Every finding on record at Terrebonne General Med CTR SNF

Based on observations, interviews, and record reviews the facility failed to ensure percutaneous endoscopic gastrostomy tube flushes before and after medication administration for 1 (Resident #11) of 1 sampled resident with a percutaneous endoscopic gastrostomy tube (a feeding tube inserted through the abdomen into the stomach, commonly used for long-term nutrition, fluids, and medication delivery).Findings:Review of Resident #11's physician's orders dated 02/08/2026 revealed, in part, flush the feeding tube with the lowest volume necessary to clear the tube before and after administration unless a specific volume is ordered.Review of Elsevier Performance Manager Training for Medication Administration via Feeding Tubes revealed, in part, flush the feeding tube with a minimum of 15 milliliters of purified water before and after the administration of medications. Observation on 02/09/2026 at 12:02PM revealed S4Registered Nurse did not flush Resident #11's percutaneous endoscopic gastrostomy tube before and after medication administration. Observation on 02/09/2026 at 4:54PM revealed S4Registered Nurse did not flush Resident #11's percutaneous endoscopic gastrostomy tube before and after medication administration. Observation on 02/10/2026 at 8:16AM revealed S4Registered Nurse did not flush Resident #11's percutaneous endoscopic gastrostomy tube before and after medication administration. Observation on 02/10/2026 at 9:19AM revealed S4Registered Nurse did not flush Resident #11's percutaneous endoscopic gastrostomy tube before and after medication administration. Observation on 02/10/2026 at 12:14PM revealed S4Registered Nurse did not flush Resident #11's percutaneous endoscopic gastrostomy tube before and after medication administration. In an interview on 02/10/2026 at 4:45PM, S4Registered Nurse stated he did not flush Resident #11's percutaneous endoscopic gastrostomy tube before and after medication administration, and should have. In an interview on 02/11/2026 at 8:36AM, S2Nurse Manager confirmed S4Registered Nurse should have flushed Resident #11's percutaneous endoscopic gastrostomy tube before and after medication administration. In an interview on 02/11/2026 at 8:50AM, S1Post Acute Care Director confirmed S4Registered Nurse should have flushed Resident #11's percutaneous endoscopic gastrostomy tube before and after medication administration.

Based on observations, interviews, and record reviews, the facility failed to implement Enhanced Barrier Precautions (EBP) for 2 (Resident #5, Resident #11) of 2 sampled residents observed for infection control practices. Findings:Review of the Centers for Disease Control's 04/02/2024 article Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 04/02/2024, revealed, in part, personal protective equipment, which included the use of gowns and gloves, should be used during high-contact resident care activities that provided opportunities for the transfer of methicillin drug resistant organisms (bacteria or other germs that developed resistance to multiple antibiotics) to staff's hands and clothing. Further review revealed examples of high-contact resident care activities included device care, which included care of feeding tubes, and wound care. Review of the facility's Infection Control policy and procedure revealed, in part, the policy did not include a developed policy for the implementation of Enhanced Barrier Precautions (EBP). In an interview on 02/10/2026 at 11:15AM, S3Infection Control Manager indicated the facility's Infection Control policy and procedure did not include a developed policy for the implementation of EBP. In an interview on 02/11/2026 at 8:51AM, S1Post Acute Care Director indicated the facility's Infection Control policy and procedure did not include a developed policy for the implementation of EBP. In an interview on 02/11/2026 at 8:52AM, S2Nurse Manager indicated the facility's Infection Control policy and procedure did not include a developed policy for the implementation of EBP. Observation on 02/09/2026 at 1:51PM revealed S4Registered Nurse initiated Resident #11's percutaneous endoscopic gastrostomy tube feeding without wearing a gown. Observation on 02/10/2026 at 8:14AM S4Registered Nurse performed wound care to Resident #11's percutaneous endoscopic gastrostomy tube without wearing a gown. In an interview on 02/10/2026 at 3:04PM, S4Registered Nurse indicated he was not aware of the Centers for Disease Control's requirements for EBP. S4Registered Nurse further indicated he wore gloves but did not wear a gown when he initiated Resident #11's tube feeding and when he performed wound care to Resident #11's percutaneous endoscopic gastrostomy tube and should have. In an interview on 02/11/2026 at 8:36AM, S2Nurse Manager indicated S4Registered Nurse should have worn a gown when S4Registered Nurse initiated Resident #11's tube feeding formula and when S4Registered Nurse performed wound care to Resident #11's percutaneous endoscopic gastrostomy tube. In an interview on 02/11/2026 at 8:45AM, S1Post Acute Care Director indicated S4Registered Nurse should have worn a gown when S4Registered Nurse initiated Resident #11's tube feeding formula and when S4Registered Nurse performed wound care to Resident #11's percutaneous endoscopic gastrostomy tube. Observation on 02/09/2026 at 8:00AM revealed S4Registered Nurse provided surgical wound care and dressing change to Resident #5's two left lateral thigh surgical wounds wearing only a mask and gloves for enhanced barrier precautions. Observation further revealed S4Registered Nurse did not wear a gown during Resident #5's wound care. Observation on 02/10/2026 at 10:10AM revealed S4Registered Nurse provided surgical wound care and dressing change to Resident #5's two left lateral thigh surgical wounds wearing only a mask and gloves. Observation further revealed S4Registered Nurse did not wear a gown during Resident #5's wound care. Observation on 02/09/2026 at 12:02PM revealed S4Registered Nurse administered Resident #11's medications via percutaneous endoscopic gastrostomy tube without wearing a gown. Observation on 02/09/2026 at 4:54PM revealed S4Registered Nurse administered Resident #11's medications via percutaneous endoscopic gastrostomy tube without wearing a gown. Observation on 02/10/2026 at 8:16 AM revealed S4Registered Nurse administered Resident #11's medications via percutaneous endoscopic gastrostomy tube without wearing a gown. Observation on 02/10/2026 at 9:19AM revealed S4Registered Nurse administered Resident #11's medications via percutaneous endoscopic gastrostomy tube without wearing a gown. Observation on 02/10/2026 at 12:14 PM revealed S4Registered Nurse administered Resident #11's medications via percutaneous endoscopic gastrostomy tube without wearing a gown. In an interview on 02/10/2026 at 3:04PM, S4Registered Nurse stated he had not worn a gown when providing wound care to Resident #5. S4Registered Nurse further stated he had not received training for EBP. In an interview on 02/11/2026 at 8:36AM, S2Nurse Manager confirmed S4Registered Nurse should have worn a gown when performing surgical wound care, percutaneous endoscopic gastrostomy tube site care, and medication administration via percutaneous endoscopic gastrostomy tube.

Based on interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA) registry verification was completed prior to hire for 1 (S6Nursing Assistant [NA]) of 5 (S3CNA, S4CNA, S5NA, S6CNA, S7CNA) personnel records reviewed for registry verification. Findings: Review of S6NA's personnel record revealed a hire date of 05/20/2024. Further review revealed no documented evidence, and the facility did not present any documented evidence, a CNA registry check was obtained prior to hire for S6NA. In an interview on 02/05/2025 at 12:10PM S1Director indicated a CNA registry check was not obtained prior to hire for S6NA, as required.

Based on interviews and record reviews, the facility failed to ensure a Notice of Medicare Non-Coverage (NOMNC) Form (CMS-10123) was given to all Medicare beneficiaries who were discharged home with benefit days remaining, at least two days before the end of a Medicare covered Part A stay, for 3 (Resident #201, Resident #202, Resident #203) of 3 (Resident #201, Resident #202, Resident #203) sampled residents reviewed for beneficiary notification. Findings: Resident #201 Review of Resident #201's medical record revealed, in part, Resident #201 was admitted for Medicare Part A services on 09/03/2024, and was discharged home on 09/20/2024. Review of Resident #201's Notice of Medicare Non-coverage (NOMNC) form revealed, in part, Resident #201's last covered day of Medicare Part A services was on 09/20/2024. Further review revealed there was no notification date documented on the NOMNC form. Resident #202 Review of Resident #202's medical record revealed, in part, Resident #202 was admitted for Medicare Part A services on 12/13/2024, and was discharged home on 12/27/2024. Review of Resident #202's Notice of Medicare Non-coverage (NOMNC) form revealed, in part, Resident #202's last covered day of Medicare Part A services was on 12/27/2024. Further review revealed Resident #202's representative was notified via telephone on 12/27/2024 that Resident #202's last covered day of Medicare Part A services was 12/27/2024. Resident #203 Review of Resident #203's medical record revealed, in part, Resident #203 was admitted for Medicare Part A services on 11/04/2024, and was discharged home on 11/15/2024. Review of Resident #203's Notice of Medicare Non-coverage (NOMNC) form revealed, in part, Resident #203's last covered day of Medicare Part A services was on 11/15/2024. Further review revealed Resident #203 was notified on 11/14/2024 of Resident #203's last covered day of Medicare Part A services was 11/15/2024. In an interview on 02/05/2025 at 8:59AM S2Minimum Data Set Coordinator confirmed Resident #201, Resident #202, and Resident #203 was not notified via NOMNC (CMS-10123) Form at least two days before the last covered day of the Medicare Part A services and it should have been.

Based on interview and record reviews, the facility failed to ensure a staff member received dementia trainings for 1 (S3Certified Nursing Assistant [CNA]) of 5 (S3CNA, S4CNA, S5Nursing Assistant [NA], S6CNA, S7CNA) personnel records reviewed for required trainings. Findings: Review of the facility's Skilled Nursing Facility assessment dated [DATE] revealed, in part, the facility had 31 residents with behavioral health needs, and serviced a population that was typically over [AGE] years old. Further review revealed CNAs were to receive trainings on Bathing and Dementia Care and Communicating with Residents with Dementia during orientation and/or annual competencies. Review of S3CNA's personnel record revealed, in part, no documented evidence, and the facility did not present any documented evidence, S3CNA received trainings on Bathing and Dementia Care and Communicating with Residents with Dementia during orientation and/or annual competencies. In an interview on 02/04/2025 at 4:25PM, S1Director indicated S3CNA had not received the above mentioned dementia trainings as determined to be required in the facility's Skilled Nursing Facility Assessment.

Based on record reviews and interviews, the facility: 1. Failed to ensure staff were provided abuse and neglect training (S8Agency Registered Nurse (RN), S9Agency RN, and S10Agency RN); and 2. Failed to ensure staff were provided dementia management training (S6Certfied Nursing Assistant (CNA) and S11CNA). This deficient practice was identified for 5 (S6CNA, S8Agency RN, S9Agency RN, S10Agency RN, and S11CNA) of 8 (S6CNA, S8Agency RN, S9Agency RN, and S10Agency RN, S11CNA, S12Licensed Practical Nurse (LPN), S13CNA, and S14CNA) personnel records reviewed. Findings: 1. Review of the facility's Skilled Nursing Facility (SNF) schedule from 10/29/2023 through 12/09/2023 revealed, in part, S8Agency RN, S9Agency RN, and S10Agency RN worked at the facility as a Registered Nurse. Review of S8Agency RN's personnel file revealed no documented evidence and the provider did not present any documented evidence abuse and neglect training was completed since date of hire of 10/18/2023. Review of S9Agency RN's personnel file revealed no documented evidence and the provider did not present any documented evidence abuse and neglect training was completed since date of hire of 10/16/2023. Review of S10Agency RN's personnel file revealed no documented evidence and the provider did not present any documented evidence abuse and neglect training was completed since date of hire of 10/29/2023. In an interview on 02/15/2024 at 3:02 p.m., S2Unit Manager confirmed the above mentioned agency employees were not provided abuse and neglect training since hire by the facility and/or the contracted nursing agency. 2. Review of the facility's Skilled Nursing Facility (SNF) schedule dated 10/29/2023 through 02/17/2024 revealed, in part, S8Agency RN, S9Agency RN, S10Agency RN, and S11CNA worked at the facility providing care to residents. Further review revealed S11CNA worked on the SNF unit as a CNA. Observation on 02/15/2024 at 10:50 a.m. revealed S6CNA was observed providing care to residents in the facility. Review of S6CNA's personnel file revealed a hire date of 10/23/2023. Further review revealed no documented evidence and the provider did not present any documented evidence dementia training and/or behavior management was completed since hire. Review of S9Agency RN's personnel file revealed no documented evidence and the provider did not present any documented evidence dementia training was completed since hire. Review of S10Agency RN's personnel file revealed no documented evidence and the provider did not present any documented evidence dementia training was completed upon hire. Review of S11CNA's personnel file revealed a hire date of 09/18/2023. Further review revealed no documented evidence and the provider did not present any documented evidence dementia training and/or behavior management was completed since hire. In an interview on 02/15/2024 at 3:02 p.m., S2Unit Manager confirmed the above mentioned CNAs were not provided dementia training since hire. S2Unit Manager further confirmed the above mentioned agency employees were not provided dementia training since hire by the facility and/or the contracted nursing agency.

Based on observations, record reviews, and interviews the facility failed to: 1. Ensure the registered nurse (RN) performed hand hygiene and applied gloves after contact with equipment and prior to touching and administering medication for 4 (Resident #56, Resident #57, Resident #58, and Resident #59) of 4 (Resident #56, Resident #57, Resident #58, and Resident #59) sampled residents observed during medication administration; 2. Ensure the RN and certified nursing assistant (CNA) performed hand hygiene and changed gloves appropriately as required during wound care for 1 (Resident #58) of 1 (Resident #58) sampled residents observed during wound care; and, 3.Ensure the licensed practical nurse (LPN) performed hand hygiene and applied gloves after contact with her uniform and equipment prior to performing blood glucose monitoring for 1 (Resident #56) of 1 (Resident #56) sampled residents observed during blood glucose monitoring. Findings: Review of the facility's Hand Hygiene policy and procedure revealed, in part: -wash hands with soap and water when hands are visibly dirty or contaminated; -perform hand hygiene before having direct contact with patients; -perform hand hygiene after contact with a patient's intact skin; -perform hand hygiene after contact with body fluids or excretions, non-intact skin, or wound dressings; -perform hand hygiene if moving from a contaminated body site to a clean body site during resident care; and, -perform hand hygiene after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. 1. Observation on 02/14/2024 at 9:43 a.m. revealed S4RN performed hand hygiene, applied gloves in the hallway, pushed the medication cart to the door, and then opened the door with his gloved hand. Further observation revealed S4RN opened the package containing Resident #59's medication, used his gloved hand to obtain the medication from the blister pack with his gloved hand, and then administered the medication to Resident #59. S4RN had not removed his gloves or performed hand hygiene from the time he applied his gloves in the hall through the time he administered Resident #59's medication. Observation on 02/14/2024 at 10:53 a.m. revealed S4RN performed hand hygiene and applied gloves in the hallway, then pushed the medication cart to the door and opened the door with his gloved hand. Observation further revealed S4RN proceeded to scan Resident #59's bracelet with the hand scanner and utilized the computer's mouse. S4RN opened Resident #59's medication packet, pulled the pill from the blister pack with his gloved hand, and handed the pill to Resident #59. Further observation revealed S4RN had not removed his gloves or performed hand hygiene from the time he applied his gloves in the hall through the time he administered Resident #59's medication. Observation on 02/14/2024 at 1:42 p.m. revealed S4RN performed hand hygiene and applied gloves, a gown, and a mask in the hallway and then opened the door with his gloved hand. Observation further revealed S4RN touched Resident #56's recliner handle to sit Resident #56 up, scanned Resident #56's bracelet with the hand scanner, and then opened Resident #56's medication packaging. S4RN used his gloved hand to pull the pill from the medication packaging and handed the pill to Resident #56. Further observation revealed S4RN had not removed his gloves or performed hand hygiene from the time he applied his gloves in the hall through the time he administered Resident #56's medication. Observation on 02/14/2024 at 2:18 p.m. revealed S4RN notified the surveyor of the medication administration with his gloves already present on his hands. Further observation revealed S4RN pushed the medication cart into Resident #58's room, and scanned Resident #58's bracelet with the hand scanner. S4RN then used the computer's mouse, opened Resident #58's medication packaging, used his gloved hand to remove Resident #58's pill from the medication package, and administered Resident #58 his medication. Further observation revealed S4RN had not removed his gloves or performed hand hygiene from the time he applied his gloves in the hall through the time he administered Resident #56's medication. Observation on 02/14/2024 at 4:19 p.m. revealed S4RN entered Resident #59's room, performed hand hygiene, and applied gloves. Further observation revealed S4RN scanned Resident #59's bracelet, used the computer's mouse, opened Resident #58's medication packaging, used his gloved hand to remove Resident #58's pill from the medication package, and administered Resident #58 his medication. Further observation revealed S4RN had not removed his gloves or performed hand hygiene from the time he applied his gloves in the hall through the time he administered Resident #56's medication. Observation on 02/14/2024 at 4:23 p.m. revealed S4RN performed hand hygiene and applied gloves. S4RN then used the vital sign machine to obtain Resident #58's blood pressure, scanned Resident #58's bracelet with the hand scanner, and used the computer's mouse. Observation revealed S4RN removed Resident #58's pill from the medication package with his gloved hand and administered the pill to Resident #58. In an interview on 02/15/2024 at 9:19 a.m., S4RN confirmed the above observations and stated he should have performed hand hygiene and changed gloves after touching items in the residents' environment and prior to administering residents' medications. In an interview on 02/15/2024 at 9:36 a.m., S2Nurse Manager stated nurses should change gloves and perform hand hygiene between touch items in the environment and administering medications. In an interview on 02/15/2024 at 9:40 a.m., S1Assistant [NAME] President of Nursing Services confirmed glove changes and hand hygiene should have been completed between touching objects in the environment and administering residents' medications. 2. Observation on 02/15/2024 at 10:50 a.m. revealed S6CNA grabbed a brown paper towel and blotted blood to Resident #58's left buttock wound. Observation revealed S4RN performed hand hygiene, applied gloves, and cleaned Resident #58's buttock with normal saline. Without performing hand hygiene or changing gloves, S4RN applied stoma paste, powder, and Calmoseptine (a topical ointment used to protect and/or treat skin irritations) to Resident #58's buttock wound rubbing the Calmoseptine in with S4RN's gloved finger. S4RN then applied calmoseptine to Resident #58's buttock wound using his, S4RN, finger without having changed gloves or having performed hand hygiene. Observation revealed S4RN then applied skin prep (solution used to prepare skin for adhesives) to Resident #58's periwound area and dressed Resident #58's buttock wound with a foam dressing without having changed gloves or performed hand hygiene. Observation revealed S6CNA used her gloved hands to hold open Resident #58's garbage can lid while S4RN disposed of the soiled wound care supplies. Without changing their soiled gloves or performing hand hygiene, S6CNA and S4RN turned Resident #58, removed soiled bed linens, and applied new bed linens to Resident #58's bed. S6CNA then placed Resident #58's soiled linen on the floor. In an interview on 02/15/2024 at 11:01 a.m., S4RN stated he should have changed gloves and performed hand hygiene after cleaning Resident #58's wound and prior to applying Resident #58's buttock wound medication and dressing. S4RN further stated he should have also completed hand hygiene and changed gloves after wound care and prior to touching Resident #58 and Resident #58's new, clean linens. In an interview on 02/15/2024 at 11:02 a.m., S6CNA stated she should have completed hand hygiene and changed gloves after assisting with Resident #58's wound care, after touching Resident #58's garbage can, and prior to touching Resident #58 and Resident #58's clean linens. S6CNA further stated she should not have placed the soiled linen directly onto the floor. In an interview on 02/15/2024 at 11:27 a.m., S2Nurse Manager stated S4RN and S6CNA should have changed their gloves and performed hand hygiene between cleaning Resident #58's wound and applying Resident #58's the medication and dressing. S2Nurse Manager further stated the staff should have also performed hand hygiene and changed gloves after wound care and prior to applying new linen. S2Nurse Manager stated S6CNA should not have blotted the blood from Resident #58's buttock with brown paper towels, and should have changed her gloves and performed hand hygiene after touching the garbage can and prior to contact with Resident #58. In an interview on 02/15/2024 at 11:30 a.m., S1Assistant [NAME] President of Nursing Services confirmed S4RN and S6CNA failed to follow infection control standards as noted during Resident #58's wound care. In an interview on 02/15/2024 at 11:53 a.m., S3Infection Control Nurse stated staff were to perform hand hygiene and change gloves between any dirty to clean tasks, and between wound care and other tasks. 3. Observation on 02/12/2024 at 10:45 a.m. revealed S5Licensed Practical Nurse (LPN) performed hand hygiene and applied gloves, a gown, and a mask in the hallway and opened the door with her gloved hand. Observation further revealed S5LPN reached into her uniform pockets with gloved hands, and pressed the call bell. Without removing her gloves or completing hand hygiene, S5LPN then utilized a lancet to puncture Resident #56's skin and obtained a blood glucose sample. In an interview on 02/15/2024 at 11:15 a.m., S5LPN stated she should have changed gloves and performed hand hygiene after reaching into her pockets, and touching Resident #56's call light and prior to obtaining Resident #56's blood glucose. In an interview on 02/15/2024 at 9:36 a.m., S2Nurse Manager further stated S5LPN should have changed gloves and performed hand hygiene between touching the inside of her pockets and pressing Resident #56's call light and performing Resident #56's blood glucose monitoring. In an interview on 02/15/2024 at 11:30 a.m., S1Assistant [NAME] President of Nursing Services confirmed S5LPN failed to follow infection control standards while obtaining Resident #56's blood glucose level. 46683

Based on record reviews, observations, and interviews, the facility failed to ensure medications were locked and not available for use at a resident's bedside for 1 (Resident #56) of 4 (Resident #56, Resident #57, Resident #58, and Resident #59) sampled residents observed for medications left at the bedside. Findings: Review of the facility's Storage of Medications after Dispensing to Provider policy revealed, in part, medications should be stored in a safe and secure manner, and storage locations should provide a locking mechanism for safety and security of medications. Further review revealed all locking mechanisms should be utilized to assure medications were secure at all times, and medications should not be left unattended or at a patient's bedside. Review of Resident #56's January and February 2024 physician's orders revealed, in part, no documented evidence of an order for Resident #56 to have medications available for self-administration at the bedside. Review of Resident #56's record revealed no documented evidence and the facility did not present any documented evidence Resident #56 requested to self-administer medications, and/or was assessed and careplanned to have medications at the bedside for Resident #46's use. Observation of Resident #56's room on 02/12/2024 at 10:45 a.m. revealed an unsecured and unattended Trelegy Ellipta 200-62.5-25 microgram (mcg) inhaler (a medication used to treat chronic obstructive pulmonary disease) on the right side of the sink and an unsecured and unattended bottle of Desenex (Miconazole Nitrate) 2% powder (a medication used to treat yeast) on the window sill. In an interview on 02/12/2024 at 10:44 a.m., Resident #56 confirmed she had a Trelegy Ellipta inhaler and a bottle of Desenex 2% powder available in her room. Resident #56 further stated she had not requested to self-administer the medications. Observation on 02/14/2024 at 12:30 p.m. revealed a Trelegy Ellipta 200-62.5-25mcg inhaler noted on the right side of Resident #56's sink in her room. Further observation revealed, Desenex (Miconazole Nitrate) 2% powder) noted on the window seal of Resident #56's room. Observation on 02/14/2024 at 1:42 p.m. revealed a Trelegy Ellipta 200-62.5-25mcg inhaler noted on the right side of Resident #56's sink in her room. Further observation revealed, Desenex (Miconazole Nitrate) 2% powder noted on the window seal of Resident #56's room. In an interview on 02/15/2023 at 11:33 a.m., S2Nurse Manager stated Resident #56 was not care planned or assessed to self-administer medications; therefore, Resident #56 should not have medications present at the bedside. Observation on 02/15/2023 at 12:00 p.m., with S2Nurse Manager present, revealed a Trelegy Ellipta 200-62.5-25mcg inhaler and a bottle of Desenex (Miconazole Nitrate) 2% powder were present in Resident #56's. In an interview on 02/15/2023 at 12:00 p.m., S2Nurse Manager confirmed the Trelegy Ellipta 200-62.5-25 mcg inhaler and the Desenex (Miconazole Nitrate) 2% powder should not have been unattended and unsecured in Resident #56's room. In an interview on 02/15/2024 at 12:00 p.m., S1Assistant [NAME] President of Nursing Services stated Resident #56 should not have had medications at the bedside.

Based on record review and interviews, the facility failed to ensure their policy and procedure included: 1. A process of screening employees to prevent abuse, neglect, and exploitation of residents; and, 2. A process for training employees on abuse, neglect, and exploitation of residents. Findings: Review of the facility's Identifying and Reporting Allegations of Abuse/Neglect policy dated 08/28/2023 revealed no documented evidence and the facility did not present any documented evidence the policy included how the facility would perform screening of employees to prevent abuse, neglect, and exploitation of residents and how employees would be trained on abuse, neglect, and exploitation of residents. In an interview on 02/15/2024 at 3:00 p.m., S1Assistant [NAME] President of Nursing Services acknowledged the facility's policies did not identify how the facility would perform screening of employees to prevent abuse, neglect, and exploitation of residents and how employees would be trained on abuse, neglect, and exploitation of residents and it should have.

Based on observations, record reviews, and interviews, the facility failed to post the most recent survey results. Findings: Review of the facility's survey history revealed the last survey conducted was the recertification survey with an exit date of 11/09/2022. Observation of the facility's past survey results on 02/12/2024 at 11:00 a.m. revealed the last survey results available for review were dated 11/09/2021 for the recertification survey. Observation of the facility's past survey results on 02/12/2024 at 2:00 p.m. revealed the last survey results available for review were dated 11/09/2021 for the recertification survey. Observation of the facility's past survey results on 02/14/2024 at 11:37 a.m. revealed the last survey results available for review were dated 11/09/2021 for the recertification survey. Observation of the facility's past survey results on 02/14/2024 at 12:59 p.m. revealed the last survey results available for review were dated 11/09/2021 for the recertification survey. In an interview on 02/14/2024 at 12:59 p.m., S1Assistant [NAME] President of Nursing Services confirmed the last survey posted was dated 11/09/2021. In an interview on 02/14/2024 at 1:01 p.m., S2Nurse Manger stated the last survey results posted was for the survey conducted on 11/09/2021.

Based on observation, record reviews and interviews the facility failed to ensure residents with a surgical incision received wound care per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: Observation on 11/09/2021 at 01:50pm, revealed Resident # 101's had a surgical incision to his left hip with [MEDICATION(S)]-Silver dressing dated 11/07/2021 and initialed. Review of Resident # 101's Medical Record revealed admission to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 101's Medical record revealed, in part, Resident # 101 had a left hip post-operative incision site. Review of the facility's policy for Prevention of Surgical Site infection revealed, in part, wound care should be performed according to physician instructions. Review of Resident # 101's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #101's Progress notes dated 11/08/2021, revealed, in part, no orders for wound care. Review of Resident #101's Treatment Administration Record revealed, in part, on 11/07/2021, documentation of incision site to left hip was cleaned with Providone iodine and application of [MEDICATION(S)]-Silver dressing. Next dressing change due on 11/14/2021. Review of Resident #101's Skin/Incision assessment revealed, in part, documentation of wound care provided on 11/07/2021, and 11/02/2021. In an interview on 11/08/2021 at 10:47am, Resident # 101 indicated he had a surgical incision and the nurses provided wound care sometimes. In an interview 11/08/2021 at 03:03pm, SN1Nurse Manager (NM) stated Resident # 101 had no wound care orders for his left hip post-operative incision site. In a phone interview on 11/08/2021 at 03:38pm SN3RN indicated she performed wound care to Resident # 101's left hip surgical incision. In an interview on 11/08/21 at 03:41pm SN1NM and SN2RN indicated there is usually an order but no wound care order was found in the nursing communication section of the orders. SN1NM stated the nurse caring for Resident # 101 should have called the doctor and received a wound care order after identifying the resident had a surgical incision. Review of the Nursing Communication section under the orders dated 10/29/2021 through 11/08/2021 revealed, in part, no wound care orders for Resident # 101's left hip incision. In an interview on 11/09/2021 at 09:16am SN1NM indicated they did not have a wound care order and it was an oversight.

Based on record reviews and interviews the facility failed to ensure their policy and procedure on prevention of intravascular device related infections was implemented. This deficient practice was identified for 1 (Resident #39) of 2 (Resident #39, Resident #86) stage 2 sampled residents reviewed who were receiving intravenous therapy and had the potential to affect any of the 8 residents documented on the Resident Census and Conditions of Residents form who were receiving intravenous therapy. Findings: Resident #39 was admitted to this facility on 1/25/17 with the following [DIAGNOSES REDACTED]. Resident #39 was discharged to a Nursing Home on 2/9/17, therefore no observations were done for this resident. Review of the facility's Prevention of Intravascular Device Related Infections Policy and Procedure with a last review date of 9/6/16 revealed the following information in part; after the intravenous catheter was inserted, secure the cannula with 1/2 inch tape using the chevron, double chevron, or crossover method. Apply semi-permeable transparent dressing and label with date, time and initials, document the condition of the IV site at a minimum of every shift, Replace dressing and complete site care every 7 days or if the dressing becomes damp, loosened, or visibly soiled, Replace peripheral intravenous catheters every 96 hours for adults, if venous sites are limited and there is no evidence of phlebitis or infection to site, peripheral intravenous lines can be left in place for longer periods, limited access and condition of the site should be charted. Review of Resident #39's record revealed an Anesthesia Note dated 1/20/17 revealing a 22 gauge intravenous catheter was inserted in his right hand and a [MEDICATION NAME] dressing was applied. Review of Resident #39's Nursing Assessment and Interventions Flow Sheet dated 1/25/17-2/8/17 revealed the resident's peripheral intravenous catheter was a 22 gauge catheter, located in his right thumb with a start date of 1/20/17, a [MEDICATION NAME] dressing was dry, clear and intact, no [DIAGNOSES REDACTED], edema or infiltration and the catheter was patent. Further review of Resident #39's intravenous dressing was dated 1/20/17. Review of Resident #39's Nurse's Notes dated 2/9/17 revealed impaired skin noted when the resident's intravenous catheter was removed. Review of Resident #39's Wound Assessment Report dated 2/9/17 revealed the resident's right thumb had a well-defined open, macerated, pale shiny area on his right thumb which was 0.7 x 0.7 x 0.2 centimeters. The wound was cleansed with normal saline and a non-adherent [MEDICATION NAME], coban dressing was applied by the facility's wound care nurse. In interview on 4/12/17 at 11:30am, S2/Minimum Data Set (MDS) Coordinator indicated she was not able to provide documentation Resident #39 received IV site care from 1/20/17 until day of discharge on 2/9/17 when the resident's intravenous catheter was discontinued and it was noted the resident had developed a stage 4 pressure ulcer under the area where the IV catheter was located on his right thumb. S2/MDS Coordinator further indicated the staff nurse's did not complete site care per the facility's policy and procedure which was due on 1/27/17 and possibly the stage 4 pressure ulcer could have been avoided if the resident would have received IV site care per their policy and procedure to prevent intravascular device related infections. In interview on 4/13/17 at 9:00am, S1/Nursing Director indicated Resident #39's intravenous site dressing was not changed according to the facility's Prevention of Intravascular Device Related Infections policy and procedure.

Based on record reviews and interviews the facility failed to ensure the resident was assessed and received the necessary treatment and services to prevent the development of a pressure ulcer, consistent with professional standards of practice. This deficient practice was identified for 1 (Resident #39) of 2 (Resident #39, Resident #87) Stage 2 sampled residents reviewed for pressure ulcers and had the potential to affect any of the 8 residents who were receiving intravenous therapy as documented on the Resident Census and Conditions of Residents form. Findings: Resident #39 was admitted to this facility on 1/25/17 with the following [DIAGNOSES REDACTED]. Resident #39 was discharged to a Nursing Home on 2/9/17, therefore no observations were done for this resident. Review of Resident #39's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/7/17 revealed the resident was cognitively intact with a BIMS score of 15. Further review of the resident's MDS revealed the resident required limited assistance with most of his ADLs', was 67 inches tall and weighed 204 pounds and received a therapeutic diet. Resident #39 was assessed for being at risk for pressure ulcers, had no pressure ulcers for this assessment, had moisture associated skin damage and had a pressure reducing device for his bed and wheelchair and was on a turning/repositioning program. Further review of Resident #39's Discharge MDS with an ARD of 2/9/17 revealed he was assessed as having a stage 4 pressure ulcer with dimensions of 0.7 x 0.7 x 0.2 centimeters. Review of Resident #39's Braden Risk assessment dated [DATE] revealed the resident scored 9 which was indicative of being at mild risk for developing pressure ulcers. Review of the facility's Prevention of Intravascular Device Related Infections Policy and Procedure with a last review date of 9/6/16 revealed the following information in part; after the intravenous catheter was inserted, secure the cannula with 1/2 inch tape using the chevron, double chevron, or crossover method. Apply semi-permeable transparent dressing and label with date, time and initials, document the condition of the IV site at a minimum of every shift, Replace dressing and complete site care every 7 days or if the dressing becomes damp, loosened, or visibly soiled, Replace peripheral intravenous catheters every 96 hours for adults, if venous sites are limited and there is no evidence of phlebitis or infection to site, peripheral intravenous lines can be left in place for longer periods, limited access and condition of the site should be charted. Review of Resident #39's record revealed an Anesthesia Note dated 1/20/17 revealing a 22 gauge intravenous catheter was inserted in his right hand and a [MEDICATION NAME] dressing was applied. Review of Resident #39's Nursing Assessment and Interventions Flow Sheet dated 1/25/17-2/8/17 revealed the resident's peripheral intravenous catheter was a 22 gauge catheter, located in his right thumb with a start date of 1/20/17, a [MEDICATION NAME] dressing was dry, clear and intact, no [DIAGNOSES REDACTED], [MEDICAL CONDITION] or infiltration and the catheter was patent. Further review of Resident #39's intravenous dressing was dated 1/20/17. Review of Resident #39's Nurse's Notes dated 2/9/17 revealed impaired skin noted when the resident's intravenous catheter was removed. Review of Resident #39's Wound Assessment Report dated 2/9/17 revealed the resident's right thumb had a well-defined open, macerated, pale shiny area on his right thumb which was 0.7 x 0.7 x 0.2 centimeters. The wound was cleansed with normal saline and a non-adherent [MEDICATION NAME], coban dressing was applied by the facility's wound care nurse. In interview on 4/12/17 at 11:30am, S2/Minimum Data Set (MDS) Coordinator indicated she was not able to provide documentation Resident #39 received IV site care from 1/20/17 until day of discharge on 2/9/17 when the resident's intravenous catheter was discontinued and it was noted the resident had developed a stage 4 pressure ulcer under the area where the IV catheter was located on his right thumb. S2/MDS Coordinator further indicated the staff nurse's did not complete site care per the facility's policy and procedure which was due on 1/27/17 and possibly the stage 4 pressure ulcer could have been avoided if the resident would have received IV site care per their policy and procedure to prevent intravascular device related infections. In interview on 4/13/17 at 9:00am, S1/Nursing Director indicated Resident #39's intravenous site dressing was not changed according to the facility's Prevention of Intravascular Device Related Infections policy and procedure.

Based on observation, interview, and record review the facility failed to ensure drugs used by the facility were stored according to professional standards by failing to ensure expired insulin (medication used to lower blood sugar) was not available for use and/or administered to residents. This deficient practice was identified for 2 (Resident #91 and Resident #92) of 3 (Resident #4, Resident #91, and Resident #93) residents identified as receiving Novolin R insulin (medication used to lower blood sugar) in a total Stage 2 sample of 18, but had the potential to affect any of the 6 residents who may receive an order for [REDACTED]. Findings: Review of the Facility's Pharmacy Policy and Procedures regarding Insulin Administration 7600-C dated 05/25/12, revealed in part, all insulin vials shall be replaced every 28 days according to stability factors. Review of Taylor's Clinical Nursing Skills Third Edition dated 05/16/15 revealed in part, Skill 5-4 Removing Medication from a vial, health workers should assess the medication in the vial, and to check the expiration date before administering the medication. Observation with S4/Pharmacist on 04/14/15 at 9:40am, of the Skilled Nurse Facility (SNF) Nurse Medication cart/omnicell, revealed a multidose vial of Novolin R insulin was being stored in the cart which had an expiration date of 03/28/15. Review of the facility's omnicell report for the SNF unit dated 03/28/15 to 04/14/15 revealed in part, that the Novolin R insulin that expired on 03/28/15 had been given to Resident #91 by S7/RN on 03/30/15 at 12:22pm and witnessed by S2/RN, to Resident #92 by S7/RN on 03/30/15 at 12:23pm and witnessed by S2/RN, and to Resident #91 by S1/Nursing Director on 04/02/15 at 12:36pm and witnessed by S2/RN. In interview on 04/14/2015 9:45am S4/Pharmacist indicated facility guidance to store insulin on omnicell carts was for no more than 28 days, and after 28 days, the insulin was to be discarded. S4/Pharmacist further indicated that insulin products were checked using the Expired Medications Report that prints daily, and insulin was to be discarded by the pharmacy technicians accordingly. In interview on 04/14/15 at 9:50am, S3/Pharmacy Director indicated an Expired Medications Report prints daily indicating which insulins need to be discarded. S3/Pharmacy Director further indicated unit inspections were done formally on a monthly basis also to remove expired, discontinued, contaminated or excess medications, and the above mentioned insulin may have been incorrectly entered into the system, and due to the possible incorrect entry, the Expired Medications Report may not have been generated. In interview on 04/14/15 at 11:00am, S4/Pharmacist indicated the Facility's Pharmacy policy and Procedures regarding Insulin Administration 7600-C and replacing insulin vials every 28 days after opening was based on the United States Pharmacopoeia Standard 797. In interview on 04/14/15 at 11:25am, S7/Registered Nurse (RN) indicated two nurses must sign off on all insulin administrations, and the omnicell alerts staff when a medication is expired. S7/RN further indicated she doesn't look at the insulin bottle to check the expiration date when giving insulin, because they (nursing staff) rely on the omnicell system to alert them if it is expired. Interview on 04/14/15 at 11:30am, S7/RN indicated, after reviewing the omnicell transaction reports regarding insulin injections dated 03/30/15 and 04/02/15, two nurses witnessed/verified the administration of the above mentioned expired insulin to Resident #91 and Resident #92. In interview on 04/14/15 at 1:45pm, S2/RN indicated prior to giving insulin to a resident, she would look to see if omnicell gave her an alert regarding expired insulin and then she would also look at the bottle of insulin itself to check the expiration date. Interview on 04/16/15 at 8:30am S1/Nursing Director indicated when giving insulin two nursing staff members must check off on the administration of insulin, and should look at the label of the insulin to check that the correct insulin was being given, look at the clarity/consistency of the insulin itself, and look at the expiration date. S1/Nursing Director further indicated nursing staff disregarded the expiration date (28 days from opening) that was applied to the insulin bottle by Pharmacy, and the facility would probably now add the specific 28 day expiration date stipulation to their nursing policy and procedures.

Based on observation and interview the facility failed to ensure food was served in a sanitary manner. The deficient practice was evidenced by 1) the presence of uncovered food items being transported to an area in the kitchen uncovered and left uncovered ten minutes later in another area of the kitchen and 2) uncovered food items on a food cart in the dairy cooler. This deficient practice had the potential to affect 6 residents as identified on the Census and Condition of Residents form that were served food from the kitchen. Findings: 1) Observation on 04/13/15 at 10:50am revealed S6/Hospitality Assistant transporting a cart of 8 uncovered individual cheese cakes on a small plate and 12 uncovered cups of fruit cocktails from the refrigerator to an area of the kitchen. Further observation revealed at 11:00am the same cart of 8 uncovered individual cheese cakes on a small plate and 12 uncovered cups of fruit cocktails were still uncovered in a different area of the kitchen. 2) Observation on 4/13/15 at 11:55am revealed revealed 3 cups of mixed fruit, 15 cups of green jellos and 10 cups of orange slices on a cart in the dairy cooler uncovered. In interview with S6/Hospitality Assistant on 04/13/15 at 11:00am she indicated she was going to cover it food items but never did it. In interview with S5/ Patient Service Manager on 04/13/15 at 11:00am she acknowledged the food items were not covered and should have been covered.

Based on interview and record review, the facility failed to inform a resident in writing of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility as evidenced by the facility failing to provide written Notice of Medicare Non-Coverage for 1 (Resident #4) of 3 (Resident #2, Resident #4, and Resident #12) residents reviewed for Liability Notices & Beneficiary Appeal Rights Review, in a total Stage 2 sample of 18. This deficient practice may affect any of the 6 residents in the facility, as documented on the Resident Census and Conditions of Residents (CMS-672 Form). Findings: Review of the electronic record revealed Resident #4 was admitted to the Skilled Nursing Facility (SNF) on 11/13/14 and discharged on [DATE]. Review of the Facility's Notice of Medicare Non-Coverage Form revealed Resident #4's SNF services would end on 11/24/14. Further review of the form revealed no signature of Resident #4, or Resident #4's Representative to indicate receipt of this notice. In interview on 04/16/15 at 10:00am, S1/Nursing Director indicated Resident #4's Notice of Medicare Non-Coverage form was not signed by Resident #4 or his/her Representative. S1/Nursing Director further indicated Resident #4's form just "slipped through." S1/Nursing Director further indicated the Notice of Medicare Non-Coverage form which notified Resident #4 of his/her Medicare coverage for SNF services ending on 11/24/14 should have been signed, and further, had no explanation as to why it was not done. S1/Nursing Director indicated Facility Policy regarding Notice of Medicare Non-Coverage was not followed. Review of the Facility's Policy regarding the Delivery of the Notice of Medicare Non-Coverage revealed, in part, beneficiaries receiving SNF services are provided with the Notice of Medicare Non-Coverage prior to 2 days before discharge. There was no documented evidence, and the facility did not provide any documented evidence that Resident #4 was provided with the required written Notice of Medicare Non-Coverage.

Based on observation and interview and record review the facility failed to distribute and serve food under sanitary conditions as evidenced by failing to use proper infection control practices while serving a lunch meal. This deficient practice was identified for 1 of 7 (Resident #91) Stage 2 sampled residents observed during dining observation. The total facility census was 8 as documented on the facility's Census and Conditions of Residents form. Findings: Observation on 03/20/14 at 12:05pm revealed S4/Hospitality Assistant serving lunch trays from a mobile food cart. During meal service, while attempting to remove the meal tray from the clean cart, S4/Hospitality Assistant spilled a cup of liquid which flowed onto the bottom of the cart, and then onto the floor. S4/Hospitality Assistant, without gloves on her hands, obtained a napkin and proceeded to wipe the bottom of the cart, then wiped the floor in front of the cart, and then, using the same napkin, wiped the bottom of the cart again, all without using gloves. S4/ Hospitality Assistant left the wet napkin at the bottom of the food cart, and without washing her hands or using hand sanitizer,or putting on gloves, removed the food items from the wet tray, and placed them on a dry tray and entered Resident #91's room and placed the tray on the bedside table for Resident #91. In interview on 03/20/14 at 12:06pm, S4/Hospitality Assistant acknowledged she spilled a liquid from a food tray, and wiped the food cart and the floor with a napkin, and touched Resident #91's food dishes without washing her hands or using hand sanitizer. She further acknowledged she should have washed her hands prior to touching the food dishes. In interview on 03/20/14 at 12:20pm, S1/Patient Services Manager and S2/Clinical Nutrition Manager indicated dietary staff has a 2 week training process upon hire that includes infection control education. Both indicated that training is ongoing, and in-services regarding infection control are held regularly. S2/Clinical Nutrition Manager indicated there is a "line up" prior to each meal service where different topics are discussed, including, in part, hand washing. Both acknowledged that S4/Hospitality Assistant has been employed with the facility for 9-[AGE] years, and has been trained in infection control practices, including hand washing. In interview on 03/21/14 at 11:25am, S2/Clinical Nutrition Manager revealed employees are monitored by a process called shadowing. In interview on 03/21/14 at 11:29am, S3/ Hospitality Assistant revealed she performs "employee shadowing" daily. This process included shadowing dietary personal to assure infection control processes are performed competently. S3/Hospitality Assistant indicated any breaks in infection control practices are reported to S1/Patient Service Manager, and employees are re-educated as necessary. Review of the Catering Associate Shadow Report dated 3/10/14 revealed S4/ Hospitality Assistant, received a score of 1, indicating consistent/satisfactory in "sanitizes hands before delivering the first tray and after serving each tray."

Based on observation, record review, and interview the facility failed to ensure services provided by the facility met professional standards of quality for 1 of 2 nurses observed during medication administration (S7) as evidenced by the nurse failing to check for a residual feeding amount before medication administration, flush a feeding tube before medication administration, and flush with the proper amount of fluid after medication administration. This failed practice had the potential to affect 1 resident who receives tube feedings (Resident #37) as documented on the facility's Resident Census and Conditions of Residents form. Findings: In interview on 4/12/13 at 10:20am S2/DON (Director of Nursing) indicated the nurses should check for residuals prior to medication administration. S2/DON further indicated the facility does not have a policy on medication administration via feeding tube, but the facility refers to the Taylor's Clinical Nursing Skills-A Nursing Process Approach-Third Edition as the facility's professional standard reference. In interview with S2/DON on 4/12/13 at 12:08pm she indicated the facility's process for feeding tube medication administration is as follows: check residual prior to medication administration, give the residual amount back to the resident via the feeing tube, administer medications with a syringe via feeding tube and flush with water after the medication is administered. Review of Taylor's Clinical Nursing Skills: A Nursing Process Approach Third Edition revealed Skill 5-2 Administering Medications via a [MEDICAL CONDITION] Tube procedure included in part: note the amount of any residual, pour 30 milliliters of water in the syringe and allow the water to enter the stomach via gravity infusion, administer medication, and follow with the last dose of medication with 30 milliliter to 60 milliliter of water flush. Observation on 4/10/13 at 10:25am revealed S7/RN (Registered Nurse) preparing to administer medications to Resident # 37 via his feeding tube. Observation further revealed S7/RN did not check for residual feeding amount or flush the feeding tube prior to administering medications. S7/RN then proceeded to insert the syringe into the feeding tube and administer the medication and water solution (45 milliliter). Further observation revealed after S7/RN administered the medication, she (S7) administered a [MEDICATION NAME] of 20 milliliters of water and recapped the feeding tube. Review of Physician order [REDACTED].

Based on observation and interview the facility failed to store and prepare food under sanitary conditions by failing to: a) ensure that food was covered until served; b) ensure dates and labels were on leftover food; c) ensure that food and plastic wrap used for food were properly stored off the floor; d) ensure the dishwashing machine table was clean; e) ensure the floor/food shelves was clean in the dry storage room; f) ensure that frozen food was stored sealed to prevent freezer burn; g) ensure that the walk-in freezer floor was dry without ice buildup; h) ensure trash cans were covered and not placed to close to the food preparation station. This failed practice had the potential to lead to food safety hazards which could affect all residents who eat in the kitchen with the total facility census being 4 as documented on the facility's Resident Census and Conditions of Residents. Findings: During tour of the kitchen on 04/11/2011 at 9:50am with S1, Director of Dietary, and on 04/12/2011 at 11:10am with the S2, Patient Services, the following observations were made: 1. On 04/11/2011 at 9:50am observation revealed an uncovered and unattended bread cart located in a very busy traffic area of the kitchen. This cart had the following uncovered food items stacked on it: 2 half pans of dessert, 5 large pans of dinner rolls (24 rolls in a pan), 3 large pans of muffins (24 muffins in a pan), 1 pan of dinner rolls (unknown quantity), and 40 glasses of drinks. In interview on 04/11/11 at 9:50am with S1, Director, she indicated that these rolls were going /out to the cafeteria and patients' rooms around 10:30am. Observation at 10:45am on 04/11/11 revealed that the bread cart was still not covered. Observation on 04/12/2011 at 11:10am during a 2nd tour of the kitchen revealed the bread cart was located in the same place with uncovered dinner rolls. Observation on 04/12/11 at 11:10am revealed many staff members passing by the bread cart. Observation on 04/12/11 at 11:10am revealed one staff member was carrying dirty mops along with a gallon of Clorox and the staff member passed next to the bread cart. 2. On 04/11/2011 at 9:50am revealed the walk-in refrigerator had leftover roast beef loosely wrapped in plastic wrap, packs of sliced ham loosely wrapped in plastic wrap, 3 containers of opened beef & chicken stocks and a 2 pound pack (indicated on the outside of the packaging) of diced ham in an undated and unlabeled plastic bag on the shelf. 3. On 04/11/2011 at 9:50am revealed the door on the produce cooler read "remember to cover, label, and date." Observation on 04/11/11 at 9:50am revealed a gallon jar of ranch dressing, a gallon jar of a sweet pickle relish, a gallon jar of mustard, a gallon jar of mayonnaise, a gallon jar of thousand island dressing, a gallon jar of dill pickles and a gallon jar of whole cherries were all opened/used and were all undated/unlabeled. 4. On 04/11/2011 at 9:50am revealed the walk-in freezer had a case of frozen shrimp, a case of frozen mustard greens, and 6 cases of chicken breasts stacked on the floor. Further observation on 04/11/11 at 9:50am revealed a thick ice build up on the floor of the walk-in-freezer in different areas. In interview on 04/11/11 at 9:50am with S1, Director of Dietary, she indicated that over the weekend the freezer defrosted and that the staff were working to clean the walk in freezer. On 04/12/2011 at 11:10am revealed the walk-in freezer had the following: 3 cases of chicken breasts, 1 case of chicken tender fritters, 1 case of chicken wings, and 1 case of tortellini which were in open plastic bags inside open boxes exposed to the air. A bag of croissants was undated/unlabeled on the shelf and staff members were in and out of the freezer. Further observation on 04/12/11 at 11:10am revealed substantial ice build up on the floor which was also observed on 04/11/11 at 9:50am. In interview on 04/12/11 at 11:10am with S2, Patient Services, she indicated that she was not sure why there was ice on the floor and she also indicated that the food should not be left open to air. Observation on 04/12/2011 at 12:00 noon of the food line steam table revealed an industrial-sized box of Saran wrap lying on the floor. 5. Observation on 04/11/2011 at 9:50am and observation on 04/12/2011 at 11:10am of the dishwashing machine room revealed a thick whitish/brown substance build up on top of the dishwashing table. 6. Observation on 04/11/2011 at 10:20am of the dry food storage room revealed food crumbs on the floor and under the shelves. Further observation on 04/11/11 at 10:20am revealed a rusty/brown sticky substance and food crumbs on all 5 food shelves. Observation on 04/11/11 at 10:20am revealed there was a 32 oz jar of chili sauce which was 2/3 full which had no date or label on the jar. On 04/12/2011 at 11:10am of the dry food storage room revealed a torn bag of chocolate chips within another bigger box and all the chocolate chips were spilled out in the bigger box and that box was open to air. 7. Observation on 04/11/2011 at 9:50am and 04/12/2011 at 11:10am of the kitchen revealed 6 trash cans in the kitchen uncovered and were placed to close to the food preparation station. In interview on 04/12/2011 at 12:10pm with S1, Director of Dietary, and S2, Patient Services, they indicated that they acknowledged the above findings.