**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to properly ensure medications were stored in accordance with pharmaceutical standards when one of 30 Ipratropium bromide and albuterol sulfate medication (a combination medication used to treat difficult breathing associated with respiratory diseases) vials was out of the manufacturer provided foil packaging. This failure had the potential to cause the medication to lose effectiveness as a result of not being stored in its intended packaging. Findings: During a review of Resident 53's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 6/16/25, the AR indicated, Resident 53 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD-a long term lung disease that makes it hard to breath). During a review of Resident 53's Order Summary Report, dated 6/16/25, indicated, .[generic name] Solution . vial inhale orally via nebulizer (medical device used to deliver inhaled medication) every 8 hours for COPD . During a concurrent observation and interview on 06/12/25 at 09:31 a.m. with Licensed Vocational Nurse (LVN) 1, the med storage cart had one Ipratropium bromide and albuterol sulfate medication vial outside of the manufacturer's foil packaging. LVN 1 stated the medication should have been stored inside the manufacturer packaging. LVN 1 stated medication stored outside of the foil packaging had a shorter duration than those stored in the foil packaging. LVN 1 stated Resident 53 had COPD and having a less effective vial delivered to her could have caused her to not feel relief from the medication. During an interview on 6/16/25 at 11:07 a.m. with the Director of Nursing (DON), the DON stated she expected staff to inspect the medication cart daily to ensure all medications were properly stored. The DON stated having the medication outside of the manufacturer foil packaging will shorten the shelf life of the medication and decrease its potency, Resident 53 needed breathing treatments so her medications should be able to provide the full therapeutic effect. During a review of the Ipratropium Bromide and Albuterol Sulfate Inhalation Solution, manufacturer guidelines, dated 2/22, indicated, [Ipratropium Bromide and Albuterol Sulfate inhalation solution] Vials should be protected from light before use, therefore, keep unused vials in the foil pouch or carton . During a review of the facility's policy and procedure tiled, Pharmaceutical Service-Labeling and Storage of Drugs, dated 5/17/24, indicated, . It is the policy of this facility that all drugs and biologicals are stored in a safe, secure an orderly manner . (m) The drugs of each patient shall be kept and stored in the originally received containers .

2. During an observation on 6/10/25 at 11:55 a.m. in the kitchen, Resident 53's meal tray did not include the chocolate ice cream dessert. During a concurrent observation and interview on 6/10/25 at 12:03 p.m. with Resident 53 and IP 1, Resident 53 was not served a chocolate ice cream cup as listed on her meal ticket. IP 1 stated Resident 53 should have been served ice cream because it was listed on her meal ticket, and it was her preference. Resident 53 stated she wanted to eat her ice cream over the rest of her food. During an interview on 6/12/25 at 8:56 a.m. with the CDM, the CDM stated Resident 53 should have received her listed preference of chocolate ice cream. The CDM stated resident meal tickets were person centered, and residents had the right to receive the food they wanted. During an interview on 6/16/25 at 11:07 a.m. with the DON, the DON stated staff should have followed Resident 53's meal preference in order for her to fulfill her nutritional needs. The DON stated she expected the nursing staff to thoroughly check the meals before serving them to residents to ensure they were accurate and met their preferences. During a review of the Job Description Dietary Aide dated 9/1/16, the Job Description Dietary Aide indicated, .Essential job functions . Serve food for meal delivery: Read tray card. Check carefully for allergies, food likes/dislikes, specific instructions .Recheck items on tray with tray card to ensure resident receives correct diet . During a review of the facilities policy and procedure titled, Food preferences, dated 2020, indicated . 5. Resident food preferences are kept on file in the Dining Services Department as a part of the meal card system and used to ensure each resident's needs and desires are met . Based on observation, interview, and record review, the facility failed to follow resident meal preferences for two of eight residents (Resident 53 and Resident 101) when: 1. Resident 101 received dessert when the resident's meal ticket (document which details resident diets, allergies, and food preferences) indicated do not serve sweets and dessert. This failure had the potential to result in a negative nutritional impact for Resident 101. 2. Resident 53 did not receive her preferred meal item of chocolate ice cream as listed on her meal ticket. This failure violated Resident 53's right to have her preferred food item and placed Resident 53 at risk for not receiving the full nutritional benefit of her meal Findings: 1. During an observation on 6/10/25 at 12:07 p.m., at the nurses' station, Resident 101 ' s lunch tray inside the meal cart with an attached meal ticket had a plate of white cake with frosting. During an observation on 6/10/25 at 12:09 a.m., Minimum Data Set Coordinator (MDSC) served the lunch tray to Resident 101. During a concurrent interview and record review on 6/10/25 at 12:10 p.m. with the MDSC in Resident 101 ' s room, Resident 101 ' s meal ticket (undated) was reviewed. Resident 101 ' s meal ticket indicated, .Do Not Serve Sweets/Dessert . MDSC stated Resident 101's lunch tray had a dessert. MDSC stated Resident 101 should not be served sweets and desserts. During a review of Resident 101 ' s admission Record (AR) dated 6/12/25, the AR indicated Resident 101 was admitted into the facility on 2/11/25. During a review of Resident 101 ' s Minimum Data Set (MDS - a resident assessment tool), dated 5/14/25, the MDS indicated Resident 101 ' s Brief Interview for Mental Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 8 out of 15 (0-7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, 13-15 cognitively intact) which indicated Resident 101 had a moderate cognitive impairment. During a review of Resident 101 ' s Diet Type Report dated 6/12/25, the Diet Type Report indicated Resident 101 was on a regular mechanical soft diet with regular, thin liquid fluids. During a review of Week 1 Cycle 2 2025 Spring menu (undated), Week 1 Cycle 2 2025 Spring menu indicated on Tuesday, 6/10/25, the noon meal included, .braised pork roast/mushrooms, duchess potatoes, seas greens, roll/[margarine], white cake/frosting, beverage . During an interview on 6/12/25 at 8:56 a.m. with the Certified Dietary Manager (CDM), the CDM stated Resident 101 should not have received dessert for lunch on 6/10/25. The CDM stated Resident 101 meal ticket should have been followed to ensure person- centered care and residents receive the food they prefer. During an interview on 6/16/25 at 11:13 a.m. with the Director of Nursing (DON), the DON stated food preferences for residents should be followed. The DON stated it was important to follow Resident 101's food preferences to help residents eat and meet their nutritional needs. During a review of the Job Description Dietary Aide dated 9/1/16, the Job Description Dietary Aide indicated, .Essential job functions . Serve food for meal delivery: Read tray card. Check carefully for allergies, food likes/dislikes, specific instructions .Recheck items on tray with tray card to insure resident receives correct diet . During a review of the facilities policy and procedure titled, Food preferences, dated 2020, indicated . 5. Resident food preferences are kept on file in the Dining Services Department as a part of the meal card system and used to ensure each resident's needs and desires are met .

Based on observation, interview, and record review, the facility failed to have a sanitary environment in the kitchen when: 1. Discoloration was observed in the ice machine in the kitchen. This failure had the potential risk of exposing residents in the facility to contaminate the ice which could result in foodborne illness (is a sickness caused by eating or drinking food or water that has germs) 2. Floors in the dry food storage room in the kitchen had food crumbs. This failure had the potential risk for pest infestation and led to contamination of food and food preparation areas which could result in compromise resident safety and health. Findings: 1. During a concurrent observation and interview on 6/10/25 at 9:42 a.m. at the ice machine in the kitchen with registered dietician (RD), the underside of the ice machine back panel had pink and blue discoloration. No ice was observed in the ice machine. The discoloration in the ice machine was confirmed by the RD. During an interview on 6/12/25 at 8:48 a.m. with Certified Dietary Manager (CDM), the CDM stated it was important for the ice machine not to have discoloration or dirty because of potential ice contamination. During a concurrent observation and interview on 6/12/25 at 9:45 a.m. with maintenance director (MD) at the ice machine in the kitchen, showed the MD the ice machine area that was observed to have pink and blue discoloration on 6/10/25. The MD stated it was important to ensure the ice machine was clean to prevent ice contamination with bacteria. During an interview on 6/16/25 at 11:13 a.m. with the Director of Nursing (DON), the DON stated the ice machine should not have discoloration to ensure proper ice sanitation. The DON stated a dirty ice machine would compromise ice sanitation. During a review of Food & Nutrition: Ice Machine-Cleaning & Sanitizing Log dated 2025, the Food & Nutrition: Ice Machine-Cleaning & Sanitizing Log indicated the ice machine in the kitchen was deep cleaned in April 2025, cleaned in May 2025 and cleaned in June 2025. The Food & Nutrition: Ice Machine-Cleaning & Sanitizing Log indicated all cleanings were conducted by MD. During a review of ice machine ' s manufacturer guideline titled Use and Care Guide (undated), the Use and Care Guide indicated, Interior cleaning . Clean and sanitize the ice machine every six months for efficient operation. If the ice machine requires more frequent cleaning and sanitizing, consult a qualified service company to test the water quality and recommend appropriate water treatment . The Use and Care Guide indicated, . Sanitize the interior of the ice machine and bin with a solution of one ounce of sanitizer to up to four gallons of water. Rinse all sanitized surfaces with clean water . 2. During a concurrent observation and interview on 6/10/25 at 9:46 a.m. with the RD in the kitchen dry food storage room, food remnants and spoons were under the storage racks. The RD confirmed food remnants and spoons underneath the storage racks. During an interview on 6/12/25 at 8:56 a.m. with the CDM, the CDM stated he sweeps the floor in the dry food storage room once a week. The CDM stated the food crumbs on the floor attracts pest and should not be there. During an interview on 6/12/25 at 2:55 p.m. with the CDM, the CDM stated there were no cleaning logs of when the dry food storage room had been swept. During an interview on 6/16/25 at 9:24 a.m. with the Cook, the [NAME] stated the food crumbs on the dry storage floor in the kitchen should have been clean. The [NAME] stated the food crumbs could attract pest and lead to pest problems. During an interview on 6/16/25 at 11:10 a.m. with the DON, the DON stated the kitchen should be kept clean. The DON stated when food remnants remained on the floor this could attract pest and lead to sanitation issues. During a review of the facility ' s policy and procedure (P&P) titled, Section F: Safety and Sanitation (undated), the P&P indicated, .Floors are to be kept clean, dry, uncluttered and free of broken tiles or defective boards . During a review of Job Description for the Culinary Director dated 11/16, the Job Description indicated, .Essential Duties . Maintain and ensure that all kitchen, dining, and storage areas as well as utensils, equipment, menus, tables, chairs and floors and uniforms are kept sanitary and clean. Ensure all local, state, and federal food handling, storage, and sanitation requirements are met or exceeded . During a review of the job description for the Registered Dietician dated 11/16, the job description indicated, Essential Duties .Maintain and ensure that all kitchen, dining, and storage areas as well as utensils, equipment, menus, tables, chairs and floors and uniforms are kept sanitary and clean .

Based on observation, interview and record review the facility failed to ensure the facility was maintained in a clean and sanitary condition for eight of eight sampled residents when the laundry room floor had an accumulation of a brown sludge-like residue approximately six inches wide and 30 inches long. This failure had the potential risk of cross contamination (the harmful transfer of germs from one surface object or substance to another) from contaminated laundry which could lead to spread of infection and compromise resident health and safety. Findings: During a concurrent observation and interview on 6/16/25 at 8:59 a.m. with Laundry Worker (LW) 1, the floor to the right of the washing machine was covered in brown sludge. LW 1 stated it appeared water had accumulated on the floor overtime. LW 1 stated the floor had not been cleaned regularly and resulted in the buildup of the brown sludge. LW 1 stated the sludge buildup made it difficult to fully clean and sanitize the floor. During a concurrent observation and interview on 6/16/25 at 9:11 a.m. with The Maintenance Supervisor (MS), the MS confirmed the brown sludge on the floor next to the laundry machine. The MS stated the floor should not have been in that condition and staff should have reported it. The MS stated the buildup would make it difficult to thoroughly clean the floor. The MS stated the buildup could have been caused by a leak from the washer, which could impact how clean the laundry and the clothes are. During an interview on 6/16/25 at 11:07 a.m. with The Director of Nursing (DON) the DON stated the laundry room should have been kept clean, and the clean floors make it easier to disinfect the whole laundry room properly. During a concurrent interview on 6/16/25 at 11:37 a.m. with Infection Preventionist (IP) 1, IP 1 stated laundry staff should have reported the brown sludge. IP 1 stated the dirty laundry room floor was an infection control concern because it could make the entire area unsanitary and could cross contaminate clothing that was washed in the washing machine. During a review of the facility's Policy and procedure titled, Laundry Room Management, undated, . Facilities must maintain a clean and sanitary environment, including laundry areas . Floors, surfaces, and equipment must be cleaned daily to maintain a sanitary environment .

Based on observation, interview, and record review, the facility failed to maintain essential equipment in safe operating condition for eight of eight residents, when the facility walk-in freezer had ice builds in several areas. This failure had the potential risk to result in unsafe food storage temperatures and foodborne illnesses (getting sick from eating contaminated foods) affecting all residents receiving meals from the facility. Findings: During a concurrent observation and interview on 6/10/25 at 9:38 a.m. with registered dietician (RD) in the kitchen walk-in freezer, ice build was seen in several areas. These included the top left of the door frame, an electrical box above the door, a shelving rack near the door, a laminated paper Refrigerator and Freezer storage chart attached to the top shelf of storage rack and a thermometer hanging on storage rack. The RD confirmed the ice buildup in the walk-in freezer and stated it would be addressed. During an interview on 6/12/25 at 8:46 a.m. with Certified Dietary Manager (CDM), CDM stated it was important to prevent ice buildup in the walk-in freezer because frozen water cold trap dirt and bacteria. During an interview on 6/12/25 at 2:12 p.m. with CDM, CDM stated he noticed the ice buildup in the kitchen's walk-in freezer back in February of 2025. The CDM stated there were no maintenance logs for the freezer, but there were emails that contained receipts from the third-party vendor who did the work. The CDM stated on 3/5/25, the third-party vendor serviced the walk-in freezer by replacing a valve cord (a pressure relief vent that helps in refrigerant flow and pressure regulation) and added refrigerant (a liquid or gas substance used in refrigeration and air conditioning systems to transfer heat). The CDM stated prior to this service, no logs had been kept of what facility staff had done to troubleshoot the ice buildup in the freezer. The CDM stated third-party vendor sent an invoice on 3/25/25 for replacing the compressor (part that is responsible for circulating refrigerant and maintaining the desired low temperature). The CDM stated the compressor was replaced on 3/29/25 by the third-party vendor. The CDM stated the third-party vendor returned on 4/18/25 and conducted a diagnostic of the freezer to determine how the new compressor was performing. The CDM stated third-party vendor stated the compressor continued to overheat because additional parts in the freezer needed to be replaced. The CDM stated there was no documentation of this diagnostic and the recommendations, only verbal conversation between the third-party vendor and himself. The CDM stated under the Administrator (ADM) direction, a second vendor was contacted and came to the facility on 5/9/25 to give a second opinion on the walk-in freezer. The CDM stated no work had been done on the freezer between 4/18/25 to 5/9/25. The CDM stated during this time frame the walk-in ice freezer had continued ice buildup. During an interview on 6/12/25 at 2:48 p.m. with the CDM, the CDM stated on 5/20/25 a third party vendor gave a bid for the repairs needed for the walk-in freezer. The CDM stated the parts to fix the freezer were not ordered until 6/10/25, after the state surveyor inspected the freezer. During an interview on 6/12/25 at 3:21 p.m. with the ADM, the ADM stated parts needed for the walk-in freezer were not ordered right away expensive projects like this needs to be done by the right vendor and with an accurate diagnosis of the problem. The ADM stated there was discussion about fixing the freezer between 5/20/25 and 6/10/25, but there was no documentation to show those conversation took place. During an interview on 5/12/25 at 3:43 p.m. with the Maintenance Director (MD), the MD stated he saw ice buildup in the walk-in freezer and replaced the door gasket (seal) and door latch on both the walk-in refrigerator and freezer. The MD stated he could not remember when the work was done and there was no documentation to show it. During a concurrent interview and record review on 6/12/25 at 4:16 p.m. with RD, Dietary Sanitation/Infection Control Audit dated 2/25/25 was reviewed. The Dietary Sanitation/Infection Control Audit indicated the freezer being free of ice and frost buildup was marked by the RD as not met. The RD confirmed the freezer had ice buildup at the time of the audit. The RD stated monthly audits of the kitchen, including the walk-in freezer, are completed and shared with the ADM and CDM. During a concurrent interview and record review on 6/12/25 at 4:20 p.m. with RD, email titled, Kitchen Inspection - March 27 dated 4/1/25, was reviewed. The email indicated, .Keep me posted on the freezer situation as well . RD confirmed this was about the ice buildup seen in the previous audit done on 2/25/25. During a concurrent interview and record review on 6/12/25 at 4:22 p.m. with RD, Dietary Sanitation/Infection Control Audit dated 4/24/25 and email titled Kitchen Inspection Report - April 24 dated 4/30/25, was reviewed. The Dietary Sanitation/Infection Control Audit indicated the freezer being free of ice and frost buildup was marked by the RD as not met. The email titled Kitchen Inspection Report - April 24 indicated, .Please resolve ice buildup in freezer . RD confirmed the freezer had ice buildup at the time of the audit. During a concurrent interview and record review on 6/12/25 at 4:50 p.m. with Infection Preventionist (IP) 1, the Infection Prevention Kitchen/Dietary Survey Tool dated 5/5/25 was reviewed. The Infection Prevention Kitchen/Dietary Survey Tool indicated compliance with food maintained at proper temperatures. IP 1 stated this was the first kitchen audit she completed, and the only thing she checked in the freezer was the temperature log. IP 1 stated she did not take a closer look inside the freezer during the audit. During an interview on 6/16/25 at 11:13 a.m. with the Director of Nursing, the DON stated there should not be ice buildup in the walk-in freezer. The DON stated ice buildup could have meant the temperature inside the walk-in freezer was not staying consistent and could have caused food freezer burn, which might have affected the taste of food. During an interview on 6/16/25 at 11:29 with the ADM, the ADM stated it was known the ice buildup in the freezer could cause future problems to residents. During a review of Job Description for the Culinary Director dated 11/2016, the Job Description indicated, .Essential Duties . Ensure all local, state, and federal food handling, storage, and sanitation requirements are met or exceeded. Create and maintain an organizational system for all required documentation to include but not limited to menus, employee documents, special diets, purchase orders, policies and procedures, and job descriptions . During a review of the job description for the Registered Dietician, dated 11/2016, the job description indicated, .Create and maintain an organizational system for all required documentation to include but not limited to menus, employee documents, special diets, purchase orders, policies and procedures, and job descriptions .