Every finding on record at Woodhaven Manor Nursing Home

Based on observation, interview and the facility's policy titled, Medication Storage Storage of Medications and Biologicals, the facility failed to ensure an opened 5 ml (milliliter) vial of influenza vaccine with the expiration date of [DATE], and twelve unopened suppositories with the expiration date of ,[DATE], were not stored in the medication storage room refrigerator on [DATE]. This affected one of one medication storage room refrigerators observed. Findings include: Review of facility's policy titled, Medication Storage Storage of Medications and Biologicals, with a date of ,[DATE], revealed: .11. Outdated .medications .are removed from stock, disposed of according to procedures for medication disposal . On [DATE] at 9:19 a.m., the Surveyor observed the medication storage room with Employee Identifier (EI) #1, Registered Nurse (RN). The refrigerator in the medication storage room contained the following: 1. an open 5 ml multi dose vial of Influenza vaccine with an expiration date of [DATE] and 2. 12 [MEDICATION NAME] -hc 25 mg (milligram) suppositories with an expiration date of ,[DATE]. On [DATE] at 9:58 a.m., the Surveyor conducted an interview with EI #1. EI #1 was asked, did she observe an open vial of influenza vaccine that was expired in the refrigerator. EI #1 replied, yes. EI #1 was asked what was the expiration date. EI #1 replied, she thought it was [DATE]. EI #1 was asked where should the expired open vial of influenza vaccine be stored. EI #1 replied, it should have been placed in the destruction container. EI #1 was asked, did she also observe twelve [MEDICATION NAME] suppositories that were expired in the refrigerator. EI #1 replied, yes and the expiration date was ,[DATE]. EI #1 was asked, what was the potential harm with having expired medication stored in the medication storage room refrigerator. EI #1 replied, the resident could have received the medication if someone did not check the expiration date before they gave the medication.

Base on observation, record review and interviews, the facility failed to ensure glassware was stored in a manner that allowed air drying, as outlined in the General Dish Room Sanitation policy. This had the potential to affect 68 residents receiving meals and beverages from Dietary. Findings Include: On 6/10/15 at 9:32 AM, an observation was made of a few glasses stored face up on a tray with noticeable drops of water on the inside of them. A review of a facility policy titled, GENERAL DISH ROOM SANITATION, with a revised date of 3/1/95 revealed the following: .Policy: Food waste material, heat and moisture are the primary contributors to unsanitary conditions .8.They are to be allowed to air dry. On 6/10/15 at 9:48 AM, an interview was conducted with Employee Identifier (EI) #6, Dietary Worker. The surveyor asked EI #6 to observe the glassware. EI #6 was then asked if the glasses were completely dry. EI #6 replied yes. EI #6 was asked how did she know when the glasses that had been washed through the dishwasher are completely dry. EI #6 explained that when the glasses are sent through the dishwasher, they are taken out and are placed face down to dry and when they are dry, glasses are placed face up. On 6/10/15 at 9:58 AM, and interview was conducted with the Dietary Manager, EI # 7. EI #7 was asked to observe the stored glasses. EI #7 was asked, inside of the glasses what did she see. EI #7 replied, I see some water inside of a few of them. EI #7 was asked what was the facility's policy and procedure regarding drying items such as glassware. EI #7 explained that glasses are to be turned face down on the tray to dry. EI #7 was asked when observing the glasses that were stored face up on the tray, what did she observe. EI #7 replied, A little moisture. EI #7 was asked how were glasses to be dried. EI #7 said, To be air dried. EI #7 was asked were the glasses she observed with moisture completely dry. EI #7 replied, No ma'am. EI #7 was asked what was the potential harm in using glasses that were not completely dry. EI #7 replied,Mold and Mildew.

Based on record review and interview, the facility failed to notify the sponsor of Resident Identifier (RI) #3 of an increase in the antipsychotic medication [MEDICATION NAME] on 2/12/2015. The facility further failed to notify the family of RI #11 of a change in pain medication [MEDICATION NAME] on 4/10/15 and the implementation of an antibiotic treatment on 5/19/2015. Findings include: The facility's policy titled, Notification of Change in Condition of a Resident revised 9/2011, included the procedures, . Notify the resident's legal representative or an interested family member of status change and new orders . Document the notification in the medical record. 1) RI #3 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. RI #3's current Minimum Data Set (MDS) assessment, date 05/01/2015, identified the resident with a Brief Interview for Mental Status (BIMS) score of 3, indicating a cognition of severe impairment. The MDS also reflected [DIAGNOSES REDACTED]. Review of RI #3's February 2015 Physician order [REDACTED]. The [DIAGNOSES REDACTED]. The order was dated 1/15/15. On 2/12/15 at 5:00 pm a nurse documented on an order sheet, Clarification order: D/C (discontinue) [MEDICATION NAME] 0.25 mg tab - 1/2 tab (0.125 mg) P.O. QHS Give [MEDICATION NAME] 0.25 mg tab - 1 tab P.O. QHS. The [DIAGNOSES REDACTED]. A review of the Nurse's Notes 2/12/15 (the date of the new order) back to 2/2/15 did not reflect the family/ sponsor of RI #3 had been notified by nursing of the change in the order. On 06/11/15 at 8:30 AM, Employee Indentifer (EI) #1, Director Of Nursing (DON), was interviewed. She was asked where the notification of family members would be documented. She replied in the charts. She said most of the time the person taking the order writes the order and notifies the family. On 06/11/15 at 10:20 AM, EI #1 was informed that notification to the family of RI #3's change in medication was not documented. She replied if not documented, it was not done. 2) RI #11 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. RI #11's Quarterly MDS assessment, date 03/12/15, identified the resident with being cognitively intact (BIMS 14). RI #11 was also identified with experiencing pain. Review of RI #11's physician's orders [REDACTED]. [MEDICATION NAME] 5/325 mg tab (1) tab po TID (three times a day) at 7 am/11 am/ 3 pm. related to pain 2. [MEDICATION NAME] 5/325 mg tab (1) tab po Q 6 H PRN (as needed) related to pain. Review of the Nurse's Notes on that date, or after that date, did not show evidence the family had been notified of the order. On 06/11/2015 at 11:15 AM, EI #4, the Registered Nurse who documented the new order, was interviewed. She was asked if she notified the family of the change in the [MEDICATION NAME] for RI #11. She replied it was an oversight on her part, if not documented, did not do it. Further review of the physician's orders [REDACTED]. [MEDICATION NAME] 180 mg cap (1) cap po QD. 2. [MEDICATION NAME] 250 mg tab (1) tab po QD related to Gastroparesis (Gullian Barre). Review of RI #11's Nurse's Notes for 05/19/15 revealed no evidence the family had been notified of the new treatment. On 06/11/2015 at 11:15 AM, EI #4, the Registered Nurse who documented the new order, was interviewed. She was asked if she notified the family of the antibiotic treatment for [REDACTED]. She replied it was an oversight on her part, if not documented, did not do it.

Based on observation, record review and interview, the facility failed to provide justification for the increase of the antipsychotic medication [MEDICATION NAME]. This affected Resident Identifier (RI) #3, one of three sampled residents for antipsychotic medication use. Findings include: The facility's, Policy 8.3 Medication Monitoring Psychoactive Drug Monitoring, date 2011, included the procedures, 1. Residents receive a psychoactive medication only if supporting documentation is provided in the medical record. 5. Initiation and dosing of the psychoactive medication follows recommendations from . regulations, . RI #3 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. RI #3's current Minimum Data Set (MDS) assessment, date 05/01/2015, identified the resident with a Brief Interview for Mental Status (BIMS) score of 3, indicating a cognition of severe impairment. The MDS also reflected [DIAGNOSES REDACTED]. Review of RI #3's care plan revealed a problem, Resident is currently taking [MEDICAL CONDITION] medication, with an onset date of 11/09/2012. Approaches included, . Report and record any episodes of delusions or hallucinations . Review of RI #3's February 2015 Physician order [REDACTED]. The [DIAGNOSES REDACTED]. The order was dated 1/15/15. On 2/12/15 at 5:00 pm a nurse documented on an order sheet, Clarification order: D/C (discontinue) [MEDICATION NAME] 0.25 mg tab - 1/2 tab (0.125 mg) P.O. QHS Give [MEDICATION NAME] 0.25 mg tab - 1 tab P.O. QHS. The [DIAGNOSES REDACTED]. A review of the Nurse's Notes 2/12/15 (the date of the new order) back to 2/2/15 did not show evidence of any increase of psychotic behaviors. The only behaviors indicated around the time of the increase of the medication was noted on 2/7/15 at 1:50 pm, Resident in room at this time watching TV no behaviors noted at this time. Resident had behavior noted earlier in shift with clothes (RI #3) was wearing. CNA (Certified Nursing Assistant) changed (RI #3's) clothes x 2 (twice) after allowing resident to pick out what (RI #3) wants to wear. Review of the facility's February 2015 Behavior Record for RI #3 did not show evidence of behaviors prior to or after the increase in the [MEDICATION NAME]. On 06/09/15, RI #3 was first observed on tour of the facility sitting in the wheelchair in the resident's room. RI #3 was very pleasant. On 06/10/2015 at 3:40 PM, Employee Identifier (EI) # 3, License Practical Nurse was interviewed regarding the increase of RI #3's [MEDICATION NAME]. She was asked what the justification was for the increase of the medication. EI #3 replied the resident was agitated about clothing (2/7/15), after she reviewed the Nurse's Notes. EI #3 said the resident gets agitated about clothes and the resident thinks others are wearing the resident's clothes and shoes. EI #3 looked at the Behavior Management form for monitored behaviors for RI #3 and said there was no behaviors indicated on the form except on 2/7/15. EI #3 said the doctor talks to the CNAs and increases the medication based on what they say. EI #3 was asked if the one indicated episode noted for RI 3's behaviors justified the increase of the medication. She said it did not, based on what was noted. On 06/11/15 at 8:30 AM, EI #1, Director of Nursing, was interviewed. She was asked what was the procedure when increasing a antipsychotic medication. EI #1 said there is usually an increase in behaviors and they try to manage the behaviors with interventions. EI #1 said she would think the doctor would look at the documentation, but he would go on staff interviews. On 06/11/15 at 9:40 AM, EI #5, the Psychiatrist for the facility, was interviewed. EI #5 was asked what he based his increase of psychoactive medications on. He said he based it on the evaluation of the resident and talking to staff and others.

Based on record review and interview, the facility failed to adequately document increases in Resident Identifiers (RI) #3's behaviors prior to increasing the antipsychotic medication [MEDICATION NAME]. This affected 1 of 3 sampled residents receiving antipsychotic medications. Findings include: RI #3 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. RI #3's current Minimum Data Set (MDS) assessment, date 05/01/2015, identified the resident with a Brief Interview for Mental Status (BIMS) score of 3, indicating a cognition of severe impairment. The MDS also reflected [DIAGNOSES REDACTED]. Review of RI #3's care plans revealed a problem, Resident is currently taking [MEDICAL CONDITION] medication, with an onset date of 11/09/2012. Approaches included, . Report and record any episodes of delusions or hallucinations . A second care plan for behaviors also included the approach, . Monitor behaviors: persons involved, length of time resident is upset, location situation, time of day. Look for pattern. Try different approaches to manage behavior. Record results of interaction. A review of RI #3's February 2015 Physician order [REDACTED].O. QHS on 2/12/15. A review of the Nurse's Notes 2/12/15 (the date of the new order) back to 2/2/15 did not reflect any documented behaviors except on 2/7/15, . Resident had behavior noted earlier in shift with clothes (RI #3) was wearing. CNA (Certified Nursing Assistant) changed (RI #3) clothes x 2 (twice) after allowing resident to pick out what (RI #3) wants to wear. A review of the facility's February 2015 Behavior Record for RI #3 did not reveal any additional documented behaviors exhibited for the month of February, with the exception of 2/7/12. On 06/10/2015 at 3:40 PM, Employee Identifier (EI) # 3, License Practical Nurse was interviewed regarding the resident's behaviors. EI #3 replied the resident gets agitated about clothing and thinks other residents are wearing RI #3's clothes and shoes. EI #3 said the staff know what RI #3's behaviors are and do not tell the nurse and the nurse does not document. EI #3 looked at the February 2015 Behavior Management form for documented behaviors for RI #3. EI #3 said there was nothing documented except on 2/7/15, when the resident got agitated about the clothes the resident was wearing. On 06/11/15 at 9:40 AM, EI #5, the Psychiatrist for the facility, was interviewed. EI #5 was informed of the surveyor finding no documentation of the resident having any increase in behaviors prior to the order for the increase of the medication [MEDICATION NAME]. EI #5 said the nurses should be documenting.

Based on record reviews and interview, the facility failed to complete a discharge summary, at the time of discharge, for Resident Identifier (RI) #14 and RI #15, two of two closed records reviewed, whose discharge was anticipated. Findings include: The facility's policy titled "Phy. NH Discharge Summary (F283; F284)" effective 6/9/04, documented " ... POLICY: 1-When the facility anticipates discharge a resident shall have a physician's discharge summary that includes: a-a recap (summary) of the resident's stay; b-information pertinent to continuing care of the resident; c-discharge preparation and education provided to resident and his/her family (continuing care provider); d-final diagnosis. (NOTE: Anticipates means that the discharge was not an emergency discharge (e.g., hospitalization for an acute condition) or due to resident's death. Applicable to discharge to a private residence; to another NF/SNF (nursing facility/skilled nursing facility), or other type of residential facility ... PROCEDURES: 1-The discharge summary should be completed at the time of discharge ... ." RI #14 was admitted to the facility on [DATE]. The Minimum Data Set with an assessment reference date of 7/2/14, indicated there was an active discharge plan for RI #14 to return to the community. RI #14 was discharged home on[DATE]. A review of RI #14's closed medical record, revealed the chart did not include a discharge summary. RI #15 was admitted to the facility on [DATE]. The Minimum Data Set with an assessment reference date of 7/8/14, indicated there was an active discharge plan for RI #15 to return to the community. RI #15 was discharged home on[DATE]. A review of RI #15's closed medical record, revealed the chart did not include a discharge summary. In an interview on 8/14/14 at 4:10 PM, Employee Identifier (EI) #3, a Registered Nurse stated the discharge summary for RI #14 and RI #15 will be completed within 90 days of the residents' discharge date . When asked if this was the facility's policy, EI #3 said yes.

Based on observation, interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA); 1. Cleaned vaginal opening and labia; 2. Did not apply Dermaseptin cream after cleaning and removing stool from Resident Identifier (RI) 7's buttock and before changing gloves. This affected RI #7, a resident identified with a history of Urinary Tract Infections [MEDICAL CONDITION], one of one resident observed during incontinent care. Findings Include: A review of the facility's policy and procedure titled, "Incontinent Care and Catheter Care with No Rinse Periwash" with a revised date of 12/2012, revealed the following: "... PROCEDURE: ... 4... Female-wash entire perineal area (outer and inner labia) ... 6. ... Wash and dry the buttocks and anal area, ... 9. Remove and dispose of gloves ... Apply clean gloves. ..." RI #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #7's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed RI #7's Brief Interview for Mental Status score of 4, indicating severe impairment in cognition. The MDS documented RI #7 required extensive assistant with toileting and was incontinent of bowel and bladder. A review of RI #7's care plan with the problem titled, "Frequently incontinent of Bowel and Bladder. At risk for UTI r/t (related to) hx (history) of UTI, ..." with a problem onset date of 03/06/13 revealed the following: "... Approaches ... Give Perineal care when resident is incontinent ... 3/13/14 UA (Urinalysis) (with) C & S (Culture and Sensitivity) ..." On 08/13/14 at 12:15 PM, the following was observed during the provision of incontinent care: Employee Identifier (EI) #1 (CNA) and EI #2 (CNA) washed their hands and applied gloves. EI #1 obtained a separate peri wipe with peri-spray and wiped the right and left groin, the vulva and wiped down the middle of the vaginal area. EI #1 did not visualize the vaginal opening and wipe the labia. EI #1 removed her gloves, washed her hands and applied clean gloves. EI #1 obtained separate peri wipes with peri-spray and wiped the buttock and the rectal area. Stool was observed on the peri -wipes. EI #1 repeated this process and wiped the right buttock twice without changing the position of the peri-wipe. EI #1 applied moisture barrier cream to the buttock and the inner thighs. EI #1 did not change gloves after cleaning the buttock and the rectal area; and before applying the moisture barrier cream. On 08/13/14 at 12:32 PM, the surveyor asked EI #1 when did she (EI #1) visualize the vaginal opening. EI #1 replied she did not visualize the vaginal opening. The surveyor asked EI #1 did she change gloves after she cleaned the resident and before she applied cream to the resident's buttock. EI #1 stated yes. The surveyor asked EI #2 was that what EI #1 had done. EI #2 replied no. The surveyor asked EI #1 what was the potential for harm to the resident. EI #1 stated UTI, bacterial infection. On 08/13/14 at 12:45 PM, repeat incontinent care was provided and the following was observed: After wiping the vaginal opening and the labia, a brownish substance was observed on the peri-wipes.

Based on observation, interview and record review, the facility failed to ensure a Certified Nursing Assistant (CNA) changed gloves after cleaning Resident Identifier (RI) #7's buttock and before applying a moisture barrier cream to the buttock. This affected RI #7, one of one resident observed during incontinent care. Findings Include: A review of the facility's policy and procedure titled, "Incontinent Care and Catheter Care with No Rinse Periwash" with a revised date of 12/2012, revealed the following: "... PROCEDURE: ... 6. ... Wash and dry the buttocks and anal area, ... 9. Remove and dispose of gloves ... Apply clean gloves. ..." RI #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #7's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed RI #7's Brief Interview for Mental Status score of 4, indicating severe impairment in cognition. The MDS documented RI #7 required extensive assistant with toileting and was incontinent of bowel and bladder. On 08/13/14 at 12:15 PM, the following was observed during the provision incontinent care: Employee Identifier (EI) #1 (CNA) and EI #2 (CNA) washed their hands and applied gloves. Stool was observed on the peri-wipes. EI #1 did not change gloves after cleaning the buttock and the rectal area, and before applying moisture barrier cream. On 08/13/14 at 12:32 PM, the surveyor asked EI #1 did she change gloves after she cleaned the resident and before she applied cream to the resident buttock. EI #1 stated yes. The surveyor asked EI #2 was that what EI #1 had done. EI #2 replied no. The surveyor asked what was the potential for harm. EI #1 stated UTI and bacterial infection.

Based on observation, interview, and document review, the facility failed to ensure raw ground beef was not stored on top of individual cartons of milk in the refrigerated milk storage box on 7/16/13. This had the potential to affect all residents receiving meals at the facility. According to the facility's "Resident Census and Conditions of Residents (Form CMS-672), dated 07/16/13, the facility had 72 residents and four of residents received nutrition via a feeding tube. Findings include: The facility's policy and procedure titled "Food Storage - Refrigerated Food," revised July 1997, documented "Policy: Perishable foods shall be refrigerated in a manner which optimizes food safety, ... Procedure: ... 15. Meat, milk and egg products are not to be stored over any item not to be cooked ... ." Chapter 3, page 64 of the 2009 Food Code documented " ... 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation. (A) Food shall be protected from cross contamination by: (1) ... separating raw animal foods during storage, ... from: (a) Raw ready-to-eat food ... (b) Cooked ready-to-eat food ... ." During the initial tour of the kitchen with Employee Identifier (EI) #4, the Dietary Manager, on 7/16/13 beginning at 3:00 PM, a pan of raw ground beef was observed to be stored on top of a crate of individual milk cartons in the milk box. When asked what would be the concern with storing raw meat on top of milk cartons, EI #4 said, "If it leaks, it will contaminate the milk."

Based on observation, interview and record reviews, the facility failed to ensure Employee Identifier (EI) #2, a Licensed Practical Nurse (LPN) did not flush Resident Identifier (RI) #6's intravenous (IV) catheter tubing with a contaminated needle and contaminated normal saline. This affected RI #6, one of 10 residents observed during medication pass. Findings include: The facility policy titled "Medication Administration Procedures ... (Policy 7.14)", dated January 2012, documented: "... Procedures ... 4. Prepare medication as follows: ... C. Prepare syringe and needle. D. Swab rubber cap with alcohol ... ." RI #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/18/13 at 8:25 AM, EI #2, a LPN was observed administering medication to RI #6. Without wiping the top of a half filled bottle of normal saline, EI #2 inserted a needle and withdrew normal saline. The surveyor asked EI #2 is she cleaned the top of the bottle and she said, "no." EI #2 then inserted the needle into the bottle and returned the normal saline to the bottle and discarded the bottle of normal saline. Using a new bottle of normal saline, with the same needle and syringe, EI #2 withdrew three cubic centimeters (cc) of normal saline. EI #2 was then observed to clean the top of the IV port, flush the IV tubing with the contaminated saline and start the infusion of an antibiotic for RI #6. On 7/18/13 at 2:20 PM, an interview was conducted with EI #2. The surveyor asked EI #2 why was it important to clean the top of a half-filled bottle (vial) of normal saline, before withdrawing the normal saline to flush the IV tubing. EI #2 said because the bacteria on the top of the vial could get into the normal saline. The surveyor asked EI #2, when she obtained the normal saline from the used vial, did she clean the top with alcohol first. EI #2 said no she did not. When the surveyor asked why not, EI #2 said she forgot. The surveyor asked EI #2 if she considered the needle used to withdraw the normal saline contaminated because she did not clean the top of the vial first. EI #2 said yes, because when the top was not cleaned the needle went into the vial and introduced bacteria into it. The surveyor asked, if the needle was contaminated, why did she use it to withdraw normal saline and flush the IV tubing. EI #2 said she did not think about it at the time. When the surveyor asked EI #2 what should she have done, EI #2 said she should have discarded the needle and syringe and got a new set-up.

Based on observations, interviews and record review the facility failed to: 1) Store thickened liquids in the dry storeroom to adhere to the standard method of "First In First Out" (FIFO). 2) Dispose of expired thickened liquids. 3) Maintain the ice machine interior in a clean/sanitary condition between scheduled monthly cleanings. 4) Assure the chemical sanitizer (chlorine) was at recommended/adequate concentration in the final rinse sanitizing solution when manual ware washing was being performed. These failures had the potential to affect 64 out of 64 residents who received meals from the kitchen. Findings include: 1) and 2) According to the 2009 Food and Drug Administration U.S. (United States) Food Code 3-501.17(B) "...refrigerated, ready-to-eat, potentially hazardous food... prepared and packaged by a food processing plant shall be clearly marked... to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded... (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date." Annex 5 of the U.S. 2009 Food Code directs food service institutions to establish procedures to ensure product rotation, for both safety and quality reasons. "First-In-First-Out" (FIFO) means that the "first batch of product prepared and placed in storage should be the first one sold or used..." "Servsafe Starters Employee Guide" (5th edition) of the National Restaurant Association specifies on page 19: "When storing food: ...2) Store food in first in, first out (FIFO) order. This means storing food that will expire first in front of items that will expire later. 3) Use the food in front first, because it will expire first." The facility "FIFO Policy" (undated), page 19 specifies: "All food coming into the unit will be roated (rotated) on FIFO." The procedure includes: "3. So when food is taken from the storage area for use in preparation, the oldest will (be) used first." During the initial tour of the kitchen on 6/19/12 at 3:30 PM, the surveyor observed three 8-oz (ounce) boxes of Resource nectar thickened "Dairy Thick" beverages stored on a shelf in the dry store room. Each of these boxes had a stamped expiration date of March 2012. Also on the shelf was an unopened case containing 27 (8-oz) boxes of "Dairy Thick" beverage, with an expiration date of June 15, 2012. Another case of unopened "Dairy Thick" beverage (nectar consistency), with an expiration date of 8/3/2012, was stored beneath a case of "Dairy Thick" nectar consistency, with an expiration date of 12/13/12, This method of storage hindered staff from using the beverages which would expire first. Resident Identifier (RI) #2 was observed on 06/20/12 at 8:05 AM during the breakfast meal. The breakfast tray contained the following: thickened water, thickened apple juice and thickened milk. The Certified Nursing Assistant (CNA), Employee Identifer (EI) #10 was observed opening the thickened water, juice, and milk. EI #10 was asked what the expiration date was on the thickened liquids. EI #10 identified the thickened milk as having an expiration of March 2012, two months after the expiration date. On 6/20/12 at 5:45 PM, when the surveyor was pointing out a case of expired "Dairy Thick" beverage dated 6/15/2012, to the Dietary Manager, Employee Identifier (EI) #11. The surveyor noticed a case of honey thickened apple juice, with an expiration date of 4/5/2012. EI #11 stated she had checked the cases earlier that morning and she "missed them." 3) Related to the frequency of cleaning food contact surfaces, regulation 4-602.11of the 2009 U.S. Food Code specifies: "(E)...surfaces of utensils and equipment contacting food... shall be cleaned; ...(4) In equipment such as ice bins and beverage dispensing nozzles and enclosed components of equipment such as ice makers... (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold." On 6/19/12 at 3:55 PM during the initial kitchen tour, the surveyor observed the interior of the ice machine to be soiled with a brown colored residue on the ice shoot. The surveyor asked EI #11 to wipe the area with a paper towel. The residue came off onto the towel while some of it fell into the ice. EI #11 stated the maintenance department cleans the machine monthly, while the kitchen staff maintained it between the monthly cleanings. 4) The facility procedure related to "Dish Washing, Manual Cleaning and Sanitizing" (dated 8/98) directs staff to sanitize as follows: "8. Equipment, dishes and/or utensils shall be sanitized in the third compartment sink according to one of the following methods:... 2. Immersion for at least one minute in a clean solution containing at least 50 parts per million, but not more than 200 parts per million of available chlorine..." On 6/19/2012 at 4:00 PM, during observation of the manual ware washing, at the three compartment sink, the surveyor asked EI #11 to check the concentration of the chlorine solution in the final rinse sink. Twice, EI #11 tested the solution, using chlorine test strips. The strips registered zero parts per million each time. There were at the time, 2 pans, 2 pan lids and 3 utensils completely immersed in the final rinse sink water. EI #11 stated she would have the maintenance department look at it.

Based on observation and interviews, the facility failed to ensure staff consistently knocked prior to entering residents' rooms. This affected Resident Identifier (RI) #5 and #12, three of 13 sampled residents on two of four halls. Findings included: During the initial tour on 06/19/12 between 3:52 and 4:45 PM, the licensed nurse, Employee Identifier (EI) #8 accompanying the surveyor, entered five rooms (including one private and four semi-private rooms) without first knocking. This included the rooms of RI #5 and #12. 1) RI #5 has resided in the facility since 05/14/09 with [DIAGNOSES REDACTED]. The quarterly review Minimum Data Set (MDS) assessment of 04/29/12 identified RI #5 as having minimal difficulty with hearing, usually able to understand others and be understood by them (good communication skills), and with a mental status score of 15 of a possible 15, indicating good cognition. On 06/20/12 at 3:40 PM, the surveyor asked RI #5 whether the staff knocked before coming into her room. RI #5 replied they typically did. When asked how it made her feel when the staff came in without knocking, RI #5 stated it did not make her feel good. "Some knock, some don't. They've been told to knock." 2) RI #12 was re-admitted on [DATE], with [DIAGNOSES REDACTED]. The 05/21/12 quarterly review MDS assessment identified RI #12 as moderately impaired in cognition with a mental status score of 10 out of 15. The resident was assessed as able to understand and be understood by others, and with moderate difficulty in hearing. Functionally, RI #12 was assessed as totally independent with walking, dressing, eating, and toileting; in need only of supervision with bathing. On 06/19/12 at 4:20 PM during the initial tour, EI #8 entered RI #12's room without knocking. On 06/20/12 at 5:30 PM, the surveyor asked RI #12 if staff routinely knocked prior to entering the room. RI #12 responded, "...Some do, some don't knock. Some are already in my room before they knock." On 06/21/12 at 8:50 AM, the surveyor asked the resident if it bothered him for staff to not knock. RI #12 explained a staff member had entered the bathroom while he was bathing (nude) that morning. The resident said he did not like it. On 06/21/12 at 10:20 AM, the Certified Nursing Assistant (EI #9) responsible for RI #12's care was interviewed. EI #9 confirmed the resident bathed himself, preferring to be completely independent other than changing his bed linens. EI #9 confirmed the resident was reliable in what he said, although a bit hard of hearing. EI #9 confirmed she had knocked on the hall door (which was open), but not on the closed bathroom door that morning, and had immediately apologized. When asked why it is important to knock before entering a resident's room, EI #9 replied, "Respect. Privacy." On 06/21/12 at 11:50 AM, the surveyor asked the Licensed Nurse (EI #8), what she could do to respect each residents' dignity and privacy. EI #8 responded, "Knock on the (resident's) door before entering and tell them I'm coming in and tell what I'm going to do." When asked why that was important, EI #8 replied, "Respect their dignity..." When asked why she had not knocked during the 06/19/12 tour, EI #8 apologized, explaining she should have knocked; she did not know why she hadn't, and did not realize she had done it. On 06/21/12 at 2:00 PM, the surveyor requested a copy of the facility's policy regarding knocking. The Administrator (EI #3) explained they educate the staff to knock before entering residents' rooms, but the facility had no written policy.

Based on observations, interviews and review of the medical record the facility failed to eliminate a malodorous smell in the room of Resident Identifier (RI) #3 on two of three days of a survey. This affected one of 13 sampled residents. Findings Include: RI #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the medical record revealed a Quarterly MDS (Minimum Data Set) with an assessment reference date of 05/09/12. The resident's BIMS (Brief Interview for Mental Status) score was listed as 15, indicating her cognition was intact. The functional status of the resident was listed as total dependence of staff for all activities daily living. The resident was incontinent of bladder, had an external catheter and was incontinent of bowel. The resident was observed on 6/19/12 at 3:50 PM, in her room seated before a laptop computer in a motorized wheelchair. A catheter was observed with a purple colored tubing and a purple colored drainage bag. The resident was alert and verbally responsive to direct questions. The resident's room was noted to have a very strong, unpleasant odor permeating throughout the room. During a brief interview with the resident on 6/19/12 at 3:55 PM, the room's strong unpleasant odor remained. RI #3 was asked if there was anything she would like to change about her room and she said, "No." She was asked about the accumulation of litter and debris on the floor and she said the room had not been cleaned for the day. An observation was made on 06/19/12 at 3:58 PM, of the adjoining bathroom, and there were no odors noted. The unpleasant odors remained in RI #3's room. On 06/20/12 at 8:00 AM, RI #3 was observed at the bedside, wearing her glasses, seated in front of her laptop computer. A strong unpleasant odor was noted in the resident's room. RI #3 was asked if she was aware of an odor and strong smell in her room, she said no. RI #3 said she did not smell an odor and housekeeping had not cleaned her room this morning. On 06/20/12 at 8:20 AM, during an interview with Employee Identifier Number (EI) #1 (housekeeper) it was revealed that the cleaning staff, care staff and the licensed nursing staff were all aware of the strong unpleasant odor in RI #3's room. When EI #1 was asked if she could smell an odor in RI #3's room, she replied yes, it was like that all the time. EI #1 was asked had she told anyone and she replied no. EI #1 was asked why not and she replied because they know; the CNAs (Certified Nursing Assistants) have to clean the resident up and everything. EI #1 was asked how often did she clean the room, and she replied everyday when she lets me, she stays in there (the room). During an interview with EI #7 (a CNA) on 06/20/12 at 8:45 AM, when asked if she noticed an odor in RI #3's room, she replied yes. When asked where did she think the odor was coming from, EI #7 replied once it was because RI #3's catheter had leaked. When asked what was done (about the leaking catheter) EI #7 replied she told the treatment nurse (EI #4) and EI #4 changed the catheter. EI #7 was asked if changing the bag made a difference and she replied, yes. EI #7 was asked if she had provided care for the resident today and she replied, yes. EI #7 was asked if she had noticed an odor and she replied, no. An observation was made of the adjoining bathroom to RI #3's room on 06/20/12 at 8:55 AM. No unpleasant odors were noted. An interview was conducted on 06/20/12 at 8:55 AM, with CNA (EI #6) who had given RI #3 a shower and provided catheter care. When asked if she had ever smelled an odor at the catheter site or catheter bag, EI #6 replied yes. When asked who had she reported the smell to, EI #6 replied, to the treatment nurse (EI #4). When asked what did EI #4 do to address the odor, EI #6 replied, changed the (catheter) bag out. When asked did changing the bag out help the odor, EI #6 replied, yes. An observation of the resident's room was made on 06/20/12 at 11:23 AM. A strong unpleasant odor was in the room. RI #3 was observed seated in her motorized wheelchair with three CNAs at the side of her chair. The resident was about to be transferred by a mechanical lift from her wheelchair to the bed for a catheter check and/or replacement by EI #4 (the treatment nurse/Licensed Practical Nurse) per the CNA staff. The resident was observed on 06/20/12 at 12:00 PM. The lunch meal was served in her room. The resident was fed by staff. A strong unpleasant odor remained in room. During an interview on 06/20/12 at 3:40 PM, the surveyor asked EI #4 if she had noted an unpleasant odor in the resident's room at any time. EI #4 replied she did not know how to describe the smell. EI #4 said she had allergies and did not smell things well. When asked to describe what odor did she smell in the resident's room, EI #4 replied, "I do not know. Strong." When asked if anyone had tried to find out why the room had the strong odor, EI #4 replied, no. During an interview with EI #4 on 06/20/12 at 5:15 PM, the surveyor asked who changed the catheter of RI #3 on 05/21/12. EI #4 replied, she had. When asked why, EI #4 explained the catheter was leaking out of her urethra instead of going through the catheter tubing. The resident was wetting her diaper and there was no urine in the bag. When asked if she had noticed an odor at that time, EI #4 replied no, none that she (the resident) did not normally have. The resident was observed during the supper meal on 06/20/12 at 5:10 PM. A strong unpleasant order remained in the room. On 06/21/12 at 8:15 AM, RI #3's room was noted to be free of all unpleasant odors. On 6/21/12 at 9:45 AM, the surveyor asked EI #3 (the Administrator) what had the facility done differently in cleaning RI #3's room that morning. EI #3 explained, that morning they wiped the bed mattress with Lysol, soap and water. They mopped the floor and cleaned the sink in the room.

Based on observations, record review and interviews, the facility failed to position Resident Identifier (RI) #6's call bell such that the resident was able to locate it. This was observed on three of three days of the survey. RI #6 had experienced two falls, one in March 2012 and another in June of 2012. RI #6 was a risk for sustaining additional falls due to her impaired vision, unsteady gait and impaired balance. This affected one of three residents sampled for falls. Findings include: The facility policy titled, "Call Light" (undated) mandates: "1. Properly functioning call light is provided for each patient." The procedure specifies: "8. Place call light where patient can reach it all times." RI #6 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's last quarterly Minimum Data Set, (MDS) assessment, with an assessment reference date of 5/5/2012 revealed the following: In Section B, Vision, the facility assessed the resident to have moderately impaired, limited vision and did not use corrective lenses. Section C, Cognitive Patterns revealed the resident's score on the Brief Interview for Mental Status was a "5" indicating the resident was severely impaired in her ability to make daily decisions. In Section G, Functional Status, the facility assessed the resident to need extensive assistance, with a one person physical assist for transfers, bed mobility, dressing, toilet use and when performing personal hygiene. She was assessed to need limited assistance, with a one person physical assist for walking in the corridor, and for locomotion on and off the unit. For balance during transitions and walking, the facility assessed the resident to be "not steady" when moving from seated to standing position, when walking, turning around, moving on and off toilet and when making surface to surface transfers. The facility also coded the resident to have impairment in her range of motion on one side of her upper extremity. Review of the resident's care plan revealed RI #6's problem (on-set date of 12/11/2011) of: "Resident requires set-up for ADLs (Activities of Daily Living) and supervision/cues for safety due to impaired vision, unsteady gait at times, poor balance, gouty arthritis to right wrist, impaired cognition". One of many approaches included, "Call light within reach. Encourage use". Another problem of, "At risk for falls r/t (related to) hx (history) of falls, ..." included two of many approaches stated as, "Keep call light within easy reach and remind to call for assistance" and "Call light in reach and instruct/remind resident how to use it." Review of an incident report dated, 3/12/2012, revealed RI #6 was found on the floor beside her bed. The resident stated, "I slip down trying to go to the bathroom." Another incident report dated, 6/2/12, revealed the resident sustained [REDACTED]. Stated 'I was going to sit on my chair and then I was on the floor.' Resident accidentally sat on floor while trying to sit on chair." On 6/19/2012 during the initial tour of the facility, at 4:10 PM, the resident was observed sitting up in her chair with her call bell tied to the arm of the chair, below and behind her right elbow. The surveyor asked RI #6 where her call bell was. The resident looked side to side and stated she had a call bell, "Some wheres around here." She was not able to locate the bell and further stated that the staff wanted her to use the call bell as she had fallen before. She also stated she had gone to the bathroom herself sometimes. On 6/20/2012 at 7:45 AM and 3:30 PM, the resident was observed up in her chair with the call bell tied on the chair arm, behind her right elbow. On 6/21/2012 at 8:20 AM, the resident was up in her chair feeding herself breakfast, and the call bell was tied to the chair arm behind her right elbow. On 6/21/12 at 9:18 AM, the Certified Nursing Assistant (CNA) EI #12 responsible for RI #6 was interviewed. EI #12 stated she took care of RI #6 every day she worked, 5 days a week. During the interview EI #12 stated RI #6 was occasionally incontinent, wore briefs and was toileted every two hours. She stated that sometimes RI #6 would tell her when she needed to toilet and sometimes RI #6 used her call bell. EI #12 also indicated that RI #6 would sometimes go to the bathroom unassisted and EI #12 knew that RI #6 had a history of [REDACTED].#12 went to RI #6's room. RI #6 was sitting up in her chair with the call bell tied to the arm of the chair behind her right elbow. The surveyor asked EI #12 to ask the resident if she could find her call bell. The resident looked side to side and was unable to locate it. EI #12 located the bell for RI #6. The surveyor asked EI #12 to ask the resident to activate the call bell. EI #12 asked the resident to activate the call bell and after two attempts, RI #6 was able to activate the bell. An interview was conducted with the MDS Coordinator, EI #13 on 6/21/2012 at 10:25 AM. During the interview, EI #13 revealed RI #6 could use her call bell and that RI #6 had limitation in range of motion in her right hand. She also was aware that RI #6 had impaired vision and had experienced previous falls. EI #13 was asked, "Does she need assistance to go to the toilet?" EI #13 indicated RI #6 did. The surveyor asked, "Why?" EI #13 stated, "Due to vision, unsteady gait and poor balance, she's at risk for falls." The surveyor asked, "If the call bell is not within easy access/reach, and resident is at risk for falls, what are potential consequences if she can't call for assistance?" EI #13 stated, "She might get up and do it herself. We will go reassess her call bell right now... and put it in a place she can reach it."

Based on observation, record review and interview: 1) The facility failed to assure hot foods were maintained at 135 degrees F. (Fahrenheit) or above when served from the trayline. 2) The facility failed to assure eating utensils were effectively sanitized to destroy potential food borne organisms. (2009 Food Code 4-501.14) 3) The facility failed to assure sectional plastic dinnerware was free of food debris and visible soil. 4) The facility failed to assure staff prevented bare hand contact with ice during beverage preparation/service. These deficient practices posed the potential for food contamination and compromised food safety. This had the potential to affect all residents receiving meals from dining services. Findings include: 1) The facility failed to assure hot foods were maintained at 135 degrees F. (Fahrenheit) or above when served from the trayline. On 5/25/11 at 10:25 AM, a food service cook, Employee Identifier (EI) # 1, was observed taking the temperature of hot foods on the trayline. Her technique was poor: a. In that she raised the foil at the corner of the pans and inserted the thermometer. (for ten items) The thermometer should be inserted in the center of a food. b. She allowed the thermometer to touch the bottom of the pan (this would yield an inaccurate reading). 2) The facility failed to assure eating utensils were effectively sanitized to destroy potential food borne organisms. (2009 Food Code 4-501.14) On 5/26/11 at 9:30 AM, machine dishwashing was observed. The soaked flatware utensils were dispersed into 5 white cylinder containers. Staff sprayed the cylinders prior to running through the machine. Spoons from one of the cylinders were examined. Four of four spoons examined contained food debris and were nested with water droplets observed (not air dried). 3) The facility failed to assure sectional plastic dinnerware was free of food debris and visible soil. On 5/25/11 at 11:15 AM, sectional plates on the trayline were examined. Four of four contained water, food debris or were badly stained. EI # 1 was asked, does that look like food to you? EI #1 replied: "Yes, Ma'am". She was asked, do you see water? She replied: "un huh". 4) The facility failed to assure staff prevented bare hand contact with ice during beverage preparation/service. On 5/25/11 at 10:55 AM, EI # 4, was observed scooping ice and filling glasses of tea with ice. EI # 4 held the scoop filled with ice in her right hand and used her bare left hand to guide ice into the glasses.

Based on record review and interview, it was determined facility staff failed to follow the plan of care outlined by the physician for monitoring the clinical status and treatment outcome for Resident Identifier (RI) # 8 and RI # 9. This deficient practice impacted 2 of 15 sampled residents. Findings include: 1. RI # 8 was admitted to the facility 6/22/04, and readmitted [DATE], after hospitalization [MEDICAL CONDITION] and [MEDICAL CONDITION]. RI # 8's [DIAGNOSES REDACTED]. According to the Minimum Data Set ((MDS) dated [DATE], RI #8 was assessed with [REDACTED]. The resident required assistance with all activities of daily living and was occasionally incontinent of bladder. The Physician ordered biochemical testing for problems of Diabetes Mellitus, [MEDICAL CONDITION], and [MEDICAL CONDITION]. The original physician order [REDACTED]. an order for [REDACTED]. These orders were carried forward to May 2011. A review of nursing notes failed to contain documented evidence that samples were drawn. For the past year, staff failed to facilitate testing in 4 of 17 opportunities. 2. RI # 9 was readmitted to the facility 10/15/09, with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), dated [DATE], RI # 9 was assessed with [REDACTED]. RI # 9 required extensive assistance of two person physical assist with all activities of daily living except dining. She required supervision with set-up only for eating. RI # 9 was frequently incontinent of urine. The Physician ordered biochemical testing for problems of [MEDICAL CONDITIONS] Bladder and [MEDICAL CONDITION].The physician's orders [REDACTED]. 12/29/05. A Lipid Panel Q 3 months (March/ June/ September/December). an order for [REDACTED]. A review of the laboratory data in the medical record revealed there was no documented evidence the December 2010, blood work was obtained for the Renal Panel, Lipid Panel, nor CBC For the past year, staff failed to facilitate testing in 3 of 14 opportunities.

Based on record review and interview, the facility failed to assure laboratory services were provided timely for diagnosing, prevention, treatment or monitoring the status of clinical conditions. This deficient practice impacted Resident Identifier (RI) # 8 and RI # 9, two of 15 sampled residents. Findings include: 1. RI # 8 was admitted to the facility 6/22/04, and readmitted [DATE], after hospitalization [MEDICAL CONDITION] and [MEDICAL CONDITION]. RI # 8's [DIAGNOSES REDACTED]. According to the Minimum Data Set ((MDS) dated [DATE], RI #8 was assessed with [REDACTED]. The resident required assistance with all activities of daily living and was occasionally incontinent of bladder. The original physician order [REDACTED]. an order for [REDACTED]. These orders were carried forward to May 2011. A review of nursing notes failed to contain documented evidence that samples were drawn. A review of the laboratory reports in the medical record revealed there was no record of a January 2011 renal panel test. There was no documented evidence the Hgb A1c was tested from January 2010 nor January 2011. There was an order for [REDACTED]. The medical record failed to contain results for the scheduled October 2010 monitoring. On 4/22/11 at 1420 PM, Physician order [REDACTED].." Laboratory data test results dated as received 4/25/11 and reported to the facility on [DATE], indicated "No stool specimen received". 2. RI # 9 was readmitted to the facility 10/15/09, with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), dated [DATE], RI # 9 was assessed with [REDACTED]. RI # 9 required extensive assistance of two person physical assist with all activities of daily living except dining. She required supervision with set-up only for eating. RI # 9 was frequently incontinent of urine. The physician's orders [REDACTED]. 12/29/05. A Lipid Panel Q 3 months (March/ June/ September/December). an order for [REDACTED]. A review of the laboratory data in the medical record revealed there was no documented evidence the December 2010, blood work was obtained for the Renal Panel, Lipid Panel, nor CBC. On 5/26/11 at 10:15 AM, a request was made for the DON (Director of Nursing) EI # 2, to validate surveyor findings. On 5/26/11 at 10:30 AM, EI # 2, documented: "That 4 of 5 missing lab (laboratory) work were not available on the resident chart. I was not able to find them on the record." EI # 2 wrote: "Reviewed nursing notes for 4/25/11, and no entry of stool specimen being sent was noted. EI # 2 indicated she was going to request staff to look in closed records (for the lab results). On 5/26/11 at 2:30 PM, EI # 3, verbalized that: "There was a break down in labs due to no audits at the end of the month and no specific date to have lab work drawn by." EI # 3 was asked, what can you do? She said: "Plan to have phlebotomist to come and draw monthly lab work. Also plan to have all labs drawn by the 25th of the month. This will allow staff to do audits and obtain missing lab work."