Based on interview and record review, the facility failed to evaluate and document the clinical rationale for the continuation of a PRN (as needed) anti-anxiety medication beyond 14 days and failed to identify a stop date of the medication for one resident (R6) of five residents reviewed for unnecessary psychotropic medication use, resulting in potential for overuse of the medication.Facts and Findings include: Record review of R6 quarterly minimum data Set (MDS) revealed Brief Interview of Mental Status (BIMS) of 2, defined as cognitively severely impaired never/rarely made decisions. Medical diagnosis included: Alzheimer's, COPD, Anxiety, Residual Schizophrenia, ASHD, Colon cancerRecord review of R6 physician order from 04/09/2025 for Ativan 0.5 mg tablet by mouth daily PRN (as needed for) anxiety, may give 1/2 hour prior to showers. Signed by NP F. There is no stop date / review date for this order.Record review of drugs.com internet search for Ativan (lorazepam) drug class: benzodiazepine anticonvulsant is used for anxiety disorders and insomnia.Record review of the latest Psychiatry note dated 6/25/25, according to the note the order for Ativan remains unchanged, it has no end date or next review noted. The medications heading of this note reads the active order as Ativan 5mg, take 1 tab, status unchanged. reconciled by NP G. The assessment and plan state continue Ativan 0.5 mg, note signed by NP G.On 8/6/25 at ~3:00pm Interview with DON, requested Psychotropic medication policy to egress. Asked what the policy on duration for PRN Psychotropic medications is, she states that medication needs to be reviewed every 14 days if it is to continue. When asked specifically about R6 PRN Ativan order from 4/09/25 with the last review date of 6/25/25, she states well he really gets the PRN mostly on shower days, he gets really upset on those days and I try to review the psychiatry notes and recommendations when we get them, you can see I put that addendum in the chart for this psychiatry note because the note said Ativan 5 mg in one spot and continue with Ativan 0.5mg in another, the original order was for Ativan 0.5 mg. She says, it was just a typo error, and no dose change was made, DON acknowledged that there is still no end or review date to this Ativan order/continued order. Inquired if a PRN Psychotropic med should have an end date, then, she replied well for antipsychotics yes, but Ativan isn't an antipsychotic it is for anxiety, so it does not need a 14-day review or end date. According to a record review of the facilities policy on Psychotropics medications:A Psychotropic drug is one that affects brain activities associated with mental processes and behavior. Psychotropic drugs include but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. PRN orders for psychotropic medications, excluding antipsychotic medications, shall be limited to no more than 14 days, unless the attending physician or prescribing practitioner believes it is appropriate to extend the order beyond the 14 days. The medical record should include documentation from the physician or prescriber for the rationale for the extended time period and indicate a specific duration.The attending physician will assume leadership in medication management by developing, monitoring, and modifying the medication regimen in collaboration with resident, their families or representatives, other professionals, and the interdisciplinary team.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop a baseline care plan for one resident (R25) of two reviewed, resulting in the lack of a baseline care plan for oxygen administration. Findings include: R25 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include chronic respiratory failure with hypoxia, hypertensive heart disease with heart failure, congestive heart failure and pulmonary fibrosis.On 08/06/2025 at 8:56AM, R25 was observed sitting in bed receiving oxygen via nasal cannula. R25 stated that she usually receives 7 liters per minute (LPM) of oxygen, but due to having different tubing she is now having to receive 8LPM and her oxygen saturation isn't nearly as high as it usually is. On 08/06/2025 at 2:33PM, record review revealed a physician's order for administration of oxygen at 7LPM, dated 7/24/25. Record review revealed there is a care plan is in place for oxygen use, it is dated 8/6/25. On 08/06/2025 at 2:46PM, record review of care plans revealed that a care plan wasn't developed for oxygen use until 8/6/25, the resident admitted to the facility on [DATE]. No baseline care plan was present for oxygen. On 08/06/2025 at 2:56PM, the minimum data set (MDS) assessment dated [DATE] indicated the resident was receiving oxygen therapy on admission. On 08/07/2025 at 2:35PM, an interview was conducted with the Director of Nursing (DON). The DON was asked if there should've been a baseline care plan in place for oxygen administration? The DON replied, Yes, I honestly believe there should have been a baseline care plan in the electronic charting. I did notify the staff on the floor that she was on 7LPM, and it varied from 7-10LPM in the hospital. But there was no baseline care plan in the electronic charting. Review of the policy titled, MRH Baseline Care Plan, revealed:Policy:A baseline care plan will be established and implemented for each resident within 48 hours of admission. The plan will include instructions needed to provide effective and person-centered care of the resident and meet professional standards of care. Procedures:B. The baseline care plan will at a minimum include: initial goals, provider orders, dietary orders, therapy services, social services and PASARR recommendations if applicable.C. The baseline care plan will be updated with any significant changes by the nurse supervisor and/or MDS coordinator and will be utilized until the interdisciplinary team completes a comprehensive assessment and develops a comprehensive care plan in accordance with state and federal guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide routine dental services for one resident (R15) of one reviewed for dental services. Findings include: R15 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include malignant neoplasm of the pancreas, neuropathy, type 2 diabetes and hypertension. On 08/05/2025 at 12:01PM, R15 was observed in her room sitting on the edge of her bed. R15 was observed to not have any upper teeth, lower teeth were visible. R15 was asked about not having upper teeth in. R15 stated that she left her upper dentures at home and that they don't fit. R15 was asked if she had been seen by the dentist since being in the facility. R15 stated she was not sure if she sees the dentist here or not, but that she would like to. R15 stated that she would like to eat more salads but cannot eat them due to not having upper dentures. On 08/06/2025 at 12:38PM, an interview was conducted with Social Worker (SW) A. SW A was asked if they are the staff member that gets consents for 360care (this is the provider of dental, vision and podiatry). SW A replied, yes. SW A was asked if the residents get information about 360 care on admission? Typically, yes they get information on admission. SW A was asked if R15 consented to be seen by the dental providers. SW A produced a document that revealed R15 had orders for dental services to be received, it was dated 11/19/2024. In addition, R15 has orders to be seen by podiatry, vision and ear cleaning. SW A was asked when was the last time R15 was seen by dental in the facility? SW A stated that R15 admitted on [DATE] and that R15 has not seen the dentist since admission. SW A was asked when the dentist was last in the facility. SW A replied that the dentist was in the facility in December of 2024 and July 30th, 2025. SW A stated that R15 has not been put on the list to be seen by the dentist. SW A was asked why R15 hasn't been put on the list since admission. SW A replied they didn't know, and it was an oversight. On 08/06/2025 at 1:05PM, record review of the minimum data set (MDS) assessment dated [DATE], indicates that the resident is edentulous (without natural teeth). On 08/07/2025 at 2:33PM, an interview was conducted with the Director of Nursing (DON). The DON was asked if R15 should have been seen by the dentist since she has been in the facility. The DON replied, yes, R15 should've been seen by now. R15 is on the list for next time. Record review of the policy titled, MRH Dental Services, revealed, Policy:Routine and emergency dental services are available to meet the resident's oral health needs in accordance with resident's assessment and plan of care. Procedure:C. [NAME] Regional Hospital Skilled Nursing Facility is contracted with 360 care to provide dental services at the facility.F. The nurse supervisor or designee is responsible to notify social worker or designee of a resident's need for dental services.

Based on observation, interview and record review, the facility failed to ensure food was properly labeled, dated and stored to maintain best practices resulting in the potential to spread food borne illness to all residents that consume food from the kitchen.Findings include:On 8/5/25 at 9:00 AM, observations and interview during Initial kitchen include: On the prep table there was a large plastic container with an open blue bag in it, the container had no label, no open or expiration date on it. During interview with dietary supervisor “C”, when asked what the product was, Dietary Supervisor C stated it was rice, and acknowledged there is no dates or label present, but reports “there should be”. Walk in freezer with (2) Large plastic baggies of pepperonis that have been opened and have no open/expiration dating on them and sitting on shelf near a box of sealed pepperonis. On another shelf there is an open bag of frozen sugar snap peas no open date, closed with a rubber band. In the dry storage line in the kitchen, there is a box of cream of wheat and pancake mix both open in plastic bags, no open / expiration dates. The flip top cooler that holds the individual cartons of milk is at 45 degrees, asked dietary supervisor “C” about what temp it should be, “well under 40”. Overheard her asking kitchen staff member “E” about it, kitchen staff member “E” said that “the cooler latches on the inside, (shows dietary supervisor “C”) and if it gets loose and doesn't close tight so if people are not paying attention and that could be the issue”. In the short cooler a crossed from the flip top milk cooler there is ~8 individual cottage cheese served out into cups, 3 sandwiches wrapped on plates, all covered with clear wrap but no labels, date made or expiration on them (nor on the tray). Kitchen staff “J” member comes over and says, “I just made those up, they are for resident's trays if they want extra or something different, so I don't label them since I am going to use them”. In the stand-up cooler there is ~2 dozen individual Jello and yogurt served out into cups, individually covered with plastic but prepare/expiration dates on them (nor on the tray). When shown, dietary supervisor verbally acknowledges there is no dating. On the dry cookie sheet tray storage rack there are 2 pans with cooked bacon (that were cooled as there was firm film of grease on tray) that was also located on the same rack as the clean cookie sheet trays. When shown, dietary supervisor “C” responds, “I do not know why those are there they definitely should not be here with the clean trays”. In stand-up freezer for café' there is an open bag of unidentifiable frozen item, asked CDM “B” what is this? She says, “its chicken strips” pulled it out the bag of what appeared to be freezer burned crumbs and says, “oh no I think its onion rings”, proceeded to throw them in trash. Record review of the facility's policy on labeling -Dietary, according to procedure step(s) Step 1 All foods prepared in operations must be covered and dated appropriately prior to storage in refrigerators, following all food storage and temperature guidelines. All open food containers are labeled to indicate the expiration date. All perishable open/prepared foods will be evaluated, used or discarded within the timeframe associated with the 2013 food code. All foods items requiring time/temperature control will be dated to expire 3-7 days from date being prepared or open.” Step 2 “All open food must be dated; When dating dairy products, like milk or cottage cheese, the manufacture date applies. If the printed date is before the used date, go by the printed date. If the use by date is before the printed date once the product is opened, go by the use by date. Milk must be dated once opened by location.” Step 3 “Purchased, ready to use foods removed from the original containers must be handled and dated as above. A label stating the common name of the product must be used if the product is not readily recognizable. Step4 “for quality and safety purposes of cut fruit, vegetables, and prepared sandwiches are dated three days with the date of reparation counted as day one.” Step 5 “foods maintained in dry storage must be labeled and dated with the date the original carton was opened.” On 08/06/2025 at 8:13 - 9:00 AM During the kitchen tour with the Dietary Supervisor C, expired roast beef was observed with a use by date of 8/2/25 in the walk-in cooler. The dietary supervisor proceeded to throw out the roast beef. Record review of the facility's policy on labeling, The food service storage area are inspected before the kitchen/cafe opens, and all items that have reached the expiration date are disposed of. According to the 2022 Food Code, 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition, .Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date.

Based on interview and record review the facility failed to maintain a comprehensive infection control program, resulting in the facility not mapping infections or completing audits and the potential for infection clusters to go unnoticed. Findings include: DPS 2 Based on interview and record review, the facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in water borne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all of the residents in the facility. Findings include:On 08/07/2025 at 1:13PM, an interview was conducted with the Director of Nursing (DON). The DON acts in the role of the infection preventionist. During record review of the monthly infection control reports, it was noted that there was no mapping of infections being completed by the facility and minimal audits being completed for infection control. The DON was asked if the facility is mapping infections that occur on the halls? The DON stated that no, they were not mapping infections. When the DON asked why not, the DON replied, it was an oversight, I really don't know. The DON stated that another nurse will be assisting with infection control moving forward. The DON was asked what other audits are performed monthly to identify areas for improvement for infection control? The DON stated, we don't necessarily do audits monthly, we use to do hand washing, but staff had been good about that, so we stopped doing it. I audit all call in slips for staff to see if there are any trends to pay attention to. PPE audits have been done in the past, but the last one was completed in February 2025. No evidence of audits being completed for the laundry area and the kitchen were observed since the last survey. Review of the policy titled, Infection Prevention and Control (IPC) Program & Plan, revealed, Statement of Purpose: To provide an effective infection prevention plan to minimize risk of infection for healthcare personnel,patients, residents, and visitors. Through continuous monitoring as well as focused improvements tothe plan, our goal is to achieve optimal outcomes in a cost-effective manner and to use all availableresources in the formulation and execution of the plan. Procedure: 3.Prevention, monitoring, and control of the transmission of HAI and infectious/communicable diseases, including but not limited to:a. Surgical prophylaxis provided as appropriateb. Aseptic techniques employed as appropriate (e.g., invasive bedside procedures such as catheter insertion or central line insertion)c. Proper hand hygiene promoted and monitoredd. Encourage prompt removal of invasive devices (e.g., foley catheters, central lines) if no longer needed 8. Maintenance of a sanitary environment for personal, patients, visitors, contractedpersonnel, volunteers and students:a. Infection Control Surveillance rounding to be completed in each clinical area quarterly and each non-clinical area at least annually. Any rounding fall outs will be reviewed by the Infection Prevention Committee during quarterly meetings with corrective actions being implemented as needed. DPS 2 On 08/06/2025 at 1:00 PM, an environmental tour with the Facilities Supervisor K and Director of Maintenance L was conducted. On 08/06/2025 at 1:00 PM, observed the water softener drain line sitting directly inside drain instead of having an air gap of at least one inch. On 08/06/2025 at approximately 1:00 PM, when asked about whether the chlorine residual is tested on site, Director of Maintenance L stated that the chlorine residual isn't tested on site. On 08/06/2025 at approximately 1:00 PM. when questioned about the chlorine levels in the drinking water at the facility, Facilities Supervisor K stated that the city doesn't use chlorine in the water. Record review of the Water Quality Report from the city listed guidelines for the maximum contaminant disinfectant level but did not list the chlorine residual results. Record review of the Water Management Plan for chlorine levels, Chlorine will be used as a disinfectant in the water lines. As such, water samples will be collected by maintenance staff from areas considered to be of high risk and will be monitored for any dramatic drops in the chlorine levels once per quarter. The results from these tests will be recorded on a log sheet and submitted to the Infection Prevention/Control Committee for review. According to the Centers for Disease Control and Prevention, Controlling Legionella in Potable Water Systems dated January 3rd, 2025, the guidance for control measures states, Ensure disinfectant residual is detectable throughout the potable water system.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to appropriately monitor for a change in condition per professional standards of practice for one resident (Resident #30) of one resident reviewed for hospitalizations, resulting in the potential for delayed treatment and a further deterioration of condition. Findings include: Resident #30 (R30): Review of R30's Minimum Data Set (MDS) assessment, dated 6/10/2024, revealed R30 was admitted to the facility on [DATE] and had diagnoses including hypertensive heart disease with heart failure, aortic valve stenosis, peripheral vascular disease, hypertension and dementia. Further review revealed R30 scored five out of 15 (5/15) on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. An observation on 8/12/2024 at 1:27 a.m. revealed R30 seated in a wheelchair in her room. R30 was observed to be receiving three liters per minute of oxygen via nasal cannula from a portable oxygen tank housed on the back of the wheelchair. When asked if she required continuous use of the oxygen, R30 reported I do now. R30 was unable to state when or why she began using supplemental oxygen. Review of R30's electronic medical record (EMR) revealed R30 was transferred to the emergency department (ED) and subsequently hospitalized on [DATE] for an exacerbation of congestive heart failure and acute pulmonary edema [excess fluid in the lungs]. R30 returned to the facility on 5/24/2024. Review of R30's ED Note, dated and signed 5/21/2024 at 7:53 a.m., revealed the following, in part: . from [facility] for evaluation of acute difficulty in breathing . the patient's respiratory symptoms were of rapid onset several hours ago and have since worsened in severity. She is reported to have a history of CHF [congestive heart failure] with chronic diuretic therapy. She is claimed to have experienced similar respiratory symptoms to a lesser extent of severity on 5/11/2024 . Pulmonary: Diffuse rhonchi and rales [abnormal lung sounds indicating air flow obstruction in the lungs]. Tachypnea [rapid respirations] with profound accessory muscle usage. No wheezes . Lab results . BNP [blood test used to detect heart failure, normal range less than 100] 1174 HIGH . Historical Results: 5/13/2024, 996 HIGH . Further review of R30's EMR prior to transfer to the ED on 5/21/2024 revealed the following: 5/11/2024 at 7:17 a.m. Patient states SOB [shortness of breath] with no chest pain. Right lower lobe crackles [rales] noted. VS [vital signs] 95% @ 3L via NC [95% oxygen saturation on three liters of oxygen per minute via nasal cannula], HR [heart rate] 95, Temp 97.2, RR [respiratory rate] 30, BP 166/79. [Provider] called and informed. Ordered labs and chest x-ray for patient. 5/11/2024 at 12:32 p.m. [Provider] called due to results of labs and chest x-ray. Chest x-ray showed atelectasis [collapse of lung or partial lung due to decreased air flow] bilaterally. Lasix [medication used to remove excess fluid from the body] dose changed to 40 mg [milligrams] BID [twice daily] . Patient is a daily weight . 5/12/2024 at 3:33 a.m. Administration Note: guaifenesin [medication used to relieve chest congestion] oral syrup 100 mg/mL [milligrams per milliliter] . Give 5 mL by mouth every 4 hours as needed for cough. 5/12/2024 at 5:25 a.m. Administration Note: guaifenesin [medication used to relieve chest congestion] oral syrup 100 mg/mL [milligrams per milliliter] . Give 5 mL by mouth every 4 hours as needed for cough. PRN [unscheduled, as needed] administration was effective. 5/13/2024 at 2:01 p.m. [R30] had laboratory tests and [chest x-ray] done over the weekend and it appeared that she has mild CHF with haziness in the perihilar [central region of lungs] area . and an elevated BNP . says she is somewhat short of breath . Diagnostic studies from 5-11-24: elevated BNP 1068 . CXR [chest x-ray] with perihilar haziness, pleural effusion [buildup of fluid in lungs] . Impression: dyspnea [shortness of breath] with CHF . 5/13/2024 at 5:40 p.m. BNP results remain high at 996 . 5/21/2024 at 3:46 a.m. Resident called for help, reported pain in her back, head, chest and everywhere . VS obtained [BP] 212/87, [RR] 27, O2 89% 2L, [HR] 110 and her congestion/lungs . wet and audible. Called cardio [cardiopulmonary therapy] for a [as needed] breathing treatment and when he came down, he assessed her and stated she was filled with fluid and so provider called and gave order to send out to [ED] . Review of R30's EMR, including progress notes, assessments and the May 2024 medication administration record [MAR], revealed no documentation of a respiratory assessment to correspond with the PRN dose of guaifenesin 100mg/mL administered on 5/12/2024 at 3:33 a.m. Further review revealed no respiratory assessments were documented for R30, apart from the nurses' note on 5/13/2024 at 2:01 p.m., from the time of R30's change in condition on 5/11/2024 until 5/21/2024 at 3:46 a.m., when R30 called out for help and was found to be in respiratory distress. On 8/13/2024 at 09:29 a.m., the Director of Nursing (DON) reported she searched R30's EMR and cardiopulmonary therapy documentation and did not find any respiratory assessments for R30 from 5/11/2024 to 5/13/2024 and from 5/14/2024 until the date of R30's transfer to the ED on 5/21/2024. The DON reported R30's vital signs were monitored daily, and her oxygen saturation was documented as monitored every shift (three times daily) but only one result was documented daily. The DON stated she would expect a full respiratory assessment, including resident appearance and assessment of lung sounds to be documented during episodes of acute change in condition until the resident returned to baseline. The DON also stated a respiratory assessment should have been documented to correspond with the administration of the PRN guaifenesin 100mg/mL on 5/12/2024.

. Based on observation, interview, and record review, the facility failed to provide care and assistance to wear and be able to use a prosthetic device for one resident (Resident #20) of one resident reviewed for activities of daily living with a prosthesis. Findings include: Resident #20 (R20): On 8/13/24 at 9:06 AM, Resident #20 (R20) was observed in the hallway sitting in his wheelchair. He explained he had lost most of his right arm in an accident many years ago. He stated he had a prosthesis, but on observation he was not wearing .the bottom portion of the prosthesis. On 8/13/24 at 11:43 AM, R20 was observed and was not wearing the bottom portion of his right arm prosthesis. R20 stated Some of them (Certified Nurse Aids or CNA's) put it on, and some can't get it on. R20 said he did not put it on himself. During an interview on 8/13/24 at 1:24 PM, CNA F and CNA G were asked about the right arm prosthesis. CNA G said she had not put the prosthesis on. CNA F stated R20's prosthesis was broken and could not be worn. CNA F said, It is in his room, and we are waiting for the orthotist to fix it (the prosthesis). During an interview on 8/13/24 at 1:32 PM, the Director of Nursing (DON) was unaware R20's prosthesis needed adjustment. During an interview on 8/13/24 at 2:40 PM, Physical Therapist I said she remembered CNA F bringing the broken prosthetic to her a few weeks ago but she had not taken action at that time and it fell through the cracks. On 8/14/24 at 9:33 AM, R20 was observed in restorative therapy riding the therapy bike and joking with staff. R20 was not wearing the bottom portion of his right arm prosthesis. CNA G said she believed the prosthesis was noted to be broken on approximately 7/29/24. During an interview on 8/14/24 at 10:18 AM, Social Services Staff E stated she was aware of R20 not wearing his prosthesis because it needed to be repaired. She said this had not been documented and the orthotist had not been made aware. The electronic medical record (EMR) for R20 had diagnoses including acquired absence of right upper limb below the elbow and presence of artificial right arm. The physician orders included: 2/23/23 OT (Occupational Therapy) recommendations: Resident to wear orthotic arm as desired, at least 2 or more hours/day for 6-7 days/week. R20's care plan included a care plan with a focus of: (R20) has an ADL (Activity of Daily Living) self-care performance deficit r/t (related to) CVA (cerebral vascular accident - stroke) with right Hemiplegia, below elbow amputation right arm. Has prosthesis for right lower arm/hand . The care plan interventions included: Assist resident with placement of prosthesis right lower arm/hand. Alert OT if problems with RT (right) prosthetic arm occurs. Resident to wear prosthesis as desired at least 2 hr./day, 6-7 days/week. Date Initiated: 08/20/2022 The facility policy titled: Rehabilitation Procedures and Modalities and dated as last approved 01/2023 read in part: Purpose: To ensure safe, competent and proficient performance of treatment procedures is necessary for the optimal outcome of treatment and to avoid injury to the patient . Procedure: All treatment procedures will be performed in a manner that takes into account the patient's medical and therapy conditions, cognitive status, and any precautions/contraindications. .

Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5% based on five medication errors of 34 medication administration opportunities. This deficient practice resulted in a medication error rate of 14.7%. Findings include: Registered Nurse (RN) A was observed administering medications on 8/13/24 at 10:15 a.m. RN A said she was passing the morning medications on the west hall. RN A prepared medications for Resident #31 (R31) consisting of 11 medications. The medications for R31 were ordered to be administered at 9:00 a.m. RN A documented the medications as administered at 10:19 a.m. on 8/13/24. RN A prepared medications for Resident #25 (R25) consisting of 17 medications. When the medications were prepared, RN A handed the medications to another nurse, RN B, to administer to R25 while RN A continued with preparing medications at the medication cart. The medications for R25 were ordered to be administered at 9:00 a.m. RN A documented the medications as administered at 10:28 a.m. on 8/13/24 despite not having administered the medications to R25 or having observed R25 taking the medications. RN A prepared medications for Resident #3 (R3) consisting of 20 medications. The medications for R3 were ordered to be administered at 9:00 a.m. RN A documented the medications as administered at 11:29 a.m. and 10:41 a.m. on 8/13/24. The medications due at 9:00 a.m. were administered during two separate medication administrations. On 8/13/24 at 12:04 p.m., RN B obtained Morphine Sulfate (MSO4) from the controlled substance box. RN B documented the MSO4 on a proof of use form at the medication cart but did not fill out the time on the proof of use form. When asked why the time wasn't documented on the proof of use form, RN B said she does not fill out the time the MSO4 was removed from the medication cart on the proof of use form. RN B said she documents the time on the proof of use form after the resident takes the medication. On 8/14/24 at 7:51 a.m., RN C prepared medications for Resident #23 (R23). RN C said R23 was administered medications crushed in applesauce. RN C opened a medication crushing pouch and placed her bare, ungloved finger inside the pouch to open the pouch wider for the placement of medication. R23 used bare, ungloved fingers to open a medication capsule to pour the content into a medication cup. The Director of Nursing (DON) was interviewed on 8/14/24 at 8:45 a.m. The DON said medication is expected to be administered within one hour before to one hour after the scheduled administration time. The DON provided the example, If a med is scheduled at 8:00 a.m., the nurse has to give the med between 7:00 a.m. to 9:00 a.m. The DON said nurses should perform hand hygiene and put on gloves to open medication capsules or place medications into a crushing pouch. The DON said the nurse who prepares a medication should be the nurse who administers that medication and observes the resident safely swallows the medication. The DON agreed RN A should not have signed out medications that were administered by RN B. When asked if she had a policy, the DON replied, No, that's a standard of practice. The DON said RN B should have filled out the proof of use sheet completely when the MSO4 was taken from the medication cart, including the time the medication was taken from the inventory, not after the medication was administered. The policy [Name of facility] Medication Administration dated 7/2024 read, in part: .4. Adhere to the 5 Rights (Resident, Dose, Route, Time and Drug) in preparing medications .9. Administer medications within sixty (60) minutes of time indicated .Infection Control Guidelines will be followed with medication administration .Narcotics: .5. A licensed nurse will document in the narcotic record at the time of removal of any narcotics. Documentation is to include: medication, dose, time of removal .

Based on observation, interview, and record review, the facility failed to properly store and dispose of medications and ensure insulin pens and eye drops were labeled with dates when opened in two medication carts of two medication carts reviewed for medication storage and labeling. Findings include: On 8/13/24 at 10:35 a.m., Registered Nurse (RN) A attempted to administer medications to Resident #3 (R3). R3 told RN A she did not want the medications because she was on the phone. RN A returned to the medication cart with the medications and obtained a marking pen. RN A wrote R3's initials on the cup containing the medications and pulled open the top drawer of the medication cart. The Director of Nursing (DON) approached and asked RN A what she was doing. RN A told the DON R3 did not want her medications at that time. The DON told RN A to dispose of the medications in the medication cup and obtain new medications when R3 was ready to take the medications. RN A emptied the medications into a Sharps container (a wasted container for sharp medical instruments). The South Hall medication cart was reviewed with RN B on 8/13/24 at 12:04 p.m. The cart was observed with four insulin pens that were opened and undated. Three of the insulin pens were prescribed for the same resident. The [NAME] Hall medication cart was reviewed with RN C on 8/14/24 at 7:51 a.m. The cart was observed with two prescription eye drops and two insulin pens opened and undated. The cart also contained a drawer with non-medication items stored with oral medications. Pens, pencils, markers were in the same drawer and same compartment as medications for residents. The DON was interviewed on 8/14/24 at 8:45 a.m. When asked about RN A writing R3's initials on the medication cup, the DON said, I'm well aware of what she was going to do - she was going to place the cup in the cart and give them later. The DON said nurses should never label a medication cup and place the cup containing medications back into the medication cart. When asked about disposal of medications, the DON said her expectation is for nurses to use [a brand name solution for medication disposal that dissolves medications on contact] to dispose of medications, and not dispose of medications in a Sharps container. The DON confirmed that insulin pens should be dated when opened, and nurses should date eye drops when opened if the eye drops are not over the counter. The policy Storage and Expiration Dating of Medications and Biological's dated 8/1/24 read, in part: .Facility should ensure that resident medication and biological storage areas are locked and do not contain non-medication/biological items . The policy [Name of facility] Medication Administration dated 7/2024 read, in part: .Multi Dose Medication 1. Will be dated month, day, year on the bottle when opened .6. All insulin vials will be dated with date of opening and expiration date when opened .All eye drops will be dated with date of opening and expiration date when opened .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement tracking of Covid-19 (a highly contagious respiratory disease) immunizations to ensure appropriate education was offered and vaccinations administered or declined for four residents (R13, R17, R30 and R35) of five residents reviewed for immunization, resulting in the potential for residents and resident representatives to be uninformed of the benefits and potential side effects of Covid-19 vaccination and the potential for eligible residents to remain unvaccinated, increasing the risk of disease. Findings include: Resident #13 (R13): Review of R13's Minimum Data Set (MDS) assessment, dated 6/24/2024, revealed R13 was admitted to the facility on [DATE]. Review of R13's immunization history obtained from his electronic medical record (EMR) revealed the date of R13's most recent Covid-19 vaccination was documented as 5/04/2022. It was noted in review of the immunization history there was no documentation of R13 being offered an up to date 2023-2024 formula Covid-19 vaccination. Further review of R13's EMR revealed no signed declination for the vaccination or proof of education provided related to the risk and benefits regarding immunization. During an interview on 8/14/2024 at 9:50 a.m., the facility's Infection Preventionist, Registered Nurse (RN) A, reported all immunizations offered to residents were recorded in the immunization history section of the EMR. RN A stated education is provided related to the benefits of the vaccination being offered and a screening form indicating acceptance or declination is completed and signed by the resident or the resident's representative. During review of R13's EMR, RN A confirmed there was no record of R13 being offered, administered or declining the updated Covid-19 vaccination. RN A stated she would search through the EMR and the previous Infection Preventionist's documents for the missing documentation. A request was made at that time to include documentation for R17, R30 and R35 in the search. Resident #17 (R17): Review of R17's MDS assessment, dated 6/03/2024, revealed R17 was admitted to the facility on [DATE]. Review of R17's EMR revealed her most recent Covid-19 vaccination was 10/18/2022. Further review of R17's EMR revealed no signed declination for the vaccination or proof of education provided related to the risk and benefits regarding immunization. Resident #30 (R30): Review of R30's MDS assessment, dated 6/10/2024, revealed R30 was admitted to the facility on [DATE]. Review of R30's EMR revealed her most recent Covid-19 vaccination was 2/04/2021. Further review of R30's EMR revealed no signed declination for the vaccination or proof of education provided related to the risk and benefits regarding immunization. Resident #35 (R35): Review of R35's MDS assessment, dated 6/06/2024, revealed R35 was admitted to the facility on [DATE]. Review of R35's EMR revealed no documented immunization for Covid-19. Further review of R35's EMR revealed no signed declination for the vaccination or proof of education provided related to the risk and benefits regarding immunization. On 8/14/2024 at 11:15 a.m., the Director of Nursing (DON) reported she and RN A reviewed the EMR and paper charts for R13, R17, R30 and R35, and could not provide documentation of the residents being offered, administered or declining the updated 2023-24 Covid-19 vaccination. Review of the facility policy titled, Vaccinations for LTC [Long-Term Care] Resident, dated 7/2024, revealed the following, in part: The Covid-19 vaccine is recommended for all residents in LTC [Long-Term Care]. Before offering Covid-19 vaccine, each resident or the resident representative receives education regarding the benefits and risks and potential side effects . On admission the screening form . will serve as documentation and consent to administer vaccines including yearly influenza vaccine. This form will also indicate any vaccines refusal . Documentation in the resident's chart will include the following: Education provided to resident/legal representative .Reason for non-vaccination such as, resident/legal representative refusal, medical contraindication, vaccine unavailability . previous vaccination, or precautions necessitating need for delay (acute illness) . Review of the Centers for Disease Control and Prevention (CDC) guidance titled, Updated (2023-2024 Formula) Covid-19 Vaccine, dated 4/03/2024, revealed the following, in part: 12 Years and Older: Covid-19 Vaccination History: Unvaccinated (0 doses) .2023-24 Vaccine Schedule: Give now; Covid-19 Vaccination History: Any number of previous doses of Covid-19 vaccine, not including at least 1 dose of 2023-24 vaccine . 2023-24 Vaccine Schedule: Give one dose at least 8 weeks (two months) after the last dose .

Based on observation, interview, and record review, the facility failed to date mark potentially hazardous foods, maintain sanitary equipment, and maintain proper glove use and handwashing, resulting in an increased risk of foodborne illness, affecting all residents that consume food from the kitchen. Findings include: On 8/12/24 at 11:40 AM, during a kitchen inspection, assisted by Certified Dietary Manager (CDM) H, an opened bag of hard boiled eggs was observed to not be provided with a date mark to identify the discard date. On 8/12/24 at 11:45 AM, a chicken wrap, located in the reach-in deli cooler, was observed to not be provided with a date mark. At this time, CDM H stated the wrap was left over from the day before. According to the 2017 FDA Food Code Section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. Pf On 8/12/24 at 11:51 AM, encrusted food debris was observed on the commercial mixer. At this time, CDM H immediately wiped down the commercial mixer. According to the 2017 FDA Food Code Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. Pf (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. On 8/12/24 at 12:06 PM, during an observation of lunch service, Dietary Staff J was observed to drop silverware on the ground. Dietary Staff J proceeded to pick up the silverware with gloved hands, set the dirty silverware to the side, then proceeded to assemble clean silverware on resident trays. Dietary Staff J did not change gloves and wash hands until prompted by the surveyor. Dietary Staff J confirmed that they could contaminate the silverware by not changing gloves. On 8/12/24 at 12:22 PM, during an observation of lunch service, Dietary Staff K was observed to be serving food onto trays with gloved hands. Dietary Staff K was observed to lightly shred the pork entrée every couple of trays and was observed on three occasions touching/adjusting their glasses with gloved hands. Dietary Staff K did not change gloves and wash hands after contaminating hands. According to the 2017 FDA Food Code Section 3-304.15 Gloves, Use Limitation. (A) If used, SINGLE-USE gloves shall be used for only one task such as working with READY-TO-EAT FOOD or with raw animal FOOD, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. P According to the 2017 FDA Food Code Section 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; P (B) After using the toilet room; P (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in 2-403.11(B); P (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating, or drinking; P (E) After handling soiled EQUIPMENT or UTENSILS; P (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; P (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; P (H) Before donning gloves to initiate a task that involves working with FOOD; P and (I) After engaging in other activities that contaminate the hands. P

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that advance directive documentation was meticulously completed and the policy/procedure implemented for one resident (Resident #129) of one resident reviewed resulting in incomplete Do Not Resuscitate (DNR) documentation and the potential for the resident's wishes to not be followed and unwanted and/or undesired medical care/treatment in a medical emergency. Findings include: Resident #129: Record review revealed Resident #129 was admitted to the facility on [DATE] with diagnoses which included Urinary Tract Infection (UTI), heart disease, falls, and weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required extensive assistance to complete all Activities of Daily Living (ADL) with the exception of daily hygiene and eating. Review of Resident #129's care plans included a care plan entitled, Advance Directives-DNR (Initiated: [DATE]). Review of Resident #129's Health Care Provider (HCP) active, discontinued, completed, and pending orders in the medical record revealed the Resident did not have a code status order in place. Review of Resident #129's paper medical record revealed an undated Code Status Form with I do NOT want cardiopulmonary resuscitation (CPR) checked. The form was signed by the Resident but not dated and/or witnessed by a staff member. An interview was completed with Resident #129 on [DATE] at 11:17 AM. When queried if the staff discussed code status and emergency care wishes with them when they were admitted , Resident #129 revealed they did not recall what was reviewed/discussed when they were admitted . Resident #129 was then queried regarding their wishes related to code status and confirmed they wanted to be a DNR. On 11:30 AM on [DATE], an interview was completed with the Director of Nursing (DON). When queried if code status documentation has to be witnessed by staff and then ordered by a HCP, the DON confirmed it did. Resident #129's code status form (letter) was reviewed with the DON at this time. When queried, the DON stated, Should have signed it. The DON verified the missing signature and order. No further explanation was provided. Review of facility policy/procedure entitled, SNF Code Status (Revised: [DATE]) revealed, The [NAME] Regional Hospital Long Term Care Unit will honor the residents/legally responsible person's choice of Code Status . A . each resident or their legally responsible person will choose a Code Status. (See attached LTC Code Status Letter) . After the resident/legally responsible person has designated the code status, the admitting nurse will obtain a physician's order for code status. If a code status has not been chosen by the resident/legally responsible person the resident will automatically be a full code until a physician's order is obtained for code status .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that Restorative Nursing services were provided to 1 resident (Resident #10) of 3 residents reviewed for range of motion and restorative services from a total sample of 27 residents, resulting in Resident #10 developing lower extremity contractures and the decreased ability to ambulate. Findings Include: Resident #10: Position, Mobility On 7/19/2023 at 12:30 PM Resident #10 was observed sitting in a wheelchair in her room and appeared to be sleeping. A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated the resident was admitted to the facility on 7/13 2018 with diagnoses: Alzheimer's Disease, heart disease, Rheumatoid arthritis, spinal stenosis, GERD, depression, history of skin cancer, hypothyroidism, hypertension and weakness. New diagnoses: 11/22/2022 Pain in left and right knees and 12/15/2022 contractures left and right knees. The MDS assessment dated [DATE] revealed the resident had full cognitive loss with a Brief Interview for Mental Status (BIMS) score of 0/15 and the resident needed 2-person extensive assistance with bed mobility, transfers, toileting and total dependence with bathing. The MDS also indicated Resident #10 had a Functional Limitation in Range of Motion: Lower Extremity on both sides. During an interview with the Director of Nursing (DON), on 7/20/2023 at 10:30 AM, the 672 Census and Condition facility document was reviewed. It identified 1 facility acquired contracture. The DON said it was Resident #10. Further review of the MDS assessments for Resident #10 revealed the MDS assessments from 8/4/2022 to 11/1/2022 identified no Functional Limitations in Range of Motion; upper and lower extremities both said No impairment. The January 31st, 2023 MDS indicated impairment on one side upper extremity and impairment on both sides lower extremity. A review of the Restorative Nursing notes for Resident #10 identified a note on 8/1/2022 and 10/7/2022 both said the resident had not been participating or maintaining goals of the restorative program: Staff will continue to approach and encourage her participation. Will continue to monitor and track. Both notes were exactly the same. There was no mention of new or modified interventions to attempt to foster better participation from the resident. A review of the Restorative notes for 8/1/2022 provided, Resident has not been participating or maintaining goals set forth by the restorative program. Has refused AROM (active range of motion) most days. Staff will continue to approach and encourage her participation. Will continue to monitor and track progress. The next Restorative nursing note dated 10/7/2022 said exactly the same thing. The next note after that was dated 12/9/2022 and indicated the resident had LE (lower extremity) contractures and Staff will continue to approach and encourage her participation . will continue to monitor and track progress. A Restorative Nursing note dated 12/9/2022 revealed, . Therapy working with resident for LE (lower extremity contractures . The note was a late entry and was intended for the November 2022 Restorative note. The note was written approximately 5 weeks late and the resident had developed contractures. Each Restorative nursing note from 10/7/2022 to 4/14/2023 was written late. A review of the Care Plan for Resident #10 identified an Activities of Daily Living (ADL) Care Plan date initiated 7/23/2018 and revised 7/17/2020 with Interventions: 12/9/2022 date initiated, and revised 5/2/2023: Perform PROM (passive range of motion/ range of motion with assistance) of all extremities with supervision of 1 assist, 15 (minutes), 3-7 days/week. A review of the physician orders identified, Restorative Nursing Program-Assist Resident to: Perform PROM to all extremities w/supervision of 1 staff, 15 minutes, 3-7 days a week, dated 12/9/2022. On 7/21/23 at 11:37 AM, interviewed the MDS nurse who was the restorative nurse at the time of the resident's facility acquired contracture lower extremity- Nurse C was asked for information related to how the contracture occurred, I don't know when it happened. We got a Quarterly screen by therapy, in October 2022, she wasn't doing any walking at all and on 11/21/2023 a therapy order for pain related to contractures 11/21/22-12/9/22 was obtained. The MDS nurse could not say when the resident acquired the contractures. A review of a Physical Therapy Evaluation, dated 9/22/2022 for Resident #10 revealed, . Per staff, resident is often lifting both legs off the floor during transfers . Recommend use of Hoyer lift when resident is fatigued, agitated or otherwise not WB (weight bearing) appropriately. Recommend continued pivot transfers with max PA (physical assistance) x 2 when resident is agreeable and responding appropriately . There were no short or long term goals written on the assessment. On 7/26/23 at 10:37 AM, the Restorative nurse aide was interviewed and said Resident #10 began lying in bed more last fall. She said therapy evaluated the resident as she was not bearing weight. She had been walking prior to this and then she needed transfer assistance with a Hoyer (mechanical) lift. She said restorative nursing works on stretching out the resident's legs as she tended to draw them up in a fetal position. The Restorative Nurse aide also said they assist with PROM (passive range of motion) and works on Active Range of Motion (AROM) of the upper extremities, if she will let them. She said she tries to perform the restorative services while the resident is dressing and the nurse aide can assist. A review of the facility policy titled, SNF Restorative Nursing Program, dated origination 11/30/2021 and revised 6/8/2022 provided, Purpose: It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level . Restorative nursing program refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently as possible . The Restorative Nurse, or designated licensed nurse, will provide oversight of the restorative aide activities, review the documentation at least weekly, and evaluate the effectiveness of the plan monthly .

Based on observation, interview and record review, the facility failed to ensure a medication error rate less than 5% when two medication errors were observed for two residents (Resident #80 and Resident #129) from a total of 29 observations, resulting in a medication error rate of 6.9%. This deficient practice resulted in the potential for adverse medication effects and decreased medication efficacy related to lack of implementation of standards of practice for medication administration and incorrect administration dosage. Findings include: Resident #129: On 7/21/23 at 8:21 AM, a medication pass observation for Resident #129 was completed with Registered Nurse (RN) T. RN T was observed removing a bottle of generic Miralax (laxative medication powder) from the medication cart. RN T opened the container and quickly poured a small amount of the powder into the medication bottle cap. Without measuring the amount of medication, RN T poured the powder into a cup for reconstitution and administration. After preparing all other medications for administration and prior to pouring water into the Miralax for reconstitution, RN T was stopped and asked what dose of Miralax Resident #129 was supposed to receive. RN T reviewed the Medication Administration Record (MAR) and stated, 17 grams (the cap of the container is used as a measuring cup). RN T was asked if they had 17 grams in the cup and indicated they did. When queried how they measured the amount of Miralax using the cap, RN T provided the bottle for review. Per the bottle, the top of the cap was equal to 17 grams. RN T reviewed the instruction on the bottle. RN T was then asked to remeasure the amount of the medication. The amount of Miralax RN T was going to administer, prior to being stopped was approximately half of the ordered dose. When asked why they had not accurately measured the medication, an explanation was not provided. Resident #80: On 7/21/23 at 9:40 AM, a medication pass observation was completed with RN I for Resident #80. RN I removed medications from the cart for Resident #80 including Digoxin (cardiac medication) 125 micrograms (mcg) tablet. (Note: Prior to administering Digoxin, an apical-radial pulse must be assessed for one minute due to severe potential side effects of the medication.) RN I was observed entering the room and administering the medications without assessing/obtaining an apical-radial pulse. RN I exited Resident #80's room and an interview was completed. When queried who obtains resident vital signs in the facility, RN I replied, The nurses do. RN I was asked when vital sign measurements are obtained but did not provide a response. When asked if they had obtained vital sign measurements today for Resident #80, RN I replied, No. RN I was then asked what they are supposed to do/obtain prior to administering Digoxin and did not provide a response. When asked why they did not obtain an apical pulse, RN I replied there was not an order to obtain a pulse prior to administering the medication and the doctor would put that in an order if that was what they wanted. No further explanation was provided. An interview was completed with the Director of Nursing (DON) on 7/21/23 at 10:00 AM. When queried if Miralax should be measured accurately prior to administration, the DON confirmed it should. When asked if an apical pulse should be assessed prior to administration of Digoxin, the DON stated it should be. The DON was made aware of Resident #80's medication pass observation with RN I and indicated they would address. No further explanation was provided. On 7/21/23 at 10:41 AM, an interview was conducted with Physician Assistant (PA) H. When queried if an apical pulse should be assessed prior to administration of Digoxin, PA H confirmed it should be. PA H was queried regarding RN I's statement indicating they did not assess Resident #80's apical heart rate prior to administering the medication because it was not included in the order, PA H stated, I consider that a standard of nursing practice. Review of facility policy/procedure entitled, LTCU Medication Administration (Reviewed: 10/2022() revealed, A licensed nurse through the nursing process will facilitate the safe and effective use of medications . Nursing will utilize current drug reference resources, and consultant Pharmacist, Physician, PA-C or FNP when needed . Adhere to 5 Rights (Resident, Dose, Route, Time and Drug) in preparing medications . Assess resident and monitor each drug for therapeutic and nontherapeutic (adverse) effects, interactions, allergies, indications and contraindications .

Based on observation, interview and record review, the facility failed to follow evidence-based practices for Infection Control, including collection and analysis of surveillance data to identify trends and patterns and implement appropriate interventions, and to follow the interventions initiated. The failure to maintain infection control practices resulted in the potential for a serious adverse outcome including infectious illness and death if appropriate Infection Prevention and Control Standards of Practice were not enacted. Findings Include: Infection Control: On 7/19/2023 at 1:05 PM, the Director of Nursing/DON was interviewed related to a Personal Protection Equipment/PPE cart outside Resident #20's room door. The DON was asked what type of precautions were in place and she said she wasn't sure. Upon inspection, the resident had a Contact Precaution sign on his door with the PPE cart outside the door. The DON said the resident had recently had eye surgery then the eye became very red; he went back to the eye doctor who said he thought he might have shingles. The DON said it was contained to the eye area. On 7/19/2023 at 1:15 PM, Resident #20 was observed coming down the hall from the dining room in his wheelchair. His right eye looked as if he had eye ointment in it. The surrounding area was shiny with ointment and pink. He had no lesion on or near his eye, but there was one red raised lesion on his cheek with no head or scab. The Resident asked for help to the bathroom and a CNA (Certified Nursing Assistant) came to the door to help him. She performed hand hygiene and entered room with no PPE. Upon exiting the room, the nurse aide was asked why the PPE was at the resident's door. She said the resident had an eye infection and you didn't have to wear PPE unless you came in contact with the eye. Reviewed with the CNA that the sign on the resident's door said Contact Precautions and it listed the PPE to be worn upon entering the room. She said she didn't know that. On 7/21/23 at 4:09 PM, Infection Control was reviewed with Nurse T and the DON. Nurse T said she was no longer in the IPC/Infection Prevention and Control role and was working as a nurse on the floor. She said she had been working in the role from February to June 2023 and the DON was helping. Before that someone else had been in the role. The DON said the plan was to hire someone new. Neither the DON or Nurse T were Certified in Infection Control or had completed certificate training. During a review of the Infection Surveillance data for January 2023 one resident was identified to have Shingles. The surveillance documents indicated the resident was in standard precautions with no further information. The DON was not employed at the facility in January 2023 and Nurse T was not working in the IPC role. Neither had information about the resident with Shingles. On further review of the monthly surveillance reports from July 2022 to July 2023, the reports did not have the admission date for each resident to aid in identifying onset of symptoms and some did not identify if the signs and symptoms/or infection noted was a Healthcare associated infection (HAI) or Community acquired infection (CAI). There was inconsistency with diagnostic results, and they did not include tracking of the organism if identified on a culture. The IPC said she counted the HAI's on the monthly summary report, but they could not be correlated to a resident, infection or organism. Some entries on the monthly Line List/Surveillance document indicated Prophylaxis for antibiotic use but didn't say what it was being provided for. On 7/26/2023 the Contact Precautions sign was still on the door of Resident #20, but the PPE cart was gone. Nurse A was asked about the sign and if the resident was still in precautions, she removed the sign and said it was no longer needed. APIC Text (Association for Professionals in Infection in Infection Control and Epidemiology), revised September 20, 2020 : Surveillance, ' . Surveillance is an essential component of an effective infection prevention and control program . emphasizes the importance of using sound epidemiological and statistical principles: and stresses the use of surveillance data to improve the quality of healthcare . Surveillance activities should support a system that can identify risk factors for infection and other adverse events, implement risk-reduction measures , and monitor the effectiveness of interventions. Surveillance plays a critical role in identifying outbreaks . Surveillance can be defined as a comprehensive method of measuring outcomes and related processes of care, analyzing the data . to assist in improving those outcomes . If surveillance data are properly collected and analyzed, they can provide information that can be used to improve the quality and outcomes of healthcare and to promote public health .' APIC Text (Association for Professionals in Infection in Infection Control and Epidemiology: Isolation Precautions (Transmission Based Precautions) published October 2, 2014 .The risk of transmission of infectious agents occurs in all healthcare settings, including acute care facilities, long-term care settings . Infections can be transmitted from patient to patient via healthcare personnel, the shared environment, or medical equipment and devices . Isolation precautions are only a part of a comprehensive infection prevention program . Unidentified patients who are colonized or infected with infectious agents represent a risk to other patients and healthcare personnel . In addition to Standard Precautions used for all patients, Transmission-based Precautions are used for select patients with specific diseases or pathogens. A category of Transmission -based Precautions including Contact Precautions, Droplet Precautions, Airborne Precautions and Protective Environment may be used alone or in combination. They are recommended to contain highly transmissible and /or epidemiologically important agents . Contact Precautions: . Personal Protective Equipment (PPEP: Wear a gown and gloves on room entry .

Based on interview and record review, the facility failed to ensure that the Infection Preventionist had completed the required training in Infection Prevention and Control. This deficient practice resulted in the potential for a lack of knowledge and appropriate response to aid in the prevention of infections that could lead to resident illness, outbreaks and possibly death. Findings Include: FACILITY Infection Control: On 7/21/23 at 4:09 PM, the Infection Control task was reviewed with Infection Prevention and Control Nurse T and the Director of Nursing/DON. The IPC said she worked as the IPC at the facility from February 2023 until June 2023 with the DON's assistance. The DON said she is trying to hire someone for the role and is currently performing the IPC role. Neither IPC T or the DON have IPC training. IPC T started the CDC /Centers for Disease Control and Prevention training Infection Control training for Long Term Care and then stopped and didn't finish. Centers for Medicare and Medicaid Services (CMS.gov), June 29, 2022, Updated Guidance for Nursing Home Resident Health and Safety; Overview of New and Updated Guidance . Infection Control: . IP (Infection Preventionist) specialized Training is required and available . CDC: Centers for Disease Control and Prevention: CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings: Introduction; Adherence to infection prevention and control practices is essential to providing safe and high quality patient care across all settings where healthcare is delivered . Core Practice Category: . Assign one or more qualified individuals with training in infection prevention and control to manage the facility's infection prevention program .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to review and revise care plans with resident changes, to ensure interventions necessary for care and services were provided for 4 resident (Resident #10, Resident #19, Resident #21, Resident #28) of 27 resident reviewed, resulting in the potential for unmet care needs. Findings Include. Resident #10: Position, Mobility On [DATE] at 12:30 PM Resident #10 was observed sitting in a wheelchair in her room and appeared to be sleeping. A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated the resident was admitted to the facility on 7/13 2018 with diagnoses: Alzheimer's Disease, heart disease, Rheumatoid arthritis, spinal stenosis, GERD, depression, history of skin cancer, hypothyroidism, hypertension and weakness. New diagnoses: [DATE] Pain in left and right knees and [DATE] contractures left and right knees. The MDS assessment dated [DATE] revealed the resident had full cognitive loss with a Brief Interview for Mental Status (BIMS) score of 0/15 and the resident needed 2-person extensive assistance with bed mobility, transfers, toileting and total dependence with bathing. The MDS also indicated Resident #10 had a Functional Limitation in Range of Motion: Lower Extremity on both sides. During an interview with the Director of Nursing (DON), on [DATE] at 10:30 AM, the 672 Census and Condition facility document was reviewed. It identified 1 facility acquired contracture. The DON said it was Resident #10. Further review of the MDS assessments for Resident #10 revealed there were noFunctional Limitations in Range of Motion; upper and lower extremities both said No impairment. The [DATE]st, 2022 MDS indicated the resident had No impairment in Functional Limitation. The [DATE]st, 2023 MDS indicated impairment on one side upper extremity and impairment on both sides lower extremity. A review of the Care Plan for Resident #10 identified an Activities of Daily Living (ADL) Care Plan date initiated [DATE] and revised [DATE] with Interventions: [DATE] date initiated, and revised [DATE]: Perform PROM (passive range of motion/ range of motion with assistance) of all extremities with supervision of 1 assist, 15 (minutes), 3-7 days/week. A review of the physician orders identified, Restorative Nursing Program-Assist Resident to: Perform PROM to all extremities w/supervision of 1 staff, 15 minutes, 3-7 days a week, dated [DATE]. On [DATE] at 11:37 AM, interviewed the MDS nurse who was the restorative nurse at the time of the resident's facility acquired contracture lower extremity- Nurse C was asked for information related to how the contracture occurred, We got a Quarterly screen by therapy, in [DATE], she wasn't doing any walking at all and [DATE] a therapy order for pain related to contractures [DATE]-[DATE]. The MDS nurse could not say when the resident acquired the contractures. A review of a Physical Therapy Evaluation, dated [DATE] for Resident #10 revealed, . Per staff, resident is often lifting both legs off the floor during transfers . Recommend use of hoyer lift when resident is fatigued, agitated or otherwise not WB (weight bearing) appropriately. Recommend continued pivot transfers with max PA (physical assistance)x 2 when resident is agreeable and responding appropriately . There were no short or long term goals written on the assessment. A review of the Restorative notes for [DATE] provided, Resident has not been participating or maintaining goals set forth by the restorative program. Has refused AROM (active range of motion) most days. Staff will continue to approach and encourage her participation. Will continue to monitor and track progress. The next Restorative nursing note dated [DATE] said exactly the same thing. The next note after that was dated [DATE] and indicated the resident had LE (lower extremity) contractures and Staff will continue to approach and encourage her participation . will continue to monitor and track progress. The Care Plan did not identify additional or new interventions that may have assisted or encouraged the resident to participate with the restorative program to aid in preventing a decline in mobility and prevention of contractures. Resident #19: Accidents On [DATE] at 3:18 PM, Resident #19 was observed sitting in a wheelchair in the hallway. She had fading purple bruising on her left cheekbone and around her eye. Nurse Aide O and the Director of Nursing/DON said the resident had previously fallen, [DATE] and [DATE] and also had multiple falls prior to that. Resident #19 was mumbling some words to Nurse Aide O who helped lift each of the resident's legs onto a foot pedal. The DON said the facility tried to use a Broda chair for positioning after the last fall, but Resident #19 was now back to a wheelchair. The resident was observed to have chair and bed alarms with floor mats beside the bed. The DON said the resident had also fallen and fractured her knee [DATE]. A review of the Face sheet and MDS assessment indicated Resident #19 was admitted to the facility on [DATE] with diagnoses: Alzheimer's Disease, hypertension, atrial fibrillation, cerebral ischemia, arthritis, history of a urinary tract infection, chronic kidney, and a history of falls. A review of the Incident and Accident Reports identified Resident #19 had Fallen: [DATE], [DATE], [DATE], [DATE] [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] = 11 falls since [DATE]: [DATE]: sitting on floor in room, wc alarm sounding shoes, floor mat next to bed-- unobserved-- cp updated [DATE]: wc alarm sounding on floor in room next to bed, floor mat unalarmed- unobserved [DATE]: sitting on floor in room, alarm sounding she said trying to transfer wc to bed- unobserved [DATE]: lowered to floor, staff standing in bathroom, alarm sounding, had to be lowered to floor during transfer [DATE]: found on floor in room on floor, alarm sounding, took off gripper socks, [DATE]: in wc leaned forward fell out [DATE]: found kneeling on bedside floor mat [DATE]: heard alarm, resident in wc, reaching to floor and fell out of chair- observed [DATE]: in room, sitting , safety mat alarm not sounding., but sounded when tested. [DATE]: tab and floor mats alarming lying on floor- q 15 minutes- neuro checks [DATE] [DATE]: observed at nurses desk in wc leaning forward as nurse reached for her she fell- hit face A review of the Care Plans for Resident #19 revealed The resident has had an actual fall with serious injury prior to admission to unit. Poor communication/comprehension, unsteady gait, poor safety awareness, impulsive, history of falls. Resident with recent falls: fall occurred [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. Date created and initiated [DATE] and revised [DATE] with Interventions updated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. All of the residents falls were not accounted for; 2 of the 11 falls were not identified. The Care Plan was not reviewed or interventions updated to try and aid in preventing further falls and serious injury. The Care Plan was not reviewed/revised for 4 of 11 falls. The resident had fallen multiple times in a row: [DATE], [DATE], [DATE], [DATE], [DATE]. The Care Plan was reviewed on [DATE] and [DATE], but not [DATE], [DATE] and [DATE]. Resident #19 continued to fall and obtain serious injuries. On [DATE] at 9:55 AM, the DON was interviewed related to Resident #19's falls. She said the resident had a Broda chair and sits in it when she was tired. The DON said she seemed that the resident was more tired for a while. She said the last couple of weeks the resident had been more alert. She said they were trying 1:1 when the resident was in the wheelchair but she did not need the 1:1 in the Broda chair. Reviewed with the DON that the Care Plan was not updated with this information until [DATE]. A review of the [NAME] for Resident #19 indicated the [NAME] did not provide interventions related to the resident using a wheel chair and Broda chair or 1:1. Resident #21: Accidents A record review of the Face sheet and MDS assessment indicated Resident #21 was admitted to the facility on [DATE] with diagnoses: heart failure, history of a stroke, left sided weakness, atrial fibrillation, and arthritis. The MDS assessment dated [DATE] revealed the resident had moderate cognitive loss and needed assistance with Activities of daily living (ADL's). On [DATE] at 4:38 PM Resident #21 was observed sitting in a wheelchair watching a movie in the dining room. A review of the Incident and Accident Reports for Resident #21 revealed he fell from bed on [DATE]; he was found lying on the floor next to the bed. A review of the Care Plans for Resident #21 indicated his Fall Care Plan was initiated on [DATE] and was not reviewed or revised after falling on [DATE]. The resident's Fall Care Plan was last updated on [DATE]. Resident #28: Nutrition A record review of the Face sheet, MDS assessment, progress notes, and assessments indicated Resident #28 admitted to the facility in 2017 with diagnoses: heart failure, diabetes, atrial fibrillation, peripheral vascular disease, anxiety and depression. The resident began receiving Hospice services beginning [DATE]. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities and needed assistance with care. Per assessments and progress notes the resident died on [DATE]. She had began refusing to eat several weeks prior to hospice and had requested comfort measures for several weeks and did not want hospice services until [DATE]. A review of the Nutrition Care Plan for Resident #28 revealed it was not updated until the day after she died. The resident had not been eating well for several weeks prior. A review of the facility policy titled, SNF Care Plans, origination date [DATE] and revised [DATE] provided, . Skilled Nursing Facility will develop a person-centered comprehensive care plan for each resident . The comprehensive care plan will be reviewed and revised by the interdisciplinary team .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement policies and procedures for use, assessment, and ongoing evaluation of bed rail use for five residents (Resident #7, Resident #12, Resident #14, Resident #17, Resident #129) of five residents reviewed resulting in lack of identification and implementation of alterative interventions, lack of entrapment assessment documentation, maintenance and monitoring of side rails, extremely loose and moveable rails, and the likelihood for injury. Findings include: Resident #7: Record review revealed Resident #7 was originally admitted to the facility on [DATE] with diagnoses which included cervical region spondylosis (degeneration of the spine), spinal stenosis (narrowing of spine which causes pain), arthritis, anxiety, right hand stiffness, Peripheral Vascular Disease (PVD), carpal tunnel syndrome, weakness, and repeated falls. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required extensive, two-person assistance for bed mobility and transfers. The MDS further revealed the Resident had functional limitation in Range of Motion (ROM) in both upper extremities and one lower extremity. Review of Resident #7's care plans revealed a care entitled, The resident has potential impairment to skin integrity r/t (related to) neuropathy and impaired mobility . (Initiated: 4/1/22). The care plan included the intervention, Bilateral upper side rails up on bed for positioning & transfer/mobility (Initiated: 4/2/22) A second care plan entitled, The resident has an ADL self-care performance deficit r/t non-displaced fracture left fibula, generalized weakness . (Initiated: 4/1/22). This care plan included the intervention, Side Rails: side rails up right and left side per Dr's orders for safety during care to assist with turning in bed and bed mobility, to access bed controls, for comfort and security, to assist with getting in and out of bed (Initiated: 4/15/22; Revised: 9/27/22). Review of Resident #7's Health Care Provider (HCP) orders revealed the following active and discontinued orders: - Safety: Fall Precautions Bed and chair alarms x 3 days then safety IDT evaluate. Side rails: Bilateral Upper for aiding in turning/Bed Mobility, Aid in getting in/out of bed, access bed controls, comfort/security (Ordered: 4/1/22; Discontinued: 4/4/22). - Safety: Fall Precautions Bilateral Upper for aiding in turning/Bed Mobility, Aid in getting in/out of bed, access bed controls, comfort/security (Ordered: 4/4/22) Further review of Resident #7's medical record revealed the following: - 4/1/22: Siderail Assessment . admission . Date Side Rails were last measured: 4/1/22 . 1a. Risk Assessment . 4. Would the Side Rail(s) create a potential for increased skin integrity concerns (ex: bruising, skin tears)? Yes . Who requested side rail(s)? 1. Resident . Alternatives to Side Rails discussed with resident and/or POA . Low Bed . PT, OT, Restorative programs to increase mobility . Personal items on bedside table . Siderail Assessment . 1. Does the mattress fit the bed frame? Yes . 2. Are side rails attached securely per manufacturer's recommendations? Yes . 5. Have alternatives to side rail(s) been considered and deemed inappropriate for resident? Yes. 6. Is it appropriate to reduce or discontinue side rail(s) at this time? Yes. 7. Comments . Upper SR (Side Rail) x 2 . - 6/22/23: IDT Note . Resident continues to require assistance with all ADLs and mobility . Remains at high risk for falls and skin breakdown/pressure injury D/T limited mobility . - 6/26/23: Siderail Assessment . type of assessment . Annually . Date Consent to use Side Rails was signed. (Consent is to be signed when initiated, if there is a significant change, and/or annually) 4/1/22/ 3. Date Side Rails were last measured: 6/25/23 . 4. Would the Side Rail(s) create a potential for increased skin integrity concerns (ex: bruising, skin tears)? Yes . Who requested side rail(s)? 1. Resident . Alternatives to Side Rails discussed with resident and/or POA . Low Bed . Call light reminders . Personal items on bedside table . Resident wishes to continue side rail use . An interview was completed with Resident #7 on 7/20/23 at 9:27 AM in their room. The Resident was sitting in a wheelchair next to their bed. Braces were in place on their lower extremities. Resident #7's hands joints were bent with visible limitations in ROM. When queried regarding their stay at the facility, Resident #7 revealed they had been living in a senior living center but came to the facility after falling and fracturing their leg. When queried how much assistance they require from staff to get out of bed, Resident #7 indicated they are unable to get up on their own and it takes two staff members to help them. Two upper side rails were observed on the Resident's bed. The side rails were very loose and moved several inches away from the mattress. When asked if they used the rails to reposition themselves in bed, Resident #7 revealed they did not really use the rails. Resident #7 was queried if the side rails always moved so freely back and forth beside the mattress and revealed they were not sure. When queried if staff had measured the bed and rails, Resident #7 replied they were not aware of anyone doing that. When asked if staff had discussed the rails with them, including the risks and benefits prior to putting the side rails on the bed, Resident #7 revealed they believed the rails had always been there and were unable to recall any risks associated with usage. Upon request, the facility provided a Side Rail consent form for Resident #7. Review revealed, Side Rail Consent Form . Federal Regulations require that facilities attempt other measures before using side rails . on a resident's bed . understand there are risks and benefits . The consent form was signed and dated by the Resident and a staff witness on 4/1/22. Documentation of an entrapment evaluation was not noted in Resident #7's medical record. Resident #12: On 7/19/23 at 1:30 PM, Resident #12 was not in their room. Bilateral upper side rails were in place on the Resident's bed. The side rails were noted to have a significant amount of lateral movement away from the mattress. Record review revealed Resident #12 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Multiple Sclerosis (MS- degenerative autoimmune disorder which effects the central nervous system and brain), stage four (full thickness tissue loss with exposed muscle, bone, and/or tendons) pressure ulcer (wound caused by pressure), psychotic disorder with hallucinations, depression, anxiety, impaired mobility, falls, and dementia. Review of the MDS assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required extensive to total, two-person assistance for bed mobility and transfers. The MDS further revealed the Resident was frequently incontinent of bladder and always incontinent of bowel. Review of Resident #12's care plans included a care plan entitled, The resident has an ADL (Activity of Daily Living) self-care performance deficit r/t Disease Process . (Initiated: 5/17/22; Revised: 5/16/23). The care plan included the intervention, Side Rails: Bilat Upper rails up as per Dr's order for comfort and security, to aid in turning and bed mobility, and to access bed controls (Initiated: 5/21/22). Review of Resident #12's medical record revealed the following progress note: - 5/25/22: MDS Note . IDT Meeting Note . Resident is non-ambulatory and is transferred by Hoyer Lift and 2 Staff. With Therapy is using [NAME]/Easy Lift to transfer . received extensive assistance for bathing, bed mobility, dressing, toileting, and hygiene, while receiving set-up assistance to independently eat. Per Therapy, it was recommended . up in wheelchair for lunch and dinner and an order was obtained for this . moderate risk for falling . is non-ambulatory at this time . consented for 2 side rails to be up for positioning-bed mobility, to access bed controls and for comfort and security. They were consented for on 5/16/22 and last measured on 5/20/22. Resident #12's Side Rail Consent Form . was requested from the facility and reviewed. The consent specified, Side Rail Consent Form . Federal Regulations require that facilities attempt other measures before using side rails . on a resident's bed . understand there are risks and benefits . was signed and dated by the Resident and a staff witness on 5/16/22. On 7/21/23 at 11:08 AM, Resident #12 was observed in their room. The Resident was in bed, positioned on their back. An interview was completed at this time. Resident #12 was pleasant but did not provide responses when asked questions related to staff assistance, repositioning, and side rails. The Resident was not observed repositioning and/or using their side rails for any reason while in the room. Documentation of an entrapment evaluation was not noted in Resident #12's medical record. Resident #14: On 7/19/23 at 3:25 PM, Resident #14 was observed sitting in a wheelchair in their room. A blue colored cushion was in place on the seat of the wheelchair. The lower half of the Resident's body was sliding down in the wheelchair with their buttocks positioned at the edge of the seat. Bilateral upper side rails were in place on the Resident's bed. The side rails had a significant amount of lateral movement with pressure and a gap was present between the mattress and the rails. A motion sensor alarm was observed on Resident #12's bed, including a floor pad alarm, and on their bathroom door. A tab motion alarm was also clipped to the back of Resident #14's shirt. An interview was attempted to be completed at this time. When asked how they were doing, Resident #14's response was unable to be understood. Resident #14 was unable to provide meaningful responses when asked further questions. Record review revealed Resident # 14 was originally admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), heart failure, schizophrenia, anxiety, pain, dementia, and Alzheimer's disease. Review of the MDS assessment dated [DATE] revealed the Resident was severely cognitively impaired, displayed inattention and disorganized thinking, was frequently incontinent of bowel/bladder, and required extensive two-person assistance for bed mobility and transferring. Review of Resident #14's care plans revealed a care plan titled, The resident has an ADL self-care performance deficit . (Initiated: 3/10/22; Revised: 9/9/22). The care plan included the intervention, Side Rails: Upper right and left side rails to aid in turning and bed mobility, for comfort and security, and to aid in getting in and out of bed (Initiated and Revised: 3/10/22). Review of the facility provided CMS-802 form revealed Resident #14 has fallen at the facility. Resident #14's Side Rail Consent Form . Federal Regulations require that facilities attempt other measures before using side rails . on a resident's bed . understand there are risks and benefits . was requested from the facility and reviewed. The consent form indicated the side rails would be beneficial to aid in turning and bed mobility, to aid in getting in and out of bed, and For comfort and security. The form was signed and dated by the Resident's spouse and a staff witness on 3/9/22. Documentation of an entrapment evaluation was not noted in Resident #14's medical record. Resident #17: Record review revealed Resident #17 was originally admitted to the facility on [DATE] with diagnoses which included cerebral infarction (stroke) with resulting right dominant sided hemiplegia and hemiparesis (paralysis), ataxia (lack of coordination of muscle movement), Right Upper Extremity (RUE) below elbow amputation, right and left foot drop, and diabetes mellitus. Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required extensive, two-person assistance for bed mobility and transfers. Review of Resident #17's care plan titled, The resident has an ADL self-care performance . (Initiated: 1/31/19; Revised: 8/30/22). The care plan included the intervention, Side Rails: Bilat Upper rails up as per Dr's order for access to bed controls, assistance with positioning and for a feeling of comfort and safety. May leave upper rail(s) up or down when out of bed (Initiated: 10/21/19; Revised: 10/18/21). Resident #17's Side Rail Consent Form . was requested from the facility and reviewed. The consent form included right and left upper rails and indicated the side rails would be beneficial to aid in turning and bed mobility, to access bed controls, and for comfort and security. The form was signed and dated by the Resident and a staff witness on 9/21/21. Documentation of an entrapment evaluation was not noted in Resident #17's medical record. Resident #129: On 7/19/23 at 3:56 PM, Resident #129 was observed sitting in a wheelchair in their room. Significant visible edema was present in both of the Resident's lower extremities, and they were wearing post operative open toe surgical shoes on both of their feet. Bilateral upper side rails were present on the Resident's bed. An interview was completed at this time. When asked how long they had been at the facility, Resident #129 replied they had been in the hospital and then the facility for Three weeks. When asked, Resident #129 indicated they came to the facility to get therapy and get their strength back so they can take care of themselves at home. When queried regarding the level of assistance they require from staff for turning/repositioning, getting out of bed, and ambulating, Resident #129 revealed they do not move well, are unable to get up on their own and require facility staff to assist them. Resident #129 was then asked how long it takes for staff to answer their call light when they need assistance and revealed they did not have any concerns on day shift. When queried if staff response to their call light was different on night shift, Resident #129 stated, I can never find the call light at night, and I don't want to bother them. When asked to explain what they meant, Resident #129 revealed the facility was short staffed on night shift and did not want to bother them. When touched, Resident #129's bed rails were noted to be exceedingly loose and moved approximately three inches away from the mattress with minimal pressure. When queried regarding the side rails, Resident #129 revealed they were on the bed when they were admitted . Resident #129 was asked if they use the bed rails to reposition themselves in bed and revealed they did not. Record review revealed Resident #129 was admitted to the facility on [DATE] with diagnoses which included Urinary Tract Infection (UTI), heart disease, pain, falls, and weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact, was frequently incontinent of bladder, not on a toileting program, and required extensive, two-person assistance for bed mobility and transfers. The MDS further detailed Resident #129 had impaired one-sided, lower extremity Range of Motion (ROM), impaired balance during all transitions/walking and was only able to stabilize with staff assistance. Review of Resident #129's care plans revealed a care plan entitled, The resident has an ADL self-care performance deficit r/t Chronic Fatigue Syndrome, Generalized Weakness, Sciatica Pain (Initiated: 7/3/23). The care plan included the interventions: - Bed Mobility: The resident requires limited to extensive assistance of 2 staff to turn and reposition in bed at least every 2 hours and as necessary (Initiated: 7/3/23; Revised: 7/16/23) - Bed Mobility: The resident uses bilateral upper side rails to maximize independence with turning and repositioning in bed (Initiated and Revised: 7/3/23) - Side Rails: Bilateral upper side rails per Dr's order for safety during care provision, to assist with bed mobility. Observe for injury or entrapment . (Initiated and Revised: 7/3/23) Review of Resident #129's active, discontinued, completed, and pending Health Care Provider (HCP) orders in the medical record revealed an order, dated 7/5/23, which specified, Safety: Fall Precautions. Siderails: Bilateral upper for turning and repositioning in bed, to assist with getting in and out of bed, to access bed controls, for a for comfort and security. Review of documentation in Resident #129's medical record revealed the following: - 7/3/23 at 2:49 PM: admission Summary . Resident admitted from acute care this morning . Bed rails reviewed, and resident requested to have them to assist with bed mobility, transfers, bed remote access and for own comfort and safety . Resident #129's Side Rail Consent Form . was requested from the facility and reviewed. The consent signed but not dated by Resident #129 and signed/dated by the Director of Nursing (DON) on 7/3/23. Documentation of an entrapment evaluation was not noted in Resident #129's medical record. An interview was completed with Registered Nurse (RN) Manager A on 7/25/23 at 10:12 AM. When queried regarding facility policy/procedure related to assessment of side rails, RN A stated they think biomed completes the assessments. An interview was completed with Administrative Maintenance Staff V on 7/25/23 at 9:15 AM. When queried regarding facility policy/procedure related to installation, assessment, and evaluation of side rails for entrapment risk, Staff V revealed they were not aware of maintenance and/or biomed completing an assessment for entrapment risk. Staff V revealed biomed staff were not in the facility and unavailable, but they would review documentation and return. At 11:15 AM on 7/25/23 a second interview was completed with Staff V. Staff V provided an Equipment Management Report dated October 2022. Review of the report revealed a list of equipment, including beds and mattresses, and when the equipment is due for PM (Preventative Maintenance). The report did not identify what PM included. When asked what was checked/evaluated by biomed when they complete PM, Staff V replied, Not sure what they check. A completed biomed PM form for a new patient bed inspection, dated 9/13/21 was provided and reviewed. The form included specific items checked by biomed but did not include side rails and/or entrapment risk assessment. Work Order Reports were also provided and reviewed. None of the work orders were related to and/or addressed side rails/entrapment risk assessments. An interview was completed with Administrative Maintenance Staff V on 7/26/23 at 9:01 AM. When queried regarding facility policy/procedure related to installation, assessment, and evaluation of side rails, Staff V stated facility maintenance and biomed staff Do not specifically check the side rails. When asked if the beds come with side rails, Staff V indicated they do but the rails have to be put on the beds by maintenance staff. Staff V continued, The majority (of beds) come with two (side rails), but a couple come with four (side rails). With further inquiry, Staff V stated, Maintenance puts them together and biomed checks to make sure they function. When queried regarding entrapment zone risk assessment, Staff V stated, No body checks it from maintenance or biomed. An interview was conducted with the Director of Nursing (DON) on 7/26/23 at 10:37 AM. When queried how side rails are assessed and evaluated for safety and entrapment risk, the DON stated, Done by CNA's (Certified Nursing Assistants) or MDS (nurse). The DON was asked where the assessments/evaluations are documented and replied, I don't know. With further inquiry, the DON revealed the assessments/evaluations are assigned to staff to complete. When queried what is assessed, the DON replied, Gaps, stability. When asked if measurements are completed for each entrapment zone, the DON revealed each zone should be addressed in the assessment. The DON was then asked why all residents reviewed had side rails implemented immediately upon admission and why alternative interventions were not attempted, an explanation was not provided. When queried if consents needed to be updated and/or reviewed, per facility policy/procedure, the DON revealed they would need to review the policy to provide an answer. At 11:10 AM on 7/26/23, RN A was queried regarding entrapment assessment related to side rail use and the location of the assessments. RN A revealed the assessments used to be kept in a binder and they would look for them. No entrapment assessment/evaluations were provided and/or received by the conclusion of the survey for any Residents. Review of facility policy and procedure entitled, LTCU Side Rail Policy (Revised 2/5/20; Effective: 2/1/23) revealed, To provide a safe environment for residents . Procedure . 1. At the time of a resident's admission to the facility, there will be a discussion with the resident and family regarding alternatives to side rails . 5. A physician's order will be obtained specifying the medical symptom/purpose for which the side rail (s) were ordered . 6. Side rails will be appropriate for the bed and installed according to the manufacturer's recommendations . 7. Staff will evaluate the resident's bed and ensure that the bed's dimensions are appropriate for the resident's height and weight . 8. With the resident laying in the bed, measurements of the resident's bed and possible entrapment zones (mattress and side rails) will be obtained daily for 5 days at the time of installation and with any change in bed and/or mattress. Entrapment zones, as identified by the F.D.A. will be measured. 9. Should any area measured be out of the safe range a corrective measure will me implemented . 10. Follow-up measurements will be obtained regularly to ensure that there are not any changes . 12. Biomedical technicians will check the beds and side rails regularly according to manufacturers recommendations .

Based on interview and record review, the facility failed to ensure that 27 out of 27 residents received their mail on Saturdays, resulting in residents not being able to exercise their right to receive mail and access communication. Findings Include: On 7/20/23 at 1:30 PM, during a meeting with a Confidential Group of Residents, they were asked if they received mail on Saturdays. The group replied, No, we don't. With further discussion, the residents said it was something they had recently been talking about, because they were not receiving their mail on Saturdays. During an interview with the Activities Director F, on 7/20/2023 at 2:30 PM, she was asked if the resident's received mail on Saturdays and she said they did not. She said the mail was handled through the storeroom in the hospital. On 7/26/2023 at 1:30 PM, during an interview with the hospital Storeroom Clerk L, she was asked how mail was handled for the facility. She said the storeroom sorted the mail and placed it in a mail slot for the facility. She said the residents did not receive mail on Saturdays because the storeroom was closed. She said she recalled when they used to receive mail, but did not remember how long ago that was. An interview with the Storeroom Manager M, on 7/26/2023 at 1:50 PM revealed, We are looking into how we will arrange for mail delivery on Saturdays. A review of the facility policy titled, Mail Handling, MM-12, dated origination 1/25/2011, last revised 7/19/2019 and last reviewed 12/6/2022 provided, Purpose: To ensure that incoming and outgoing mail is handled responsibly. To properly maintain patient, staff, and resident confidentiality. Materials Management maintains responsibility of mail handling for all business material . Mail will be sorted and put in department mailboxes in the morning Monday through Friday . The policy did not mention the residents were to receive mail on Saturday. A review of the Rights of Residents in Michigan Nursing Facilities, dated 2022 revealed, As a resident of a Michigan nursing facility, you have extensive rights guaranteed under federal and state law. As a basic premise, all residents have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility . You have the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for you .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility 1) Failed to ensure appropriate medication practices including appropriate removal of narcotics from the medication dispensing system and Failed to ensure that the medication refrigerator freezer in the Medication Room was defrosted routinely and to obtain routine temperatures of the medication room refrigerator to ensure medications remained at an appropriate temperature to retain efficacy, potentially effecting all 27 residents in the facility. Findings Include: FACILITY Medication Storage and Labeling On 7/21/23 at 9:04 AM, during a review of the medication storage room with the Director of Nursing/DON, a yellow sticky note was observed stuck to the front of the medication dispense system in the med room. The sticky note had multiple crossed off months and years ending with July 2023. At the top of the note it read NNANCY21. The DON was asked what the note was and she said that shouldn't be on there. When asked if that was a name of a nurse at the facility, she stated, No. The DON was asked how the nurses disposed of narcotics and she said 2 nurses would witness and place the meds in the drug buster. The DON was asked if there were 2 nurses on nights and she said not always. She was asked how they would dispose of narcotics when there was only 1 nurse; asked if a nurse from the hospital would witness and she said No. The DON was asked if 2 nurses were needed to remove a narcotic and she said Yes. The DON was asked if the password on the medication dispensing system was used to show a 2nd nurse had witnessed the removal of a narcotic and she stated, Probably. A report from the medication dispensing system was requested to show narcotic removal for the past 30 days. The DON said she would need to contact the pharmacy to run the report. A policy was requested for narcotic management, removal medications from the medication dispensing system, medication administration and destruction of narcotics. During the review of the medication room with the DON, Nurse I entered to retrieve a medication. Nurse I was asked about the note on the medication dispensing system with the Month Year and what appeared to be a pass code, she didn't respond. She was asked if it was supposed to be there and she said, I don't think so. Further review of the medication storage room identified the medication refrigerator had a freezer that had not been defrosted recently it had several ice packs stuck in it and the freezer was coated with ice about 3-4 inches thick. It wasn't possible to determine what else was in the freezer. The DON stated, It needs to be defrosted. The DON was asked where the temperature log for the medication refrigerator was and she said the July 2023 temperature log should be in the medication room on a clip board and at the end of the month should be sent to her. She said she kept refrigerator temp logs in her office; there were additional refrigerators for staff and resident foods in the facility. The DON could not locate a July 2023 refrigerator temperature log in the medication room. She looked in a folder in her office and she said she did not have any temperature logs for the medication refrigerator. A medication refrigerator policy was requested. On 7/21/23 at 12:55 PM, a Confidential Person was interviewed related to retrieving medications from the medication dispensing system, she said there was a fake nurse sign on NNancy21 with the password being the month and year example July 2023. The nurse stated, I don't think that is safe. I would be more comfortable with a real nurse instead of a fake nurse. She said the acute care/hospital nurse does not come over to be the 2nd nurse to assist in signing out narcotics from the medication dispensing system if the facility only has one nurse at night (the facility and hospital are connected in the same building). A record review of the medication dispensing report titled, Transactions by Item/Procedure, for 6/1/2023 to 7/21/2023 revealed [NAME], [NAME] (NNancy21) was used as a sign on for multiple days and shifts per the following: 6/10/2023 at 7:12 PM: used once for Null-Wrong item or restock label bar code scanned during Restock. This is the verbiage provided each time the [NAME], [NAME] fake nurse code was used. You could not discern if someone was accessing the wrong drawer or if they were restocking. 6/10/2023 at 7:13 PM: the code was accessed once. 6/13/2023 at 10:13 PM: the code was used >3 times. 6/19/2023 at 10:26 PM: the code was used once for a narcotic. 6/21/2023 at 3:29 AM and 3:30 AM: the code was used >10 times. 6/30/2023: the code was used >twice. 7/3/2023 at 6:02 PM: the code was used once for a narcotic. 7/5/2023 at 4:42 PM: the code was used >3 times. 7/10/2023 at 8:22 PM and 8:27 PM: the code was used >9 times. The medications accessed were: Eliquis, Dexamethasone, Prednisone, Lantus insulin, Sodium Chloride 0.9% IV solution 100 ml bag, Dextrose 5%-0.9% Sodium Chloride IV solution 1000 ml bag, Allopurinol, Quetiapine 25 mg tab (Seroquel), Insulin Glargine, Metoprolol, Tamsulosin, Mirtazapine, Ropinirole, Tramadol (a narcotic/no witness), Levofloxacin, Simvastatin, Doxycycline, Nystatin powder, Lorazepam (a narcotic/with a witness). There were multiple instances when there were not two nurses at a time accessing the narcotics: one to remove the medication and one to witness the transaction. A review of the document titled, Users Table List Report, dated 7/21/2023 at 10:51 AM, revealed there were 13 nurses listed as having a User ID to access the medication dispensing system. NNancy21/[NAME], [NAME] (the fake nurse) was not listed. A review of the facility's employee list indicated there were 15 nurses working on the floor with potential access to the medication dispensing system. All of the nurses had access to the fake nurse sign on code that was attached to the front of the medication dispensing system. A review of the facility policy titled, Automated Medication Dispensing Systems (AMDS), effective date 12/01/07 and revised 8/17/20 provided, This Policy 6.5 sets forth the procedures relating to automated medication dispensing systems (AMDS) . Facility should ensure that only licensed Facility personnel who have the approval of the Director of Nursing and who have received appropriate training have access to medications in the AMDS . Secure user names and passwords should be maintained by the Director of Nursing and the Pharmacy. When a facility that has adopted a policy to have another nurse witness the removal of a controlled substance from the AMDS, but a witness is unavailable before the dose is administered, nurse removing the dose should have a nurse on the unit or the nursing supervisor verify: the medication, the strength, dosage form, and the quantity removed. The verification by the unit nurse or supervisor should be documented in the resident's medical record or the perpetual inventory record . Facility should document staff training on the use of the AMDS including: . Security and appropriate access to the AMDS, Accessing the medications . Wasted dose disposal . A review of the facility policy titled, LTCU Medication Administration, origination 7/1/2012 and revised 10/10/2019 provided, Policy: A licensed nurse through the nursing process will facilitate the safe and effective us of medications in collaboration with Healthcare team, resident/responsible person .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: 1. Properly label and date food and food products, 2. Dispose of expired food and food products, 3. Ensure chemical cleaning agents were maintained separate from food, 3. Ensure use of a beard restraint by kitchen staff, 4. Ensure cold food items were stored at 41 degrees Fahrenheit or less, 5. Ensure dry food products were stored in a manner to prevent contamination, 6. Institute monitoring of chemical dishwasher processes to ensure staff understanding and correct chemical sanitization dishwasher temperature and chemical levels, and 7. Maintain sanitary conditions in the kitchen, resulting in the increased potential for cross-contamination and foodborne illness. These deficient practices had the potential to affect 27 residents who receive food from the kitchen. Findings include: A tour of the facility kitchen was completed on 7/19/23 at beginning at 10:19 AM with Anonymous Kitchen Manager P. The floor of the kitchen with visibly dirty with dirt and dust build up under all food preparation and storage areas including movable refrigerator/freezers. There were two stand up refrigerators side by side next to a food preparation area. In one refrigerator, a mixed and undated Iced Tea and an open and undated container of lemon juice were present along with bowls of undated Jello. When asked what the refrigerator was called, Manager P replied they call it the Pop Cooler. There were clipboards on the outside of the refrigerator with temperature logs. When asked which refrigerator each log was for, Manager P reviewed the logs and indicated they were for all the refrigerators/freezers in the area. A copy of the temperature logs was requested at this time. A rolling tray with undated and wrapped cookies, brownies, buns, bread, and syrup in individual cups was positioned near the end of the Milk cooler. The metal shelves on the rolling tray were visibly dusty and dirty. When queried regarding the food items, Manager P replied they thought they were for the trays. Manager P was queried regarding the date the items were made and/or packaged and revealed they did not know. Dry storage of food items was observed across from the walk-in cooler in freezer on metal shelving. Bags of food mixes were present. The bags were not contained in an airproof containers and or sealed and allowing for contamination and insect infiltration. The non-contained, open, and uncovered and/or unsealed items included but were not limited to: - Bag of cookie crumbs, no date - Corn starch, no date - Instant mashed potato dry mix - Bag of taco seasoning mix - Two bags of cream soup base mix - Bag of roasted chicken gravy mix - Bag of beef flavored gravy mix - Bag of [NAME] mix - Natural cane sugar; Expired 11/11/22 Staff R was observed moving throughout the kitchen, preparing, and cooking food. Staff R was observed to have large gauge, round earrings and facial hair but was not wearing a beard net. Manager P was queried regarding Staff R's facial hair and revealed they had not noticed but would address. When queried regarding facility policy/procedure related to dress code and if the staff member should have a beard net/covering in place, Manager P confirmed they should. A work area with shelves below and above containing spices and other dry food products including vinegar and boxes of baking soda were observed. The spice containers appeared to be coated with dirt/dust. When touched, the containers were noted to be sticky, and the shelving was tacky and visibly soiled. Visible dirt and multiple unknown sticky substances were present on the shelving. A box of baking soda and barley were open, unsealed, and undated as well as 2 open and undated bottles of vinegar, and 20 containers of spices. A 13-ounce container of dill weed was noted to have an expiration date of 7/12/23. When queried regarding facility policy/procedure related to dating and disposal of spices/dry goods, Manager P replied, Should be dated when opened. Manager P proceeded to was observed to be discernibly unclean with significant amounts of built-up dirt, dried up off-red colored vegetables, and other unknown substances. When queried what the off red colored substance on the floor was, Manager P replied, Looks like it was a tomato. Manager P was asked about the dirt observed on and under the workstation and stated, It needs to be cleaned. When asked who is responsible to clean the floors in the kitchen, including under the appliances and tables, Manager P stated, Housekeeping. The floor vent under the food prep table had a significant amount of dirt build up. The hood over the cooking surface was noted to have caked on food substances and debris. When asked who mopped the floors and cleaned the cooking appliances, Manager P indicated Kitchen staff clean cooking items and housekeeping cleans the floors. No other explanation was provided. A rack containing trays with bread products was present near an exit door of the kitchen. The shelves appeared to be coated in dirt and when touched, this Surveyor's fingers were coated with dirt. Manager P was present and observed the dirt. When queried the last time the shelving unit was cleaned, Manager P was unable to provide a response. On another food prep station, an open bucket of cleaning solution with a rag in it was sitting directly next to an open and unsealed Creamy Quick Wheat and Gluten Free Pancake mix. When queried what was in the open bucket, Manager P replied it was sanitizer solution. When queried regarding the sanitizer solution being stored directly next to the open containers of food mixes, Manager P quickly moved the sanitizer solution and indicated it was not supposed to be stored near open food. During a tour of the walk-in cooler/refrigerator, the following items were observed: - Two eight-pound (lbs.), four-ounce (oz) containers of Pace Salsa; Open and undated - 128 oz container of sweet pickles with two dates (8/12/23 and 12/18/23) written on the container - Seven lbs. container of coleslaw, open and undated - 32 oz container of Hidden Valley Caesar Dressing, open and undated - 32 oz container of Hidden Valley Italian Dressing, open and undated, Manufacturer Expiration Date: 4/2/23 - 135 oz container of Enchilada sauce, opened and undated, Manufacturer Expiration Date: 6/5/23 - 4.5 lbs. container of Sweet and Sour Sauce, opened, Expired: 4/14/23 - One gallon container of Sweet Baby Ray BBQ sauce, open and undated - Three separate, packages of cheese, open and undated - 16 oz. container Maraschino Cherries, open and undated An interview was conducted with Kitchen Staff P on 7/19/23 at 7:00 PM. When queried who responsible to clean and deep clean the kitchen, including moving items and cleaning underneath, Staff P replied, Nobody does. Staff P revealed the tray line was cleaned after this Surveyor completed a tour of the kitchen. Staff P stated, Tray line was full of stuff under it. When asked what kind of stuff, Staff P revealed there was food such as tater tots which had not been made/served in a very long time. Staff P was asked if there are cleaning assignment sheets for staff in the kitchen and indicated there were. Staff P stated, Nobody (staff) does it (cleaning), they just sign it indicating they did it. When queried if the work area and shelves where the spices are stored are included on the cleaning assignment sheets, Staff P revealed they did not know but stated, Not been cleaned in two and a half years. Staff P was then asked how long pre-packed lunch meat is good for after being opened and stated, We don't date the lunch meats after we open it. When asked how long they used and served the meat to residents for, Staff P did not provide a response but stated, (Prior Kitchen Manager) had us write two and a half weeks after open. When queried how long packaged sandwich meat was able to be used for after opened, Staff P indicated they believed it was supposed to be one week. When asked about the dishwasher and how staff ensure dishes are clean and sanitized, Staff P revealed test strips are used and the results are documented. Staff P was asked how the test is performed and stated, You just stick it in and remove it immediately. Staff P indicated the color of the test strip is compared to the bottle and that is the number that gets written on the form. When queried what the number (chemical ppm) is supposed to be, Staff P revealed they did not know. When asked what the temperature of the dishwasher was supposed to be, Staff P was unable to provide a response. Staff P revealed the sheet (form) does not include acceptable levels. When asked how they know if the dishes are clean and sanitized if they do not know what the temperature and/or chemical ppm is supposed to be, a response was not provided. An interview was completed with RN S on 7/19/23 at 7:45 PM. When queried regarding food provided/prepared in the kitchen, RN S revealed the milk is always soiled prior to the expiration date on the container and has even been curdled with chunks in it. An interview was completed with Housekeeping Staff U on 7/20/23 at 7:00 AM. When queried what housekeeping cleans in the kitchen, Staff U revealed housekeeping staff do not clean the kitchen. When asked if they assisted in cleaning the floors, Staff U revealed the floors are cleaned with a buffer machine on a schedule but specified it is not a daily occurrence and done to keep the floors in good repair. When asked, Staff U revealed the equipment/furniture in the kitchen is not moved when the person uses the machine to do the floors. Review of provided kitchen refrigerator/freezer temperature log copies received during the initial tour on 7/19/23 revealed three logs with temperature documentation for the Ice Cream freezer, Juice-2 door cooler, and the Milk/flip top cooler. Review of the log for the Ice Cream Freezer log detailed, Maintain freezer temperature at 0 F or below during table times . Check and record temperature once a day . Complete corrective action column if temperatures are not in proper range . Month: (Blank) . Year: (Blank) . The form was completed for the 1st to the 19th at 5:30 (did not specify AM or PM) daily. The temperatures recorded were higher than 0 degrees F for 12 of the 19 recorded dates. There was no documentation of corrective active completed. Review of the log for the Juice - 2 Door Cooler Refrigerator Temperature log detailed, Maintain refrigerator temperature at 40 F or below . Check and record temperature once a day . Complete corrective action column if temperatures are not in proper range . Month: (Blank) . Year: (Blank) . The form was completed for the 1st to the 19th at 5:30 (did not specify AM or PM) daily. The refrigerator temperature was recorded at or below 32 F (freezing- from 26 to 32 F) for nine of the 19 recorded dates. There was no documentation of corrective active completed. Review of the log for the Milk/Flip-top Refrigerator Temperature log detailed, Use a separate Temperature log sheet for each walk-in /reach-in refrigerator location. Maintain refrigerator temperature at 40 F or below . Check and record temperature once a day . Complete corrective action column if temperatures are not in proper range . Month: (Blank) . Year: (Blank) . The form was completed for the 1st to the 19th at 5:30 (did not specify AM or PM) daily. Time . Milk . Flip-top were written on the top of the columns of the form. Review of the Milk column detailed the temperature was: - 44 F on the 2nd. There was no documentation of corrective action. - 46 degrees on the 6th. The Corrective Action/Comments column specified, 37 F at 6:12 AM but did not specify if the action was for the Milk or the Flip-top refrigerator (38 F). - 43 F on the 10th - 44 F on the 16th The Flip-top column indicated the temperature was 46 F on the 7th. There was no correction action documented. Upon request for additional temperature monitoring logs, the following were received and reviewed. For March 2023, the facility provided seven Kitchen temperature monitoring logs, for 10 appliances. Review of the provided Kitchen temperature logs revealed the following: - Cooks/Flip Top . (Refrigerator) Maintain . temperature at 40 F or below . had Cooks written in one column and Flip-top written in another. Between the two columns, 21 temperatures were recorded at or below 32 degrees (range - 22F to 32F) with no corrective action taken. - Juice- Pepsi on Tray line . Maintain . temperature at 40 F or below . Recorded temperatures were greater than 40 degrees on 3/3/23, 3/8/23, 3/17/23, 3/20/23, and 3/26/23. No documentation of corrective action was present. - Milk/Flip-top . Maintain . temperature at 40 F or below . The recorded temperatures were greater than 40 degrees F on 3/3/23 (Milk), 3/4/23 (Milk), 3/5/23 (Milk), 3/8/23 (Milk), 3/18/23 (Milk), 3/18/23 (Flip Top), 3/20/23 (Milk), 3/21/23 (Milk), 3/21/23 (Flip Top), 3/24/23 (Flip Top), 3/25/23 (Flip Top), and 3/26/23 (Flip Top). On 3/3/23, a corrective active was documented which detailed the refrigerator temperature was rechecked four hours and 10 minutes and the temperature was down to 32 F from the initial recorded temperature of 46 F. On 3/18/23, a single temperature was documented under the corrective action column but did not indicate which refrigerator the temperature was for. - Ice Cream/2 Door . Maintain freezer temperature at 0 F or below . Under the corrective action column on the log, Cooler was written, and the form appeared to have both freezer and refrigerator temperatures documented. The 31 temperatures written in the corrective action column ranged from 32 F to 36 F. The documented freezer temperature was greater than 0 F 12 out of 31 days with no documentation of corrective action. - Freezer Walk-In . Maintain freezer temperature at 0 F or below . Review revealed the recorded temperatures were greater than 0 F on 3/3/23, 3/4/23, 3/5/23, 3/6/23, 3/8/23, 3/9/23, 3/11/23, 3/16/23, 3/17/23, 3/20/23, and 3/21/23. The highest temperature documented was 19 F on 3/8/23 with no corrective action. Corrective action was documented on 3/2/23, 3/6/23, and 3/9/23. Temperature logs for the Cooks Z-Door Under Counter and Walk-in refrigerator were also provided for March 2023. The facility provided eight Kitchen temperature monitoring logs, which included documentation for 10 appliances, for April 2023. Review of the provided Kitchen temperature logs revealed the following: - Freezer Walk-In . Maintain freezer temperature at 0 F or below . The recorded temperatures were greater than 0 F on 4/2/23, 4/5/23, 4/6/23, 4/7/23, 4/12/23, 4/13/23, 4/18/23, 4/20/23, and 4/22/23. Corrective action was documented one time, on 4/18/23 and detailed, 0 (degrees F) at 8:30 AM. - Milk/Flip-top . Maintain . temperature at 40 F or below . The recorded temperatures were greater than 40 degrees F on 4/4/23 (Flip Top), 4/5/23 (Flip Top), 4/17/23 (Milk) and 4/23/23 (Milk). There was no documentation of corrective action. - Retail . Maintain . temperature at 40 F or below . The recorded temperatures were below 32 F (freezing) 13 of the 30 days with no documentation of corrective action. - Juice- Pepsi on Tray line . Maintain . temperature at 40 F or below . Recorded temperatures were greater than 40 degrees on 4/3/23, 4/4/23, 4/20/23, 4/23/23, and 4/27/23. There was no documentation of corrective action. Temperature logs for a Retail freezer as well as the Walk-in, Cooks/Flip-top, and Cooks Z door undercounter refrigerator were also provided for April 2023. The facility provided six Kitchen temperature monitoring logs for May 2023 which included monitoring for seven appliances. Review of the logs revealed the following: - Milk/Flip-top . Maintain . temperature at 40 F or below . The recorded temperatures were greater than 40 degrees F on 5/3/23 (Milk), 5/15/23 (Milk), 5/16/23 (Milk), 5/21/23 (Milk), 5/25/23 (Milk), and 5/29/23 (Milk) with no documentation of corrective actions. - Freezer Walk-In . Maintain freezer temperature at 0 F or below . The recorded temperatures were greater than 0 F on 5/3/23, 5/7/23, 5/15/23, 5/16/23, 5/25/23, and 5/29/23. There was no documentation of corrective action. - Juice- Pepsi on Trayline . refrigerator log provided showed documented temperatures greater than 40 F on 5/2/23 and 5/15/23 with no corrective action documented. The provided Ice Cream temperature log contained documentation of what appeared to be both refrigerator and freezer temperatures but only identified the Ice Cream freezer on the form. On 5/1/23, there was only one temperature documented (6 F) and one temperature on 5/7/23 (32 F). Twenty two of the 31 days had freezer temperature readings greater than 0 F. Temperature logs for the Walk-in and Pass-thru refrigerators were also provided for May 2023. The facility provided eight Kitchen temperature monitoring logs for June 2023 with temperature recordings for ten appliances. Review revealed the following: - Juice- Pepsi on Tray line . Maintain . temperature at 40 F or below . Recorded temperatures were greater than 40 degrees on 6/8/23, 6/13/23, and 6/14/23 with no documentation of corrective action. - Cooks/Flip-top . Maintain . temperature at 40 F or below . On 6/8/23, the temperature for both refrigerators were documented as a question mark. - Milk/Flip-top . Maintain . temperature at 40 F or below . The recorded temperatures were greater than 40 degrees F on 6/8/23 (Milk), 6/14/23 (Milk), 6/18/23 (Milk), 6/27/23 (Milk), and 6/28/23 (Milk). There was no documentation of corrective action. Note: the Flip-top temperature recordings were not the same temperature. - Ice Cream . Maintain freezer temperature at 0 F or below . Twenty-one of the thirty recorded temperatures were greater than 0 degrees F. There was no documentation of corrective action. The Freezer Walk-In . Maintain freezer temperature at 0 F or below . temperature log provided via email file labeled Temps-June did not include a month/year on the actual form. Review of the log provided revealed a temperature was not documented on the 4th. On the 5th, the comment written on the form detailed, Freezer was off all night- will check later morning. The refrigerator temperature was not clearly written and unable to be discerned. The recorded temperatures were greater than 0 degrees F on the 8th, 13th, 14th, 22nd, 27th, and 28th. Temperature logs for the Cooks Z Door under counter, Juice -2 Door Cooler, and Walk-In refrigerators were also provided for June 2023. On 7/20/23 at 2:20 PM, an interview was conducted with Kitchen Manager P. When queried if the logs were for the current month (July 2023), Manager P stated they were. Manager P was asked why the month and year were not written on the log. Manager P did not provide an explanation. When queried if they review the refrigerator and freezer temperature logs, Manager P replied that they did. The facility provided temperature logs from all the kitchen refrigerators and freezers were reviewed with Manager P at this time. Manager P was asked if they were aware of the out-of-range temperatures and did not provide a verbal response. When queried regarding the facility policy/procedure related to temperatures which are outside of the safe range, Manager P revealed staff are supposed to report any temperature concerns to them. Manager P was then asked if staff are reporting the temperatures and stated, No. The kitchen cleaning assignment forms were reviewed with Manager P at this time. When asked if the cleaning tasks were being completed and if the kitchen was clean, Manager P replied, No. When queried why the logs and appliance names were not the same each month, Manager P did not provide an explanation but stated, That's an easy fix. A tour of the kitchenette was completed on 7/26/23 at 7:45 AM. The kitchenette contained a refrigerator/freezer containing food items for residents. A temperature log labeled July 2023 was present on the side of the refrigerator/freezer. Review of the form detailed, Maintain freezer temperature at -.04 to -10 F (degree Fahrenheit) . Record temperature at least twice a day . Complete corrective action column if temperature are not in proper ranges . Maintain refrigerator temperature at 32 - 40 F . There was no documentation of temperature monitoring on the following dates/shifts: - 7/1/23, 7/2/23, 7/4/23, 7/7/23, and 7/10/23 Midnight Shift - 7/2/23, 7/3/23, 7/4/23, 7/8/23, 7/9/23, 7/10/23, and 7/14/23 Day Shift The following out of range refrigerator temperatures were documented: - 7/5/23 Day Shift: 30 F - No documentation of corrective action documented - 7/8/23 Midnight Shift: 30 F - No documentation of corrective action documented - 7/9/23 Midnight Shift: 30 F - No documentation of corrective action documented - 7/25/23 Midnight Shift: 30 F - No documentation of corrective action documented All documented Freezer temperatures were higher than -4 F except on 7/23/23 midnight shift. The freezer temperatures ranged from -4 degrees to 8 degrees. No corrective action was documented. Review of facility policy/procedure entitled, Food Storage (Revised: 6/30/22; Expired: 6/30/23) revealed, Food and supplied will be received and stored in proper areas and at proper temperatures . All cleaning supplies are stored in an area removed from food . Cleaning . the actual cavity space when . foods are stored are maintained by Nutrition Services . Frozen foods are stored in a freezer and the temperature is maintained at 0 to (negative) -10 below zero for the Nutrition Service department . temperatures will be monitored three times daily . Units failing to maintain the specified minimum required temperature will be reported immediately to the manager/supervisor . A 15-30-minute temperature check monitor cycle will begin . until the desired temperature is achieved . Produce is stored in a refrigerator that is maintained a 40 F or below . temperature checks will be recorded . three times daily . for the Nutrition Services . Units failing to maintain the specified minimum required temperature will be reported immediately to the manager/supervisor . A 15-30-minute temperature check monitor cycle will begin . until the desired temperature is achieved . Foods requiring refrigeration will be expiration dated as to the manufacturer's specified date or recommendation . once opened packages of food requiring refrigeration will have an expiration date of no more than 7 dates unless it is aged, pickled, or brined . salad dressings will display an expiration limit of 30 days after being opened. Dairy and deli productions will be displayed either by the manufacturer's expiration date, or 8 days after opening . Review of facility policy/procedure entitled, NS . Infection Control (Revised: 12/16/22) revealed, To prevent and control contamination and the spread of infection . Provide for the proper reviving and storage of all food . Maintain proper storage of perishable foods at 41 F or below. Store frozen food at 0 F or below. Temperatures will be checked twice daily . Storage areas shall be adequate, cleaned thoroughly weekly and inspected daily by the Manager . Food not in its original container shall be stored in the smallest container possible, covered, labeled and expiration dated. Foods stored in opened original containers must be covered and expiration dated . Personnel . No jewelry is to be worn with the exception of watches, wedding rights and small stud-style earrings . Environment . Fruits, vegetables, dairy products, meat and poultry shall be stored at temperatures between 33 -41 F . frozen foods shall be stored between 0-10 F .