Every finding on record at Westminster Woods on Julington Creek

Based on kitchen food service observations, staff interviews, facility record review, and a review of the facility's policies and procedures, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect more than a few residents who consumed foods from the facility. The facility failed to 1) Ensure food items were properly labeled and dated, 2) Maintain cleanliness of essential kitchen equipment, and 3) Maintain proper sanitation in the cooking area. Food handling and sanitation are important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure.The findings include:A tour of the kitchen was conducted on 8/3/26 from 10:20 AM to 11:00 AM. During the tour, an observation was made of one crate filled with four containers of Sun Orchard Lime Juice; the manufacturer best before date was 8/2/26 and one of four containers was open inside the walk-in refrigerator with no open date or label.A follow-up tour of the kitchen was conducted on 8/5/26 from 11:00 AM to 11:50 AM. Observations during the tour revealed grease buildup, debris, and grime on the top and bottom inside and door areas of the convection oven located next to the fryer; the oven tray and exterior surface located directly below the flat-top oven was not maintained, and the top and bottom inside and door areas of the convection oven located next to the steamer were in the same condition. Food residue and debris were stuck on and around the mixer and a buildup of grease and/or food residue was observed on or around the meat slicer slide rod. During the same tour, observations of the Rapid Recovery pantry freezer revealed two containers of Yoplait original yogurt with a best before date of 7/26/26. The pantry refrigerator revealed four Very Vanilla Soy Silk supplements dated 11/23/25, one container of [NAME]-Dazs strawberry ice cream and one container of Talenti Gelato chocolate fudge brownie with no labels or date marking. One 1-liter bottle of Alkaline water was observed with no label or date marking; one open 2-ounce container of sauce was observed with no label or date marking; one bottle of Olive Garden Italian dressing with a manufacturer's best by date of 7/30/26 was observed with no label or date marking; one Heinz turkey gravy was observed with no label or date marking; and one carton of whole milk with an expiration date of 1/30/26 were observed. All items were discarded.A follow-up visit to the kitchen on 8/6/2026 at 8:15 AM revealed heavy grease accumulation on the exterior side panels between the fryer and oven, heavy grease accumulation on the exterior surface located directly below and on the side of the flat-top oven, observations of black biological growth on and around the ceiling air vents above the hallway entry and prep station next to the fire system box, and above the hallway entry air vent adjacent to the chemical storage room, above the standing mixer, and above the fruit and salad prep station area. The same observations were made in the walk-in refrigerator. One crate contained four containers of Sun Orchard Lime Juice (best before 8/2/2026), and one of those four containers was open with no open date. A buildup of grease and food residue was observed on or around the meat slicer slide rod.On 8/6/2026 at 8:45 AM, Dietary Aide (DA) A reported that the Chef and the Dining Director were responsible for stocking the dry storeroom, refrigerator, and freezer. The facility's policy around date marking food was to add the open date to all food opened. If staff were not sure when the food was opened, the food item should be discarded. Chefs and Dish Washers were responsible for cleaning kitchen and food service equipment; the Dining Director would assist when needed. DA A was unsure of when the kitchen equipment was last deep cleaned.On 8/6/2026 at 9:00 AM, DA B stated the Chef was responsible for stocking the dry storeroom, refrigerator and freezer. If items were found missing, staff were to document what was needed on the dry erase board. Dietary Aides are responsible for checking pantry rooms and the supervisor checks behind the DAs. The facility policy around date marking food was to discard expired items and once food was opened, it was labeled with an open date and expiration date. When a food item was opened, used, and placed back in the refrigerator or freezer, the item was to be properly sealed, labeled with an open and expiration date, and discarded after three days. When DA B was asked who was responsible for cleaning kitchen and food service equipment. DA B replied, the cooks; cooks clean mixers also. DA A was unsure when the kitchen equipment was last deep cleaned.On 8/6/2026 at 9:00 AM, [NAME] C stated the Chef was responsible for stocking the dry storeroom, refrigerator and freezer. When the Chef was asked what happened when a food item was opened, used, and placed back in the refrigerator or freezer., [NAME] C stated if there was no label, the item should be discarded. Food items should be wrapped, labeled, dated, and discarded after 2-3 days. Night staff were responsible for cleaning kitchen and food service equipment such as stoves, ovens and oven trays. The Chef deep cleaned the fryer every Friday and changed the oil every three to four days.On 8/6/2026 at 9:34 AM, Dining Director D confirmed that the Cooks, Sous Chef and Dining Director are all responsible for stocking the dry storeroom, refrigerator and freezer. Diet Techs/DAs check expiration dates and the Certified Dietary Manager (CDM) follows up behind them. They have been educated on how to use First-In-First-Out (FIFO). As food items come in, staff label them with dates. When a food item is opened, used, and placed back in the refrigerator or freezer, an open and expiration date is added to the food item, and the item is to be discarded after seven days of the open date. Cooks and utility staff are responsible for cleaning kitchen and food service equipment. Mixers are cleaned by the staff who use it; usually the Cook. Deep cleaning of kitchen equipment is completed once weekly. When asked who was responsible for cleaning air vents in the kitchen, Dining Director D replied, The Director cleaned them in the past.A review of the facility's policy and procedure titled Sanitation Inspection (Date reviewed/revised: 3/20/2026), revealed:Policy: It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations.Policy Explanation and Compliance Guidelines: 1. All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects.3. The sanitation program will provide for inspections to be conducted of the food service areas. 4. Sanitation inspections will be conducted in the following manner: a. Daily: Food service staff shall inspect refrigerators/coolers, freezers, storage area temperatures, and dishwasher temperatures daily. b. Weekly: The dietary manager shall inspect all food service areas weekly to ensure the areas are clean and comply with sanitation and food service regulations. 5. Inspections will be conducted but not limited to the following areas: .a. Dry storage .c. Refrigerator .f. Main production area g. Food preparation area h. General dietary observations. Policy and procedure entitled Date Marking for Food Safety, date reviewed/revised: 3/2026 revealed Policy: The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food. Policy Explanation and Compliance Guidelines: .2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded.4. The marking system shall consist of a label, the day/date of opening. 5. The discard day or date may not exceed the manufacturer's use-by date, or four days, whichever is earliest. The date of opening or preparation counts as day 1. 6. The Chef, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly. The Dietary Manager, or designee, shall spot check refrigerators weekly for compliance, and document accordingly. Corrective action shall be taken as needed. (Copy obtained)A review of the Dining Services Performance Improvement Plan (Q2 April 2026), revealed:Areas of Concern: 1. Proper food labeling and dating.Strategies/actions/follow ups status: Designee to inspect food items weekly for proper date and label. Ensure food labels are legible and accurate. Education to be provided to dining staff on concerns identified during inspection. Responsible party: CDM or designee, Dining Service Director, Assistant Dining Service Director, Executive Chef.Completion Target date: April-ongoing. Areas of Concerns: 2. Inspect and discard expired food items. Strategies/actions/follow ups status: 1. Designee to check food storage areas 3x a week for refrigerators and freezers for expired items. 2. Expired items to be discarded when identified. 3. Nursing team to inspect items before serving and report concerns to CDM/Dining Service Director. 4. Ongoing education on FIFO with dining team. 5. Education provided to dining team on food storage guidelines. Responsible party: CDM or designee, Weekend Supervisor. Completion Target date: April-ongoing.A review of the facility dining audits dated 5/21/2026, 6/19/2026 and 7/7/2026, including food labeling, dating, expired item checks, and cleaning and sanitation audits failed to show proof or documentation of execution for the corrective actions outlined in the performance improvement plan.Reference: FDA Food Code 2022, https://www.fda.gov/media/184685/download?attachment reviewed 8/13/2026, Chapter 4. Equipment, Utensils, and Linens. 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. 4-6 Cleaning of Equipment and Utensils, 4-601 Objective, Equipment Food-Contact Surfaces and Utensils. (A) Equipment Food Contact Surfaces and Utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Annex 5 - C. Intervention Strategies for Achieving Long-term Compliance. 4. Establish First-In-First-Out (FIFO) Procedures. Page 555. Product rotation is important for both quality and safety reasons. First-In-First Out (FIFO) means that the first batch of products prepared and placed in storage should be the first one sold or used. Date marking foods as required by the Food Code facilitates the use of a FIFO procedure in refrigerated, ready-to-eat, TCS foods. The FIFO concept limits the potential for pathogen growth, encourages product rotation, and documents compliance with time/temperature requirements.

Based on observations, interviews, and record review, the facility failed to provide adequate supervision and assistive devices, failed to develop and implement a process for maintenance of bed rails, and failed to implement interventions to prevent falls for one (Resident #1) of three residents reviewed for falls. The findings include: The medical record for Resident #1 was reviewed. She was admitted to the facility on [DATE]. Her primary medical diagnosis was nondisplaced fracture of lateral end of right clavicle. Secondary diagnoses included [CONDITION(S)], diabetes, and anxiety. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS score of 13, indicating intact cognition. Resident #1 required extensive assistance of one staff member for bed mobility and extensive to total assistance with other activities of daily living. A nursing progress note dated 7/29/2021 at 11:06 AM indicated Resident #1 was observed lying on the floor on her right side. Prior to the fall, the Certified Nursing Assistant (CNA) was providing care in the room. The resident was assessed for injuries and was noted to have a small skin tear to the right arm and a hematoma to the right eye. The resident was assisted back to bed using the Hoyer lift by three staff members. The resident then began complaining of back pain. Routine pain medication was administered. The Advanced Registered Nurse Practitioner (ARNP) was notified, and an order was obtained to transfer the resident to the ER for evaluation. On 9/15/2021 at 11:40 AM, an interview was conducted with Resident #1. She was awake and lying in her bed. Bruising was observed to the right side of her face from temple to jaw. The resident's left arm and hand were contracted. The resident was having difficulty managing the television remote with her right hand. Two floor mats were observed stacked against the wall and there were no floor mats on either side of the resident's bed. When asked about the fall on 7/29/2021, Resident #1 explained that the CNA was assisting her with incontinence care and bathing. She stated the CNA rolled her onto her right side and the resident was holding the right bed rail. The resident explained that the CNA left the room for a couple of minutes and left the resident positioned on her right side holding onto the rail. While the CNA was out of the room, the resident stated the bed rail swung open and she fell out of the bed onto the floor. Resident #1 explained that the CNA then came back into the room, noticed the resident was on the floor, and called for the nurse. She was then transferred to the hospital and was diagnosed with a fracture. The resident stated she didn't know that the bed rail opened and explained that staff informed her the bed rail wasn't locked. During the interview, Resident #1 was asked about her pain. She rated her pain an 8 on a 0-10 verbal scale radiating through her right shoulder and explained that she had received her pain medication about thirty minutes prior to the interview. She explained that the pain was ongoing and that it was related to the fracture. Resident #1 stated she had been seen by a pain management physician and received cortisone injections in her neck but that they did not alleviate the pain. She also explained that she had attended a follow up appointment at Jacksonville Orthopedic Institute on 9/14/2021. The doctor saw her for five minutes and released her without any information. Resident #1 stated that she now had difficulty feeding herself and that she was reluctant to ask for help because the staff are so busy. Review of the resident's comprehensive care plans revealed a focus area for falls. The care plan included an intervention dated 7/30/2021 for fall mats to both sides of the resident's bed. (Photographic evidence obtained) On 9/15/2021 at approximately 12:50 PM, an interview was conducted with Employee A, CNA. She confirmed that she was caring for Resident #1 at the time of the fall. She stated that she was assisting the resident with bathing and incontinence care at the time of the fall. While bathing Resident #1, the resident requested pain medication. Employee A informed the resident that it wasn't time for her medication but the resident insisted. The CNA acknowledged that she left the room to notify the nurse and to gather some more supplies that she had forgotten to bring into the room. Upon returning to the room the CNA observed the resident on the floor. She explained that the bed rail was open and stated, I thought it was closed when I left. The resident was complaining of pain in her back and her arm. The CNA notified the nurse, and the resident was assisted back into bed. During the interview, the CNA confirmed that she left the resident in a right, side-lying position and that the resident was holding the bail rail when she left the room. The bed was at a working height. When asked about the floor mats that were stacked against the far side of the room during an earlier observation, the CNA confirmed that they should've been placed on both sides of the resident's bed any time Resident #1 was in bed. On 9/15/2021 at 1:15 PM, an interview was conducted with the Director of Nursing (DON). She explained that she was familiar with the Resident #1's fall on 7/29/2021. The DON explained that the resident had been left unattended in a side-lying position and that the bed was at a working height when the CNA left the room. She explained that the facility's expectation is that residents be positioned in the center of the bed prior to leaving them unattended. Additionally, the facility expectations were to ensure items needed for personal care are to be retrieved prior to providing care and ensure that bed rails are properly latched before positioning dependent residents on their side. The DON explained that she was not aware of any facility processes for ensuring bed rails were audited and maintained. Review of a five-day report submitted by the facility revealed a corrective action that indicated an audit of resident beds was conducted and that all the bed enablers were found to be functioning properly. Review of a facility audit dated 7/30/2021 identified concerns with a total of 28 of the facility's bed rails. Two of the concerns indicated the bed rails were not latching. (Photographic evidence obtained) On 9/15/2021 at 3:15 PM, an interview was conducted with the Maintenance Director. He explained that after the incident, an audit of the bed rails was conducted and that several other bed rails were found to be loose or not closing correctly. The maintenance department was unable to duplicate the issue on Resident #1's bed, but the locking mechanism was replaced. He explained that prior to Resident #1 sustaining the fall on 7/29/2021, the facility did not have a process in place to monitor or maintain its bed rails. The Maintenance Director was asked for the facility's policy for the bed rails. He explained that the facility did not have one. A review of the facility's fall prevention policy dated 7/2020 directed staff to implement universal environmental interventions that decrease the risk of resident falls to include ensuring assistive devices were in good repair. (Photographic evidence obtained)

Based on observations and staff interviews, the facility failed to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality with regard to the manner in which residents were referred to and their dining experience. The findings include: An observation was conducted on 02/15/2016 at 11:45 AM of the main dining room with residents eating lunch, and in the activity room with 6 residents who were not eating. An observation was conducted on 02/15/2016 at 12:12 PM of Employee D, Certified Nursing Assistant (CNA), placing clothing protectors on multiple residents and not asking before she pulled it over their heads. An interview was conducted on 02/15/2016 at 11:50 AM with Employee A, Licensed Practical Nurse, (LPN), who was questioned if the facility has two different dining times. The employee replied, Yes, there is a second one that is for the feeders. An interview was conducted on 02/15/2016 at 12:16 PM with Employee B, (CNA), who was sitting with four residents in the activity room. The employee was asked when the residents would be served lunch. The employee replied, After the independent diners, these are the feeders, and we have to feed one and when they have room, they will come get another feeder. An interview was conducted on 02/15/2016 at 12:19 PM with Employee A, who was questioned why Resident #39 was sitting at a table with two other residents who were already eating lunch and she wasn't served. She replied, She's a feeder. When the staff is done with somebody else, they will feed her. An interview was conducted on 02/15/2016 at 12:30 PM with Employee C, CNA, who was questioned when the four residents in the activity room would have their lunch and she replied, They are feeders. When they feed a resident, they will take another feeder in. An observation was conducted on 02/15/2016 at 12:34 PM of Employee D, CNA, standing over Resident #39 with a spoon in her hand and placing it to the resident's mouth. Employee D then walked over and obtained a clothing protector and placed it on the resident without asking. An interview was conducted on 02/15/2016 at 12:37 PM with Employee E, CNA, who was asked when the residents will be served their meals. He replied, We do the feeders one by one and when we're done with one, we go get another feeder. During a meal observation in the Health Center dining room on 2/17/16 between 11:39 AM-12:55 PM, it was observed that there was minimal interaction between residents and staff. Staff were observed asking residents being assisted with dining to open their mouths or swallow in preparation for another bite of food. This was observed with two dependent residents. Cloth napkins were being used, along with paper place mats and clear colored plastic cups. Dependent residents were being removed from dining tables by staff, and other residents needing assistance were brought to the vacated spots without staff wiping off the tables following the prior resident. Independent residents who were still eating when new residents were brought to the table were ignored, with no introductions made of the new meal companions, and no asking of new residents coming in to dine their preferences in seating or dining companions. An interview was conducted on 2/17/16 at 11:39 AM with Employee I, CNA, who was asked about the locations of residents during dining. CNA I stated some were in their bedrooms, and feeders were in the activity room. An interview was conducted on 02/17/2016 at 5:24 PM with Employee F, CNA, who was asked how the dining works for dinner. She stated, We have about 20-30 residents that eat in here. We try to bring in as many feeders as we can, but we can't get all the feeders in here, so we bring the feeders in one by one as we take the other feeders out. An observation of the dining room set up on 2/18/16 at 12:00 PM revealed that there was a difference in dining arrangements between floors. The Restorative Dining Room on the first floor had tablecloths, wine glasses, and cloth napkins. The Health Center on the second floor had paper place mats, cloth napkins, and clear colored plastic glasses. On 2/19/16 at 8:42 AM in the Health Center dining room, 20 residents were observed eating breakfast at tables set with paper mats and plastic, colored glasses. An interview was conducted on 2/19/16 at 9:08 AM with Employee K, Director of Dining, who was asked about the discrepancy in dining room settings. He responded that it has always been done this way, referring to the use of paper and plastic in the Health Center 2nd floor area. He stated he was not sure how appropriate it would be to use glasses upstairs with Health Center residents. An interview with the Assistant Director of Nursing on 02/19/2016 at 11:40 AM confirmed staff are to refer to residents who require assistance as diners with assistance. She stated, We have trained them and they have been told they are to be referred as diners with assistance. An interview with the Director of Nursing on 02/19/2016 at 12:18 PM confirmed the staff are to refer the residents who require assistance with dining as 'diners who require assistance'.

Based on observations, staff interviews, and record review, the facility failed to ensure that a resident with a limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 3 sampled residents for range of motion, out of a sample of 19 residents (Resident #39). The findings include: Record review for Resident #39 revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) Quarterly, dated 11/23/15, revealed Resident #39 requires extensive to total assist with Activities of Daily Living (ADL). Resident #39 was coded as having limitation in range of motion in both upper extremities. The care plan was reviewed which noted ADL dependence, requires extensive to total assist with ADLs and mobility related to history of joint pain with movement, [MEDICAL CONDITION] joint disease, legally blind, dementia, and hand contractures. One intervention was for hands which included to carefully wash hands to prevent odor and dry thoroughly, but gently. There were no interventions for splints or range of motion documented. Resident #39 was observed in a reclining geri chair at 10:10 AM on 2/17/16 in the activity room. Both hands were contracted into fists and pressing into her palms. Both hands were contracted into fists. There were no splints or devices for contractured hands. An interview was conducted with Employee D, CNA, on 2/17/16 at 2:30 PM. Employee D stated, Resident #39 does not have any splint to her hands. Record review revealed a progress note in the medical record, dated 1/11/16, confirming a contracture to the right hand. An X-Ray on 10/16/14 revealed suggestive dislocation of 3rd, 4th, and 5th metacarpals with 90% angluation. The note was signed by a physician. An observation of Resident #39's contracted hands was conducted with Employee D, at 1:45 PM on 2/18/16. The resident's hands were opened to observe palms. Two fingernails on the right hand left red indentations in the palm. The left hand was observed with red indentations where fingers were pressed into the palm. The nails were approximately 1/4 inch long. Employee D stated she tried to cut the resident's fingernails on Sunday, but was not able to because the resident was moving her arms and jerking her hands away. Employee D was afraid she would cut the resident's skin. An interview was conducted with the MDS Coordinator at 9:30 AM on 2/19/16 which revealed the contractures of the hands are progressively worse. A record review for Resident #39 revealed carrots were used as splints i the hands which were discontinued on 1/5/15. There were no physician orders or interventions implemented in the medical record since 1/5/15 for the contractures of the hands. The resident was not receiving restorative or therapy services. An interview with the DON at 10:55 AM on 2/19/16 confirmed Resident #39 does not have splints at this time. The DON was advised of an observation of indentations in resident's palms.

Based on record reviews and staff interviews, the facility failed to ensure a physician ordered dose reduction for an anti-psychotic medication was followed, and instead increased the medication for 1 of 5 residents reviewed in a sample of 19 residents (Resident #10). The findings include: Record review for Resident #10 revealed she was admitted to the facility on [DATE]. She was on antipsychotic, antianxiety and antidepressant medications for depression, anxiety, [MEDICAL CONDITION], and dementia. The resident was care planned for quality of life being compromised related to episodes of delusions, anxiety, agitation, and irritability. Review of the physician orders [REDACTED]. The order was for a decrease from [MEDICATION NAME] 0.25 mg in the AM and [MEDICATION NAME] 0.50 mg at the hour of sleep, to [MEDICATION NAME] 0.25 mg twice a day. Review of the February 2016 Medication Administration Record [REDACTED]. Rather than a total daily dose of 0.50 mg ordered, the resident was receiving 1.0 mg daily. In an interview with the Director of Nursing (DON) on 2/18/2016 at 9:57 AM, she was asked why the [MEDICATION NAME] 0.5 mg was continued. She stated there was a medication error that was not discovered until surveyor inquiry into the medication orders.

Based on observations, staff interviews, and record reviews, the facility failed to ensure 1 of 3 residents reviewed for an appropriate diet received food in a form to meet their needs. (Resident #10) The findings include: Record review for Resident #10 revealed she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Further record review found physician orders [REDACTED]. Resident remains alert and oriented. Verbal and able to make needs known. Feeds self with tray set up. Tolerates current dietary orders with tolerance. Food intake varies. Resident continues to receive a diet of mechanically soft with extra gravy provided. During a dining observation on 2/17/16 at 12:20 PM, Resident #10 was observed coughing after eating cherry pie. She was approached by Employee J who stated, It might be best you leave that pie alone. A dining observation was conducted in the facility on 2/17/2016 at 5:25 PM. At 6:00 PM, Resident #10 was served mashed potatoes, fried okra, and meatloaf. The meatloaf was chopped. Gravy was poured over the meatloaf and mashed potatoes. The resident was able to eat her food on her own with a spoon. Resident #10 asked for dessert at 6:18 PM. A Certified Nursing Assistant (Employee O) was observed asking the Director of Dining Services (Employee K) what dessert was mechanical soft. He stated it was the cherry pie. Employee O served the resident cherry pie. The crust on the pie was a very dark brown, slightly charred color. Resident #10 was observed eating the cherry pie. She left the majority of the bottom crust and the entire end crust on her plate. After she had left the dining room, a fork was used to test the crust. It was found to be hard and when cut, it snapped. Employee O was asked during the dining observation on 2/17/2016 at 5:25 PM how staff were aware of the diet each resident was on. She provided a book with the names of each resident and their diet. Review of the book revealed Resident #10 was on a mechanical soft diet. The Dietary Manager was asked on 2/17/2016 at 6:00 PM for the menu for the current week. Review of the mechanical soft menu for the 2/17/2016 supper found the dessert was cherry pie. Record review for Resident #10 revealed a nurses note, dated 2/17/2016, with the following information, Resident had a choking episode at lunch. She was able to clear her throat herself. She stated I do this every now and then. An interview was held with the Registered Dietitian (Employee L) on 2/18/2016 at 11:00 AM. She stated she only goes into the kitchen once a month at the request of the facility, and she does not monitor the food served. She confirmed that cherry pie with a hard crust would not be suitable for a resident on a mechanically soft diet. An interview was held with Employee M, the Certified Dietary Manager (CDM) Clinical Nutritional Supervisor on 2/18/16 at 11:20 AM. She stated she does clinical assessments and ensuring the correct consistency of food would involve her. She does not check the food downstairs before it comes up. She observes in the dining room several times a week, and was not in the dining room to see the cherry pie. She stated it should not have been served if the crust was hard. During further interview with Employee M on 2/18/2016 at 2:46 PM, she stated she thought more about what happens in the evening and on the weekends when she was not at the facility. She stated the cooks would be responsible to ensure that mechanically altered food was prepared correctly. She stated that she has worked at the facility 2 years and had done training in scoop sizes for staff, but not in consistency of food. She stated it would be the experienced cook who would work with the new cook to ensure they know how to prepare mechanically altered food. Record review of the dietary book used by the facility found a mechanically soft diet should not have chewy or tough/hard desserts.

Based on record review and staff interview, the facility failed to obtain physician ordered laboratory services for 1 of 5 residents reviewed for unnecessary medication in a sample of 19 residents (Resident #38). The findings include: Record review for Resident #38 revealed he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the 2/2016 physician orders [REDACTED]. Further record review for Resident #38 found no evidence of the lab work after 6/23/2015. During an interview with the Director of Nursing on 2/18/2016 at 12:04 PM, the findings were confirmed. She confirmed the physician orders [REDACTED]. She stated the nurse who took the order wrote every 3 months in the computer system, but did not set up an alert to the staff, so the labs were not done in September or December.

Based on room observations and interviews with staff, the facility failed to ensure a functional resident call system in 11 out of 30 resident rooms observed (rooms #1, 2, 5, 6, 7, 10, 15, and 32). This affected a total of 17 call bells in the facility. The findings include: Observations of resident rooms were conducted on 12/2/14 between 10:30 am and 1:30 pm. The following call bells were found to be non-operational: Room #1's bedside call bell (private room); room #2's (private room) bedside call bell; room #5's bathroom call bell; room #6's (private room) bedside and bathroom call bells; room #7's (private room) bedroom and bathroom call bells; room #10 A and B beds' call bells; room #15's (private) bedside and bathroom call bells; and room #32 B's bedside call bell. An interview was conducted on 12/2/14 at 1:16 pm with the resident in room #7. She confirmed that she utilized her call bell, and demonstrated doing so. She also confirmed she used her bathroom daily. An interview was conducted at 1:25 pm on 12/2/14 with the resident in room #32 B. She confirmed that she was capable of using the call light, but it was not always operational. An interview was conducted with Employee D, Registered Nurse, at 2:10 pm on 12/2/14. She confirmed that the residents in rooms #1, 2, 5, 6, 7, 10 A and B, 15, and 32B were capable of using their call bells when needed. An interview was conducted with the Maintenance Manager on 12/2/14 at 1:40 pm. He stated he checked call bells weekly for functional status. He was not aware that 17 call lights were non-operational at the time of survey. He said that a maintenance request should have been completed to alert him to the problem. He acknowledged that a majority of the resident rooms were affected. He said the nurse call light system was "pretty important," and that bathroom lights were on an emergency system, and should flash. .

Based on record review, staff interview and facility policy review, the facility failed to meet professional standards of quality related to the administration of physician ordered treatment for [REDACTED].#15). The findings include: Professional Standard of Care is defined in Chapter 766.102 as "the prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which in light of all relevant surrounding circumstances is recognized as acceptable and appropriate by reasonably prudent similar health care providers." According to the Florida Nurse Practice Act, Chapter 464.003: (3)(a) "Practice of professional nursing" means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: 1. The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. 2. The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. (e) "Nursing diagnosis" means the observation and evaluation of physical or mental conditions, behaviors, signs and symptoms of illness, and reactions to treatment and the determination as to whether such conditions, signs, symptoms, and reactions represent a deviation from normal. (f) "Nursing treatment" means the establishment and implementation of a nursing regimen for the care and comfort of individuals, the prevention of illness, and the education, restoration, and maintenance of health. Record review for Resident #15 revealed a physician's order dated 7/21/2014 for [MEDICATION NAME] 0.1 milligram (mg) by mouth every 4 hours as needed for hypertension or high blood pressure) , give the medication for a systolic blood pressure of 165 or greater and for a diastolic blood pressure greater than 90. Record review of Resident #15's October and November, 2014 Medication Administration Records (MAR) revealed that on October 7, 2014 the resident's blood pressure was recorded as 183/94, but the prescribed [MEDICATION NAME] 0.1mg was not administered as ordered for the resident's elevated blood presuure. On October 11, 2014 the resident's blood pressure was 177/98, but the prescribed [MEDICATION NAME] was not administered. On October 16, 2014 the resident's blood pressure was 168/80. On October 30, 2014 the resident's blood pressure was 163/92. On November 5, 2014 the resident's blood pressure was 168/92, and on November 7, 2014 the resident's blood pressure was 163/92. The prescribed [MEDICATION NAME] 0.1 mg was not administered to the resident for any of these elevated blood pressures. Resident #15 received a dose of [MEDICATION NAME] 0.1mg for an elevated blood pressure only once in October, 2014, on October 10, 2014 at 9:40 pm. On 12/5/2014 at 9:26 AM in an interview with Employee E, Registered Nurse, she stated upon review of Resident #15's electronic medical record, including documented vital signs, that the nurses were not following Resident #15's orders for treatment of [REDACTED]. On 12/4/2014 at 2:00 PM in an interview with Employee A, Registered Nurse, she stated the medication [MEDICATION NAME] should have been given to Resident #15 on all of the dates listed above when the resident's blood pressure was elevated, and the physician should have been notified. Review of the facility policy entitled "Monitoring Blood Pressures" stated "If the systolic blood pressure is equal or greater than 160, if the diastolic blood pressure is greater than 100, administer [MEDICATION NAME] 01.mg as ordered, recheck the blood pressure in 3 hours, and if it is still elevated, notify the physician". .

Based on record review and staff interview the facility failed to ensure a qualified person followed the care plans for high blood pressure and nutrition for 1 resident (Resident #15), out of 5 residents reviewed for unnecessary medications, and out of 3 residents reviewed for nutritional status, out of 33 sampled residents. The findings include: 1) Record review for Resident #15 revealed a plan of care for hypertension (high blood pressure) with a stated goal that the blood pressure will remain comfortable through review, with interventions to monitor the blood pressure, administer medications as ordered, and contact the physician with any concerns. Record review for Resident #15 revealed a physician's orders [REDACTED]. Record review of Resident #15's October and November, 2014 Medication Administration Records (MAR) revealed that on October 7, 2014 the resident's blood pressure was recorded as 183/94, but the prescribed [MEDICATION NAME] 0.1mg was not administered as ordered for the resident's elevated blood presuure. On October 11, 2014 the resident's blood pressure was 177/98, but the prescribed [MEDICATION NAME] was not administered. On October 16, 2014 the resident's blood pressure was 168/80. On October 30, 2014 the resident's blood pressure was 163/92. On November 5, 2014 the resident's blood pressure was 168/92, and on November 7, 2014 the resident's blood pressure was 163/92. The prescribed [MEDICATION NAME] 0.1 mg was not administered to the resident for any of these elevated blood pressures. Resident #15 received a dose of [MEDICATION NAME] 0.1mg for an elevated blood pressure only once in October, 2014, on October 10, 2014 at 9:40 pm. On 12/4/2014 at 2:00 PM in an interview with Employee A, Registered Nurse, she stated that the medication [MEDICATION NAME] should have been given to Resident #15 on all of the dates listed above when the resident's blood pressure was elevated. On 12/5/2014 at 9:26 AM in an interview with Employee E, Registered Nurse, she stated upon review of Resident #15's electronic medical record, including documented vital signs, that the nurses were not following the resident's plan of care for hypertension to administer prescribed medications and report to the physician. 2) Review of Resident #15's Minimum Data Set ((MDS) dated [DATE] revealed that she had a significant weight loss over 180 days. Review of Resident #15's nutritional plan of care dated 10/29/2014 revealed an approach to provide fortified food at every meal and a Magic Cup at lunch. The recorded weights for Resident #15 were as follows: 219.6 pounds (lbs) on 5/9/14 207.5 lbs on 6/9/14 (12.1 lb loss, 5% over 1 month=significant weight loss) 197.0 lbs on 7/9/14 (10.5 lb loss) 201.4 lbs on 8/6/14 (4.4 lb gain, 12% over 3 months=severe weight loss) 195.6 lbs on 9/10/14 (5.8 lb loss) 189.2 lbs on 10/10/14 (6.4 lb loss) 185.4 lbs on 11/20/14 (3.8 lb loss, 19% over 6 months=severe weight loss) 181.6 lbs on 12/5/14 (3.8 lb loss) Record review of the Dietitian's note for Resident #15, dated 10/29/2014, stated that the resident was triggered for a significant weight loss over 6 months. the resident was noted to have an intake of 50% average, and there were meals she did not accept. The recommendations were to add a Magic Cup daily at lunch, in addition to other interventions. Record review of the dietary notes dated 11/21/2014 for significant weight loss stated that Resident #15's meal intake as 25-100%. Fortified foods were ordered and she had a 15.57% weight loss in 6 months. The note revealed Magic Cup at lunch, and Mighty Shakes three times daily were in place. Review of Resident #15's dietary order dated 10/30/2014 revealed Magic Cup at lunch daily. physician's orders [REDACTED]. On 12/3/2014 at 12:38 PM an observation was made of Resident #15 sitting at the dining room table. She said the food tastes good. She had steak, green beans, broccoli and steak fries. She only ate about 40% of her meal. She then asked for dessert and was given chocolate cake. She did not have a Magic Cup during her lunch meal. On 12/4/2014 at 11:00 AM in an interview with Employee A, as she reviewed Resident #15's Medication Administration Records (MAR), she stated she did not see the Magic Cup on the resident's November or December, 2014 MAR. Employee A stated there was nowhere else in the record that the Magic Cup would be documented if given. She stated the order was not placed in the computer correctly. The order was showing, but not allowing the nurses to document it. She said she would correct it. On 12/4/2014 at 11:40 AM, in an interview with Employee B, Certified Nursing Assistant, she stated that she was Resident #15's caregiver. She said Resident #15 did not get any nutritional supplements she was aware of. She said Resident #15 definitely does not receive Magic Cups at breakfast or lunch. On 12/5/2014 at 10: 25 AM in an interview with Employee F, Registered Dietician, she stated that Resident #15 had continued to lose weight since the Dietician made the recommendation for Magic Cup, and that could be because the resident had not received the Magic Cups. The Dieticien said she was not aware that Resident #15 was not getting the Magic Cup as ordered. She said Resident #15 did not refuse the supplement. She said Resident #15 may have gained some weight back if she had received the Magic Cup. She said she cannot say for sure because she doesn't know if she would have liked it. The Dietitian stated that nursing wrote a note on 11/10/2014 that Resident #15 desired the weight loss, "but that was after the significant weight loss," and not planned. She said if a resident desired weight loss she would discuss it with the resident, and she would not allow too much weight loss too soon as occurred in this case. She stated if she had known about Resident #15's desire to lose weight, she still would have recommended the supplements due to too much weight loss in a short period. On 12/5/2014 at 9:26 AM in an interview with Employee E , Registered Nurse, she reviewed Resident #15's MAR and confirmed that the nurses were not giving the Magic Cup according to the plan of care. .

Based on record review, staff interview and facility policy review, the facility failed to provide physician ordered care and treatment for [REDACTED].#15), out of 5 residents reviewed for unnecessary medications, out of 33 sampled residents. The findings include: Record review for Resident #15 revealed a physician's order dated 7/21/2014 for [MEDICATION NAME] 0.1 milligram (mg) by mouth every 4 hours as needed for hypertension (high blood pressure), give the medication for a systolic blood pressure of 165 or greater and for a diastolic blood pressure greater than 90. Record review of Resident #15's October and November, 2014 Medication Administration Records (MAR) revealed that on October 7, 2014 the resident's blood pressure was recorded as 183/94, but the prescribed [MEDICATION NAME] 0.1mg was not administered as ordered for the resident's elevated blood presuure. On October 11, 2014 the resident's blood pressure was 177/98, but the prescribed [MEDICATION NAME] was not administered. On October 16, 2014 the resident's blood pressure was 168/80. On October 30, 2014 the resident's blood pressure was 163/92. On November 5, 2014 the resident's blood pressure was 168/92, and on November 7, 2014 the resident's blood pressure was 163/92. The prescribed [MEDICATION NAME] 0.1 mg was not administered to the resident for any of these elevated blood pressures. Resident #15 received a dose of [MEDICATION NAME] 0.1mg for an elevated blood pressure only once in October, 2014, on October 10, 2014 at 9:40 pm. On 12/5/2014 at 9:26 AM in an interview with Employee E, Registered Nurse, she stated upon review of Resident #15's electronic medical record, including documented vital signs, that the nurses were not providing physician ordered treatment of [REDACTED].#15. On 12/4/2014 at 2:00 PM in an interview with Employee A, Registered Nurse, she stated that the medication [MEDICATION NAME] should have been administered to Resident #15 on all of the dates listed above when the resident's blood pressure was elevated, and the physician should have been notified. Review of the facility policy entitled "Monitoring Blood Pressures" stated "If the systolic blood pressure is equal or greater than 160, if the diastolic blood pressure is greater than 100, administer [MEDICATION NAME] 01.mg as ordered, recheck the blood pressure in 3 hours, and if it is still elevated, notify the physician." .

Based on record review and staff interview, the facility failed to maintain the nutritional status for 1 resident with severe weight loss (Resident #15), out of 3 residents reviewed for nutrition concerns, out of 33 sampled residents. The findings include: Record review for Resident #15 revealed [DIAGNOSES REDACTED]. Review of Resident #15's nutrition note dated 10/29/2014 revealed that the resident triggered for a significant weight loss over 6 months. The current recorded weight was 189.2 lbs. The resident had a food intake of 50% average and there were meals she did not accept. No diuretics were in place now or in the past. The resident had a history of [REDACTED]. In October, 2014 podiatry noted 4+ [MEDICAL CONDITION]. Medications included [MEDICATION NAME] (for depression, increased on 10/16/14), [MEDICATION NAME] and [MEDICATION NAME] (high blood pressure medications), Calcium-Vitamin D, [MEDICATION NAME], and [MEDICATION NAME] (antipsychotic). Neurology and psychiatric consults were done on 10/17/14 for altered mental status. Some weight loss may be due to previously elevated [MEDICAL CONDITION] stimulating hormone (TSH) in July, 2014. [MEDICATION NAME] medication was subsequently increased. TSH normal in October, 2014. Also weight loss due to decreased intake. The recommendations were to add a Magic Cup daily at lunch, in addition to other interventions. Review of Resident #15's nutrition note dated 11/21/14 revealed that the resident's weight was 185.4 lbs, height 67 inches, and body mass index 29. Weight history: 2% loss in one month; 7.94% significant loss in 3 months; 15.57% significant loss in 6 months. Diet regular. Food intake varies from 25-100% per meal. Interventions included fortified food at every meal (started on 10/30/14), mighty shake three times a day (7/24/14), and multivitamins with minerals (10/30/14). Recommend to continue current plan of care. The recorded weights for Resident #15 were as follows: 219.6 pounds (lbs) on 5/9/14 207.5 lbs on 6/9/14 (12.1 lb loss, 5% over 1 month=significant weight loss) 197.0 lbs on 7/9/14 (10.5 lb loss) 201.4 lbs on 8/6/14 (4.4 lb gain, 12% over 3 months=severe weight loss) 195.6 lbs on 9/10/14 (5.8 lb loss) 189.2 lbs on 10/10/14 (6.4 lb loss) 185.4 lbs on 11/20/14 (3.8 lb loss, 19% over 6 months=severe weight loss) 181.6 lbs on 12/5/14 (3.8 lb loss) Record review of the Minimum Data Set ((MDS) dated [DATE] revealed that Resident #15 had a significant weight loss over 180 days. The resident was not on a physician prescribed weight loss regimen. Review of Resident #15 ' s care plan for nutritional risk dated 10/29/14 revealed the resident had a significant weight loss, leaving 25% or more of food uneaten at meals and altered mental status with lethargy. The resident receives a regular diet. This diet is tolerated without difficulty. The resident requires some assist from staff for all feedings. The stated goal was " resident will not have further significant weight loss in the next 90 days. Approaches included provide nutritional supplement of mighty shake three times a day with medication pass, remind to pick up fork, try arousing if sleepy, assist with eating, and provide fortified food at every meal and magic cup at lunch. Review of Resident #15 ' s interdisciplinary team notes dated 11/10/14 revealed that the team discussed the resident ' s significant weight loss. It was noted that the resident had also been on a gradual dose reduction of her antipsychotic medications, and her cognition had improved over the last 3 months. The resident stated she was pleased with her weight loss, and she had all she wanted to eat. Record review of Resident #15 physician orders [REDACTED]. The diet order for Magic cup at lunch daily was dated 10/30/2014. On 12/3/2014 at 12:38 PM an observation of Resident #15 sitting at the dining room table. She said the food tastes good. She has Gordon crisp steak, green beans, broccoli and steak fries. She only ate about 40 % of her meal. She then asked for dessert and was given chocolate cake. She did not have a Magic Cup during her lunch meal. On 12/4/2014 at 11:00 AM an interview with Employee A, Registered Nurse (RN), as she reviewed the Medication Administration Record [REDACTED]. Employee A stated there is nowhere else that it would be documented that she received the Magic Cup. She stated the order was not placed in the computer correctly. The order was showing, but not allowing the nurses to document it. She said she would correct it. On 12/4/2014 at 11:40 AM in an interview with Employee B, Certified Nursing Assistant (CNA), she stated that she was Resident #15 ' s caregiver. Employee B said that Resident #15 did not get any nutritional supplements. She said Resident #15 definitely did not receive Magic Cups at breakfast or lunch. On 12/5/2014 at 10:04 AM in an interview with Employee D, RN, she stated that the Magic Cups are given in the dining room. She said that when they are ordered with meals, the CNAs get them out of the freezer and give them to the resident. She said the nurse's will usually go into the dining room and make sure the resident received it, and then sign it on the MAR indicated [REDACTED] On 12/5/2014 at 10: 25 AM in an interview with Employee F, Registered Dietitian, she stated that she was not aware that Resident #15 was not getting the Magic Cup as ordered. She said Resident #15 may have gained some weight back if she had received the Magic Cup. The Dietitian stated that nursing wrote a note on 11/10/2014 that Resident #15 desired the weight loss. "But that was after the significant weight loss." She said if a resident desired weight loss, she would discuss it with the resident, and she would not allow too much weight loss too soon. She stated that the supplements were indicated due to too much weight loss over a short period of time. .

Based on observation and staff interview, the facility failed to ensure that stored medications were within acceptable date range for 2 of 2 nursing units (Health Center Unit and Rapid Recovery Unit). The findings include: On [DATE] at 2:40 PM an observation of the Health Center Medication Room revealed a bottle of Slow Release Iron 50 milligram (mg) with an expiration date of ,[DATE]. On [DATE] at 2:42 PM in an interview with Employee D, Registered Nurse (RN), she stated, "This Slow Release Iron is expired." She said the central supply clerk stocks the medications in the medication rooms. She said it is the central supply's responsibility to check for expiration dates. On [DATE] at 3:10 PM an observation of the Rapid Recovery Medication Room revealed that the intravenous (IV) emergency kit contained Heparin 100units/10 milliliter (ml) with an expiration date of [DATE]. On [DATE] at 3:10 PM Employee C, RN, stated that the Heparin was expired. She said she would call the pharmacy and have them exchange the whole emergency kit tonight. .

Based on a review of clinical and facility records, and interview with staff, the facility failed to maintain complete and accurate clinical records for 3 of 5 sampled residents whose medications were reviewed (Residents #15, #28 and #62), in accordance with accepted professional standards and practices. The findings include: A record review conducted for Resident #15 revealed [DIAGNOSES REDACTED]. Further record review revealed that Resident #15 had a hand-written order dated 10/29/14 for multivitamin with minerals, fortified foods at each meal, and a magic cup at lunch daily for significant weight loss. The staff person who took the order failed to include her credentials, the time the order was received or written, or whether it was a telephone or a verbal order from the prescriber, or a recommendation. An order to discontinue [MEDICATION NAME] cream was dated 10/30 (no year), noted no time, did not specify a telephone or verbal order, and lacked a date in the physician's signature box. An order dated 10/31/14 to discontinue [MEDICATION NAME] 1 milligram (mg) twice daily and start [MEDICATION NAME] 0.5 mg twice daily for extreme agitation was noted without the time or type of order indicated (verbal, telephone). A record review conducted for Resident #28, who was admitted on [DATE] with readmit on 7/1/13 revealed [DIAGNOSES REDACTED]. Review of orders for Resident #28 revealed a handwritten order dated 9/2/14 for [MEDICATION NAME] powder beneath left breast twice daily for 14 days for [MEDICAL CONDITION], and dermatology consult for recurring [MEDICAL CONDITION] beneath breasts. There was no documentation of who wrote the order, or what time it was written. There was no indication whether it was a verbal or telephone order received from the physician. No credentials were identified for the writer. An order dated 9/20/14 at 8:00 pm to discontinue skin prep to the heel, and cleanse and dress a sternum wound did not identify the credentials of the writer. The order was not signed or dated by the prescribing physician. An order dated 10/5/14 for a foot x-ray was not signed or dated by the physician. An order dated 10/4/14 to discontinue skin treatment mid-sternum did not document the writer's credentials, the time the order was written, the nature of the order (telephone or verbal), and was not dated when the prescriber signed the order. an order for [REDACTED]. A record review conducted for Resident #62 found he was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #62 had a written order dated 8/27/14 to send the resident to the emergency room for evaluation for a [DIAGNOSES REDACTED]. At the bottom of the order, the space intended for the Physician/prescriber's signature and date were left blank. A handwritten order dated 9/2/14 for an outpatient GI (gastrointestinal) consultation for rectal bleeding was signed by the physician on 9/2/14, but did not include the transcribing nurse's name, the time the order was received, or whether it was a verbal or telephone order. An order flu vaccine dated 10/21/14 was not annotated with the time, the nature of the order, and had not been signed or dated by the prescriber. On 11/4/14, an order to discontinue [MEDICATION NAME] 20 mg was written at 2:00 pm. The physician did not sign the order. An order dated 11/21/14 for permission for an alcoholic beverage during special activities per resident request was not dated and was not signed by the physician. A review of the facility's Nursing Policies and Procedures manual instructions for Telephone Orders dated December 2008 stated "Verbal telephone orders may be accepted from each resident's attending physician." The guidelines specified: 1. Verbal telephone orders may only be received by licensed personnel (e.g. RN (Registered Nurse), LPN/LVN (Licensed Practical Nurse/Licensed Vocational Nurse), pharmacist, physician, etc...). Orders must be reduced to writing, by the person receiving the order, and recorded in the resident's medical record. 2. The entry must contain the instructions from the physician, date, time and the signature and title of the person transcribing the information. 3. Telephone orders must be countersigned by the physician during his or her next visit. The policy for Verbal orders specified "Verbal orders shall only be given in an emergency or when the attending Physician is not immediately available to write or sign the order. Verbal orders must always be based on actual conversations with the prescribing practitioner or on approved written protocols. The guidelines specified: 1. The nurse receiving the verbal order must write it on the physician's orders [REDACTED].o." (verbal order) or "t.o." (telephone order). 2. The nurse transcribing the verbal order must read the order back to the physician to ensure that the information is clearly understood and correctly transcribed.

Based on observation, staff interview and facility record review, the facility failed to store food under sanitary conditions in 1 (main kitchen) of 3 kitchen areas. The findings include: During a tour of the main kitchen with the Dining Services Director (DSD) and Assistant DSD (ADSD) on 6/9/14 between 11:15 a.m. and 12:15 p.m., multiple opened boxes of uncovered lettuce and a box containing multiple bags of romaine lettuce with a use by date of 6/3/14 were observed in the salad refrigerator. The ADSD stated the items were delivered on 6/6/14. She stated this was the second time the facility had received trucks with expired food items. The DSD and ADSD were unsure who checked the truck during the delivery on 6/6/14. They further stated there was no system in place to check the deliveries to the kitchen for expired foods. Cauliflower, mixed vegetables and peas were observed in pans on a serving cart inside the beverage refrigerator. The cart was covered with a large piece of plastic. There were no individual covers for the pans of vegetables. The vegetables were unlabeled and undated. The ADSD stated the vegetables were for that day's meal. She stated she would have someone label the items. During the tour, a bulk container of fudge frosting was observed with an open date of 4/25/14 in the refrigerator for leftovers and milk. The refrigerator also contained two bulk horseradish containers that were prepared 5/18/14 with use by dates of 5/22/14, two containers (32 ounces) of plain yogurt with expiration dates of 6/7/14 and three cottage cheese containers that were expired on 5/23/14. In addition, a thick, gray dust like substance was noted on the cooling fans in the refrigerator. The tour continued in the storage room for dry and can goods. The room contained ten unopened bags of brown sugar with no date of receipt or expiration date, a large bulk can dated 3/27/14 without a manufacturer's label, and a 10.5 ounce can of fruit cocktail dated 5/27/14 on the floor underneath a storage cart. A tour of the kitchen's storage room for snack items and paper goods revealed a foam container holding 12 rectangular plastic packages of crackers that were unlabeled and undated. In an interview, the DSD and ADSD stated any items removed from original containers should contain a label with a date. A review of the facility's adopted policy titled Food and Nutrition Services Dry Storage Life of Foods, revised 2/24/14, revealed staff may defer to the manufacturer's expiration date if provided for unopened food items. Refrigerated icings have a maximum storage period of one month when opened. A review of the facility's Dining Services Standards and Guidelines, Revised 9/2011, revealed the dining service staff will make every attempt to maintain food items in a clean, safe and sanitary environment. Food shall be rotated as delivered and used in a " First In, First Out " (FIFO) method. A method of ensuring this practice will be identified at each community by ...(2) the dating of individual items upon receipt, (3) or maintaining the original carton with shipping label intact and facing outward on the shelf, are some suggestions to accomplishing FIFO. In any event, one practice of FIFO must be in evidence. Prepared or opened foods stored in the refrigerator until served shall be covered, labeled and dated with the expiration date which could be 5 days later, day 1 being the day of preparation or opening. Such food stored in a refrigerator must be placed in a storage container and tightly sealed with a tight fitting lid marked with the name of the item, and date of expiration, or wrapped tightly with foil or plastic wrap and labeled. Other items in dry storage must be stored after opening in a storage container with a tightly sealing lid or plastic bag with a zipper style seal. Place "date of expiration" from the original container, or the "date of opening" if an expiration date is not apparent. The "expiration date" may be instead a "use by" or "best by" date on the box or package. In any case, they are all the "date" when you would dispose of the item. .

Based on observation, staff interview and facility record review, the facility failed to maintain an effective pest control program to ensure that 1 (main kitchen) of 3 kitchen areas were pest free. The findings include: During a tour of the main kitchen with the Dining Services Director (DSD) and Assistant DSD (ADSD) on 6/9/14 between 11:15 a.m. and 12:15 p.m., multiple dead roaches were observed along the back wall near the food preparation area, and along a door in the Bakery Area. In addition, debris including dead pests was noted in a container housing a scoop used for the ice machine. In the room used for storage of items such as can goods and sugar, multiple live gnats were observed flying around. In an interview during the tour, the DSD and ADSD were unsure of the facility's pest control policy. The DSD stated the exterminator was on-site and that she would inform him of the gnats and other issues. A review of the Pest Control Sighting Log dated March, 2014 to May, 2014 revealed multiple sightings of various pests including roaches, rats and ants throughout the facility, including the main kitchen. Sightings occurred in the main kitchen on 3/11/14, 4/17/14, 5/6/14 and 5/8/14. on 6/9/14 at 1:59 p.m. with the Director of Maintenance (DM), he stated he does not receive monthly/quarterly information from the pest control company for services provided per the General Service Schedule. He indicated a representative from the pest control company frequents the facility every Wednesday. In an interview on 6/9/14 at 2:23 p.m. with the DM he stated that he does not have a tracking system in place to identify what facility areas are treated by the pest control company, and when they are treated. he confirmed that the pest control company initialed the Pest Control Sighting Log, but there was no tracking of what areas were treated on these intermittent visits. The DM indicated he will develop a system for use in the future as part of his "corrective action plan."

Based on observation and staff interview, the facility failed to ensure proper disposal of garbage and refuse in containers with lids and ensure that garbage disposal prevented the harborage and feeding of pests in 2 (Dumpster #1 and "Cardboard Only" dumpster) of 3 dumpsters. The findings include: On 6/9/14 at 12:10 p.m., the dumpster used for "Cardboard Only" was observed with one of two lids open. The Assistant Dining Services Director was unable to close the lid. In a separate fenced area, Dumpster #1 was observed with one of two lids open and a squirrel was observed diving in and out of the dumpster. The smell of garbage was noted. In the same area, a small bag of trash was observed behind Dumpster #2. The Dining Services Director (DSD) was unable to close the lid to Dumpster #1. The DSD verified that the dumpster lids should have been closed, and she stated she would obtain someone to close them. On 6/9/14 at 6:15 p.m., Dumpster #1 remained with an open lid and a squirrel was observed diving in and out of the dumpster. .

Based on observation and staff interview the facility failed to store and serve food in a sanitary manner in two areas of the facility. 1.) Kitchen and 2.) Main Dining Room in the Health Care Center. The findings include: Observation of the kitchen walk-in cooler on 11/04/13 at 10:55 AM revealed a half gallon of opened cream with no date mark. Observation in the walk-in cooler on 11/06/13 at 1:20 pm revealed a half gallon of opened buttermilk, 2 gallons of opened milk, and three quarts of opened liquid eggs, with no date mark on any of the opened items. Interview with the Dietary Manager on 11/06/13 at 1:20 PM during observation revealed that he acknowledged the opened products should be date marked and he stated, "I will have to reiterate to the staff to date mark the products when they are opened." Observation of Employee #1 serving the lunch meal on 11/04/13 at 12:00 PM revealed that she dialed the phone next to the covered steam table with gloves on, and held the receiver to her ear while talking. She hung up the phone and proceeded to dish up and serve another plate of food, without changing her gloves or washing her hands. Employee #1 proceeded to change her gloves 5 times without washing her hands in between. Employee #1 was observed touching her forehead with her right gloved thumb, and then continue to plate food without washing her hands and changing her gloves. Interview of the Dietary Manager on 11/06/13 at 1:45 PM revealed he acknowledged that the food service employees should wash their hands between glove changes, and change gloves between tasks. Dining observation was conducted for breakfast in the main dining room on 11/5/13 at 8:00 AM. Employee #3 was observed assisting an unidentified resident to transfer into a chair. She removed the transfer belt from around her own waist and placed it around the resident. She assisted the resident to stand, pivot and sit in a dining chair. She removed the belt from the resident's waist and placed it around her own. Employee #3 went to the window and retrieved a plate of food with her unwashed and unsanitized right hand, while placing her thumb on top of the plate. Employee #3 delivered the plate to the unidentified resident. Employee #3 proceeded to assist a male resident in a wheelchair to position himself at a table. She then proceeded to retrieve a plate of food from the window with her unwashed and unsanitized right hand, while placing her thumb on the top of the plate. During the dining observation on 11/5/13 at 8:15 AM Employee #2 was observed assisting a female resident to transfer into a dining chair. The resident had a belt around her waist and was being assisted by another employee as well. Employee #2 removed the transfer belt and placed it around her own waist. She then proceeded to retrieve a plate of food from the window with her unwashed and unsanitized hand, while placing her thumb on top of the plate. She delivered the plate to a resident, returned to the window, and retrieved another plate of food with her unwashed and unsanitized right hand, while placing her thumb on top of the plate. She delivered the plate to a resident and, without washing her hands, assisted the resident with cutting up her french toast. Observation in the dining room on 11/6/13 at 12:00 PM revealed Employee #2 retrieved a plate of food from the counter with her thumb on top of the plate. She then delivered the plate to a resident and unwrapped the resident's straw. Holding the straw in her hand and touching the drinking surface, Employee #2 placed the straw into the resident's beverage. .

Based on observation and staff interview the facility failed to store and serve food in a sanitary manner in three areas of the facility. 1.) Kitchen 2.) Main Dining Room upstairs in the Health Care Center and 3.) Main Dining Room downstairs in the Rapid Recover Unit. The findings include: Observation of the kitchen walk-in cooler on 01/24/14 at 1:30 pm revealed a half ham with a date mark of 01/15/14; a gallon size container of mayonnaise with no date mark; and bag of shredded Swiss cheese with a date mark of 01/15/14. An interview on 01/24/14 at 1:35 pm with the Dining Services Director (DSD)revealed that he acknowledged the opened products should be date marked and he stated, "I have some work to do with the staff to date mark the products when they are opened. We do a lot of catering here and sometimes we don't use up all the food within seven days. I'll have to talk to our distributor about getting smaller bags of food so we don't have as much waste." Observation of dietary staff Employee #1 serving the lunch meal on 01/24/14 at 11:45 pm revealed that she answered the phone next to the covered steam table with gloves on, and held the receiver to her ear while talking. She hung up the phone and proceeded to continue to set up the food in the steam table, without changing her gloves or washing her hands. Employee #1 was interviewed regarding her training on hand washing, and when to change gloves during food service. She stated that she should have changed her gloves and washed her hands after she used the telephone. Interview on 01/24/14 at 12:45 pm with the Clinical Nutrition Supervisor revealed she acknowledged that the food service employees should wash their hands between glove changes, and change gloves between tasks, especially after using the telephone. She stated, " She's been trained. I think she was just nervous. " On 1/24/14 at 11:40 a.m., the DSD and dietary staff Employee #2 were observed entering the Rapid Recovery Unit (RRU) serving kitchen with a portable warmer containing food for the lunch service. A hand washing sink was observed to the right upon entry to the kitchen. The DSD and Employee #2 entered the kitchen, removed food items from the portable warmer, placed them on the stove top, and began manually measuring temperatures of the items without washing their hands. At 12:13 p.m. on 1/24/14, Employee #2 was observed placing trash in the main receptacle in the dining area after she washed her hands. She returned to the kitchen, donned gloves without washing her hands, and began serving soup to residents. She removed the gloves and placed them in a trash receptacle under the sink. She then poured iced tea for another resident without washing her hands. An interview on 1/24/14 at 12:15 p.m. with Employee #2 revealed that the only trash can for the kitchen was located behind the cabinet below the hand washing sink. She stated it is too tall and you have to tip it to place trash in the can. She further revealed that a hands free trash receptacle would be preferable, and she displayed an area in the serving kitchen where it could be placed. The DSD was observed returning to the RRU serving kitchen with additional lunch items on 1/24/14 at 12:17 p.m. He again placed the food items on the stove top and began measuring temperatures of the items without washing his hands. During an interview with the DSD at 12:25 p.m., he stated that hand washing is required prior to entering the kitchen. He further stated gloves are only required when handling raw foods. He verified the observations of the absence of hand washing for the DSD and Employee #2 upon entering the RRU serving kitchen, and during food set-up and monitoring of temperatures. He indicated he washed his hands in the main kitchen prior to returning to the RRU serving kitchen with the re-heated food items. The DSD was observed washing his hands in the RRU serving kitchen at 12:26 p.m. on 1/24/14. After drying his hands with paper towels, he opened the cabinet beneath the sink with his bare hands and discarded the paper towels in the trash can. An interview with the DSD at 12:26 p.m. confirmed the observation. He stated, "We need to have a way to discard trash without having to touch the door."

Based on observation and staff interview the facility failed to maintain dishwashing equipment in safe operating condition. The findings include: During initial tour of the kitchen on 11/04/13 at 10:40 am it was observed that the dishwasher was a chemical sanitizing machine. Employee # 4 was observed using the dish machine. When asked to test the level of sanitizer he was not sure if the machine used chlorine or quaternary ammonium. He used the test strips for quaternary ammonium. The test strip he used indicated no sanitizer in the water. The Dietary Manager then was alerted to the fact that the machine was not sanitizing properly. He brought the test strips over for chlorine sanitizer and tested the machine using chlorine test strips. The test strip did not turn blue and remained white, indicating no sanitizer at the level of the plates being washed. The Dietary Manager instructed the staff not to use the machine and to use paper plates for food service until the machine was fixed. Interview with the Dietary Manager on 11/04/13 at 2:15 pm revealed the company that performs maintenance on the machine made a service call to the facility and replaced a part on the machine. He stated the machine was fixed now, and when tested the chlorine level was in the right range for chlorine sanitation. He showed this surveyor a letter from the company stating the machine had been fixed. Observation of the dish machine on 11/05/13 at 2:30 pm revealed Employee # 5 tested the level of chlorine using a test strip. The test strip was a dark blue. When compared with the scale on the test strip container the dark blue color indicated that the level of chlorine was well above 200ppm (the highest level on the scale). Interview with Employee #5 on 11/05/13 at 2:40 pm revealed she had washed the breakfast dishes and the lunch dishes that day and was aware that the dark blue color of the test strip indicated a toxic level of sanitizer. She stated that when she tested the machine while washing the breakfast dishes the test strip was a very dark blue color. She stated that it looked like the one just used for the lunch dishes. She confirmed to this surveyor that she understood that she needed to let the Dietary Manager know when she tested the machine and got a very high reading or a very low reading, however she had not informed him.