Every finding on record at Blessing Hospital Snu

Based on observation, interview, and record review the facility failed to follow a physician's order for oxygen for one of one resident (R115) reviewed for oxygen therapy in the sample of 16. Findings include: The Oxygen Delivery policy dated 11/2023 documents Upon physician order, a licensed respiratory therapist (RT) or respiratory student working under a licensed RT will provide supplemental oxygen to adult, pediatric, and infant patients to treat or prevent hypoxia. R115's Physician Order dated 10/14/24 at 9:09 AM, documents 2 (two) liters of oxygen per cannula only at night. On 10/15/24 at 10:55 AM, 10/16/24 at 10:33 AM, and 10/17/24 at 12:13 PM, R115 was sitting in his room wearing oxygen. On 10/17/24 at 12:40 PM, V11/Registered Nurse stated that R115's oxygen order was for R115 to wear the oxygen at night only. On 10/17/24 at 12:40 PM, V12/R115's Power of Attorney stated that she was glad to hear that R115 did not need to be wearing the oxygen during the day because R115 did not like to wear it. On 10/17/24 at 1:05 PM, V2/Director of Nursing stated that respiratory therapy sets the oxygen supply up. The nurses are responsible for following the physician orders.

Based on interview and record review the facility failed to ensure all as needed psychotropic medications were only ordered for 14 days for 2 residents (R60 and R162) of five residents reviewed for psychotropic medications, in a total sample of 11. Findings include: The Facility's undated Psychotropic Medication Administration and Monitoring policy documents As needed psychotropics will be limited to 14 days, at which time the Attending Physician will assess the current need for the drug prior to reordering. R60's current Physician Order Sheet documents an order dated 8/8/23, Lorazepam .25 mg (milligrams) by mouth every 6 hours as need for anxiety. The Lorazepam order documented a stop date of 8/29/24. R162's current Physician Order Sheet documents an order dated 8/21/23 Lorazepam .25 mg (milligrams) every 6 hours IV (Intravenous) Push as needed for anxiety . The Lorazepam order documented a stop date of 8/20/24. On 8/30/23 at 12:00 PM, V2 (Director of Nursing/DON) stated, Those (Lorazepam) orders got missed. I usually catch when the doctors do not put in a stop date. 34542

Based on observation, interview, and record review, the facility failed to consistently use cool down temperature logs to ensure potentially hazardous food items are safely cooled in the recommended time period; discard outdated food items (Asian dressing; cherry pie filling, sliced onion, sausage patties), label all perishable food items (chicken salad; Parmesan cheese; raw chicken; fresh pineapple, [MEDICATION(S)]; ham); record thaw date on food items taken out of the freezer (beef cubes); maintain a clean can opener, can opener base, slicer and convection ovens; and keep ladles out of dry food items (brown rice). This has the potential to affect all 12 residents living in the facility. Findings: The policy, Cooling, dated 2018, states, Ensure all foods are cooled to the proper temperatures. Cool hot foods from 140 degrees Fahrenheit (F) to 70 degrees F within two hours. Continue cooling from 70 degrees F to 41 degrees F within four hours. Make sure cooling time does not exceed a total of six hours. Monitor and record the temperatures of all cooled foods. Make sure (staff) complete the Cooling Log to record information for all items being cooled. On 6/28/21 at 11:00 AM, the Cooling Temperature Logs dated 2/17/21 through 6/15/21 were not completed as required. V4, Dietary supervisor, confirmed the logs were incomplete, stating, The cooks need to (correctly) cool down (potentially hazardous) foods and record the temperatures. This is unacceptable. The policy, Labeling, dated 2021, states, Proper labeling ensures the food we serve is fresh and safe to eat. Write the product name, the date the (food) item was prepared, the use by date and the initials of the person who prepared it. The policy, Storage, dated 2019, states, Keep foods covered while refrigerated. Ensure that bulk dry food storage bins are equipped with dispensing scoops stored out of the product in clean holders or containers. On 6/28/21 at 11:10 AM, the following foods were in the cooler with the following discard dates: Asian Dressing, two cups, 6/23/21; Cherry Pie Filling, a third pan (size of pan), half full, 6/25/21; Sliced Onion, four cups, 6/27/21; Beef Cubes, a third pan, half full, 6/25/21; Sausage Patties, a dozen, 6/25/21; Meat Sauce, a third pan, full, original date 6/13/21, when put into the freezer; thawed, without the thaw date; foods without labels an opened: five pound container of chicken salad; five pound package of shredded parmesan cheese three fourths full; raw, cut up chicken in a half pan a quarter full; a flat of fresh pineapple and a flat of fresh [MEDICATION(S)], (both packages were opened without a cover or label) one 15 pound ham, uncovered, very light pink with a dried out appearance; An opened ten pound bag of brown rice, half full, contained a ladle stored inside the package of rice. V4, Dietary Manager, confirmed that the items should have been discarded on their discard date, all food items should have had a label, frozen food items require a label with a thaw date and discard date and ladles are not to be stored in the food item. On 6/28/21, at 11:15 AM, the can opener and the base of the can opener had a build up of a black, sticky substance. The large slicer was covered/stored and had dried bits of meat on the blade and on the flat area underneath the blade where slices of meat accumulate when the slicer is used. The convection ovens had dried/burned food debris inside the ovens under the oven racks and dried splashes on the inside walls and on the inside and outside oven doors. R4, Dietary manager confirmed the slicer, can opener and the convection ovens were soiled and stated All of this needs to be cleaned. The Centers for Medicare and Medicaid (CMS) Resident's Census and Condition of Residents Report, form 672, dated 6/29/21 and signed by V10, Minimum Data Set Coordinator, documents that at the time of the survey 12 residents live in the facility. The policy, Cleaning and Sanitation, dated 6/2019, states, Everything needs to be kept clean to prevent the introduction and growth of pathogenic microorganisms. All can cause foodborne illness, injury or allergic reactions. Keep food contact surfaces free of food residue, grease deposits and soil accumulations at all times.

Based on interview, and record review, the facility failed to ensure a code status was recorded correctly on the electronic health records for one of eight residents (R160) reviewed for Advance Directives in a sample of 19. Findings include: A facility Advance Directive policy dated ,d+[DATE] documents: Adult patients have the right to formulate advance directives and Advance Directive: A written instruction prepared by a person, recognized under state law, which provides directives on how their future medical decisions will be made when the person is not capable of making decisions for him/herself. R160's Electronic Orders (POS) dated [DATE], document that R160 was admitted on [DATE] and further documents: Code Status: No cardiopulmonary resuscitation (no CPR). R160's Electronic Health Records Patient Information Comments document: Full Code, Active Status. On [DATE] at 9:25 a.m., V2 Director of Nursing (DON) stated that the advance directive wishes of the patient should match in all places on the electronic health record and that it does document Full Code Active Status under Patient Info/Comments. On [DATE] at 10:30 a.m., V5 MDS Coordinator stated: Oh, it does state that the code status under Comments says Full Code Active Status for (R160). I get what you are saying now, it should read what the current patient wishes are. On [DATE] at 11:20 a.m., V1 Administrator stated that we cannot give you the screen that states the resident (R160) is a full code and that we have corrected the patient information comments summary and that active code status Full Code has now been made inactive.

Based on observation, interview, and record review, the facility failed to attempt to use appropriate alternatives prior to instilling a side rail, failed to assess the resident for risk of entrapment before rails were installed and failed to ensure the bed's dimensions were appropriate for the residents size and weight for 4 of 12 residents (R56, R57, R58, R59) reviewed for side rails in the sample of 19. Findings: The Bed Rail Information for Residents and Families dated 07/2020, documents Bed rails (side rails) are not used routinely, and only used if alternatives fail or are not appropriate and assessment indicates the need for a bed rail, (regulations) indicate that prior to bed rails (side rails) use, the resident must be assessed for benefits of use and risk of entrapment between the mattress, bed rails and head/foot board of the bed which could result in serious injury or death. Assessment will include, at a minimum medical condition, medications, cognition, mobility and risk of entrapment. Alternatives to bed rail use such as call light, seat alarms, low bed, and floor mattress will be attempted if appropriate. On 06/26/21 at 11:13 am, R56 was in bed with a side rail on each side of his bed in the up position. On 06/26/21 at 10:10 am, R57 was in bed with the side rails up on each side of the bed On 06/28/21 2:22 PM R58 was sitting in her room in her recliner. The bed had side bed rails in the up position. On 06/28/21 12:45 PM, R59 was sitting in bed eating his dinner. The bed had side rails on each side and they were both up. On 6/30/21 at 12:52 pm, R56 stated I use the side rails a little bit. I wasn't asked anything about getting them, they were already here. On 6/30/21 at 1:05 pm, R57 stated I do use the side rails. I didn't have to ask for them they just gave them to me on my first day. On 6/30/21 at 12:55 pm, R58 stated the side rails were on the bed when she came. She said she does use them, but she did not ask for them. On 6/30/21 at 1:02 pm, R59 stated I wasn't asked if I wanted the side rails, but I do use them. They were here when I got here. On 6/29/21 at 2:30 pm, V3 (Maintenance Director) stated he remembers the side rails being an issue on one of the other reviews. After that review the bed manufacturer was contacted to get guidance about using bed rails with the beds. V3 said there was a cone that was provided by the manufacturer to use as a tool to measure to make sure the side rails were the correct distance from the bed. V3 said He does not know what happened to the cones and has not seen any around for awhile. V3 said he is aware they are not in compliance with the regulation at this time, but they are ordering more cones immediately. On 6/29/21 at 2:30 pm, V2 (Director of Nursing) stated there is a side rail assessment form a nurse fills out when each resident is admitted . V2 said they ask the resident if they want side rails and if they want them they can have them. V2 stated there are no other alternatives tried if the resident wants to use a side rail. V2 stated On the bed rail assessment sheet there is an area where the bed measurements are suppose to be checked. However, at this time we are not doing any measurements to make sure the beds are safe. The Bed Rail and Entrapment Risk Assessment for R56 dated 6/24/21, signed by V7 (Registered Nurse) documents I have measured and determined that on installation of bed rails the following measurements were in compliance. Based on the size/weight of the resident, the dimensions of the bed are appropriate to the resident. R57 Bed Rail and Entrapment Risk assessment dated [DATE], signed by V8 (Registered Nurse) documents I have measured and determined that on installation of bed rails the following measurements were in compliance. Based on the size/weight of the resident, the dimensions of the bed are appropriate to the resident. R58 Bed Rail and Entrapment Risk assessment dated [DATE], signed by V6 (Registered Nurse) documents I have measured and determined that on installation of bed rails the following measurements were in compliance. Based on the size/weight of the resident, the dimensions of the bed are appropriate to the resident. R59 Bed Rail and Entrapment Risk assessment dated [DATE], signed by V9 (Registered Nurse) documents I have measured and determined that on installation of bed rails the following measurements were in compliance. Based on the size/weight of the resident, the dimensions of the bed are appropriate to the resident. The Bed Rail Policy origination date of 05/1998, documents the policy statement: The use of bed rails requires an assessment for medical indication, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An assessment for entrapment risk will be included as well. The Procedure: During the admission process, the resident will be assessed for medical indication for the use of bed rails. Alternatives to bed rails will be attempted if appropriate. The nurse will complete an entrapment assessment and will verify that the bed rails are functioning properly. .

Based on interview, and record review, the facility failed to screen visitors upon entry into the Skilled Nursing Unit (SNU) on June 28, 2021. This failure has the potential to affect all 12 residents residing in the SNU. Findings include: A facility policy COVID-19 Testing Plan and Response Strategy for (Hospital) Skilled Nursing Unit dated 3/2021 documents: VIII. Visitor - Considerations (include management of visitor access and movement within the facility): a. Points of entry to the facility have been limited and screening of all potential visitors will be performed. On June 28, 2021 at 10:30 a.m., three state surveyors entered the SNU to complete an annual survey. No state surveyor was screened prior to entering the SNU. The surveyors began their survey and entered all 12 rooms of the residents. These same surveyors were not screened at the main level of the hospital prior to coming up to the SNU. On June 29, 2021 at 10:45 a.m., V2 Director of Nursing stated that we didn't screen any of the three surveyors yesterday upon admission to the SNU. The Centers for Medicare and Medicaid (CMS) Resident's Census and Condition of Residents Report, form 672, dated 6/29/2021 and signed by V10 MDS Coordinator, documents that at the time of the survey 12 residents reside in the facility.

Based on record review and interview, the facility failed to develop and implement an Abuse policy that includes reporting all allegations of alleged abuse to the State Agency. This has the potential to affect all 19 residents residing at the facility. Findings Include: A policy dated 5/2017 and titled Abuse: Prevention and Detection states, Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. 3. Prevention of Abuse: e. Investigation: i. Any charge or accusation by a patient or family that there has been abuse or theft must be reported to the Administrator so it can be properly investigated, even if it is obvious the patient is incorrect or mistaken. 1. The staff member is not to make the decision about an accusation on their own. The Abuse: Prevention and Detection policy also states, 3. Prevention of Abuse: g. Reporting/Responses: i. Initial Reporting of Allegations: 1. If, during the course of an incident investigation, (the facility) Administrator or designee has determined there is reasonable cause to suspect that mistreatment of [REDACTED]. a. During weekdays, notify the (Regional State Agency - phone number included). During off hours the (State Agency's) complaint hotline is (phone number included). 2. Within 24 hours after the occurrence, send the 24 Hour Preliminary Investigation Report to the (State Agency). ii. Five Day Final Investigative Report: 1. Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation (including steps the facility has taken in response to the allegation) goes to the (State Agency). On 4/19/18 at 11:10 a.m., V2 (DON/Director of Nursing) confirmed that the facility Abuse policy only requires allegations to be reported to the state agency if there is reasonable cause to suspect that mistreatment of [REDACTED]. A Resident Census and Condition of Resident form dated 4/17/18 and completed by V2 (DON) documents there are currently 19 resident residing at the facility.

Based on observation, record review, and interview the facility failed to assess for risk of entrapment for the use of side rails and failed to obtain informed consent for the use of side rails for eight of eight residents reviewed for siderails (R11, R116, R117, R118, R166, R167, R168 and R173) in a sample of 11 and 10 (R113, R114, R119, R163, R164, R165, and R169-R172) residents not on the sample. Findings include: On 04/18/18 from 1:30 p.m. to 1:45 p.m., R11, R113, R114, R116-R119, and R163-R173 were in bed with bilateral 1/2 side rails in the raised position. R11, R113, R114, R116-R119, and R163-R173's electronic medical records do not contain documentation of an individualized assessment for the risk of entrapment for the use of side rails, and do not contain informed consent for the use of side rails. On 04/18/18 at 12:30 PM, V2 (Director of Nursing) stated that R11, R113, R114, R116-R119, R163-R173 utilize 1/2 side rails. V2 also stated that side rail consents and side rail assessments for entrapment risks have not been obtained for any of the residents who use side rails. V2 stated that all residents utilize beds with ½ side rails in the facility, unless a resident requests to use a chair instead of a bed, and stated that the facility has never obtained consents or assessed the risks of entrapment for any residents who utilize side rails.

Based on record review and interview, the facility failed to ensure an allegation of abuse and the results of the investigation into it were reported to the State Agency for one of one resident (R63) reviewed for abuse, who was not on the sample. Findings include: On 4/19/18 at 11:10 a.m., V2 (DON - Director of Nursing) reported V2 received an allegation of abuse on 2/09/18. V2 (DON) provided a single paged, type written, unsigned word document detailing an allegation of 2/09/18 and V2's investigation of that allegation. V2 (DON's) investigation states, on 2/09/18, R63 stated to V2 (DON) that V11 (CNA - Certified Nursing Assistant) had been Rude and verbally abusive toward R63. R63's MDS (Minimum Data Set) assessment dated [DATE] included a BIMS (Brief Interview for Mental Status with a score of 14, indicating R63's cognitive skills are intact. On 4/19/18 at 11:10 a.m., V2 (DON) indicated R63's allegation was investigated and from that investigation R63's allegation was determined to be unfounded. V2 (DON) stated the (State Agency) was not notified of R63's allegation, V2's investigation of R63's allegation, or the conclusions or outcome of V2's investigation into R63's allegation.

Based on observation, interview, and record review the facility failed to develop a plan of care for isolation for two residents (R10, R12), develop an anti-anxiety plan of care for two residents (R9, R14), develop a gastrostomy plan care for one resident (R9), develop a peripherally inserted central catheter plan of care for one resident (R11), and develop a communication plan of care for one resident (R13). These failures had the potential to affect six of eight residents (R9, R10, R11, R12, R13, and R14) reviewed for care plans in a sample of eight. Findings include: The facility's Plan of Care Policy dated 2017, documents, POC (Plan of Care)--individualized, interdisciplinary directions for the care of a patient that prioritizes healthcare needs for the patient/family; may be initiated by any discipline but ultimately the RN (Registered Nurse) will assume accountability for its presence; POC will be reviewed and /or updated daily. 1. On 5-22-17 at 12:45 p.m., a sign on R10's door documents This patient is on Multi-Drug Resistant Droplet Precaution. R10's Significant Event/Health Issues dated 5-16-17, documents, MultiDrug;[MEDICAL CONDITION] ([MEDICAL CONDITION]-Resistant Staphylococcus Aureus) nares. R10's current plan of care, dated 5-17-17, does not address R10's isolation precautions. On 5-23-17 at 1:20 p.m., E4 (MDS/Minimum Data Set Coordinator) stated, (R10's) isolation is not addressed on (R10's) current plan of care and it should have been included. 2. On 5-22-17 at 10:45 a.m., a sign on R12's door documents, This patient is on Multi-Drug Resistant Precaution. A local hospital Laboratory report dated 2-28-17, for R12 documents, Left Plantar Foot culture; Staph Aureus [MEDICAL CONDITION] Resistant; Isolation Precautions Required. R12's current Wound Care Physician order [REDACTED]. R12's current plan of care dated 5-16-17, does not address R12's wounds to the left foot or R12's isolation due to the infection to the left foot. On 5-23-17 at 1:20 p.m., E4 (MDS/Minimum Data Set Coordinator) stated, (R12's) current care plan does not include R12's present wounds or (R12's) isolation; both the wounds and the isolation should be included in the plan of care. 3. R9's Physician order [REDACTED]. On 5/22/17 at 2:00 PM, E3 Registered Nurse administered a nutritional supplement into R9's gastrostomy tube. Review of R9's plan of care dated 5/13/17 does not document R9's use of an antianxiety medication or that R9 has a gastrostomy tube. On 5/23/17 at 1:20 PM, E4 Minimum Data Set Coordinator stated R9 does not have a plan of care for the antianxiety medication or the gastrostomy tube. 4. R14's Physician order [REDACTED]. Review of R14's plan of care dated 5/13/17 does not document R14's use of an antianxiety medication On 5/23/17 at 1:20 PM, E4 stated R14 does not have a plan of care for the antianxiety medication. 5. On 5/22/17 at 10:45 a.m., a peripherally inserted central catheter (PICC) line was observed to R11's left arm. R11's current adult plan of care does not include the care of the PICC line or the use of a PICC line. On 5/24/17, E2 (Director of Nursing) stated that R11's adult plan of care does not include the care of the PICC line and the use of a PICC line. 6. R13's Interest Survey & Activity Plan of Care dated 5/19/17 documents, Due to [MEDICATION NAME] degeneration cannot see well and therefore considered blind. On 5/23/17 at 9:40 am, Z1 (R13's spouse) stated (R13) is now legally blind and deaf in one ear. R13's current Adult Plan of Care dated 5/19/17 does not include a communication plan of care for R13's vision and hearing deficits. On 5/23/17 at 2:30 pm, E4 MDS (Minimum Data Set) Coordinator stated R13's hearing and vision deficits are not addressed on R13's care plan and that they should be part of the plan of care.

Based on observation, interview, and record review the facility failed to check the residual and failed to check the placement of a gastrostomy tube for one of one residents (R9) reviewed for gastrostomy tubes on the sample of eight. Findings include: On 5/22/17 at 2:00 PM, E3 Registered Nurse administered a nutritional supplement into R9's gastrostomy tube. Prior to pouring the feeding into the gastrostomy tube, E3 did not check placement of the gastrostomy tube. After E3 was finished administering the nutritional supplement, E3 stated she did not check the placement of the gastrostomy tube. On 5/22/17 at 2:10 PM, E4 Care Plan Coordinator stated R9's residual and placement should have been checked prior to administering the medication. The facility's [DEVICE] policy dated 06/2016 documents under residual checks for patients receiving bolus feedings, Aspirate gastric contents before each bolus feeding using a 60 milliliter aspirating syringe. This policy also documents under procedure for Bolus/Intermittent Feedings, 1. Confirm bowel tones. 2. Check for residual.

Based on interview and record review the facility failed to document the nonpharmacological interventions used prior to the administration of an as needed antianxiety medication and failed to document the behaviors warranting the use of an as needed antianxiety medication for two of two residents (R9, R14) reviewed for antianxiety medications in the sample of eight. Findings include: The facility's Medication Orders policy under PRN (As Needed) orders documents, PRN orders must include all of the elements of a valid medication order. a. Additionally, the clinical indication for the use of the PRN medication must be specified. The facility's [MEDICAL CONDITION] Drug Flowsheet policy documents, The Plan of Care should reflect the patient's use of [MEDICAL CONDITION] medications and any updates as appropriate. 1. R9's Physician order [REDACTED]. R9's [MEDICAL CONDITION] Drug Flowsheets dated 5/13/17, 5/15/17, 5/16/17, 5/17/17, 5/18/17, 5/19/17, 5/20/17, 5/21/17, and 5/22/17 document R9 is receiving [MEDICATION NAME] 0.5 mg every one hour as needed. These flowsheets document R9's behavior as calm. R9's Medication Administration Record [REDACTED]. This Administration Record does not document what behaviors warranted the use of the as needed [MEDICATION NAME] or the nonpharmacological interventions used prior to the use of the [MEDICATION NAME]. Review of R9's plan of care dated 5/13/17 does not document R9's use of an antianxiety medication. R9's Minimum Data Set Tracking Forms dated 5/16/17 through 5/22/17 documents behavior tracking for R9. These forms document that on 5/18/17, R9 had an episode of repetitive calling out for help and was easily cheered up. On 5/24/17 at 10:14 AM, E2 Director of Nursing stated, There is not a specific plan of care for the use of the [MEDICATION NAME] for R9. There is not any non-pharmacological interventions documented that were tried prior to the use of the [MEDICATION NAME]. 2. R14's Physician order [REDACTED]. R14's [MEDICAL CONDITION] Drug Flowsheets dated 5/12/17, 5/13/17, and 5/14/17 document R14 is receiving [MEDICATION NAME] 0.5 mg three times a day as needed for a behavior of Anxious at times. R14's [MEDICAL CONDITION] Drug Flowsheets dated 5/15/17, 5/16/17, 5/17/17, 5/18/17, 5/19/17, 5/20/17, 5/21/17, 5/22/17, and 5/23/17 document R14 is receiving [MEDICATION NAME] 0.5 mg three times a day as needed. These flowsheets document R14's behavior as calm. R14's Medication Administration Record [REDACTED]. This Administration Record does not document what behaviors warranted the use of the as needed [MEDICATION NAME] or the nonpharmacological interventions used prior to the use of the [MEDICATION NAME]. Review of R14's plan of care dated 5/13/17 does not document R14's use of an antianxiety medication. On 5/24/17 at 10:14 AM, E2 Director of Nursing stated that there were two episodes of anxiousness documented for R14 on 5/22/17 and 5/14/17. The rest of the time the behaviors warranting the use of the [MEDICATION NAME] was not documented. There were no nonpharmacological interventions documented prior to the use of the [MEDICATION NAME]. There is not a plan of care for the use of R14's [MEDICATION NAME].

Based on observation, interview and record review the facility failed to date items in refrigeration, keep appliances/ovens clean, use the proper procedure for handwashing when handling dirty pots and pans before handling clean items, maintain a freezer gasket which caused water to drip down the freezer wall and onto a pan of food, and to date food items when removed from the freezer and put into the cooler. This has the potential of affecting all seven of the residents residing in the Skilled Nursing Unit at this time. Findings include: The document Receiving & Storage dated 9/2012 Refrigerated/Frozen Food Label Use For: All refrigerated foods after opening, preparing, cooking, and cooling; And, All refrigerated foods that have been frozen. Also, Freezers: Keep all freezer gaskets in good repair. The document Use By Dates for Kitchen Locations dated 9/2012 states Once (a frozen food) is removed from the freezer and thawed serve within two (2) days (P + 2 days - starts on the day that the product is thawed (P). The Equipment Cleaning Schedule dated 9/02/2010 states daily, wipe down oven all sides, and weekly states, Scrub out and detail inside and outside of ovens and racks. Daily clean mixer .weekly detail Mixer top to bottom. The Associate Hygiene Standards, Hand and Arm Hygiene policy dated 9/2012 states All associates (with no exclusions) engaged in . warewashing . must wash their hands with soap and warm water . when handling dirty equipment and utensils (dishwashing area) in the designated hand washing sinks. On 6/06/16 at 10:40 AM the Reach In Cooler in the Trayline Room held two trays of 20 single serving dishes - one of peaches and one of gelatin cubes, four separate single serving dishes which were two chocolate puddings, one of custard and one of salad, all undated. On 6/06/16 at 10:55 AM six convection ovens in the bakers area had a large amount of brown/black build up of dried/baked on grease and debris in the interior of the ovens and on the oven racks. The mixer had dried splattered batter underneath the motor and on the neck of the mixer. On 6/06/16 at 11:05 AM E5 (Dietary worker/pots and pans dishwasher) stacked dirty pots and pans into a rack to be put into the dishwasher. E5 then opened the door and pulled out clean pots and pans, removed the clean items from the rack and placed them on a cart to be put away. E3 (Certified Dietary Manager) spoke with E5, telling him these items needed to be rewashed and that E5 was to wash his hands before touching the clean items. E5 stated, No one has ever told me that before. E3 confirmed that E5 stated that he didn't know he was supposed to wash his hands when handling dirty items and clean items. On 6/06/16 at 11:20 AM the freezer in the back kitchen storeroom contained a large build up of ice that surrounded a third-size steam table pan from water that had dripped from the condenser down the freezer wall due to a faulty gasket. On 6/06/16 at 11:30 AM the Food Preparation Walk-In Cooler contained two full quarter-size steam table pans of gravy dated 5/29/16 to 6/29/16. E4 (Dietary Supervisor/Chef) stated these were the dates that are put on an item when first putting into the freezer. E4 stated that E4 did not know when the pans of gravy had been taken from the freezer and put into the cooler. E4 stated that foods are kept for three days in the cooler before being disposed of. E3 (Certified Dietary Manager) on 6/08/16 confirmed that food items in the Tray Line Room refrigerator held food without a date, the convection ovens and mixer needed to cleaned, E5 should have washed his hands when going from dirty to clean pans, the freezer gasket should have been repaired in the storeroom and food should be dated when taken out of the freezer and put into the refrigerator. According to the Centers for Medicare and Medicaid Census and Condition of Residents' Report, form 672, dated 6/06/16 and signed by E6, (RN, Associate Manager) documents that currently seven residents reside in the Skilled Nursing Unit.

Based on observation, interview and record review the facility failed to monitor and maintain the pot and pan stationary rack dishwasher so that the final rinse gauge temperature was at least 180 degrees Fahrenheit for sanitization. This has the potential to affect all seven of the residents residing at the facility at this time. Findings include: The WareWashing Machines and Dish Room Best Practices, no date, documents 4. The ultimate goal is to raise the surface temperature of the Ware to 165 degrees Fahrenheit at the Completion of the Final Rinse to achieve Sanitization. On 6/06/16 at 11:05 AM the dishwasher in the pots and pans area had a broken rinse gauge on this stationary machine. A 180 degree Fahrenheit thermolabel was put on a pan and then put into the dishwasher for a wash/rinse cycle. The gauge on the dishwasher showed the wash temperature to reach 160 degrees Fahrenheit and a gauge that was broken (glass busted off and calcium/lime deposits dripped down into the gauge) showed the rinse temperature as 170 degrees Fahrenheit. E5 (Dietary Worker, Pots and Pans Dishwasher) stated the gauge arrow could be manually moved. When the wash rinse cycle was completed and the pan taken from the machine, the Thermolabel had not changed to black as it shows it should on the label which was 180 degrees Fahrenheit. E5 stated that it never turned black On 6/07/16 at 1:40 PM E4 (Dietary Supervisor/Chef) states The gauge has been broken for some time - two weeks or so. The repair service came (6/06/16) but didn't have a gauge with them to replace the one on the dishmachine. We had the wrong Thermolabel but now we have them for 160 degrees Fahrenheit. E4 stated the dishwasher was to use a thermometer when washing pots and pans but did not know where the thermometer was or when it was last used. On 6/08/16 E3 (Certified Dietary Manager) confirmed the gauge on the pots and pans dishwasher was broken and incorrect thermolabels were being used. The Dishmachine Temperature Log dated 10/2013 with notations on the following days, 5/29/16 to 6/03/16. It had a column for the gauge temperatures for those days which ranged from 170 to 175 degrees Fahrenheit, below the required 180 degrees Fahrenheit for the final rinse. According to the Centers for Medicare and Medicaid Census and Condition of Residents' Report, form 672, dated 6/06/16 and signed by E6, (RN, Associate Manager) documents that at the time of the survey seven residents reside in the Skilled Nursing Unit.

Based on interview and record review, the facility Abuse Policy failed to specify to notify the Administrator immediately and the facility failed to effectively educate staff on reporting abuse allegations. These failures have the potential to affect all seven residents residing in the facility. Findings include: The facility Abuse Prevention and Detection policy dated 4/20/16, documents under the law and the facility's policy, every employee is obligated to report any incident or suspicion of abuse, neglect, or theft to the Nurse Manager or (Skilled Nursing Unit) Administrator .Any charge or accusation by a patient or family that there has been abuse or theft must be reported to the Nurse Manager. The Abuse Prevention and Detection policy also documents employees will receive abuse education upon hire and on a periodic basis. On 6/07/16 at 9:20 AM E7 (Student Nurse) stated that she had never been educated on Abuse and had gone through Orientation. She said she did not know who the Abuse Coordinator was but could ask her preceptor to find out. E7 was unable to identify all forms of abuse. On 6/07/16 at 9:30 AM E8 (Certified Nursing Assistant) stated abuse was to be reported to her one up, which would be her supervisor for that day. E8 was unable to identify all forms of abuse On 6/07/16 at 9:50 AM E9 (Unit Secretary) stated abuse was to be reported to a supervisor. E9 was unable to identify all forms of abuse. On 6/07/16 at 9:55 AM E10 (Therapy Technician) stated he did not know who to report abuse to. E10 was unable to identify all forms of abuse. On 6/8/16 at 1:09 p.m., E2 (Director of Nursing) stated E2 was the Abuse Coordinator. E2 stated staff are educated to report allegations of abuse to E2, the charge nurse, or the house supervisor. E2 verified the policy did not specify to notify E1 (Administrator) immediately. The Centers for Medicare and Medicaid Services (CMS) form # 672 Resident Census and Conditions of Residents report dated 6/6/16, completed by E6 (Registered Nurse, Associate Manager), documents the facility has seven residents residing in the facility.

Based on interview, record review and observation, the facility failed to prevent cross-contamination for 4 residents (R9, R10, R11, and R15) of four residents reviewed in a sample of eight and one resident (R18) on the supplemental sample. Findings include: 1. On 4-15-15 at 10:45am, E6, (Registered Nurse/RN), put on gloves without washing hands and removed R10's coccyx dressing. E6 held R10's coccyx area with right gloved hand and checked for skin blanching on R10's bare coccyx area with left gloved hand. E6 then applied the dressing with the contaminated gloved hands and pulled up R10's sweatpants. E6 removed the gloves, pulled back the curtain and exited R10's room without performing hand hygiene. On 4/15/15 at 11:15am, E2, (Director of Nursing/DON), stated that staff would be expected to perform hand hygiene before putting on gloves, after removing gloves, while performing wound care, and upon exiting resident rooms. The Hand Hygiene, Including Hand Antisepsis, Handwashing & Surgical Scrub Policy, dated 3/13, documents that hand hygiene should be performed upon entry and exit from a patient room; before and after having direct contact with patients; after contact with non-intact skin and wound dressings; whenever moving from a contaminated body site to a clean body site during patient care; and after removing gloves. 2. On 4-15-15 between 8:10am - 8:30am, E4, (Licensed Practical Nurse/LPN), administered medications during a medication pass to R11, R15 and R18. E4 did not perform hand hygiene upon exiting R11's room, or entering and exiting R15's and R18's room. During the medication administration, E4 also did not perform hand hygiene before putting on gloves to administer R15's 3 separate eye drops ([MEDICATION NAME], Brimolidine and [MEDICATION NAME]). E4 continued to administer R15's oral medications with the contaminated gloved hands. When R15 struggled to remove the last pill in the medicine cup, E4 assisted R15 by dislodging the pill, with E4's contaminated right gloved hand. E4 removed the gloves and exited R15's room and did not perform hand hygiene. On 4-15-15 at 11:15am, E2, (Director of Nursing/DON), verified that staff would be expected to perform hand hygiene before entering and upon exiting resident rooms, and before and after gloving. E2 also verified that staff would be expected to assist a resident with dislodging a pill from a medicine cup, but not with a contaminated glove. The Hand Hygiene, Including Hand Antisepsis, Handwashing & Surgical Scrub Policy, dated March 2013, documents that hand hygiene should be performed upon entry and exit from a patient room; before and after having direct contact with patients; and after removing gloves. 3. On 4-15-15 at 8:50am, E4, Licensed Practical Nurse (LPN), removed R9's right lower extremity wound dressing. With the same contaminated gloves, E4 removed R9's right sock then unwrapped R9's gauze to right foot and removed two non-adherent dressings saturated with yellow wound drainage. E4 proceeded to remove R9's left sock, gauze wrap and non-adherent dressing saturated with yellow wound drainage from R9's left lower extremity. Next E4 touched R1's wound tubing and machine, incontinence pad, pants, and bare skin. E4 removed gloves and left R9's room without performing hand hygiene. On 4-15-15 at 9:30am, E4, LPN, stated "I should have changed my gloves before touching anything clean. I should have used hand gel after removing my gloves and before leaving the resident's room." The Hand Hygiene, Including Hand Antisepsis, Handwashing & Surgical Scrub Policy, dated March 2013, documents that hand hygiene should be performed upon entry and exit from a patient room; before and after having direct contact with patients; and after removing gloves.

Based on observation, record review and interview the facility failed to properly store dry pasta and candy for seven residents (R9-R11, R13-R25) in a sample of eight; and eight residents (R18-R25) in the supplemental sample. Findings include: On 4-14-15 at 1:15 pm, and 4-15-15 at 9:35 am, open packages of unwrapped pastel dinner mints, uncooked spaghetti and shell pasta were in the dry storage room unsealed and not dated. On 4-14-15 at 1:30 pm, E9 (Dietary Production Manager) verified that the opened pasta and mints should be sealed and have a date on the package when the product was opened. On 4-15-15 at 9:50 am, E5 (Dietary/Patient Services Manager) verified that the open pasta and mints should be sealed and have a date on the package when the product was opened. The dietary department's Receiving and Storage Policy, dated September 2012, documents that all items must be labeled and date marked for all food products in storage areas.

Based on record review and interview, the facility failed to document resident and/or representative education and offer pneumococcal immunization to four of eight residents (R11, R12, R14, and R16) reviewed for immunization status in a sample of eight. Findings include: R11's computerized clinical record documents R11's admission on 4-03-15 and indicates R11 is [AGE] years old. R11's clinical record does not include documentation that verifies R11 or R11's representative received education regarding pneumococcal vaccine or that pneumococcal vaccine was offered, refused, or administered. R12's computerized clinical record documents R12's admission on 4-08-15 and indicates R12 is [AGE] years old. R12's clinical record does not include documentation that verifies R12 or R12's representative received education regarding pneumococcal vaccine or that pneumococcal vaccine was offered, refused, or administered. R14's computerized clinical record documents R14's admission on 4-11-15 and indicates R14 is [AGE] years old. R14's clinical record does not include documentation that verifies R14 or R14's representative received education regarding pneumococcal vaccine or that pneumococcal vaccine was offered, refused, or administered. R16's computerized clinical record documents R16's admission on 4-01-15 and indicates R16 is [AGE] years old. R16's clinical record does not include documentation that verifies R16 or R16's representative received education regarding pneumococcal vaccine or that pneumococcal vaccine was offered, refused, or administered. A policy dated 10-21-14 and entitled Pneumococcal Vaccination D/C (Discontinue) Standing Orders states, "Effective immediately (the facility) will no longer utilize the standing order to offer pneumococcal vaccinations to patients." On 4-15-15 at 2:45 p.m., E2 (DON - Director of Nursing) stated, "As of (10-21-14) we no longer assess the need for or offer the pneumococcal vaccination."

Based on interview and record review, the facility failed to develop an abuse policy that includes the component of identification of possible incidents/allegations which need investigation. This has the potential to affect all 16 residents in the facility. Findings include: The facility policy, Abuse: Prevention & Detection (2-17-15), does not have documentation that the facility will identify events such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse and determine the direction of the investigation. This same policy does not have documentation for analysis of the occurrences to determine what changes are needed, if any, to facility policies and procedures to prevent further occurrences. On 4-15-15 at 3:30pm, E2, Director of Nursing (DON), confirmed that the facility policy, Abuse: Prevention & Detection (2-17-15), does not include the area of identifying events such as suspicious bruising of residents or that the facility will analyze the occurrences for any changes needed to their policies and procedures. The Centers for Medicaid and Medicare form, 672, Resident Census and Conditions of Residents, dated 4-14-15 as completed by E3, Associate Nurse Manager, indicates there are currently 16 residents residing at the facility.

Based on record review and interview, the facility failed to ensure that a physician designee attended the Quality Assurance meetings. This failure has the potential to affect all 16 residents who reside in the building. Findings include: The QA meetings attendance list does not document the presence of a physician designee for any dates of meetings held from April 2014 through February 2015. On 4-16-15, at 10:30 am, E2, Director of Nursing (DON), stated that Z1 (Physician/Medical Director) does not attend the QA meetings. The facility's Central Partnership Council (QA/Quality Assurance) Bylaws, dated 12-21-05, does not appoint a physician designee on the membership list of attendees The Centers for Medicaid and Medicare form, 672, Resident Census and Conditions of Residents, dated 4-14-15 as completed by E3, Associate Nurse Manager, indicates there are currently 16 residents residing at the facility. ¿ ¿