Based on observation, interview and review of a facility policy Cleaning of Miscellaneous Equipment and Utensils, the facility failed to ensure the drying rack did not have dust and rust on it. This deficient practice had the potential to affect 74 of the 77 residents receiving meals from the kitchen. Findings Include A review of a facility policy, titled, Cleaning of Miscellaneous Equipment and Utensils with an effective date of September 3, 2019 revealed . PURPOSE: to prevent the spread of bacteria that may cause food borne illness. STANDARD: Equipment and utensils should be cleaned . 36. Shelving - Metal and Wood: (monthly or as needed) * Remove contents from shelves * Wash and scrub * Rinse and sanitize * Air dry . On 4/11/22 at 5:29 PM during the initial tour of the kitchen the surveyor observed the drying rack with rust and had visible dust particles. The rack contained a large stainless-steel bowl. On 4/14/22 at 9:45 AM, an interview was conducted with Employee Identifier (EI) #1, Dietary Manager. EI #1 was asked if she could describe what was on the pot rack. EI #1 replied, it was rusty and dusty. EI #1 was asked who was responsible for keeping the rack from being rusty and having dust on it. EI #1 replied they all were responsible for keeping the rack from being dusty and rusty. EI #1 was asked what was the policy for keeping the pot rack free from dust and rust. EI #1 replied, they were supposed to clean it and keep it free from the dust and the rust. EI #1 was asked what the harm was in having brown looking rust and dust on the rack. EI #1 replied, it could cause someone to get sick. Some of the particles could break off and get in the food. EI #1 was asked if it was sanitary; she replied, no it was not sanitary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview and a facility policy titled, Nursing Assessments, the facility failed to ensure a Quarterly MDS (Minimum Data Set) assessment was completed timely for RI (Resident Identifier) #1. This deficient practice affected RI #1, one of 25 residents reviewed for MDS assessments. Findings Include: A review of a facility policy titled, Nursing Assessments with an effective date of August 15, 2018, revealed: .STANDARD: Comprehensive assessments should be completed on admission, quarterly and with a significant change in the resident .condition. PROCESS: .III. Quarterly .Nursing Assessments include: (once every 3 months) . RI #1 was admitted to the facility on [DATE]. RI#1's admission MDS assessment was done on 1/14/19. An interview was conducted with EI (Employee Identifier) #1, MDS Coordinator on 6/5/19 at 4:14 p.m. EI #1 was asked when should comprehensive assessments be done on residents. EI #1 said every 92 days. EI #1 was asked when was RI #1's last comprehensive assessment done. EI #1 said on 1/14/19. EI #1 was asked when should RI #1's next comprehensive assessment have been done. EI #1 said on 4/15/19. EI #1 was asked if RI #1's comprehensive assessment was done on 4/15/19. EI #1 said, No. EI #1 was asked why was RI #1's comprehensive assessment not done on 4/15/19. EI #1 said, I have a grid that I use, I just over looked it. EI #1 was asked what was the concern with comprehensive assessments not being completed on time. EI #1 said, CMS (Center for Medicare Services) would not know the resident was here and I would not know if there were any changes with the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, interview, and a facility policy titled, Oxygen Administration, the facility failed to ensure staff dated oxygen tubing and stored the oxygen tubing in a plastic bag when not in use. This affected RI( Resident Identifier) #9 and RI #32, two of four residents sampled for receiving oxygen. Findings Include: A facility policy titled, Oxygen Administration with an effective date of December 8, 2005, revealed: .PURPOSE: To administer high purity oxygen for the treatment of certain diseases or conditions . PROCESS: . 11. Cannulas and masks should be changed weekly . 14. O2 (oxygen) cannuala (cannula)/mask should be stored in a plastic bag when not in use . 1) RI #9 was admitted to the facility on [DATE] and re-admitted on [DATE], with a diagnosis of Chronic Atrial Fibrillation. A review of RI #9's June 2019 Physician Orders revealed: .OXYGEN AT 2 LITERS VIA (BY WAY OF) NASAL CANULA (CANNULA) .REPLACE AND DATE NEBULIZER MASK AND HOLDING BAG Q (EVERY) THURSDAY ON 11-7 .REPLACE AND DATE O2 TUBING AND WATER BOTTLE Q THURSDAY ON 11-7 . On 06/04/19 at 1:54 p.m., the surveyor observed RI #9 receiving Oxygen at two liters per minute by nasal cannula. There was no date on the cannula tubing or the tubing connecting the concentrator to the water bottle. There was no date on the water bottle. There was a nebulizer on the bedside table. There was no date on the nebulizer mask tubing. The nebulizer tubing was not stored inside of a plastic bag. 2) RI #32 was admitted to the facility on [DATE], with a diagnosis of Dyspnea. A review of RI #32's June 2019 Physician Orders revealed: .OXYGEN @ (AT) 2 L (LITERS)/MIN (MINUTE) PER NC (NASAL CANNULA) TO KEEP SATS (SATURATION) ABOVE 92% FOR COPD (CHRONIC OBSTRUCTIVE PULMONARY DISEASE) . An observation was made of RI #32's room on 06/04/19 at 2:14 p.m. RI #32 was not in the room. Oxygen tubing was observed laying on a bedside table, not stored in a plastic bag. An interview was conducted on 06/06/19 at 9:53 a.m. with EI (Employee Identifier) #3, RN (Registered Nurse)/Unit Manager. EI #3 was asked, who was responsible for changing oxygen tubing. EI #3 replied, eleven to seven shift on Thursday nights. EI #3 was asked, how often should oxygen tubing be changed. EI #3 replied, it is once a week. EI #3 was asked, how did she know when it was time to change the oxygen tubing. EI #3 replied, there was an order that fired off to the MAR (Medication Administration Record) on Thursday nights for the eleven to seven shift to change it. EI #3 was asked, how should the tubing be labeled. EI #3 replied, with the date it was changed. EI #3 was asked, how should oxygen tubing be stored when not in use. EI #3 replied, it was supposed to be stored in zip lock bags and sealed, and labeled with the date and the resident's name on it. EI #3 was asked, what was the potential concern for not dating the oxygen tubing. EI #3 replied, some one may assume that it had already been changed. EI #3 was asked, what was the potential concern of the oxygen tubing not being changed weekly. EI #3 replied, infection control. EI #3 was asked, what was the potential concern of the oxygen tubing not being stored correctly when not in use. EI #3 replied, infection control.

Based on observation and interview, the facility failed to ensure Room Locators (RL) # 1 was free of a missing dresser drawer, RL #2, 3 and 4 was free of missing caps on the commode bolts and RL #5 was free of scrapped and peeling sheetrock on the wall behind bed A. This affected five of 42 rooms in the facility. Findings Include: On 6/6/18 and 6/7/18, RL #1 was observed with the top dresser drawer on the left missing. 6/7/18 at 4:00 PM an observation and interview was done with EI (Employee Indentifer) #4, Maintenance Director. In RL#1, EI #4 was asked what did he see. EI #4 replied the top dresser drawer was missing. EI #4 was asked if there should be a drawer. EI #4 replied, yes. EI #4 was asked why was there no drawer. EI #4 replied, he had not had time to build a new one. EI #4 was asked what was the harm in no dresser drawer. EI #4 replied, there was no where for the resident to put things. On 6/6/18 and 6/7/18 an observation was made of RL #2, 3 and 4's commodes with missing caps over the bolts. On 6/07/18 4:10 PM an observation and interview was conducted in RL #2, 3 and 4. EI #4 was asked what did he see. EI #4 replied, the commode bolt caps were gone. EI #4 was asked if the bolts should be covered. EI #4 replied, yes. EI #4 was asked why where the bolts not covered. EI #4 replied, he was not sure. EI #4 was asked what were the risks for the bolts not being covered. EI #4 replied, it could result in a skin tear if a resident fell. On 6/6/18 and 6/7/18, observations were made of RL #5. There was scratched and peeling sheetrock on the wall at the head of the bed. On 6/7/18 at 4:20 PM, an observation and interview was made of RL #5. EI #4 was asked what did he see. EI #4 replied, scratches and peeling sheetrock behind the bed. EI #4 was asked why was there scratched and peeling paint behind the bed. EI #4 replied, staff had the bed too close to the wall when they let it up and down. EI #4 was asked what were the risks with the scratched and peeling sheetrock. EI #4 replied, there were no risks, but it was not appealing to look at. EI #4 was asked how was he notified of needed repairs. EI #4 replied, staff either told him or filled out a form and placed it in the maintenance folder and he would check the folder daily. EI #4 was asked if he had the policy on maintenance and repairs. EI #4 replied no, when staff noted the concerns he checked on them. EI #4 said some maintenance needs had priority over others.

Based on record review and review of facility policy titled,Non-Controlled Medication Destruction, the facility failed to ensure medication destruction for non-controlled medication for November 2017 had two signatures. This affected one of 12 months of medication destruction sheets reviewed. Findings Include: A review of a facility policy titled, Non-Controlled Medication Destruction dated 3/11 revealed: .NON-CONTROLLED MEDICATION DESTRUCTION .Procedures .3. The registered nurse and/or pharmacist witnessing the destruction, .ensures that the following information is entered on the Record of Medication Destruction form . J. Signature of witnesses, two witnesses required for non-controlled substances, . in the designated areas on the destruction form On 6/6/18 at 9:00 AM, the surveyor reviewed the medication destruction sheets from May 2017 through May 2018. The destruction sheets for November 2017 the non-controlled medications did not have the required two signatures. On 06/07/18 11:19 AM, an interview was conducted with Employee Identifier (EI) #1, Director of Nursing. EI #1 was asked what was the policy on signatures for medication destruction. EI#1 replied, on non-controlled medications, it was a nurse and the pharmacist. EI #1 was asked to review the non-controlled medication destruction sheet for November 2017. EI #1 was asked how many signatures did she review. EI #1 replied, one only, the pharmacist. EI #1 was asked what was the risk of only one signature on the medication destruction sheets. EI #1 replied, it could lead to a possible diversion (an unauthorized rerouting).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of facility policy titled, Wound Care Procedure for Major Wounds, the facility failed to ensure licensed staff: 1. did not place a container of 4x4's on Resident Identifier (RI) #49's bed during wound care, and 2. licensed staff did not touch a pen pulled from another staff member's pocket then touch the hydrogel treatment for RI #49. This was observed on 6/7/18 and affected one of one residents observed for wound care. Findings Include: A review of a facility policy titled, Wound Care Procedures for Major Wounds with an effective date of 12/1/09 revealed: PURPOSE: To provide guidelines for clean technique in doing wound care NOTE: . Care must be taken to prevent contamination of the supplies and surfaces used in wound care . RI #49 was admitted to the facility on [DATE], with a diagnosis of Pressure Ulcer of Sacral Region. On 6/07/18 at 8:30 AM, Employee Identifier (EI) #2, Licensed Practical Nurse, was observed performing wound care for RI #49. EI #2 washed her hands and donned new gloves. EI #2 placed the container of premoistened 4 x 4 gauze on RI #49's bed. EI #2 cleaned the wound then discarded the container. EI #2 washed her hands and donned new gloves. The staff person assisting in holding RI #49 handed EI #2 a pen she took from her pocket. EI #2 marked the date and her initials on the outer dressing then with the same gloves, cut a piece of hydrogel dressing and placed it on RI #49's wound. EI #2 then placed the outer cover. On 6/07/18 at 9:11 AM, an interview was conducted with EI #2, she was asked what was the policy on placing supplies during wound care. EI #2 replied, she was to clean table, place a barrier then place clean supplies on the barrier. EI #2 was asked when would she place a 4x4 container on a resident's bed. EI #2 replied, she would not. EI #2 was asked if she placed the container on RI #49's bed. EI #2 replied, yes. EI #2 was asked when would you touch a pen for dating a dressing then handle hydrogel. EI #2 replied, she should have washed her hands, put on clean gloves, then picked up the hydrogel dressing. EI #2 was asked what would the harm be in placing a 4x4 container on a resident's bed and touching a pen, then touching clean hydrogel with the same gloves. EI #2 replied, risking cross contamination. On 6/07/18 at 2:49 PM, an interview was conducted with EI #3, Infection Control Nurse. EI #3 was asked what was the policy on placing supplies during wound care. EI #3 replied, place the supplies on a barrier on the bedside table. EI #3 was asked when would staff place a container of 4x4's on a resident's bed during wound care. EI #3 replied, should not unless a barrier was placed on the bed. EI #3 was asked when should a staff member touch a pen with gloved hands then touch hydrogel dressing to cut a piece and place it on a wound. EI #3 replied, never. EI #3 was asked what were the risks when staff placed a container of 4x4's on a resident's bed, touched a pen with gloved hands, then cut a piece of hydrogel and placed it on a resident's wound. EI # 3 replied, infection and transferring germs.

Based on observations, interviews, a review of facility policies titled, Hand-washing Guidelines, Food Cooking and Serving Temperatures, Cleaning of Miscellaneous Equipment and Utensils, and review of a document titled, Lunch Menu Log, the facility failed to ensure: 1. staff washed their hands when entering the kitchen; 2. food temperatures on the tray line were taken and recorded on the menu log and 3. plates were not stacked wet. This had the potential to affect 67 of 69 residents who received meals from the kitchen. Findings Include: 1) A review of a facility policy titled, Hand-washing Guidelines with an effective date of 2/1/2002, revealed: .PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses PROCESS: 1. Frequency of Hand-washing: Hands should be washed in the following situations: Every time an employee enters the kitchen; . On 6/6/18 at 8:05 a.m., EI (Employee Identifier) #5, the Dietary Manager along with the Surveyor, entered the kitchen. The dietary manager did not wash her hands. On 6/06/18 at 11:14 a.m., EI #6, Assistant Cook, entered the kitchen and did not wash her hands. The hand washing sink was located near the kitchen entrance. On 6/6/18 at 5:09 p.m., the surveyor conducted an interview with EI #6. EI #6 was asked when should she wash her hands in the kitchen. EI #6 replied, every time she did something different. EI #6 was asked why she did not wash her hands when she first entered the kitchen. EI #6 replied, she went to clock in. EI #6 was asked what was the facility policy on washing her hands in the kitchen. EI #6 replied, wash her hands every time they needed to be washed. EI #6 was asked why was it important to wash her hands when entering the kitchen. EI #6 replied, to prevent cross contamination and diseases. EI #6 was asked what was the potential harm to the residents when staff did not wash their hands in the kitchen. EI #6 replied, infection control, sickness and virus. EI #6 was asked did she wash her hand when she entered the kitchen. EI #6 replied, no ma'am. EI #6 was asked should she have washed her hands. EI #6 replied, yes ma'am. On 6/7/18 at 2:20 p.m., an interview was conducted with EI #5. EI #5 was asked did she wash her hands when entering the kitchen on 6/6/18. EI #5 replied, she did not. EI #5 was asked why she did not wash her hands. EI #5 replied, she was nervous. EI #5 was asked, when should she wash her hands in the kitchen. EI #5 replied, every time she entered the kitchen or touched something. EI #5 was asked, what did the facility policy say regarding washing her hands in the kitchen. EI #5 replied, when entering the kitchen, touching her body, changing gloves, or dealing with food. EI #5 was asked why was it important that she wash her hands when entering the kitchen. EI #5 replied, so she would not pass any bacteria, infection or germs to anyone else. 2) A review of a facility policy titled, Food Cooking and Serving Temperatures with a effective date of 8/23/17, revealed: .PURPOSE: Safe and sanitary food handling practices include effective control of food temperatures, in order to prevent food borne illnesses.PROCESS: l. Food Cooking Temperatures: . b. The temperature of foods should be taken at the end of cooking, to ensure doneness.III. General Guidelines: .b. Holding temperatures of TCS (Temperature Control for Safety) foods, prior to meal service. (When replenishing or batching items to the steamtable, new product should not be mixed with existing product, and the temperature of the new product should be recorded). A review of a document titled, Lunch Menu Log with a date of 6/6/18, reveal the puree meat temperature was different from the temperature the surveyor recorded. On 6/6/18 at 11:17 a.m., the surveyor observed EI #7, the [NAME] taking temperatures of the food on the trayline. EI #7 did not record the food temperature as she took them. The surveyor and EI #7 observed the puree chicken finger temperature to be 165 degrees. When she recorded the puree temperature, she put a temperature of 180 degrees on the menu log. The surveyor observed EI #8, another cook, cooking chicken tenders. As she cooked the chicken tenders she did not take the temperature of the second batch of chicken tenders before putting it in the pan on the steam table. At 11:41 a.m., a third batch of chicken was put in the deep fryer. When the chicken was removed, no temperatures were taken and the chicken was placed in the pan on the tray line. Chicken from the fourth batch of chicken was not taken. When it was done, it was placed in a pan on the steam table with eight pieces of chicken tenders already in the pan. On 06/07/18 at 12:19 p.m., an interview was conducted with EI #7. EI #7 was asked what was the temperature of the puree chicken tenders. EI #7 replied,180 degrees. EI #7 was asked did she record the temperature as she took the food temperatures on the tray line. EI #7 replied, no. EI #7 was asked why she did not record the temperatures as she took them. EI #7 replied, because she was trying to hurry up and get the lunch meal out. EI #7 was asked what did the facility policy say regarding recording food temperatures on the tray line. EI #7 replied, record as soon as possible. EI #7 was asked who took the temperature of the second batch of chicken tenders. EI #7 replied, EI #8. EI #7 was asked who took the temperature of the third and fourth batch of chicken. EI #7 replied, she was not sure. EI #7 was asked was there chicken in a pan on the steam table and new chicken was placed in the pan that was on the steam table. EI #7 replied, yes. EI #7 was asked should new chicken be placed on top of chicken already in a pan. EI #7 replied, no. EI #7 was asked what did the facility policy say on placing new food items on top on old food items. EI #7 replied when bringing fresh chicken to the trayline, they should put it in a new pan. EI #7 was asked what was wrong with putting new chicken on top of old chicken. EI #7 replied, they were not using the first in first out method. EI #7 replied, the old chicken would have gotten cold. EI #7 was asked who was responsible for taking food temperatures. EI #7 replied, the cook. EI #7 was asked why was there a difference between the surveyor temperature of the puree chicken tenders and her temperature on the log. EI #7 replied she did not record her temperatures as soon as she took them and she mixed up the numbers. On 06/07/18 at 2:16 p.m. ,the surveyor conducted an interview with EI #8, the cook. EI #8 was asked who recorded and took the temperature of the second, third and fourth batch of chicken. EI #8 replied, no one. EI #8 was asked who was responsible for taking food temperature on the tray line. EI #8 replied, the cook (morning cook). EI #8 was asked should new chicken be placed on top of old chicken that was in a pan on the tray line. EI #8 replied she should have gotten another pan and brought it over to the line. EI #8 was asked why new chicken should not put place on old chicken. EI #8 replied, old chicken temperatures would have dropped, it would not be the same as the new chicken. EI #8 was asked did she put new chicken on top of old chicken already in a pan on the trayline. EI #8 replied, yes, she did. EI #8 was asked why did she put new chicken on top of old chicken. EI #8 replied, she was rushing trying to get trays out. EI #8 was asked what did the facility policy say regarding putting new chicken on top of old chicken. EI #8 replied, we were not suppose to do it. EI #8 stated we were supposed to get a pan and put it in a separate pan. EI #8 was asked what was wrong with putting new chicken on top of old chicken. EI #8 replied, contamination. 3) A review of a facility policy titled, Cleaning of Miscellaneous Equipment and Utensils with an effective date of 2/23/2017, revealed: .PURPOSE: .8. Place dishes in dish rack; avoid overloading and nesting On 6/7/18 at 8:45 a.m., the surveyor observed EI #5 stacking wet plates on top of each other and putting them in the dish warmer. The surveyor observed a total of 13 plates with water in them. On 06/07/18 at 2:54 p.m.,the surveyor conducted an interview with EI #5, Dietary Manager. EI #5 was asked what was stacked on top of each other in the plate warmer. EI #5 replied, plates. EI #5 was asked what was inside the plates. EI #5 replied, water. EI #5 was asked why was there water in the plates. EI #5 replied, the dishes just came out of the dish machine and did not sit long enough to air dry. EI #5 was asked how should dish ware be allowed to dry. EI #5 replied, take them out of the dish machine and put them on a rack to air dry. EI #5 was asked who was responsible for making sure dishes were air dried. EI #5 replied, everyone. EI #5 was asked what was the facility policy on wet plates stacked on top of each other. EI #5 replied, they should not be stacked on top of each other, they should be allowed to air dry. EI #5 was asked why should plates not be stacked when wet. EI #5 replied, it could cause bacteria to grow.