Every finding on record at Spring Harbor at Green Island

Based on observations, staff interviews, and review of facility policies titled Labeling Food Product and Pots and Pans - Sanitizing Solution, the facility failed to ensure opened food items were properly dated after opening and failed to discard food items after the best by date. In addition, the facility failed to prevent wet-nesting in stored steam table pans to ensure there was no bacterial growth. These deficient practices had the potential to place the 29 residents who were receiving an oral diet from the kitchen at increased risk of contracting a foodborne illness. Findings include: Review of the facility policy titled Labeling Food Product revealed that all prepared foods, leftovers, and opened products stored for later use will be labeled according to food safety standards, along with local and state regulations.Review of the facility policy titled Pots and Pans - Sanitizing Solution revealed allow all items to air dry. When items are dry, store in proper storage area. 1. Observation in the main kitchen on 1/16/2026 at 8:58 AM of the first walk-in refrigerator revealed it contained mainly produce and dairy items. Observation revealed a five-pound container of sour cream that had been opened with no open date. Further observation revealed a five-pound container of cottage cheese with a best by date of 1/2/2026. During an interview on 1/16/2026 at 8:58 AM, the General Manager of Dining Services (GMDS) confirmed that the container of sour cream had been opened, and dietary staff failed to place an open date. The GMDS stated that dietary staff are to label and date any food item for storage in the refrigerator. The GMDS revealed that labeling and dating food items are discussed almost daily during group meetings. Continued interview with the GMDS confirmed that the cottage cheese container had a best-by date of 1/2/2026 and that it should have been discarded. The GMDS revealed that all dietary staff are responsible for reviewing dates on food items and discarding them appropriately. The GMDS stated that the cottage cheese container was overlooked. 2. Observation on 1/16/2026 at 9:12 AM of the pot and pan rack revealed that one rack had several stacks of steam table pans. A stack of five medium-sized square steam table pans was pulled apart, and the inside of the top pan had visible moisture drops. A stack of four small square steam table pans was pulled apart, and the top two pans had visible moisture drops on the inside. During an interview on 1/16/2026 at 9:12 AM, the GMDS confirmed that the identified pans were stored stacked and contained moisture. The GMDS stated that all dishes, including pots and pans, are washed and sanitized using the dish machine. The GMDS stated that dietary staff are to let all dish items, including steam table pans, completely air dry before stacking.

Based on observations, staff interviews, record review, and review of the facility's policy titled Medication Administration, the facility failed to ensure unauthorized medication was not left at the bedside for one of 20 sampled residents (R) R6. This deficient practice had the potential to place R6 at increased risk of unauthorized use of medication. Findings include:Review of the facility's policy titled Medication Administration, revised 6/11/2025, documented Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice.Review of the facility's electronic medical records (EMR) for R6 revealed diagnoses included, but were not limited to, dry eye syndrome of bilateral lacrimal glands.Review of the Quarterly Minimum Data Set (MDS) for R6, dated 10/14/2025, revealed that Section C (Cognitive Patterns) documented the resident's decision-making skills were severely impaired, never/rarely made decisions, and the resident had disorganized thinking continuously. Review of Physician's Orders for R6, dated 1/6/2026, revealed an active order for Systane Ultra eye drops; instill 1 drop into both eyes three times daily for dry eyes. Further review revealed no order for medication self-administration.Review of the care plan for R6, dated 4/24/2025, revealed no care plan area for medication self-administration. Review of the EMR for R6 revealed no evidence of a medication self-administration assessment.Observations on 1/16/2026 at 8:23 AM, 2:46 PM, and 4:40 PM revealed one bottle of Systane Ulta eyedrops on the bedside table in R6's room.In an interview on 1/16/2026 at 4:40 PM, Licensed Practical Nurse (LPN) AA confirmed there was one bottle of Systane Ultra eyedrops on the bedside table in R6's room. She stated that the bottle of eye drops should not be on R6's bedside table.In an interview on 1/17/2026 at 10:44 PM, Registered Nurse (RN)/Unit Manager (UM) DD stated medications should be locked in the medication cart. He stated that if medications were left at the bedside table, the resident could take too much of it, or another resident could take it. In an interview on 1/17/2026 at 4:40 PM, the Director of Nursing (DON) stated that medications should not be left at the resident's bedside and should be locked in the medication cart. She stated that if a resident used the medication and they were not ordered to self-administer their own medication, it could cause adverse reactions for the resident.

Based on record review, staff interview, and review of the facility's policy titled Reference and Background Checks, the facility failed to ensure pre-employment screenings, specifically reference checks, were conducted prior to employment for four of 10 employees reviewed. This deficient practice had the potential to place residents residing in the facility at risk of abuse, neglect, and exploitation from staff. The census was 29 residents.Findings include:Review of the facility's policy titled Reference and Background Checks, effective date 7/1/2014, revealed the Policy section included, It is the policy of [facility name] to conduct reference and background checks on all applicants who are being seriously considered for employment. The Reference Checks section included, A. Human Resources will perform the reference check on all job applicants being seriously considered for employment. D. All reference checks will be documented in writing and become part of the official records maintained in Human Resources.Review of employee files revealed:1. The Director of Nursing (DON) was hired on 2/21/2023, and there were no documented reference checks. 2. Certified Nursing Aide (CNA) FF was hired on 1/6/2026, and there were no documented reference checks. 3. Registered Nurse (RN) Unit Manager DD was hired on 9/16/2025, and there were no documented reference checks. 4. RN GG was hired on 11/18/2025, and there were no documented reference checks. The DON had an active, unencumbered RN license.CNA FF had an active, unencumbered CNA certification.RN DD had an active, unencumbered RN license.RN GG had an active, unencumbered RN license.There were no concerns identified related to abuse or neglect within the facility.In an interview on 1/17/2026 at 10:07 AM, the Human Resources Director (HRD) confirmed there were no documented reference checks completed for the identified employees. The HRD stated that attempts for reference checks were made, yet there was no documentation reflecting this effort. In a telephone interview on 1/17/2026 at 11:14 AM, the Human Resource Assistant (HRA) EE stated that once a candidate is selected for employment, they initiate the drug screening, followed by background checks. During this timeframe, she completed reference checks. HRA EE explained that if a candidate provides the necessary information, she attempts to contact their references, and if the candidate does not provide the reference information, no action is taken while waiting for the background check to be finalized. In an interview on 1/17/2026 at 5:24 PM, the Administrator stated he expected the Human Resource Department to carry out all necessary requirements with the onboarding process.

Based on observation and staff interviews, the facility failed to place an open date on one vial of blood glucose strips on one of two medication carts. This deficient practice had the potential to place residents at risk of incorrect blood sugar readings.Findings include: Observation on 1/17/26 at 10:40 AM of the medication cart located in the 2200 Hall revealed one vial of blood glucose strips in the top-right drawer of the cart, with no open date. Observation of the container label revealed a field for the Date Opened. And instructions to use within 90 days of first opening. In an interview on 1/17/26 at 10:40 AM, Licensed Practical Nurse (LPN) CC confirmed there was no open date on the vial of glucose strips and that there should be an open date on the vial. She stated that the blood glucose strips could not be used after a certain time after the vial was opened, and if there was no open date, no one would know when it was opened. She further stated that if the strips with no open date were used for a resident, there could be incorrect blood glucose readings for the resident.In an interview on 1/17/26 at 10:44 AM, Registered Nurse (RN) DD/Unit Manager (UM) stated that there should be open dates on the vials of blood glucose strips because the strips need to be used within a specific time frame. He stated that the strips would no longer be useful after a certain timeframe when the vial was opened, and if the strips were used for a resident, there could be incorrect blood glucose readings.In an interview on 1/17/2026 at 4:40 PM, the Director of Nursing (DON) stated there should be open dates on the vials of blood glucose strips. She stated her expectations were for the nurses to place open dates on the vials when they were first opened, because no one would know when they were opened without open dates, and the strips could go bad after a certain time period. The DON further stated that if the strips were used on the residents, they could cause adverse reactions, including negative reactions, as well as highs and lows in blood sugar readings.

Based on observations, interviews, and review of the facility's policy titled, Labeling Food Product, the facility failed to ensure that opened food items were labeled, dated, and secured from open air. The deficient practice had the potential to affect 34 residents who received an oral diet and were served food from the kitchen. Findings included: Review of the facility policy, Labeling Food Product, revised 1/3/2024, revealed that all prepared foods, leftovers and opened products stored for later use would be labeled according to food safety standards along with local and state regulations. All labels would contain the complete name of the product, the date the product was prepared or opened, and the date the product must be utilized by. Observation on 11/8/2024 at 8:16 am of the stand-alone freezer revealed the following: One box of [brand name] pork patties not secured, and the food was open to the air; one box of [brand name] pork links not secured and open to the air. Observation on 11/8/2024 at 8:20 am of the walk-in refrigerator revealed the following: One cinnamon spice cake opened and not labeled or dated; two boxes of chicken tenders open to the air and not labeled or dated; one open tray of tres leches cake covered in clear plastic wrap not labeled or dated. Observation on 11/8/2024 at 8:25 am of the walk-in freezer revealed the following: One package of bratwurst was opened, unlabeled, and undated; one box of [brand name] pork chops was opened and not labeled or dated; one clear plastic bag of grit balls was opened and not labeled or dated; one clear plastic bag of tortellini was opened and not labeled; one large plastic bag of pepperoni was opened and not labeled; one 9 round cheesecake covered in plastic wrap was not labeled or dated; one plastic bag of green beans was opened and not labeled or dated; one bag of battered okra was opened and not labeled or dated; and one bag of wheat rolls was opened and not labeled or dated. Observation on 11/8/2024 at 8:31 am of the stand-alone freezer in the main kitchen revealed the following: One clear plastic bag of French fries was opened and not labeled or dated; one clear plastic bag of broccoli was opened and not labeled or dated; one clear plastic bag of okra was opened and not labeled and dated; one clear plastic bag of hashbrown patties was opened and not labeled or dated; and one clear plastic bag of grit balls was opened and not labeled or dated. Observation on 11/8/2024 at 8:34 am of the stand-alone refrigerator on the front line revealed the following: One bag of [brand name] Bread was opened and not labeled or dated; opened salmon dip covered in clear plastic wrap was not labeled or dated; and one small pan of chutney covered in a clear plastic wrap was not labeled or dated. Interview on 11/8/2024 at 8:40 am, with the Executive Chef (EC) revealed that dietary staff were supposed to label and date all opened and prepared food items stored in the refrigerators and freezers. Interview on 11/8/2024 at 10:43 am the Dietary Manager (DM) revealed that he expected dietary staff to ensure all items stored in the freezers and refrigerators were covered and secured from the open air. Additionally, he said all staff was supposed to make sure all prepared and opened foods stored in the freezers and refrigerators were labeled and dated.

Based on record review, staff interview, and review of the facility's policy titled, Use of Psychotropic Medication, the facility failed to ensure a stop date was implemented, not to exceed 14 days, for psychotropic medications for three residents (R) (R1, R29, and R7) of six residents reviewed for unnecessary medications. Findings included: Review of the facility's policy titled Use of Psychotropic Medication, revised 1/1/2024, revealed that if the attending physician or prescribing practitioner believed that it was appropriate for PRN (as needed) order to be extended beyond the 14 days, he or she shall document their rationale in the resident's medication and indicate the duration for the PRN order. 1. Review of Physician Orders dated 9/23/2024 for R1 revealed an order for Valium 1 mg by mouth (PO) daily as needed (PRN) for anxiety. The order had no end date. Review of Note to Attending Physician/Prescriber dated 5/1/2024 revealed the pharmacist sent a note to the prescriber regarding R1's diazepam 2 mg PRN for anxiety; indicated the CMS limitation of PRN psychoactive medications. The note stated all PRN psychotropic medication orders, even for Hospice patients, had a 14-day limit. The physician indicated he agreed and changed the order to 180 days, however, the order was not changed. A review of the Medication Administration Record (MAR) revealed R1 was administered Valium 1 mg PO on 9/15/2024 at 7:14 pm, 9/20/2024 at 10:17 am, 10/1/2024 at 10:00 pm, 10/2/2024 at 9:15 pm, 10/3/2024 at 9:18 pm, 10/4/2024 at 9:41pm, 10/7/2024 at 8:25 pm, 10/8/2024 at 8:53 pm, 10/9/2024 at 8:12 pm, 10/10/2024 at 9:36 pm, 10/12/2024 at 8:51 pm, 10/13/2024 at 9:00 pm, 10/14/2024 at 9:30 am, 10/16/2024 at 7:29 pm, 10/17/2024 at 8:30 pm, 10/18/2024 at 7:50 pm, 10/19/2024 at 2:05 pm, 10/20/2024 at 9:09 am, 10/21/2024 at 7:20 pm, 10/22/2024 at 8:12 pm, 10/23/2024 at 8:00 am, 10/24/2024 at 5:42 pm, 10/27/2024 at 8:00 pm, 10/28/2024 at 9:34 am, 10/30/2024 at 7:30 pm, 10/31/2024 at 7:30 pm, 11/4/2024 at 8:00 pm, 11/5/2024 at 8:00 pm, 11/6/2024 at 8:10 pm, and 11/7/2024 at 7:30 pm. 2. Review of Physician Orders dated 9/16/2024 for R29 revealed an order for Xanax 1 mg by mouth (PO) every eight hours as needed for anxiety. The order had no end date. Review of Note to Attending Physician/Prescriber dated 10/3/2024 revealed the pharmacist sent a note to the prescriber regarding R29's alprazolam 1 mg PRN for anxiety; indicated the CMS limitation of PRN psychoactive medications. The note stated all PRN psychotropic medication orders, even for Hospice patients had a 14-day limit. The physician indicated other and did not make a change to the medication on the form. Review of the Medication Administration Record (MAR) revealed R29 was administered Xanax 1 mg PO on 9/19/2024 at 9:15 pm, 9/20/2024 at 2:15 pm, 9/25/2024 at 7:05 pm, 9/27/2024 at 6:52 pm, 9/28/2024 at 8:16 pm, and 9/30/2024 at 8:28 pm, 10/2/2024 at 8:23 pm, 10/3/2024 at 8:56 pm, 10/4/2024 at 9:35 pm, 10/7/2024 at 8:27 pm, 10/8/2024 at 8:28 pm, 10/9/2024 at 4:18 pm, 10/10/2024 at 8:17 pm. 10/11/24 at 7:29 pm. 10/12/2024 at 8:00 pm, 10/13/2024 at 3:30 pm, 10/14/2024 at 10:09 pm, 10/15/2024 at 9:37 pm. 10/16/2024 at 8:00 pm, 10/17/2024 at 8:00 pm, 10/18/2024 at 8:54 pm, 10/20/2024 at 5:06 pm, 10/21/2024 at 8:36 pm, 10/22/2024 at 11:13 pm, 10/24/2024 at 5:00 pm, 10/26/2024 at 8:42 pm, 10/27/2024 at 8:00 pm, 10/28/2024 at 8:37 pm, 10/29/2024 at 8:00 pm, 10/30/2024 at 8:00 pm, 10/31/2024 at 8:00 pm, 11/4/2024 at 7:27 pm, 11/5/2024 at 8:00 pm, 11/6/2024 at 8:00 pm, and 11/7/2024 at 8:00 pm. 35062 3. Review of Physician Orders dated 8/18/2024 for R7 revealed an order for Xanax 0.5 mg by mouth twice per day as needed for anxiety disorder due to known physiological condition. The order had no end date, and no duration indicated. Review of Note to Attending Physician/Prescriber dated 10/15/2024 revealed the pharmacist sent a note to the prescriber regarding R7's Xanax 0.5 mg PRN for anxiety. The note documented all PRN psychotropic medication orders, even for Hospice patients, had a 14-day limit. The physician indicated he agreed and changed the order to 120 days, however, the order was not changed and indicated no new orders. A review of the MAR revealed R7 was administered Xanax 0.5 mg by mouth PRN on 8/12/2024, 8/14/2024, 8/15/2024, 8/18/2024, 8/21/2024, 8/23/2024, 8/25/2024, 8/27/2024, 8/29/2024, 8/30/2024, 9/1/2024, 9/2/2024, 9/6/2024, 9/9/2024, 9/10/2024, 9/13/2024, 9/15/2024, 9/17/2024, 9/19/2024, 9/23/2024, 9/25/2024, 9/26/2024, 9/29/2024, 9/30/2024, 10/1/2024, 10/2/2024, 10/3/2024, 10/4/2024, 10/7/2024, 10/8/2024, and 10/10/2024. Interview with the Director of Nursing (DON) on 11/9/2024 at 9:00 am revealed that all psychotropic medications were supposed to have a 14-day stop date. If the medical doctor (MD) determined there was a clinical rationale to extend the medication beyond 14 days, the MD would write a progress note noting the clinical indication, and the note would be added to the resident's chart. Per the DON, she or the unit manager would add the indicated duration date to the orders and the MAR. The DON acknowledged there was no stop date for R1's, R29's, and R7's psychotropic medications.

Based on observations, staff interviews, and review of the facility's policy titled, Glucometer Disinfection, the facility failed to ensure proper infection control measures were followed for cleaning and disinfecting a glucometer (a device used to measure blood glucose) on one of one resident (R) (25) reviewed during a glucometer test. In addition, the nurse did not use a barrier before placing the glucometer on the surface of the medication cart. The deficient practices placed residents at risk of potential exposure to infections due to cross-contamination. Findings included: Review of the facility policy titled Glucometer Disinfection dated 9/28/2010 indicated Procedures: Disinfecting Instructions: To disinfect, use a germicidal disposable cloth to remove heavy soil, unfold a second clean wipe and thoroughly wet surface. Treated surface must remain visibly wet for a full two minutes. Use additional wipes if needed to assure continuous two minutes. Use additional wipes if needed to assure continuous two minutes wet contact time. Let air dry. Glucometer must be disinfected before and after each using new wipes every time. Observation on 11/9/2024 at 12:05 pm of Licensed Practical Nurse (LPN) AA perform a blood sugar check and glucometer reading on R25. The LPN removed the glucometer from the medication cart and placed the glucometer on top of the medication cart without a barrier. The LPN gathered additional supplies and carried the supplies to the resident's room. After obtaining the residents blood sugar the LPN exited the room and placed the glucometer on the top of the medication cart without a barrier. The LPN wipe the glucometer with one alcohol pad and placed the glucometer in the top drawer of the medication cart. The LPN stated that is how the glucometer was cleaned after each use. Interview on 11/9/2024 at 12:10 pm the Director of Nursing Service (DNS) revealed the glucometer device should be cleaned with a germicidal disposable wipe. She also revealed a barrier must be used when placing the glucometer and supplies on any surface. The DNS revealed she would start educating staff on the proper way to disinfect the glucometer and use a barrier. Interview on 11/9/2024 at 2:35 pm the DNS revealed that the facility had five residents with a physician order for blood sugar reading. She revealed R25 had an order for a fingerstick blood sugar check. Four of the residents' blood sugar was obtained by using the continuous glucose monitor system (a wearable device that tracks blood sugar levels in real time). She revealed if the readings appeared to be inaccurate, or the sensor was not scanning, the alternative was to use the glucometer device to obtain the residents blood sugar.

Based on record review, staff interviews, and review of the facility policies titled, Infection Prevention and Control Program and Antibiotic Stewardship Program, the facility failed to provide evidence of a process for periodic review of antibiotic prescribing practices, and to document follow-up measures in response to the data for 11 of 12 months of infection control data reviewed (May 2022 through April 2023). The deficient practice had the potential to affect any resident who was prescribed an antibiotic. Findings include: Review of the facility's policy titled, Infection Prevention and Control Program with a revision date of 11/11/2022 Antibiotic Stewardship: a. An antibiotic stewardship program will be implemented as part of the overall infection prevention and control program. b. Antibiotic use protocols and a system to monitor antibiotic use will be implemented as part of the antibiotic stewardship program. c. The Infection Preventionist, with oversight from the Director of Nursing, serves as the leader of the antibiotic stewardship program. d. The Medical Director, consultant pharmacist, and laboratory manager will serve as resources for the antibiotic stewardship program. Review of the facility's policy titled, Antibiotic Stewardship Program with a revision date of 11/11/2022 reads it is the policy of Spring Harbor to implement an Antibiotic Stewardship Program as part of Spring Harbor's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. 4. The program includes antibiotic use protocols and a system to monitor antibiotic use. a. Antibiotic use protocols: i. Nursing staff shall assess residents who suspected to have an infection and notify the physician. ii. Laboratory testing shall be in accordance with current standards of practice. b. Monitoring antibiotic use: i. Monitor response to antibiotics, and laboratory results when available, to determine if the antibiotic is still indicated, or adjustments should be made. ii. Antibiotic orders obtained upon admission, whether new admission or readmission, to Spring Harbor shall be reviewed for appropriateness. iii. Antibiotic orders obtained from counseling, specialty, or emergency providers shall be reviewed for appropriateness. iv. Monitor during each monthly medication regimen review when the resident has been prescribed or is taking an antibiotic or any antibiotic regimen review. Review of the facility's Infection Monitoring Logs revealed that they did not capture information monthly that included the resident's name; room number; date of S/S (signs and symptoms); I/C (infection control) Cat. (category); and ABT Tx (antibiotic treatment). Further review of these monthly line listings revealed that they did not contain information such as the resident's signs and symptoms; if a culture or x-ray was done; and if the organism was sensitive to the ordered antibiotic. There was not a line listing of the antibiotics/infections, no mapping of infections, and the facility's infection rate was not calculated for months May 2022 through April 2023. During an interview on 6/3/2023 at 1:16 p.m. with Infection Control Preventionist (ICP) it was revealed that she is new to the position at the facility. She further stated that she consults with the Director of Nursing (DON) for guidelines related to the facility's policy and protocol related to the infection control practices and the Antibiotic Stewardship Program. During interview, ICP stated that she was aware that prior to her coming to the facility mid-April 2023 there were not any infection assessment tools to assess the minimum criteria for initiation of antibiotics. She further reported that the Physician and nurses should have looked at the resident's signs and symptoms, vital signs, lab reports, etc. before ordering an antibiotic, but she has been unable to locate any documentation of this. The Infection Control Nurse stated during continued interview that the pharmacy provides the facility with a monthly report that included antibiotic usage. During an interview on 6/3/2023 at 2:09 p.m. with DON revealed that she was not aware that the Infection surveillances and monthly calculations rates were not being done. DON further stated that she has only worked at the facility for four 4 weeks. DON stated that it is her expectation that residents should be monitored, signs and symptoms documented, and followed up with any labs or diagnostic test completed, and followed up with the physician.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, Resident Self-Administration of Medication, the facility failed to assess one resident (R) R#11 sampled for the ability to self-administer medications prior to leaving medications at the bedside. The deficient practice had the potential to allow access to medications otherwise not prescribed by a physician to other residents. Findings include: Review of the facility policy titled, Resident Self-Administration Medications revised date 11/11/2022 revealed: Policy: It is the policy of Spring Harbor to support each resident's right to self-administer medication. A resident may only self-administer medications after the Spring Harbor's interdisciplinary team has determined which medications may be self-administered safely. 1. Each resident is offered the opportunity to self-administer medications during the routine assessment by Spring Harbor's interdisciplinary team. 2. Resident's preference will be documented on the appropriate form and placed in the medical record. 3. When determining if self-administration is clinically appropriate for a resident, the interdisciplinary team should at a minimum consider the following: a. The medications appropriate and safe for self-administration, g. The resident's ability to ensure that medication is stored safely and securely. 4. The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration assessment Form, which is placed in the resident's medical record. 5. Upon notification of the use of bedside medication by the resident, the medication nurse records the self-administration on the Medication Administration Record (MAR). 8. All nurses and aides are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage. Unauthorized medications are given to the charge nurse for return to the family or responsible party. Families or responsible parties are reminded of policy and procedures regarding resident self-administration when necessary. Observation on 6/2/2023 at 8:36 a.m. of R#11's room revealed one bottle of Mylanta sitting on the bedside dresser. An interview with R#11 revealed the nurse normally leaves the medication for him to take when he desires. Further observation of the bedside table revealed one (1) container of VapoRub, one (1) bottle of Vicks [NAME] Severe Nasal Decongestant, one (1) bottle of Clear Eyes lubricant eye drops, and one (1) container of Penetrex Intensive Concentrate Roll-on Gel Joint & Muscle Therapy. Observation on 6/3/2023 at 9:35 a.m. in R#'11's room revealed the bottle of Mylanta, container of VapoRub, bottle of Vicks [NAME] Severe Nasal Decongestant, bottle of Clear Eyes lubricant eye drops, and container of Penetrex Intensive Concentrate Roll-on Gel Joint & Muscle Therapy continues to be present in residents' room. Observation and interview on 6/3/2023 at 1:27 p.m. with R#11 revealed resident stated he had taken a sip of the Mylanta for occasional indigestion. R#11 told surveyor, he has neuropathy in his foot and ordered the joint cream off the internet, he uses the [NAME] nasal spray at night before he goes to sleep for allergies, his eyes were bothering him a couple of weeks ago so he started self-administering the eye lubricant, he has sinus headaches from time to time, so he applies a small amount of the VapoRub on his forehead to relieve his headache. R#11 further stated that the facility's staff is aware of the medications in the room, and he is allowed to have the medications because it is over the counter stuff. During an interview on 6/3/2023 at 1:30 p.m. with Certified Nurse Aide (CNA) BB revealed that she only enters R#11's room to make his bed because resident is able to perform his own ADLs at this time. CNA BB also stated that she did not notice any medications in residents room today. During an interview on 6/3/2023 at 1:39 p.m. with Registered Nurse (RN) AA revealed that R#11 uses nasal spray, and she has it on her medication cart. RN AA further stated that resident does not have orders to keep medications at bedside and should not have medications in his room. RN AA also stated that she had been in the residents' room several times on 6/2/2023 and today and she did not observe any medications in his room. During an interview and observation on 6/3/2023 at 1:48 p.m. with RN AA and Director of Nursing (DON) verified medications in resident's room. DON stated currently there is not a resident residing in the facility who had been assessed and deemed appropriate to self-administer medications. DON further stated that there should not be any medications at resident's bedside. DON further stated that the process of allowing residents to self-medicate involves the licensed nurse completing the self-medication form, obtaining an order from the physician, and updating the plan of care. DON stated that she has only worked at the facility for 4 weeks and conducted daily rounds and had not seen the medications. DON stated R#11 had the ability to order stuff and have sent to the facility himself. DON reviewed the electronic and paper record and was unable to locate any orders or a form to self-administer medications. DON and RN AA also confirmed R#11 did not have a physician order for the medications located at resident's bedside. Record review of the Electronic Medical Record (EMR) for R#11 revealed diagnosis including but not limited to type 2 diabetes mellitus, sleep apnea, displaced fracture of condyle of right femur, and morbid (severe) obesity due to excess calories. Review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating R#11 was cognitively intact, and required limited to extensive assistance with activities of daily living (ADLS). Resident received an antidepressant seven of seven days. Review of the physician's orders revealed medication orders to include: Amiodarone tablet 100 milligrams (mg) take one tablet by mouth daily, orig. date 2/13/2023, amlodipine 10 mg tablet take 1 tablet by mouth daily, orig. date 2/13/2023, aspirin adult low strength 81 mg take 1 tablet by mouth daily, orig. date 2/13/2023, atorvastatin 20 mg tablet take 1 tablet by mouth at bedtime, orig. date 2/13/2023, calcium 500 mg tablet take 1 tablet by mouth twice daily, orig. date 3/28/2023, carvedilol 12.5 mg tablet take one tablet by mouth twice daily, orig. date 4/20/2023, doxazosin mesylate 4 mg take 1 tablet by mouth twice daily orig. date2/13/2023, Eliquis 2.5 mg take 1 tablet by mouth daily orig. date 2/13/2023, gabapentin 300 mg capsule take one capsule by mouth twice daily orig. date 2/13/2023, hydralazine 10 mg tablet take one tablet by mouth every eight hours orig. date 6/1/2023, hydrocortisone 2.5% cream apply on left arm on red and itchy sores for seven days twice daily orig date 6/2/2023, Insulin Lispro 100U/ML KWIKPEN Inject 7 units three times daily with meals orig. date 3/28/2023, Lantus Solostar. Inject 10 units subcutaneously at bedtime orig. date 4/13/2023, pantoprazole 40 mg tablet take one tablet by mouth at bedtime orig. date 2/13/2023, senna plus 8.6-50 mg tablet give 2 tablets by mouth twice daily orig. date 5/8/2023, Thera-M tablet take one tablet by mouth every morning orig date 2/13/2023, Venlafaxine ER 75 mg capsule take one capsule by mouth daily orig date 2/13/23, Victoza Pen 18 MG/3 ML. Inject 1.8 mg (0.3 ml) subcutaneously daily orig date 2/13/2023, vitamin B-12 1000 mcg tablet take one tablet by mouth daily orig date 2/13/2023, vitamin D3 125 mcg capsule take one capsule by mouth daily orig date 2/13/2023, vitamin D3 50,000 mcg take one capsule by mouth every week orig date 5/23/2023, acetaminophen 325 mg tablet take 2 tablets by mouth every 4 hours as needed for pain orig date 2/13/2023, bengay ultra-strength cream 45 cream apply 2 grams to affected areas on right lower leg every 6 hours as needed orig date 5/29/2023, guaifenesin AC 100-10 mg/5 ml syrup give 10 ml by mouth every 6 hours as needed for congestion and cough orig date 3/31/2023, Ipratropium-albuterol 0.5-2.5 (3) MG/ 3ML Soln Inhale 1 vial every 6 hours as needed for shortness of breath and wheezing orig date 3/31/2023, Oxycodone/APAP 5/325 Take 1 tablet by mouth every eight hours as needed for pain orig date 5/23/2023, polymethyl glycol powder take 17 gm by mouth once per day as needed for constipation orig date 2/13/2023. There was not a physician's order for the medications which were observed at bedside. Review of the clinical record revealed there was no assessment for medication self-administration. During an interview on 6/4/2023 at 9:30 a.m. with R#11 revealed he was not asked or has not been assessed to be able to self-administer medications.

Based on observations, staff interviews, record review, and a review of the facility's policies titled, CPAP/BIPAP Cleaning, and Nebulizer Therapy the facility failed to ensure oxygen equipment was properly stored while not in use and failed to have a current physicians order for Continuous Positive Airway Pressure (CPAP) for one (1) of Four (4) residents (R) (#11) receiving treatment for respiratory care. The deficient practice had the potential to increase the probability of respiratory infection for R#11 by not properly storing oxygen equipment when not in use. Findings include: Review of policy titled, Nebulizer Therapy revised 7/11/2022, Policy Explanation and Compliance Guidelines: 16. Disassemble and rinse the nebulizer with sterile or distilled water and allow it to air dry. Care of the Equipment: 4. Rinse the nebulizer cup and mouthpiece with sterile or distilled water. 5. Shake off excess water. 6. Air dry on an absorbent towel. 7. Once completely dry, store the nebulizer cup and the mouthpiece in a zip lock bag. Review of policy titled CPAP/BiPAP Cleaning revised 7/11/2022, Policy Explanation and Compliance Guidelines: 2. Respiratory therapy equipment can become colonized with infectious organisms and serve as a source of respiratory infections. 6. Clean mask frame daily after use with CPAP cleaning wipe or soap and water. Dry well. Cover with plastic bag or completely enclosed in machine storage when not in use. Review of the clinical record for R#11 revealed he was admitted to the facility with diagnoses including but not limited to sleep apnea and morbid (severe) obesity due to excess calories. Record review of the June 2023 Physician orders for R#11 revealed an order dated 3/31/2023 for ipratropium-albuterol 0.5-2.5 mg(milligrams) /3ml (milliliters) SOLN inhale 1 vial every six hours as needed for shortness of breath and wheezing. Further review of the physician orders revealed there was not a current physicians order for the CPAP which resident was using. Record review of R#11's June 2023 Medication Administration Record (MAR) from 5/1/2023 through 5/31/2023 and 6/1/2023 through 6/3/2023 revealed there was not a physician's order for the CPAP. Observation on 6/2/2023 at 8:36 a.m. and 6/3/2023 at 9:35 p.m. of R#11's room revealed a CPAP on the bedside dresser alongside of the bed with the mask lying on the table not properly bagged while not in use. Further observation revealed a nebulizer on the floor beside the bedside dresser. Observation and interview on 6/3/2023 at 1:27 p.m. with R#11 revealed he further stated he uses the CPAP at night, every night, for sleep apnea and has used it for the last [AGE] years. R#11 further stated he previously had a touch of pneumonia and used the nebulizer for a while to help with that. During an interview on 6/3/2023 at 1:39 p.m. with Registered Nurse (RN) AA revealed she is aware R#11 uses the CPAP at night, but she was not aware that resident did not have a current physicians order for the CPAP usage. RN AA told surveyor that the nebulizer should not be on the floor at any time and the CPAP mask should be cleaned and stored in a plastic bag when not in use. During an interview on 6/3/2023 at 1:48 p.m. with the Director of Nursing (DON) she verified the CPAP mask not being properly stored while not in use and the nebulizer on the floor. DON stated there should be an order for the CPAP and the mask should be bagged when not in use and the nebulizer should not be stored on the floor at any time.

Based on observation, interviews, record review, and review of the facility policy titled, Comprehensive Care Plan the facility failed to develop a comprehensive care plan related to use of oxygen for one resident (R) (#2) of 13 residents sampled. Findings include: Review of the facility policy titled, Comprehensive Care Plan effective date 4/20/2021 revealed '6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented as needed.' Review of the Admission Minimum Data Set (MDS) for R#2 dated 11/2/2021 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating cognitively intact. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section O - Special Treatments and Programs revealed oxygen therapy was documented/marked. Review of the Physician Orders for R#2 revealed an order dated 10/22/2021 for 'O2 (oxygen) via NC (nasal canula) to keep sats (oxygen saturation) above 92% and change oxygen tubing every Wednesday night. Review of the comprehensive care plan completed 11/9/2021 did not reveal a care plan for oxygen use or respiratory diagnoses. During an observation on 11/30/21 at 9:10 a.m. R#2 was observed lying in bed with oxygen (O2) via nasal canula at 2 liters per minute from a concentrator located at the bedside. During an observation on 12/1/21 at 11:04 a.m. R#2 was observed lying in bed with O2 via nasal canula at 2 liters per minute from a concentrator located at the bedside. During an observation on 12/2/21 at 7:52 a.m. R#2 was observed lying in bed with O2 via nasal canula at 2 liters per minute from a concentrator located at the bedside. During an interview on 12/2/21 at 10:25 a.m. with MDS/Care Plan Coordinator confirmed R#2 did not have a care plan for oxygen. During an interview on 12/2/21 at 10:27 a.m. with Director of Nursing revealed she expects resident care plans to reflect current conditions. Further revealed R#2 should have a care plan to address his oxygen use.

Based on interviews, record review, and review of the facility policy titled, Comprehensive Care Plan the facility failed to revise the comprehensive care plan related to advance directives for one of 13 residents (R#2). Findings include: Review of the facility policy titled, Comprehensive Care Plan revealed: 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS) assessment. Review of the Admission Minimum Data Set (MDS) for R#2 dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating cognitively intact and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section J - Health Conditions revealed J1400-Prognosis revealed resident has a condition or chronic disease that may result in a life expectancy of less than six months. Section O - Special treatment and programs revealed resident receiving hospice services. Review of a Hospice care plan dated [DATE](from the hospice provider) revealed a care plan for: Patient experiences peaceful death with dignity and symptoms managed within limits of disease process-dyspnea, pain, anxiety. Interventions include do not resuscitate. Review of 'Report Sheet' dated [DATE] revealed R#2's code status was Do Not Resuscitate (DNR). Review of the 'Profile Face Sheet' dated [DATE] revealed a Living Will, No CPR/DNR. Review of Living Will located in the resident's chart dated [DATE] revealed resident wants natural death to occur without intervention. However, review of the facility's care plan for R#2 dated [DATE] revealed a care plan for 'Advance Directives' with approaches that included: Social Services will place MPOA and living will on chart; Communicate resident's living will/advance directives to interdisciplinary team; resident does wish to be resuscitated. During an interview on [DATE] at 9:39 a.m. with the Social Worker revealed R#2 had recently reinstated his Living Will. States she is responsible to update this information on the care plan and in the electronic health record. Review of R#2 medical records did not reveal documentation that R#2 revoked his Living Will.

Based on observation, record review, interviews, and review of the facility policy titled, Oxygen, the facility failed to ensure that physician's orders were followed for one of two residents (R) #2 receiving oxygen therapy. Findings include: Review of the facility policy titled, Oxygen effective 4/20/21 revealed 'Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician, except in the case of an emergency 4. The resident's care plan shall identify the interventions for oxygen therapy, based upon resident's assessment and orders. Record review revealed R#2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set, dated dated dated [DATE] revealed a Brief Interview for Mental Status score of 15, indicating intact cognition. Section O - Special Treatments and Programs revealed oxygen therapy documented/marked. Review of the physician orders for R#2 dated 12/1/21 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed there was no order for a flow rate for the oxygen. During an observation on 11/30/21 at 9:10 a.m. R#2 was observed lying in bed with oxygen (O2) via nasal canula at 2 liters per minute from a concentrator located at the bedside. During an observation on 12/1/21 at 11:04 a.m. R#2 was observed lying in bed with O2 via nasal canula at 2 liters per minute from a concentrator located at the bedside. During an observation on 12/2/21 at 7:52 a.m. R#2 was observed lying in bed with O2 via nasal canula at 2 liters per minute from a concentrator located at the bedside. During an interview on 12/2/21 at 10:22 a.m. with Registered Nurse Unit Manager (UM) confirmed the physician order did not specify a flow rate for R#2's oxygen. UM stated the order should specify a flow rate and this should have been clarified on admission.

Based on observation, staff interview and policy review, the facility failed to provide hands free trash receptacles at two hand washing sinks; failed to label and date opened food items in the reach in cooler, walk-in cooler, and dry food storage area; failed to ensure cleanliness of kitchen floors, oven, hot boxes and can opener; failed to ensure cleanliness and proper storage of ice machine scoop; failed to follow standard sanitizing procedures during puree food processing; failed to ensure a cold food desert was served below 41 degrees Fahrenheit (F); and failed to ensure that staff personal items were not stored on the food preparation table. The deficient practice had the potential to affect 27 residents receiving an oral diet. The facility census was 29 residents. Findings include: During initial observation and interview of the kitchen conducted on 6/4/19 from 10:20 a.m. to 11:30 a.m., Dietary Manager (DM) CC revealed no foot activated trash cans located at the two handwashing sinks. Continued observations of the Healthcare Kitchen with DM CC present included: a large white, rolling, barrel-type trash receptacle with a removable lid (by hand) was noted across the room currently in use by the kitchen staff prepping food; the ice machine scoop was observed lying on top of the ice machine. After questions were asked about the scoop, DM CC removed the scoop and placed it in a large bowl on top of the ice machine. The ice scoop was not cleaned prior to placing it the bowl for use. The DM confirmed the large ice machine was the main one that provided ice for the main kitchen, the Healthcare Kitchen, and the Bistro Café. The metal food preparation table was observed with food prep in process. An open pink backpack was observed on the lower shelf along with kitchen equipment. The DM had the kitchen staff member preparing food at the table to remove her backpack. A can opener shared by both kitchens was observed to be dirty with what appeared to be red, firmly dried food substances. The DM removed the can opener and told staff to clean it. The observation tour continued with DM DD who confirmed she was responsible for the Healthcare Kitchen food service. Two distinct kitchen areas were noted with the nursing home side separate for meal prep and cooking, but both sharing some equipment and food storage areas. Continued observations with DM DD present included: the floors appeared dirty with food debris; and two holding ovens (hot boxes) were observed with old blackened food debris present. The HealthCare (SNF) reach in cooler contained an opened large container of chopped butternut squash, partially covered with a plastic covering that did not cover completely and had no date or label. The #1 shared walk in cooler contained one opened package of plastic wrapped shredded parmesan cheese (per the DM) and two packages of opened plastic wrapped mozzarella cheese (per the DM) with no date or label. The #2 shared walk in cooler contained one opened package of plastic wrapped croissant rolls, a partial bag of opened white bread, one opened bag of four hot dog buns and an opened bag containing one hamburger bun; all with no date or label. The shared walk in freezer contained two large frozen previously cooked pork loins (per DM) wrapped in plastic with no dated or label. Observations of the shared dry food storage room with the DM included: an opened partially used bag of elbow macaroni with no date, an opened partially used bag of tortilla chips with no date, an opened partially used package of brown rice with no date, an opened Siracha hot sauce bottle half empty with no date, an opened A-1 steak sauce with no date, an opened ice cream topping with no date, and one box of corn starch with the top of the box and inner sleeve opened to air with no date. During interview at the end of the kitchen tour at 11:30 a.m., DM DD confirmed that once opened for use, all food items packages/containers should be closed after use, have a label and be marked with a use by date. Observation of the puree process on 6/5/19 at 11:50 a.m. revealed Cook EE rinsing the lid to the high-speed food processor with running tap water at the adjacent sink, after pureeing the broccoli without washing/sanitizing or drying the lid. The cook then continued to use the same wet lid with another clean food processor canister to puree the baked chicken. After pureeing the baked chicken, she rinsed that canister, blade, and lid with running tap water in the sink and started the puree process for the chopped sirloin. The canister, blade, and lid were not washed/sanitized or dried between pureeing these food items. A further observation was conducted in the kitchen on 6/5/19 at 12:05 p.m. with the DM DD as follows: The Healthcare Kitchen oven was dirty at the bottom with dried black/gray substances; and a small hot box/warming oven was observed to have dried black/gray substances on the bottom. A kitchen staff member was observed at the metal prep table making sandwiches and preparing food for lunch meal. On the shelf below was a toaster, food items of cooking oil, a container of rolled oats and a plastic covered bowl of roux. Also, on this shelf, was a clear baggy containing personal items such as pens and medications. A cell phone in a blue/black case was also lying on the shelf. The kitchen staff preparing sandwiches at the prep table confirmed those items were hers. During steam table temperature checks on 6/6/19 at 12:40 p.m. with DM DD revealed ambrosia desert to be 51 degrees F. The chilled fruit desert was pulled from tray line by DM DD and re-chilled for a half hour. The retested observation of ambrosia was 36.8 F. The DM stated it was now able to be served. The DM confirmed the fruit must not had time to chill down. During an interview on 6/7/19 at 2:35 p.m., DM DD explained that the housekeeping staff clean the kitchen floors by buffing bi-weekly and the kitchen staff mop between all meals. She stated that the ovens were cleaned on the weekends. She explained she would put in a work order for the ice scoop to be mounted on the large ice machine. She confirmed that the large ice machine is shared for all residents, and the whole facility shares the ice machine and hydration carts. She further stated that she does not know who didn't label the cheese in the walk-in coolers and stated the other items in the dry storage area could have been anyone because the two walk-in coolers and the dry storage are shared by the other kitchen. She stated the pork loins had just been placed on the shelf in the cooler; they were not on her menu, and they hadn't had a chance to label them before the tour of the kitchen. She stated the expectation is for all kitchen staff to place all personal items in their lockers. Review of the blank task form titled AM Cook 6A-2P and PM Cook 11A-7P revealed a daily routine task list to be checked off up completion. The daily task items for the 6A-2P cook listed 23 tasks including but not limited to: document all food temperatures, clean the line, and clean the hot box, check coolers for label and dated food items, remove any out dated food items, clean all equipment and wipe down counters, clean oven inside and out for spills, and to sweep and mop hot line under and around equipment. The facility was unable to provide completed task forms. Review of the undated facility policy titled Food Safety: Labeling and Dating documented storage and packaging practices help assure proper ingredient usage and food safety as follows: Storage and packaging practices help assure proper ingredient usage and food safety. Any food that is not in its original packaging must be labeled. Section: Dating for Food Storage documented that all food that require time and temperature control should be labeled with the following: common name of the food, date the food was made, and use by date. Section: Dating for Cold & Hot Foods without Temperature Control documented to remember to also label foods not being monitored for temperature control. If temperature-controlled food is being served and the temperature is not being maintained, it needs to be labeled with the following: common name of the food, time it was removed from the refrigerator, time it needs to be discarded. Review of the provided documentation from the HACCP Manual 1.1.4 dated 8/17/16 reflects all food left over after a meal may be used if the company's HACCP food safety requirements are adhered to always. This includes monitoring and recording HACCP temperatures during refrigeration storage, production, cooking, display, holding, service, cooling and reheating as appropriate. C. Handling food during preparation, cooking, holding, cooling, reheating, and serving. Cold foods: hold foods at 40 degrees F or below.

Based on observation, record review, review of facility policies titled Comprehensive Care Plan and Resident Alarms, and staff interview, the facility failed to revise and update the care plan to address the use of safety alarms for one resident (R) (#21) of three residents that have both a bed pad-type alarm and a chair alarm. Findings include: Review of the clinical record revealed R#21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a fall from wheelchair on 3/11/19. The Quarterly Minimum Data Set (MDS) Assessment for R#21 dated 4/29/19 documented in Section J - Health Conditions, no falls since admission or prior assessment. Observation on 6/5/19 at 1:42 p.m. revealed R#21 in activities. A personal chair alarm was attached to her sweater and secured to the back of the wheel chair. During an interview and observation of R#21 on 6/7/19 at 3:00 p.m. with Certified Nursing Assistant (CNA) BB, she confirmed Resident #21 was in her private room asleep with the bed alarm in use. Review of the care plan revised 5/2/19 revealed R#21 has a potential for falls related to end stage Dementia as evidenced by extensive to total assistance needed with mobility. Interventions for falls included: wearing non-skid socks, a fall risk assessment upon admission and quarterly, place the call light within reach, and keep the room clutter free and well lit. No evidence was found to indicate the care plan had been updated to include the use of a bed alarm and chair alarm. During an interview on 6/6/19 at 11:15 a.m., Registered Nurse (RN) AA revealed R#21 had a fall on 3/11/19 with no injury and he thought it was the family's request for the chair alarm. During an interview on 6/6/19 at 11:30 a.m., the MDS Coordinator confirmed that no updates for a chair or bed alarm were documented. She stated the aides usually notify her that the resident has an alarm and she will input it into the MDS and care plan. She confirmed she would consider the issue and find out how the alarms were missed. Review of the facility's policy titled, Comprehensive Care Plan, effective 6/7/19, documented that the facility must develop and implement a comprehensive person-centered care plan for each resident within the resident's rights. This policy includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs. Review of the facility's policy titled Resident Alarms dated 11/28/18 revealed: it is the policy of the facility to utilize resident alarms in limited circumstances, in accordance with the resident's needs, goals and preferences, so the resident will be able to attain or maintain his or her highest practicable level of physical, mental and psychosocial well-being. Policy explanation and compliance guidelines: 5. Implementation of interventions. D) Interventions shall be communicated to all relevant staff, including frequency/ time frames and responsibility.

Based on observations, record reviews and staff interviews, the facility failed to ensure that appropriate hand hygiene was performed during wound care for two of two residents (R) (#20 and #4 ) that were observed for wound care. The Sample size was 24 residents. Findings include: Multiple Reviews of evidence based information and facility policy revealed: from the World Health Organization: Glove Use Information Leaflet revealed that gloves should be used during all patient-care activities that may involve exposure to blood and all other body fluid (including contact with mucous membrane and non-intact skin), during contact precautions and outbreak situations. Nevertheless, health-care workers should be informed that gloves do not provide complete protection against hand contamination. Pathogens may gain access to the caregivers' hands via small defects in gloves or by contamination of the hands during glove removal. Hand hygiene by rubbing or washing remains the basic to guarantee hand decontamination after glove removal. From the Dressing Change (clean) facility policy for basic responsibility: Licensed Nurse page 20 under Procedure: Step 5. Put on first pair of disposable gloves. Step 6. Remove soiled dressing and discard in plastic bag. Step 7. Dispose of gloves in plastic bag and wash hands. Step 8. Put on second pair of disposable gloves. Step 15. Wash hands. In addition, the education materials on web training required of all licensed staff titled Handwashing: The Latest CDC Recommendations with expiration date of 12/31/17 revealed the use of gloves or other personal equipment is not a substitute for handwashing. Observation on 4-19-17 at 2:30 .m., of LPN BB providing wound treatment to R 20's sacral area: Washed hands, applied gloves, and removed old dressing, cleansed with NS. Without washing or sanitizing her hands LPN BB applied clean gloves. Pressure area measured - 0.8 x 0.6 x <0.1 L upper buttock crease. Without washing or sanitizing her hands, LPN BB was observed to change her gloves, apply [MEDICATION NAME] and covered the wound with [MEDICATION NAME]. Observation revealed that LPN BB did not wash hands between glove changes. Review on 4-20-17 at 8:30 a.m., of education material revealed the following: Handwashing: The Latest CDC Recommendations with expiration 12/31/2017, the use of gloves or other Personal Protective Equipment (PPE) is not a substitute for hand washing. Review of the Course Completion History revealed that LPN BB completed her in-service on 2/2/17. Interview on 4-20-17 at 9:50 a.m., with LPN BB, revealed that LPN BB confirmed that she did not wash or sanitize hands prior to donning clean gloves during the dressing changes. She further revealed that it had been a long time since she had read the policy. Interview on 4/20/17 at 11:28 a.m., with RN CC (facility delegated Infection Control nurse) stated that his expectation was to wash hands between dirty versus clean and changing gloves. 2. Review of the medical record for R#4 revealed the resident with the following pressure ulcers: Stage IV to the left ischium - onset date 9/10/14, stage IV to the distal left leg - onset date 11/9/16, stage IV to the right leg - onset date 10/21/16, Deep Tissue Injury (DTI) to the coccyx - onset date 2/24/17, and Stage II to the right ankle - onset date 3/6/17. Observation of pressure ulcer treatment for [REDACTED]. leg and ankle. After removing her soiled gloves and without washing or sanitizing her hands, LPN BB donned clean gloves and provided treatment for [REDACTED]. After removing her soiled gloves and washing/sanitizing her hands, the nurse then donned clean gloves and removed the old dressing on the Stage IV pressure ulcer on the resident's left leg. After removing those soiled gloves and without washing/sanitizing her hands, the nurse donned clean gloves and provided treatment for [REDACTED]. After removing her soiled gloves and washing/sanitizing her hands, the nurse then donned clean gloves and removed the old dressing on the Stage IV pressure ulcer on the resident's left ischium and stage II to the resident's coccyx. After removing those soiled gloves and without washing or sanitizing her hands, the nurse donned clean gloves and provided treatment for [REDACTED]. Although the nurse changed gloves during and between treatments of the five pressure ulcers, she failed to wash or sanitize her hands after removing the soiled gloves and prior to donning the clean gloves in order to prevent possible contamination. Interview with the Licensed Practical Nurse (LPN)/Wound Care Nurse BB on 04/20/2017 at 9:50 a.m. revealed that her process for wound care is to wash hands, put on gloves, remove the dirty dressing, change gloves and apply the clean dressing. LPN BB stated that in-services are provided for wound care but it has been some time since she read the wound care policy. Review of the policy provided by the facility with no revision date titled, Dressing Change (Clean): Basic Responsibility: Licensed Nurse - Procedure documented to put on first pair of disposable gloves, remove soiled dressing and discard in plastic bag, dispose of gloves in plastic bag, wash hands, and put on second pair of disposable gloves.

Based on observation and staff interview, the facility failed to ensure that one (1) of one (1) ice machine was maintained in a sanitary manner, to prevent the spread of infection. Findings include: Observation and interview on 1/20/15 at 10.50 a.m. with Dietary Director and Dietary Manager of the ice machine located in the service kitchen revealed a moderate amount of brownish pink substance on the plastic shield inside the ice compartment. The Dietary Director, at this time, verified the presence of the brownish pink substance. An interview on 1/21/15 at 11.05 a.m. with the Dietary Manager revealed there is no policy on when to clean the ice machine, however, she instructs her staff to clean the ice machine monthly. Review of the HACCP Ice Machine Cleaning Log -- One Form Per Month revealed a signature in the Associate Responsible For The Sanitation Of The Ice Machine column and a date of January 1st.

Based on observation, review of a dish machine temperature log, and staff interviews the facility failed to ensure that the temperature gauge was functioning properly for one (1) of one (1) satellite dish machine for the skilled nursing unit. The facility census was twenty-seven (27) residents. Findings include: Observation of the dish machine during the wash cycle conducted 5/29/13 between 12:45 p.m. and 1:00 p.m. revealed the thermometer gauge needle did not move. The cover to this thermometer gauge was noted to be cracked and broken. The facility contact ECOLAB and the broken gauge was replaced on 5/29/13 at 1:37 p.m. During this observation dietary staff "BB" indicated that this machine had been checked by the service company the previous month and a new gauge was ordered. "BB" could not provide the surveyor with evidence of a new gauge had been ordered. Dietary staff "AA" could not locate any temperature logs for this dish machine. During the state agency Quality Assurance review, the facility submitted a temperature log dated May 17 though May 31st. Review of this log revealed no wash temperatures were recorded for any time until the morning of May 29th. After May 29th wash temperatures were recorded for morning, afternoon and evening wash cycles. The facility could not provide any evidence that the facility had a method in place to ensure the temperature of the wash cycle was monitored from May 17-May 29th.

Based on observation and interview, it was determined that the facility had failed to identify a potential hazard in the kitchenette when it was not in use and implement interventions to minize the potential risk. Findings include: During an observation on 1/31/12 at 3:30 p.m., the small kitchenette next to the dining room was unsupervised. The two entrance doors into the kitchenette were unlocked and one of them was open. There was a steam table inside the kitchenette which had been turned on to its the highest setting (6). It was noted that there was steaming hot water in four of the steam table's five wells. The steam table was hot to the touch. Dduring an inteview on 1/31/2010 at 3:55 p.m., the Director of Nursing confirmed that the steam table was left turned on (after lunch) but said that it should not have been.

Based on observations during medication administration and staff interview, it was determined, that the facility failed to ensure that one nurse used standard precautions in disposing of waste after obtaining finger stick blood sugar levels for two residents (#9 and #25) from a sample of twenty-four residents. Findings include: According to the Center for Disease Control, one of the key precautions of standard precautions to help decrease the spread of infectious agents is medical waste management. Contaminated disposable items should be placed in a plastic bag at the point of use and disposed of in a trash container. During medication pass observations with Licensed Practical Nurse (LPN) "G" on 02/01/12 at 5:00 p.m., the nurse used resident #9's glucometer to test his/her finger stick blood sugar level but failed to use standard precautions to dispose of the waste. . After using a retractable lancet to obtain resident # 9's finger stick blood sugar, LPN "G" removed his/her soiled gloves and rolled the finger stick lancet retracted device, the testing strip and alcohol pad up in them and put them in the resident's bathroom trash can. LPN "G" obtained the resident #25's finger-stick blood sugar level at 5:20 p.m., then rolled the retractable lance, testing strip and alcohol pad in his/her soiled gloves and disposed of them in the resident's bathroom trash can. According to the administrator, it was facility's policy for glucometers to be assigned to individual residents. The supplies and equipment such as finger stick devices and glucometers are maintained in the individual resident's room if possible. Staff are supposed to dispose of finger stick devices and lancets at the point of use in an approved sharps container.

Based on record review, resident interview, staff interview, and observation, the facility failed to ensure the safe use of a heating pad for one (1) resident ("A") from a survey sample of seven (7) residents. This failure resulted in actual harm, a second degree burn, to the resident. Findings include: Record review for Resident "A" revealed a March 2009 Minimum Data Set assessment which indicated that the resident had no short-term or long-term memory problems. A 03/19/2009, 4:20 p.m. physician's orders [REDACTED]. A Daily Skilled Nurses Note of 03/19/2009 at 10:00 p.m. documented that a heating pad had been brought to the facility by the resident's spouse, and the March 2009 Medication Administration Record indicated to apply the heating pad to the resident's lower back every two-to-three hours for 20 minutes. During an interview with Nurse "AA" conducted on 03/30/2009 at 1:30 p.m., Nurse "AA" stated that the resident's family had brought a heating pad for the resident's use, and that the heating pad had been left in the resident's room for the resident to apply. During an interview with Resident "A" conducted on 03/30/2009 at 3:05 p.m., the resident stated that the heating pad had been applied most of the day of 03/20/2009. However, further record review revealed no evidence to indicate that facility staff had monitored the application or use of the heating pad throughout the day of 03/20/2009. During the 03/30/2009, 1:30 p.m. interview with Nurse "AA" referenced above, Nurse "AA" acknowledged that nursing staff had did not monitor the use and application of the heating pad throughout the day of 03/20/2009. A Daily Skilled Nurses Note of 03/20/2009 at 5:00 p.m. documented that a quarter-size blister had been noted to the resident's mid-back, with red, splotchy areas surrounding the blister, and that the nurse practitioner was notified. A 03/20/2009, 5:00 p.m. physician's orders [REDACTED]. twice daily until healed. During the 03/30/2009, 1:30 p.m. interview with Nurse "AA" referenced above, Nurse "AA" stated that when she was called to the resident's room at approximately 4:00 p.m. on 03/20/2009, she had noted the resident had sustained a quarter-sized blistered area to the mid-back area and had called the physician. A 03/23/2009 physician's progress note documented that the resident had sustained a burn to the spinal thoracic area related to the heating pad. The wound care nurse documented on 03/24/2009 that the resident had sustained a thermal injury, probably second degree, measuring 3.4 centimeters (cms.)-by-2.2 cms. to the T-12 back area. Observation of the resident's back on 03/30/2009 at 3:05 p.m. revealed an area of eschar measuring approximately 3 cms.-by-1/2 cm. over the mid-back area.