Every finding on record at Twin Oaks Rehabilitation and Healthcare Center

Based on observations, interviews, resident record review, and review of facility policies titled Hand Hygiene, Standard Precautions, and Infection Prevention and Control Program the facility failed to ensure staff provided care to residents, handled soiled linen, lift slings, and mechanical lifts, in a manner to prevent the spread of infection in the facility. On 10/24/2023 during surveyor observations, staff failed to: wash or sanitize hands between residents; dispose of lift slings appropriately after resident use; sanitize the mechanical lift appropriately after resident use. This had the potential to affect Resident Identifier (RI) #81, RI #20, RI #3, and RI #19, four of 28 sampled residents. A facility policy titled Standard Precautions revised 09/2010 documented: . 1. Hand Hygiene a. Wash hands after touching . contaminated items . 5. Resident-Care Equipment . a. Handle used resident-care equipment soiled with blood, body fluid, secretions, and excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of other microorganisms to other residents and environments. b. Ensure that reusable equipment is not used for the care of another resident until it has been appropriately cleaned and reprocessed . A facility policy titled Hand Hygiene dated 05/2020 revealed: . PURPOSE: To provide guidelines to employees for proper and appropriate hand hygiene techniques that will aide in the prevention of the transmission of infections. Hand hygiene should be performed using Alcohol Based Hand Rub (ABHR) . Before and after touching residents . On 10/24/2023 at 9:19 AM Employee Identifier (EI) #4 CNA was observed making RI #81's bed and touching RI #81's bedside table and remote control. EI #4 then, without washing or sanitizing her hands, assisted in making RI #20's bed. On 10/24/2023 at 9:25 AM EI #4 placed the mechanical lift with the used lift sling, that had been used to transfer RI #81, down the hallway in the education/restorative room without sanitizing the mechanical lift or disposing of the used lift sling. EI #8 CNA pushed the unsanitized mechanical lift and the dirty lift sling up against the wall in the education room and closed the door. On 10/24/2023 at 10:36 AM EI #6 CNA took the mechanical lift, along with the used lift sling still hanging on the lift, from the education room to RI #3's room. The used lift sling was then placed under RI #3 and the mechanical lift was used by EI #6 and EI #7 to transfer RI #3 to a wheelchair. The unsanitized mechanical lift was then left in the hallway with the used lift sling hanging on the lift. On 10/24/2023 at 10:44 AM EI #6 CNA wiped the mechanical lift with bleach wipes and left the used lift sling hanging on the lift. EI #7 CNA came and got the lift with the dirty sling and pushed it to RI #19's room. On 10/24/2023 at 11:01 AM RI #19 was transferred using the mechanical lift then EI #7 cleaned the mechanical lift in the hallway with bleach wipes. EI #7 cleaned part of the mechanical lift, moved the used lift sling to the clean side, and continued to wipe the mechanical lift with the bleach wipes. On 10/24/2023 at 10:07 AM EI #4 CNA was asked about the lift sling and mechanical lift. EI #4 stated, she did not sanitize the mechanical lift before removing it from RI #81's room or before pushing it into the education room. EI #4 stated, she was supposed to put the lift sling down the laundry shoot. EI #4 stated, she did not have a reason why she did not dispose of the used lift sling and left the lift sling hanging up on the mechanical lift. EI #4 said, the risk of leaving the used lift sling on the mechanical lift was infection control and cross contamination. EI #4 stated, putting an unsanitized lift and a dirty lift sling in the education room was a risk of cross contamination and infection control issue. EI #4 was asked when she sanitized her hands after caring for RI #81 before assisting with RI #20's bed. EI #4 replied, she did not and and it was a cross contamination and infection control issue. On 10/24/2023 at 09:51 AM EI #8 CNA asked about the mechanical lift. EI #8 stated, she pushed the mechanical lift up against the wall in the education room. EI #8 stated, the mechanical lift is mostly used for restorative but at times other staff members use the mechanical lift. EI #8 stated, there was a lift sling hanging on the mechanical lift. On 10/24/2023 at 10:47 AM EI #6 stated, she used the lift sling that was hanging on the mechanical lift. EI #6 stated, after she used the lift sling for RI #3 she put the lift sling back on the lift. EI #6 stated, the lift sling was considered dirty after use and she did not know why she put it back on the lift. EI #6 stated, the residents could get sick and cross contamination from using dirty lift slings. On 10/24/2023 at 11:15 AM EI #7 CNA stated, she used the lift pad that was already on the lift when she got it out of RI #3's room. EI #7 stated, she should have used a clean lift sling from the linen cart for RI #19. EI #7 stated, when cleaning the mechanical lift and putting the used lift sling on the sanitized area, she would consider the lift contaminated. EI #7 stated, using the dirty lift sling was a risk for infection. On 10/26/2023 at 8:45 AM an interview was conducted with EI #3 Assistant Director of Nursing (ADON)/Infection Control (IP). EI #3 was asked, after the mechanical lift was used by a staff member for a resident what was the procedure. EI #3 replied, the lift sling should be thrown down to laundry and then the lift wiped down with sanitizing wipes. EI #3 said, lifts should be wiped down before leaving the resident's room. EI #3 stated, taking a lift out of a room that had not been sanitized was a risk of spreading infection. EI #3 stated, after the use of a lift sling staff should put it in a bag and throw it down the laundry shoot. EI #3 stated, touching dirty equipment and not sanitizing hands was a risk for spreading infection. EI #3 was asked, what was the risk of the lift not being cleaned before taking it out of the room. EI #3 replied, the risk of spreading infection. EI #3 was asked, what was the risk of a lift having a dirty sling stored on the lift. EI #3 replied, risk of spreading infection. EI #3 was asked, what was the risk of utilizing a dirty lift sling on different residents. EI #3 replied, risk of spreading infections. EI #3 was asked, when should staff go from making one residents bed and then start touching another residents bed without sanitize or washing their hands. EI #3 stated, never, you should always wash or sanitize hands between residents. On 10/26/2023 at 10:04 AM an interview was conducted with EI #2 Director of Nursing (DON). EI #2 said, they should clean the lift between uses, after use, and before they come out of the room. EI #2 was asked, what should staff do with the lift sling after use. EI #2 replied, leave under resident or send down to laundry. EI #2 was asked, how should the staff clean the lift. EI #2 replied, sanitizing wipes. EI #2 was asked, what was the risk of using the same lift slings on multiple residents. EI #2 replied, infection control issue. EI #2 was asked, when a staff member went from making one resident's bed to another resident's bed what should they do. EI #2 replied, hand sanitize in between. EI #2 was asked, what was the risk of not washing or sanitizing hands between changing or making different residents beds. EI #2 replied, infection control issue.

Based on observation, interviews, and review of a facility policy titled MEDICATION STORAGE IN THE FACILITY, the facility failed to ensure stock Ativan (Lorazepam), a controlled medication, was stored in the medication refrigerator in a secured non-removable container, this was observed on 10/26/2023. This affected one of two medication refrigerators reviewed. Findings include: A facility policy titled MEDICATION STORAGE IN THE FACILITY with a revised date of 08/2014 documented: . CONTROLLED SUBSTANCE STORAGE . Policy Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, . Procedures . C. Controlled-substances that require refrigeration are stored within a locked box within the refrigerator. This box must be attached to the inside of the refrigerator. On 10/26/2023 at 8:30 AM, the medication room on 100 hall was observed with Employee Identifier (EI) #9 Licensed Practical Nurse (LPN). EI #9 removed from the medication refrigerator a plastic storage box with a red lock tag containing two vials of Ativan along with other medications that were not controlled. EI #9 was asked where the ativan was. EI #9 replied, in the plastic box. EI #9 said, there was a secured non-removable box in the refrigerator and it had nothing in it. On 10/26/2023 at 8:35 AM, EI #2, Director of Nursing (DON), came to the medication room and observed the removal plastic storage box. EI #2 said, the two vials of Ativan was included in the stock medication in the box. EI #2 said, the Ativan should be stored in the non-removable secured box in the refrigerator. EI #2 said, the harm in the Ativan not being secured in the non-removable secured locked box was that, anyone with a key to the medication room and refrigerator could take the medication.

Based on interview, review of facility forms CERTIFICATE OF INVENTORY AND DESTRUCTION and review of facility policies titled, CONTROLLED SUBSTANCE DISPOSAL and MEDICATION DESTRUCTION FOR NON-CONTROLLED MEDICATIONS, the facility failed to ensure the required number of signatures for destruction of controlled and non-controlled medications were present and documented on the destruction forms. This affected two of twelve months reviewed for destruction for the year 2020 and three of six months reviewed for the year 2021. Findings Include: Review of a facility policy titled, CONTROLLED SUBSTANCE DISPOSAL with a revised date of August 2014 revealed, Policy Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal and state laws and regulations. Procedures . E. The (administrator), nurse(s) and/or pharmacist witnessing the destruction ensures that the following information is entered on the (individual controlled substance accountability record/book) . 6) Signatures of witnesses. Review of facility forms CERTIFICATE OF INVENTORY AND DESTRUCTION with printed and handwritten dates of 7/2/21 and handwritten times of 1:18 PM and 2:18 PM, for controlled medication, revealed only two of the three required signatures were documented on the forms. Review of a facility policy titled, MEDICATION DESTRUCTION FOR NON-CONTROLLED MEDICATIONS with a revised date of August 2014 revealed, . Procedures . E. Medication destruction occurs only in the presence of at least two licensed healthcare professionals . F. The licensed healthcare professionals witnessing the destruction ensure that the following information is entered on the (medication disposition form): . 6) Signatures of witnesses. Review of facility forms CERTIFICATE OF INVENTORY AND DESTRUCTION with printed and handwritten dates of 10/27/20 for non-controlled medication, revealed only one of the two required signatures were documented on the forms. Review of facility forms CERTIFICATE OF INVENTORY AND DESTRUCTION with printed dates of 3/26/21 and 4/6/21, and with handwritten dates of 5/3/21 at 11:55 AM, for non-controlled medication, revealed only one of the two required signatures were documented on the forms. Review of facility forms CERTIFICATE OF INVENTORY AND DESTRUCTION with printed dates of 8/4/21 for non-controlled medication, revealed only one of the two required signatures were documented on the forms. On 8/05/21 at 10:31 AM, the CERTIFICATE OF INVENTORY AND DESTRUCTION sheets were reviewed with Employee Identifier (EI) #1, the Director of Nursing (DON). EI #1 was asked how often medications were destroyed. EI #1 replied, it varied. EI #1 was asked how many signatures were on the non-controlled medication destruction sheets. EI #1 replied, only one. EI #1 was asked how many signatures were required for non-controlled medications. EI #1 replied, two. EI #1 was asked how many signatures were on the controlled medication destruction sheets. EI #1 replied, two. EI #1 was asked how many signatures were required for destruction of controlled medications. EI #1 replied, three. EI #1 was asked why was it necessary to have the required signatures for controlled and non-controlled medication destruction sheets. EI #1 replied, to verify accurate accounts of the medications destroyed. EI #1 was asked what was the facility policy for signatures related to non-controlled medication destruction. EI #1 replied, medication destruction should occur in the presence of two licensed staff. EI #1 was asked what was the facility policy for destruction of controlled medications. EI #1 replied, three verifying and three signatures and if the pharmacist was not in the building it could be the administrator and two nurses.

Based on observations, interviews, review of Assure Prism multi Blood Glucose Monitoring System User Instruction Manual, an article published by the Centers for Disease Control and Prevention, the McKesson Alcohol Prep Pad product information, product information for the Dispatch Hospital Cleaner Disinfectant Towels with Bleach, Employee Identifier (EI) #1's Glucometer Sanitizing Skills Validation report, an undated facility document and www.merriam-webster.com, the facility failed to ensure EI #1, a Registered Nurse (RN) cleaned and disinfected the Assure Prism multi Blood Glucose Monitoring System according to the manufacturer's instructions between each resident when she performed finger stick blood sugar testing on Resident Identifier (RI) #64, RI #100 and RI #102 during the evening medication pass observation on 10/30/2019. After the RN performed RI #102's finger stick blood sugar, she wiped the glucometer with a wet paper towel, then laid the glucometer on the counter beside the sink in the resident's room. The RN did not clean or disinfect the multi-use glucometer per manufacturer's instructions, before she proceeded to check RI #100's finger stick blood sugar. After the RN performed RI #100's finger stick blood sugar, she wiped the glucometer with a McKesson Alcohol Prep Pad. The RN did not clean or disinfect the multi-use glucometer per manufacturer's instructions, before she proceeded to check RI #64's finger stick blood sugar. After the RN performed RI #64's finger stick blood sugar, she wiped the side, front and top of the glucometer with a McKesson Alcohol Prep Pad. This deficient practice affected RI #64, RI #100 and RI #102, three of nine residents observed for finger stick blood sugar monitoring and placed these residents in immediate jeopardy for serious injury, harm, impairment or death. The facility has 48 residents who require finger stick blood sugar monitoring. On 11/1/2019 at 4:50 PM, the Administrator, Director of Nursing, Director of Operations, Director of Clinical Services and regional Director of Quality Assurance were given a copy of the Immediate Jeopardy (IJ) template and notified of the finding of immediate jeopardy in the area of Infection Prevention & Control, F 880. Findings include: The Assure Prism multi Blood Glucose Monitoring System User Instruction Manual with a revision date of (MONTH) (YEAR), documented . Important Safety Instructions: * All parts of the Assure Prism multi Blood Glucose Monitoring System should be considered potentially infectious and is capable of transmitting blood-borne pathogens between patients and healthcare professionals . * The meter should be cleaned and disinfected after use on each patient . Caring for Your System * To minimize the risk of transmission of blood-borne pathogens, the cleaning and disinfection procedure should be performed as recommended in the instructions below . Cleaning and Disinfecting: The cleaning procedure is needed to clean dirt as well as blood and other body fluids on the exterior of the meter and lancing device before performing the disinfection procedure. The disinfection procedure is needed to prevent transmission of blood-borne pathogens. * The meter should be cleaned and disinfected after each use on each patient . * We have validated Clorox Germicidal Wipes, Dispatch Hospital Cleaner Disinfectant Towels with Bleach, CaviWipes1, and PDI Super Sani-Cloth Germicidal Disposable Wipe for disinfecting the Assure Prism multi meter . Cleaning and Disinfecting Procedures: NOTE: Two disposable wipes will be needed for each cleaning and disinfecting procedure; one wipe for cleaning and a second wipe for disinfecting. Cleaning . (3) Wipe the entire surface of the meter 3 times horizontally and 3 times vertically using one towelette to clean blood and other body fluids. (4) Dispose of the used towelette in a trash bin. The meter should be cleaned prior to each disinfection step. NOTE: No actual drying of the meter is necessary before starting the disinfecting procedure. Disinfecting (5) Pull out 1 new towelette and wipe the entire surface of the meter 3 times horizontally and 3 times vertically using a new towelette to remove blood-borne pathogens. (6) Dispose of the used towelette in a trash bin. (7) Allow exteriors to remain wet for the corresponding contact time for each disinfectant . During medication pass observation on 10/30/2019 beginning at 3:19 PM, EI #1, a RN pricked the left middle finger of RI #102 to obtain the resident's blood sugar reading. After EI #1 performed RI #102's finger stick blood sugar testing, she wiped the glucometer with a wet paper towel then laid the glucometer on the counter beside the sink in the resident's room. Without cleaning or disinfecting the multi-use glucometer per manufacturer's instructions, at 4:12 PM, EI #1 proceeded to gather supplies to perform a finger stick blood sugar for RI #100. After the resident's right index finger was pricked to obtain blood for the finger stick blood sugar, EI #1 removed her gloves and wiped the multi-use glucometer with a McKesson Alcohol Prep Pad. According to the McKesson Alcohol Prep Pad, it is a sterile pad that is saturated with 70% volume by volume [MEDICATION NAME] Alcohol. It is a first-aid antiseptic used for the preparation of the skin prior to an injection. According to an article published by the Centers for Disease Control and Prevention, titled Frequently Asked Questions (FAQs) regarding Assisted Blood Glucose Monitoring and Insulin Administration last updated 8/19/2016, . Blood Glucose Meters . 2. What products are acceptable for cleaning and disinfection of blood glucose meters? . The disinfections solvent you choose should be effective [MEDICAL CONDITION](Human Immunodeficiency Virus), [MEDICAL CONDITION], and [MEDICAL CONDITION] virus. Outbreak episodes have been largely due to transmission of [MEDICAL CONDITION] and [MEDICAL CONDITION]. However, of the two, [MEDICAL CONDITION] virus is the most difficult to kill. Please note that 70% [MEDICATION NAME] solutions are not effective against [MEDICAL CONDITION] bloodborne pathogens and the use of 10% bleach solutions may lead to physical degradation of your device . Without cleaning or disinfecting the multi-use glucometer per the manufacturer's instructions, at 4:28 PM, EI #1 was observed to lay the multi-use glucometer on the over-bed-table of RI #64. After RI #64's left thumb was pricked to obtain blood for the finger stick blood sugar, EI #1 wiped the side, front and top of the glucometer with a McKesson Alcohol Prep Pad. After the above observations, EI #1 was asked what she cleaned the glucometer with. EI #1 replied she used an alcohol pad (McKesson Alcohol Prep Pad). EI #1 was asked what she cleaned the glucometer with after she performed RI #102's finger stick blood sugar. EI #1 said she cleaned the glucometer off with a wet paper towel. When asked what she was supposed to use the clean the glucometer, EI #1 answered an alcohol prep pad. EI #1's Glucometer Sanitizing Skills Validation report indicated on 6/26/2019, EI #1 was observed by EI #3, the Assistant Director of Nursing (ADON) and satisfactorily completed the glucometer sanitizing skills validation tasks. In a follow-up interview on 10/30/2019 at 5:25 PM, EI #1, RN stated the type of glucometer used was an Assure Prism. EI #1 was asked how many glucometers were on the medication cart. EI #1 answered, there was only one glucometer. When asked if she used the same glucometer on all three residents, EI #1 replied, yes ma'am. EI #1 was asked, what she was supposed to clean and disinfect the glucometer with. EI #1 pointed to the container of Dispatch Hospital Cleaner Disinfectant Towels with Bleach that were located in the bottom drawer of the medication cart. When asked if she cleaned and disinfected the multi-use glucometer between each resident, EI #1 answered no. When asked why she didn't, EI #1 stated she was rushing and didn't see it on the cart. EI #1 was asked, what was the harm in not cleaning the glucometer correctly. EI #1 replied, a patient may be exposed to germs. When asked what the potential for harm was for not disinfecting the glucometer between resident use, EI #1 answered Spreading germs. The product information for the Dispatch Hospital Cleaner Disinfectant Towels with Bleach indicated it was an Environmental Protection Agency (EPA) registered disinfectant that was recommended for cleaning and disinfecting blood glucose meters and effective [MEDICAL CONDITION].[MEDICAL CONDITION] and [MEDICAL CONDITION]. During an interview on 10/31/2019 at 4:23 PM, EI #3, the ADON/Infection Control Nurse was asked who trained the staff on how to clean and disinfect the glucometer. EI #3 said she did. EI #3 was asked how nurses were trained to clean and disinfect the glucometer. EI #3 replied, they are trained to use a bleach-based wipe. EI #3 acknowledged the staff should use a bleach based disinfectant wipe to clean and disinfect the glucometer. EI #3 explained the glucometer should be cleaned before use and after use. EI #3 further stated the glucometer should be disinfected before it is used on another resident. When asked what the potential for harm was for not cleaning and disinfecting the glucometer per the manufacturer's instructions, EI #3 replied cross contamination. In an interview on 10/31/2019 at 4:39 PM, EI #2, the Director of Nursing acknowledged the nursing staff have been trained to clean and disinfect the glucometer before and after each use. EI #2 stated the Dispatch Hospital Cleaner Disinfectant Towels with Bleach were on the medication carts for the staff to use to clean and disinfect the glucometer. When asked what the potential for harm was for not cleaning and disinfecting the glucometer per the manufacturer's instructions, EI #2 replied it could possibly spread infection. An undated typed document on facility letterhead indicated 48 residents in the facility required finger stick blood sugar monitoring, of which three residents were diagnosed as having a communicable disease. A communicable disease, as defined by www.merriam-webster.com, is an infectious disease transmissible by direct contact with an affected individual or the individual's discharges or by indirect means. ************************* On 11/2/2019 at 10:08 AM, the facility submitted an acceptable Removal Plan, which documented: November 2, 2019 Removal Plan for F880 1. On (MONTH) 30, 2019, education was provided to EI#1, the nurse who failed to perform cleaning and disinfecting of the Assure Prism multi use glucometer per manufacturer's recommendation for Resident identifiers #64, #100 and #102. On (MONTH) 1, 2019 EI #1 provided a return demonstration to the ADON on the cleaning and disinfecting of the Assure Prism multi use glucometer per the manufacturer's recommendations. The Medical Director was informed by the DON on 11/1/19 of the deficient practice involving RI's # 64, #100 and #102. In addition each resident was assessed by the DON/designee on 11/1/19 and no adverse reactions were identified. 2. All licensed staff on duty on today's date, (MONTH) 1, 2019 have received training by the DON and ADON regarding cleaning and disinfecting of the Assure Prism multi use glucometer according to manufacturer's recommendations. Return demonstrations are being done and will be completed for each licensed staff currently on duty today's date (MONTH) 1, 2019. Retraining and return demonstrations for all licenses staff who are not on duty will receive training on cleaning and disinfecting the Assure Prism multi use glucometer prior to performing blood glucose monitoring. Date of alleged immediacy removal is 11/1/19. 3. Monitoring of glucometer cleaning and disinfecting return demonstrations on the Assure Prism multi use glucometer began on 11/01/19 by the DON/designee. Monitoring will be for three nurses per shift for one week, then one nurse every shift for two weeks. Thereafter, three nurses will be monitored per week for one month. Monitoring tools will be maintained by the DON. ************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented by way of observations, staff interviews and record review, the scope/severity level of F 880 was lowered to a D level on 11/1/2019, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on observation, interviews, review of Resident Identifier (RI) #7's medical record and the facility's policy titled Glucose Monitoring Equipment - Care and Quality Control Testing, the facility failed to ensure Employee Identifier (EI) #15, a Licensed Practical Nurse (LPN) disposed of a lancet in a Sharps container rather than in RI #7's trash can in the resident's room after she performed a finger stick blood sugar on RI #7 on 10/30/2019. This deficient practice affected RI #7, one of nine residents observed receiving finger stick blood sugars, and performed by EI #15, one of seven nurses observed performing finger stick blood sugars. Findings include: The facility's policy titled Glucose Monitoring Equipment - Care and Quality Control Testing, with a revised date of (MONTH) 2010, documented . PR[NAME]ESS: I. General Information . c) Disposable lancets and test strips should be discarded in the nearest sharps container . RI #7 was admitted to the facility on [DATE], with a medical history to include [DIAGNOSES REDACTED]. RI #7's physician orders [REDACTED]. On 10/30/2019 at 5:20 PM, EI #15, an LPN was observed performing a finger stick blood sugar on RI #7. EI #15 pricked the resident's finger with a lancet. After obtaining RI #7's blood sugar, EI #15 removed her gloves and placed the gloves and lancet in trash can in RI #7's room. In an interview on 10/30/2019 at 5:26 PM, EI #15, an LPN was asked where she placed the lancet. EI #15 said in a trash can in RI #7's room. When asked what the potential for harm was with placing a lancet a trash can, EI #15 said someone could get stuck. During an interview on 11/1/2019 at 7:41 PM, EI #3, the Assistant Director of Nursing (ADON) was asked what the nurse should do with the lancet after a finger blood stick has been performed. EI #3 said the lancet should be placed in the Sharps container. When asked what the potential for harm was with placing a lancet in a trash can, EI #3 said a needle stick could occur.

Based on interviews and review of Employee Identifier (EI) #7's, EI #11's and EI #12's, all Certified Nursing Assistants' (CNAs) employee files, the facility failed to ensure these staff members had the required yearly Dementia and/or Abuse training. This deficient practice affected three of 34 employee files reviewed. Findings include: EI #7's employee file indicated the CNA had a hire date of 1/13/2014. For the time period 1/13/2018 to 1/13/2019, EI #7 did not receive any Dementia training. EI #11's employee file indicated the CNA had a hire date of 7/27/2009. For the time period 7/27/2018 to 7/27/2019, EI #11 did not receive any Abuse training. EI #12's employee file indicated the CNA had a hire date of 6/18/2014. For the time period 6/18/2018 to 6/18/2019, EI #12 did not receive any Dementia training. In an interview on 10/31/2019 at 5:11 PM, EI #2, the Director of Nursing stated she was not certain why EI #7, EI #11 and EI #12 had not had the required annual Abuse and/or Dementia training. When asked when the CNAs should receive training on Abuse and Dementia, EI #2 said anniversary date to anniversary date.

Based on observations, interviews and record reviews, the facility failed to: a) monitor the chemical concentration of the sanitizing rinse in the three-compartment (pot and pan) sink; b) protect items served to residents from dripping ceiling water during the 12/13/16 supper tray line; and c) maintain individual portions of ice cream in a frozen state during storage. This had the potential to affect all 95 residents for whom meals were prepared and served at the time of this survey. Findings included: 3-COMPARTMENT SINK SANITATION 1) The facility policy regarding Manual Warewashing (revised 11/2014), directs staff to wash food service pots and pans that cannot fit in a dishmachine to be cleaned and sanitized in a three-compartment sink. The procedure specifies: .5) b) ii) If chemical sanitizing is used . Follow manufacture recommendations . 3) Quats--immerse for 30 seconds in water temp 75 degrees F (Fahrenheit) .9) The employee using the three compartment sink documents on the Pot and Pan Sink Chemical/Temperature Log. During the initial inspection of the facility's kitchen on 12/13/16 at 12:45 p.m., the Dietary Manager affirmed staff use quaternary ammonia to sanitize utensils processed in the three-compartment (pot and pan) sinks. A posted log of the daily Pot Sink Temperature reflected no monitoring by staff of this chemical agent to ensure effective sanitization. CROSS-CONTAMINATION 2) During the supper tray line on 12/13/16 at 4:45 p.m., the surveyor observed water dripping from a metal conduit (electrical) juncture box attached to the ceiling. Water dripped throughout the meal service onto the tray line Starter cart. The cart contained items placed on residents' trays, including large-handled adaptive eating utensils, packaged crackers, paper-wrapped drinking straws, condiments and meal trays. At 5:05 p.m., the surveyor interviewed the Dietary Manager, Employee Identifier (EI) #6. EI #6 did not know how long the ceiling leakage had occurred, but confirmed a (repair) work order had not been placed. On 12/14/16 at 9:10 a.m., EI #6 explained she had spoken with the Maintenance Director (EI #7) and determined the metal box leaked only when it rained, due to a roof problem. At 9:25 a.m., the surveyor interviewed the Maintenance Director. EI #7 explained the metal box was a juncture which connected several electrical conduits. EI #7 explained water (from a heavy rain) had come through the roof and down into the pipe (conduit), possibly from a hole in the roof; it had not previously been a problem. The 2013 FOOD CODE, 3-305-11 Food Storage, specifies: (A) .Food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination . FROZEN FOOD STORAGE 3) On 12/13/16 at 4:55 p.m., individual portions of ice cream were observed, stored in the reach-in freezer. When pressure was applied, the cups of ice cream were found to be soft. The interior thermometer (in the freezer) registered 20 degrees F. The Dietary Manager (EI #6) was interviewed at 5:10 p.m. and found the internal temperature to be 28 degrees F. EI #6 explained the freezer was in the defrost cycle, which would last 30 minutes. EI #6 checked a container of ice cream and described it as real soft. The 2013 FOOD CODE mandates under 3-501.11, that Stored frozen foods shall be maintained frozen.

Based on record reviews and interview, the facility failed to ensure the Quarterly Minimum Data Set ((MDS) dated [DATE] was coded to reflect [MEDICAL TREATMENT] for Resident Identifier (RI) #18. This affected one of 24 sampled residents for whom the MDS was reviewed. Findings Include: RI #18 was readmitted to the facility 11/25/15 with a [DIAGNOSES REDACTED]. A review of RI #18's MDS with an Assessment Reference Date of 11/21/16 revealed RI #18 was dependant on [MEDICAL TREATMENT]. However, the MDS Section O (Treatment) was not coded for [MEDICAL TREATMENT]. On 12/15/16 at 9:00 a.m., an interview was conducted with Employee Identifier (EI) #3, the MDS Coordinator for the facility. EI #3 was asked to review the MDS dated [DATE] for RI #18. She was then asked if [MEDICAL TREATMENT] should be coded. EI #3 replied it should be. EI #3 was asked if [MEDICAL TREATMENT] was coded. She replied no. EI #3 was asked why [MEDICAL TREATMENT] was not coded; she replied it was an oversight. EI #3 was asked with [MEDICAL TREATMENT] not coded, would this assessment be considered accurate. EI #3 replied no. EI #3 was asked what the concern would be with an inaccurate assessment. EI #3 replied it could impede progress in the the resident's medical condition.

Based on observation, record reviews and interview, the facility failed to ensure Resident Identifier (RI) #9's Foley catheter bag was not on the floor on 12/14/16. This affected one of three residents sampled for the use of indwelling catheters. Findings Include: A review of a facility policy titled Urinary Catheter Care with an effective date of February 1, 2004 revealed: PROCESS: . I. General . i) Catheter tubing and drainage bags are kept off the floor to prevent contamination. RI #9 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 11/22/16 revealed the use of a catheter for RI #9. On 12/14/16 at 8:05 a.m., RI #9's Foley catheter drainage bag was observed directly on the floor, with a total of 600 milliliters of urine in the bag. On 12/14/16 at 8:30 a.m., an interview was conducted with Employee Identifier (EI) #5, a Licensed Practical Nurse. EI #5 observed the catheter bag on the floor when she entered the room to administer a.m. medications for RI #9. EI #5 was asked what the potential for harm would be with the catheter bag on the floor. EI #5 replied it was an infection control hazard. EI #5 was asked what was the facility's policy regarding catheter bag placement. EI #5 explained the bag was to be attached to the bed frame.

Based on record reviews and interviews, the facility failed to ensure the abuse policy was updated to include new federal regulations that went into affect 11/28/16. This had the potential to affect all 119 residents in the facility at the time during the survey. Findings include: A review of a facility policy titled: .ADMINISTRATIVE PROCEDURE, SUBJECT: Reports of Abuse, Neglect, Misappropriation of Resident Property, Suspicious Injury of Unknown Origin, Fires and Five-Day Investigations revised 07/2012 revealed: It is the policy of (name of the corporate company) that all alleged violations involving mistreatment, neglect or abuse including injuries of unknown origin, misappropriation of resident property and fires will be reported immediately (as soon as possible but not to exceed 24 hours) to the Facility Administrator and to other officials in accordance with State law inclusive of the State survey and certification agency. Alleged violations that would constitute violations of criminal statues, such murders, rapes, and assaults will be reported to the appropriate local law enforcement agency. The review of the policy revealed no mention of the updated federal requirements regarding the immediate reporting, no later than two hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury. On 12/15/16 at 9:52 a.m., an interview was conducted with Employee Identifier (EI) #1, the Director of Nursing of the facility. EI #1 was asked what was the policy on reporting abuse. EI #1 replied, (To report within) 24 hours of the notification of the problem and 5 days to complete the report. EI #1 was asked what should the facility report within 2 hours. EI #1 stated, That I am not aware of at this time. I do not have the information. It has not came down from corporate. The surveyor asked EI #1 if she was aware of the changes to the abuse policy which went into effect 11/28/16. EI #1 stated, I'm not. EI #1 was asked what did the facility's current policy mandate regarding, reporting to the state. EI #1 stated, That we report within 24 hours of (a) problem and 5 days to complete the report. EI #1 was asked what was the concern when a facility did not report abuse within 2 hours. EI #1 stated, If we do not report there could be penalties, issues or concerns of what the situation is. EI #1 was asked, what was the concern when the abuse policy was not updated to reflect changes. EI #1 responded, Misinformation could impact the process of making sure the problem is corrected timely. On 12/15/16 at 10:02 a.m., an interview was conducted with EI #4, the Administrator of the facility. EI #4 was asked what was the policy on reporting abuse. EI #4 stated, The abuse coordinator is notified and we have a certain amount of time online, and we have 5 days to complete our investigation. EI #4 was asked what allegations should the facility report to the state agency, within 2 hours. EI #4 replied, Any allegations of abuse, any of the 5 types of abuse. EI #4 was asked what should be reported within the 24 hour time span. EI #4 stated, Start (the) investigation immediately confirmed or not confirmed. The surveyor asked EI #4 what did the current facility's policy mandate regarding, reporting abuse to the state agency. EI #4 stated, 24 hours to report it. EI #4 was asked what the concern was when the facility did not report to the state within the required 2 hour time span. EI #4 stated, If abuse is confirmed you want to get the resident out of harms way. I would think that is why. The surveyor asked EI #4 what the concern was when the abuse policy was not updated to reflect changes that went into effect on 11/28/16. EI #4 responded, The possibility of the resident not removed from the situation timely but regardless of 2 hours or 24 hours we would remove them quickly. EI #4 was asked if he was aware of the changes in the federal regulations regarding abuse that came into effect 11/28/16. EI #4 stated, I am not. On 12/15/16 at 12:09 p.m., an interview was conducted with EI #1. EI #1 was asked when staff was inserviced on the new federal regulations regarding abuse that went into effect on 11/28/16. EI #1 stated, We haven't. We did not know. EI #1 was asked what were the staff taught on the new regulations on abuse. EI #1 responded, They were not taught anything because the policy has not been updated or revised for the new regulations as for the new information that has come out. EI #1 was asked why the staff members were not inserviced on the new changes in the abuse regulations. EI #1 said, We did not have the policy revised. The surveyor asked EI #1, what was the concern when staff members were not trained on the new federal guidelines implemented regarding abuse. EI #1 replied, Potential for harm, danger, misrepresentation, or misinformation.

Based on observation, record review and interview, the facility failed to ensure the Nursing Staff information was posted at the beginning of each shift. The schedule was observed posted for all shifts, but the worked hours were not filled in for any shift. Findings Include: On 12/13/16 at 12:30 p.m., the Nurse Staff Posting was observed with all shifts completed. The (actual) worked hours for all shifts were not completed. On 12/14/16 at 9:30 a.m., the Nurse Staff Posting was observed with all the shifts completed. The (actual) worked hours for all shifts were not completed. On 12/15/16 at 8:30 a.m., the Nurse Staff Posting was observed with all the shifts completed. The (actual) worked hours for all the shifts were not completed. On 12/15/16 at 9:10 a.m. an interview was conducted with Employee Identifier (EI) #2, Assistant Director of Nursing. EI #2 was asked when was the Nursing Staff Report posted each day; she replied it was posted everyday at 7:30 a.m., for the whole day. EI #2 was asked when should the Nurse Staff Posting be done. EI #2 replied she had been there since July of this year and that was the way she was taught to do it, however, it was to be done at the beginning of each shift. EI #2 was asked if all shifts were to be completed at the same time; she replied no. EI #2 was asked what the concern would be when the Nurse Staff Posting was not completed accurately. EI #2 replied it could be a lack in the public seeing actual hours worked.

Based on observations, record reviews and an interviews, the facility failed to serve the beverage as planned for the 12/13/16 supper and 12/14/16 lunch meals. The facility staff also failed to serve the pureed dessert as planned during the 12/14/16 lunch meal. This affected all 95 residents for whom meals were prepared and served at the time of the survey. Findings included: A review of the menu for the 12/13/16 supper meal included iced tea as one of the pre-planned beverages. However, tea was not prepared and served during an observation of this tray line. Instead, staff served assorted fruit drinks and other beverages. On 12/13/16 at 4:45 p.m., the surveyor asked the Dietary Manager, Employee Identifier (EI) #6, if they had iced tea. EI #6 explained they never served tea at night, only water (and other beverages). EI #6 said iced tea was served only at lunch due to the caffeine content. On 12/14/16 a (lunch) test tray was requested and sampled at 12:05 p.m., by both the surveyor and EI #6. The pre-planned menu specified iced tea at the meal. Rather than tea, EI #6 confirmed the residents were served pink lemonade and iced water instead. A pureed test tray was also requested and tasted at this time. The planned dessert was mandarin oranges. When tasted, the surveyor questioned the source of the pureed (orange) fruit. EI #6 confirmed it was peaches rather than the oranges, because they pureed better. On 12/15/16 at 9:00 a.m., the surveyor interviewed EI #6 about the menu changes. EI #6 explained the staff alternated the tea and punch every other day at lunch and no tea was served at night. EI #6 explained she thought it was an option on the menu to serve tea at night. She said water and milk were usually served at night (supper). The surveyor asked who was responsible for preparing pureed peaches instead of the mandarin oranges at the 12/14/16 lunch meal. EI #6 stated a staff member had made the decision to substitute peaches (served at the previous supper meal) because there were not enough oranges to serve to the residents on pureed diets.

Based on observations, interviews, and document reviews, the facility failed to ensure 1. Pans and utensils were not found wet nesting on 1 of 3 survey days. 2. Dietary staff did not cover cartons of liquids and frozen treats with ice on 1 of 3 survey days. This had the potential to affect all 105 residents receiving meals from the kitchen. Findings include: 1) A review of the 2013 FDA (Food and Drug Administration) Food Code revealed, . 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (B) Clean EQUIPMENT and UTENSILS shall be stored as specified under . of this section and shall be stored: (1) In a self-draining position that allows air drying; . A review of a facility policy with a revision date of 04/09 revealed, . ADMINISTRATIVE POLICY SUBJECT: Manual Warewashing POLICY: Food service pots and pans that cannot fit in the dishmachine are cleaned and sanitized in a three compartment sink. PROCEDURE: . 7. Air-dry all items. An observation was made on 10/28/15 at 9:15 AM. Two large shallow sheet pans were stacked flat together on top of a large steel bowl that was lying flat with water standing in the lip of the upside down bowl. An observation was made on 10/28/15 at 10:28 AM of 5 serving utensils that had been washed in the 3 compartment sink, sitting up/bottoms down with water pooling in each of them. An interview was conducted during the observation on 10/28/15 at 9:17 AM. EI (Employee Identifier) #1, the DM (Dietary Manager), was asked if wet items were supposed to be stacked. She answered, No ma'am. An interview was conducted with EI #1 on 10/29/15 at 11:08 AM. EI #1 was asked how should wet washed items be left to dry. She answered, Standing up so the water can drain down, not sitting in pooling water. EI #1 was asked why. She answered, Because wet nesting is a sanitation hazard. EI #1 was asked what was the facility's policy regarding wet washed items stacked and unable to air dry. She answered, We have a dish rack that is elevated above the counter where dishes can stand up and are unable to wet nest now. 2) A review of the 2013 FDA Food Code revealed, 3-303.12 Storage or Display of Food in Contact with Water or Ice. (A) PACKAGED FOOD may not be stored in direct contact with ice or water if the FOOD is subject to the entry of water because of the nature of its packaging, wrapping, or container or its positioning in the ice or water . A review of an undated facility document titled, . Procedure for Cooling Health Shakes and Milk for Tray Line Service, revealed, .PROCEDURE: 1. The Dietary Aide will gather enough milk and health shakes for each cart on tray line. 2. 30 min (minutes) before service milk and shakes will be chilled in the freezer to bring down to an optimal temperature for service. 3. Once tray line starts the diet aide will remove the milk place on a clean tray and temp all products to ensure the temperature is well below 40 (degrees symbol) F (Fahrenheit). An observation was made on 10/28/15 at 11:35 AM of a steel pan of cartons of milk, cartons of mighty shakes, foam containers with paper lids of sherbet and ice cream covered with ice. The temperature of the mighty shakes was 46 degrees F. EI #1 discarded the entire contents of the pan and retrieved a deeper plastic bin, puts fresh cartons of milk, mighty shakes, sherbet, and ice cream in it and passed it to EI #2, the Dietary Manager Trainer. EI #2 poured 2 large pitchers of ice over the cartons, fully covering the cartons. EI #1 placed the cartons covered with ice on the trayline to be served. An interview was conducted with EI #1 during the observation on 10/28/15 at 11:39 AM. EI #1 was asked where was the ice in the pan of milk cartons, shakes and ice cream. She answered, On the top. It should be submerged in ice. An interview was conducted with EI #3, a Dietary Aide, on 10/28/15 at 1:55 PM. EI #3 was asked how she lowered the temperature of the milk and shakes in the metal pan. She answered, I put it in the ice first; then the cartons, and then another layer of ice over it. EI #3 was asked if ice should be on top of cartons of milk and shakes. She answered, I'm so confused by what I've been told. It's supposed to keep it cold so it should be on the top and bottom. EI #3 was asked what she was trained regarding ice and cartons of fluids. She answered, A long time ago I was trained to put the ice on the bottom and on the top. EI #3 was asked why she would not want to put ice on top of cartons. She answered, Cause it would melt. If you had plastic to go between the ice and carton it would help. An interview was conducted with EI #1 on 10/29/15 at 11:08 AM. EI #1 was asked about her response regarding where the ice was in the pans of milk, shakes, and ice cream on 10/28/15. She answered, I don't remember exactly, but it was under it and on top. EI #1 was asked if cartons should be submerged in ice and she answered, No ma'am. EI #1 was asked why not. She answered, Because it's a sanitation issue, potential hazard. EI #1 was asked what was the facility's policy regarding ice on top of paper cartons and lids of ice cream. She answered, We no longer ice down the beverages, we cool them to a lower temperature 30 minutes prior to trayline. An interview was conducted with EI #2 on 10/29/15 at 11:31 AM. EI #2 was asked what she did when the new cartons of milk and shakes were brought to her. She answered, I put ice on them. EI #2 was asked what was the proper procedure regarding ice and cartons. She answered, We have a milk box and when we get ready, we have what we need. EI #2 was asked if ice should be poured on tops of cartons and served to residents. She answered, No ma'am. EI #2 was asked why not. She answered, It's a sanitation issue. EI #2 was asked what was the potential harm of ice on top of cartons of liquids or frozen treats being served to residents. She answered, It's a sanitation issue.

Based on an observation and document reviews, the facility failed to ensure the grease trap was not found with a heavy accumulation of crumbs, debris and greasy build-up on 1 of 3 survey days. This had the potential to affect all 117 residents residing in the facility. Findings include: A review of the 2013 FDA (Food and Drug Administration) Food Code revealed, 5-501.116 Cleaning Receptacles.(B) Soiled receptacles and waste handling units for REFUSE, recyclables, and returnables shall be cleaned at a frequency necessary to prevent them from developing a buildup of soil or becoming attractants for insects and rodents. A review of an undated facility document titled, . Cleaning Instruction for Grease Tank ., revealed, . POLICY: Equipment shall be maintained in a clean and sanitary condition. PROCEDURE: 1. After filtering/cleaning Deep Fat Fryer dirty grease should be disposed of in grease tank. 2. Make sure while disposing of grease that no excess grease get on the ground surrounding the tank or on the outside of the tank itself 3. After pouring grease in the grease tank make sure all debris is clear and cleaned from grating under the grease tank lid. 4. Using a steel bristle brush to scrap and scrub remaining debris off of grating until all debris is safely disposed of inside the tank. An observation was made on 10/27/15 at 12:29 PM of the grease trap outside of the facility. The grease trap was observed with a heavy accumulation of crumbs, debris, and grease covering the grate. Over 50% of the grate was completely covered over by the build up. An interview was conducted with EI (Employee Identifier) #1, the DM (Dietary Manager), on 10/27/15 at 12:29 PM, during the observation of the grease trap. EI #1 was asked what was the potential harm of the grease traps condition. She answered, Rodents, I was supposed to get rid of it before you came. A subsequent interview was conducted with EI #1 on 10/29/15 at 11:08 AM. EI #1 was asked how the grease trap was observed on 10/27/15. EI #1 answered, Debris, excessive, all over the grate. EI #1 was asked what was the potential harm of build up on the grate of the grease trap to the point that approximately 50% of it was closed by crumbs and greasy build-up. She answered, Rodents and other pests.

Based on record reviews and interviews, the facility failed to ensure the Physician's Medication orders included all required components for administration of medication. This affected RI (Resident Identifier) #s 9, 13, 14, 15, 16, 21, and 23, seven of twenty-five residents sampled. Findings included: A review of the facility Policy and Procedure titled, Medication Orders, with an effective date of February 1, 2004, revealed, PURPOSE: To establish uniform guidelines concerning the facility's rules for the ordering of medications. STANDARD: Medications should be administered only upon the signed order of a person lawfully authorized to prescribe. PROCESS: I. Elements of the Medication Order a) Medication orders should specify the following: · Date and resident's name · Name of medication · Strength of medication, where indicated · Dosage. · Time or frequency of administration · Route of administration · Quantity of duration (length of therapy. · [DIAGNOSES REDACTED]. · Any allergies [REDACTED]. 1) A review of RI #9's medical record revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Physician's Orders for RI #9, dated 10/01/2015 through 10/31/2015, revealed an order for [REDACTED]. 2) A review of RI #13's medical record revealed the resident was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #13's Physician's Orders dated 10/01/2015 through 10/31/2015, revealed an order for [REDACTED]. There was no route noted on either of these orders for the administration of these medications. 3) A review of RI #14's medical record revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Physician's Orders for RI #14, dated 10/01/2015 through 10/31/2015, revealed an order for [REDACTED]. There was no route for administration noted on these two orders. 4) A review of RI #15's medical record revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Physician's orders for RI #15, dated 10/1/2015 through 10/31/2015, revealed the following orders, [MEDICATION NAME] 3 ml (milliliter) inj. (injection) pen, Inject 50 units q (every) AM and [MEDICATION NAME] 3 ml inj. Pen, Inject 25 units q PM. These orders did not include the route for the administration of the medication. 5) A review of RI #16's medical record revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Physician's Orders for RI #16, dated 10/01/2015 through 10/31/2015, revealed an order for [REDACTED].= (equals) CALL MD (Medical Doctor); 180-230=4 U (units); 231-280=6 U; 281-220=8 U; 331-400=10 U; > (greater than) 400= CALL MD. There was no route of administration included in these medication orders. Also, for RI #16 there were the following orders identified without mention of how frequently the medication could be administered as a PRN medication. [MEDICATION NAME] 500 MG TABLET . GIVE 1 TABLET BY MOUTH AS NEEDED FOR PAIN *NOT TO EXCEED 3 GM (grams) [MEDICATION NAME]/24 HRS* and POLYETHYLENE [MEDICATION NAME] OTC (Over the counter) POWD (powder) . MIX 17 GRAM IN 8 OZ (ounces) LIQUID & (and) GIVE BY MOUTH AS NEEDED FOR CONSTIPATION. 6) A review of RI #21's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Physician's Orders for RI #21, dated 10/01/2015 through 10/31/2015, revealed an order for [REDACTED]. 7) A review of RI #23's medical record revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #23's Physician's Orders, dated 10/1/2015 through 10/31/2015, revealed the following orders TYLENOL 650 MG EVERY 8 HOURS X 72 HOURS, [MEDICATION NAME] R 100 UNITS/ML (milliliter) VIAL 150-200=4 U (units); 201-250=6 U; 251-300=8 U; 301-350=10 U; <70 OR >325=CALL MD. There was no route for administration of these medications included in the order. On 10/29/2015 at 1:50 PM, an interview was conducted with EI (Employee Identifier) #9, an LPN (Licensed Practical Nurse). EI #9 was asked what was necessary for a complete medication order. EI #9 stated the right patient's name, room number, MD name, frequency, the route, and the dosage. The surveyor then showed an MD order to the Nurse for her to state the name of the drug should be included in the order. EI #9 was asked what the acceptable Standard of Nursing practice was when administering medications which was ordered by a Physician. EI #9 stated the right drug, right time, right dose, right patient, and the right route. EI #9 was asked if all of the above components were not included on the MD order, what she would do. EI #9 stated she would contact the MD to clarify and do this before the medication was given. EI #9 was asked what the facility's Policy was regarding the administration of medication. EI #9 stated to make sure they had the five rights in place at all times. EI #9 was shown MEDICATION ORDERS FOR [REDACTED]. EI #9 was asked regarding the specific medication orders, as addressed above for each resident, what did she find missing from the orders. EI #9 stated for RI #9 the [MEDICATION NAME] and the Extra Strength Tylenol there was no route for administration included in the orders. EI #9 stated for RI #13's order for [MEDICATION NAME], there was no route included in the order. EI #9 stated for RI #14 there was no route on the Tylenol Extra Strength order. EI #9 stated for RI #15 there was no route included for the Sliding Scale order. EI #9 was asked if she would have given any of those medications. EI #9 stated no. When asked why not, EI #9 stated because they did not have a route. EI #9 was asked what was the potential harm or negative outcome of administering medications if the orders written or given by the Physician were incomplete. EI #9 stated it could be dangerous or life threatening to the resident. On 10/29/2015 at 2:03 PM, an interview was conducted with EI #8, an LPN. EI #8 was asked what was necessary for a complete Physician's order related to medication. EI #8 stated the resident's name, room number, MD needs to sign, date, and write the time of the order, the signature of the person taking the order, the name of the medication, frequency, dose, and what route the medication was to be given. EI #8 was asked what the acceptable Standard of Nursing practice was when administering medications as ordered by the Physician. EI #8 stated the right medication, dose, frequency, route, and the right resident. EI #8 was asked if all of these components were not present what would she do. EI #8 stated she would need to get a clarification order before giving the medication. EI #8 was shown MEDICATION ORDERS FOR [REDACTED]. EI #8 stated the route was missing from the Insulin order for RI #9. EI #8 was shown RI #13's orders for [MEDICATION NAME]. EI #8 stated the route was missing from RI #13's [MEDICATION NAME] order. EI #8 was shown RI #14's medication orders. EI #8 stated the route was missing from the Extra Strength Tylenol order. EI #8 was shown the orders for RI #15's Sliding Scale. EI #8 stated the route was missing from RI #15's Sliding Scale order and also the Extra Strength Tylenol order. EI #8 was asked would she have given any of these medications as written. EI #8 stated they should not and should get a clarification order. EI #8 was asked why. EI #8 stated because a key component to the order was missing which could cause an error. EI #8 was asked what was the potential harm or negative outcome of administering medications if the orders written or given by the Physician were incomplete. EI #8 stated something as simple as a reaction or as severe as death to the patient. On 10/29/2015 at 5:07 PM, an interview was conducted with EI #6, the DON (Director of Nursing). EI #6 was asked what was necessary for a complete Physician's order related to medications. EI #6 stated the 5 components, route, dose, drug, route, and time. EI #6 was asked what were the Patient's rights in regards to receiving medications. EI #6 stated time, dose, patient, drug, and route. EI #6 was asked what was the acceptable Standard of Nursing practice when administering medications which were ordered by a Physician. EI #6 stated to transcribe the order accurately and all five rights carried out. EI #6 was asked if all of these named components were not present in an order what would she do. EI #6 stated there had to be a clarification to ensure all the components were present. EI #6 was asked what was the facility's Policy and Procedure regarding administering medications. EI #6 stated to ensure MD orders were carried out as given. EI #6 was shown the MEDICATION ORDERS FOR [REDACTED]. EI #6 stated the route was missing from the [MEDICATION NAME] and the Sliding Scale Insulin orders. EI #6 was shown the orders for RI #13 and asked what was missing. EI #6 stated the route was missing from the [MEDICATION NAME] order. EI #6 was shown the MEDICATION ORDERS FOR [REDACTED]. EI #6 stated the route was missing from the Tylenol order. EI #6 was shown the MEDICATION ORDERS FOR [REDACTED]. EI #6 stated there was no route on the Tylenol order or the Sliding Scale Insulin order. EI #6 was asked what was the potential harm or negative outcome of administering medications if the orders written or given by the Physician were incomplete. EI #6 stated an act of [MEDICATION NAME] medicine, breaching Standards of Practice, for the Patient there could be a negative outcome.

Based on interviews and record reviews, the facility failed to ensure: 1. RI (Resident Identifier) #1's daughter was notified regarding the resident's admission to the hospital on [DATE]. 2. RI #5's sponsor was notified the resident refused all of their medications for three days. Findings Included: A review of the facility's policy and procedure titled: Change in Medical Condition of Residents, dated February 1, 2004 revealed: PURPOSE: To keep the physician, . and family members . informed of the residents medical condition so they may direct the plan of care as needed. STANDARD: Notification . should occur promptly, .when there is a change in condition. Change in condition is defined as: .A decision to transfer . 1. RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's Quarterly MDS (Minimum Data Set), dated [DATE], revealed. The resident had a BIMS (Brief Interview for Mental Status) score of 10 out of 15 possible points. This score indicated RI #1 was moderately impaired for cognitive performance and daily decision making. An interview was conducted with RI #1's daughter and sponsor on [DATE] at 11:00 AM. The surveyor asked her about her concern regarding the admission of RI #1 to the hospital on [DATE] from the [MEDICAL TREATMENT] center. She said her main complaint with the facility was she wanted to be involved in RI #1's care. RI #1's daughter said her understanding was RI #1 was admitted to the hospital around 2:00 PM on [DATE]. She received a call from the hospital around 9:00 PM. When the daughter arrived to the hospital, RI #1 was being transported to the Intensive Care Unit. The daughter stated she called the facility and was told the admission happened on day shift. She said the facility did not know what happened. RI #1's daughter went to the facility the next day and the facility was not aware RI #1 had died . During a second interview with RI #1's daughter on [DATE]/at 12:15 PM, she said when the call came from the hospital, she thought it was from the facility, but it was a nurse calling her from the hospital. The nurse at the hospital told her she needed to get to the hospital. A review of RI #1's medical record revealed: XXX[DATE] 1:14 PM .Category: Nursing Notes 1300 (1:00 PM) [MEDICAL TREATMENT] center called facility. spoke with RN Supervisor r/t (related to) [MEDICAL TREATMENT] will be sending Resident to ER (emergency room ) for eval (evaluation) r/t HR (heart rate) 125/ HR 140 after [MEDICAL TREATMENT]. A review of RI #1's medical record revealed: XXX[DATE] 5:54 PM .Category: Nursing Notes RECEIVED REPORT FROM (name of nurse)/RN (Registered Nurse), RESIDENT admitted TO (name of hospital and room #). DX: [MEDICAL CONDITION] FIBRILLATION WITH RVR (Rapid Ventricular Response) [MEDICAL CONDITION]. A review of the document from the [MEDICAL TREATMENT] center titled, Treatment Sheet For Facility: (name of the [MEDICAL TREATMENT] center) revealed: .NEW COMPLAINT OR OBSERVATIONS WHICH DEVELOPED DURING [MEDICAL TREATMENT]: .date/time: [DATE] 12:37 . pt., has an elevated h/r. pt. (patient), receives additional n.s.(Normal Saline) 250. Team leader, (name of nurse) DATE/TIME: [DATE] 13:18 (1:18 PM) . discharged TO: Hospital A review of the document from the [MEDICAL TREATMENT] center titled, Treatment Sheet For Facility: (name of the [MEDICAL TREATMENT] center) revealed: XXX[DATE] 1:13:00 PM Social Services signing off as pt's (patient's) daughter notified staff/CM (Case Manager) of pt's death last night at (name of hospital). She inquired re: notification process and will meet with NH (nursing home) staff as well . A review of RI #1's Physician order [REDACTED].#4 (Employee Identifier), RN/Unit Manager at the nursing facility. On [DATE] at 4:15 PM, an interview was conducted with the RN/Clinical Manager at the [MEDICAL TREATMENT] center where RI #1 received treatment. The surveyor asked the RN who notified the facility RI #1 was hospitalized on [DATE]. The RN named the nurse who sent the resident out to the hospital. She said the nurse notified the facility and the Nephrologist. The Clinical Manager said the nurse was not at work at that time. The surveyor asked what was the facility told. The Clinical Manager said, the patient was being transported to the hospital. An interview was conducted on [DATE] at 5:15 PM with EI #4, a Unit Manager of the facility. The surveyor asked EI #4 how did she find out RI #1 was admitted to the hospital on [DATE]. EI #4 stated, I was contacted by the [MEDICAL TREATMENT] center. The surveyor asked EI #4 what she did after she was contacted. EI #4 said she informed the charge nurse EI #5. EI #4 was asked what did the [MEDICAL TREATMENT] center tell her. EI #4 stated, I know they said .it is fuzzy .They said that they were sending her over. I'm sure that they said they notified the family. I am not sure about the reason she was sent to the hospital. I believe it was for an elevated temp. The surveyor asked EI #4 what was the concern when a family member and/or sponsor was not notified that a resident was transported to the hospital. EI #4 stated, They are not being kept in the loop of their care. It is their right to know. EI #4 and the surveyor looked at the nursing notes. The surveyor asked EI #4 if there was documentation regarding RI #1's daughter being notified of the resident's admission to the hospital on [DATE]. EI #4 stated, No ma'am. The surveyor asked EI #4 who was responsible for notifying the family of a resident's admission to the hospital. EI #4 stated, It is the responsibility of the facility to notify the family. In this case, due to being informed that they were notified by the [MEDICAL TREATMENT] center, this facility did not inform her. On [DATE] at 2:15 PM, EI #5, an LPN (Licensed Practical Nurse) for the facility, was interviewed. EI #5 was asked how did she know RI #1 was admitted to the hospital. EI #5 stated, her RN supervisor told her she received a call from the [MEDICAL TREATMENT] center. She was told RI #1 was being transported to the hospital from [MEDICAL TREATMENT]. The surveyor asked EI #5 what did she do when she was informed about the transfer. EI #5 stated after she completed her medication pass, she wrote a nurse's note related to the information she received from her supervisor. EI #5 stated EI #4 told her the [MEDICAL TREATMENT] center had contacted the family of RI #1, and let them know RI #1 was being transported. An interview was conducted by EI #6, the facility's DON (Director of Nursing), on [DATE] at 3:20 PM. The surveyor asked EI #6 if RI #1's daughter was contacted on [DATE], the day the resident was admitted to the hospital, from the [MEDICAL TREATMENT] unit. EI #6 stated there was a communication that the [MEDICAL TREATMENT] center contacted the family. The facility later found out that was not the case. EI #6 stated it was not until the next day or days later. She said RI #1's daughter came to the facility and spoke with the administrator of the facility, regarding notification. The surveyor and EI #6 reviewed RI #1's nursing notes dated [DATE]. The surveyor asked EI #6 if RI #1's daughter was notified of the admission to the hospital, from the [MEDICAL TREATMENT] center. EI #6 stated, According to this documentation, I can not say that she was. 2. RI #5 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #5's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 3 out of 15 possible points. This score indicated RI #5 was severely impaired for cognitive performance and daily decision making skills. A review of RI #5's medical record revealed, XXX[DATE] 2:17 PM .Category: Nursing Notes .Resident refused all meds (medications) and patch this shift No acute signs of distress noted . A review on RI #5's medical record revealed: XXX[DATE] 3:33 PM .Category: Nursing Notes .Resident refused all meds and patch No signs of acute distress noted . A review of RI #5's medical record revealed: XXX[DATE] 3:36 PM .Category: Nursing Notes .Resident refused all meds and patch No signs of acute distress noted . An interview was conducted with EI #5's son and sponsor on [DATE] at 3:27 PM. The surveyor asked him if he was notified regarding RI #5's refusal of medications on [DATE], and 5 of 2015. He stated, No, I was not. Several unsuccessful attempts were made to contact the Nurse failing to notify the sponsor of the residents refusal of medications on 3 occasions.

Based on observation, interviews, and record reviews, the facility failed to ensure an LPN (Licensed Practical Nurse) did not administer a medication that was placed on hold by the Physician. This affected RI (Resident Identifier) #15, one of six residents observed for medication pass. Findings include: A review of Potter Perry Fundamentals of Nursing 7th Edition revealed, . Chapter 35 . (page 704) Nurse's Role The administration of medications to clients requires knowledge and a set of skills that are unique to the nurse. Medication Errors A medication error can cause or lead to inappropriate medication use or client harm. Medication errors include inaccurate prescribing, administration of the wrong medication, giving the medication using the wrong route or time interval, and administering extra doses or failing to administer a medication. A review of RI #15's medical record revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #15's Quarterly MDS (Minimum Data Set), with and ARD (Assessment Reference Date) of 8/4/15, revealed the resident had a BIMS (Brief Interview for Mental Status) score of 3 out of a possible 15. This score indicated the resident was severely impaired of cognitive skills for daily decision making. A review of RI #15's medical record revealed a physician's orders [REDACTED]. 1) Hold [MEDICATION NAME] & (and) [MEDICATION NAME] until alert 2) Then have RN (Registered Nurse) call me for future Rx (prescription) A review of RI #15's MAR (Medication Administration Record) revealed, . [MEDICATION NAME] ([MEDICATION NAME]) 20 mg (Milligrams) 1 cap (capsule) daily . Hold (handwritten on the 0900 line at the 19th, 20th, and 21st) . An observation was made on 10/28/15 at 9:20 AM, of EI (Employee Identifier) #7, an LPN, administering medications to RI #15. During this observation, EI #7 administered [MEDICATION NAME] 20 MG to RI #15. An interview was conducted with EI #7, on 10/29/15 at 3:40 PM. EI #7 was asked who was responsible for transcribing medication orders from the order sheet to the MAR. EI #7 answered the LPN or RN (Registered Nurse). EI #7 was asked what was the process when a medication was ordered to be on hold. EI #7 answered to get a date, write hold on the order for how long it was going to be held, wrap the medicine with a piece of paper and rubber band-put how long it was going to be held. EI #7 stated if no date, just put hold or clarify with supervisor or call MD (Medical Doctor). EI #7 indicated clarification was usually done by the supervisor. EI #7 was asked when a medication was put on hold, how does she ensure the medication was not given. EI #7 answered the same as the process. EI #7 was asked if she had administered medications for RI #15 on 10/28/15 at 9:00 AM. She answered yes. EI #7 was asked if she administered the [MEDICATION NAME]. She said yes. EI #7 was asked if there was a reason the [MEDICATION NAME] was given when it was supposed to be on hold. She replied she did not see a hold. The surveyor showed the Nurse the MAR and the Nurse stated she took the hold with a line underneath it to mean it was on hold for 3 days. The line was under the word hold over the days of the 19th, 20th, and 21st. EI #7 was asked what would be the potential negative effect of administering a medication that was on hold. EI #7 replied there could be a lot of potentials, could be harmful or could have adverse reaction to it. An interview was conducted with EI #6, the DON (Director of Nursing) on 10/29/15 at 4:40 PM. EI #6 was asked who was responsible for transcribing medication orders from the order sheet to the MAR. She answered Charge Nurses/Unit Managers. EI #6 was asked what was the process when a medication was ordered to be on hold. She answered the order should be explicit; MD should be called for clarification. EI #6 was asked when a medication was placed on hold, how did they ensure the medication was not given. She answered have to look at the medication to check adverse reactions. EI #6 stated she always had to look at the medication knowing what the potential ramifications could be.

Based on observations, interviews, and document reviews, the facility failed to ensure: 1) Dietary support staff was aware of how to wash /sanitize eating utensils for the residents, and, 2) Dietary support staff was aware of how to calibrate a thermometer, and the acceptable temperature for the calibrated thermometer This was observed one of three survey days, and had the potential to affect 89 residents served meals from the kitchen. Findings include: 1) A review to the facility's policy dated 09/04, and titled, "MACHINE WAREWASHING," revealed, "POLICY: All dishes and utensils will be washed and sanitized after each use. PROCEDURE: ... d. Load dishes into racks so that all surfaces are exposed to the wash and rinse. ... Silverware should be placed with eating surfaces up in cylinders or arranged in a single layer in a rack. ..." During an observation of dishwashing on 1/22/2015 at 8:41 AM, EI (Employee Identifier) #3, a Dietary Aide, was observed to sort and place silverware in cylinders with the eating ends upright, and sent the silverware to be run through the dish machine. When the utensils were removed from the dish machine, EI #3, using her gloved hands and touching the eating ends, flipped the utensils with the eating ends down this time into the cylinder. The utensils (in cylinders) were placed on a flat rack and were re-run through the dish machine. On 1/22/2015 at 8:50 AM, EI #3 removed the utensils and flipped them with the eating ends up, again while using her gloved hands and touching the eating ends. EI #3 placed the utensils on a top shelf as completed. EI #3 was informed by EI #4, the Dietary Manager, at this time, "You are doing that wrong. You've been inserviced (EI #3); You've been inserviced." EI #4 went on to say, "They need to be flipped down so when they come on the receiving end they (staff) won't touch the mouthpieces." During an interview on 1/23/2015 at 1:25 PM, EI #3 was asked if it was appropriate to invert flatware using gloved hands and touching the eating ends. EI #3 stated, "No you (are) supposed to use the cups and go cup to cup." EI #4 was asked why the flatware was not flipped using 2 cylinders during the observation on 1/22/2015. EI #3 replied, "I had so many in all of them. I had utensils in all the cups. I used my hand, and I wasn't supposed to." During an interview on 1/23/2015 at 2:58 PM, EI #4, the Dietary Manager, was asked if it was appropriate to invert flatware using gloved hands and touching the eating ends. EI #4 stated, "You're supposed to do cylinder to cylinder. No touching of hand." 2) A review of the "Food Code U.S. (United States) Public Health Service," 2013 Edition, revealed, "... 4-302.12 Food Temperature Measuring Devices. (A) FOOD TEMPERATURE MEASURING DEVICES shall be provided ... for use in ensuring attainment and maintenance of FOOD temperatures as specified under Chapter 3. ..." During the lunch tray line observation on 1/22/2015 at 11:02 AM, EI #5, a Cook, was observed to calibrate thermometers prior to testing the food items. EI #5 was asked what the temperature of thermometer should be when calibrated. EI #5 replied, "Should be, I think 40 degrees. It's been so long." EI #5 calibrated one thermometer using ice and water in a cup, and it read 190 degrees F (Fahrenheit). EI #5 informed the surveyor, "Nothing's wrong. This one's working." The surveyor asked EI #5 to try another thermometer, and it read 50 degrees F during calibration. The surveyor asked EI #5 if these thermometers with the readings of 190 and 50 degrees F were ok to use, and EI #5 replied, "Yes ma'am." EI #5 proceeded to test food items, and the surveyor requested that EI #5 get the Dietary Manager, EI #4. At 11:10 AM on 1/22/2015, EI #4 informed the surveyor and EI #5 the temperature for the calibrated thermometers should be 32 degrees F. EI #4 provided another thermometer for EI #5 to use. During calibration, this thermometer read, 35.6 degrees F. EI #5 stated this thermometer with a reading of 35.6 degrees was, "OK to use." EI #4 instructed EI #5, "Temp should be 32 degrees while in ice." On 1/23/2015 at 2:00 PM, an interview was conducted with EI #5. EI #5 was asked when thermometers should be calibrated, and what the temperature should be during calibration. EI #5 replied, "Before every meal. We should make sure thermometer is calibrated to 32 degrees (F). ..." An interview was conducted with EI #4, on 1/23/2015 at 2:58 PM. EI #4 was asked when thermometers should be calibrated. EI #4 stated, "Each time before you use them." EI #4 was asked how thermometers were calibrated, and she replied, "Submerged in ice water." EI #4 was asked what the temperatures should be during calibration, and she replied, "Temps should be 32 degrees (F)."

Based on observations, interviews, and document reviews, the facility failed to ensure: 1) Dietary staff was not observed with earrings uncovered while working in the kitchen on 2 of 3 survey days. 2) Dietary staff was not observed with hair partially uncovered by the hair net while working in the kitchen on 1 of 3 survey days. 3) A pie was not observed unlabeled in the cooler, and an opened gallon of mustard was not observed in the cooler without a lid. This was observed on 1 of 3 survey days, 4) Ground Beef was not observed thawing in the cooler above cookies, juice and other snack items. This was observed on 1 of 3 survey days. 5) Food cover domes were re-washed after being removed from the dish machine upright, with standing water in them, the water dumped and the domes placed with other clean domes to air dry. This was observed on 1 of 3 survey days. 6) Dietary staff removed gloves and washed hands between tasks while working in the kitchen. This was observed on 1 of 3 survey days. These deficient practices had the potential to affect 89 residents served meals from the kitchen. Findings include: 1) A review of the facility's policy revised, 04/2009, and titled, "ADMINISTRATIVE POLICY," revealed, "POLICY: Food service employees shall follow sanitary practices to prevent the spread of food borne illness. PROCEDURE: ... 2. Proper Work Attire a. Food service employees will dress and maintain their hair and skin to prevent the transfer of pathogens to food and food equipment. ... c. The food service employee observes the following dress standards: ... ii. Wears a clean hat or other hair restraint (e.g. {for example} hair nets, hat ...) in the food production area. The restraint must cover all hair and prevent the hair from contacting exposed food. ..." During a tour of the kitchen on 1/21/2015 at 8:22 AM, EI (Employee Identifier) #2, a Dietary Floater, was observed working in the kitchen with the sides and a back portion of her hair uncovered by the hair net. An interview was conducted with EI #4, the Dietary Manager, on 1/23/2015 at 2:58 PM. EI #4 was asked what the facility's policy was on hair coverings in the kitchen. EI #4 stated, "All hair is to be covered." EI #4 was asked why all hair should be covered while working in the kitchen. EI #4 replied, "Because it can fall in the food." On 1/23/2015 at 4:35 PM, an interview was conducted with EI #2. EI #2 was asked what the facility's policy was on hair coverings in the kitchen. EI #2 replied, "We're supposed to have hair nets on and cover all the hair." EI #2 was asked if all the hair should be covered and she replied, "Yes, because you don't want it to get in food." EI #2 was asked what the potential harm was of all hair not being covered while working in the kitchen. EI #2 stated, "It could fall in the food." 2) A review of the facility's policy, revised 04/2009, and titled, "ADMINISTRATIVE POLICY," revealed, "POLICY: Food service employees shall follow sanitary practices to prevent the spread of food borne illness. ... 2. Proper Work Attire ... ii. Does not wear jewelry except for a plain ring band. Rings, bracelets, watches, earrings, necklaces, and facial jewelry are not allowed. ..." During a tour of the kitchen on 1/21/2015 at 8:22 AM, EI #1, a Dietary Aide, was observed working in the kitchen with diamond earrings uncovered in both ears. The earrings were approximately ? (one half) cm (Centimeters) in size. On 1/22/2015 at 8:14 AM, EI #1 was again observed working in the kitchen with silver, diamond earrings in both ears uncovered. The earrings were approximately ? cm in size. An interview was conducted with EI #1 on 1/23/2015 at 2:32 PM. EI #1 was asked what the facility's policy was on jewelry in the kitchen. EI #1 stated, "We can't wear any jewelry." EI #1 was asked what the potential harm was of earrings uncovered in the kitchen. EI #2 replied, "They could fall into foods or liquids." During the interview on 1/23/2015 at 2:58 PM, EI #4, the Dietary Manager, was asked what the facility's policy was on jewelry in the kitchen. EI #4 replied, "No jewelry unless it's a flat wedding band." E#4 was asked what the potential harm was of earrings uncovered in the kitchen. EI #4 stated, "They could fall in the food." 3) A review of the facility's policy, revised 04/2009 and titled, "ADMINISTRATIVE POLICY," revealed, "POLICY: The facility ensures the quality and safety of refrigerated foods through accepted storage practices. PROCEDURE: ... 4. Food taken out of original containers is put in a clean sanitized container with a tight fitting lid. No food is left uncovered. 5. All non-hazardous, opened foods are labeled with name of food; date stored and use-by date. 6. All hazardous foods are labeled with name of food and date to be discarded or the date stored. ..." During the tour of the kitchen on 1/21/2015 at 8:22 A M, a plate containing an unlabeled food item was observed in the produce cooler. EI #3, a Dietary Aide, informed the surveyor it was, "Pie they had yesterday." In the milk cooler, a gallon of mustard was observed without a lid, with plastic partially covering the top. During the interview conducted on 1/23/2015 at 1:25 PM, EI #3 was asked what the facility's policy was on labeling and dating food items for storage in the refrigerator. EI #3 stated, "You label with a date and a use by date." EI #3 was asked why the pie was observed unlabeled and undated in the refrigerator on 1/21/2015 during the tour. EI #3 replied, "I don't know. I was off the day before." EI #3 was asked what the potential harm was of undated food items being left in the refrigerator. EI #3 stated, "... You won't know when it was cooked or made up if it's no label on there." EI #3 was asked what the potential harm was of the opened mustard observed without a lid, during the tour on 1/21/2015. EI #3 stated, "You can't leave it open because you can get sick. It's supposed to be covered at all times. It's a lid and I don't know why the plastic was on there." During the interview on 1/23/2015 at 2:58 PM, EI #4, the Dietary Manager, was asked what the facility's policy was on labeling and dating food items for storage in the refrigerator. EI #4 replied, "Any leftovers should have a date and use-by date on them." EI #4 was asked why the pie was observed unlabeled and undated in the refrigerator on 1/21/2015 during the tour. EI #4 stated, "Someone failed to label and date before putting it in the refrigerator." EI #4 was asked what the potential harm was of undated food items being left in the refrigerator. EI #4 stated, "You don't know how long it's been in there. Could be out of date." EI #4 was asked what the potential harm was for an open mustard observed without a lid. EI #4 replied, "Something else in the refrigerator could have spilled over in it." EI #4 was asked why the lid was not on the mustard during the tour. EI #4 stated, "I guess someone had misplaced it and thought they could put film over it to secure it." 4) A review of the facility's policy dated 09/04, and titled, "FOOD SERVICE OPERATIONAL STANDARDS FOR PURCHASING, COOKING AND STORAGE," revealed, "POLICY: The facility stores, prepares, distributes and serves food under sanitary conditions to prevent the spread of food borne illness and to reduce those practices that result in food contamination and compromised food safety. ...PROCEDURE: ... 5. Thawing. A. The preferred method is to thaw under refrigeration at a temperature of 40 degrees F(Fahrenheit) or below. i. Store raw foods on the lowest shelf to prevent them from dripping or splashing onto other foods. ..." During the tour of the kitchen on 1/21/2015 at 8:22 AM, four rolls of Ground Beef was observed thawing in the Snack and Juice Cooler on the top shelf, above cookies, juice and other snacks. During the interview on 1/23/2015 at 4:35 PM, EI #2, a Dietary Floater, was asked what the facility's policy was on storing raw meats in the cooler. EI #2 stated, " ... We're supposed to put it in the cooler on the bottom, in a pan (a clear pan. No steam table pan is allowed in the refrigerator)." EI #2 was asked if it was appropriate for Ground Beef to be stored over cookies and snacks. She replied, "No ma'am." EI #2 was asked why, and she stated, "Because that juice could get on cooked foods or snacks." During the interview on 1/23/2015 at 2:58 PM, EI #4, the Dietary Manager, was asked what the facility's policy was on storing raw meats in the cooler. EI #4 stated, "They should be on the very bottom." EI #4 was asked if it was appropriate for Ground Beef to be stored over cookies and snacks, and she replied, "No ma'am." EI #4 was asked why not. EI #4 stated, "Because it could drip into the cookies or whatever, and cause cross-contamination." 5) A review to the facility's policy dated 09/04, and titled, "MACHINE WAREWASHING," revealed, "POLICY: All dishes and utensils will be washed and sanitized after each use. PROCEDURE: ... d. Load dishes into racks so that all surfaces are exposed to the wash and rinse. ... 4. ...c. If bowls and cups flip, place a empty dishmachine rack on top of loaded dishes. D. All dishes, glassware and silverware are air dried. No towels are to be used. During an observation of dishwashing on 1/22/2015 at 8:41 AM, EI #3 was observed to remove 3 plate cover domes from the dish machine which contained standing water. The domes had flipped upright in the dish machine. EI #3 poured the water out, and the domes were placed in the drying area with other domes. EI #3 did not have the domes re-washed. At 8:58 AM on 1/22/2015, EI #3 removed 2 more plate cover domes that had flipped upright in the dish machine and the cover domes contained standing water. EI #3 poured the water out of these domes and placed them with other domes in the storage area. EI #3 did not have these domes re-washed. During the interview conducted on 1/23/2015 at 1:25 PM, EI #3 was asked what should be done if plate cover domes flipped upright in the dish machine and contained standing water when they were removed from the dish machine. EI #3 stated, "Pour the water out and put them on the rack to air dry." EI #3 was asked why the dome covers containing water from the dish machine were not re-washed during the observation on 1/22/15. EI #3 replied, "I didn't see nothing on them. I should have gave them back to the other lady and she should have used a different rack for them." EI #3 was asked what the potential harm was of not re-washing the plate cover domes. EI #3 stated, "They should have been re-washed because water and food could have been in them. Water was sitting in them." During the interview on 1/23/2015 at 2:58 PM, EI #4, the Dietary Manager, was asked what should be done if plate cover domes had flipped upright in the dish machine and contained standing water when they were removed from the dish machine. EI #4 replied, "They should be sent back through the dish machine." EI #4 was asked what the potential harm was of not re-washing the plate cover domes. EI #4 stated, "They could still be dirty." 6) A review of the 2013 Edition of the Food Code U. S. (United States) Public Health Services Manual revealed, "... 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands ...(F) During FOOD PREPARATION, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; (H) Before donning gloves to initiate a task that involves working with FOOD; and ..." During the lunch tray line observation on 1/22/2015 at 11:40 AM, EI #5, a Cook, was observed working the tray line plating food items. EI #6, an Evening Cook, was observed working with raw Ground Beef. EI #5 asked for EI #6's assistance while she left the tray line. EI #6 removed the gloves she was wearing and applied new gloves. EI #6 did not wash her hands prior to donning gloves and serving cooked foods on the tray line. At 11:47 AM on 1/22/2015, EI #5 resumed her duties of plating foods on the tray line. EI #6 returned to working with the raw Ground Beef. EI #6 did not wash her hands or change gloves. EI #6 was observed to apply mittens over her gloves and placed the Ground Beef in the oven. EI #6 then removed the mittens and disposed of paper from a work counter. EI #6 removed her gloves at this time and obtained cans of Baked Beans from the Supply Room. EI #6 donned gloves, but did not wash her hands, and opened the cans of beans. EI #6, using her gloved fingers, pushed the can lids down into the beans to remove the lids. After pouring beans into a pan, EI #6 used these same gloves, and with her gloved hands to remove a white substance from the beans. On 1/22/2015 at 12:00 PM, EI #6 removed a trash bag and placed it outside the kitchen door. While still wearing the same gloves, EI #6 resumed covering the beans, wiped off the counter and placed the beans in the oven. While still wearing the same gloves, EI #6 removed green grapes from stems and placed them in a strainer and rinsed them. EI #6 did not wash her hands or change her gloves. On 1/23/2015 at 2:40 PM, an interview was conducted with EI #6. EI #6 was asked what should be done when moving from one task or duty to another, while working in the kitchen. EI #6 replied, "Change your gloves and wash your hands." EI #6 was asked if it was appropriate to apply mittens over gloves, then not remove the gloves. EI #6 stated, "No ma'am, because it's contamination from the gloves to the mittens." EI #6 was asked if it was appropriate to place gloved fingers in liquids from the beans to remove the can lids. EI #6 replied, "No ma'am, because the glove touches the food." EI #6 was asked if it was appropriate to place gloved fingers in beans when the gloves had been used to perform multi tasks. EI #6 stated, "No. You're supposed to have utensils to do it." EI #6 was asked if it was appropriate to not remove gloves and wash hands after taking trash from a trash can. EI #6 replied, "No. Because I've touched the trash can. I should have pulled the gloves off and washed my hands." EI #6 was asked what the potential harm was with all of the above things, and she stated, "Contamination." During the interview on 1/23/2015 at 2:58 PM, EI #4, the Dietary Manager, was asked what should be done when moving from one task or duty to another, while working in the kitchen. EI #4 stated, "Gloves taken off, hands washed and re-glove." EI #4 was asked if it was appropriate to apply mittens over gloves, then not remove the gloves. EI #4 stated, "No ma'am. That's infection control. You don't know who's hands have been in the mittens and if they were clean or not. EI #4 was asked if it was appropriate to place gloved fingers in liquids from the beans to remove the can lids. EI #4 replied, "No ma'am. Infection control issue." EI #4 was asked if it was appropriate to place gloved fingers in beans when the gloves had been used to perform multi tasks. EI #4 responded, "No ma'am, because of infection control." EI #4 was asked if it was appropriate to not remove gloves and wash hands after taking trash from a trash can. EI #4 stated, "No ma'am, because of infection control / cross contamination." EI #4 was asked what the potential harm was with all of the above things, and she stated, "Could make someone sick."

Based on observations, interviews, and record reviews, the facility failed to ensure the ice machine on Unit 3 was not observed with a black substance inside on the plastic area where ice was dispensed from. This was observed on 3 of 3 survey days. In addition, the facility failed to ensure the ice machine on Unit 2 was not observed with a brown substance inside the ice machine where ice was dispensed. This was observed on 1 of 3 survey days. These observations were made on 2 of 3 ice machines in the facility. Findings include: A review of the facility's undated policy titled, "PRODUCTION, STORAGE & (and) DIPENSING OF ICE," revealed, "POLICY: Ice is prepared, stored and dispensed from clean, sanitized equipment without contamination from hands or dispensing equipment. PROCEDURE: ... 3. Ice is stored in the storage bin or other sanitized equipment ... 7. Ice storage areas are washed and sanitized when soiled or at least monthly. ..." A review of the facility's Policy and Procedure titled, "SUBJECT: Ice Maker and Dispenser - Cleaning Instructions," with a Modified date of 11/2008 revealed, "POLICY STATEMENT Equipment shall be maintained in a clean and sanitary condition. PROCEDURE: ... Ice Making System The ice making system can be cleaned in place without diassembling the water system. The cleaning process should be performed at least every 6 months or more often if local water conditions dictate. ..." On 1/21/15 at 9:25 AM, the surveyor observed a dark substance on the plastic rim area at the top of the outer dispenser area of the ice machine on Unit 3. On 1/22/15 at 8:05 AM, the surveyor observed the ice machine on Unit 3. The substance was still present in the ice machine. The substance was dark in color and was observed on the plastic area on the rim of the dispenser. On 1/23/15 at 9:15 AM, the surveyor observed the ice machine on Unit 3. The ice machine continued to have the dark substance observed on the top rim area with drops of water dripping from under the plastic rim which contained the dark substance. The water was dripping onto the ice and the ice was observed to be touching the plastic rim which contained the dark substance. On 1/23/15 at 9:17 AM, the surveyor observed a brown discolored substance on the white plastic in the ice machine on Unit 2 where the ice was dispensed from. The machine was observed to be full of ice with the ice almost touching the area where the brown discolored substance was noted. On 1/23/15 at 2:12 PM, the surveyor toured the units with EI (Employee Identifier) #12, Maintenance Supervisor. EI #12 was asked what the brown discoloration was in the ice machine on Unit 2. EI #12 stated, "That's age, we cleaned it 2 to 3 weeks ago." The brown substance was removed when scrapped with a fingernail. EI #12 was asked what the grayish, black substance was in the ice machine on Unit 3. EI #12 stated, "I don't know, when we clean them we scrub them down and a lot of that stuff don't come off." On 1/23/15 at 2:20 PM, an interview was conducted with EI #12. EI #12 was asked who was responsible for assuring the ice machines on the units were clean and free of dark substances. EI #12 stated, "I am." EI #12 was asked how often the ice machines in the facility, on the units, were monitored. EI #12 stated, "We monitor them weekly. They are supposed to be cleaned every 6 months. We try to clean them every 2 to 3 months." EI #12 was asked how often ice machines were cleaned on the different units. EI #12 stated, "Every 2 to 3 months we try to clean them. By the maintenance schedule they are checked once a month." EI #12 was asked when were the ice machines on Unit 3 and Unit 2 last cleaned. EI #12 stated, "Unit 2, it was 2 to 3 weeks ago because a resident's cup fell in there by accident. They had me take all (of) the ice out and sanitize it. Unit 3, I'd have to check on it." EI #12 was asked what the dark substance was observed in the ice machine on Unit 3. EI #12 stated, "I don't know, some is age discoloration, but some could be scrapped off." EI #12 was asked what the dark substance was in the ice machine on Unit 2. EI #12 stated, "Same situation." EI #12 was asked what the potential harm of the dark substances in the ice machine. EI #12 stated, "I wouldn't say a harm because it could be hard water and I don't think that would be a harm. It did not look like mold to me."