Every finding on record at Gottlieb Memorial Hospital

Based on interview and record review, the facility failed to plan and serve menu items per facility menu planning standards. This applies to 6 of 6 residents (R27, R35, R36, R39, R40, R41) reviewed for menu planning in a sample of 8.The findings include:Review of Room Service Diet reports, dated 3/9/26, show R35, R36, R39, R40, and R41 all had physician orders for Regular Diets. Physician order, dated 2/28/26, shows R27 had a physician order for a pureed diet. On 3/10/26 at 1:04 PM, V7 (Regional Clinical Nutrition Manager/ Registered Dietitian) stated the menus should contain 6 serving a day of whole or enriched grains including bread, cereal, dry cereal, rice, buns, tortillas, desserts. V7 stated she did not consider potatoes as a grain serving. V7 stated the other therapeutic diets should follow the same pattern as the regular diet as long as the food items do not exceed the nutrient parameters for the therapeutic diets. V7 stated the pureed diet did not have nutrient parameters that restricted menu items. Review of facility pureed diet shows the following servings of grains were total number of default grain servings provided to a non-select resident (a resident who did not fill out their daily menus and select food preferences) receiving pureed diets on each day:Day 1 - 2 Grains (oatmeal and penne pasta)Day 2 - 2 Grains (French toast and cream of wheat)Day 3 - 4 Grains (waffle, oatmeal, penne pasta and macaroni/cheese)Day 4 - 2 Grains (cream of wheat and lasagna)Day 5 - 2 Grains (French toast and oatmeal)Day 6 - 3 Grains (pancake, cream of wheat and penne pasta)Day 7 - 3 Grains (waffle, oatmeal, macaroni/cheese) Review of facility regular diet shows the following total number of default grain servings were provided to a non-select resident receiving regular diets on each day:Day 4 - 3 Grains (cream of wheat)Day 7 - 5 Grains (2 English muffin halves, 2 burger bun halves, macaroni/cheese)Review of Days 1-3 and 5-6 show residents were provided a total of 6 default grain servings each day. On 3/10/26 at 12:41 PM, V8 (Patient Services Manager/Registered Dietitian) reviewed the total number of default grain servings offered on the daily non-select pureed diet residents and stated, It seems a little low. V3 (General Manager) stated the pureed diet menu items should mirror the items served on the standard, general diet menu pattern that is provided to the cooks to follow. V8 stated menus were developed to follow the Nutrition Care Manual. Menu planning guidelines were reviewed in the Nutrition Care Manual provided during the survey and V8 and V3 were unable to determine what specific guidelines were being followed to plan the pureed diets and were unable to determine if the menus were meeting facility standards. On 3/10/26 at 1:04 PM, V7 (Regional Clinical Nutrition Manager/ Registered Dietitian) stated she planed the facility Regular menu based on the Dietary Guidelines for Americans in conjunction with the nutrition care manual. V7 stated she creates the diet spread sheets, such as the pureed diet, based on the nutrition care manual. V7 confirmed the default pureed menus provided during survey were the facility default menus provided to residents who did not select their menus. V7 reviewed the menus, acknowledged the menus did not meet the expected minimum daily grain servings, and stated she would review the menus and adjust the menus to meet the menu planning expectations of 6 servings of grains each day. Facility Nutrition Care Manual - Diet Manual, dated 1/14/25, shows Developing a house Diet 1. Review all Federal and State Regulations. Refer to the Regulations section for additional resources 2. Determine Nutritional content - Determine kilocalorie range for facility diet Determine kilocalorie range for facility diet Research the average, range, and most common weight of your residents. These data can give you a general idea of your resident population's energy needs Determine protein range Determine carbohydrate range. Setting range for carbohydrates: carbohydrates should provide 45%-65% of total energy and be evenly distributed throughout the day. Keep the carbohydrates consistent and balanced through the day to meet many patients' nutrition needs and medical nutrition therapy Steps for writing a menu 1. Determine which meal planning guide will be used at your facility. It may be necessary to create a menu checklist to ensure all components are met. Adjust as needed to meet state regulations and patient requests. See Menu Planning Checklist for Nutritionally Balanced Meals for a template

Based on interview and record review, the facility staff failed to immediately report an allegation of abuse to the abuse task coordinator. This applies to 1 of 12 residents (R62) reviewed for abuse in the sample of 12. The findings include: The EMR (Electronic Medical Record) showed that R62, a [AGE] year-old was admitted to the facility on [DATE] from the acute setting of the hospital. R62 had a recent abdominal surgery to repair hernia on 2/17/2024. R62 has other diagnoses that included gout, hypertension, chronic kidney disease, gastric bypass, and morbid obesity. The MDS (Minimum Data Set) dated 3/3/2024 showed R62 was cognitively intact with BIMS (Brief Interview Mental Status) score of 15/15. On 3/04/2024 at 10:18 A.M., R62 was sitting in a lounge chair in her room. R62 said, I was abused, hurt emotionally, felt disrespected and helpless. This PCT (Patient Care Technician) that had worked the night shift on 2/28/24 - 2/29/2024 came into my room early morning of 2/29/2024 when I was sitting in my lounge chair. I always feel cold, so I asked this PCT for a blanket. I don't know the name of this PCT, but I can describe her to you, she was light skinned African American, height of around 5'2, somewhat obese but not much. This PCT did not write her name on the board, I guess she did not want me to know her name. When I asked this PCT for a blanket, she was so nasty, with angry face, did not help placing the blanket on me and I can't move due to my recent surgery, I needed help. The PCT with her arms stretched out towards me with blankets in her hand said in a nasty angry voice here are your blankets! The PCT then asked me what kind of surgery I had, since I cannot help myself. Oh, I felt so helpless. I then asked her to hand me the phone so I could order my breakfast. She then handed my cell phone. She knows that I must use the land line to order breakfast, but I do not know why she handed my cell phone. I told her that I needed the land line phone which I could not reach since the land line phone was behind my bedside table. The PCT took the land line phone and slammed it down on the overbed table that was in front of me. I reported what this PCT did to me to (V5, Registered Nurse) and (V6, Physical Therapist) the morning of 2/29/2024. The surveyor asked V6 to come to R62's room. R62 said to V6 I reported to you what that PCT did to me that day it happened. V6 confirmed and said she did not report the allegation to V1 (Administrator) and V2 (Director of Nursing) because she was busy, and she thought V5 had reported this allegation already. On 3/4/2024 at 3:30 P.M., V5 said, I felt that what (V4/PCT) did to (R62) was inappropriate and an investigation was needed to determine abuse. I called (V2) on 3/1/2024 not on 2/29/2023 when (R62) informed me about how rude and nasty (V4) was to her and how (R62) felt she was treated. This might constitute an emotional abuse. I don't know, maybe I need more abuse training. On 3/4/2024 at approximately 12:30 P.M., V1 and V2 were asked if the facility had any allegation of abuse/or any concern /voiced by their patients regarding care that might be suspicious of potential abuse. V1 and V2 said there was no allegation of abuse reported to them and no investigation was held. Surveyor prompted V1 and V2 regarding R62's allegation of emotional abuse that occurred on 2/29/2024 early morning. V1 and V2 identified that the PCT that R62 was referring to was V4. The facility's abuse policy dated 7/10/2023 showed (This facility) is fully committed to the safety and well-being of its patients and strives to continually ensure the protection of patient's rights while maintaining their safety. The purpose of this policy is to describe the process used to investigate and remediate patients' or visitors' allegations of abuse or neglect by staff or employee . Procedure: 1. Reporting: Employees are required to immediately report any occurrences of potential abuse or injury they observe, hear about or suspect towards a patient to their department manager or Administration The employee who witnessed or was made aware of the allegation is additionally responsible for completing and incident report .2. Notification: Notify risk management of any occurrences of potential abuse . Risk management will initiate a quality investigation and follow up process .Risk Management reports to IDPH (Illinois Department of Public Health) within 24 hours of allegation .

Based on interview and record review, the facility failed follow their abuse policy to suspend the alleged perpetrator and initiate an investigation for an allegation of abuse in a timely manner. This applies to 1 of 12 residents (R62) reviewed for abuse in the sample of 12. The findings include: The facility's abuse policy dated 7/10/2023 showed, (This facility) is fully committed to the safety and well-being of its patients and strives to continually ensure the protection of patient's rights while maintaining their safety. The purpose of this policy is to describe the process used to investigate and remediate patients' or visitors' allegations of abuse or neglect by staff or employee . Procedure: 1. Reporting: Employees are required to immediately report any occurrences of potential abuse or injury they observe, hear about or suspect towards a patient to their department manager or Administration The employee who witnessed or was made aware of the allegation is additionally responsible for completing and incident report .2. Notification: Notify risk management of any occurrences of potential abuse . Risk management will initiate a quality investigation and follow up process. 5. The safety of the victim will be secured by a) Immediately removing the involved staff from further contact . b.) the staff will be removed from further patient contact .9.) External Reporting . Risk Management reports to IDPH (Illinois Department of Public Health) within 24 hours of allegation . The EMR (Electronic Medical Record) showed R62, a [AGE] year-old was admitted to the facility on [DATE] from the acute setting of the hospital. R62 had a recent abdominal surgery to repair hernia on 2/17/2024. R62 has other diagnoses that included gout, hypertension, chronic kidney disease, gastric bypass, and morbid obesity. The MDS (Minimum Data Set) dated 3/3/2024 showed R62 was cognitively intact with BIMS (Brief Interview Mental Status) score of 15/15. On 3/04/2024 at 10:18 A.M., R62 was sitting in a lounge chair in her room. R62 said, I was abused, hurt emotionally, felt disrespected and helpless. This PCT (Patient Care Technician) that had worked the night shift on 2/28/24 - 2/29/2024 came into my room early morning of 2/29/2024 when I was sitting in my lounge chair. I always feel cold, so I asked this PCT for a blanket. I don't know the name of this PCT, but I can describe her to you, she is light skinned African American, height of around 5'2, somewhat obese but not much. This PCT did not write her name on the board, I guess she did not want me to know her name. When I asked this PCT for a blanket, she was so nasty, with angry face, did not help placing the blanket on me and I can't move due to my recent surgery, I needed help. The PCT with her arms stretched out towards me with blankets in her hand said in a nasty angry voice here are your blankets! The PCT then asked me what kind of surgery I had, since I cannot help myself. Oh, I felt so helpless. I then asked her to hand me the phone so I could order my breakfast. She then handed my cell phone. She knows that I must use the land line to order breakfast, but I do not know why she handed my cell phone. I told her that I needed the land line phone which I could not reach since the land line phone was behind my bedside table. The PCT took the land line phone and slammed it down on the overbed table that was in front of me. I reported what this PCT did to me to (V5, Registered Nurse) and (V6, Physical Therapist) the morning of 2/29/2024. The surveyor asked V6 to come to R62's room. R62 said to V6, I reported to you what that PCT did to me that day it happened. V6 confirmed and said she did not report the allegation to V1 (Administrator) and V2 (Director of Nursing) because she was busy, and she thought V5 had reported this allegation already. On 3/4/2024 at approximately 12:30 P.M., V1 and V2 were asked if the facility had any allegation of abuse/or any concern /voiced by their patients regarding care that might be suspicious of potential abuse. V1 and V2 said there was no allegation of abuse reported to them and no investigation was held. Surveyor prompted V1 and V2 regarding R62's allegation of emotional abuse that occurred on 2/29/2024 early morning. V1 and V2 identified that the PCT that R62 was referring to was V4. V2 said that on 3/1/2024 around 7:45 A.M., V5 reported to her that V4 was nasty/rude to R62 and that R62 wanted to talk to her. V2 said that she tried to call R62 the same day (3/1/2024) but R62 did answer her phone. V2 added that she did not come to see R62 for a follow up and did not initiate an investigation till 3/4/24 at 12:30 PM. On 3/4/2024 at 5:30 P.M., together with V2, R62 was interviewed. R62 said, I was hurt and emotionally abused, disrespected and felt so helpless because of (V4's) treatment of me. R62 said V4 slammed the phone in front of her, was not gentle when she handed me the blankets and said here! V2 apologized for not following up with R62 on 3/1/24, 3/2/24, and 3/3/2024 nor had asked any managers on duty when she was not able to contact R62 on 3/1/2024. On 3/4/2024 at 3:30 P.M., V5 said, I felt that what (V4/PCT) did to (R62) was inappropriate and an investigation was needed to determine abuse. I called (V2) on 3/1/2024 not on 2/29/2023 when (R62) informed me about how rude and nasty (V4) was to her and how (R62) felt she was treated. This might constitute an emotional abuse . On 3/6/2024 at 3:00 P.M., V1 said, If (R62) said she was abused, then we considered it as an abuse and an immediate implementation of abuse policy should have been done that included investigation, suspension/protection and reporting. The facility's schedule showed V4 worked the night shift on 3/3/24 and this was also confirmed by V2.

Based on observation, interview, and record review, the facility failed to follow standard infection control practices related to hand hygiene and gloving during medication administration. This applies to 2 of 3 residents ( R64 and R220) observed during medication pass administration in the sample of 12. The findings include: 1. On 3/4/2024 at 1:09 PM, V15 (Registered Nurse) went inside R64's room to administer the resident's IV (intravenous) medication. While inside R64's room, V15 put on a new pair of gloves, then used the computer mouse, computer bar code scanner to scan the IV medication (inside the syringe), placed the IV medication (Cefazolin 2 grams injection) on top of the medication cart and held/close the medication cart drawer. While wearing the same gloves, V15 cleaned R64's PICC (Peripherally Inserted Central Catheter) line lumen (single). After cleaning the PICC line lumen, V15 got the IV medication (from the top of the medication cart) and was about to administer the said medication via the PICC line. V15 was asked if she was ready to give the IV medication and she responded, yes. V15 was asked to step out of R64's room. While outside of R64's room, V15 was prompted to remove her used gloves, perform hand hygiene and apply a new pair of gloves then reclean the PICC line lumen, before continuing to administer the IV medication. 2. On 3/6/2024 at 9:50 AM, V10 (Registered Nurse) and V16 (Registered Nurse orientee) put on their gown and gloves to enter R220's room to administer the resident's medication. V10 and V16 were already wearing their mask. V10 stated R220 was on contact precaution due to history of ESBL (Extended Spectrum Beta-Lactamase). V10 with her gloved hands, prepared (removed from packaging) R220's oral medications consisting of eight (8) different tablets and/or capsules and placed then all together inside the medication cup. The prepared oral medications included Metoprolol 50 mg (milligram), 1 tablet and Entresto 24 mg/26 mg, 1 tablet. After preparing the said oral medications, V10 was handing the said medication cup to R220. R220 requested to have his blood pressure be taken again because he does not want to take his blood pressure medications if his blood pressure was low. V10 got the blood pressure cuff that was hanging on the foot part of R220's bed, attached it on the blood pressure machine, applied the blood pressure cuff on the resident's arm, placed the pulse oximeter on the resident's finger and pressed the machine to start. R220's blood pressure registered at 102/62. V10 handled the computer mouse to check the computer for pictures and markings of the medications to hold (not to give) as ordered due to low blood pressure result. With the same gloves that she (V10) used during the entire medication administration procedure (described above), including blood pressure monitoring, V10 took out the Entresto and Metoprolol tablets from inside the medication cup, then administered the rest of the medications to R220. Again, with the same gloves, V10 proceeded to open R220's Spiriva 18 mcg (microgram) capsule packet, held the capsule with the same gloves and placed the capsule inside the inhaler chamber and handed the inhaler to the resident to administer the Spiriva inhaler. On 3/6/2024 at 10:05 AM, V10 and V16 were inside the nursing station and were informed of the infection control concerns. V10 acknowledged that she used the same gloves all throughout the medication observation from preparing R220's medications, taking R220's blood pressure, taking out the two (2) medications from the medication cup and handling/placing the inhaler capsule to the inhaler chamber. V10 stated she should have removed her gloves, washed her hands and applied a new gloves before picking out the two medications and handling the inhaler capsule, to prevent cross contamination and to maintain infection control. On 3/6/2024 at 10:12 AM, V2 (Director of Nursing) stated that after V15 handled the computer mouse, bar code scanner and drawers, V15 should have removed her gloves, washed her hands or sanitized then re-gloved before handling R64's PICC line for IV medication administration. V2 stated V10 should have removed her gloves, washed her hands or sanitized and then re-gloved after handling the blood pressure machine and computer mouse before taking out the medications from the medication cup and before handling the inhaler capsule. V2 stated for any procedure from dirty to clean, the nursing staff should remove their gloves, perform hand hygiene either washing hands or sanitizing and then put on a new gloves to maintain infection control and prevent cross contamination. The facility's policy regarding infection control-hand hygiene last reviewed on 7/31/2023 showed under purpose, Hand hygiene is the single most important measure used in health care worker practice to reduce the risk of transmitting pathogenic organisms. Incorporating an antiseptic agent into the hand hygiene process reduces bacterial counts on hands thus reducing potential morbidity and mortality from healthcare-associated infections. The same policy showed in-part, C. Hands may be decontaminated by washing with antiseptic soap and water or using a hospital approved, alcohol-based waterless antiseptic handrub/hand gel: .4. Before donning non-sterile gloves, 5. After contact with a patient's intact skin ([for example], taking a pulse or blood pressure, or lifting a patient), 6. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient, 7. After removing gloves, .10. After contact with blood, body fluids or other contaminated surfaces. E. The use of gloves does not replace the need of hand hygiene. Hands often become contaminated despite glove use; therefore, hand hygiene must be performed before and after removal of gloves.

Based on observation, interviews, and record review, the facility failed to post the daily staffing information so it can be read by residents and family. This affects all 22 residents residing at the facility at the time of the survey. On 3/4/2024 at 12:35pm, the Nurse staffing was posted on the wall behind the Nurses station above eye level while standing. The staffing information was on a sheet of paper inside a plastic page protector that reflected the overhead lights to obscure the writing on the page. Additionally, the paper was purple with black print and handwriting, creating a dim contrast. The information on the staffing sheet was not readable. On 3/5/2024 at 10:50am, the daily staff posting had been updated and was on purple paper posted behind the Nurse's station and above eye level. On 3/5/2024 at 10:52am, R66, wearing eyeglasses, was in a wheelchair working with Physical Therapist. At that time, R66 was wheeled as close to the Nurses Station as possible and tried to read the daily staffing sheet but was unable to do so. R66 cited the reflection of the lights and the distance. According to the most recent MDS (minimum data set) dated 3/5/2024 for R66, R66 is cognitively intact and requires moderate assist from one person for transfers. On 3/5/2024 at 1:45pm, V1 (Administrator) stated she agreed the daily staffing posting was difficult to read.

Based on observation, interview, and record review, the facility failed to provide intravenous site care by not cleaning the dirty insertion site or removing unused IV (intravenous) catheters. This applies to 1 of 1 resident (R64) reviewed for IV treatment and care in a sample of 10. Findings include: On 4/11/23 at 10:23 AM, R64 was observed with a right forearm peripheral IV heparin lock. The insertion site was dirty with black-colored dry blood around the insertion site. Record review on Physician Order Sheet (POS) indicates that R64 is not getting any intravenous treatment. On 4/11/23 at 12:28 PM, V3 (Registered Nurse) stated, R64 is not on any IV medication. He was admitted with an IV on 3/31/23 (11 days earlier). It should have been removed if he doesn't need anything through the IV. The dirty IV insertion site with dry black blood should have been cleaned to prevent infection. On 4/12/23 at 10:00 AM, V2 (Director of Nursing) stated, Our new protocol is to remove IV in 96 hours (four days). It should have been removed if the resident doesn't need intravenous access. The facility IV Catheter Removal policy (dated August 19, 2022) documents: Removal of a short peripheral IV catheter should occur as soon as the catheter is no longer indicated for the patient's plan of care or when the catheter hasn't been used for at least 24 hours.

Based on observation, interview, and record review, the facility failed to perform deep cleaning to prevent pest infestation, maintain clean and sanitized foodservice equipment, store food in a manner that prevented contamination, utilize chemical sanitizing solution per manufacturer's instructions, and perform proper hand hygiene before/after touching food. This applies to all 15 residents receiving oral diets at the facility. The findings include: Facility document Alphabetical List of All Residents, dated 11/7/21, shows there were 15 residents in the facility. Facility document NPO (Not By Mouth) Patients, dated 11/7/21, shows there were no residents in the facility that had physician diet orders of NPO. 1. On 11/7/21 at 11:02 AM with V6 (Food Service Manager), a cockroach scurried out from behind the small steam-jacketed kettle equipment, turned around, and returned back underneath the equipment. There was a large amount of food debris located on the floor behind the small steam-jacketed kettle. The equipment did not have casters, was not movable, and the floor behind the equipment was not easily cleanable. V6 (Food Service Manager) stated she was aware that the pest control service was working to eradicate cockroaches recently in the kitchen. Pest control reports, dated 10/26/21, 10/27/21, 10/28/21, 10/29/21 and 11/5/21, show there was an accumulation of food crumb debris found under coolers of the cook production line creating a German roach harborage. The 1/26/21 report shows German cockroach activity was found in several areas of the kitchen. On 11/09/21 at 1:15 PM V20 (Regional Food Service Manager) stated there needed to be a greater effort to perform more deep cleaning in the kitchen. V20 stated the foodservice operation has experienced a chronic lack of staff and the operation has had to prioritize meal service. On 11/9/21 at 12:20 PM with V6, V19 (Director of Environmental, Transportation, and Linen) stated the roach problem has been a longstanding problem, especially in the facility kitchen. V19 stated the kitchen has been chemically treated three times a week by pest control for approximately a year. V19 stated there has consistently been a cleaning concern identified in the pest control reports regarding the facility kitchen. V19 stated the food service staff were responsible for the cleanliness of the kitchen. On 11/09/21 at 12:49 PM, V4 (Administrator) stated she was not aware of the ongoing concerns about roaches in the food service. 2. On 11/7/21 at 11:10 AM with V6, V7 (Cook) was setting up food on the tray line for lunch service. A red sanitation bucket with a white rag was sitting below the steam table on the shelf. V7 stated she was utilizing the sanitation bucket at her station while working on the tray line. V7 stated she changed the sanitizing solution in the sanitizing bucket approximately one hour prior and that the staff were expected to change the sanitizing solution in the sanitizer buckets every two hours. V6 stated the kitchen utilized quaternary ammonium in the sanitizing buckets to sanitize food service work areas. V6 checked the concentration of the sanitizing solution in the cook's sanitizing bucket which measured 0-100 ppm (parts per million) of quaternary ammonium. On 11/7/21 at 11:12 AM with V6, V7 emptied the sanitizing solution from the bucket in the mop room and refilled the sanitizing bucket with sanitizing solution which was premixed and dispensed from a wall dispenser. As the bucket was filled, none of the pink sanitizing solution was siphoned up through the tubing and into the dispenser from the sanitizing chemical bucket. When the bucket was filled, V6 checked the concentration of the liquid in the sanitizing bucket and the solution measured 0-100 PPM. Sanitizer Solution Log, undated, stated the required quaternary ammonium sanitizer solution concentration was 150-400 ppm. Facility Procedure Infection Prevention and Control Guidelines for Food and Nutrition Services, dated 9/2018, shows, D. Sanitizing Food Contact Equipment . 3. All food preparation areas and equipment that come into contact with foods will be washed, rinsed, and sanitized after each use, or after any interruption during which contamination could occur. 3. On 11/7/21 at 11:20 AM in the walk in cooler with V6, there were four cases of raw chicken breasts stored directly over a tray holding large tubes raw ground beef. V6 stated the raw chicken should be stored under the raw ground beef. Facility Procedure Receiving and Storage, October 2020, shows, Fresh meat must be stored in the following order from top to bottom: Ready-to-eat (top), Seafood, Whole cuts beef or pork, Ground meat and ground fish, Whole and ground poultry (bottom). 4. On 11/7/21 at 11:35 AM with V6, V8 (Cold Prep Cook) was using gloved hand to touch quesadillas while cutting and folding them after touching handles on food preparation drawers, utensils, countertops, plates, plate warmers, and without washing her hands or changing her gloves. V6 sated V8 should have changed her gloves and washed her hands before and after touching the quesadilla. Facility Procedure Infection Prevention and Control Guidelines for Food and Nutrition Services, dated 9/2018, shows, B Hand Hygiene 1. Hand hygiene shall be conducted in a timely manner before resuming food handling or duties in the kitchen . 2. Food shall be prepared with minimal manual contact. Colleague should use utensils, such as tongs, spatulas, and single use gloves. Colleague will not touch any foods with their bare hands 5. On 11/7/21 at 11:02 AM with V6, the can opener near the cold preparation area had a dark red substance dried around the blade of the can opener. In addition, a scoop was stored in the rice bin with the handle of the scoop embedded into the rice. V6 stated the scoop should not have been stored in the rice to prevent contamination.

Based on observation, interview and record review, the facility failed to follow standard professional practices by not implementing its policy and practices for hand hygiene and gloves usage during medication administration and wound care. This applies to 4 of 7 residents (R6, R67, R68 and R166) reviewed for quality of care during wound care and medication administration in a total sample of 8. The findings include 1. On 11/07/21 at 12:14 P.M., V17 (RN/Registered Nurse) administered 2 units of Insulin subcutaneously via injection into R68's right side of the abdominal area. Prior to administering the insulin injection, V17 did not perform hand hygiene, and proceeded to touch computer keys, then lifted R68's shirt and injected the Insulin. V17 also did not don gloves prior to injecting the insulin. On 11/07/2021 at 3:33 P.M., V5 (Director of Nursing) stated that they do not have policy for donning on gloves when injection was provided. However, the expectation and standard of practice to ensure infection control was for the nurse/staff to perform hand hygiene and don on gloves prior to injection due to a risk for contact exposure of bodily fluids. The H&P (History and Physical) dated 11/4/2021 shows that R68, an [AGE] year old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. On 11/08/21 from 8:45 A.M. to 9:43 A.M., medications were administered to R166 by V16 (RN/ Registered Nurse). The following were the medications that were administered: [MEDICATION(S)] 10 mg. 1 tab., [MEDICATION(S)] 10 mg. 1/2 tab., Vitamin D 50, 000 units, Vitamin E 400 mg. 1 tab., and [MEDICATION(S)] 400 mg. 1 tab. In between medication administration, V16 informed R166 that she will apply the [MEDICATION(S)] ointment to R166's buttocks area. R166 pulled down his pants with V16's assistance. Then V16's stated I have to get gauze to clean the buttocks area before applying the [MEDICATION(S)]. V16 left the room and took the gauze from the nursing station, then R166 said I am going to therapy in few minutes, I just want my Tylenol and the medication for blood clot (Eloquis), will take shower after therapy then you can apply the cream ([MEDICATION(S)]). V16 washed hands at R166's bathroom hand sink and then turned off the water from faucet with bare hands and did not use a paper towel for creating a barrier to prevent cross contamination, and proceeded to administer R166's Tylenol 2 tablets. The H&P (History and Physical) dated 11/3/2021 shows that R166, a [AGE] year old with PMH (Past Medical History) of [CONDITION(S)] ([CONDITION(S)]), OSA (Obstructive Sleep Apnea), [CONDITION(S)], hypertension, severe lumbar stenosis of lumbar 3 and 4, and had undergone discectomy on 10/16/2021. Discussed infection control concerns with V4 (Administrator) and V5 on 11/08/21 at 10:45 A.M. 3. The facility Weekly Pressure Ulcer log dated November 2021 showed that R67 was admitted with a stage 2 pressure ulcers to the left and right gluteal fold and the sacrum. The EHR (Electronic Health Record) showed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/09/21 at 12:20 P.M., R67's pressure ulcer wound dressing was changed by V11 (Registered Nurse). V15 (CNA/ Certified Nurse Assistant) assisted V11. V11 donned a pair of gloves, proceeded to remove the soiled dressing from R67's sacrum/gluteal folds. The soiled dressing had a black substance on it. V11 continued to wipe R67's sacrum and the left and right gluteal folds using a moistened towelette. There were stage 2 pressure ulcers of R67's right and left gluteal fold and sacrum. After V11 wiped the sacrum and gluteal folds, V11 removed her soiled gloves, and donned a new pair of gloves. V11 failed to perform hand hygiene prior to donning a new pair of gloves. The H&P (History and Physical) dated 10/29/2021 shows that R67, [AGE] year old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/09/21 at 12:25 PM, V5 (Director of Nursing) stated that it is the facility's practice to implement hand hygiene after removing soiled gloves and before donning a new pair of gloves during wound dressing changes when the soiled dressing was removed. 4. According to the Physician History and Physical dated 09/21/2021, R6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) dated [DATE] showed R6 needed extensive assistance of two people for bed mobility, transfers, and toilet use. R6's cognition was intact. R6 had unhealed pressure ulcers and was at risk for developing pressure ulcers. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/08/21 at 1:44 PM, V14 (Registered Nurse/RN Wound Care) assisted V2 (RN) during wound care. V2 donned gloves and cleansed R6's wound using wound cleanser and gauze. Without changing gloves, V2 applied [MEDICATION(S)] ointment to the wound using a wooden depressor, then placed a new foam dressing cover to the wound. V2 took a marker from her pocket to write the date on the dressing. On 11/09/21 at 12:55 PM, V5 (Director of Nursing/DON) said the nurse should change gloves and perform hand hygiene after the wound was cleaned and before applying the medication and dressing. V4 (Administrator) was present. The facility's Hand Hygiene policy dated 07/2019 includes to perform hand hygiene if moving from a contaminated body site to a clean body site during patient care. Review of the facility's policy for Handwashing with revision date of 7/2019 showed: II. a). Handwashing; c. Wet hands with running water. Apply soap thoroughly . Rinse hands thoroughly under running water. d) Paper towels should be use to dry hands. Paper towels should be used to turn off the water faucet. The policy for hand hygiene also showed Perform hand hygiene before donning gloves and after removing gloves.

Based on observation and interview the facility failed to provide food palatable for the resident. This applies to 5 of 7 residents (R116, R6, R117, R118, R119) reviewed for food palatability in a total sample of 8 residents. The findings include: 1. On 1/07/21 at 10:06 AM, R116 said the Food tastes terrible. R116 said there weren't a lot of choices of food that taste good. 2. On 11/07/21 at 10:16 AM, R6 said the food did not taste very good and was very bland. On 11/08/21 at 02:21 PM, R6 said for lunch he had tomato soup and the macaroni and cheese. R6 said the macaroni and cheese didn't taste like anything, I'm not sure what kind of cheese it was supposed to be. R6 said he placed the macaroni and cheese into his tomato soup and was able to eat it that way. 3. On 11/07/21 at 11:32 AM, V12 (R117's family member-son) said he had asked for R117's food to be cut up before bringing it in to R117. V12 said the facility went to the extreme of putting R117's food through a blender and the taste of the food was very bland. V12 said even though the food was bland, R117 liked pasta and had enjoyed [NAME] the penne noodles onto the fork to eat. On 11/08/21 at 12:10 PM, V13 (R117's family member-wife) said R117 liked and ate all of the potato soup independently. R117 tried the pasta and said he didn't like it, No. This is no good. V13 tasted the pasta and said it was Ehh, it doesn't taste like much. On 11/09/21 at 12:09 PM, V13 (R117's family member) said he has the famous pasta for lunch today. The diet sheet showed R117 had a mechanical soft diet of penne pasta with marinara sauce and chopped green beans. 4. On 11/02/21 at 11:53 AM, R118 said the food was not good. R118 said the food was bland tasting and she was tired of seeing same bland food choices. 5. On 11/07/21 at 12:09 PM, R119 said she doesn't like the food here. R119 said she was a very finicky eater but she did not like the taste of the food at the facility. On 11/08/21 at 11:38 AM, a test tray was requested and the food was sampled. The macaroni pasta and cheese was a pale yellow with pale yellow liquid underneath. Both the macaroni and cheese and the corn were flavorless. The baked cod visibly looked moist and seasoned but when tasted, was dry and chewy.

Based on observation, interview, and record review, the facility failed to administer medication as ordered by the physician. There were 27 opportunities with 2 errors resulting in a 7.40 % error rate. This applies to 2 of 13 residents (R68, R120) observed during medication pass. The findings include: 1). On (MONTH) 11, 2019 at around 8:25 AM, V4 (Registered Nurse, RN) administered two puffs of [MEDICATION NAME] (mometasone-[MEDICATION NAME]) ten seconds apart to R120 along with her morning medications. On (MONTH) 11, 2019 at 2:25 PM, V4 when asked stated I waited for 10 seconds between puffs, that is what I told the patient to do. 2). On (MONTH) 11, 2019 at around 9:43 AM, V5 (RN) administered two puffs of [MEDICATION NAME] fifteen seconds apart to R68. On 06/11/19 at 2:20 PM, V5 stated I thought, I waited for a minute. V5 was notified that the surveyor was timing her and the two puffs were given 15 seconds apart. On 06/11/19 at 01:06 PM, V2 (Unit Manager/Director of Nursing), stated we follow Lippincott procedures as we are part of the teaching hospital. As of 6/11/19 at 2:30PM, the drug information that is available for the staff in the facility's Electronic MAR (Medication Administration Record) titled Lexicomp shows that [MEDICATION NAME] is a long acting Beta2 Agonist. Under the subtitle Administration: Inhalation, it states to wait for greater than or equal to 30 seconds prior to administering the second inhalation dose. On 06/12/19 at 01:31PM, V8 (Clinical Pharmacist) stated he expected nursing staff to refer to the drug information link in the MAR (Medication Administration Record) for information on the drug/medication. V8 further stated, as of 6/12/19, the pharmacy department have updated the drug information link under [MEDICATION NAME] to highlight waiting 30 seconds between administration of inhalation medication.

Based on observation, interview and record review, the facility failed to perform hand hygiene; failed to change gloves during patient care; and failed to wear (Personal Protective Equipment) PPE before entering an isolation room. The facility also failed to ensure blood glucose machine is sanitized between patient use and also failed to ensure urinary catheter is off the floor. This applies to 5 of 12 residents (R22, R77, R79, R175 and R177) reviewed for infection control issues in the sample of 12. The findings include: 1. On 7/11/18 at 9:52am, R79 was lying on his left side. R79 is alert and oriented to self, time and place. V6 (Nurse) was to perform wound care dressing change on R79. V6 did not clean R79's wound prior to treatment. V6 applied her gloves and took off dressing, failed to wash her hands, went outside of the room to get a packet of unopened 4 x 4 packet. V6 placed the packet against R79's wound to measure R79's wound. V6 placed the used 4 x 4 packet on top of her medication cart. V6 used the dirty gloves to put the Venelex tube in the packet and also in a Ziploc bag. V6 removed her gloves multiple times during the wound dressing changes without washing her hands. V6 did not perform any type of hand hygiene until the completion of the wound dressing changes. On 7/10/18 around 9am, the Facility provided wound skin issue list. The list showed R79 was admitted with stage II right buttocks ulcer. R79's electronic health record (EHR) showed R79 was admitted to the facility 7/5/18 with [DIAGNOSES REDACTED]. 2. On 7/11/18 10:35am, V7 (Nurse) was to perform wound care dressing change on R22. R22 was observed in the chair. R22 is alert and oriented. R22 speaks predominantly Spanish language. R22 had bilateral lower extremity ace wraps. V7 had a pair of gloves on, lifted R22's left lower leg and removed the old dressing. V7 did not change her gloves or wash her hands. V7 measured R22's wound with the same gloves on. V7 cleaned R22's wound, and applied a a gentle border dressing. V7 used the same gloves throughout the dressing change. On 7/12/18 at 11:12am, V2 stated V7 should have changed her gloves. Review of R22's EHR showed R22 was admitted to the facility 6/20/18 with post-operative wound infection, sinus pause and abdominal distention. R22's minimum data set (MDS) dated .showed R22 with brief interview for mental status of 15 - cognitively intact. 3. The EHR (electronic health record) of R177 showed R177 is on contact isolation for history [MEDICAL CONDITION] ([MEDICAL CONDITION]. On 7/10/18 at 8:17 AM, V9 (Food Service Worker) entered the room of R177 without any gloves and wearing an untied blue isolation gown. V9 used the sleeves of the gown to carry the tray. After placing the tray on the table in R177's room, V9 removed the gown, rolled it up and placed it in the trash. Without using any hand hygiene or washing of hands, V9 left the room, grabbed the food tray cart and pushed it forward as V9 continued to enter resident's rooms and pass out food trays. On 7/10/18 at 9:15 AM, in the presence of V10 (Food Service Director), V9 stated she usually uses gloves. 4. On 07/10/18 at 11:32 AM, V11 (CNA/Certified Nursing Assistant) obtained a blood glucose specimen using a glucometer for R129 in the physical therapy room. After providing the blood sugar reading of 126, V11 quickly wiped the outer surface of the glucometer for about 30 seconds, walked out and handed the glucometer to V12 (CNA) who in turn used it to obtain a blood glucose reading on resident R77 at 11:39 AM. The facility provided policy titled Nova StatStrip effective 5/3/18 showed cleaning and disinfecting are generally performed at the same time; cleaning removes visible soil and organic material and disinfecting destroys most recognized pathogenic microorganisms. Per Infection Prevention, the NOVA StatStrip meter must be disinfected after each patient use with a bleach wipe. The manufacturer's contact time is 4 minutes; the equipment needs to dry thoroughly (contact time) do not wipe off the bleach. Under the heading Glucose meter cleaning and disinfection procedure, the policy also showed the following: 1. perform hand hygiene, don gloves 5. Using a fresh bleach wipe, wipe the external surface of the meter .followed by 3 times 6. Gently wipe he surface areas of the test strip port making sure that no fluid enters the port 7. Observe the 4 minute wet contact time 8. Dry the meter thoroughly with a dry cloth or gauze The facility policy dated 8/17 and titled Guidelines for Standard Precautions, Transmission-Based Precautions showed the following: Standard Precaution: Hand Hygiene 1: Perform hand hygiene before and after contact with the patient and their environment 2: Perform hand hygiene before placing and after wearing gloves The facility policy dated 8/17 and titled Hand Hygiene showed to perform hand hygiene before and after having direct contact with patients and their environment. Perform hand hygiene before donning gloves and after removing. 5. On (MONTH) 09, (YEAR) at 11:03 AM, during room visit on initial tour, R175 was noted sitting on a chair doing diversional activities with V15 (activities). R175 had a urinary catheter bag which was on the floor inside a protective bag. Part of (about 1/4th) of the urinary catheter bag was out of the protective bag and lying directly on floor showing dark amber colored urine in the bag. V15 was not sure whether the catheter bag should be on the floor or not. R175's EMR (electronic medical record) included [DIAGNOSES REDACTED]. On (MONTH) 10, (YEAR) at 10:20 AM, V13 (Minimum Data Set Nurse) stated that the urinary catheter should be off the floor. V13 stated that the urinary catheter bag should be hung up beside the bed. Facility policy and procedure titled Urinary bladder Catheter insertion, monitoring and/or maintenance included the following: When caring for a patient with a urinary bladder catheter, measures that reduce the risk of urinary bladder catheter related complications are adhered to. Policy principles included bag-floor contact is avoided.

Based on observations, interview and record review, the facility failed to develop individualized care plan for residents with pressure ulcers/skin breakdown. This applies to 2 of 12 residents (R4 and R22) reviewed for plan of care in the sample of 12. The findings include: 1. On (MONTH) 10, (YEAR) at 9:30 AM during room visit, R22 was noted to have a bandage under the left heel. R22 was wearing non skid socks over the bandage. R22 acknowledged that he has a skin breakdown on his heel. On (MONTH) 10, (YEAR) at 11:20 AM V14 (family member) stated that R22 acquired the skin breakdown on his heel in the facility due to wearing shoes that were not fitting well, as his feet were swollen. V14 stated that the family had brought in shoes for R22 to wear as he does not like to be in socks alone. V14 stated that the family notified the nurses about a week ago about the skin breakdown. R22's EMR (electronic medical record) included that R22 was admitted on [DATE] with [DIAGNOSES REDACTED]. Nursing progress notes in R22's EMR (electronic medical records) dated 7/4/18 documented the following: Noted with stage 2 pressure injury on sacrum and fluid filled blister on left heel which remains intact, see flow sheet. Dry foam applied to both sites. No drainage noted. The facility could not provide a comprehensive care plan of the skin breakdown as of (MONTH) 9, (YEAR). On (MONTH) 11, (YEAR) at 11:30 AM, V13 (Minimum Data Set Nurse) stated that care plans should be done upon identification and it was missed. 2. R4's Admission Care Plan showed R4 was admitted on [DATE] with skin impairment on the left heal. On 6/30/18 at 4:37 PM, a nursing note for R4 showed left heel new socks and dressing applied. On 6/30/18 at 5:24 PM a history and physical admission was performed which noted for R4 left heel has an ulcer. On 7/2/18 at 10:42 AM, V7 (nurse) documented R4 voiced pain to heels .left heel DTI (deep tissue injury) assessed, no new changes noted. Allevyn patch applied to bilateral heels. On 7/3/18 at 2:42 PM, V17 (nurse) entered a plan of care for R4 without an identified problem listed that showed the patient stated the goal as: I want my heel pain to go away. No interventions were noted. On 7/6/18 at 12:03 AM, V16 (nurse) documented R4 had DTI to left heel, complained of pain and medicated. On 7/6/18 at 2:07 PM, V18 (nurse) entered a plan of care with a problem identified as: Skin Integrity with the intervention noted as: Skin care provided, Allevyn changed as needed, increase activity reinforced and hydration provided. On 07/09/18 at 11:24 AM, R4's family stated R4 has some sort of skin condition on his right foot. R4 was noted wearing a yellow non-grid sock with a bandage underneath covering the left heal. On 07/10/18 at 11:02 AM, V5 (nurse) stated there is not a comprehensive care plan with interventions for care of the foot wound and confirmed no plan could be located in the EHR. On 7/12/18 at 11:34 AM, in the conference room, V2 stated, We have our initial care plan upon admission but the other care plans are very general. R4's electronic record review showed no care plan specific to left heel care.

Based on observation, interview and record review, the facility failed to ensure that resident admitted with pressure sore did not increase in size and also failed to assess and document a resident with deep tissue injury on admission. This applies to 2 of 3 residents (R4 and R79) reviewed for pressure sore in the sample of 12. The findings include: 1. On 7/11/18 at 9:52am, R79 was lying on his left side. R79 is alert and oriented to self, time and place. R79's pant and incontinence brief were pulled down. V6 (Nurse) was to perform wound care dressing change on R79. V6 did not clean R79's wound prior to treatment. V6 applied gloves and took it off. V6 did not wash her hands, went outside of the room to get a packet of unopened 4 x4 packet. V6 placed the packet against R79's wound to measure the wound. V6 placed the used 4x4 packet on top of her medication cart. R79's coccyx wound measurements is 1.0cm x 0.75cm. The wound has no odor and is dry. V6 stated R79's wound was cleaned by the certified nursing assistant (CNA) earlier in the shift. V6 applied Venelex ointment/cream on R79's coccyx wound, re-applied R79's incontinence brief and pulled R79's pant up. V6 used the dirty gloves to put the Venelex tube in the packet and also in a Ziploc bag. V6 removed her gloves and did not wash her hands until after the completion of the dressing change. On 7/12/18 at 1:25pm, R79 was sitting in the therapy room. R22 denied having pain stating, He did not give me any of those but a lot of soreness. R79 further stated, You sit around all day doing nothing. When asked where the soreness is, R79 made a gesture to his buttocks area. On 7/10/18 12:34pm, V5 (MDS/Wound care Nurse) stated proper documentation and description of wounds were lacking because there are new nursing staff. V5 stated nursing staff are trained to perform head to toe assessment when residents are admitted . V5 stated the documentation was lacking a follow up. On 7/12/18 at 11:12am, V2 Director of Nursing (DON) stated R79's wound should have been cleaned as per protocol. V2 stated the facility has a wound care competency listing that nursing staff should follow. On 7/10/18 around 9am, the Facility provided wound skin issue list. The list showed R79 was admitted with stage II right buttocks ulcer. R79's electronic health record (EHR) foresheets dated 7/5/18 showed R79's Braden scale as 15. It also showed pressure ulcer/injury stage 2 right buttocks that measured 0.5cm x 0.4cm, dry, open to air and no drainage. R79's wound measurement taken on 7/11/18 showed 1cm x 0.75cm showed an increase in R79's wound size. R79's nursing note dated 7/7/18 showed nursing staff would ask the physician in the morning for treatment to the pressure sore. On 7/7/18 another nursing notes showed R79 admitted with stage 2 to buttocks, red and excoriated. There was no treatment ordered for the coccyx wounds from 7/5/18 when admitted until the morning of 7/7/18. R79's EHR showed the facility initiated skin impairment care plan for R79 on 7/5/18 which showed R79's coccyx wound was identified as stage 2. Progress note dated 7/7/18 showed nursing staff - Venelex ointment to buttocks and coccyx stage II lesion. R79's EHR showed R79 was admitted to the facility 7/5/18 with [DIAGNOSES REDACTED]. Review of facility's competency titled, Clean Dressing Change Competency with no date, showed Put on first pair of disposable gloves. 9. Remove soiled dressing. 10. Dispose of gloves in plastic bag. 11. Wash hands and put on second pair of gloves. 12. Cleanse wound with prescribe solution. 14. Remove gloves, cleanse hands. 15. Apply prescribed medication using a clean tongue blade or Q-tip. 16. Apply prescribed dressing, and secure per order. 17. Remove gloves and discard in to plastic bag. 2. R4's Admission Care Plan showed R4 was admitted on [DATE] with skin impairment on the left heal. On 6/30/18 at 4:38 PM, V19 (nurse) nursing note for R4 showed left heel new socks and dressing applied without any description of the wound or assessment noted. On 6/30/18 at 5:24 PM, V20 (physician) performed an admission history and physical which noted for R4 left heel has an ulcer. On 7/2/18 at 10:42 AM, V7 (nurse) documented R4 voiced pain to heels .left heel DTI (deep tissue injury), without any description of the wound or assessment noted. On 7/3/18 at 2:42 PM, V17 (nurse) entered a plan of care for R4 without an identified problem listed, that showed the patient stated the goal as: I want my heel pain to go away. No interventions were noted. On 7/6/18 at 12:03 AM, V16 (nurse) documented R4 had DTI to left heel, complained of pain and medicated without any description of the wound or assessment noted. On 7/10/18 at 2:43 PM, V7 provided the first documented measurement of the heel wound after request for a description of the wound by writer. In addition, V7 contacted a physician to see R4 regarding the left heel. On 7/12/18 at 10:15 AM, V2 shared she did not see a physician order [REDACTED].>The facility policy titled Skin Management with a revision date of 5/10 showed: all wounds (open and pressure ulcers) will be measured on admission and every Wednesday. The undated TCU (Transitional Care Unit) Program Protocol provided by the facility showed the following under the category of interventions for identified pressure ulcers: f. DTI still measure. The undated document provided titled Assessment of Wounds provided by the facility showed: to measure all pressure ulcer including unstageable and to make a separate nursing note to describe the wound. The NPUAP (National Pressure Ulcer Quick Reference Guide) Advisory Panel showed: 1.2 Document the findings of all comprehensive skin assessments.

Based on observation, interview and record review, the facility failed to administer medications as ordered. There were 25 opportunities with 2 errors resulting in a 8% error rate. This applies to 2 of 7 residents (R3, R128) observed during medication pass. Finding Include: On 7/10/18 at 8:05 AM, V8 (nurse) administered [MEDICATION NAME] crushed medication and mixed with applesauce to R3. The EHR (electronic health record) medication summary showed the following: Do not divide, crush, chew or dissolve tablet. On 7/11/18 at 9:22 AM, V6 (nurse) applied [MEDICATION NAME] powder only under the breast and in the abdominal folds to R128 while resident was seated in the chair at the bedside. The EHR (electronic health record) medication summary showed the following: apply under breasts, abdominal folds, groin and peri area redness 07/11/18 10:47 AM V5 (Wound Nurse) visualized and acknowledged reddened areas in the groin and peri areas without [MEDICATION NAME] and told R3 that she would come back and apply. V5 acknowledged it would be difficult to apply in the groin and peri area while R3 is still seated On 7/11/18 at 1:14 PM in the presence of V2 (nurse manager), V8 confirmed she crushed R3's medications because of R3's dysphasia and stated, Oh my gosh, I have been crushing it every day; let me call Dr.(NAME)and the pharmacy to see if they can order a different medication. On 7/11/18 at 1:16 PM in the presence of V2, V6 stated the [MEDICATION NAME] was not really placed everywhere it should have been due to the patient sitting and added usually she places the resident in the bed.

Based on observation, interview, and record review, the facility failed to properly sanitize blood glucose monitoring equipment according to the manufacturer guidelines, while performing blood glucose testing on one (R5) of one residents in the sample of 10 and two (R11, R12) residents from the supplemental sample, reviewed for blood glucose monitoring. Findings include: On 8/28/17 at 4:47 pm E12 (registered Nurse) performed blood glucose testing on R11. After performing the blood testing E12 cleaned the glucometer, wiping the glucometer for 15 seconds using a germicidal disposable wipe then allowed the glucometer to dry. At 4:59pm E12 performed blood glucose testing on R12. E12 then cleaned the used glucometer, wiping the glucometer with germicidal disposable wipe for 52 seconds and then allowed the glucometer to dry. At 5:06pm E12 stated the glucometer should be wiped for 30 to 45 seconds with the disinfectant wipes and then let the glucometer air dry for 4 minutes. On 8/29/17 at 11:28 am E11 (Patient Care Assistant) performed blood glucose testing on R5. After performing the blood glucose testing E11 then cleaned the glucometer by placing the germicidal disposable wipe around the glucometer for 3minutes and 40 seconds. There were no wiping action observed the wipe was not touching all of the surfaces of the glucometer. On 8/29/17 the E2 (Director of Nursing) stated that the glucometer should be clean according the manufactures guidelines. The germicidal disposable wipe manufacture guidelines document in part the following: To Disinfect and Deodorize: Unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet for a full two (2) minutes. Let air dry. Review of the facility's policy dated May 3, 2016 Nova Stat-Strip Glucose Meter: Glucose meter cleaning and disinfection procedure in part indicates wipe the external surface of the meter thoroughly with fresh bleach wipe and discard. Use a fresh bleach wipe , wipe the external surface of the meter (top to bottom left and right sides) a minimum of 3 times horizontally followed by 3 times vertically. Observed the 4 minutes wet contact time.

Based on observation, interview and record review, the facility failed to follow its food storage policy and to ensure foods stored are within the used-by dates. The deficiencies affect all 27 residents receiving oral diet from the facility kitchen. Findings Include: On 9/7/16 at 12:20pm, the following observation was made during a kitchen tour with Z1 (General Manager of Dietary): In the reach-in refrigerators: One full-size, 2 (inch) deep stainless steel pan of red diet Jell-O was labeled with preparation date: 8-31 and used-by date: 9-4. One full-size, 2 deep stainless pan of yellow diet Jell-O was labeled with preparation date: 9-2 and used-by date: 9-6. One 1/3 -size, 4 deep stainless pan of leaf lettuce was labeled with preparation date: 8-31 and used by date: 9-3. Water was observed on the bottom of the pan, brown spots were observed on the leaf lettuce. Asked Z1 about foods stored exceeding the used-by dates, Z1 stated that: we are supposed to toss them . In the dry storage room: A plastic bag of dry cereal was found with no product name or date on the bag. Asked Z1 what is in the bag, Z1 stated: Granola . Asked Z1 should a date be labeled on the bag, Z1 replied: yes . The following products do not have manufacturer used-by dates or receiving dates: 3- 1 gal (gallon) containers of buffalo wing sauce, 3-1 gal containers of honey barbeque sauce, 9-1 gal containers of soy bean oil, 6-46 oz (ounce) of sea clam juice, 2-1 gal containers of hot giardiniera, 2-1 gal containers of white vinegar, 4-4 lb (pound) jars of apricot preserves, 6-4 lb jars of orange marmalade, 5-4 lb jars of grape jelly and 3-1 gal containers of soy sauce. The following opened products do not have the opened dates: 1- 4-liter container of balsamic dressing, 1- 6 lb container of honey, 1-1 gal container of soybean oil, 1- 1-gal container of cooking wine. Asked once the product is opened, should an opened date be placed on the product? Z1 replied: yes . On 9/7/16 at 3:15pm, Z1 stated in an interview: if the individual containers or cans are out of the manufacturer boxes, the dates when the cans or containers are removed from the box should be written on the products. The reason for it is to follow FIFO (First-In, First-Out), to use the old products before using the new products A date should be labeled for any opened products . The kitchen staff were told to go over the refrigerated products and throw away products that exceed the used-by date because it is very important to make sure the foods are safe to use Facility ' s Food Safety Policy entitled Food safety Product Labeling and Dating Guide denotes, in part: FIFO system must be in place Facility ' s policy entitled: Food Product Shelf-Life Guideline denotes, in part; .,.Gelatin: refrigerator storage 3 to 4 days

Based on observation, interview and record review facility failed to ensure that eyedrops were administered correctly by following their policy for one of one resident (R13) from the supplemental sample during medication administration observation and based on observation, interview and record review, the facility failed to assess the pain level for two of two supplemental residents (R13 and R14) before and after administering pain medication, reviewed for pain. FINDINGS INCLUDE: On 9/8/16 at 10:02 am E8 (Registered Nurse/RN) administered an eye drop to R13 to R13's right eye by lifting the upper eyelid and the eye drop did not completely fell inside the inner aspect of the eye rather part of the drop was touching her right lower lashes. R13 then wiped the drop by using a facial tissue paper. On 9/8/16 at around 2:00pm while explaining how E8 administerd eye drops, she stated in part that E8 pull the upper eye lid upward and drop the medication into the eye. On 9/8/16 at 4:00 PM the unit Manager (Director of Nurse for transitional care /D.O.N)) stated that the Facility follow Nursing Manual Procedure for Eyedrop Administration. Review of the Nursing Manual Procedure provided by the facility indicated on page 2 of 5 for Eyedrop administration in part that to instill eyedrops, pull the lower lid down to expose the conjunctival sac, Have the patient look up and away, and then squeeze the prescribed number of drops into the sacs. Release the patient's eyelid, and have the patient blink to distribute the medication. Facility did not follow the above. On 9/8/15 at 10:02 am R13 and at 10:12am R14 received pain medication from E8 RN. E8 did not rate the pain level for R13 and R14 before or after administering the pain medication. On 9/8/16 at 11:17am, the surveyor asked both R13 and R14 how is their pain level? R14 state that I'm Slow with everything for the same reason my pain is still the same. No one came and ask me, how is my pain, after I took the pain pill. R13 stated that R13's pain went down a little but it did not went down completely. When asked E8 stated that E8 was too busy and forgot to assess the pain. Facility's pain management policy dated 4/95 stated that Pain is considered the fifth vital sign in the hospital's care of patients. Pain intensity ratings are done before and after administering pain medications. On page 6 of 8 in the same policy it says in part reassessment of pain is done after a pain medication is given. Any healthcare person can have the patient rate his/her pain on the appropriate pain scale the assessment will occur no later than one hour after administration of [MEDICATION NAME].

Based on observation, interview and record review, the facility failed to post isolation signage, follow hand hygiene policy and follow glucometer sanitizing. this failure applies to 1 of 5 residents (R5) in the sample of 10 reviewed for infection control and 1 resident (R11) in the supplemental residents. Findings include: On 9/7/16 at 1:00pm E7 (Nurse) administered Intravenous (I.V) antibiotic for R11. After gathering all the equipment E7 went to the resident ' s room put his gloves on and started the procedure. Just before priming the tubing E7 was holding the left arm and assessed the insertion site and the resident stated that the skin is irritating her where the tape is touching. Then E7 touched the area around the I.V insertion site and told the resident he will be back to adjust the tape. Then E7 flushed the tubing with normal Saline attached the tubing with medication to R11 ' s peripheral line. E7 did not perform Hand hygiene before the procedure and walked out of the room. When asked E7 stated, I used the hand gel. Review of Hand Hygiene policy dated 11//02 indicated that Perform hand hygiene before and after having direct contact with patients and their environment. On 9/7/16 at 10:49am during an initial unit tour, it was observed that E6 (Patient Care Assistant) putting on gown and gloves outside of R5 ' s room, knocked on the door and entered into R5 ' s room. E6 did not perform hand hygiene prior to putting on gloves. No isolation signage visible. On 9/7/16 at 11:00am, asked E2 (Unit Manager, Director of Nursing) how does the facility identify residents on isolation. E2 stated: there should be a sign on the resident ' s door .it must have fell off On 9/9/16 at 10:17am, E6 stated during an interview: when someone is on contact isolation, I put on my PPE (Personal Protective Equipment) which is gown and gloves before entering the room I put my hand sanitizer first and I wash my hands before leaving the room . Asked E6 if hand sanitizer was used prior to putting on gloves on 9/7? E6 stated: no, I forgot . Review of Physician order [REDACTED]. Facility policy entitled Guidelines for Standard Precautions, Transmission-based precautions and Management of Multidrug Resistant Organisms (MDRO) denotes, in part: Contact Precautions 3. Use of Personal Protective Equipment- Gloves and Hand Hygiene a) Before entering the patient ' s room, perform hand hygiene and don gloves upon entering the room Isolation Protocol: A. Implementing Isolation: 4. When a patient is placed on precautions precaution card is placed onto patient ' s door. This card is to remain on the door until the isolation is discontinued and the room is cleaned .

Based on observation, interview and record review the facility failed to maintain privacy, and dignity during medical examinations for two of two (R3, R4) residents in a total sample of 11, reviewed for dignity and two (R12, R13) residents outside of the sample. Findings Include: On 10/28/15 at 12:25, Z1 (Doctor) entered the room of R12 and completed a bedside exam without knocking on the door,without pulling the privacy curtain and without closing the door. Once this exam was completed, Z1 went into the room of R13 without knocking, pulling the curtain or closing the door, and completed this examination, also leaving the complete exam visible to anymore passing in the hall. Z1 continue after R13's exam to R3 with not pulling the curtain or closing the door during R3's exam. After completing R3's exam, Z1 proceeded to examined R4 with the door and curtain open. On 10/28/15 at 12:53pm E2(Interim Director of Nursing) was asked if the door of the resident should be closed while Z1 is examining the residents, E2 failed to respond. Facility Confidentiality and Patient Privacy Policy indicate that residents/patients should be examined in a surrounding designed to assure audio and visual privacy is maintained.

Based on observation, interview and record review the facility failed to maintain infection control for 2 of 2 (R3,R4) residents in a total sample of 11, and 2 (R11,R12) residents outside of the sample reviewed for infection control. Findings Include: On 10/28/15 at 12:25pm, Z1(Doctor) entered the room of R11, removed gloves from the glove box and put them on. Z1 used no hand hygiene prior to entering the room. Z1 examined R12 and checked the dressing site to R12's right knee. Once the exam was complete, Z1 removed the gloves, left the room without using hand hygiene and went to the next resident R13. Z1 entered R13's room without any hand hygiene, applied gloves and examined R13. Once this exam was completed, Z1 went into R3's room, applied gloves without hand hygiene and examined R3. R3 was on isolation for[DIAGNOSES REDACTED] (Clostridium Difficile). Z1completed the exam of R3 and left the room without hand hygiene and went into the room of R4. Z1 once again applied gloves without hand hygiene and examined R4. Once completing the exam, Z1 removed the gloves, and left R4's room without hand hygiene. Z1 also did not sanitize the stethoscope before and after examined R3, R4, R11 and R12. On 10/28/15 at 1:20pm E3 (Infection Preventionist) states, Z1 should have washed Z1's hand when entering and leaving a residents room. When gloves were removed Z1 should have cleaned Z1's hands. Facility Infection Prevention and Control policy effective 11/02 indicate that hand hygiene is to be done before putting gloves on and after removing the gloves. Policy further indicate that hand hygiene is to be performed after direct contact contact with residents and their environment.