shall be washed with soap and water . after direct or indirect contact . d. Wash hands after removing gloves . 2. Gloves a. Wear gloves . when . direct contact with . body fluids, mucous membranes .b. when in direct contact with a resident . e. change gloves, during the care of a resident to prevent cross-contamination from one body site to another (when moving from a dirty site to a clean one). RI #3 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/16/2017 revealed RI #3 required limited assistance with personal hygiene and was always incontinent of bowel and bladder. On 7/11/2017 at 3:42 p.m. an observation of incontinent care was made for RI #3. Upon entering RI #3's room, EI #3, CNA and EI #4, CNA failed to wash their hands before donning gloves. RI #3 was rolled to his/her right side by EI #4 while EI #3 cleaned RI #3's buttocks area where bowel movement was observed. After cleaning the buttock area RI #3 was rolled on his/her back and EI #4 cleaned RI #3's perineal area and removed the soiled waterproof pad and underpad. RI #3 was rolled to his/her right side and a clean underpad and waterproof pad was placed under the resident. RI #3 was then rolled to his/her left side where EI #3 unrolled and straightened the underpad and waterproof pad. The waterproof pad was then pulled up between RI #3's legs. Throughout the incontinent care observation, EI #3 and EI #4 did not change their soiled gloves or wash their hands. On 7/12/2017 at 5:13 p.m. an interview was conducted with EI #3, CNA. EI #3 was asked what did the facility's policy indicate about when gloves should have been changed and hand should have been washed during care of a resident. EI #3 said, change gloves and wash hands before touching clean items. EI #3 was asked when did she wash her hands and change her gloves. EI #3 said, after the care was done. EI #3 was asked should she have changed her gloves and washed her hands when performing incontinent care for RI #3. EI #3 said, yes. EI #3 was asked what was the potential harm to a resident when hands were not washed and gloves were not changed during incontinent care. EI #3 said, contamination. On 7/13/2017 at 9:34 a.m., an interview was conducted with EI #5, Infection Control Nurse. EI #5 was asked what did the facility's policy indicate regarding when hands should be washed and gloves changed when performing incontinent care. EI #5 said, hands should have been washed and gloves changed before care, after touching dirty, gloves should have been removed and hands washed and before touching clean items. EI #5 was asked was it an appropriate practice of that facility for a CNA to not change her gloves or wash her hands during incontinent care. EI #5 said, no. EI #5 was asked what was the potential harm to a resident when hands were not washed and gloves were not changed during incontinent care. EI #5 said, spread infection. On 7/13/2017 at 2:30 p.m., an interview was conducted with EI #4, CNA. EI #4 was asked when should hands have been washed and gloves changed when performing incontinent care. EI #4 said, before and after care. EI #4 was asked should she have washed her hands and changed her gloves during incontinent care of RI #3. EI #4 said, yes. EI #4 was asked what was the potential harm to a resident when hands were not washed and gloves were not changed during incontinent care. EI #4 said, germs.

Based on observation, interviews and a facility policy titled, GASTROSTOMY TUBE FEEDINGS the facility failed to ensure a licensed staff member checked the placement of a percutaneous endoscopic gastrostomy (PEG) tube prior to administering a bolus feeding to Resident Identifier (RI) #5. This affected one of two residents sampled for feeding tubes. Findings include: A facility Policy titled: GASTROSTOMY TUBE FEEDINGS with a revision date of 2/25/04, revealed: . PROCEDURE . 5. Check for placement . Listen with stethoscope over upper quadrant while injecting 15-20 milliliters (ml) air into tube and aspirate back gastric content. To ensure gastrostomy tube in correct position . RI #5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #5's quarterly MDS (Minimum Data Set) with an ARD of 6/13/2017 revealed RI #5 received tube feedings. On 7/11/2017 at 4:21 p.m. RI #5's tube feeding was observed. Employee Indentifer (EI) #2, LPN (Licensed Practical Nurse) exposed RI #5's feeding tube and provided a bolus feeding and flush. EI #2 failed to check the placement of the PEG tube before she administered the flushes and feeding. On 7/13/2017 at 9:30 a.m. an interview was conducted with EI #1, Director of Nursing (DON). EI #1 was asked what did the facility policy indicate about what should be done prior to administering a bolus feeding through a PEG tube. EI #1 said, check for placement by auscultation, check residual and ensure patency. EI #1 was asked what was the potential harm to a resident when the placement of a feeding tube was not checked prior to a bolus feeding. EI #1 said, the tube might not be in the stomach and cause the feeding to go somewhere else. On 7/13/2017 at 2:40 p.m. an interview was conducted with EI #2, Licensed Practical Nurse (LPN). EI #2 was asked what should have been done before administering a bolus feeding to RI #5. EI #2 said, check the placement of the tube. EI #2 was asked what did she fail to do when she administered a bolus feeding to RI #5. EI #2 said, I didn't check for placement or residual. EI #2 was asked what was the potential harm to a resident when the placement of a feeding tube was not checked prior to administering a bolus feeding. EI #2 said, the resident could have been too full or the tube could not be in the right place.

Based on observation, record review and interview the facility failed to ensure: 1. Four silverware bags of forks, spoons and knives were not wet nesting. 2. An Oatmeal box was sealed after opening. 3. Hashbrowns were labeled with a use by date. 4. A dietary aide did not touch the inside of plates and saucers and then touch a dish rack that was on the floor with bare hands. These failures had the potential to affect 102 of 105 residents receiving meals from the kitchen Findings Include: A review of a facility policy titled, SILVERWARE WASHING AND HANDLING with no revised date revealed: POLICY: Silverware is to be maintained and handled in a manner to prevent contamination. PROCEDURE: . 7. Allow to air dry A review of another facility policy titled, In-Service on Daily Responsibilities/Duties with no revised date revealed: . If you remove something from the original case it is required to have received date, open date, and use by date, no matter what it is A review of a facility policy titled, Employee Sanitary Practices no revised date revealed: .Policy: All kitchen employees will practice standard sanitary procedures. Procedure: . 9. Use these guidelines in handling clean dishware, glasses and silverware: Pick dishes up by their rims 1) On 7/13/2016 at 11:15 the surveyor observed silverware in a caddy. The surveyor picked up four packages of silverware and there was water on the utensils inside of the bag (fork, knife and spoon). The surveyor asked the aide what was on the inside of the bag. The aide said something was on the bag and continued to put utensils on the residents tray. On 7/14/2016 at 12:55 p.m., an interview was conducted with EI #4 (Employee Identifier) dietary aide. EI #4 was asked what was inside the silverware bag. EI #4 replied, water. EI #4 was asked why was there water in the bags. EI #4 replied, she hastily put the silverware in the bags. EI #4 was asked, who was responsible for cleaning utensils. EI #4 replied, she was and the dishwasher. EI #4 were asked how was utensils suppose to dry. EI #4 replied, once sent through the machine, put on the drying rack to air dry. EI #4 was asked what was the potential harm when utensils are not allowed to air dry. EI #4 replied, possible bacteria, and residents can get a bacteria. On 7/14/2016 at 1:00 p.m., an interview was conducted with EI #2, District Manager. EI #2 was asked what was inside of the silverware bags. EI #2 replied, water droplets. EI #2 was asked why was there water droplets in the silverware bags. EI #2 replied, they had not completed air drying. EI #2 was asked what was the potential harm when utensils were not allowed to air dry. EI #2 replied, there was a risk of bacteria growing and causing cross contamination. EI #2 was asked who removed the packages of silverware from the silverware caddy. EI #2 replied she did. 2) On 7/12/2016 at 9:45 a.m. during initial tour, the surveyor observed a box of Quick Oats lid opened. On 7/14/2016 at 3:11 p.m., an interview was conducted with EI #2. EI #2 was asked what item did you see opened in dry storage. EI #2 replied oatmeal. EI #2 was asked why was the box not sealed. EI #2 replied the cook used it and did not put it in a zip lock bag. EI #2 was asked what covering was over the item. EI #2 replied nothing but the box flap it was not sealed. EI #2 was asked who was responsible for making sure dry storage items were sealed after opening. EI #2 replied the kitchen supervisor and manager. EI #2 was asked what was the potential harm when food items were left opened. EI #2 replied, something like bugs can get into it and cause contamination. EI #2 was asked what was the facility policy on opening food items in dry storage. EI #2 replied, opened container must be stored in a seal container with open date and use by date. 3) On 7/12/2016 at 10:03 a.m., the surveyor observed hashbrowns in the reach in freezer with no use by date on them. On 7/14/2016 at 3:23 p.m., the surveyor conducted an interview with EI #3. EI #3 was asked what was the use by date of the hashbrowns. EI #3 replied, there was no use by date on them. EI #3 was asked, why was there no use by date on the hashbrowns. EI #3 replied, the individual who opened it did not include the use by date. EI #3 was asked who was responsible for putting use by dates on food items. EI #3 replied, every employee in dietary. EI #3 was asked when should a use by date be placed on a food item. EI #3 replied, everytime it was opened and taken out of the original container. EI #3 was asked what was the potential harm when food had no use by date on them. EI #3 replied, someone can use something that has expired. EI #3 was asked where were the hash browns located. EI #3 replied, in the reach in freezer. 4) On 7/12/2016 at 2:15 p.m., the surveyor observed the worker picking up saucers, and plates with her thumb in the middle of the dishware. The worker did not have on gloves. The worker touched a plate rack that was on the floor. She continued to remove clean dishes from the plate rack without washing hands. On 7/14/2016 at 4:43 p.m., the surveyor conducted an interview with EI #5, dietary aide. EI #5 was asked how did she pick up plates and saucers from the plate rack. EI #5 replied, by the thumb. EI #5 was asked how should she pick up plates and saucers when taking them out of the dish rack. EI #5 replied, by the edge of the plates and saucers. EI #5 was asked what was the facility's policy on picking up plates and saucers after they have been washed. EI #5 replied, pick up by the edge and make sure they are not wet. EI #5 was asked what was the potential harm when fingers were touching the inside of plates and saucers. EI #5 replied, any germs on your hands can contaminate the plate. EI #5 was asked what was the potential harm when you touch a plate rack on the floor and continue to put up clean dishes from the clean plate rack. EI #5 replied, cross contamination. EI #5 was asked when putting away the dishes from the plate rack what position was your thumb on the plate. EI #5 replied inside of the plate.

Based on observations, interviews, and record reviews, the facility failed to ensure: A licensed nurse observed during medication pass washed or sanitized her hands between residents. This deficient practice affected one of four nurses observed during medication pass on one of three nursing units. Findings include: A review of a facility policy titled, SPECIFIC MEDICATION ADMINISTRATION PROCEDURES with an effective an effective date of July 1, 2009 revealed: .Policy To administer medications in a safe and effective manner Procedures .H. Cleanse hands before handling medication and before contact with resident . 1. On 07/12/2016 at 4:15 p.m., Employee Identifier #1 (EI), a Licensed Practical Nurse, was observed preparing RI #22's medications. EI #1 did not wash her hands prior to pouring the medications into the cup and administering the medications to RI (Resident Identifier) #22. EI #1 did not wash her hands after the medications were administered to the resident. 2. At 07/12/2016 at 4:22 p.m., EI #1 administered RI # 23's medications and did not wash or gel her hands before administering the medications which included one injection. EI #1 applied gloves before administering the injection but did not wash hands before or after removing the gloves. EI #1 did not wash her hands before administering medication to the next resident. 3. On 07/12/2016 at 4:30 p.m., EI #1 was observed as she prepared five medications to be administered by mouth to RI #24. EI #1 was not observed to have washed her hands before or after administering the medications. An interview was conducted with EI #1 on 07/12/2016 at 4:40 p.m. The surveyor asked EI #1 if she wash her hands after removing gloves. EI #1 replied no. EI #1 was asked what does the facility policy say about washing hands. EI #1 replied, before applying gloves and removing gloves. The surveyor ask what was the importance of washing your hands. EI #1 replied, Infection.

Based on observation, record review and interviews, the facility failed to ensure manually washed utensils and counter surfaces were consistently sanitized between use. This had the potential to affect all 97 residents for whom meals were prepared and served at the time of the survey. Findings include: The facility's policy and procedure related to Cleaning Dishes - Manual Dishwashing (2013), p. 4-16 directs staff to: .6. Check sanitation sink often using a test strip to assure the level of sanitizing solution is appropriate.Sanitize all dishes by immersion in. Quaternary Ammonium (at a strength of) 150 to 200 ppm (parts per million). During the initial kitchen tour, on 06/02/15 at 3:45 PM, a staff member was processing cooking and food preparation utensils through the three compartment sink. The surveyor used a chemical test strip above the final rinse (sanitizing) sink to test the concentration of quaternary ammonia in the sink. The test strip was immersed 15 seconds. The test strip registered less than 100 ppm of chemical sanitizer. The surveyor then asked the staff member at the sink, if she knew what the chemical concentration should be. The staff member stated she did not know the concentration level; she was part-time and new (since March 2015). A Dietary Aide/Cook nearby, stated the goal concentration of quaternary ammonia (quat) was 150 to 400 ppm. The Sanitizing Sink Temperature/Chemical Record posted by the 3-compartment sinks identified a daily concentration of 100 ppm quaternary ammonia in the final rinse sink for two of six entries (three entries per day on each of two days). The Sanitizing Sink Temperature/Chemical Record for the entire month of May documented a (substandard) chemical concentration of 100 ppm on 23 of 31 days, following the dinner meal. On 06/03/15 at 10:25 AM, the chemical concentration of the sanitizing sink was tested by the Regional Dietary Manager, Employee Identifier (EI) #9. EI #9 found the concentration of quat to be 100 ppm when tested two times. Immersed in the sanitizing sink water were steam table pans, a wire whip attachment and other utensils. When asked, EI #9 stated the concentration of quaternary ammonia was supposed to be at least 150 ppm, with a goal of 200 ppm. On 06/03/15 at 11:20 AM, the Cook took a cloth from the red sanitizing bucket, wrung the chemical from the cloth, and thoroughly wiped the preparation counter (across from the convection oven). Immediately thereafter, the surveyor asked the Dietary Manager (EI #10) to check the concentration of the sanitizing solution in the red bucket. Using a test strip, EI #10 determined the solution was 100 ppm. EI #10 stated the solution had been changed a couple of hours earlier; their goal was 200 ppm and the manufacturer's recommendation was 150 to 400 ppm. At 11:35 AM, the cook used a cloth from the same sanitizing bucket to wipe off the tray line counter surface. On 06/04/15 at 10:15 AM, the surveyor asked the Regional Dietary Manager (EI #9) what had happened with the sanitizing sink. EI #9 explained she had contacted the Auto-Chlor representative on 06/03/15 regarding the inadequate quat concentrations. EI #9 explained the Auto- Chlor technician determined the tubing inside the quat dispenser at the three-compartment sink was stopped up, preventing the chemical sanitizer from dispensing correctly. EI #9 stated she had refilled the sink numerous times on 06/03/15 and kept checking the chemical concentration, but it had never risen above 100 ppm. Their goal was 150-400 ppm. On 06/04/15 at 10:45 AM, the surveyor asked the Cook (EI #11) whether or not she ever refilled the sanitizer bucket with quat, and if she checked the level of sanitizing agent. EI #11 explained she sometimes filled her own bucket of sanitizer, and checked the concentration every two hours. EI #11 stated she may not have checked the bucket she used on 06/03/15. When asked what hazard could be caused by an inadequate concentration of sanitizing chemical, EI #11 responded, it would not sterilize; they could pick up bacteria.

Based on observation, interviews and record review, the facility failed to ensure a Liberal Cardiac menu was pre-planned for staff referral. This affected 15 residents for whom a Liberal Cardiac diet was ordered at the time of this survey. Findings included: The facility policy related to Diet Orders (2013), p. 1-20 mandates: When there is a nutritional indication, the facility will provide a therapeutic diet that is individualized to meet the clinical needs and desires of the patient/resident to achieve outcomes/goals of care. These diets coincide with the therapeutic diets on the facility menus. The corresponding procedure specifies: 1. The registered dietitian (RD) will approve all therapeutic diets on the menus. The RD or designee will be notified of any therapeutic (special) diets not listed on the menu, so that they can be developed as appropriate. The facility's Diet Formulary provided a conversion to liberalized geriatric diets for commonly ordered therapeutic diets. Among those diets listed was the Cardiac Prudent diet, which specified: regular (diet), skim milk, eggs 3x week, no fried foods. The facility Diet Manual (approved January 2014) described the Liberalized Cardiac Diet as less restrictive than a therapeutic cardiac prudent diet, in an effort to increase meal consumption in long term care residents. Additional dietary restrictions, as per physician or dietitian, will be specified on the resident's individual tray card.Cured meats such as ham, bacon, sausage, corned beef, and hot dogs are not served. An appropriate alternate will be served, as listed on the daily menu guides. On 06/02/15 at 3:45 PM (soon after entry), the surveyors requested a listing of all residents and their diet orders. Based on this list, 16 total residents were found with orders for a Liberal Cardiac diet. A comparison of the diet list with the facility's planned menus, revealed the lack of a Liberal Cardiac menu. On 06/04/15 at 10:45 AM, the surveyor asked the morning cook, Employee Identifier (EI) #11, how she knew what to serve to the residents on the Liberal Cardiac diets. EI #11 explained she followed the menu planned for the residents on the Liberal Renal diet. When asked how the Cardiac (Renal) menu differed from the regular menu, EI #11 explained they did not give salt packs or fried foods. On 06/04/15 at 10:55 AM, the surveyor asked the Regional Dietary Manager (EI #9) if the department had a (pre-planned) Liberal Cardiac menu. EI #9 stated no. On 06/04/15 at 2:30 PM, the facility's Registered Dietitian (RD) was interviewed by phone. The surveyor asked why there were no planned Liberal Cardiac menus to which the trayline staff could refer. The RD (EI #12) explained that all the facility diets (including the Liberal Cardiac) were in place when the current contract food service company arrived (in February 2015). EI #12 stated the food service company changed the menus, but she had not yet addressed the changes. On 06/05/15 at 9:30 AM, the Medical Director (EI #13) was interviewed by phone. When asked why he ordered the Liberal Cardiac diets, EI #13 explained that State and Medicare required it. EI #13 stated he would prefer the residents continue receiving a Liberal Cardiac diet, or to at least limit the deep fat fried foods and foods high in saturated fat.

Based on observation, interviews and record review, the facility failed to ensure privacy was maintained for Resident Identifier (RI) #23. Employee Identifier (EI) #14, a LPN (Licensed Practical Nurse) failed to close the door during Medication Administration Observation on 6/3/15 to maintain RI #23's privacy. One (1) of four (4) residents was affected by this deficient practice during the observation of medication administration. Findings included: RI #23 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #23 current Physician order [REDACTED]. On 6/3/15 at 8:55 a.m., during the morning Medication Administration Observation, EI #14 was observed administering medications to RI #23. EI #14 administered the [MEDICATION NAME] Inhaler. EI #14 failed to maintain RI #23's privacy by closing the door to the room. RI #23's door remained open to the hallway and the resident could be observed receiving inhalation treatment by anyone passing the doorway. On 6/3/15 at 3:32 p.m., the surveyor conducted an interview with EI #14. The surveyor asked EI #14, when giving a treatment such as an inhaler, what should she do to maintain the resident's privacy. EI #14 stated, Close the door, pull the curtains if another resident is in the room. The surveyor asked EI #14 why would she close the door to the room. EI #14 stated, So that people going up and down the hall don't see (RI #23) is getting a treatment.