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Based on observations, interviews and findings during a complaint investigation, it was determined the chief executive officer failed to ensure written process and procedures were in place for tracking patient remains placed in the facility's Morgue and maintaining the Morgue unit.

The findings included:

The surveyors entered the facility on 02/27/2017 at 10:15 a.m. and after a brief introduction with Staff Member #1 a tour was requested of the facility's Morgue.

While walking to the Morgue, Staff Member #1 explained the facility's Morgue was a built in refrigeration unit located on the first floor in a hallway, which had access to the loading dock. Staff Member #1 and the surveyors arrived at the Morgue unit by 10:28 a.m. on 02/27/2017. Staff Member #1 then placed a call for access to the Morgue refrigeration unit. At 10:36 a.m. on 02/27/2017 Staff Members #4 and #5 arrived with the key to the Morgue unit. Staff Member #5 opened the Morgue unit to reveal one black body bag with remains.

During the observation, Staff Member #6 arrived at approximately 10:38 a.m., and explained the Morgue unit was under his/her department's responsibility. The surveyor requested the past eighteen (18) months of temperature logs for the Morgue unit. Staff Member #6 explained his/her department did not keep documented temperature logs for the Morgue unit. Staff Member #6 stated, "When my personnel performs rounds they glance at the gauge and if it is alright, they move on." The surveyor inquired how Staff Member #6's staff would know if the Morgue unit was working at the right temperature. Staff Member #6 reported if the unit was running, it was at the right temperature." The surveyor requested a list of patients' remains stored in the Morgue unit with their disposition and documented maintenance service performed on the Morgue unit for the past three years.

At 10:41 a.m. on 02/27/2017 Staff Member #5 presented a document titled "Funeral Home-August [no year designated]" to the surveyors. Staff Member #4 stated "We started a process in August (2016)." Staff Member #4 reported the document listed the names of the deceased patients with the date the body was placed in the Morgue unit and which funeral home picked up the bodies. The document listed three (3) bodies for the month of August 2016, one (1) body for October 2016 and one (1) body for January 2017. Staff Member #4 could not offer the reason the log was started or if the log was complete. Staff Member #4 verified the form only listed one date, which Staff Member #4 reported was the date the body was placed in the Morgue unit. The surveyor inquired regarding determination when the bodies were picked up by the funeral home. Staff Member #4 stated, "In order to determine the date the body was released to the funeral home you would have to look at each patient's death record."

An entrance conference and interview was conducted on 02/27/2017 at 11:50 a.m., with Staff Members #1, #2, and #3. The surveyors discussed the findings and requested the policies, procedures, and the previously requested list of all remains held in the facility's Morgue for the past three (3) years as well as any remains held longer than one (1) year.

An interview was conducted on 02/27/2017 at 2:02 p.m., with Staff Member #6 and Staff Members #1 and #2 were present. Staff Member #6 presented two (2) service invoices for service performed on the "Body Cooler" by an outside vendor. Staff member #6 reviewed the vendor documents with the surveyor. One invoice documented the bodies within the Morgue unit needed to be removed. The surveyor requested information related to the bodies that were removed, where the bodies went and if they returned to the facility's Morgue unit once it had been repaired. The documents presented by Staff Member #6 were difficult to read and the surveyor requested legible copies. Staff Member #6 reported he/she would have to contact the service vendor to email their copy of the original invoices. Staff Member #6 reported if any other service had been performed by facility's maintenance staff on the Morgue unit, it had not been documented.

Staff Member #6 presented legible copies at 2:31 p.m. on 02/27/2017. Review of the outside vendor's "Service Work Order" dated "9/18/2016 [Sunday]" read: "Evap (evaporator) coil block of ice. Unit running after condenser water restarted. Waiting for bodies to be removed. Send tech (technician) Monday morning [Sic]." The second invoice was dated "09/19/2016" read in part: "Located leak Liquid valve not back seating & (and) valve stem Packing ^ (increase) packing & add dress fitting ... Pull vacuum & recharge. Set water valve ... Install Temp (temperature) control to maintain temp in box [Sic]."

On 02/27/2017 Staff Member #2 presented a list of patients who had died at the facility for the past three (3) years. Staff Member #2 reported the list would also contain patients that died on hospice service. Staff Member #2 explained that a hospice service rented space within the facility and utilized the facility's Morgue unit. Staff Member #2 reported if the patient died while on that hospice service the facility would not have a death record, "since the hospice nurse would be completing the form and it would be part of the hospice service's medical record." Staff Members #1 and #2 verified the facility did not have a system to determine if or when a deceased hospice patient's remains were picked up from the facility's Morgue unit since the date for pick-up was only listed on the death record. The surveyors picked a sample from the deceased patients list provided and the "Funeral Home-August" document.

A review was conducted on 02/28/2017 of the lease agreement between the facility and the hospice service. The lease agreement did not include the hospice service's use of the facility's Morgue unit. The lease agreement did not include information related to the actions to be taken by the hospice service staff whenever a hospice patient died at the facility.

On 02/28/2017 at 8:25 a.m., the surveyor reviewed Patient #8's electronic medical record (EMR) which included scanned paper documents with Staff Member #15. Patient #8's name was pulled from the facility's "Funeral Home-August" form the date associated with Patient #8 was "8/26/16." During the review of Patient #8's medical record, it was determined the patient died at the facility. The review revealed Patient #8's "Death Report" did not have documentation the funeral home had picked up the remains. The surveyor inquired if the body currently in the facility's Morgue unit belonged to Patient #8.

An interview was conducted on 02/28/2017 at 8:51 a.m., with Staff Members #1 and #2. Staff Member #2 provided the name of the patient's remains, which was currently in the Morgue unit. Staff Member #2 clarified the date on the "Funeral Home-August" form was the date the funeral home pick-up the body not the date the body had been placed in the Morgue unit. The surveyor informed Staff Members #1, #2, and #15 the name provided for the remains currently in the Morgue unit was not included on the list of patients that had died in the past three (3) year or the "Funeral Home-August" form. Staff Members #2 and #15 verified the patient had not been included. The identified patient was added to the survey sample and designated as Patient #10.

An interview was conducted on 02/28/2017 at 2:12 p.m., with Staff Members #1, #2, and #3. Staff Member #1 reported the facility did not have a means to track the remains of patients placed in the Morgue unit by the facility or the hospice service. Staff Member #1 reported the facility did not have a log or tracking documentation related to if the deceased patient's remains were "picked up from here and transported to another one of our facilities during the repairs on the Morgue unit. We will only have when the funeral home picked the patient up on their death record." Staff Member #1 reported the facility did not have a means to determine which remains were removed when the Morgue unit was under repair, where the remains were transported, if families were notified of the transfer, or if the remains were returned to the facility.

An interview and document review was conducted on 03/01/2017 with Staff Member #1. Staff Member #1 reported he/she had contacted the manufacturer of the Morgue refrigeration unit. Staff Member #1 reported the manufacturer did not have an operation manual for the exact model of the facility's Morgue unit. Staff Member #1 reported the manufacturer had assured him/her the information being presented regarding the facility's Morgue unit's operation would be the same. Staff Member #1 reported the manufacturer's "Maintenance Instructions" only recommended but did not require annual inspection of the unit. Staff Member #1 did verify the manufacturer's "Maintenance Instructions" included cleaning the unit to eliminate organisms.

Review of the manufacturer's "Maintenance Instructions" read in part: "1. To protect the cabinet finish as well as the product, the refrigerator should be cleaned often using lukewarm water and a good fungicidal detergent to eliminate air borne low temperature growing organisms ... 3. The condensing unit is completely sealed and needs no oiling or other lubrication. However, the finned condensing unit through which air passes can become clogged with lint and other foreign substances in the air. The opening between the fins should be cleaned of lint every few months ... 4. An annual inspection of the mechanical refrigerating equipment by a competent serviceman is recommended, as a mechanic can frequently make adjustments, which prevent breakdown in the future ..."

An interview was conducted on 03/01/2017 at 2:35 p.m., with Staff Member #11. Staff Members #1 and #2 were present during the interview. Staff Member #11 reported the cleaning of the Morgue unit was not directly his/her department's responsibility. Staff Member #1 reported related to the findings the facility recognized opportunity for change. Staff Member #1 reported the Morgue unit, had not previously been included on the facility's environment of care rounds but would be added. A request was made for the facility's policy related to cleaning the Morgue unit.

An interview was conducted on 03/01/2017 at 3:32 p.m., with Staff Members #1, #2, and #3. Staff Member #1 verified the lease agreement did not include how the hospice service would handle their deceased patient's remains. Staff Member #1 reported the facility had viewed the hospice service used of the facility's Morgue unit, "like electrical or water services provided to a tenant."

An interview was conducted on 03/02/2017 with Staff Member #1. Staff Member #1 presented a policy titled "Morgue Cleaning." Staff Member #1 reported the policy was primarily for facilities within their healthcare system that performed autopsies.

Review of the facility's policy titled "Morgue Cleaning" read in part: "Purpose: To ensure systematic cleaning procedure. Responsible Persons: All Environmental Service Staff [EVS]. Policy: EVS: The morgue will be cleaned daily as needed and after autopsy ..." The policy directed staff to clean the room including floors, window sills and walls. The policy was not specific to the cleaning of a refrigerated Morgue unit.

An interview was conducted on 03/02/2017 at 1:11 p.m., with Staff Member #6. Staff Member #6 presented documentation related to the facility's preventative maintenance program. Staff Member #6 presented the rating system utilized by the facility, which placed equipment on a semi-annual, annual, or no maintenance required schedule. Staff Member #6 presented documentation that the facility's Morgue unit had been placed on the "no maintenance required" status related to the mechanical functions. Staff Member #6 stated, "The body holding unit did not need annual maintenance like oiling. The unit was built to just continuously run and it fell off the annual list. But an infection control score will be added, which will pull the unit back on an annual schedule."

An interview was conducted on 03/03/2017 at 10:29 a.m., with Staff Member #1. Staff Member #1 reported he/she became aware of an issue with the facility's Morgue unit "around the Holidays (2016)." Staff Member #1 stated, "I received a complaint from the staff that worked in the two offices on the same hallway as the unit." The surveyor inquired related to the nature of the staff complaints. Staff Member #1 stated, "It was about odor." Staff Member #1 stated, "The hospice policies and procedure did not hold them accountable to provide information related to their deceased patients placed in our Morgue." Staff Member #1 reported the facility's policy and procedures did not emphasize the hospice service's accountability for documenting their patient remains with the facility or the removal of unclaimed remains from the facility's Morgue unit. Staff Member #1 reported due to the necessary filing with the court system the patient remains, were not removed until the beginning of February 2017.

Based on interview and document review, it was determined the facility staff failed to develop a restraint plan of care for one (1) of five (5) restrained/secluded patients included in the survey sample. (Patient #13)

The findings included:

A review of Patient #13's electronic medical record (EMR) was conducted on 03/01/2017 at 8:57 a.m., with Staff #3. Patient #13's EMR indicated the patient was placed in non-violent soft restraints on 02/08/2017 through 02/09/2017. Staff Member #3 navigated Patient #13's EMR and reported he/she could not find a restraint plan of care. Staff Member #3 reported it was the facility's policy to initiate a plan of care for restraints or seclusion which reflected the interventions to employ and to ensure the least restrictive method of restraint was utilized. Staff Member #3 verified the findings.

Review of the facility's policy titled" Seclusion, Restraints and Restraint Alternatives" read in part: "Document Requirements: The medical record contains documentation of: ... l. Modifications of the plan of care ..."

Based on observations, interview, document review and as part of a complaint investigation, it was determined the facility staff failed to maintain completed death records for six (6) of twelve (12) deceased patients medical records reviewed. (Patients #8, #9, #10, #11, #21 and #22)

The findings included:

The surveyors entered the facility on 02/27/2017 at 10:15 a.m. and after a brief introduction with Staff Member #1 a tour was requested of the facility's Morgue.

While walking to the Morgue, Staff Member #1 explained the facility's Morgue was a built in refrigeration unit located on the first floor in a hallway, which had access to the loading dock. Staff Member #1 and the surveyors arrived at the Morgue unit by 10:28 a.m. on 02/27/2017. Staff Member #1 then placed a call for access to the Morgue refrigeration unit. At 10:36 a.m. on 02/27/2017 Staff Members #4 and #5 arrived with the key to the Morgue unit. Staff Member #5 opened the Morgue unit to reveal one black body bag with remains. The surveyor requested a list of patients' remains stored in the Morgue unit with their disposition and documented maintenance service performed on the Morgue unit for the past three years.

At 10:41 a.m. on 02/27/2017 Staff Member #5 presented a document titled "Funeral Home-August [no year designated]" to the surveyors. Staff Member #4 stated "We started a process in August (2016)." Staff Member #4 reported the document listed the names of the deceased patients with the date the body was placed in the Morgue unit and which funeral home picked up the bodies. The document listed three (3) bodies for the month of August 2016, one (1) body for October 2016 and one (1) body for January 2017. Staff Member #4 could not offer the reason the log was started or if the log was complete. Staff Member #4 verified the form only listed one date, which Staff Member #4 reported was the date the body was placed in the Morgue unit. The surveyor inquired regarding determination when the bodies were picked up by the funeral home. Staff Member #4 stated, "In order to determine the date the body was released to the funeral home you would have to look at each patient's death record." On 02/27/2017 Staff Member #2 presented a list of patients who had died at the facility for the past three (3) years.


1. Review of Patient #8's electronic medical record (EMR), which included scanned paper documentation, was conducted on 02/28/2017 at 8:25 a.m., with Staff Member #3. Patient #8's EMR documented the patient's death occurred on 08/25/2016. The review revealed Patient #8's "Death Report" was signed by nursing staff only. Patient #8's "Death Report" did not have a physician's signature with time and date. Patient #8's "Death Report" did not list a funeral home and did not have documentation the patient's remains had been removed from the facility's Morgue. Staff Member #3 verified the findings.

2. Review of Patient #9's EMR was conducted on 02/28/2017 at 9:20 a.m., with Staff Member #3. Patient #9's EMR included scanned paper documentation. The initial review of Patient #9's EMR Staff Member #3 could not locate the patient's "Death Report." Review of the physician's "Discharge Summary" for Patient #9 indicated the patient died on 09/22/2016. At 10:39 a.m. Staff Member #1 presented Patient #9's "Death Report." Patient #9's "Death Report" was only signed by nursing staff and did not have a physician's signature with time and date. Patient #9's "Death Report" did not list a funeral home and did not have documentation the patient's remains had been removed from the facility's Morgue. Staff Member #3 verified the findings.

3. Review of Patient #10's EMR was conducted on 02/28/2017 at 12:24 p.m., with Staff Member #3. Patient #10's Emergency Department [ED] documentation indicated the patient died on 11/25/2016. Staff Member #1 identified the remains currently in the facility's Morgue as of 02/28/2017 belonged to Patient #10. Review of Patient #10's "Death Report" did not have documentation of the patient's "Preliminary Cause of Death," "Race," "Marital Status," "Valuables/Valuables Disposition," and "Address." Patient #10's "Death Report" did not indicate notification or attempted notification of the patient's attending physician or family. Patient #10's "Death Report" was not signed, dated or timed by neither nursing staff nor a physician. Staff Member #3 verified the findings.

4. Review of Patient #11's EMR was conducted on 02/28/2017 at 12:37 p.m., with Staff Member #3. Patient #11's ED documentation indicated the patient died on 07/26/2016. Review of Patient #11's "Death Report" did not have nursing staff signature with date and time. Patient #11's "Death Report" did not have a signature with time and date to indicate the patient's remains were picked up or which facility staff released the patient's remains. Staff Member #3 verified the findings.


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5. The electronic medical record (EMR) for Patient #21 was reviewed on 02/28/17 at 10:42 a.m. with Staff Member #2. Patient #21's death report revealed the physician pronounced Patient #21's death on 12/12/15 at 1:58 a.m. and electronically signed the form on 12/21/15 at 6:03 p.m. However, the "Death Record" for release of the remains revealed the actual time of death was 2:09 a.m. The surveyor was unable to locate in the EMR, any documentation of the funeral home person/persons responsible for signing the release of the deceased remains when removed from the facility. On 02/28/17, the surveyor requested further information regarding evidence of Patient #21's remains being released to a funeral home from Staff #2.

The surveyor, along with assistance from facility Staff Member #2, who was navigating the EMR, were unable to locate further documentation revealing the responsible party to whom Patient #21's remains were released to.

6. A review of Patient #22's EMR was conducted on 02/28/17 at 10:29 a.m. with Staff Member #2. Patient #22's death report revealed the physician pronounced Patient #22's death on 03/20/15 at 03:00 a.m. The surveyor was unable to locate in the EMR, any "Death Record" documentation showing evidence the funeral home person/persons responsible for signing the release of the deceased remains when removed from the facility. On 02/28/17, the surveyor requested further information regarding evidence of Patient #22's remains being released to a funeral home from Staff #2.

An interview was conducted with Staff Member #2 on 02/28/17. Staff Member #2 reported Patient #22's EMR did not have evidence Patient #22's remains were released to a funeral home, as it was not completed and it should have been.

On 02/28/17 at 4:15 p.m., the survey team reviewed the concerns of incomplete medical records with the Administrative Staff Members #1 (CEO), Staff Member #2 (Vice President of Quality), and Staff Member #3 (Chief Nursing Officer).

Based on observations, interviews, and document review during a complaint investigation, it was determined the facility's food service department failed to meet the Condition of Participation requirements by evidence of rodent droppings, multiple areas that were dirty or not maintained in a sanitary manner and lack of repair work recommended by the pest control vendor.

The findings included:

An unannounced observational tour was conducted of the facility's kitchen at 10:50 a.m. on 02/27/2017, with Staff Members #1 and #6. Observations included a staff member leaving the kitchen area carrying food that was not covered. Observations also included multiple ceiling tiles in the kitchen area which had rodent droppings.

The surveyors noted a door in the kitchen's dry storage area. This door led to the outside and there was a gap at the bottom edge, large enough for pests to enter. A partial review of the pest control service invoices revealed that twenty-three service records (from 11/2014 - 1/2017) noted the need for a "sweep for the dock plate door to exclude pest".

Other observations included food items and trash on the floor, grayish material - described by staff as "dust", uncovered food in a refrigerator, rusting and pitting of the freezer floor, dust and rodent droppings on top of a refrigerator, and torn plastic on the tray line. Also, a broken temperature gauge on the dish washer was not repaired until a surveyor was observing the temperature of the dishwasher, and noted it did not reach the required temperature.

The pest control service records also showed a recommendation to repair the laminate above the serving line on seven (7) invoices between 11/2014 and 2/2017. This had not been repaired at the time of the survey. Pans washed at the three compartment sink were noted to be stacked when wet.

An interview was conducted on 02/28/2017 at approximately 9:00 a.m., with Staff Member #10. Staff Member #10 reviewed an eight (8) page document related to kitchen staff and their area to clean, with the surveyor. Staff Member #10 acknowledged although he/she had documented assignments for the kitchen staff his/her staff had not been monitored to ensure their assigned task was performed. A contracted service also had cleaning responsibilities in the kitchen area.

Please refer to A-0620 for additional information.

Based on observations, interviews, and document review during a complaint investigation, it was determined the facility's food service director failed to ensure dietary services were managed in manner to prevent the potential spread of infectious agents related to pests and practices.

The findings included:

1. An unannounced observational tour was conducted as part of a complaint investigation within the facility's kitchen at 10:50 a.m. on 02/27/2017, with Staff Members #1 and #6. On arriving at the kitchen doorway the observation revealed Staff Member #12 leaving the kitchen and entering the hallway with two (2) uncovered half-size pans of fried chicken. Staff Member #12 entered into the facility's cafeteria side door. The surveyor inquired of Staff Member #6, a non-food handler, what was observed. Staff Member #6 reported although he/she did not work in the kitchen, "[Staff Member #12's name] should not have left the kitchen with the food uncovered." The surveyor knocked on the cafeteria's side door to speak with Staff Member #12. Staff Member #12 immediately acknowledged he/she should not have left the kitchen with the food uncovered.

Staff Members #1 introduced the surveyors to Staff Member #10. The surveyors obtained hairnets and with Staff Member #10 assistance began the kitchen tour. The observation revealed the kitchen had drop in ceiling tiles within a metal grid over the majority of the kitchen area. The surveyors initially requested one (1) ladder but suggested a second ladder for the facility's staff to simultaneously view the space between the ceiling and the drop in ceiling tiles with the surveyor.

An observation conducted while walking to the kitchen's dry storage room revealed a door leading to the outside area (Ambulance side). The door had a gap at the bottom edge, which provided a route pests could enter.

An initial observation was conducted on 02/27/2017 at 10:53 a.m. with Staff Members #1, #6, and #10 in the kitchen's dry storage room. The observation revealed a "beverage rack" with three (3) observable cans of soda on the floor under the rack, the base of the rack had multiple layers of brownish crumbling material under the right side front leg. The wire shelving unit to the right of the beverage rack had two (2) bent cans of soda on the floor under the wire rack. On the floor under a third wire shelving unit that lined the wall of the room was a bottle of ensure, a green cup, two (2) plastic dinning bowls, and three (3) packages of eating utensils. Four (4) of the wire shelving unit had a plastic sheeting cover for the bottom shelf. The plastic sheeting on each shelf had a layer of grayish material, identified by Staff Member #10 as "dust."

An initial observation was conducted on 02/27/2017 at 11:04 a.m. in the walk-in refrigerator with Staff Member #1 and #10. The observation revealed string beans had been spilled on the floor and an apple was clearly visible lying on the floor in the corner of the unit between two (2) wire shelving units. The walk-in refrigerator had a cart with two (2) trays of prepared food items in a red sauce partially covered with plastic wrap, the trays did not have an intact cover to prevent the introduction of contaminates. The observation revealed a lump of whitish substance, which appeared to be molding, on the floor under a food storage wire rack. Staff Member #10 identified the whitish lump as "probably a zucchini that has been left on the floor too long."

An initial observation was conducted on 02/27/2017 at 11:09 a.m. in the walk-in freezer with Staff Members #1 and #10. The observation revealed broken frozen noodles scattered across the floor. The intact surface of the floor within the unit was worn off in multiple areas revealing rust and pitting. The floor did not have an intact surface which could be cleaned and disinfected.

An observation was conducted at 11:15 a.m. on 02/27/2017 with Staff Member #6 and the surveyor. Staff Member #6 and the surveyor utilized ladders to view the space between the Kitchen ceiling and the drop-in ceiling tiles. Since Staff Member #12 was in the process of preparing sandwiches; ceiling tiles outside of the food preparation area was chosen for inspection. The area was near the information board towards the back of the kitchen. The surveyor used a flashlight during the observation, which revealed approximately four (4) blacken rice-size droppings on the fifth (5th) from the wall drop-in ceiling tile and approximately three (3) blacken rice-size droppings on an adjacent drop-in ceiling tile. Staff Member #6 identified the blacken rice-size droppings as mouse droppings. Related to the findings a second location was selected by the surveyor at 11:21 a.m. on 02/27/2017. The area selected was center-oriented between the dishwashing area to the rear, above and to the front of Refrigerator #7. Staff Member #6 removed two drop-in ceiling tiles, with the aid of a flashlight the surveyor and Staff Member #6 observed an uncountable number of blacken droppings ranging in size from larger than a dried-grape to rice-size on the surface of the two ceiling tiles removed. Staff Member #6 verified the observation findings and identified the dropping to be more than "just" mouse dropping and "possibly rat dropping."

Staff Member #6 and the surveyor moved up another level on the ladder and utilized the flashlight to observe a larger area of the space between the ceiling and the drop-in ceiling tiles. The surveyor was able to access an observable area of thirteen (13) ceiling tiles in length by eight (8) ceiling tiles across [each ceiling tile approximately twenty-four (24) inches by twenty-four (24) inches] the entire area had an innumerable spreading of rodent droppings of various sizes. The surveyor questioned Staff Member #6 regarding the extent of the rodent droppings and whether the contaminated area extended over the tray line and tray prep area. Staff Member #6 verified the findings and that the contaminated area was over the tray prep area and the tray line. The ceiling vents and light fixture components obstructed the view as to whether the rodent droppings were over the cooking area. Staff Member #6 informed Staff Members #1 and #13 of the findings.

At 11:26 a.m. on 02/27/2017 Staff Member #6 and Staff Member #13 moved the ladders and re-positioned them between Refrigerator #7 and the tray line preparation area. Staff Member #6 removed two (2) ceiling tiles to provide an observation area from above the tray line to above the cooking area [approximately twenty (20) ceiling tiles in length and thirteen (13) ceiling tiles across]. Staff Member #6 and the surveyor viewed the drop-in ceiling tiles with the aid of a flashlight. The drop-in ceiling tiles in this area were also covered with an incalculable amount of rodent droppings. These findings were verified by Staff Member #6. Staff Member #6 stated, "We have to replace the entire ceiling (drop-in ceiling tiles).

Observations were conducted from 11:29 a.m. through 11:38 a.m. on 02/27/2017 with Staff Members #1, #6 #10, #13 and the surveyors. The surveyor questioned the reason for the torn plastic sticking up from the surface on the top shelf of the tray line. Staff Member #10 stated, "That is the shipping plastic when the unit was brought in." Staff Member #10 could not provide the date the unit was delivered and stated, "It's been a while." Staff Member #6 and the surveyor conducted observations of the top surface of Refrigerator #7. The observation revealed multiple layers of gray matter and a cluster of blacken rice-size material. Staff Member #6 identified the gray matter as dust and the blacken rice-size material as rodent droppings. Staff Member #6 and the surveyor observed the top of Refrigerator #5, which revealed the entire top of the refrigerator was covered with gray matter/dust.

An observation of the top of Refrigerator #4 revealed layers of dust and a cluster of "mouse droppings" as identified by Staff Member #6. An observation of the top of Refrigerator #8, located within the cooking area, revealed both dust and evidence of rodent activity. Staff Member #6 verified the findings. The surveyor asked Staff Member #10 for the cleaning schedule for the kitchen, including the appliances, and major equipment utilized during meal preparation. Staff Member #10 reported the kitchen staff was responsible for general cleaning of the kitchen on a daily and weekend schedule. Staff Member #10 reported an outside vendor also cleaned the kitchen. Staff Member #10 verified the facility staff and the outside vendor failed to clean the tops of the refrigerator units and failed to note or report rodent activity. The surveyor requested documentation of the pest control service for the past three (3) years and the last two (2) food inspection reports conducted in conjunction with the Health Department.

Review of the facility's "Food Establishment Inspection Report" for "19 Oct 2016" and "1 Feb 2017" did not have documentation included for the presence of "Insects, rodents & animal..." The surveyor reviewed two additional "Food Establishment Inspection Report" for "24 Feb 2016" and "9 Jun 2016" both documented line 36 "Insects, rodents & animal not present" as in compliance.

A partial review of the pest control service invoices was conducted on 03/01/2017. The review revealed three (3) continued repeated recommendations, which involved the kitchen and the adjacent cafeteria. The three (3) repeated recommendations were:

a. The need for a "sweep for the dock plate door to exclude pest" this recommendation was listed on the invoices for-11/2014, 1/21/15, 3/25/15, 4/7/15, 6/10/15, 7/15/15, 8/19/15, 10/28/15, 11/18/15, 12/29/15, 1/20/16 and then monthly throughout 2016 and 01/2017.

b. The needed repair of the laminate above the serving line- this recommendation was listed on the invoices for-11/2014, 12/17/14, 2/15/15, 9/30/15, 11/18/15, 12/16/15, 1/20/2016, 1/18/2017 and 2/15/2017.

c. The recommendation to pour water down drains (for common areas and the kitchen) to prevent traps from drying out and becoming "harborages" for pest and rodents- the recommendation was listed 11/2014, 112/10/14, 1/21/15, 2/11/15, on three (3) invoices for September 2015, two (2) invoices in October 2015, and 11/23/2016. Review of the pest control vendor invoices revealed one invoice dated 2014 related to placing rodent traps in the kitchen ceiling. The surveyor did not find recent pest control invoices (2016-2017), which documented inspection of the kitchen ceiling or the placement of rodent traps in the kitchen ceiling.

An interview was conducted on 02/28/2017 at approximately 9:00 a.m., with Staff Member #10. Staff Member #10 reviewed an eight (8) page document related to kitchen staff and their area to clean with the surveyor. Staff Member #10 acknowledged although he/she had documented assignments for the kitchen staff his/her staff had not been monitored to ensure their assigned task was performed.

2. Observations were conducted on 03/02/2017 from 9:28 a.m. through 1:43 p.m. in the kitchen area to determine compliance with the Condition of Participation regarding food services. The tour was conducted in a manner to view equipment at the outer perimeter of the kitchen and then to work inward towards the cooking area.

Staff Member #10 reported the breakfast dishes had not been washed. Staff Member #10 started the dish washer unit the surveyor acknowledged that the unit made need to run through a couple of cycles prior to reaching the required temperature of 160 degrees Fahrenheit (F). Staff Member #10 ran the dish washer through five (5) cycles and the gauge for the wash temperature never reached 160 degrees F. Staff Members #2, #10 with the surveyors reviewed the dish washer temperature logs, which recorded the wash temperature for the past three months for the wash of each meal's dishes and equipment as exactly "160" F. Staff Member #10 stated, "I guess it broke last night."

The facility staff did contact a service vendor regarding the dishwasher during the time of the survey. The temperature gauze was broken and once repaired, showed the water temperature to be 170 to 180 degrees.

The observation continued to the three (3) compartment sink area. Staff Member #10 informed the surveyors the white dishware turned upright positioned on a table was clean. The table was positioned next to a water heater. The top of the water heater and the top of the side panel were both covered with a thick layer of gray matter. Staff Member #10 identified the gray material as dust. A cart was positioned next to the table, which had stacked pans. Staff Member #10 informed the surveyors that all pans/pots were air dried prior to stacking. The observation revealed four (4) quarter-size pans had a greasy residue on outside of the pan, which was in direct contact with the inner surface of the pan stack upon it. Three (3) full-size pans were stacked together with wet inner surfaces. Staff Member #10 verbalized that wet pans stacked together provided a breeding medium for bacteria. Staff Member #10 reported the utility staff should have made sure the pans did not have greasy residue on their outer surfaces

An observation of the air gap for the ice machine revealed a concave funnel like metal device positioned over the floor drain. A copper tubing line ran from the back of the left side of the ice machine an ended in the metal device. The observation revealed liquid dripping from the center of the bottom of the ice machine. Staff Member #10 and the surveyor donned gloves to inspect the bottom of the ice machine by touch. The inspection revealed the liquid dripped/drained from bottom of the ice machine through a round opening and within that was a smaller opening. The smaller opening contained a brownish gelatin like substance. The surveyor inquired regarding the last cleaning of the drain/opening in the bottom of the ice machine. Staff Member #10 reported he/she had not been aware of the ice machine having an opening which needed to cleaned. Staff Member #10 verified the brownish gelatin like substance had been removed from the smaller drain opening.

The observations continued to the "Breakfast Cereal" storage area. The prep table had stored pans stacked together. Staff member #10 reported the pans were clean and ready for use. Staff Member #10 and the surveyor found two (2) half-size pans stacked together with wet inner surfaces.

A reach-in freezer located in the food prep area contained one (1) opened bag of peaches and one (1) opened bag of mixed berries, which were not sealed and did not have an opened date.

An observation of the pot rack in the cooking area revealed two (2) brazier pots were stacked with wet inner surfaces.

Observations conducted in walk-in freezer #2 revealed brownish-tan clumps on the floor. Staff Member #10 identified the material as "sausage crumbles." Staff Member #10 reported the staff must have dropped it when preparing pizzas. In the next freezer one (1) box each of carrots and corn were opened with the inner plastic liner not covering the food product. Staff Member #10 stated, "The box can be left open but the plastic should be covering the food to prevent contamination." In Freezer #1 two boxes was open with frozen cakes neither box had been covered to protect the cakes from contamination; three (3) lemon-poppy seed on one box and two (2) chocolate cakes in the second box . Staff Member #10 removed the two boxes and asked Staff Member #12 to place all of the cakes in one box and cover the box. Staff Member #10 reported that kitchen staff had received training regarding methods to reduce and prevent the contamination of food product and kitchen equipment. Staff Member #10 verified the surveyor findings.

Staff Member #10 reported the survey process revealed areas of opportunity for re-education of his/her staff.

An interview was conducted on 03/02/2016 at approximately 12:44 p.m., with Staff Member #10. The surveyor presented control binders and invoices and inquired regarding the recommended repairs to keep pest from entering the kitchen. Staff Member #10 stated, "I don't receive those invoices. I didn't know about that information."

Based on observations, interviews, complaint investigation, and document review, it was determined facility staff failed to ensure the Condition of Participation was met by failing to ensure

1. The facility's kitchen was maintained in a manner to prevent harborage of rodents and
2. The Morgue unit was maintained to prevent pervasive odors.
3. Annual fire safety inspections were conducted.

The findings included:

An unannounced observational tour as part of a complaint investigation was started in the facility's kitchen at 10:50 a.m. on 02/27/2017, with Staff Members #1 and #6

An observation conducted while walking to the kitchen's dry storage room revealed a door leading to the outside area. The door had a gap at the bottom edge, which provided a route for pests to enter the kitchen area.

A partial review of the pest control service invoices was conducted on 03/01/2017. The review revealed repeated recommendations, which involved the kitchen and the adjacent cafeteria. This included the need for a "sweep for the dock plate door to exclude pest" this recommendation was listed on the invoices for-11/2014, 1/21/15, 3/25/15, 4/7/15, 6/10/15, 7/15/15, 8/19/15, 10/28/15, 11/18/15, 12/29/15, 1/20/16 and then monthly throughout 2016 and 01/2017.

An observation was conducted at 11:15 a.m. on 02/27/2017 with Staff Member #6 and the surveyor. Staff Member #6 and the surveyor utilized ladders to view the space between the Kitchen ceiling and the drop-in ceiling tiles. Since Staff Member #12 was in the process of preparing sandwiches; the initial selection of ceiling tiles for opening and inspection were outside of the food preparation area. The area initially chosen was near the information board towards the back of the kitchen. The surveyor used a flashlight during the observation, which revealed approximately four (4) blacken rice-size droppings on the fifth (5th) from the wall drop-in ceiling tile and approximately three (3) blacken rice-size droppings on an adjacent drop-in ceiling tile. Staff Member #6 identified the blacken rice-size droppings as mouse droppings. Related to the findings a second location was selected by the surveyor at 11:21 a.m. on 02/27/2017. The area selected was center-oriented between the dishwashing area to the rear, above and to the front of Refrigerator #7. Staff Member #6 removed two drop-in ceiling tiles, with the aid of a flashlight the surveyor and Staff Member #6 observed an uncountable number of blacken droppings ranging in size from larger than a dried-grape to rice-size on the surface of the two ceiling tiles removed. Staff Member #6 verified the observation findings and identified the dropping to be more than "just" mouse dropping and "possibly rat dropping."

In the same area Staff Member #6 and the surveyor moved up another level on the ladder and utilized the flashlight to observe the larger area of the space between the ceiling and the drop-in ceiling tiles. The surveyor was able to view an area of thirteen (13) ceiling tiles in length by eight (8) ceiling tiles across [each ceiling tile was approximately twenty-four (24) inches by twenty-four (24) inches]; the entire area had an innumerable spreading of rodent droppings of various sizes. Additional rodent droppings were also found in other areas of the kitchen.

Pest control invoices also revealed recommendations to pour water down drains (for common areas and the kitchen) to prevent traps from drying out and becoming "harborages" for pest and rodents- the recommendation was listed 11/2014, 112/10/14, 1/21/15, 2/11/15, on three (3) invoices for September 2015, two (2) invoices in October 2015, and 11/23/2016.

An interview was conducted on 03/02/2016 at approximately 12:44 p.m., with Staff Member #10. The surveyor presented the pest control binders and invoices and inquired regarding the recommended repairs to keep pest from entering the kitchen. Staff Member #10 stated, "I don't receive those invoices. I didn't know about that information."

An interview was conducted on 03/02/2017 at 1:11 p.m., with Staff Member #6. The surveyor inquired regarding which staff was responsible for overseeing and correcting the repeated recommendations documented by the pest control vendor. Staff Member #6 stated, "What recommendations, one of my staff signs the electronic pad there isn't a printout given." The surveyor reviewed the binders with the pest control vendor's invoices with Staff Member #6. Staff Member #6 reported the pest control vendor places the invoice in the binder on their return visit. Staff Member #6 reported the facility staff did not monitor the binders; the invoices were kept in the binders for proof of pest control services. The surveyor inquired which of facility staff was responsible for inspecting for rodents and other pest. Staff Member #6 stated, "All of us are. I think you saw my face when we looked in the ceiling, I was taken back. When I came down I said to [Staff Member #1's name] we have a problem."

Review of the facility's policy titled "Environmental Services Infection Prevention Guidelines" read in part: "H. Pest Control 1. An effective pest control program will be maintain to forestall or prevent infestation and/or eliminate infestation should it develop. 2. A preventative maintenance and inspection program will be maintained throughout all constructed spaces and surrounding property ..."

2. An observation was conducted as part of a complaint investigation of the facility's Morgue refrigeration unit on 02/27/2017 from 10:15 a.m. through 10:44 a.m., with Staff Member #1 with other staff members joining the observation. The Morgue unit's door had a built-in thermometer, which read 34 F (degrees Fahrenheit). At approximately 10:38 a.m. Staff Member #6 joined the observation and explained the Morgue unit was under his/her department's responsibility. The surveyor requested the past eighteen (18) months of temperature logs for the Morgue unit. Staff Member #6 explained his/her department did not keep documented temperature logs for the Morgue unit. Staff Member #6 stated, "When my personnel performs rounds they glance at the gauge and if it is alright, they move on." The surveyor inquired how Staff Member #6's staff would know if the Morgue unit was working at the right temperature. Staff Member #6 reported if the unit was running, it was at the right temperature." The surveyor requested documented maintenance and service performed on the Morgue unit for the past three years.

An interview was conducted on 02/27/2017 at 2:02 p.m., with Staff Member #6 and Staff Members #1 and #2 were present. Staff Member #6 presented two (2) service invoices for service performed on the "Body Cooler" by an outside vendor. Staff member #6 reviewed the vendor documents with the surveyor. One invoice documented the bodies within the Morgue unit needed to be removed. The surveyor requested information related to the bodies that were removed, where the bodies went and if they returned to the facility's Morgue unit once it had been repaired. The documents presented by Staff Member #6 were difficult to read and the surveyor requested legible copies. Staff Member #6 reported he/she would have to contact the service vendor to email their copy of the original invoices. Staff Member #6 reported if any other service had been performed by facility's maintenance staff on the Morgue unit, it had not been documented.

Staff Member #6 presented legible copies at 2:31 p.m. on 02/27/2017. Review of the outside vendor's "Service Work Order" dated "9/18/2016 [Sunday]" read: "Evap (evaporator) coil block of ice. Unit running after condenser water restarted. Waiting for bodies to be removed. Send tech (technician) Monday morning [Sic]." The second invoice was dated "09/19/2017" read in part: "Located leak Liquid valve not back seating & (and) valve stem Packing ^ (increase) packing & add dress fitting ... Pull vacuum & recharge. Set water valve ... Install Temp (temperature) control to maintain temp in box [Sic]."

An interview was conducted on 03/01/2017 at 2:35 p.m., with Staff Member #11. Staff Members #1 and #2 were present during the interview. Staff Member #11 reported the cleaning of the Morgue unit was not directly his/her department's responsibility. Staff Member #1 reported related to the findings the facility recognized opportunity for change. Staff Member #1 reported the Morgue unit, had not previously been included on the facility's environment of care rounds but would be added.

An interview was conducted on 03/02/2017 at 1:11 p.m., with Staff Member #6. Staff Member #6 presented documentation related to the facility's preventative maintenance program. Staff Member #6 presented the rating system utilized by the facility, which placed equipment on a semi-annual, annual, or no maintenance required schedule. Staff Member #6 presented documentation that the facility's Morgue unit had been placed on the "no maintenance required" status related to the mechanical functions. Staff Member #6 stated, "The body holding unit did not need annual maintenance like oiling. The unit was built to just continuously run and it fell off the annual list. But an infection control score will be added, which will pull the unit back on an annual schedule."

An interview was conducted on 03/03/2017 at 10:29 a.m., with Staff Member #1. Staff Member #1 reported he/she became aware of an issue with the facility's Morgue unit "around the Holidays (2016)." Staff Member #1 stated, "I received a complaint from the staff that worked in the two offices on the same hallway as the unit." The surveyor inquired related to the nature of the staff complaints. Staff Member #1 stated, "It was about odor." Staff Member #1 reported the odor was due to unclaimed remains. Staff Member #1 reported due to the necessity of filing documentation with the court system the patient remains were not removed until the beginning of February 2017.

3. When the surveyors asked to review the State or County Fire Marshall inspections, facility staff stated they were not sure of the last inspection, that it may have been in 2012 or 2013.

Please see A-0701 and A-0715 for additional information.

Based on observations, interviews, complaint investigation, and document review, it was determined facility staff failed to ensure:

1. The facility's kitchen was maintained in a manner to prevent harborage of rodents and
2. The Morgue unit was maintained to prevent pervasive odors.

The findings included:

An unannounced observational tour as part of a complaint investigation was started in the facility's kitchen at 10:50 a.m. on 02/27/2017, with Staff Members #1 and #6. Staff Member #1 introduced the surveyors to Staff Member #10. The surveyors obtained hairnets and with Staff Member #10 assistance began the kitchen tour. The observation revealed the kitchen had drop-in ceiling tiles within a metal grid over the majority of the kitchen area. .

An observation conducted while walking to the kitchen's dry storage room revealed a door leading to the outside area. The door had a gap at the bottom edge, which provided a route for pests to enter the kitchen area.

An observation was conducted at 11:15 a.m. on 02/27/2017 with Staff Member #6 and the surveyor. Staff Member #6 and the surveyor utilized ladders to view the space between the Kitchen ceiling and the drop-in ceiling tiles. Since Staff Member #12 was in the process of preparing sandwiches; the initial selection of ceiling tiles for opening and inspection were outside of the food preparation area. The area initially chosen was near the information board towards the back of the kitchen. The surveyor used a flashlight during the observation, which revealed approximately four (4) blacken rice-size droppings on the fifth (5th) from the wall drop-in ceiling tile and approximately three (3) blacken rice-size droppings on an adjacent drop-in ceiling tile. Staff Member #6 identified the blacken rice-size droppings as mouse droppings. Related to the findings a second location was selected by the surveyor at 11:21 a.m. on 02/27/2017. The area selected was center-oriented between the dishwashing area to the rear, above and to the front of Refrigerator #7. Staff Member #6 removed two drop-in ceiling tiles, with the aid of a flashlight the surveyor and Staff Member #6 observed an uncountable number of blacken droppings ranging in size from larger than a dried-grape to rice-size on the surface of the two ceiling tiles removed. Staff Member #6 verified the observation findings and identified the dropping to be more than "just" mouse dropping and "possibly rat dropping."

In the same area Staff Member #6 and the surveyor moved up another level on the ladder and utilized the flashlight to observe the larger area of the space between the ceiling and the drop-in ceiling tiles. The surveyor was able to view an area of thirteen (13) ceiling tiles in length by eight (8) ceiling tiles across [each ceiling tile was approximately twenty-four (24) inches by twenty-four (24) inches]; the entire area had an innumerable spreading of rodent droppings of various sizes. The surveyor questioned Staff Member #6 regarding the extent of the rodent droppings and whether the contaminated area extended over the tray line and tray prep area. Staff Member #6 verified the findings and that the contaminated area was over the tray prep area and the tray line. The ceiling vents and light fixture components obstructed the view as to whether the rodent droppings were over the cooking area. Staff Member #6 informed Staff Members #1 and #13 of the findings.

At 11:26 a.m. on 02/27/2017 Staff Member #6 and Staff Member #13 moved the ladders and re-positioned them with Refrigerator #7 at the rear and in front of the tray line preparation area. Staff Member #6 removed two (2) ceiling tiles to provide an observation area from above the tray line to above the cooking area [approximately twenty (20) ceiling tiles in length and thirteen (13) ceiling tiles across]. Staff Member #6 and the surveyor viewed the drop-in ceiling tiles with the aid of a flashlight. The drop-in ceiling tiles in this area were also covered with an incalculable amount of rodent droppings. These findings were verified by Staff Member #6. Staff Member #6 stated, "We have to replace the entire ceiling (drop-in ceiling tiles)."

Observations were conducted from 11:29 a.m. through 11:38 a.m. on 02/27/2017 with Staff Members #1, #6 #10, #13 and the surveyors. The surveyor questioned the reason for the torn plastic sticking up from the surface on the top shelf of the tray line. Staff Member #10 stated, "That is the shipping plastic when the unit was brought in." Staff Member #10 could not provide the date the unit was delivered and simply stated, "It's been a while." Staff Member #6 and the surveyor conducted observations of the top surface of Refrigerator #7. The observation revealed multiple layers of gray matter and a cluster of blacken rice-size material. Staff Member #6 identified the gray matter as dust and the blacken rice-size material as rodent droppings. Staff Member #6 and the surveyor observed the top of Refrigerator #5, which revealed the entire top of the refrigerator was covered with gray matter/dust. An observation of the top of Refrigerator #4 revealed layers of dust and a cluster of "mouse droppings" as identified by Staff Member #6. An observation of the top of Refrigerator #8, located within the cooking area, revealed both dust and evidence of rodent activity. Staff Member #6 verified the findings. The surveyor asked Staff Member #10 for the cleaning schedule for the kitchen, including the appliances, and major equipment utilized during meal preparation. Staff Member #10 reported the kitchen staff was responsible for general cleaning of the kitchen on a daily and weekend schedule. Staff Member #10 reported an outside vendor also cleaned the kitchen. Staff Member #10 verified the facility staff and the outside vendor failed to clean the tops of the refrigerator units and failed to note or report rodent activity. The surveyor requested documentation of the pest control service for the past three (3) years and the last two (2) food inspection reports conducted in conjunction with the Health Department.

A partial review of the pest control service invoices was conducted on 03/01/2017. The review revealed three (3) continued repeated recommendations, which involved the kitchen and the adjacent cafeteria. The three (3) repeated recommendations were:

a. The need for a "sweep for the dock plate door to exclude pest" this recommendation was listed on the invoices for-11/2014, 1/21/15, 3/25/15, 4/7/15, 6/10/15, 7/15/15, 8/19/15, 10/28/15, 11/18/15, 12/29/15, 1/20/16 and then monthly throughout 2016 and 01/2017.

b. The needed repair of the laminate above the serving line- this recommendation was listed on the invoices for-11/2014, 12/17/14, 2/15/15, 9/30/15, 11/18/15, 12/16/15, 1/20/2016, 1/18/2017 and 2/15/2017.

c. The recommendation to pour water down drains (for common areas and the kitchen) to prevent traps from drying out and becoming "harborages" for pest and rodents- the recommendation was listed 11/2014, 112/10/14, 1/21/15, 2/11/15, on three (3) invoices for September 2015, two (2) invoices in October 2015, and 11/23/2016. Review of the pest control vendor invoices revealed one invoice dated 2014 related to placing rodent traps in the kitchen ceiling.

An interview was conducted on 03/02/2016 at approximately 12:44 p.m., with Staff Member #10. The surveyor presented the pest control binders and invoices and inquired regarding the recommended repairs to keep pest from entering the kitchen. Staff Member #10 stated, "I don't receive those invoices. I didn't know about that information."

An interview was conducted on 03/02/2017 at 1:11 p.m., with Staff Member #6. The surveyor inquired regarding which staff was responsible for overseeing and correcting the repeated recommendations documented by the pest control vendor. Staff Member #6 stated, "What recommendations, one of my staff signs the electronic pad there isn't a printout given." The surveyor reviewed the binders with the pest control vendor's invoices with Staff Member #6. Staff Member #6 reported the pest control vendor places the invoice in the binder on their return visit. Staff Member #6 reported the facility staff did not monitor the binders; the invoices were kept in the binders for proof of pest control services. The surveyor inquired which of facility staff was responsible for inspecting for rodents and other pest. Staff Member #6 stated, "All of us are. I think you saw my face when we looked in the ceiling, I was taken back. When I came down I said to [Staff Member #1's name] we have a problem."

Review of the facility's policy titled "Environmental Services Infection Prevention Guidelines" read in part: "H. Pest Control 1. An effective pest control program will be maintain to forestall or prevent infestation and/or eliminate infestation should it develop. 2. A preventative maintenance and inspection program will be maintained throughout all constructed spaces and surrounding property ..."

2. An observation was conducted as part of an complaint investigation of the facility's Morgue refrigeration unit on 02/27/2017 from 10:15 a.m. through 10:44 a.m., with Staff Member #1 with other staff members joining the observation. The Morgue unit's door had a built-in thermometer, which read 34 F (degrees Fahrenheit). At approximately 10:38 a.m. Staff Member #6 joined the observation and explained the Morgue unit was under his/her department's responsibility. The surveyor requested the past eighteen (18) months of temperature logs for the Morgue unit. Staff Member #6 explained his/her department did not keep documented temperature logs for the Morgue unit. Staff Member #6 stated, "When my personnel performs rounds they glance at the gauge and if it is alright, they move on." The surveyor inquired how Staff Member #6's staff would know if the Morgue unit was working at the right temperature. Staff Member #6 reported if the unit was running, it was at the right temperature." The surveyor requested documented maintenance and service performed on the Morgue unit for the past three years.

An interview was conducted on 02/27/2017 at 2:02 p.m., with Staff Member #6 and Staff Members #1 and #2 were present. Staff Member #6 presented two (2) service invoices for service performed on the "Body Cooler" by an outside vendor. Staff member #6 reviewed the vendor documents with the surveyor. One invoice documented the bodies within the Morgue unit needed to be removed. The surveyor requested information related to the bodies that were removed, where the bodies went and if they returned to the facility's Morgue unit once it had been repaired. The documents presented by Staff Member #6 were difficult to read and the surveyor requested legible copies. Staff Member #6 reported he/she would have to contact the service vendor to email their copy of the original invoices. Staff Member #6 reported if any other service had been performed by facility's maintenance staff on the Morgue unit, it had not been documented.

Staff Member #6 presented legible copies at 2:31 p.m. on 02/27/2017. Review of the outside vendor's "Service Work Order" dated "9/18/2016 [Sunday]" read: "Evap (evaporator) coil block of ice. Unit running after condenser water restarted. Waiting for bodies to be removed. Send tech (technician) Monday morning [Sic]." The second invoice was dated "09/19/2016" read in part: "Located leak Liquid valve not back seating & (and) valve stem Packing ^ (increase) packing & add dress fitting ... Pull vacuum & recharge. Set water valve ... Install Temp (temperature) control to maintain temp in box [Sic]."

An interview was conducted on 03/01/2017 at 2:35 p.m., with Staff Member #11. Staff Members #1 and #2 were present during the interview. Staff Member #11 reported the cleaning of the Morgue unit was not directly his/her department's responsibility. Staff Member #1 reported related to the findings the facility recognized opportunity for change. Staff Member #1 reported the Morgue unit, had not previously been included on the facility's environment of care rounds but would be added.

An interview was conducted on 03/02/2017 at 1:11 p.m., with Staff Member #6. Staff Member #6 presented documentation related to the facility's preventative maintenance program. Staff Member #6 presented the rating system utilized by the facility, which placed equipment on a semi-annual, annual, or no maintenance required schedule. Staff Member #6 presented documentation that the facility's Morgue unit had been placed on the "no maintenance required" status related to the mechanical functions. Staff Member #6 stated, "The body holding unit did not need annual maintenance like oiling. The unit was built to just continuously run and it fell off the annual list. But an infection control score will be added, which will pull the unit back on an annual schedule."

An interview was conducted on 03/03/2017 at 10:29 a.m., with Staff Member #1. Staff Member #1 reported he/she became aware of an issue with the facility's Morgue unit "around the Holidays (2016)." Staff Member #1 stated, "I received a complaint from the staff that worked in the two offices on the same hallway as the unit." The surveyor inquired related to the nature of the staff complaints. Staff Member #1 stated, "It was about odor." Staff Member #1 reported the odor was due to unclaimed remains. Staff Member #1 reported due to the necessity of filing documentation with the court system the patient remains were not removed until the beginning of February 2017.

Based on interview and document review, it was determined the facility staff failed to ensure regular fire inspections were conducted and documentation maintained.

The findings included:

An interview was conducted on 03/02/2017 at 1:11 p.m., with Staff Member #6. The surveyor requested documentation related to the last two State or County Fire Marshall inspections. Staff Member #6 stated, "I don't have hard copies of our last Fire Marshall inspection." The surveyor inquired when the last Fire Marshall inspection occurred. Staff Member #6 reported he/she was not sure "it might have been 2012 or 2013." Staff Member #6 reported there had been a change in the leadership within the entity, which used to performed fire inspections.

Based on observations, interviews and documents reviewed, it was determined the facility staff failed to implement a system to ensure staff practiced infection reducing behaviors as evidenced by:

1. Ensuring proper hand hygiene and handling blood glucose monitoring equipment in a manner to prevent the spread
of hospital acquired infection;
2. Failure to administer medication in an aseptic environment;
3. Failure to perform environmental cleaning after patient on contact isolation and before new patient contact;
4. Facility staff failed to ensure facility's structure is in good repair and operating condition as evidenced by one (1)
of three (3) walk-in refrigerator floors did not have an intact surface and could not be disinfected;
5. Failure to maintain a sanitary physical environment as no evidence of collaboration to implement measures to
develop, identify, investigate, and evaluate measures for pest control in the food service area; and
6. Failure to handle linens in a manner to prevent the spread of infectious agents.

The findings included:

1 A. On 02/28/17 at approximately 11:35 a.m., the following was observed with Staff Member #15 (Staff Educator) during use of a point of care device: Staff Member #16 performed hand hygiene and donned gloves to perform a blood glucose check on Patient #15 in room #505. Staff Member #16 placed all supplies including alcohol pad, gauze pads, box of finger stick lancet devices, glucometer strips container and glucometer on Patient #15's bedside table. Staff Member #16 cleaned the site with alcohol prior to finger stick for blood sample. The first drop of blood was wiped away with gauze pad and second drop was placed on strip in glucometer. The glucometer was then placed on the bedside table where the box of finger stick lancets and glucometer strips remained. Staff Member #16 stated, "There are no wipes to clean the meter with, so I will need to get some." Staff Member #16 removed his/her gloves, picked up the contaminated glucometer, placed the glucometer strips container in the box of finger stick lancet devices and left Patient #15's room with no hand hygiene and a contaminated glucometer. Staff Member #16 was observed reaching into a box of gloves on the wall in the hall outside Room #509 to get another pair and no hand hygiene was performed. Staff Member #16 entered into the clean medication room, placed the contaminated glucometer on top of the box of finger stick lancets directly next to nine (9) individual staff drinking containers (some containing straws) neatly covered and sitting on a paper napkin covering the countertop. Staff Member #16 wiped the glucometer once with a "sani-cloth," waited four (4) minutes for the contact time, placed the glucometer into the clean docking station, then removed gloves and performed hand hygiene. The container of glucometer strips were not cleaned and the box of finger stick lancets were returned to the clean supplies for other patient use after they had been in a patient's room and in contact with a contaminated glucometer.

An interview was conducted on 02/28/17 at the 5 East Nursing Station with Staff Member #14 (Nurse Manager) and Staff Member #15 in regard to observations of Staff Member #16 during patient care in room #505. Staff Member #15 revealed that the glucometers are used on multiple patients and the hospital policy for cleaning glucometers is directly from the manufactures guidelines. Staff Member #15 brought the concerns of the surveyor's observations to Staff Member #14, who said he/she would re-educate Staff Member #16 regarding proper hand hygiene and point of care cleaning procedures.

Staff Member #16 failed to perform hand hygiene when leaving a patient's room and prior to donning new gloves. The container of glucometer strips were not cleaned and the box of finger stick lancets were placed for other patient use after they had been in a patient's room and in contact with a contaminated glucometer. Staff Member #16 failed to clean the glucometer according to the facility policy and procedure and manufacture's guidelines.

A review of the policy titled, "Whole Blood Glucose by Nova Statstrip" read in part the following: "Purpose: The Statstrip Glucose Hospital Meter System is intended for in-vitro diagnostic, multiple-patient use for the quantitative determination of glucose in capillary finger stick, venous whole blood, arterial whole blood, and neonate heel stick specimens. Patient Testing: Adhere to Standard Precautions and Infection Control guidelines. 24. The comment "meter cleaned" must be added to each patient result, follow the below cleaning procedure between each patient test...25. Dock the meter to allow results to transmit to meditech. Maintenance: Cleaning the exterior: The meter should never be immersed in cleaning agents...The meter's external surface should be cleaned and disinfected with a fresh bleach wipe from the EPA-approved list D. 1. Remove a fresh wipe from the canister and thoroughly wipe the surface of the meter (top, bottom, left, and right sides) a minimum of 3 times horizontally and 3 times vertically avoiding the meter's bar code scanner and electrical connector. 2. Gently wipe the surface area of the test strip port making sure no fluid enters the port. 3. Ensure the meter surface stays wet for the appropriate time based on the specific cleaner being used at the facility."

2. Observations were conducted on 02/28/17 beginning at 11:44 a.m., with Staff Member #15 and Staff Member #17 during the administration of medication on the 5 East Unit room #506 for Patient #16 on "Contact Precautions." Staff Member #17 placed the medications on a flat surface table in the designated clean area. Staff Member #17 performed hand hygiene prior to donning his/her personal protection equipment (PPE) and offering a gown and gloves to the surveyor. Staff Member #17 opened a small cabinet mobile work station within the patient's room and placed the medications on the wooden surface. The surveyor observed the mobile work station to be dirty with multiply visible white round marks and two (2) pieces of paper trash.

Staff Member #17 gathered additional supplies to prepare Patient #16's medications. Staff Member #17 informed the surveyor that Patient #16 was on contact precautions for a history of Methicillin-resistant Staphylococcus aureus (MRSA). During the observation, Staff Member #17 was observed taking Patient #16's vital signs. Staff Member #17 opened the following single dose pill packages on the dirty mobile work station and placed into a pill cup for Patient #16: Oxybutynin 5 mg tab - one tab (antispasmodics that helps decrease muscle spasms of the bladder and the frequent urge to urinate), and Ferrous sulfate 25 mg tab - one tab (treat iron deficiency anemia). Staff Member #17 obtained two (2) thirty (30) cc (cubic centimeter) syringes from the patient's supplies, opened the packaging laying the contents on the contaminated mobile work station within the patient's space. Staff Member #17 used the thirty (30) cc syringe to add sterile water for diluent use to administer the Meropenem ( ultra-broad-spectrum antibiotic used to treat a wide variety of infections) and drew up a thirty (30) cc syringe to flush Patient #16's intravenous (IV) line once the Meropenem was administered. Staff Member #17 was not observed disinfecting the vial's rubber septum on the two (2) vials of sterile water or the vial of Meropenem before administering to Patient #16.
Staff Member #17 returned to the medication preparation area on the mobile work station and started to discard the empty single dose pill packages and empty vials. Staff Member #17 used the same contaminated gloves to enter information into Patient #16's electronic medical record via mobile work station within the patient's room. Staff Member #17 closed the mobile work station and did not wipe off the medication preparation area before or after use, and did not put down a protective barrier before opening the single pill packages or drawing up the Meropenem. Staff Member #17 removed his/her PPE within the designated clean area and utilized the hand sanitizer on the way out of the room.

An interview was conducted on 02/28/17 at the 5 East Nursing Station with Staff Member #14 and Staff Member #15 in regard to observations of Staff Member #17 during patient care in room #506. Staff Member #15 acknowledged the mobile work station was dirty and should have been cleaned before and after administering the patient's medications, and the rubber septum on the vials should have been disinfected before inserting the needle into them. Staff Member #15 reported nursing staff receive training related to infection control and these observations reveal breaches in infection control practices.

The surveyor requested the facility's policy for medication administration from Staff Member #15. Staff Member #15 presented the surveyor a policy titled "Safe Use of Single and Multiple Dose Vials." The policy read in part the following: "PROCEDURE: Single-use vials: A. Use of a SDV for a single patient during the course of a single procedure. The vials should be discarded after the single use. B. If a SDV must be entered more than once during a single procedure for a single patient to achieve safe and accurate titration of dosage, use a new needle and syringe for each entry...Multi-Dose Vials: ...D. Disinfect the vial's rubber septum before piercing by wiping (and using friction) with a sterile 70 percent isopropyl alcohol swab (or other approved antiseptic swab). Allow the septum to dry before inserting a needle....."

3. At 11:30 a.m. on 02/28/17, the surveyor observed a housekeeping staff member exiting room #508, a room which had a sign that the patient in that room was on contact precautions. Neither the mop head nor the mop water was changed before the housekeeping staff moved to clean the next room #509. The surveyor was actively involved observing a staff member perform a scheduled glucometer check before lunch arrived to the unit. After the completion of the glucometer check for Patient #15's blood sugar level, the surveyor proceeded to follow-up with the observation of the housekeeping staff member.

At 12:02 p.m. the surveyor observed a housekeeping staff member (Staff Member #18) cleaning room #519. Staff Member #18 was the same housekeeping staff member previously observed at 11:30 a.m. exiting room #508. Staff Member #18 was observed performing daily cleaning for room #519. After the daily cleaning of room #519 was completed, the surveyor inquired if Staff Member #18 was available for an interview outside of room #508, a contact isolation room. Staff Member #18 stated that would be fine and acknowledged he/she was covering 5 East Unit duties for a staff member that had to be off. Staff Member #18 verified he/she normally does the facility's floors and just fills in for staff as needed. The surveyor inquired when Staff Member #18 exits a contact isolation room after daily cleaning and enters into another patient room, are the mop heads/water changed. Staff Member #18 acknowledged that the cleaning process at the facility was to change the mop head and water every three (3) rooms. Staff Member #18 continued reporting that most of the environmental services' staff don't like using the string mop because it is too heavy, but will use the microfiber mops, which are changed after each room cleaning.

An interview was conducted on 03/01/17 at 2:51 p.m. in the conference room with the Director of Environmental Services (Staff Member #11). The facility administration staff were informed of the findings and a policy/procedure was requested. Housekeeping practices should minimize the potential for transmission of microorganisms, including proper methods to clean and disinfect equipment and environmental surfaces. Staff Member #11 stated, "Everyone should have the same training, even the employees that fill in." Staff Member #11 verified he/she had only been in the director position for approximately six (6) weeks and currently some staff are using carts with ring mops (string mops) and the water is changed every three (3) patient rooms, and some staff are using the microfiber mops that get changed between each patient's room. Staff Member #11 stated, "My goal is to make sure all staff have and implement the same microfiber system."

The policy titled "Patient Room Daily Cleaning" was received on 03/01/17 at 3:20 p.m. and read in part: "Purpose: To ensure proper cleaning techniques for cleaning in patient rooms. PROCEDURE: 1. Protective gloves should be worn, along with other applicable personal protective equipment as needed.For [sic] 2. isolation rooms. Guidelines for the listed precautions and procedure EVS 303 will be followed. Hands will be washed before putting on gloves and after each glove change. Gloves will be changed between rooms and if torn or punctured. 3. Solution in mop bucket should be changed after every isolation room cleaning, if it appears to have visible dirt and as often as needed with a minimum change out of every three rooms. 4. Wet mop and dust mop heads should be changed after cleaning every isolation room cleaning, whenever they have visible dirt/soil and as often as needed with a minimum change out of every three rooms. 5. Separate cleaning cloths should be used in patient rooms and patient restrooms....."

4. An observation was conducted on 03/02/17 starting at 9:28 a.m. in the Food Service area. The observation revealed one (1) of three (3) walk-in refrigerator floors in Refrigerator #3 (Produce Box) having an exposed porous metal surface, with evidence of a previous smooth coating that had been worn, revealing a porous and non-intact surface. The surveyor conducted the observation in the presence of Staff Member #10 (Director of Dietary Services), Staff Member #31 and a second surveyor. The walk-in metal floor covered an area approximately eight (8) foot by six (6) foot. Staff Member #10 verified the findings.

During an interview with Staff Member #10, the survey team asked how the metal floors are cleaned. Staff Member #10 stated the floors are cleaned daily. Staff Member #10 confirmed the metal coating had worn off and the floor was back to a porous, non-intact metal surface. Staff Member #10 verified the floor's non-intact surfaces prevented it from being disinfected.

The survey team held a discussion of the observations and concerns with Staff Member #1 (CEO), Staff Member #2 (Vice President of Quality), Staff Member #3 (Chief Nursing Officer) on 03/02/17 during the end of the day meeting at 3:45 p.m.

5. The initial tour of the Food Service area was conducted on 02/27/17 at 10:53 a.m. with the presence of Staff Member #1 (CEO), Staff Member #2 (VP of Quality), Staff Member #6 (Director of Physical Plant), Staff Member #10 (Director of Dietary Service), and Staff Member #13. At 11:15 a.m., observations were conducted from two (2) ladders utilized by one (1) surveyor and Staff Member #6, opening and observing into the following drop ceiling areas: observations at 11:15 a.m. in the drop ceiling area by the "Information Board" and linen closet revealed mouse/rat feces located on the fifth ceiling panel from the wall. Observations at 11:21 a.m. in the drop ceiling area by Refrigerator #7 located in the center of the kitchen area looking toward the food prep area for an area of ceiling tiles covering eight (8) across and thirteen (13) long were covered in mouse/rat feces. Observations at 11:29 a.m. revealed mouse/rat feces on the top of Refrigerator #4. Observations at 11:32 a.m. revealed mouse/rat feces and chewed up rat debris on the top of Refrigerator #8 located across from the food prep area where food is prepared on the stove/grill. The facility administration staff were informed of the findings and a pest control policy/procedure was requested.

An interview was conducted with the Director of Infection Control (Staff Member #28) on 02/28/17 at 2:26 p.m. in the conference room. The surveyor asked Staff Member #28 what is the infection control officer's role in maintaining a sanitary physical environment related to pest control. Staff Member #28 stated, "We (Infection Control) are not involved in pest control or scheduling the vendor. Unless we (Infection Control) observe rodents/pest or receive information that there is a pest problem, then we (Infection Control) are not involved." The surveyor asked Staff Member #28 if he/she was aware of a rodent problem in the Food Service area. Staff Member #28 stated, "I was not aware of any problems." Staff Member #28 reported the infection control officer participates in conducting EOC rounds once a week in different areas of the hospital. The Food Service area is included in the rounds; however the EOC rounds are on a rotating schedule that include all areas of the hospital, each area gets observed at least twice a year. Staff Member #28 confirmed a food inspector from the Virginia Department of Health (VDH) are inspecting the Food Service area as required and completing reports on the findings. Staff Member #28 acknowledged the most recent project in pest control was developing a policy related to bed bugs due to the rise of cases in the community being brought into the facility. Staff Member #28 confirmed, "The staff know to call us if there is a problem with bed bugs."


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1 b. Glucometer techniques and hand hygiene observations:

An observation was conducted on 02/28/2017 from 11:38 through 112:05 p.m., with Staff Member #7. Staff Member #3 was present during the observation. Staff Member #7 performed a blood glucose check for Patient #20. Staff Member #7 laid the glucometer on the bed with the patient. After performing the glucose check Staff member #7 removed the test strip with blood from the glucometer with a gloved hand. Staff Member #7 other gloved hand to roll the glove with an enclosed used test strip from his/her hand and discard. Staff Member #7 used his/her ungloved hand to place the glucometer under his/her left arm pressing it against his/her body contaminating his/her uniform. Staff Member #7 removed his /her other glove and started to exit Patient #20's room. Staff Member #7 returned to the glove box in the patient's room, removed gloves without performing hand hygiene, and then performed hand hygiene on the way out of the patient's room. Staff Member #7 entered the area across from the automated medication dispensing system, placed the contaminated glucometer on a desk. Staff Member #7 donned the contaminated gloves and started a four minute process of cleaning the glucometer. Staff Member #7 reported the process was complete placed the glucometer in its docking unit. Staff Member #7 reviewed Patient #20's medication orders and prepared the patient's dose of insulin. Staff Member #7 did not disinfect the desk where the contaminated glucometer had been placed.

The observation with Staff Member #7 continued at approximately 11:59 a.m. Staff Member #7 administered the insulin to Patient #20. Staff Member #7 used the same gloves to enter data into the computer in the patient's room.

An observation was conducted on 03/01/2017 from 11:37 a.m. through 12:29 p.m., with Staff Member #32 during the cleaning of a discharged patient's room. Staff Members #3 and #11 observed the cleaning process from the doorway and hall. The observation revealed that Staff Member #32 changed his/her gloves three times without performing hand hygiene between glove changes. The observation revealed Staff Member #32 left the room to obtain linens to make the bed but did not perform hand hygiene on exiting the room. When Staff Member #32 returned to the room he/she did not perform hand hygiene after entering the room.

An interview was conducted on 03/01/2017 at 12:29 p.m., with Staff Member #3. Staff Member #3 reported Staff Member #32 failed to perform hand hygiene between three glove changes and failed to perform hand hygiene on exiting and entering the room.

6. An observation was conducted on 03/01/2017 from 11:37 a.m. through 12:29 p.m., with Staff Member #32 during the cleaning of a discharged patient's room. Staff Member #32 left the room to obtain linens to make the bed but did not perform hand hygiene on exiting the room. On entering the clean linen storage room Staff #32 failed to utilize the hand sanitizer. Staff member #32 retrieved the clean linens with contaminated hands. When Staff Member #32 returned to the room he/she did not perform hand hygiene after entering the room. Staff Member #32 placed the linens on the over the bed table. During the placement of the sheet on the bed, Staff Member #32 fanned the sheet in the air several times in an attempt to spread the sheet evenly on the bed.

An interview was conducted on 03/01/2017 at 12:29 p.m., with Staff Member #3. Staff Member #3 reported Staff Member #32 failed to correctly follow infection prevention process for "gently unfolding the sheet on the bed." Staff member #3 reported it was not the facility's policy to fan the sheet in the air during the bed making task.

Review of the facility's policy titled "Environmental Services Infection Prevention Guidelines" read in part: "B. Discharge and transfer bed cleaning ... 5. Hands will be washed after cleaning each bed and before handling clean linen ..."