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This Condition of Participation is not met based on the facility failure to comply with state licensure requirements for food service standards, laws and regulations as evidenced by failure of the facility to ensure all dishes, utensils, and containers used for preparing and cooking of patient food are adequately cleaned and sanitized properly to prevent the potential for food borne illnesses.

The findings include:

1) On 12/13/10 at 10:00 a.m. a dietary staff employee was observed washing pots, pans, and cooking utensils by hand in a three compartment sink. He stated he tested the sanitizer levels in the third sink earlier and was unable to verbalize the results to the surveyor. When asked if he recorded the results anywhere there was no answer and the certified dietary manager (CDM) arrived with the sanitizer test strips obtained from his office. The CDM tested the sanitizer and obtained the result of 200 ppm. The CDM confirmed at that time that there is no records kept of the sanitizer testing and could not produce proof the staff was consistent in sanitizing hand washed items.

During an interview with the Infection Control Coordinator on 12/14/10 at 10:02 a.m. revealed she inspects the kitchen three times a week according to the facility sanitation inspection checklist. She stated she goes into the CDM's office and obtains the test strip and randomly tests the sanitizer. She states she is unaware if the dietary staff documents their daily results anywhere. Review of a blank sanitation inspection check list the Infection Control Coordinator uses reveals on the back under the clean up dish area number five states, "Verify sink sanitation with ppm (parts per million) strip, staff records this daily. Recording to be 400 ppm." Further review of completed checklists by the Infection Control Nurse reveals no readings recorded only a check mark indicating the task was completed.

Review of the facility policy titled Manual Washing (pots and pans) reveals in number eight: "Be sure that the sanitizing agent remains effective by using test kit. Replace with fresh water and sanitize as needed." During the interview with the CDM on 12/13/10 at 10:07 a.m., the CDM was unable to produce proof that the staff is compliant with ensuring all equipment washed by hand in the three compartment sink was sanitized properly to prevent food borne illnesses.

2) Observation on 12/13/10 at 10:09 a.m. of the dish washing area revealed a cart under a counter next to the dishwasher across from the three compartment sinks containing upside down stacked cereal bowls and desert bowls. Further inspection of the bowls revealed they were recently washed and "wet nesting" on each other. Further inspection of the same wet bowls reveal food particles remaining on the bowls. A few of the bowls were observed to be chipped on the edges producing a potential hazard for residents or staff. The CDM stated, "Someone is not doing their job" and removed the bowels to be washed again. Observation of the bottom of the cart revealed old food particles including a piece of lettuce.

Observation on 12/13/10 at 1:05 p.m. of the dish washing machine reveals the thermometer dials read as follows while the dish machine was not in use: Wash - 140 degrees, Rinse - 90 degrees, and Final Rinse - 180 degrees. The employee assigned to washing dishes was then observed to spray a rack of plates and Dinex plate covers then pushed them into the dish machine. The complete process took 90 minutes before they reappeared on the other side. The dials were observed to not move during the wash measuring Wash- 140, Rinse - 90, and Final Rinse - 180. The CDM then dismantled the machine, drained it and added a large container of ice and water. The dials then read wash -120, Rinse - 90, and final rinse- 160. He then restarted the dishwasher, started a cycle and peered inside stating, "The rinse sprayers are not working." After two complete cycles the dials measured as follows: Wash - 138 -142, Rinse - 90, and final rinse - 200. He stated he would call the dishwasher company and have a repairman come out to inspect it.

During an interview with the CDM on 12/14/10 at 8:37 a.m. he stated the repairman came late the night before and the repairman reported to him, "One of the motors was gone and the bearings needed replaced." He stated the maintenance department will attempt to fix the dishwasher.

During another interview with the CDM on 12/14/10 at 10:50 a.m. reveals there is no policy to guide him on how to proceed when the dishwasher is not functional. He stated that they are developing a policy and states the facility will do one of three processes, 1) Use paper products, 2) Hand wash using the sanitizer in the three compartment sink, or 3) Transport the dirty dishes to the sister facility next door to be washed.

Observation of the tray line on 12/14/10 at 11:20 a.m. revealed the facility using regular china dishware and utensils to plate the lunch meal.

Observation on 12/14/10 at 1:00 p.m. revealed the dietary staff handwashing dishes in the three compartment sink. The CDM tested the sanitizer which measured 100-200 ppm.

A policy titled "Warewashing" was submitted by the CDM on 12/14/10 at 4:00 p.m. revealing in the procedure under dishwashing article seven: "If the dish machine is incapacitated, disposable plates, utensils, and supplies will be used."

On 12/14/10 at 4:55 p.m. on the second floor patients were observed seated in the hallway across from the nurses station and eating from regular china plates and flatware.

Based on clinical record review the facility failed to ensure patients receive care in a safe setting for 1 (Patient #7) of 55 patients, as it relates to the safe and accurate administration of medications. Refer to A-0406 for additional information.

The findings include:


During a clinical record review on 12/15/10 for Patient #7, physician's orders were reviewed. The following medication orders were received by pharmacy and nursing and followed. The medication orders were incomplete and the clinical record did not contain any clarification of the orders prior to nursing administering the medications:
11/21 - 2115 (9:15 p.m.)
Ativan 0.5 mg IM) (intramuscular) times one dose now - no indication for use

11/23 - 1525 (5:25 p.m.)
Seroquel 25 mg p.o. q 1700 (5:00 p.m.) - no indication for use

11/25 - 2100 (9:10 p.m.)
Ativan 1 mg IM (intramuscular) or p.o. (by mouth) now- no indication for use

11/30 - 1620 (4:20 p.m.)
Seroquel 75mg p.o. (by mouth) q (every) 1400 (2:00 p.m.) - no indication for use
Seroquel 25mg p.o. q 1700 (5:00 p.m.) - no indication for use
Seroquel 50mg p.o. q 2100 (9:00 p.m.) - no indication for use

Seroquel is an Antipsychotic - unlabeled uses for Agitation and dementia. (Mosby's Nursing Drug Reference, 23rd Edition, 2010)
Ativan is a sedative, hypnotic, antianxiety medication. (Mosby's Nursing Drug Reference, 23rd Edition, 2010)
In accordance with standard practice, elements that must be present in orders for all drugs and biologicals to ensure safe preparation and administration include:
o Name of patient (present on order sheet or prescription);
o Age and weight of patient, when applicable;
o Date and time of the order;
o Drug name;
o Exact strength or concentration, when applicable;
o Dose, frequency, and route;
o Quantity and/or duration, when applicable;
o Specific instructions for use, when applicable; and
o Name of prescriber.

Based on observation, interviews, and record review, the facility failed to ensure the nursing staff develops, and keeps current, a nursing care plan for each patient. 4 (Patients #42, #47, #48, and #50) of 55 sampled patients did not have current care plans to reflect the needs of the patient.

The findings include:

1. Patient #42 was admitted to the hospital on 11/29/10 with a diagnosis of, but not limited to, status post right hip fracture with ORIF (open reduction internal fixation); morbid obesity anxiety and sleep apnea.

Review of the patient's clinical record revealed interdisciplinary assessment dated 11/29/10. The printed body figure shows the patient has staples on right hip and a blister on the posterior left thigh. A picture of the blister was in the wound assessment/re-assessment record and it was documented to be 4 cm long and 3 cm wide. Current treatment: initial.

A second wound assessment/re-assessment was dated 12/09/10. Wound type: other; unable to stage; 2 cm long and 1 cm wide; undermining: no; is there a change in the treatment from previous update: no; has the patient's skin condition improved? yes a bit now 2x1.

After obtaining permission from the patient to observe the area with the wound care nurse, on 12/13/10 at 11:45 a.m. an observation of the wounds was made. Both areas appeared to be healed. The wound care nurse stated the area on the right thigh was caused by sheering when positioning the patient in bed.

Review of the care plan dated 11/29/10 reads in part: "use lift/draw sheets to prevent friction while moving patient in bed."

During an interview with the wound care nurse on 12/14/10 at 10:30 a.m. she confirmed there was no other documentation of the wound on the right thigh. She could not find another assessment to compare the re-assessment with. There were no orders for treatment. The care plan did not address the wounds.

On 12/14/10 at 2:45 p.m. these concerns were shared with the CNO (chief nursing officer).


2. Patient #47 was admitted to the facility on 11/29/10 with a diagnosis of, but not limited to, encephalopathy due to traumatic brain injury, subdural hematoma, and dysphagia. Observation of the patient on 12/13/10 revealed the patient returning from a physical therapy treatment. He was alert and oriented. A sign by the door in the hallway revealed the patient is NPO (nothing by mouth).

Review of the patient's care plan for nutrition revealed the patient is receiving Jevity 1.5 and water flushes by tube feeding (TF). Concerns- "Pt did not tolerate higher TF rate for nocturnal feeds." Accomplishment of goals notes: "12/07/10 -TF is tolerated at continuous rate 45ml per hour."

Review of physician orders dated 12/10/10 reveals the following: change Jevity 1.5 to 75 ml/hr to run from 1600-0800. Change flushes to 150ml every 4 hrs. per nutrition protocol.

The care plan did not reflect the increase of the Jevity.

During an interview with the RD (registered dietician) on 12/13/10 at 3:45 p.m. she confirmed the higher TF rate was not documented in the care plan.

3. Patient #48 was admitted to the facility on 12/03/10 with a diagnosis of, but not limited to, status post stabbing to left neck; left carotid artery laceration; CVA (cerebral vascular accident) left hemispheric with right hemiparesis. The patient was admitted with a naso-gastric (NG) feeding tube.

Review of the physician order dated 12/07/10 reads in part: change diet to pureed and nectar thick liquids. An order dated 12/09/10 reads in part: start mechanical soft diet with thin liquids. An order dated 12/10/10 reads in part: discontinue (D/C) Jevity 1.5 tube feed. Carnation instant breakfast twice a day (BID). An order dated 12/13/10 reads in part: Texture increased: regular/ thin. Nurse's note dated 12/13/10 reads in part: "Took HS (hour of sleep) meds with water. Speech slow and understandable."

Review of the patient's care plan for neurological system revealed the problems were aphasia and dysphagia. Interdisciplinary Team interventions (ITI): dated 12/03/10: swallowing precautions to include- NPO (nothing by mouth)HOB (head of bed) elevated 30 degrees.

ITI dated 12/07/10: puree/nectar. The care plan was not updated to reflect the order dated 12/13/10 for the regular diet with thin liquids.

Observation of the patient on 12/15/10 at 1:30 p.m. revealed the patient in bed, talking to someone on the telephone. The patient's mother was also in the room, she stated she was told the patient would be going home before Christmas.

4. Patient #50 was admitted to the facility on 11/29/10 with a diagnosis of but not limited to a Cerebrovascular Accident (CVA). Review of the clinical record on 12/14/10 reveals a care plan initiated on admission identifying the resident as a high risk to fall. Interventions documented between 11/29/10 and 11/30/10 failed to include the use of any alarms. On 12/1/10 an entry to the care plan read, "Compliant with safety alarms discontinued." The resident was documented as being found on the floor in the bathroom 12/8/10. The care plan has an entry on 12/8/10 "Bed/Chair alarm reinstituted" and "Education for safety." No further documented interventions noted after 12/8/10.

Review of the daily progress notes dated 12/9/10 reveal a second incident documented at 0145 a.m. "as per patient - slid off the toilet onto ground when I lost balance," no injuries obtained. Patient will be alarmed in bed and chair and will not be left alone in restroom secondary to loosing her balance." At 6:15 a.m. the patient is documented as being alert and oriented x3 and documented "patient educated to being alarmed again and not to stay by self in restroom." At 8:00 a.m. a narrative note read "Bed/chair alarm now for recent fall off the commode. Patient is embarrassed. Comfort provided." Another entry at 12:00 p.m. reveals a note stating, "Cardex updated: Do not leave patient alone in the bathroom, same note put up on outside of bathroom door."

Further review of the fall care plan fails to contain any toileting plan or directions regarding the use of the bathroom.

Based on record review, the facility failed to assure that nursing clarified incomplete medication orders prior to administering medications for Patient #7. In accordance with community standard practice, elements that must be present in orders for all drugs and biologicals to ensure safe preparation and administration include:
o Name of patient (present on order sheet or prescription);
o Age and weight of patient, when applicable;
o Date and time of the order;
o Drug name;
o Exact strength or concentration, when applicable;
o Dose, frequency, and route;
o Quantity and/or duration, when applicable;
o Specific instructions for use, when applicable; and
o Name of prescriber.

The findings include:
During a clinical record review on 12/15/10 for Patient #7, physician's orders were reviewed. The following medication orders were received and followed. The medication orders were incomplete and the clinical record did not contain any clarification of the orders prior to nursing administering the medications:
11/21 - 2115 (9:15 p.m.)
Ativan 0.5 mg IM) (intramuscular) times one dose now - no indication for use

11/23 - 1525 (5:25 p.m.)
Seroquel 25 mg p.o. q 1700 (5:00 p.m.) - no indication for use

11/25 - 2100 (9:10 p.m.)
Ativan 1 mg IM (intramuscular) or p.o. (by mouth) now- no indication for use

11/30 - 1620 (4:20 p.m.)
Seroquel 75mg p.o. (by mouth) q (every) 1400 (2:00 p.m.) - no indication for use
Seroquel 25mg p.o. q 1700 (5:00 p.m.) - no indication for use
Seroquel 50mg p.o. q 2100 (9:00 p.m.) - no indication for use

Seroquel is an Antipsychotic - unlabeled uses for Agitation and dementia. (Mosby's Nursing Drug Reference, 23rd Edition, 2010)
Ativan is a sedative, hypnotic, antianxiety medication. (Mosby's Nursing Drug Reference, 23rd Edition, 2010)