**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow the manufacturer's recommendations by ensuring the sling for a mechanical lift was secure, prior to transfer, for 1 of 3 residents (R2) reviewed for incidents/accidents, in the sample of 5. Findings include: R2's Care Plan dated 4/20/23 documents R2 is transferred via a mechanical lift with the assistance of two staff. It further documents R2 is at risk for falls and the goal is for R2 to be free of falls. R2's Minimum Data Set, MDS, dated [DATE] documents R2 is moderately cognitively impaired and requires extensive assistance from two staff members for transfers. On 11/30/2023 at approximately 11:45 AM, V10, Certified Nursing Assistant (CNA) stated, (V7, CNA) and I were transferring (R2) to bed after lunch. I was on (R2's) left side and (V7) was on the right side. We hooked the top and bottom two straps. I swore I pulled down on the sling to make sure it locked into place. I went to raise the machine and (V7) pulled the chair out (from under R2). It happened out of nowhere (R2 falling). (V7) went to the floor to catch (R2's) head and I caught her back/hip area. We lowered her to the floor. The plastic piece from the sling was off. We've had problems with these machines before with other residents. She did have a small little bump on the back side of her head. The front of her leg was bad. It had 3 or 4 shears. (R2's) leg was hanging in the sling. (R2) has paper thin skin. On 11/30/2023 at 1:11 PM, V11, Registered Nurse/Physical Therapy Assistant stated, I have been going around observing the staff using the lift. They are supposed to ensure the sling is hooked in all the way and raise the resident above the surface and then move the chair. I am thinking one of the straps wasn't correctly hooked and became un-hooked during the transfer. On 11/30/2023 at 1:32 PM, V12, R2's daughter, stated R2 fell from the lift during a transfer and added, It could have been really bad if (V7) hadn't caught her (R2's) head. She fell from 4 or 5 feet in the air. On 12/4/2023 at 10:23 AM, V3, Registered Nurse (RN) stated, When I entered the room, (R2) was on the floor and the top left side of the sling was unlatched and hanging down. It was fine when they started to lift her up and pulled the wheelchair out from under her. She fell from a pretty high height, so we sent her to the ER (Emergency Room) for x-rays. On 12/4/2023 at 10:45 AM, V7, CNA stated, (V10) was on the left and I was on R2's right side. We hooked her up and as she was going up, I pulled the wheelchair out. Next thing you know, I saw her going down. It was the top left part of the sling. It happened so fast. It was just loose and not hooked all the way. Normally we double check by pushing down on them. It wasn't all the way fastened. It was a complete accident. I did see blood on her legs. Her skin is so thin. R2's Progress Notes dated 11/24/2023 at 4:06 PM documents, This nurse was notified by other nurse that pt (Patient) fell out (mechanical) lift. This nurse went to room and noted pt laying on floor supine (on her backside) head was on pillow and pt was laying on back . Nurse assess pt- neuro (neurological) checks - WNL (within normal limits). VS (Vital Signs)- 98/58, P- 98, R- 20, spo2 97% 97.0F. R2's Progress Notes further documents R2 sustained multiple skin tears to her left thigh and lower legs and was sent to the local emergency room for evaluation. The Facility's Untitled document dated 11/24/2023 documents the mechanical lift hook came undone or was not latched all the way. The Facility's Untitled Document dated 11/24/2023 documents, I immediately went to her (R2's) room where she was laying on the floor with a pillow under her head. (Mechanical lift) was above and only 3 hooks were attached. This document was signed by V6, Licensed Practical Nurse (LPN). The Facility's Untitled Document dated 11/24/2023 documents, (V6) came and told me the (R2) fell out of the (mechanical lift). I went to check on her to find out why this happened. (R2) was laying on the floor on her back. She had skin tears to her legs and (V4) was taking pictures of all the wound obtained from the sling when her feet slid out going down. The (mechanical lift) was still in the air above bed level. The left top latch to the sling was hanging down. The latch was no defective or broken. It was strong and intact. (V10) and (V7) said that the top latch came off and (V7) went to the ground to try and protect her head while (V10) caught her mid-section and lowered her to the floor. This document was signed by V3, Registered Nurse (RN). The Facility's Untitled Document dated 11/24/2023 documents, Around 1 PM after lunch, (V10) and I took (R2) back to her room to lay her down. (V10) was on the left side of her and I was on the right. (V10) lowered the (lift) down close enough to hook the pad to (the lift). We then hooked the top first then lowered more to fasten in between the legs. (V10) then lifted the (lift) enough to where she pulled the (pad) out and I pulled back the wheelchair. As (R2) was being lifted and chair was being moved, she stared sliding out from the left side (top). It further documents V4 and V6 provided wound care. It continues to document, I believe the hook on the left side was not all the way fastened causing (R2) to slide out of the lift pad. I am always very careful to check to make sure all hooks are tightly fastened. This document was signed by V7, CNA. The Facility's Untitled Document dated 11/24/2023 documents R2 was observed on the floor underneath the mechanical lift laying on her back and slightly to the left. It further documents V7 and V10 stated the lift hook slipped off. It continues to document, I questioned if it was double checked and both CNAs stated they thought they did. This nurse re-educated CNAs on importance of both staff to check all equipment prior to using. This document was signed by V4, LPN. The Facility's Untitled Document dated 11/24/2023 documents, I was getting the machine up in the air so the (V7) could move the wheelchair out from the (lift). As I was raising the sling a bit more and was ready to move the (lift), I just so happened to see the left should of the sling drop to the floor. This document was signed by V10, CNA. The Facility's Performance Skill-Transfer Using a Mechanical Lift document, undated, documents staff should ensure they are using the appropriate lift for the resident, applying the correct sling, attaching the sling to the lift and to check to ensure all 4 hooks are completely latched. It continues to document, Staff must verbally confirm that each hook is latched properly before beginning the transfer. The two staff pull down on the sling for a triple check that the hooks are completely slipped into position before raising the (full body mechanical lift). On 12/4/2023 at 2:16 PM, V2, Director of Nurses (DON) stated the incident was user error and she would expect staff to follow the manufacturer's instructions for the mechanical lift. On 12/4/2023 at 2:34 PM, V1, Administrator stated the piece to the sling wasn't completely in place and that V3 checked to ensure the sling wasn't torn and the plastic was in good condition. The Facility's Hoyer Lift Sling Safety undated, documents, Two staff must check all four hooks to make sure they are completely latched. Two staff must make sure the hooks are in the correct position (must be touching and in the top curve pictured below). Two staff must verbally confirm that each hook is latched properly before beginning transfer. Two staff are to pull down on sling for a triple check that the hooks are completely slipped into position before raising lift. Two staff then raise resident using the lift above the surface transferring from before moving away from the surface. Do not pull the wheelchair away before raising the lift. The Manufacturer's Information for the mechanical lift documents, (Mechanical lift) must always be handled by a trained care giver and in accordance with the instructions outlined in this manual. Failure to understand and follow these instructions may result in injury to yourself and others. It continues to document, Caution: Always check that all the sling attachment clips are fully in position before and during the lifting cycle and in tension as the patient's weight is gradually taken up.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to report an injury of unknown origin in 1 of 1 resident (R4) reviewed for abuse in the sample of 23. Findings include: R4's Face Sheet documents, R4 was admitted to the facility on [DATE] and has diagnoses including chronic kidney disease stage 3; schizoaffective disorder, bipolar type; bipolar disorder; type 2 diabetes mellitus without complications; anxiety disorder; and pain, unspecified. R4's Minimum Data Set, (MDS), dated [DATE] documented, R4 was cognitively intact, required extensive two or more-person physical assistance with bed mobility and transfer, and had no documented skin conditions. R4's Care Plan, undated, does not address risk of abuse. The Facility's Unusual Occurrence Reports/Quality Assurance Review Log for the month of July 2023 documents R4 had a bruise to her left forearm on 07/12/23 that could have happened during transfer. The Date IDPH (Illinois Department of Public Health) Notified column documented, N/A. The Facility's Unknown Injury Report dated 07/12/23 documents, Nursing Description: Resident has a dark purple bruise measuring 2.5 x 3 on her left forearm as well as two small dark purple bruises under her watch. Resident Description: Resident states, she has no idea what happened to cause the bruises. MD, (Medical Doctor), POA, (Power of Attorney) and Admin, (Administrator), Nurses informed. There are no documented witness statements. The Notes added on 07/21/23 document, Could have been during transfer. R4's Progress Note dated 07/12/23 at 11:31 AM documents, Note Text: Resident called this nurse to her room and showed me a bruise to her left forearm. Bruise is located on her left forearm and is 2,4 x3 cm, (centimeters), color is dark purple. Resident states it is not painful but itches. R4's Progress Note dated 07/12/23 at 2:03 PM documents, Bruise remains dark purple in color. No pain reported with bruise. Resident states it kind of itches. On 08/10/23 at 9:47 AM, R4 stated, she thinks the bruising on her forearm last month was probably just from scratching. On 08/10/23 at 10:35 AM, V13, Certified Nurse Assistant, (CNA), stated, she remembers the bruising on R4's forearm. She said R4 didn't remember what happened but said she had been bruising a lot easier. V13 stated she and R4 both reported it to V16, Licensed Practical Nurse, (LPN). On 08/10/23 at 10:00 AM, V2, Director of Nursing, (DON), stated V16, LPN, was on leave from the Facility due to illness. On 07/12/23 at 1:55 PM, V6, MDS Coordinator, stated there were no witnesses to explain what happened to R4's forearm. On 08/09/23 at 2:30 PM, V2, DON, stated the bruise of unknown origin to R4's forearm was not reported to IDPH. On 08/10/23 at 3:43 PM, V1, Administrator, stated she always reports injuries of unknown origin, but she did not report R4's bruise. The Facility's Abuse Investigation and Reporting Policy revised July 2017 documents, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor) or Record; d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: two (2) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury; or twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to investigate an injury of unknown origin in 1 of 1 resident (R4) reviewed for abuse in the sample of 23. Findings include: R4's Face Sheet documents R4 was admitted to the facility on [DATE] and has diagnoses including chronic kidney disease stage 3; schizoaffective disorder, bipolar type; bipolar disorder; type 2 diabetes mellitus without complications; anxiety disorder; and pain, unspecified. R4's Minimum Data Set, (MDS) dated [DATE] documented R4 was cognitively intact, required extensive two or more-person physical assistance with bed mobility and transfer, and had no documented skin conditions. R4's Care Plan, undated, does not address risk of abuse. The Facility's Unusual Occurrence Reports/Quality Assurance Review Log for the month of July 2023 documents R4 had a bruise to her left forearm on 07/12/23 that could have happened during transfer. The Date IDPH (Illinois Department of Public Health) Notified column documented N/A. The Facility's Unknown Injury Report dated 07/12/23 documents, Nursing Description: Resident has a dark purple bruise measuring 2.5 x 3 on her left forearm as well as two small dark purple bruises under her watch. Resident Description: Resident states she has no idea what happened to cause the bruises. MD (Medical Doctor), POA (Power of Attorney) and Admin (Administrator) Nurses informed. There are no documented witness statements. The Notes added on 07/21/23 document, Could have been during transfer. R4's Progress Note dated 07/12/23 at 11:31 AM documents, Note Text: Resident called this nurse to her room and showed me a bruise to her left forearm. Bruise is located on her left forearm and is 2,4 x3 cm, (centimeters), color is dark purple. Resident states it is not painful but itches. R4's Progress Note dated 07/12/23 at 2:03 PM documents, Bruise remains dark purple in color. No pain reported with bruise. Resident states it kind of itches. On 08/10/23 at 9:47 AM, R4 stated she thinks the bruising on her forearm was probably just from scratching. On 08/10/23 at 10:35 AM, V13, Certified Nurse Assistant, (CNA), stated she remembers the bruising on R4's forearm. She said R4 didn't remember what happened, but R4's watch was tight on her risk near the location of the bruise. V13 stated she told V16, Licensed Practical Nurse, (LPN) and stated, Any time there is an injury of unknown origin we are supposed to do a write up. On 08/10/23 at 10:00 AM, V2, Director of Nursing, (DON), stated V16, LPN, was on leave from the Facility due to illness. On 07/12/23 at 1:55 PM, V6, MDS Coordinator, stated, That (the unknown origin report) is the investigation. There were no witnesses so it must have happened during transfer. So, am I just supposed to write down their names and say they didn't know anything about it? Should I start making them a skin injury instead of an unknown origin? On 08/09/23 at 2:30 PM, V2, DON, stated she would expect the investigation to include statements from staff. On 08/10/23 at 3:43 PM, V1, Administrator, stated she expects the Facility to conduct an investigation for all injuries of unknown origin. The Facility's Abuse Investigation and Reporting Policy revised July 2017 documents, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. The individual conducting the investigation will, as a minimum: a. Review the completed documentation forms; b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) reporting the incident; e. Interview the resident (as medically appropriate); f. Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition; g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; h. Interview the resident's roommate, family members, and visitors; i. Interview other residents to whom the accused employee provides care or services; and j. Review all events leading up to the alleged incident.

Based on interview and record review, the facility failed to establish an infection prevention and control program that reduces the risk of adverse events, including the development of antibiotic-resistant organisms from unnecessary or inappropriate antibiotic use in 4 of 4 residents (R6, R17, R15, and R176) reviewed for antibiotic stewardship in the sample of 23. Findings include: 1-The Facility's Antibiotic Surveillance Tracking Log for the month of January 2023 documents, No culture ordered for R6's urinary infection. R6's Order Summary Report printed 8/11/23 documents the order, Cipro Oral Tablet 250 mg (Ciprofloxacin HCl) - Give 1 tablet by mouth related to benign prostatic hypertrophy with lower urinary tract infection symptoms for 7 days until finished with Start Date of 1/23/23 and End Date 1/30/23. R6's MAR for January 2023 documents R6 received 14 doses of Cipro. On 8/9/23 at 4:15 PM, culture for R6's January 2023 UTI, (Urinary Tract Infection), was requested from V2, Director of Nursing, (DON). On 8/11/23 at 10:00 AM, no C&S was received from the Facility. 2-The Facility's Antibiotic Surveillance Tracking Log for the month of April 2023 documents, N/A for organism identified and UTI prophylaxis as site of R17's urinary infection. R17's Order Summary Report printed 8/9/2023 documents, ordered Bactrim DS 800-160 MG, (milligram), (Sulfamethoxazole-Trimethoprim) - Give 1 tablet by mouth one time a day related to urinary tract infection, site not specified with Start Date of 5/4/23 and no End Date listed. R17's Medication Administration Record, (MAR), for May 2023 through August 9, 2023, documents R17 received 98 doses of the antibiotic Bactrim DS. On 8/9/23 at 12:55 PM, culture for R17's UTI was requested from V2, DON. On 8/11/23 at 10:00 AM, no C&S was received from the facility. 3-Facility's Infection Control log dated 5/16/2023 documents, R15 prescribed Macrobid 100mg 1 capsule by mouth twice daily given 5/16/2023-5/23/2023. No culture and sensitivity, (C&S), ordered. Facility was asked for culture and sensitivity on 8/9/2023. No results given. R15's Order sheet dated 5/16/2023 Macrobid Oral Capsule 100 MG (Nitrofurantoin Monohyd Macro). Give 1 capsule by mouth two times a day related to Urinary Tract Infection, (UTI), for 7 days. R15's Medication Administration Sheets, (MAR), dated 5/1/2023-5/31/2023 documents, Macrobid Oral Capsule 100 MG. Give 1 capsule by mouth two times a day related to UTI. MAR documents dated administered 5/16/2023-5/23/2023. R15's Nurse's Notes dated 5/16/2023 documents, hospice nurse returned phone call, new order for Macrobid 100 mg two times daily x 7 days. Hospice nurse stated, if we see not see improvement within 48 hours to notify hospice. 4-Facility's Infection Control log dated 2/14/2023 documents, R176 ordered Bactrim DS and started on 2/14/2023-2-17/2023. UA and culture done at radiation appointment. No results obtained by facility. Facility's Infection Control log dated 2/24/2023 documents, R176 was ordered Bactrim DS which started on 2/24/2023-3/1/2023. No growth noted on culture. Antibiotic started based on initial UA results. R176's February 2023 medication administration sheets, (MAR), document Sulfamethoxazole-Trimethoprim Oral Tablet 800-160 MG (Sulfamethoxazole Trimethoprim). Give 1 tablet by mouth two times a day related to UTI. MAR documents, dates administered 2/14/2023-2/17/2023, 2/24/2023-3/1/2023. R176's Progress Notes dated 2/14/2023 at 5:38PM documents, R176 returned from radiation with a bottle of 6 Bactrim DS pills for a UTI that was found while at radiation. First dose to be given this evening. R176 is alert and able to make needs known. Vitals are within normal limits and in chart. Skin is warm and dry and bowel sounds are present. Respirations are even and nonlabored. Medications taken without difficulty. R176's Progress Notes dated 2/16/2023 at 11:33AM documents, Antibiotic for UTI. R176 has no signs and symptoms noted from antibiotic for UTI. Denies burning or discomfort. R176's Progress Notes dated 4/17/2023at 6:00PM documents, R176 reported burning upon urination and suprapubic discomfort when up to restroom. Will plan to obtain UA with culture and sensitivity per clean catch as per standing orders of Physician. R176 sitting up in bedside chair with call light in reach. R176's order sheets dated 4/18/2023 document, Macrobid Oral Capsule 100 MG (Nitrofurantoin Macro) Give 1 capsule by mouth two times a day related to UTI. R176's Progress Notes dated 4/18/2023 at 7:52PM, Physician in this evening and addressed residents UA. Received verbal orders from Physician to start Macrobid 100mg twice daily x 10 days. R176's Progress Notes dated 4/19/2023 at 12:51PM documents, Urinalysis results came back with preliminary culture which states there was no growth in 1 day. R176 on Macrobid 100mg by mouth twice daily. UA and preliminary sent to physician. R176's Progress Notes dated 4/21/2023 at 6:45AM document, Received UA with C&S with no indication of infection. Push PO fluids and cranberry juice. Update provider if symptoms arise or do not resolve. R176's Progress Notes dated 4/21/2023 at 1:36PM Note Text: Discontinued antibiotic. Urine culture came back and showed no signs of infection. Facility infection control log documents, on 4/21/2023 R176's antibiotic discontinued due to no UTI. No infection present. R176's MARS dated 4/1/2023-4/30/2023 documents; Macrobid Oral Capsule100 MG (Nitrofurantoin Macro) Give 1 capsule by mouth two times a day related to UTI. Start Date04/19/2023 0900-D/C Date04/21/2023. MARS document, dosage administered from 4/19/2023-4/21/2023. Facility policy dated 12/2016 states, Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents. Appropriate indications for the use of antibiotics include: Pathogen susceptibility, based on culture and sensitivity, to antimicrobial (or therapy begun while culture is pending. When a culture and sensitivity is ordered, it will be competed, and Lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotics therapy should be started, continued, modified, or discontinued.

Based on observation, interview, and record review, the facility failed to store, prepare and distribute food in a manner that prevents foodborne illness. This has the potential to affect all 21 residents living in the facility. Findings include: On 08/08/23 at 11:20AM V5, Cook, was removing items from the standing refrigerator. One container was labeled mechanical ham and was dated 07/31/23. On 08/08/23 at 11:22AM in the walk-in refrigerator there was an opened bag of mozzarella cheese that was sealed with plastic wrap but was not dated. On 08/08/23 at 11:24AM in the walk-in freezer there was a plastic bag containing round slices of meat, each approximately two inches in diameter. The bag was dated 07/13 but was not labeled. There was a plastic bag of corn on the cob that was sealed but was not labeled or dated. There was a bag of breaded meat that was sealed, but not dated or labeled. There was an unknown cylindrical shaped item wrapped in brown paper and plastic wrap that was not dated or labeled. On the top shelf of the freezer, there was a fifteen-pound box of chicken breasts, a twelve-pound box of panko shrimp and three boxes of breaded catfish. The lower levels of shelving below contained various types of foods, including vegetables and mozzarella cheese sticks. V5, Cook, stated, the items on the top shelf are not pre-cooked. On 08/08/23 at 11:30AM, V4, Dietary Manager, stated, items can be arranged any way in the freezer because they are frozen. On 08/08/23 at 11:44AM the resident refrigerator in the dining room held a container of diced fruit with no label or date. There was a half empty container of blackberries with no date. There was a plastic bag containing half a cucumber and another plastic bag with a whole cucumber, neither of which were labeled or dated. There was an opened eight-ounce carton of chocolate milk that was not resealed, labeled with resident information, or dated. There was a container with a name written in black marker, but the contents inside were not labeled or dated. There was a foam container labeled R22 with no food item label or date. There was stack of sliced white cheese approximately one inch thick and a stack of sliced yellow cheese approximately two inches thick that were wrapped in plastic wrap. The dates written in black marker were not legible, and there were no item labels. On 08/08/23 at 11:47AM the freezer in the resident dining room had ice crystals on the shelves that were approximately one-half inch thick. There were four waffles in a plastic package that was not resealed after opening. The waffles were open to air and were not labeled or dated. There was a plastic bag containing several square breaded items with no label or date. On 08/08/23 at 12:05PM, V5, Dietary Manager, (DM), poured a can of tomato soup into a bowl, placed bowl in the microwave, and began heating. On 08/08/23 at 12:07PM, V5, DM, removed soup from the microwave and placed on the meal cart to be served. V5 did not check the temperature of the soup. On 08/08/23 at 12:11PM, V5, DM, stated, Soup is more of a side item, so we normally don't check it (for temperature). I don't know if we should be, but we try to get it nice and hot. On 08/08/23 at 12:13PM, temperatures were obtained from the steamtable after the last resident tray was served using a metal calibrated thermometer. The pureed pork measured 134°F (Fahrenheit), the pureed turnip greens measured 127ºF, and the mechanical soft pork measured 125°F. The Facility's Diet Type Report dated 08/09/23 documented, R1, R10, and R12 were on pureed diets, and R3, R7, R8, R14, and R22 were on mechanical soft diets. On 08/10/23 at 3:43PM V1, Administrator, stated, she expects staff to follow food service policies. The Facility's Food Receiving and Storage revised October 2017 documents, Foods shall be received and stored in a manner that complies with safe food handling practices. All foods stored in refrigerator or freezer will be covered, labeled and dated (use by date). Uncooked and raw animal products and fish will be stored separately in drip-proof containers and below fruits, vegetables, and other ready-to-eat foods. All foods belonging to residents must be labeled with the resident's name, the item and the use by date. Beverages must be dated when opened and discarded after twenty-four (24) hours. Other opened containers must be dated and sealed or covered during storage. Partially eaten food may not be kept in the refrigerator. The Facility's Food Preparation and Service revised April 2019 documents, The danger zone for food temperatures is between 41°F and 135°F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. Fresh, frozen or canned fruits and vegetables are cooked to a holding temperature of 135ºF. Mechanically altered hot foods prepared for a modified consistency diet remain above 135°F during preparation or they are reheated to 165ºF for at least 15 seconds. The temperatures of foods held in steam tables are monitored throughout the meal by food and nutrition services staff. The Facility's Resident Census and Condition of Residents Form CMS-672 dated 08/08/23 documents there are 21 residents living in the facility.

Based on interview and record review the facility failed to adequately develop an ongoing infection control program that adequately collects data to calculate and analyze infection rates and failed to operationalize infection control policies to adequately define infection control practices in the facility. The facility staff also failed to utilize appropriate Personal Protective Equipment, (PPE), when entering a COVID-19 rooms. This has the potential to affect all 21 residents living in the facility. Findings Include: 1. The facility's Antibiotic Surveillance Tracking Form for the month of January documents, R6 was given Cipro for a Urinary Tract Infection, (UTI) from 1/23/23 through 1/30/23, and no culture was ordered. The Antibiotic Surveillance Tracking Form did not document the organism causing the infection. R6 Physician Order Sheet, (POS), dated 1/23/23 documents, Cipro 250mg, (milligrams), BID, (twice daily), for bladder pain related to, benign Prostatic Hyperplasia for 7 days. 2. The facility's Antibiotic Surveillance Tracking form for the month of May documents R15 was treated from 5/16/23 through 5/23/23 for a UTI. R15 was on hospice and was treated for signs and symptoms. A Culture and Sensitivity, (C/S), was not completed. The resident (R15) was on Macrobid. R15's POS dated 5/16 through 5/23 documents, R15 was on Macrobid 100mg BID, related to UTI. The Antibiotic Surveillance form did not document the organism causing this infection. 3. The facility's Antibiotic Surveillance Tracking Form for the Month of April documents, R16 was placed on Cipro and a culture was not completed. The organism causing the infection was not found on the form. R16's POS dated 4/9/23 through 4/16/23 documents, R16 was on Cipro 500mg BID for 7 days related to, a personal history of UTI. 4. The facility's Antibiotic Surveillance Tracking Form for the month of April documents R176 was on Macrobid. The Antibiotic Surveillance Tracking Form did not document the organism causing the infection. R176's POS documented, R176 was ordered Macrobid 100mg twice daily from 4/19/23 to 4/21/23 for a UTI. The Antibiotic Surveillance Tracking Form for the month February documented, that R176 was placed on Bactrim DS 800mg /160mg BID for urinary tract infection for 6 doses, on 2/14/23. The Antibiotic Surveillance Tracking form did not document the organism for this UTI. The Antibiotic Surveillance Tracking Form For the month of February also documented, that R176 was ordered Bactrim DS 800mg/160mg BID x, (times), 10 days on 2/24/23. The Antibiotic Surveillance Tracking form did not document the organism for this UTI. 5. On 08/09/23 at noon, V12 Certified Nursing Assistant, (CNA), entered the room of R9 and R19 who are on contact and droplet precautions for being symptomatic for COVID-19. V12 CNA donned gloves, gown, and goggles but, did not put on a N95 mask. V12 entered the room wearing a surgical mask. 6. On 8/9/23 at 1:00 PM V13 CNA donned PPE, (Personal Protective Equipment), and entered the room of R14 and R11. R11 and R14 are both positive for COVID-19. V13 CNA took a sit to stand machine into the room. V13 wiped down the sit to stand with a bleach wipe and rolled it out of the room. V13 then took the sit to stand sling that was used in the room and placed it on top of the sit to stand that was in the hallway. On 8/9/23 at 1:30 PM V13 CNA stated, I don't know why I did that. I was going to put it in the laundry, because they already have one in their room. On 8/11/23 at 12:08 PM V2 Director of Nursing stated, Yes we do, we are going to make sure all hospice residents get a UA/culture before starting ABT, (antibiotics), and we are addressing/stopping the prophylactic ABT we have with family and doctor. It isn't working anyway. The facility policy Infection Prevention and Control Program dated October 2018 documents surveillance tools are used for recognizing the occurrence of infections recording their number and frequency detecting outbreaks and epidemics monitoring employee infection monitoring adherence to infection control practices and detecting unusual pathogens with infection control implications. Prevention of Infections: educating staff and ensuing that they adhere to proper techniques and procedures. The Facility's Resident Census and conditions Form dated 8/8/23 documents the facility had a census of 21 residents.

Based on observation, interview and record review, the facility failed to provide residents properly cooked food for 1 of 20 residents (R20) reviewed for food temperatures in the sample of 18. Findings include: R20's Care Plan dated 2/29/2020 documents, Regular Diet, Mechanical Soft texture, thin consistency. On 6/22/2022 at 11:32 AM, during the lunch service V8, Dietary Aid, prepared a plate of mechanical meat for R20 and it was served to her at the dining room table. On 6/22/2022 at 11:28 AM, the mechanical meat temperature was taken with a metal, calibrated thermometer and registered 121.1 degrees Fahrenheit (F). On 6/22/2022 at 11:27 AM, during the lunch service the lid to the mechanical meat was not hot to the touch. On 6/22/2022 at 11:00 AM, the Food Log Temperature Book was reviewed and does not document any temperatures were taken for the mechanical meat. The area was blank. On 6/23/2022 at 9:35 AM, V7, Dietary Manager, stated, After we talked (V8) went and added the temperature to the mechanical meat food log book. I was there with you and it was blank and not filled out when you asked to see it. I am not sure where she got that temperature but I know it was not correct. On 6/22/2022 at 11:30 AM, V8, Dietary Aid, stated, I did not take a temperature on the mechanical meat, only the regular meat, and it was within range. The area was blank because I did not take it for the mechanical soft meat. On 6/22/2022 at 11:32 AM, V7, Dietary Manager, stated, I expect all food on the steam table to be at least 135 degrees (F) or higher. The mechanical meat should have been at a higher temperature and the temperatures should have been taken. On 6/23/2022 at 1:45 PM, V14, Dietician, stated, On 6/23/2022 at 2:01 PM, V14, Dietician stated, I would expect all of the food on the steam table to be held at 135 degrees Fahrenheit (F) or higher. If a food item temperature is lower than 135, I would not expect it to be served to the residents. When the food is under 135 F, it can be a danger zone/hazardous. The danger zone is an ideal environment for bacterial growth. On 6/22/2022 at 3:31 PM, V2, Director of Nursing (DON), provided a list of residents on pureed and/or mechanical texture diets and the following residents were documented: R3, R14, R17 and R20. The Facility Food Preparation and Service Policy with a revision date of 4/2019 document, Food and Nutrition services employees prepare and serve food in a manner that complies with safe food handling practices. The danger zone for food temperatures is between 41 F and 135 F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause food borne illness. Potentially hazardous food include meats. Mechanically altered hot foods prepared for a modified consistency diet remain above 135 degrees F during preparation or they are reheated to 165 F for at least 15 seconds.