**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that respiratory care and services consistent with professional standards of practice pertaining to oxygen equipment maintenance was provided for two Residents (#9 and #23), out of a total sample of 19 residents. Specifically, for Resident #9 and Resident #23, the facility failed to maintain the Resident's oxygen concentrator (device used to deliver supplemental oxygen) air intake gross particle filter in accordance with Physician orders and manufacturer's guidelines, placing both Residents at risk for contamination, equipment malfunction, and impaired oxygen delivery. Findings include: Review of the facility policy titled Concentrator Maintenance, undated, included but was not limited to the following: -All oxygen concentrators should be wiped down to ensure cleanliness and filters should be cleaned at least weekly to prevent overheating. >Filter Cleaning: Cabinet filters should be pulled from the sides of the concentrator .can be cleaned by: *Manually removing dust by wiping with towel and/or shaking particles free, *Vacuuming the dust from the filter or, *Placing them in warm soapy water and allow to air dry. Once dry replace the filter by placing them back into the cabinet of the concentrator. Review of the New Life Elite Oxygen Concentrator Service Manual, undated, retrieved at https://files.caireinc.com/MN105-1-E.pdf indicated: -To ensure accurate output and efficient operation of the oxygen concentrator, the user must clean the gross particle filter weekly, as described below: >Remove the dirty air intake particle filter from the back of the unit, and install the clean filter stored in the pocket on the back of the unit. >Wash the dirty filter in warm soapy water and rinse. >Use a soft absorbent towel to remove excess water. >Place the clean air intake gross particle filter in the pocket on the back of the unit. 1. Resident #9 was admitted to the Facility in May 2021, with diagnoses including Chronic Obstructive Pulmonary Disease (COPD). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #9: -Resident #9 was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of a total score of 15. -was receiving oxygen therapy. Review of Resident #9's Person-Centered Care Plan, included but not limited to: -Focus- the Resident has COPD and was dependent on oxygen, initiated 1/24/25. -Goal- the Resident will display optimal breathing patterns daily through next review, initiated 4/17/25. -Interventions- Oxygen per orders, initiated 1/24/25 Review of Resident #9's May 2025 Physician's orders, included but was not limited to: -Oxygen at 3 Liters Per Minute (LPM) via nasal cannula (NC), start date 11/4/24. -Clean outside of oxygen concentrator with warm cloth, clean and rinse filter with warm water every evening shift (3:00 P.M.-11:00 P.M.), every Wednesday, start date 11/4/24. On 5/13/25 at 8:46 A.M., the surveyor observed Resident #9 seated at his/her bedside in a wheelchair with oxygen flowing at 3 LPM from the oxygen concentrator via NC to the Resident. The surveyor observed the oxygen concentrator filter was coated in thick gray dust. On 5/13/25 at 2:47 P.M., the surveyor observed Resident #9 lying in bed with oxygen being administered at 3 LPM via NC from the oxygen concentrator. The surveyor observed the oxygen concentrator filter remained coated in a thick film of gray dust. Review of Resident #9's May 2025 Medication Administration Record (MAR) included but not limited to: >The evening shift (3:00 P.M.-11:00 P.M.) Nurse signed off the completion of task for cleaning the outside of the Resident's oxygen concentrator and cleaning the filter on 5/14/25. On 5/15/25 at 9:19 A.M., the surveyor observed Resident #9 lying in bed with oxygen being administered at 3 LPM via NC from the oxygen concentrator. The surveyor observed that the oxygen concentrator filter was coated in a thick film of gray dust. During an interview at the time, Nurse #1 said that she was the Nurse caring for Resident #9. Nurse #1 said the oxygen equipment was supposed to be cleaned and changed by the evening shift Nurses on Wednesdays. The surveyor and Nurse #1 observed the Resident's oxygen concentrator and Nurse #1 said that the Resident was using a New Life Elite Airsep oxygen concentrator. Nurse #1 said that the concentrator filter was dirty and coated in dust. Nurse #1 said that the filter did not appear to have been cleaned on 5/14/25 evening shift as it should have been. Nurse #1 said she was unsure of why the oxygen concentrator filters needed to be cleaned. 2. Resident #23 was admitted to the Facility in July 2019, with diagnoses including COPD. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #23: -was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of seven out of a total score of 15. -was receiving oxygen therapy. Review of Resident #23's Person-Centered Care Plan included but was not limited to: -Focus- Resident has COPD, initiated 12/9/24. -Goal- Resident will display optimal breathing patterns daily through next review, revised 4/28/25. -Interventions- Oxygen as ordered, initiated 12/9/24 Review of Resident #23's May 2025 Physician's orders included but was not limited to: -Oxygen 2 LPM via NC at bedtime, effective 10/24/24. -Clean outside of oxygen concentrator with warm cloth, clean and rinse filter with warm water every evening shift (3:00 P.M.-11:00 P.M.), every Wednesday, start date 11/4/24. On 5/13/25 at 8:22 A.M., the surveyor observed Resident #23 lying in bed with oxygen flowing at 2 LPM via NC from the oxygen concentrator. The oxygen concentrator filter was observed to be coated in thick gray dust. Review of Resident #23's May 2025 MAR indicated but was not limited to: >The evening shift (3:00 P.M.-11:00 P.M.) Nurse had signed off completion of task for cleaning the outside of the Resident's oxygen concentrator and cleaning the filter on 5/14/25. On 5/15/25 at 9:23 A.M., the surveyor observed Resident #23 lying in bed with oxygen administered via NC at 2 LPM from the oxygen concentrator. The oxygen concentrator filter was observed coated in a thick film of gray dust. During an interview at the time, Nurse #1 said that she was the Nurse caring for Resident #23. Nurse #1 said that oxygen equipment was supposed to be cleaned and changed by the evening shift Nurses on Wednesdays. The surveyor and Nurse #1 observed the Resident's oxygen concentrator and Nurse #1 said that the Resident was using a New Life Elite Airsep oxygen concentrator. Nurse #1 said that the concentrator filter was dirty and coated in dust. Nurse #1 said that the filter did not appear to have been cleaned on the 5/14/25 evening shift as it should have been. Nurse #1 said she did not know anything about cleaning the oxygen concentrator filters. During an interview on 5/15/25 at 9:55 A.M., Unit Manager (UM) #2 said that the evening shift Nurses should be cleaning the concentrator filters weekly on Wednesday. UM #2 said filter cleaning was indicated in the Resident Physician orders and on the Resident MAR.The surveyor and UM #2 observed Resident #9's and Resident #23's oxygen concentrators and UM #2 said both Resident's oxygen concentrator filters were dirty, and the filter cleaning had not been done last night (5/14/25) but should have been. UM #2 said that a dirty concentrator filter could affect the function of the concentrator and oxygen flow to the Resident. During an interview on 5/15/25 at 12:15 P.M., the Infection Preventionist (IP) said that Nurses should be cleaning the oxygen concentrator filters weekly per Physician's orders. The IP said that failure to clean the oxygen concentrator filters could result in Resident nasal irritation as well as causing the oxygen concentrator to overheat and affect the oxygen concentrator's function.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to monitor adverse consequences (side effects) of an antipsychotic (psychotropic medication capable of affecting the mind, emotions, and behaviors) medication in accordance with professional standards of practice for one Resident (#38) of five applicable residents, out a total sample of 19 residents. Specifically, for Resident #38, the facility failed to: -complete an Abnormal Involuntary Movement Scale (AIMS - an assessment used to identify the existence and severity of movement side effects associated with antipsychotic drugs) within the required time frame -act upon the Pharmacist Consultant's recommendation following the Resident's monthly medication regimen review indicating a need for AIMS when Resident #38 had been prescribed and administered Clozapine (antipsychotic medication). Findings include: Review of the facility policy titled Psychotropic Medications/Informed Consent, dated 7/16/93 with revision date 3/29/17 included but was not limited to: -Residents who use psychotropic drugs will be monitored for effectiveness of drug therapy and the presence of side effects. -Special considerations regarding the use of antipsychotic drugs: >The AIMS scale will be completed when the drug therapy is first started and at least every six months. >The pharmacy consultant will review the appropriateness of psychotropic therapy during the monthly medication review and the emergence of any adverse consequences. >Recommendations regarding psychotropic medication use by the pharmacist .will be communicated to nursing. Nursing will notify the provider, and the providers response and rationale will be documented. Review of the Increasing Abnormal Involuntary Movement Scale (AIMS) Screening for Tardive Dyskinesia in an Outpatient Psychiatry Clinic: A Resident-Led Outpatient Lean Six Sigma Initiative article at https://pmc.ncbi.nlm.nih.gov/articles/PMC10292174/ included but was not limited to: -The Abnormal Involuntary Movement Scale (AIMS) is used not only to detect tardive dyskinesia but also to follow the severity of a patient's TD over time. -AIMS is a valuable tool for clinicians who are monitoring the effects of long-term treatment with neuroleptic medications and for researchers studying the effects of these drugs. -The AIMS is administered every three to six months to monitor the patient for the development of TD. -The American Psychiatric Task Force report on tardive dyskinesia (TD) in its guidelines for the avoidance and management of TD, recommended: >regular examinations for early signs of choreoathetosis and oral-lingual dyskinesias. > .examinations that use instruments such as the AIMS should be done before the institution of neuroleptic drug therapy and then repeated on a regular basis. >American Psychiatric Association (APA) practice guidelines stated that patients receiving conventional antipsychotic medications should be monitored for TD every three to four months, and patients on newer atypical antipsychotics should be monitored for TD every five to six months. Resident #38 was admitted to the facility in March 2021 with diagnoses including unspecified psychosis and delusional disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #38: -was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of three out of a total possible score of 15. -was receiving antipsychotic medication. Review of Resident #38's May 2025 Physician's orders included but was not limited to: -Clozapine 100 milligram (mg) tablet, one tab (tablet) by mouth once daily at 8:00 P.M., start date 11/4/24. -Clozapine 50 mg tablet 1.5 tablets (total dose 75 mg) by mouth daily at 6:00 A.M, start date 11/4/24. Review of the Residents person-centered Care Plan included but was not limited to: -Focus: Resident #38 was on Clozapine for Psychosis, initiated 1/16/25. -Goal: Resident #38 would remain free from Psychotropic drug related complications including movement disorder .through next review, revision date 3/19/25. -Interventions: Monitor/document/report adverse reactions to psychotropic mediations. Further Review of Resident #38's Medical Record included but was not limited to: -The Resident had his/her most recent AIMS completed on 7/9/24, with a score of zero out of a possible total score of 28. -The Resident was administered Clozapine as prescribed by the Physician from 7/10/24 through 5/14/25 (10 months since the initial AIMS). -The Resident had a Pharmacist Medication Regimen Review conducted and a Pharmisist Progress Note dated 12/16/24, which indicated recommendation for: AIMS now and every six months to monitor therapy. -No evidence that AIMS assessment had been conducted since the Pharmacist recommendation on 12/16/24 or the AIMS becoming due on 1/9/25 (6 months after the 7/9/24 initial AIMS). During an interview on 5/14/25 at 3:23 P.M., Unit Manager (UM) #1 said that Pharmacist recommendations come monthly via email to the Unit Managers. UM #1 said when the Pharmacy recommendations arrive, she would print them and address the recommendations with the Resident's Provider(s). The surveyor and UM #1 reviewed Resident #38's Pharmacy Progress Note dated 12/16/24 and UM #1 said that the recommendation indicated an AIMS was due at that time. UM #1 was unable to locate a completed AIMS in the Resident's record or the emailed Pharmacy Reccomendation Form. During a follow-up interview on 5/15/25 at 11:21 A.M., UM #1 said that an AIMS should have been completed every six months for Resident #38 but UM #1 was unable to locate a current AIMS in the Resident's medical record after 7/9/24. During an interview on 5/15/25 at 11:31 A.M., the Staff Development Coordinator (SDC) said that Nurses were educated about the AIMS policy upon hire and that the AIMS scale should be done every six months. The SDC said that each Unit Manager should be maintaining a list of residents that are on psychotropic medications as well. The SDC said that there was no current system for tracking AIMS testing within the facility to her knowledge. The SDC said that she would have concerns if the Resident's AIMS was not completed on time because Resident #38 could be at risk for unidentified side effects or may not supposed to still be taking an antipsychotic medication. During an interview on 5/15/25 at 1:09 P.M., the Director of Nursing (DON) said that Resident #38 was taking an antipsychotic medication and should have had an AIMS completed every six months for monitoring but had not.

Based on record review, and interview, the facility failed to ensure one Resident (#86) out of a total sample of 19 residents, was free of a significant medication error. Specifically, for Resident #86, the facility failed to ensure that a daily PRN (as needed medication) Methocarbamol (central nervous system depressant - used to treat pain and muscle spasms while relaxing the brain and the spinal cord) medication was administered as ordered by the Physician. Findings include: Review of the facility's policy titled, Medication Orders, revised 2018, indicated the following: -Any dose or order that appears inappropriate considering the resident's age, condition, allergies to the medication, or diagnosis is verified by nursing and the attending physician. -Medication orders specify the following: >Time or frequency of administration. Resident #86 was admitted to the facility in December 2024 with diagnoses including hemiplegia and hemiparesis following Cerebral Infarction affecting the left non-dominant hand. Review of Resident #86's May 2025 Physician's orders indicated the following: -Methocarbamol Oral Tablet 500 milligram (mg). Give 500 mg by mouth as needed for muscle spasm once daily, ordered 3/31/25. -Methocarbamol Oral Tablet 500 mg. Give 500 mg by mouth two times a day for pain/spasm, ordered 3/31/25. Review of Resident #86's April 2025 Medication Administration Record (MAR) indicated that the Methocarbamol Oral Tablet 500 mg tablet, give 500 mg by mouth as needed (PRN) for muscle spasm once daily was administered on the following dates and times: -4/10/25: 2:54 A.M. and 1:34 P.M. -4/11/25: 12:40 A.M., and 6:02 A.M. -4/17/25: 3:00 A.M., and 3:21 P.M. -4/29/25: 6:33 A.M., and 1:28 P.M. Review of Resident #86's April 2025 MAR indicated that the Methocarbamol Oral Tablet 500 mg tablet, Give 500 mg by mouth two times a day for pain/spasm, was administered as ordered at 8:00 A.M. and 8:00 P.M. Review of Resident #86's May 2025 MAR indicated that the Methocarbamol Oral Tablet 500 mg tablet, give 500 mg by mouth as needed (PRN) for muscle spasm once daily, was administered on 5/12/25 at 5:36 A.M. and 2:39 P.M. Review of Resident #86's May 2025 MAR indicated that the Methocarbamol Oral Tablet 500 mg tablet, Give 500 mg by mouth two times a day for pain/spasm, was administered as ordered at 8:00 A.M. and 8:00 P.M. During an interview on 5/14/25 at 11:08 A.M., Unit Manager (UM) #1 said the Methocarbamol had been administered outside the parameters of the Physician orders. UM #1 said administering the medications too close to the Resident's scheduled doses could cause increase lethargy and sleepiness. UM #1 said the Methocarbamol was ordered as once daily PRN, but the Nurses had administered the medications as twice a day PRN on the identified dates. During a follow-up interview on 5/14/25 at 1:45 P.M., UM #1 said the PRN Methocarbamol for Resident #86 had been administered in error on the identified dates. UM #1 said the Physician would be notified. During an interview with the Director of Nursing (DON) on 5/14/25 at 3:06 P.M., the DON said the Methocarbamol for Resident #86 was administered twice a day in error on the identified dates and that the Physician had been notified about the significant medication error.

Based on observation, interviews, and record reviews, the facility failed to maintain an effective infection control and prevention program to stop the spread of organisms and infections for one Resident (#9) out of a total sample of 19 residents. Specifically, for Resident #9, the facility failed to implement appropriate hand hygiene during wound care for Resident #9 who was on Enhanced Barrier Precautions (EBP: infection prevention practice of wearing gown and gloves to reduce transmission of multi-drug-resistant organisms [MDRO's - bacteria that are resistant to three or more types of antimicrobial drugs]) during high contact resident care). Findings include: Review of the facility's policy titled, Handwashing/Hand Hygiene, undated, included but was not limited to: -This facility considers hand hygiene the primary means to prevent the spread of infections. >Use of alcohol-based hand rub (ABHR) over soap and water is preferred in most clinical situations. -Use ABHR or soap and water for the following situations: >Before handling clean or soiled dressings, gauze pads, etc . >After contact with a resident's skin. >After removing gloves. -The use of gloves does not replace hand washing/hand hygiene. Resident #9 was admitted to the facility in May 2021 with diagnoses including Stage Two Pressure Injury to the left ischium (lower back of the hip bone also known as the sitting bone). Review of Resident #9's May 2025 Physician orders included: -Maintain EBP, effective 4/11/24. -Medihoney (Manuka antibacterial honey) Wound and Burn Dressing external paste (wound dressing). >Apply to left ischium topically as needed for stage two pressure injury. >Normal Saline wash, pat dry, apply Medihoney, followed by (f/b) bordered gauze dressing twice a day (BID) and as needed (PRN), effective 5/13/25. Review of Resident #9's Person-Centered Care Plan included but was not limited to: -Focus: The Resident has actual skin impairment: Stage Two Pressure Injury of the left ischium .on Enhanced Barrier Precautions, effective 4/11/25 with revision date 4/24/25. -Goal: The Resident's skin injury of left ischium will be healed in 12 weeks, initiated 4/11/25 with revision date 4/17/25. -Interventions: *Maintain EBP, effective 4/24/25. *Treatment to the area as ordered, effective 4/14/25. On 5/13/25 at 8:46 A.M., the surveyor observed Resident #9 seated in a wheelchair in his/her room and eating. The surveyor observed signage hanging on the Resident's doorway that indicated: -STOP ENHANCED BARRIER PRECAUTIONS STOP -EVERYONE MUST: *Clean their hands including before entering and when leaving the room. *Wear gloves and a gown for the following high contact resident care activities: >Wound Care: any skin opening requiring a dressing. During an interview on 5/14/25 at 4:29 P.M., Nurse #2 said she was the Nurse caring for Resident #9. Nurse #2 said that Resident #9 had a pressure ulcer to the left buttock area, was on EBP due to the wound and she would be doing the wound treatment today. Nurse #2 said that she was going to collect supplies and would meet the surveyor at the Resident's room. The surveyor observed wound care provided by Nurse #2 to Resident #9 who was lying in bed, as follows: -Nurse #2 cleansed her hands with ABHR and donned (put on) a gown and gloves. -Nurse #2 entered the Resident's room and explained the wound treatment to Resident #9. -Nurse #2 used a disinfectant wipe to clean the Resident's over the bed table for use as a work surface. -Nurse #2 doffed (removed) her gloves, donned new gloves and set out the dressing supplies on the cleaned work surface. Nurse #2 failed to perform hand hygiene between the glove change. -Nurse #2 positioned Resident #9 into a right-side lying position and removed the old dressing from the Resident's left ischium. -Nurse #2 discarded the old dressing into the trash can. -Nurse #2 then doffed the soiled gloves and discarded the gloves into the trash can. -Nurse #2 donned a new pair of gloves without performing hand hygiene between the glove change. -Nurse #2 cleansed the Resident's wound with Normal Saline Solution on a gauze pad. -Nurse #2 used a new gauze pad to pat the wound area dry. -Nurse #2 applied Medihoney Wound and Burn Dressing external paste with a tongue depressor to the wound bed and covered the wound area with a bordered gauze dressing. -Nurse #2 discarded the unused supplies and waste into the trash can. -Nurse #2 then positioned the Resident for comfort in his/her bed. -Nurse #2 doffed the soiled gloves, discarded them into the trash can and cleansed her hands with ABHR. During an interview immediately following the wound care observation, Nurse #2 said that she did not cleanse her hands between glove changes during the Resident's wound care that she had provided. Nurse #2 said that she should have washed her hands every time she changed her gloves because not washing her hands could cause the spread of germs to Resident #9. During an interview on 5/14/25 at 5:00 P.M., the Infection Preventionist (IP) said all staff were educated on hand hygiene and got checked for competency throughout the year. The IP said that Nurse #2 should have cleaned her hands between glove changes because germs could spread from Nurse #2 to the Resident when hands are not cleaned between glove use.

Based on observation, interview, policy and record review, the facility failed to administer parenteral fluids (delivery of fluid or medication through an intravenous [IV: within a vein] . route) according to professional standards of practice and in accordance with the Physician's order for one Resident (#70) out of a total sample of 22 residents. Specifically, the facility staff failed to verify patency (openness of an IV line, allowing medication to flow directly into one's vein) of Resident #70's midline catheter (small tube inserted into a vein in one's arm used to deliver medication and take blood samples), prior to administering an IV antibiotic (medication used to treat infection), as required per the Physician's order, increasing the Resident's risk for complications during antibiotic treatment. Findings include: Review of the facility's policy, titled Administration of IV Fluids and Medications: Setting Up a Primary Infusion (Hydration or Medication), dated 2011, indicated the following: -Scrub needleless connector (device which connects to the end of the midline catheter and enables access for infusion [slow injection of medication into a vein] and aspiration [drawing out by suction]) on resident's catheter with antiseptic (substance used to prevent infection) wipe. -Attach flush syringe (medical device used to ensure IV lines stay clean and prevent blockages), aspirate for a blood return to determine patency and then flush resident's IV catheter with appropriate flush solution as ordered . -Scrub needleless connector on resident's catheter with antiseptic wipe. -Attach . IV tubing to the needleless connector. - . begin infusion. Resident #70 was admitted to the facility in November 2019 with a diagnosis of rash and other non-specific Skin Eruption (abnormal outbreak on the skin's surface as a symptom of disease). Review of Resident #70's February 2024 Physician's orders indicated: -IV Midline - Insertion site: Right upper arm, . dated 2/12/24. -Cefepime (antibiotic medication used to treat bacterial infections) 2 Gram (gm) Solution for injection: Infuse 2 gm by injection route two times per day for five days, dated 2/12/24 and discontinued 2/16/24. -Verify patency: Attach flush syringe, aspirate for a blood return to determine patency prior to administration of medications and solutions ., dated 2/12/24. -Cefepime 2 gm Solution for injection: Infuse 2 gm in 100 milliliters (ml) in 0.9 percent (%) Normal Saline (NS) over 30 minutes intravenously every 12 hours, dated 2/16/24. Review of Resident #70's IV Therapy Care Plan, dated 2/13/24, indicated: -The Resident required IV antibiotic therapy due to Pseudomonas (environmental bacteria) in his/her bilateral lower extremity wounds. -The IV site would remain free from signs of infiltration (dislodgement), . extravasation (leakage of medication into the tissue rather than remaining in the vein), . until the course of IV therapy was completed. Review of Resident #70's Medical Progress Note, dated 2/14/24, indicated the Resident was transferred to the hospital from the facility on 2/7/24, and: -admitted with diagnosis of bilateral lower extremity Cellulitis (serious bacterial infection of the skin) in the setting of Chronic Venous Stasis Ulcers (sores that develop due to poor blood circulation). -Lower extremity wound cultures grew Pseudomonas. -The Resident was treated with Cefepime. -The Resident returned to the facility on 2/12/24. -The plan was to continue IV Cefepime twice daily to complete a seven-day course. On 2/14/24 at 9:31 A.M., the surveyor observed Resident #70 seated in a recliner chair with both lower extremities wrapped in gauze and elevated on the chair's footrest. An IV pole was positioned to the right side of the Resident's chair. On 2/16/24 at 9:45 A.M., the surveyor observed the following in Resident #70's room: -Resident #70 was seated in a recliner chair in his/her room, with both lower extremities wrapped in gauze and elevated on the chair footrest. -The resident had a midline catheter in place in his/her right upper extremity. -An IV pole was positioned to the right of the Resident. -Nurse #4 hung one bag of Cefepime 2 gm Solution on the IV pole and programmed the IV pump. -Nurse #4 scrubbed the needleless connector of Resident #70's midline catheter with an antiseptic wipe and flushed the midline catheter with 10 ml of NS. -Nurse #4 did not aspirate for a blood return to determine patency. -Nurse #4 scrubbed the needleless connector with an antiseptic wipe a second time, attached the IV tubing to the needleless connector of Resident #70's midline catheter and began the antibiotic infusion. During an interview on 2/16/24 at 1:39 P.M., Nurse #4 said Nurses were required to flush the residents' IV catheters prior to administering medications through an IV but Nurse #4 did not state how to verify patency of the line. When the surveyor asked whether there was a process in place to verify patency, Nurse #4 said yes, that she should have aspirated for a blood return to verify patency of Resident #70's midline catheter before administering the antibiotic, but she skipped that step. During an interview on 2/20/24 at 4:23 P.M., the Director of Nurses (DON) said Nurses administering medications to residents via midline catheters were required to verify patency prior to medication administration by aspirating for a blood return. The DON said this was important to ensure that the line was open and working properly. The DON also said Nurse #4 should have aspirated for a blood return prior to administering Resident #70's antibiotic infusion on 2/16/24. Please refer to F726.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record and policy review, and interview, the facility failed to perform a trauma assessment on admission to the facility for one Resident (#61) out of a total sample of 22 residents. Specifically, the facility failed to assess whether Resident #61 had a past history of trauma, and/or any triggers which may cause re-traumatization. Findings include: Review of the facility's policy titled Trauma Policy, undated, indicated but was not limited to: -Residents will be assessed by social services upon admission for mental, psychosocial adjustment difficulty, with a history of trauma and or Post-Traumatic Stress Disorder (PTSD: a mental health condition triggered by a terrifying event, causing flashbacks, nightmares and severe anxiety). -Interviews with the resident, resident's family, or representatives, will be conducted as able, to determine: a. Their awareness of the current condition(s) or history of the condition(s) or diagnosis/diagnoses. b. To have their participation in the development of a person-centered care plan. c. To ensure Resident choices are considered. Resident #61 was admitted to the facility in January 2024 with the following diagnoses: Depression ( a mood disorder where the patient experiences persistent symptoms of depressed mood, sadness, and a loss of interest in daily activities to the point where it affects their normal function such as their appetite, energy levels, concentration levels and sleep) and Anxiety (intense, excessive, and persistent worry and fear about everyday situations). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #61 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. Review of Resident #61's medical record did not include any documentation that an assessment for Trauma and the prevention of potential re-traumatization had been initiated. During an interview on 2/20/24 at 11:44 A.M., Social Worker (SW) #2 said that when a new resident is admitted to the facility, Social Services would ask them about a history of trauma. SW #2 further said that if the resident answered that they have had trauma then the staff are prompted to ask additional questions to avoid re-traumatization of the residents and that Social Services would develop a plan of care. During an interview on 2/20/24 at 5:02 P.M., the surveyor and SW #2 reviewed the medical record for Resident #61 and SW #2 said that the Resident was not asked about a trauma history on admission to the facility and that he/she should have been asked about previous trauma.

Based on observation, interview, and record review, the facility failed to ensure that nursing competencies (measurable patterns of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) were assessed, according to the Facility Assessment and care needed by the resident population for two Nurses (#3 and #4) out of four Nurses reviewed. Specifically, the facility failed to: 1. Assess any skill competencies for Nurse #3 since May 2022, including clean dressing (use of a clean procedure field, clean gloves, and with avoidance of direct contamination of materials and supplies) technique, when the Nurse was assigned to care for one Resident (#70) who required daily dressing changes to his/her lower extremities. 2. Assess annual competency for Nurse #4 relative to care of intravenous (IV: within a vein) catheters when Nurse #4 was assigned to care for one Resident (#70) who required IV antibiotic administration through a midline catheter (small tube inserted into a vein in one's arm used to deliver medication and take blood samples). Findings include: Review of the Facility Assessment, updated January 2024, indicated the following: -Staff assigned to care for residents were assigned with the objective of ensuring that there were staff with appropriate training, experience, and expertise to meet the needs of the residents on each unit, as best as possible. -Competencies were determined according to the amount of resident interaction required by the job role, job specific knowledge, skills and abilities and those needed to care for the resident population. -Competencies were to be verified upon orientation, at least annually, and as needed. Review of the facility's Annual Nursing Skills Competency Checklist, undated, indicated competencies to be assessed included, but were not limited to: -Clean Dressing Technique -IV (intravenous) Basic and Pump -Precaution Policy Resident #70 was admitted to the facility in November 2019 with a diagnosis of rash and other non-specific Skin Eruption (abnormal outbreak on the skin's surface as a symptom of disease). 1. Review of the Centers for Disease Control and Prevention (CDC) guidance titled Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 11/29/22, indicated the following: -Adherence to infection prevention and control practices is essential to providing safe and high-quality patient care across all settings where healthcare is delivered. -Require training before individuals are allowed to perform their duties and at least annually as a refresher. Review of the facility policy titled Infection Control, dated 2001 and revised July 2014, indicated the following: -The facility's infection control . practices were intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. -Objectives of the infection control practices included establishing guidelines for implementing . Standard (minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient) and Transmission-Based (second tier of basic infection control and are to be used in addition to Standard Precautions for patients who may be infected . with certain infectious agents for which additional precautions are needed to prevent infection transmission) Precautions. Review of Resident #70's Wound Care Plan dated 9/12/23, indicated the Resident had venous wounds (wounds that develop due to poor blood flow) to his/her bilateral lower extremities. Review of Resident #70's Wound Infection Care Plan, dated 2/13/23, indicated: -The Resident had a current infection of Pseudomonas (environmental bacteria) in his/her bilateral lower extremities. -Staff were to maintain Enhanced Precautions (infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) and involve gown and glove use during high-contact resident care activities). Review of Resident #70's February 2024 Physician orders indicated an order, initiated 1/5/24, as follows: -Cleanse bilateral lower extremities with wound cleanser, apply Triad (sterile coating that can be applied directly onto the skin) cream to periwound (skin around a wound that has been affected by the wound), apply Calcium Alginate (absorbent wound dressing) followed by Optilock (super absorbent dressing which locks in drainage under compression) dressing. -Wrap with Cling (gauze wrap) daily and PRN (as the situation demands). On 2/15/24 between 1:26 P.M. and 2:00 P.M., the surveyor observed an Enhanced Barrier Precaution (targeted glove and gown use during high contact resident care) sign posted outside of Resident #70's room. The surveyor observed Nurse #3 donning (putting on) a disposable gown, gloves, and a mask and then entered the Resident's room. Resident #70 was observed seated in a recliner chair in his/her room, both legs wrapped in gauze (which was stained with a yellow and brown substance) and elevated on the chair footrest. The surveyor observed the following care and services being provided: -Nurse #3 used her gloved hands to lift the Resident's legs and place a towel under both legs, on the footrest of the recliner. -Nurse #3 then used the same gloved hands to reach under her gown and into her pant pocket, removed a pair of scissors, and cut and removed the dressings from the Resident's lower extremities. -The surveyor observed the dressings to be thick, wet and soiled. -Nurse #3 placed the Resident's lower extremities back onto the towel, and dropped the soiled dressings into the trash can. -Nurse #3 was observed to remove her gloves, performed hand hygiene, and don a new pair of gloves. -Nurse #3 then cleansed Resident #70's lower extremities with wound cleanser and completed the dressing change but did not change the towel under the Resident's legs from a soiled towel to a clean towel. -Nurse #3 was observed to remove her gloves, performed hand hygiene, and don a new pair of gloves. -Nurse #3 then pushed the dirty dressings down into the trash can using her right hand, and used the same gloved right hand to reach into her pant pocket. Nurse #3 said she was looking for a Sharpie marker but did not have one with her. -Nurse #3 then removed her gloves, left the room, and entered the hallway still wearing the same gown she wore during the dressing change. -Nurse #3 returned with a Sharpie marker, initialed and dated the dressings on the Resident's legs, placed the Sharpie marker into her pocket, put on a new pair of gloves, and removed the trash bag containing the soiled dressings from the trash can. -The surveyor observed Nurse #3 enter the hallway wearing the same gown she wore during the dressing change and walked toward the trash bin that was positioned down the hallway from the Resident's room to discard the trash bag. -Nurse #3 then removed her gown while in the hallway and placed it in the trash bin located in the hallway. Review of Nurse #3's Skills Competency record indicated annual competencies had not been assessed for the Nurse since June 2020. Further review of Nurse #3's Skills Competency record indicated facility identified periodic skill competencies had not been assessed since May 2022, including: -Hand Washing Competency -Sterile and Clean Dressing Competency Please refer to F880. 2. Review of the facility's policy, titled Administration of IV (intravenous: directly into a vein) Fluids and Medications: Setting Up a Primary Infusion (Hydration or Medication), dated 2011, indicated the following: -Scrub needless connector (device which connects to the end of the midline catheter and enables access for infusion [slow injection of medication into a vein] and aspiration [drawing out by suction] on resident's catheter with antiseptic (substance used to prevent infection) wipe. -Attach flush syringe (medical device used to ensure IV lines stay clean and prevent blockages), aspirate for a blood return to determine patency (openness) and then flush resident's IV catheter with appropriate flush solution as ordered . -Scrub needless connector on resident's catheter with antiseptic wipe. -Attach IV tubing to the needleless connector. - . begin infusion. Review of Resident #70's February 2024 Physician orders indicated: -IV Midline - Insertion site: Right upper arm, . dated 2/12/24. -Cefepime (antibiotic medication) 2 Gram (gm) Solution for injection: Infuse 2 gm by injection route two times per day for five days, dated 2/12/24 and discontinued 2/16/24. -Verify patency: Attach flush syringe, aspirate for a blood return to determine patency prior to administration of medications and solutions ., dated 2/12/24. -Cefepime 2 gm Solution for injection: Infuse 2 gm in 100 milliliters (ml) in 0.9 percent (%) Normal Saline (NS) over 30 minutes intravenously every 12 hours, dated 2/16/24. On 2/16/24 at 9:45 A.M., the surveyor observed Resident #70 was seated in a recliner chair in his/her room, with both lower extremities wrapped in gauze and elevated on the chair footrest. The surveyor observed that the Resident had a midline catheter in place in his/her right upper extremity and an IV pole/pump was positioned to the right of the Resident. The surveyor observed Nurse #4 hanging one bag of Cefepime 2 gm Solution on the IV pole and programming the IV pump. Nurse #4 was observed to scrub the needleless connector of Resident #70's midline catheter with an antiseptic wipe and flush the midline catheter with 10 ml of NS. The surveyor did not observe Nurse #4 performing an aspiration procedure for a blood return to determine patency. Nurse #4 was observed to scrub the needleless connector again with an antiseptic wipe, attach the IV tubing to the needleless connector of Resident #70's midline catheter and start the antibiotic infusion. During an interview on 2/16/24 at 1:39 P.M., Nurse #4 said Nurses were required to flush the residents' IV catheters prior to administering medications through an IV. Nurse #4 did not state how to verify patency of the IV line. When the surveyor asked whether there was a requirement to verify patency, Nurse #4 said there was, but she skipped that step. Nurse #4 then said she should have aspirated for a blood return to verify patency of Resident #70's midline catheter before administering the antibiotic, but she did not. Review of Nurse #4's Skills Competency Record indicated competency assessment relative to care of IV catheters had not been completed since July 2022. During an interview on 2/20/24 at 4:50 P.M., the Staff Development Coordinator (SDC) said nursing competencies were to be assessed on hire and annually, but there were no skill competency assessments on file for Nurse #3 since May 2022. The SDC also said there was no annual or periodic skill competency assessment on file for Nurse #4 relative to the care of IV catheters.

Based on observation, interview, record and policy review, the facility failed to ensure that medications and biologicals for two Resident's (#61 and #70) were appropriately managed by staff in a safe and secure manner. Specifically, the facility staff failed to: 1. For Resident #61, store and/or dispose of medications after Resident refusal. 2. For Resident #70, ensure that medications and biologicals left at the Resident's bedside were stored and secured in locked compartments and not accessible to unauthorized individuals. Findings include: 1.Review of the facility policy titled Storage of Medications, Destruction and Disposal of Medication, revised 11/20, indicated: -drugs and biologicals are stored in the packaging containers or other dispensing systems in which they are received. -The nursing staff is responsible for maintaining medication storage and preparation areas in a clean safe and sanitary manner. Resident #61 was admitted to the facility in January 2024 with the following diagnoses: Depression (a mood disorder where the patient experiences persistent symptoms of depressed mood, sadness, and a loss of interest in daily activities to the point where it affects their normal function such as their appetite, energy levels, concentration levels and sleep) and Anxiety (intense, excessive, and persistent worry and fear about everyday situations). Review of the Minimum Data Set (MDS) assessment, dated 1/21/24, indicated Resident #61 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. Review of Resident #61's Physicians orders, dated 1/16/24, indicated the following medications to be administered by oral (mouth) route at 8:00 A.M. daily: -Atenolol (Beta-blocker, used to treat high blood pressure) 25 milligram (mg) tablet -Bupropion HCL (antidepressant, used to treat depression) 75 mg tablet -Finasteride (alpha-reductase inhibitor, used to shrink an enlarged gland) 5 mg tablet -Folic acid (Vitamin B-complex, used for folic acid deficiency) 1mg tablet -Lisinopril (ace inhibitor, used to treat high blood pressure) 5 mg tablet -Flomax (used to treat BPH) 0.4 mg tablet -Thiamine HCL (vitamin, needed by the body to turn food into energy) 100 mg -Aspirin (nonsteroidal anti-inflammatory drug [NSAID] used to reduce pain, fever, and/or inflammation) 81 mg tablet During an observation and interview on 2/20/24 at 2:29 P.M. with Nurse #3 on the third floor unit, Nurse #3 unlocked medication cart two (2) and the surveyor observed a medication cup filled with several prepared medications in the top drawer of the medication cart. Nurse #3 said the prepared medications belonged to Resident #61. Nurse #3 further said that Resident #61 had refused the medications in the morning and that the medications should have been disposed of [wasted] when he/she refused them in the morning and not left in the medication cart. Review of the February 2024 MAR (Medication Administration Record) indicated that the 8:00 A.M. medications that were dispensed on 2/20/24 for the Resident and documented as refused by the Resident, was signed off on the MAR as 'refused' by the Nurse. Nurse #3 kept the medications that were refused by Resident #61 stored in the medication cart from the time of the morning medication pass to 2:29 P.M. 2. Review of the facility's policy titled Storage of Medications, dated 2001 and revised November 2020, indicated: -The facility stores all drugs and biologicals in a safe, secure, and orderly manner. -Drugs and biologicals used in the facility are stored in locked compartments . -Only persons authorized to prepare and administer medications have access to locked medications. Resident #70 was admitted to the facility in November 2019 with a diagnosis of rash and other non-specific Skin Eruption (abnormal outbreak on the skin's surface as a symptom of disease) and Dementia (general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Review of a Minimum Data Set (MDS) Assessment, dated 11/22/23, indicated Resident #70 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status Score (BIMS) of three out of 15 total possible points. Review of Resident #70's February 2024 Physician orders indicated: -Nystatin (antifungal antibiotic used to treat skin infections caused by yeast) Powder: Apply by topical (pertaining to a specific part of the body) to ABD (abdominal) fold and groin after incontinent care every day at 7:00 A.M. - 3:00 P.M.[day shift]; 3:00 P.M. - 11:00 P.M.[evening shift] for 14 days, dated 2/7/24. -Hydrocerin with Petrolatum (medication used as a moisturizer to treat or prevent dry, rough, scaly, itchy skin and skin irritations) Topical Cream: Apply one applicatorful [sic] by topical route two times per day to the affected areas, dated 2/12/24. On 2/14/24 at 9:31 A.M., the surveyor observed the following in Resident #70's room: -Resident #70 was seated in his/her recliner chair. -One 30 milliliter (ml) bottle of Saline Spray Maximum Strength Oxymetaloine HCl 0.05% (decongestant that shrinks blood vessels in the nasal passages) Nasal Decongestant on the nightstand. -One container of Nystop (Nystatin) Topical (applied directly to a part of the body) Powder 100,000 units (u)/gram (gm) on the nightstand. -One 106 gm jar of Hydrocerin with Petrolatum Topical Cream on the nightstand. On 2/15/24 from 11:08 A.M. through 12:00 P.M., the surveyor observed the following in Resident #70's room: -The Resident was seated in his/her recliner in the room and had a visitor. -The Resident's visitor periodically walked around the room. -One 30 milliliter (ml) bottle of Saline Spray Maximum Strength Oxymetaloine HCl 0.05% Nasal Decongestant remained on the nightstand. -One container of Nystop Topical Powder 100,000 units (u)/gram (gm) remained on the nightstand. -One 106 gm jar of Hydrocerin with Petrolatum Topical Cream remained on the nightstand. During an interview on 2/15/24 at 2:06 P.M., Nurse #3 said all medications and biologicals were to be stored in locked compartments and should not be left in any resident rooms. Nurse #3 said all medications and biologicals should be stored properly to ensure that only the staff with the authority to administer the medications and biologicals to residents had access. Nurse #3 said the Saline Spray, Nystop Topical Powder, and Hydrocerin with Petrolatum should have been stored in a secure manner and not left on the Resident's nightstand.

Based on record and policy review, and interview, the facility failed to ensure that the required members were included in the Quality Assessment and Performance Improvement (QAPI) committee quarterly meetings. Specifically, the facility failed to provide evidence that the Infection Preventionist (IP) attended three out of the four quarterly QAPI meetings, as required. Findings include: Review of the facility policy for Quality Assessment and Assurance Committee, last revised 11/28/18, indicated that the Quality Assessment and Assurance (QAA) Committee will consist of the following individuals: -Director of Nursing -Medical Director or his/her designee -At least three other members of the facility's staff, one of whom must be the Administrator, Owner. A board member or other individual in a leadership role, and -Infection Preventionist (effective 11/28/19). During a meeting on 2/20/24 at 3:37 P.M., the surveyor reviewed the quarterly QAA Committee sign in sheets provided by the facility with the Administrator, and the Director of Nurses (DON). The quarterly QAA Committee sign in sheets did not indicate any evidence that the IP had attended the quarterly QAPI meetings as required, that were held on 7/27/23, 10/26/23 and 1/25/24. During an interview on 2/20/23 at 3:54P.M., the DON said that the IP was a required member of the QAA Committee and should have attended the quarterly QAPI meetings but did not. The DON further said that there had been no other team member certified as an IP or assigned to present on the IP's behalf during the quarterly QAPI meetings held on 7/27/23, 10/26/23 and 1/25/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the facility's policy titled, Transmission-based (Isolation) Precautions, dated 2023, indicated: -Facility staff will apply Transmission-Based Precautions, in addition to standard precautions, to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission. -Nursing staff may place residents with suspected or confirmed infectious diarrhea, influenza, or symptoms consistent with a communicable disease on transmission-based precautions/isolation empirically while awaiting confirmation. -An order for transmission-based precautions/isolations will be obtained for residents who are known or suspected to be infected or colonized with infectious agents that require additional controls to prevent transmission effectively. -Signage that includes instructions for use of specific PPE will be placed in a conspicuous location outside the resident's room. -Based upon the pathogen or clinical syndrome, if there is risk of exposure of mucous membranes or substantial spraying of respiratory secretions is anticipated, gloves and gown as well as goggles or face shield should be worn. Resident #102 was admitted to the facility in January 2024 with diagnoses including Periprosthetic fracture (a broken bone that occurs around an orthopedic implant) with wound infection, Vancomycin Resistance Enterococcus (VRE: a serious infection caused by bacteria that are resistant to the antibiotic Vancomycin) in the wound and Cough. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #102 was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15. Review of Resident #102's Physician's orders dated 2/13/24, indicated Influenza A/B swab (a laboratory test) with diagnosis of Acute Cough. On 2/14/24 at 9:15 A.M., the surveyor observed a Contact Precaution sign outside the resident's room. The Contact Precaution sign indicated: -Clean hands, including before entering and when leaving the room. -Providers and staff must also put on gloves before room entry, discard gloves before room exit. -Put on gown before room entry, discard gown before room exit. During an observation at the time, the surveyor observed several staff members entering and exiting Resident #102's room without wearing gowns. During an interview on 2/14/24 at 11:00 A.M., Resident #102 said that he/she had been coughing and the facility staff had obtained a sputum sample and sent it to the lab as they were questioning whether he/she had Influenza. Resident #102 said he/she had a fever and was being treated for an infection to his/her right hip with intravenous (IV - medications through the vein) antibiotics. Review of the Physician's orders for February 2024 indicated an order for Droplet Precautions for Influenza A had been added on 2/14/24. On 2/15/24 at 7:24 A.M., the surveyor observed that a Droplet Precautions sign, in addition to a Contact Precautions sign were posted outside Resident #102's bedroom door. The Droplet Precaution sign indicated: -Everyone must clean hands before and after entering the room. -Make sure their eyes, nose and mouth are fully covered before room entry, remove face protection before the room exit. On 2/15/24 at 9:07 A.M., the surveyor observed Certified Nurses Aide (CNA) #1 entering Resident #102's room wearing a face mask but no gloves or eye protection. CNA #1 was observed to exit the room with the Resident's breakfast tray and placed the tray in the unit kitchenette. During an interview at the time, CNA #1 said that all new residents are placed on precautions for five days when they are newly admitted , and she was not aware of any additional precautions that needed to be taken. During an interview on 2/15/24 at 9:16 A.M., Nurse #1 said that Resident #102 had tested positive for the Influenza A virus and had been placed on Droplet Precautions. Nurse #1 further said Resident #102 was started on Droplet Precaution after the results for Influenza A had been obtained the evening of 2/14/24. During an interview on 2/15/24 at 9:25 A.M., UM #1 said Droplet Precautions were initiated after the lab results for Influenza had been obtained on 2/14/24 and that CNA #1 should have worn gloves and face shield before entering the Resident's room. During an interview on 2/15/24 at 9:52 A.M., the IP said Droplet Precautions were initiated for Resident #102 after the positive result for Influenza had been obtained and that the Droplet Precautions should have been initiated when the Resident became symptomatic and an order was obtained for the Influenza swab, but was not done as required. During a follow-up interview on 2/15/24 at 2:16 P.M., the IP said CNA #1 should have worn eye protection and gloves (as indicated on the Contact Precautions and Droplet Precautions signs) when she entered Resident #102's room. Based on observation, interview, policy and record review, the facility failed to adhere to infection control practices and standards to mitigate the spread of infection during a COVID-19 outbreak and for two Residents (#70 and #102). Specifically, the facility staff failed to: 1. Implement timely outbreak testing for COVID-19 when the facility experienced an outbreak of COVID-19. 2. Adhere to infection control practices during wound dressing changes and implement Contact Precautions (gown and gloves for all interactions that may involve contact with the patient or the patient's environment) for one Resident (#70) when the Resident required wound dressing changes to his/her bilateral lower extremities and required Contact Precautions due to the presence of a wound infection. 3. Implement timely Droplet Precautions (precautions used for patients known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by a patient who is coughing, sneezing, or talking) on the Post Acute Unit ([NAME]) when one Resident (#102) presented with symptoms of respiratory infection, then tested positive for Influenza. Findings include: 1. Review of the Centers for Disease Control and Prevention (CDC) document titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 5/8/23, indicated: -Asymptomatic patients with close contact with someone with SARS-CoV-2 infection should have a series of three viral tests for SARS-CoV-2 infection. -Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. -This will typically be at Day 1 (where day of exposure is day 0), Day 3, and Day 5. Review of the Massachusetts (MA) Department of Public Health (DPH) memorandum titled Update to Infection Prevention and Control Considerations When Caring for Long-Term Care Residents, including Visitation Conditions, Communal Dining, and Congregate Activities, dated 5/10/23, indicated: -Long-term care facilities are required to perform outbreak testing of residents and staff as soon as possible when a case is identified. -If the long-term care facility identifies that the resident or staff member's first exposure occurred less than 24 hours ago, then they should wait to test until 24 hours after any exposure, if known. -Once a new case is identified in a facility, following outbreak testing, long-term care facilities should test exposed residents and staff at least every 48 hours on the affected unit until the facility goes seven days without a new case unless a DPH epidemiologist directs otherwise. Review of the facility's policy titled COVID-19 - Infection Prevention and Control Measures, undated, indicated the facility follows infection prevention and control practices recommended by the CDC to prevent the transmission of COVID-19 within the facility. Review of the facility's as-worked Nursing Daily Schedule Report, dated 2/14/24, indicated Nurse #5 worked the 7:00 A.M. through 3:00 P.M. (Day) shift that day on the [NAME]. Review of the facility's document titled 2024 Staff Positives, undated, indicated Nurse #5 tested positive for COVID-19 on 2/15/24. During an interview on 2/16/24 at 12:55 P.M., the Infection Preventionist (IP) said Nurse #5 tested positive for COVID-19 on 2/15/24 and had last worked at the facility on 2/14/24. The IP said Nurse #5 was assigned to care for six residents on the [NAME], so those residents were being tested and monitored for signs and symptoms of COVID-19, and staff who had worked on the [NAME] with Nurse #5 on 2/14/24 were also being tested for COVID-19. The IP further said outbreak testing was scheduled to start for those residents and staff members on 2/17/24 and would continue every 48 hours until the facility identified no new positive COVID-19 cases for a period of seven days. During an interview on 2/20/24 at 11:45 A.M., the IP said outbreak testing for COVID-19 was conducted on 2/17/24 and 2/19/24 for residents and staff identified as having been exposed to Nurse #5 on 2/14/24. The IP said she was not aware of any staff or residents with COVID-19 symptoms. The IP said she was not sure if any testing had resulted in any new positive COVID-19 cases at that time, but the Director of Nurses (DON) would know. At this time, the Director of Nurses (DON) joined the interview and said when an outbreak of COVID-19 was isolated to one unit, outbreak testing for residents and staff on that unit would be implemented and that the facility had 48 hours to initiate this testing. The DON said the facility would then continue testing affected residents and staff every 48 hours until no new cases of COVID-19 were identified over a period of seven days. The DON said outbreak testing began for residents and staff on 2/17/24 and more testing was conducted on 2/19/24, and that no new cases of COVID-19 had been identified. During a follow-up interview on 2/20/24 at 1:53 P.M., the DON said the facility adhered to CDC and MA DPH guidance relative to guidelines for COVID-19 testing. The surveyor reviewed the CDC and MA DPH guidelines for COVID-19 outbreak testing with the DON and the DON said she thought she had 48 hours to initiate outbreak testing after a positive case of COVID-19 was identified. The DON further said the facility had no contact with their Epidemiologist for guidance during this outbreak and that initiating outbreak testing timely was important to help mitigate transmission of COVID-19 in the facility. 2. Resident #70 was admitted to the facility in November 2019 with a diagnosis of rash and other non-specific Skin Eruption (abnormal outbreak on the skin's surface as a symptom of disease). Review of the facility policy titled Infection Control, dated 2001 and revised July 2014, indicated the following: -The facility's infection control . practices were intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. -Objectives of the infection control practices included establishing guidelines for implementing . Standard (used for all resident care) and Transmission-Based (used to reduce the risk for spread of infection) Precautions. Review of the Centers for Disease Control and Prevention (CDC) guidance titled Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 11/29/22, indicated the following: -Adherence to infection prevention and control practices is essential to providing safe and high-quality patient care across all settings where healthcare is delivered. -Provide job-specific, infection prevention education and training to all healthcare personnel for all tasks. -Require training before individuals are allowed to perform their duties and at least annually as a refresher. -Require healthcare personnel to perform hand hygiene for the following clinical indications: >Immediately before touching a patient >Before moving from work on a soiled body site to a clean body site on the same patient >After touching a patient or the patient's immediate environment >After contact with blood, body fluids or contaminated surfaces >Immediately after glove removal -Remove and discard personal protective equipment (PPE) . upon completing a task before leaving the patient's room or care area. Review of Resident #70's Wound Care Plan, dated 9/12/23, indicated the Resident had venous wounds (wounds that develop due to poor blood supply) to his/her bilateral lower extremities. Review of Resident #70's Wound Infection Care Plan, dated 2/13/23, indicated: -The Resident had a current infection of Pseudomonas (environmental bacteria) in his/her bilateral lower extremities. -Staff were to maintain Enhanced Precautions (infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) that involve gown and glove use during high-contact resident care activities). Review of Resident #70's February 2024 Physician orders indicated an order, initiated 1/5/24, as follows: -Cleanse bilateral lower extremities with wound cleanser, apply Triad cream to periwound (area of skin surrounding a wound that is affected by the wound), apply Calcium Alginate (highly absorbent dressing) followed by Optilock (highly absorbent dressing which locks in drainage under compression) dressing. -Wrap with cling (gauze wrap) daily and PRN (as the situation demands). On 2/15/24 between 1:26 P.M. and 2:00 P.M., the surveyor observed the following during a wound dressing change: -Nurse #3 put on a disposable gown, gloves, and a mask while outside of Resident #70's room. -Resident #70 was seated in a recliner chair in his/her room, with both legs elevated on the chair's footrest. -The Resident's legs were wrapped with gauze and the front of the gauze was stained with yellow and brown colored substance. -Nurse #3 retrieved a towel from Resident #70's closet, used her gloved hands to lift the Resident's legs, and placed the towel on the footrest of the recliner, under the Resident's legs. -Nurse #3 then used the same gloved hands to reach under her gown and into her pant pocket, removed a pair of scissors, and began cutting the gauze off of the Resident's lower extremities. -Nurse #3 removed the gauze, then removed the Optilock dressings which were thick and wet, placed the Resident's lower extremities back onto the towel, and dropped the dressings into the trash can. -Nurse #3 removed her gloves, performed hand hygiene, and donned a new pair of gloves. -Nurse #3 proceeded to cleanse Resident #70's lower extremities with wound cleanser and completed the dressing change but did not change the soiled towel under the Resident's legs to a clean towel. -Nurse #3 removed her gloves, completed hand hygiene and donned a new pair of gloves, then pushed the dirty dressings down into the trash can using her right hand. -Nurse #3 then used the same gloved right hand to reach into her pant pocket. -Nurse #3 said she was looking for a Sharpie marker but did not have one with her. -Nurse #3 then removed her gloves and left the room, entering the hallway wearing the same gown she wore during the dressing change. -Nurse #3 returned with a Sharpie marker, initialed, and dated the dressings on the Resident's legs, placed the Sharpie marker into her pocket, donned a new pair of gloves, and removed the trash bag containing the soiled dressings from the trash can. -Nurse #3 then entered the hallway wearing the same gown she wore during the dressing change and walked toward the trash bin that was positioned down the hallway away from the Resident's room to discard the trash bag. -Nurse #3 then removed her gown and placed it in the trash bin in the hallway, and then performed hand hygiene. During an interview on 2/15/24 at 2:06 P.M., Nurse #3 said that Resident #70 required Enhanced Precautions but had been changed to Contact Precautions due to Pseudomonas in his/her lower extremity wounds and that the signage for Contact Precautions had just not been posted as yet. Nurse #3 said Resident #70 had been experiencing a large amount of drainage from his/her lower extremity wounds and that the Optilock dressings were saturated with drainage and were heavy when she removed them from the Resident's legs. Nurse #3 said she would typically have replaced the soiled towel under the Resident's legs after removing the soiled dressings and cleaning the Resident's wounds, but that residents were only allotted two bath towels per shift, so she did not replace it during the dressing change. When the surveyor asked if there was a shortage of towels, the Nurse said there was not, and when asked if residents could have more than two towels per shift, the Nurse said she imagined they could. Nurse #3 also said she should have removed her gown after completing the dressing change, prior to entering the hallway, but she did not. During an interview on 2/15/24 at 3:23 P.M., with the Infection Preventionist (IP) and Unit Manager (UM) #2, the UM said Resident #70 had been placed on Enhanced Precautions after a recent return from the hospital. UM #2 said that Contact Precautions had been initiated for the Resident on 2/15/24 due to the Resident having Pseudomonas in his/her lower extremity wounds. UM #2 said she was not aware of any limitation on how many bath towels were allowed for residents and that Nurse #3 should have removed and replaced the towel used during the wound dressing change. The IP said she had done more research on Pseudomonas and due to a concern for multi-drug resistant organisms (MDROs), it was determined that Contact Precautions should be implemented in order to help reduce the risk of spreading infection. The IP further said whether a Resident required Enhanced or Contact Precautions, all staff were required to remove their gowns and gloves prior to leaving a Resident's room, contain the gown and gloves in a bag, then transport it to the trash bin in the hall if there was no trash bin located in the room. The IP said Nurse #3 should have followed this procedure. The IP also said Nurse #3 should have removed her gloves and performed hand hygiene after touching the soiled dressings in the trash can and before reaching into her pant pocket. On 2/15/24 at 4:40 P.M., the surveyor observed that a Contact Precaution sign was placed outside of Resident #70's room. The surveyor also observed a three-drawer bin located outside the room, under the Contact Precaution sign, which contained disposable gowns, gloves, and masks. The surveyor observed CNA #2 enter Resident #70's room without donning a gown and gloves. CNA #2 was observed assisting the Resident to drink from a cup, talked with the Resident, then moved the call bell from the bed to the chair where the Resident was seated. CNA #2 then exited the room and did not perform hand hygiene. During an interview at the time, CNA #2 said Resident #70 had been on Enhanced Precautions and was now on Contact Precautions, but that there was no change in what staff were required to use for PPE. CNA #2 said Contact Precautions meant staff had to put on a gown and gloves only when they performed high contact care and that neither a gown nor gloves were required upon room entry or to handle items within the Resident's environment. During an interview on 2/15/24 at 4:45 P.M., UM #2 said Resident #70 was on Contact Precautions and that staff were required to don a gown and gloves for high contact care only. The surveyor reviewed the Contact Precaution sign outside of Resident #70's room with UM #2. UM #2 read the sign, then said since the sign indicated a gown and gloves were required for room entry, that was what needed to be done and she would need to educate staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review, the facility failed to store food in accordance with professional standards for food service safety in the main kitchen and maintain a refrigerator temperature log for one out of four kitchenettes in the facility. Specifically, the facility staff failed to ensure the following: -in the main kitchen: >that expired food items were discarded. >that food items were labeled, dated, and included an expiration date after being opened. -in the Post Acute Unit ([NAME]) kitchenette: >that temperature logs were maintained for the kitchenette refrigerator. >expired food was discarded from the refrigerator by the discard date. Findings include: Review of the facility's policy titled Dining Services, dated 4/1/06, indicated: -Food will be properly stored to preserve flavor, nutrition, and appearance. -Dry bulk foods are to be stored in plastic containers with tight covers, or bins that are easily sanitized. The container should be clearly labeled. -Refrigerated storage temperatures should be 40 degrees or below. -Thermometers placed so as to be easily visible for checking and in the upper third of storage unit [of the refrigerator]. Temperatures will be recorded on the Freezer/Cooler Temperature Record [log] on a regular basis. -Food should be covered, dated and stored loosely to permit air circulation. -All foods in the freezer are to be wrapped in moisture-proof wrapping or placed in a suitable container, to prevent freezer burn. They are to be labeled and dated. On 2/14/24 at 7:19 A.M., during an observation of the main kitchen, the surveyor observed in the walk-in freezer that eight (8) pies were on cookie sheets, and placed on a rack. The surveyor further observed that the 8 pies were not covered and had no identifying labels, use by dates or expiration dates. On 2/15/24 at 11:15 AM., during an inspection of the main kitchen with the Food Service Director (FSD), the following was observed: -in the walk-in feezer: >4 cream pies with no covers, dates, or labels. >A large tray of breadsticks that was not labeled and not dated. -in the walk-in refrigerator: >A box of tortillas with a manufacturer date of 11/22/23, but no expiration date, the box was opened and the tortillas partially removed and re-wrapped with no date indicating when the box had been opened. >A large tray of fish with a sticker indicating it was taken out of the freezer on 2/11/24, to be discarded 2/14/24. -in the kitchen area: -An open box of wine with no date indicating when it was opened. During an interview on 2/15/24 at 12:15 P.M., the FSD said the 4 cream pies and breadsticks should have been dated, labeled, and covered but they were not. The FSD said the fish in the walk-in refrigerator should have been discarded on 2/14/24 but it was not. The FSD further said the box of wine should have been dated with a date opened sticker, but it was not. On 2/15/24 at 4:29 P.M., during an inspection of the [NAME] kitchenette with Unit Manager (UM) #1, the following was observed in the refridgerator: -a Styrofoam cup with a lid labeled maple syrup, dated 2/1/24 -8 cans of pomegranate juice -6 cans of vegetable juice -5 bottles of nutritional health shakes -the refrigerator felt warm to touch. During an interview at the time, UM #1 said the kitchenette refrigerator was used to store food for the unit residents. UM #1 also said that the refrigerator temperature log was managed by the Dietary Department but was unable to locate the thermometer in the refrigerator or provide evidence of a temperature log. UM #1 further said that the refrigerator felt warm to touch. During an observation and interview on 2/15/24 at 4:50 P.M., in the [NAME] kitchenette with the FSD, the FSD said the refrigerator was managed by the nursing staff. The FSD further said there was no thermometer in the refrigerator or temperature log (with the refrigerator temperatures). The FSD also said that the refrigerator felt warm to touch. During a follow-up observation and interview on 2/16/24 at 1:49 P.M., in the walk-in refrigerator of the main kitchen, the FSD said the box of tortillas had expired on 2/5/24 and should have been discarded but they were not. On 2/16/24 at 7:56 A.M., the surveyor observed that there was a thermometer in the kitchenette refrigerator on the [NAME], and the temperature on the thermometer read 46 degrees. The surveyor also observed a temperature log that was initiated on 2/15/24 with a documented temperature reading of 42 degrees. The surveyor further observed a refrigerator temperature reading documented on 2/16/24 of 46 degrees. During an interview on 2/20/24 at 8:58 A.M., the Director of Nurses (DON) said the dietary department was responsible for managing the refrigerator temperature logs and that there should have been a thermometer and a temperature log record but there had not been. The DON further said that the refrigerator temperature should have been 40 degrees or below, but it was not.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), who was severely cognitively impaired and dependent on staff for care, the Facility failed to ensure staff implemented and followed their Abuse Prohibition Policy, when on 10/05/23 Certified Nurse Aide (CNA) #2 witnessed an alleged incident of potential physical abuse involving CNA #1 and Resident #1, but did not immediately report the incident per facility policy, and waited until the following day to report it, therefore placing other residents at risk for potential abuse. Findings include: Review of the Facility's Policy, dated as effective 09/20/18, titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property indicated that all staff who suspect abuse, neglect, mistreatment and or misappropriation must immediately make an oral report to his or her supervisor. The Policy indicated the alleged perpetrator will be immediately removed and the resident will be protected. The Policy indicated the employees accused of alleged abuse will be immediately removed from the facility and will remain removed pending the results of a thorough investigation. Resident #1 was admitted to the Facility in October 2022, diagnoses included vascular dementia, anxiety disorder and aphasia (a disorder that causes a person to have trouble expressing their thoughts with spoken and/or written language.) Review of Resident #1's most recent Annual Minimum Data Set (MDS) Assessment, dated 09/05/23, indicated that Resident #1's cognitive patterns were severely impaired and that he/she was dependent on two staff members for mobility and Activities of Daily Living (ADLs). Review of the Facility's Incident Report, dated 10/06/23, indicated the facility was made aware (on the afternoon of 10/06/23) of an allegation of possible physical abuse, involving CNA #1 and Resident #1, that had occurred at approximately 8:30 P.M. on 10/05/23. The Report indicated that CNA #2 alleged that CNA #1 put a shirt on Resident #1's face to stop him/her from spitting. Review of the Facility's Nursing Schedule, dated 10/05/23, indicated CNA #1 and CNA #2 worked from 3:00 P.M. to 11:00 P.M. (for the entire shift). During an interview on 11/01/23 at 2:58 P.M. with Certified Nurse Aide (CNA) #2 (which also included a review of her written witness statement dated 10/10/23), CNA #2 said that sometime between 7:00 P.M. and 8:00 P.M. on 10/05/23, she observed CNA #1 put a shirt over Resident #1's face to prevent him/her from spitting during care. CNA #2 said that CNA #1 held the shirt firmly in place over Resident #1's face, with one hand, for approximately 8-10 seconds. CNA #2 said that she told CNA #1 that holding a shirt over Resident #1's face was not okay. CNA #2 said she reported the alleged incident to someone in the Human Resources (HR) Department on 10/06/23 at approximately 3:00 P.M., (the following day), and they immediately notified Unit Manager #1. CNA #2 said she had not immediately reported the incident on 10/05/23, because she had not known the proper procedure for reporting suspected abuse. During an interview on 11/01/23 at 4:38 P.M., Nurse #1 said he worked the evening shift on 10/05/23. Nurse #1 said that at the time of the alleged incident, CNA #2 was on orientation and she was shadowing CNA #1. Nurse #1 said no one reported any incidents to him on 10/05/23, and he did not recall if anything unusual happened that evening. During an interview on 11/01/23 at 3:25 P.M., Unit Manager #1 said that around 3:00 P.M. on 10/06/23, someone from HR notified her that CNA #2 had just reported an allegation of abuse. Unit Manager #2 said she immediately went to the HR Department to meet up with CNA #2. The Unit Manager said that CNA #2 accompanied her to the Administrator's office where she (CNA #2) reported an incident of potential physical abuse that occurred on 10/05/23, involving CNA #1 and Resident #1. During an interview on 11/01/23 at 4:00 P.M., the Administrator said CNA #2 should have immediately reported the incident involving potential physical abuse to a supervisor on 10/05/23, but she had not reported the incident until 10/06/23. The Administrator said CNA #1 worked the remainder of her shift (approximately 2.5 hours) on 10/05/23 and was not suspended until 10/06/23 when the incident was reported, therefore the residents were not immediately protected from potential abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure that its staff assessed two Residents (#407 and #66), out of a total sample of 23 residents for self-administration of medication, while medication was not stored safely and securely at the bedside. Specifically, the facility staff failed to determine if self-administration of medications was clinically appropriate for Residents #407 and #66. Findings include: Review of an undated facility policy, titled Self-Administration of Medications, included but was not limited the following: -Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. - If a resident expresses their wishes to self-administer medication, the interdisciplinary team (IDT) assesses the resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. -If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely self-administer medications is re-assessed periodically based on changes in the resident's medical and/or decision-making status. -Residents who are identified as being able to self-administer medications must sign the consent form. -For self-administering residents, the nursing staff is responsible for documenting that medications are taken. -Self-administered medications are stored in a safe and secure place, which is not accessible by other residents 1. Resident #407 was admitted to the facility in August 2022 with a diagnosis of dry eye syndrome of unspecified lacrimal gland (a scratchy feeling in the eyes which occurs when the tears fail to keep the eye surface adequately lubricated). Review of a Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #407 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. On 8/23/22 at 8:28 A.M., the surveyor observed two bottles of eye drops located on the bedside table while the Resident was lying in the bed. Resident #407 said that he/she used the eye drops as needed for extreme dry eyes, and he/she was currently using them without staff assistance. The two bottles were labeled as Anti-Microbial Lid and Lash Solution and Systane eye drops. Review of the August 2022 Physician's orders indicated an order, initiated on 8/12/22, for Systane (propylene glycol) 0.4%-0.3% eye drops (a solution specially formulated to moisten the eyes) instill 1 drop by ophthalmic (eye) route in each eye every 4 hours as needed. Review of the Self-Administration of Medication Consent and Assessment, signed 8/12/22, indicated the determination of the Resident's ability to self-medicate was not assessed and Resident #407 indicated that they wished to have a Nurse administer medications. During an interview on 8/23/22 at 9:35 A.M.with Nurse #1, the two bottles of eye medications were observed at the bedside of Resident #407 and Nurse #1 said she didn't know why they were left there. She further said the policy was to obtain an order for self-administration of medication and that the patient (Resident) would be required to do a return demonstration before a determination of self-administration would be made. On 8/23/22 at 9:40 A.M., Nurse #1 reviewed the medical record with the surveyor and said there was no evidence that a self-administration form for the eye drops was completed. 2. Resident #66 was admitted to the facility in January 2021. Review of a MDS assessment, dated 7/12/22, indicated Resident #66 was cognitively intact as evidenced by a BIMS score of 15 out of 15. On 8/23/22 at 9:09 A.M., the surveyor observed Resident #66 eating breakfast in his/her room. There was a cup on the bedside table containing several pills. The surveyor asked about the medications in the cup and Resident #66 said that Nurse #2 left them for him/her because he/she preferred to take them after breakfast. Review of a facility Clinical Self-Administration of Medication Informed Consent and Assessment form, signed by Resident #66 on 1/2/21, indicated that the Resident wished to have the Nurse administer his/her medications. The back of the form, titled Assessment of Resident's Cognitive, Physical and Visual Ability to Self-Administer Medications, was left blank. Review of the August 2022 Physician's orders indicated there was no order to self-administer medications. During an interview on 8/23/22 at 9:15 A.M., Nurse #2 said that he left Resident #66's 8:00 A.M. medications on the bedside table because Resident #66 liked to take them after eating breakfast. He further said that he administered the eye drops and hearing aids and left the remaining medications in the cup for the Resident to self-administer. Review of the August 2022 Medication Administration Record (MAR) indicated that Resident #66 was administered the following medications on 8/23/22 at 8:00 A.M.: -Metamucil 3.4 grams/5.4 gram oral powder (fiber supplement) -Artifical tears, (eye drops) -Metoprolol succinate extended release 150 milligrams (mg), (beta blocker) -Vitamin D3 50,000 International Units (IU), (vitamin D supplement) -Amlodipine 5 mg, (blood pressure medication) -Tylenol extra strength 1000 mg, (pain reliever) -Uloric 40 mg, (decreases uric acid in body) -Pantoprazole delayed release 20 mg, (treats acid reflux) -Ferrous gluconate 325 mg, (iron supplement) During an interview on 8/24/22 at 10:46 A.M., the Infection Preventionist (IP) reviewed Resident #66's medical record with the surveyor and said there was no evidence that the Resident had been assessed to safely self-administer medications and there was no Physician's order for self-administration. The IP reviewed the Clinical Self-Administration of Medication Informed Consent and Assessment form, signed by the Resident on 1/2/21, and said the Resident indicated on the form that he/she wanted the Nurse to administer medications therefore, an assessment was not completed. She said an assessment must be completed when a Resident indicates that they wish to self-administer medications to determine if it would be clinically appropriate. The IP said that Nurse #2 should not have left the medications at the Resident's bedside for self-administration when there was no Physician's order and an assessment had not been completed.

b) On 8/24/22 at 9:10 A.M., during an inspection of the refrigerator located on Unit 3 between Pods #1 and #2, the surveyor observed the following: - three plates covered with plastic wrap not labeled with contents or dated - an unsealed box containing a partial cake that was not labeled or dated During an interview on 8/24/22 at 9:10 A.M., Dietary staff #3 said that the three plates contained brownies and that they should have a label and date on the outer plastic wrap. She also said that the unsealed cake box should have a label and date on it to indicate which Resident the cake belonged to and the date it was brought into the facility. Dietary staff #3 said that any unlabeled food items should have been discarded. Based on observation, policy review and interview the facility failed to ensure that its staff stored, prepared, distributed, and served food in accordance with professional standards for food service safety. Specifically: 1) The staff failed to monitor and record food temperatures, and 2) Date refrigerated food items. Findings include: Review of the facility policy titled Temperature Monitoring, revised 9/2009, included: The objective was to reduce the risk of food borne illness. Food temperatures will be monitored and recorded before serving. Review of the facility policy titled Handling Leftover Food, revised 9/2009, included: Leftover foods will be handled in an appropriate food safe manner to minimize risk of food borne illness. Refrigerated items should be dated and used within seventy-two hours after opening. 1. The facility failed to ensure that its staff monitored and recorded food temperatures. On 8/23/22 at 7:30 A.M., during the initial tour of the kitchen, the surveyor observed the breakfast line was in process. The surveyor asked Dietary Staff #2 if he had taken the temperatures of the breakfast foods before he started to serve. Dietary Staff #2 said he did but did not write the temperatures down and did not know where the food temperature logbook was located. During an interview on 8/23/22 at 7:40 A.M., Dietary Staff #1 said the food temperature log was in her office. The surveyor and Dietary Staff #1 entered her office, she opened the temperature logbook and attempted to find temperatures for breakfast, lunch, and dinner. Dietary Staff #1 said there were no documented temperatures for any meals during the past two months. The surveyor asked when the last time food temperatures were taken, and she said she did not know. Dietary Staff #1 said temperatures should be taken and documented for all meals. 2. The facility failed to ensure that its staff dated refrigerated items in a) the kitchen and b) on one out of four Resident units. a) On 8/23/22 at 7:50 A.M., during a follow-up tour of the kitchen, the surveyor observed five plated salads and three sandwiches that were not dated, in the condiment refrigerator. Dietary Staff #1 said all plated items should be dated and thrown away if not used within three days, and all refrigerated items should be dated when opened. The surveyor observed the following in the walk-in refrigerator: -an undated plastic container of whip cream -one block of blue cheese, not dated when opened -one bag of shredded parmesan cheese, not dated when opened -one bag of shredded cheddar cheese, not dated when opened