Every finding on record at Penn Nursing Center

Based on the record review and staff interviews, the facility failed to schedule a Registered Nurse (RN) for at least 8 consecutive hours a day for 4 of 60 days (12/7/24, 12/24/24, 1/3/25, and 1/28/25) reviewed for staffing. Findings included: Review of the facility's daily staff posting and staffing schedules from 12/1/24 through 1/28/25 revealed the following: a.) On 12/7/24 the daily staff posting indicated daily census of 67 and 1 RN working for both evening shift (3PM - 11 PM) and night shift (11 PM to 7 AM). Review of the staffing schedule revealed there was no RN working on any shift that day. b.) On 12/24/24 the daily staff posting indicated daily census of 65 and 1 RN working for both evening shift (3PM - 11 PM) and night shift (11 PM to 7 AM). Review of the staffing schedule revealed there was one RN working from 7 PM to 12 PM, which was for 4 consecutive hours that day. c.) On 1/3/25, the daily staff posting and staffing schedule indicated the daily census of 62 and 0 (zero) RN on duty. d.) On 1/28/25, the daily staff posting and staffing schedule indicated daily census of 67 and 0 (zero) RN on duty. During an interview on 1/30/25 at 12: 00 PM, the Scheduler indicated she had included the Minimum Data Set (MDS) nurses and Assistant Director of Nursing (ADON) as RN for the day. There were RNs available in the facility but were not on the cart or assigned to the residents. During an interview on 1/30/25 at 12:18 PM, the Director of Nursing (DON) stated she overlooked the daily staffing schedule to ensure the staff were properly scheduled for the day. There was no difference in the number of staff scheduled for weekdays or weekends. Staffing was based on census and acuity of the resident. The DON indicated the scheduler was in constant contact with the DON related to staffing. The DON stated she does not review the Payroll Based Journal (PBJ) report to ensure there was an RN working 8 consecutive hours a day for 7 days. The Administrator reviews and submits the PBJ report. The DON stated she was only assigned to work on the medication cart when needed which was very rare and the facility was unable to find an RN to work the shift. During an interview on 1/30/25 at 12:45 PM, the Administrator indicated that he does the validation and submission of PBJ report to Center for Medicare and Medicaid (CMS). The DON and the scheduler work closely to ensure adequate staff and RN for 8 consecutive hours/ day were available for patient care. The staffing was based on the census and acuity of the resident.

Based on observation, record review and staff interview the facility failed to revise a care plan intervention for 1 of 2 sampled residents (Resident #26) reviewed for range of motion. The findings included: Resident #26 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] [CONDITION(S)]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #26's cognition was impaired and he had range of motion impairment on one side. Review of Resident #26's care plan dated 6/10/22 revealed a problem that sated resident required supervision to total assistance with Activities of daily living related to Dementia and impaired mobility secondary to [CONDITION(S)] with right [CONDITION(S)]. The goals stated he would have his needs met by staff and would participate as able. The interventions were not updated to include Resident #26's splinting device. A review of Occupational Therapy discharge recommendation dated 6/17/22 indicated Resident #26 was to have range of motion to wrist, digits, and thumb prior to donning splint and have patient wear splint for 4 hours every day. An interview was conducted with the Rehab Director on 8/17/22 at 9:46 AM. The Rehab Director explained that Resident #26 received therapy for splinting and once released from therapy, training was conducted with the nursing staff. The Rehab Director further explained therapy gave their recommendations to the nursing staff and MDS staff on a form in everyday language which included directions for wearing the splint. An interview with the MDS Coordinator #2 on 8/17/22 at 1:39 PM revealed she was made aware of devices through a form from therapy and was also in-serviced along with nursing floor staff. She further revealed splinting would be included in care planning and added under the Activities of Daily Living (ADL) interventions, however for Resident #26 it was missed. An interview with MDS Coordinator #1 on 8/17/22 at 1:43 PM revealed splinting and skin integrity checks should be on the care plan, however it was not on Resident #26's care plan. She further revealed when the overall update of the annual care plan was completed splinting was not added to the care plan. An interview was conducted with the Director of Nursing (DON) on 8/18/22 at 10:33AM, The DON indicated the care plan interventions should have been revised to reflect Resident #26's splinting and staff education needs.

Based on record review, observation, resident, and staff interviews the facility failed to anchor an indwelling urinary catheter for 1 of 1 resident reviewed for indwelling urinary catheters (Resident #54). The findings included: Resident #54 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set (MDS) for significant change in status assessment dated [DATE] indicated Resident #54 to be cognitively intact and totally dependent on bed mobility, transfer, dressing, toilet use, and personal hygiene. The resident was coded as having an indwelling urinary catheter. The Care Area assessment dated [DATE] noted a focus area of indwelling urinary catheter which was to be addressed in the care plan. Review of the care plan dated 07/22/22 revealed Resident #54 to have a focus area for the potential of complications and infection related to indwelling urinary catheter and closed drainage system. The goal indicated Resident #54 would not develop urinary tract infections related to urinary catheter use and drainage bag would remain patent. Interventions included do not allow drainage tube to be become kinked or coiled causing obstruction flow of urine and to anchor the urinary catheter to leg per facility policy to prevent pulling on the urinary catheter during movement by resident or staff. An observation on 08/17/22 at 8:17 AM revealed the Treatment Nurse turning Resident #54 on her side. The urinary catheter tubing was observed to have not been anchored to her thigh. An additional observation on 08/17/22 at 9:51 AM revealed Resident #54 to be lying in bed and was in the process of being transferred by 2 Nursing Assistants (NA #1 and NA #2). NA #1 and NA #2 were observed to lift resident's left leg up, which revealed the urinary catheter was not anchored to Resident #54's thigh. NA #1 was interviewed on 08/17/22 at 10:01 AM. She stated she was trained on urinary catheter care which included placement of the urinary catheter, cleaning the urinary catheter, and anchoring the urinary catheter. She indicated residents who had urinary catheters should have their urinary catheter below their bladder as well as the urinary catheter should be anchored to their inner thigh. She stated Resident #54's urinary catheter was not anchored to her inner thigh and did not know why it was not anchored. She did not indicate where the urinary catheter anchoring device was located. An interview with NA #2 on 08/17/22 at 10:05 AM revealed she was assigned to work with Resident #54 and had not worked with Resident #54 in the past. She indicated she was trained on urinary catheter care which included placement of the urinary catheter, cleaning the urinary catheter, and anchoring the urinary catheter. She stated Resident #54's urinary catheter was not anchored to her thigh nor was it anchored to her thigh when she arrived to start her shift. She further indicated Resident #54's urinary catheter should have been anchored to ensure the catheter did not get pulled. An interview with Resident #54 on 08/17/22 at 12:40 PM revealed she had gotten the urinary catheter during her last hospital stay. She indicated the reasoning for her urinary catheter was because she had urinary retention. She stated she had never had a urinary catheter anchoring device since she had resided at the facility. She indicated the urinary catheter had been tugged in the past by a facility staff member, but it did not cause discomfort. Nurse #1 was interviewed on 08/17/22 at 1:14 PM which revealed she was familiar with Resident #54's urinary catheter care needs. She indicated to prevent pulling of the urinary catheter, the urinary catheter needed to be anchored to the resident's thigh. She indicated it was important to prevent pulling on the urinary catheter as this may cause bleeding, discomfort, and pain. She further stated she always checked residents with urinary catheters to ensure the urinary catheter was anchored to their inner thigh. She indicated she thought Resident #54 had a urinary catheter anchoring device on her inner thigh. She stated she did not know why Resident #54 did not have a urinary catheter anchoring device on. An interview with the Assistant Director of Nursing (ADON) on 08/17/22 at 1:51 PM revealed Resident #54 did not have her urinary catheter anchored to her thigh because the previous anchoring device had fallen off. She stated they had placed another one on after the surveyor's observation 08/17/22 on Resident #54's left upper thigh. She indicated she did not know when the previous one had fallen off. An interview with the Director of Nursing (DON) on 08/17/22 at 1:35 PM revealed urinary catheter anchoring devices were placed on residents who had urinary catheters to prevent excessive tension and pulling of the urinary drainage tubing. She stated standing physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She indicated if the urinary catheter anchoring device falls off or gets soiled, a NA or Nurse can go to the supply room to retrieve another one.

Based on observation, record review, staff interview, and review of the facility's policy and procedures, staff failed to implement the guidelines regarding use of personal protective equipment (PPE) during COVID-19 by not wearing the full PPE required when passing meal trays to 2 of 8 newly admitted residents (Resident #4, and #5) residing on the isolation unit. This failure occurred during the COVID-19 pandemic. Findings included: Review of the Isolation -notice of transmission-based precautions policy, revised date June 2020, read in part When transmission-based precautions are implemented an appropriate sign will be placed on the entrance/doorway of the resident's room. Sign will be used to alert staff of the implementation of transmission-based precautions. The policy indicated staff should follow practices that included wearing of masks, eye protection, face shield, gowns and gloves for contact with residents or their environment. Observation of the signage posted on the resident's rooms doorway on isolation unit were 1) droplet precaution 2) CDC sign Use Personal Protective equipment (PPE) when caring for patients with confirmed or suspected COVID-19 , 3) Contact precaution. All signs indicate gowns, mask, eye protection, gloves should be worn prior to entering the resident's room. During an interview on 11/9/20 at 10:30 AM, with the Director of Nursing (DON), she stated one resident tested positive for COVID on 10/21/20. She further stated no residents tested positive the following week. The DON explained that all new admissions and readmissions were placed on the isolation unit for quarantine for 14 days. The new admissions tested negative for COVID -19 prior to admission and were placed on transmission-based precautions which included contact and droplet precautions. The DON added if the resident tested positive for COVID-19 then the resident would be placed under enhanced transmission-based precautions. The DON stated there were signs placed on each doorway of the resident rooms on the isolation unit indicating the type of precautions ordered for the resident, The signs indicate, the personal protective equipment (PPE) required to be worn by the staff prior to entering these rooms. An observation of the lunch meal was conducted on the isolation unit on 11/9/20 between 12:10 PM and 12:25 PM. Signage on the outside of the resident room doors indicated, when staff entered the rooms, they should be wearing a mask, eye protection, gown, and gloves. Nursing Assistants (NA) #1, passed meal trays to Residents # 4 and Resident # 5 on the isolated unit. The NA# 1 entered the resident rooms wearing only masks and eye protection. During an interview on 11/9/20 at 12:25 PM, NA #1 stated it was her understanding that staff only had to wear full PPE which included masks, eye protection, gloves, and gowns when providing personal care to residents on the quarantine/isolation unit. She stated only masks and eye protection were required if no physical contact was made with the residents such as during the delivery of meal trays. NA #1 indicated that the residents were tested for COVID-19 by the facility and tested negative. NA #1 further indicated she needed clarification if full PPE should be worn during delivery of meal trays. During an interview with the DON on 11/03/20 at 12:30 PM, she stated the staff delivering meal trays on the isolation unit should follow the signs posted on resident doors . Staff should wear full PPE which included masks, eye wear, gloves, and gowns prior to entering the resident's rooms. The DON further stated appropriate full PPE as indicated on the signs should be worn for all services and activities provided to the residents in isolation rooms. The DON indicated all staff were in-serviced about following signs posted on resident doors and on wearing the appropriate PPE every time they entered the resident rooms.

Based on observation, staff interview and record review the facility failed to secure the indwelling urinary catheter for 3 of 3 sampled residents. (Residents #71, #148 and #59.) The facility also failed to keep the urinary drainage bag below the level of urinary bladder for 1 of 3 sampled residents. (Resident #71.) Findings Included: 1. Resident #71 admitted on [DATE]. His [DIAGNOSES REDACTED]. A review of the recent Minimum Data Set (MDS), dated [DATE], revealed the resident ' s cognition was intact. The MDS specified Resident #71 required limited assistance with activities of daily living and used an indwelling urinary catheter. Review of Resident #71 ' s plan of care, dated 4/21/16, revealed the resident was at risk for complications from the use of an indwelling catheter, related to [MEDICAL CONDITION]. The Care plan ' s goal was to prevent urinary tract infection [MEDICAL CONDITION], related to catheter and drainage bag use. The approaches included keep the catheter not kinked or coiled to prevent urinary flow obstruction, and to never raise the drainage bad above the urinary bladder to prevent urine flow back into the bladder. On 3/7/16 at 7:45 AM, Resident #71 was observed sitting in the wheelchair with a urinary drainage bag attached to the right side of the wheelchair frame, above the level of the resident ' s urinary bladder. On 3/9/16 at 8:20 AM, Resident #71 was observed sitting in the wheelchair at the sink in his room washing his face and hands in the sink. His urinary catheter was observed without any securing devices. The urinary drainage bag was near the resident on the seat of the wheelchair, on the same level as urinary bladder. On 3/9/16 at 9:15 AM, during an interview, Nurse #3 stated that the indwelling urinary catheter needed to be secured to the resident ' s inner thigh to prevent friction/movement. The urinary drainage bag needed to be below the bladder level all the time. On 3/9/16 at 11:45 AM, during an interview, Nurse Aide #3 stated Resident #71 used an indwelling urinary catheter and drainage bag. She indicated the urinary catheter needed to be secured to the resident ' s leg. On 3/9/16 at 1:00 PM, during an interview, the Director of Nursing stated that she expected the staff to maintain indwelling urinary catheters anchored to residents ' legs and to keep the urinary drainage bags below the level of urinary bladder. 2. Resident #148 admitted on [DATE]. His [DIAGNOSES REDACTED]. A review of the recent Minimum Data Set (MDS), dated [DATE], revealed the resident ' s cognition was severely impaired. The MDS specified Resident #148 required extensive assistance with ADLs and used an indwelling urinary catheter. Review of Resident #148 ' s plan of care, dated 1/26/16, revealed the resident was at risk for complications from the use of an indwelling catheter, related to [MEDICAL CONDITION]. The goal was to prevent urinary tract infections, related to catheter and drainage bag use. The approaches were to keep the catheter not kinked or coiled to prevent the urinary flow obstruction and to never raise the drainage bag above the urinary bladder to prevent urine flow back into the bladder. On 3/8/16 at 1:40 PM, during Resident #148 ' s wound care observation, provided by Nurse #2 and Nurse Aide #2, the indwelling catheter was not secured to the leg. On 3/8/16 at 1:45 PM, during an interview, Nurse #2 confirmed that the catheter was not secured. She added that the catheter needed to be secured to the resident ' s thigh all the time. On 3/8/16 at 1:55 PM, during an interview, Nurse Aide #2 confirmed that the urinary catheter was not secured to the resident ' s leg. The aide indicated that the catheter needed to be secured all the time. On 3/9/16 at 8:45 AM, Resident #148 was observed in his room. The indwelling catheter was not secured to the thigh. The Nurse #3 was called to the resident ' s room and she confirmed that the catheter was not secured to the resident ' s leg. On 3/9/16 at 11:45 AM, during an interview, Nurse Aide #3 stated that Resident #148 used indwelling urinary catheter and drainage bag. She did not observe any devices to hold the urinary catheter in place. On 3/9/16 at 1:00 PM, during an interview, the Director of Nursing stated that she expected the staff to maintain indwelling urinary catheters anchored to residents ' legs and to keep the urinary drainage bags below the level of urinary bladder. 3. Resident #59 was admitted on [DATE], with a [DIAGNOSES REDACTED]. The most recent minimum data set ((MDS) dated [DATE], revealed the resident ' s cognition was moderately impaired, and he used an indwelling urinary catheter. He had not rejected care Review of Resident #59 ' s care plans dated 2/17/16, revealed no documentation to use a device to secure the urinary tubing to the thigh, and no care plan indicating Resident #59 chose not to use a catheter stabilizing device. During wound care observation on 03/08/2016 at 11:11 AM, there was no device to secure the indwelling catheter tubing to Resident #59 ' s thigh. During an observation on 03/09/2016 at 9:30 AM of Resident #59 ' s catheter tubing, Nurse Aide #1 indicated there was no device to secure the tubing to the thigh. She revealed catheters were required to be secured to a resident ' s thigh. During the observation, Resident#59 indicated he had never had device on his catheter tubing since he had been admitted . He stated, that he laid with it on his thigh and tried not to tug it. During an interview on 3/9/16 at 1:00 PM, the Director of Nursing indicated she expected the staff to use a device on indwelling urinary catheters to secure the tubing to the resident ' s thigh.

Based on record review, and resident and staff interviews, the facility failed to report an allegation of abuse to the State within required time frames for 1 of 3 sampled Residents (Resident # 2). The findings included: Resident #2 was admitted to the facility on [DATE]. Resident #2 had [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], indicated Resident #2 had no problems with short or long term memory and was independent with decision making. Resident #2 required extensive to total assistance with all activities of daily, transfers and mobility. Review of the grievance form dated 9/23/15, revealed Resident #2 reported to the social worker on Sunday 9/20/15 a third shift nursing assistant broke her foot after she had asked the nursing assistant for assistance to put on her tennis shoes before going to the bathroom. Review of the initial 24 hour report dated 9/29/15, revealed the resident's allegation of abuse incident date was on 9/20/15. The report specified Resident #2 stated that a nursing assistant broke her foot. The 24 hour and 5 day report was sent to the Division of Health Service Regulation on 9/30/15. Review of the abuse investigation paperwork revealed witness statements were not obtained until 9/29/15 through 10/14/15. During an interview on 1/12/16 at 12:10PM, Resident #2 indicated that she had reported to the 3rd shift nurse supervisor that a nursing assistant had broken her foot, by not putting on her tennis shoes when she needed to go to the bathroom back in September. Resident #2 reported she heard something pop in her foot. Resident #2 added that she preferred to wear the tennis shoe when she needed to go to the bathroom, because it gave her support and balance when she stood up to walk. She further stated that the nursing assistant had an attitude and because she needed to go to the bathroom right away and could not hold it any longer. I told the nurse and the nursing assistant that my foot hurt and it started to swell right away. This could have been avoided had she put my shoes on as I asked. She further stated after the incident the physician had come in and looked at her foot and did not like was he saw so she was sent over to the hospital for x-ray and that was when the break of the 5th right metatarsal was found. The 1st x-ray didn't show anything, but the swelling and discoloration was so bad. I was sent for a second x-ray that's when it was found. During an interview on 1/12/16 at 2:20PM, the Social Worker indicated that she received a call from the weekend supervisor on 9/20/15. The weekend supervisor reported that Resident # 2 stated staff broke her foot. The Social Worker stated that the 24 hour report should have been completed on Monday 9/21/15 in accordance with the abuse policy. She confirmed that the policy and procedures for reporting allegations of abuse was not done until 9/29/15. The 5 day report was done on 9/29/15. During an interview on 1/12/16 at 4:20PM, Weekend Supervisor confirmed that Resident #2 reported to her a nursing assistant (NA) on 3rd shift was rude to her and she thought the nursing assistant broke her foot. She indicated that she had spoken with the resident about the incident that evening and checked her for injury. The nurse stated she did not notice any injuries at that time. She indicated that the resident was asking for assistance to use the bathroom and NA#1 was rude in the way she spoke to her. She could not recall the details of the conversation or whether the resident had reported any physical contact or injury. If the resident had reported any physical interaction she would have started the abuse protocol. She does not recall whether she had contacted the Social Worker, the Director of Nursing or the Administrator. She stated she put her statement under the Social Worker's door. During an interview on 1/12/16 at 4:45PM, the Administrator indicated the expectation was for the first person who had received report of allegation of abuse should have initiated the abuse investigation procedures. The Social Worker and Director of Nursing should have been contacted immediately. The Social Worker and Director of Nursing would share the information with the Administrator after the investigation was completed The staff that received must complete the designated reports (24 hour and 5 day) and perform the process in accordance to the abuse policy. The Administrator confirmed the 24 hour report and 5 day report were not completed in accordance to facility policy. Nursing Assistant #1 was unavailable for interview after several attempts.

Based on staff and resident interviews, record review and review of the abuse policy, the facility failed to implement their abuse policy for reporting allegations of abuse for 1 of 3 sampled residents who reported abuse (Resident #2). The findings included: The facility policy entitled Resident Abuse and Neglect dated June 2007, read in part; all reports of abuse, suspected or witness will be reported immediately to the Director of Nursing and the Administrator. All alleged violations will be reported to the NC health Care Personnel Registry. Initial report are completed within 24 hours of the event with the final report to follow within 5 working days. The reports would be sent to the state nurse aid registry and discipline specific licensing authorities. The resident involved in the incident and/or their POA will be notified of the outcome of the investigation as well as all further occurrences. The other components of the policy were followed. Resident #2 was admitted to the facility on [DATE]. Resident #2 had [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], indicated Resident #2 had no problems with short or long term memory and was independent with decision making. Resident #2 required extensive to total assistance with all activities of daily, transfers and mobility. The fractured 5th metatarsal was found on the second x-ray. Review of the grievance form dated 9/23/15, revealed Resident #2 reported to the social worker on Sunday 9/20/15 a third shift nursing assistant broke her foot after she had asked the nursing assistant for assistance to put on her tennis shoes before going to the bathroom Review of the initial 24 hour report dated 9/29/15, revealed the resident's allegation of abuse incident date was on 9/20/15. The report specified Resident #2 stated that a nursing assistant broke her foot. The 24 hour and 5 day report was sent to the Division of Health Service Regulation on 9/30/15. Review of the abuse investigation paperwork revealed witness statements were not obtained until 9/29/15 through 10/14/15. During an interview on 1/12/16 at 12:10PM, Resident #2 indicated that she had reported to the 3rd shift nurse supervisor that a nursing assistant had broken her foot, by not putting on her tennis shoes when she needed to go to the bathroom back in September. Resident #2 reported she heard something pop in her foot. Resident #2 added that she preferred to wear the tennis shoe when she needed to go to the bathroom, because it gave her support and balance when she stood up to walk. She further stated that the nursing assistant had an attitude and because she needed to go to the bathroom right away and could not hold it any longer. I told the nurse and the nursing assistant that my foot hurt and it started to swell right away. This could have been avoided had she put my shoes on as I asked. She further stated after the incident the physician had come in and looked at her foot and did not like was he saw so she was sent over to the hospital for x-ray and that was when the break of the 5th right metatarsal was found. The 1st x-ray didn't show anything, but the swelling and discoloration was so bad. I was sent for a second x-ray that's when it was found. During an interview on 1/12/16 at 2:20PM, the Social Worker indicated that she received a call from the weekend supervisor on 9/20/15. The weekend supervisor reported that Resident # 2 stated staff broke her foot. The Social Worker stated that the 24 hour report should have been completed on Monday 9/21/15 in accordance with the abuse policy. She confirmed that the policy and procedures for reporting allegations of abuse was not done until 9/29/15. The 5 day report was done on 9/29/15. During an interview on 1/12/16 at 4:45PM, the Administrator indicated the expectation was for the first person who had received report of allegation of abuse should have initiated the abuse investigation procedures. The Social Worker and Director of Nursing should have been contacted immediately. The Social Worker and Director of Nursing would share the information with the Administrator after the investigation was completed The staff that received must complete the designated reports (24 hour and 5 day) and perform the process in accordance to the abuse policy. The Administrator confirmed the 24 hour report and 5 day report were not completed in accordance to facility policy.

Based on observations, staff interviews, and record review, the facility failed to maintain sanitary conditions in the kitchen by 1) ensuring that fresh produce was removed from spoiled/rotten produce in 1 of 1 walk in refrigerator, 2) clean the ice cream cooler 3) Clean and remove the food debris and grease from hot plate cart warmer, 4) label and date food products in 1 of 1 freezer and dry products, 5) clean floor surfaces of refrigerator and freezer, 6) clean and remove food debris and grease from 9 silver trays stored on the dry storage rack and 7) clean surface where 32 domes were stored. The findings Included 1. During an observation of the kitchen on 4/13/15 at 10:00AM, the walk in refrigerator had 1 box of fresh tomatoes which contained spoiled/rotten tomatoes, 1 ½ box of spoiled and rotten lemons. During an interview on 4/28/14 at 8:05PM, the interim dietary manager (DM) indicated the fresh produced should be checked when delivered and the spoiled/rotten produce should be discarded. 2. During an observation on 4/13/15 at 10:00AM, the ice cream cooler was dirty and filled with trash on the inside and the outside was dirty with dried ice cream and food debris on the surfaces. During an interview on 4/13/15 at 10:00AM, the interim DM indicated the ice cream cooler should be cleaned and wiped down daily by staff. 3. During an observation on 4/13/15 at 10:00AM, the hot plate warmer had a large volume of grease and food/liquid build up on the inside and outsides of the units. During an interview on 4/13/15 at 10:00AM, the DM indicated the equipment should be cleaned daily after each usage. There was no identified system for cleaning presented at the time of the survey. 4. During an observation on 4/13/15 at 10:00AM, the following items were opened, unlabeled or dated a 1/2 bag of opened exposed sausage, cauliflower unlabeled and a pan of black product was in a clear container. During an interview on 4/13/15 at 10:00AM, the interim DM indicated that all food and produce should be sealed properly, labeled and dated before stored in refrigerators, freezers or dry storage areas. The DM identified the each of the unlabeled/undated products. 5. During an observation on 4/13/15 at 10:00AM, the floor surfaces in the refrigerator and freezer had large volumes of trash and food products on the floor. During an interview on 4/13/15 at 0:00AM, the interim DM, indicated that staff was responsible for sweeping and cleaning the refrigerator, freezer area out daily. 6. During an observation on 4/13/15 at 10:00AM, 9 silver serving trays had a large volume of dried food debris and grease build up on the surface and edges of the tray stored on the dry storage rack. During an interview on 4/13/15 at 10:00AM, the interim DM indicated that staff was responsible for ensuring all trays should be cleaned and free of food debris before storage on the dry storage racks. 7. During an observation on 4/23/15 at 10:00AM, 32 clean domes were stored on dirty counter top surface in preparation for usage the next meal. During an interview on 4/13/15 at 10:00AM, the interim DM indicated that the domes should not be stored on dirty surfaces. The staff was responsible for cleaning surfaces before any domes or other kitchen equipment was stored. During a follow-up observation on 4/15/15 at 11:40AM, rechecked the freezer and there was a box of white cheese with green molded surface and the freezer floor surface remained dirty with trash. During an interview on 4/15/15 at 11:40AM, the dietary general manager and interim DM indicated the items should have been discarded from the freezer and the floor surfaces should have been clean. During an interview on 4/16/15 at 8:30AM, the administrator indicated the expectation was the kitchen manager should monitor and ensure the kitchen meets the standards of cleanliness and food safety.

Based on observations, staff interviews, and record reviews, the facility 1) failed to air-dry 7 of bowls and 7 racks of cups. Findings included: During tray line observation on 10/19/11 at 11: 55 a.m., 7 racks (112) of blue bowls and 7 racks (146) of blue cups were observed stacked on top of each other on a cart at the serving line .The dietary staff were serving the residents lunch meal with wet bowls and cups. Water was running off the bowls and cups on the residents tray on the tray line. The operational manager acknowledged the condition of the bowls and cups, saying that they were clean, wet, and ready to be used. In an interview with the dietary aide on 10/19/11 at 12:05 p.m., she stated, " I do not know who stored the bowls wet on the cart." In an interview on 10/19/11 at 2:30 p.m. with the Director of Nutritional Services, she stated, " I cannot say why the bowls and cups were wet. " She further indicated that a representative from a named lab would come to check the titration of the rinse additive to make sure it is at a proper level. She further added that, they have develop a new process for drying dishes and that the staff would be in-serviced on the new process and proper procedures for ware washing.