**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately document medication administration times for 1 of 4 residents (R2) observed during the medication administration observation. Findings include: A review of R2's Face Sheet, dated 11/20/24, revealed R2 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R2's Face Sheet revealed they had multiple diagnoses that included osteoarthritis, neuropathic (nerve) pain of both feet, closed lumbar spine closed fractures with delayed healing, chronic pain syndrome, pneumonia, closed fracture of the humerus (bone in the upper arm), and right hand pain. During the medication administration observation on 11/19/24 from 6:45 AM to 7:30 AM, the surveyor observed Registered Nurse (RN) A administer Tylenol, docusate sodium (a stool softener), Vitamin B Complex, metoprolol (a blood pressure medication), Eliquis (a blood thinner), Lasix (a water pill), pantoprazole (a medication for gastric reflux- heartburn), gabapentin (a pain medication), and Oxycontin (a pain medication) to R2. RN A stated R2 also had a potassium packet (powered potassium) ordered. However, RN A did not have the packet because it looks like it's a new order, so pharmacy did not send it. She stated she will have to wait until pharmacy makes their next delivery of medications, which will probably be tomorrow. In addition, RN A stated R2 had an order change where she was only receiving 25 milligrams (mg) of metoprolol. She had 50 mg ordered before. But the doctor changed her pain medication, so she has not required that high of a dose. RN A verbally verified R2's medications and doses as she prepared them. The surveyor observed these medications being administered to R2. In addition, the surveyor heard RN A tell R2 that she was only receiving 25 mg of metoprolol because the physician changed her pain medications and the new pain medications had been helped to lower her blood pressure by reducing her pain. A review of R2's Medication Administration Record (MAR), dated 11/19/24 from 7:01 AM to 9:53 PM, revealed the following: - Voltaren (diclofenac sodium) gel (a medication for osteoarthritis) was documented as given at 7:16 AM (not observed by the surveyor during the medication administration observation) - Flonase (fluticasone) nasal spray was documented as given at 7:01 AM (not observed by the surveyor during the medication administration observation) - Metoprolol succinate (Toprol-XL- a medication for high blood pressure) 50 mg was documented as given at 7:01 AM (the surveyor only observed RN A administer a 25 mg dose to R2 during the medication administration observation) - Potassium chloride 20 mEq (millequivalents) packet (a medication for low potassium levels) was documented as given at 7:01 AM (not observed by the surveyor during the medication administration observation) A review of R2's physician orders revealed the physician discontinued R2's metoprolol 25 mg dose on 11/18/24 at 10:54 AM and started R2 on metoprolol 50 mg beginning with her daily morning dose on 11/19/24. During an interview on 11/20/24 at 10:26 AM, RN A stated stated she administered R2 her potassium packet later (she did not specify the time) after she received it from the pharmacy. She also stated she administered the Voltaren and Flonase after the nursing assistant had settled R2 in her chair with her blankets (the nursing assistant had toileted and dressed R2 immediately prior to the medication administration observation and had finished up getting her settled in her chair after RN A had administered the medications that the surveyor observed). RN A stated she did not remember the exact dose of metoprolol that she had administered to R2, but was sure that she had verified the dose with R2's MAR and the surveyor when she prepared it. However, the surveyor's procedure (which was adhered to) was to only check the medications when they are prepared with the packages that they come in, to have the nurse verbalize the medications and their doses, and to not view the MAR during the medication administration observation in case the physician's order does not match the MAR (this would be discovered when the medications are reconciled with the physician's orders after the observation was completed). During an interview on 11/20/24 at 11:32 AM, the Director of Nursing (DON) was notified that the surveyor had a concern with the administration times that were documented for R2's potassium chloride packet, Voltaren gel, and Flonase. The surveyor shared with the DON that these medications were administered after the medication administration observation was completed (after 7:30 AM) and RN A had verified this during their interview with the surveyor an hour before. The DON stated RN A should have documented the actual times that these medications were given and should not have documented that they were given at 7:01 AM or 7:16 AM if those were not the times they were given. A review of the facility's Medication Management policy, dated 4/21/23, revealed, All medications will be prepared and administered for one resident at a time following the rights of medication administration . right dose . right time, and right documentation .

Based on observation, interview, and record review, the facility failed to secure 1 of 1 medication refrigerators and 2 of 3 medication carts, resulting in the potential for misappropriation of medications. Findings: During an observation on 01/03/23 at 9:58 AM, the refrigerator in the medication storage room, that contained controlled substances, was unlocked. During an interview at the same time, the Director of Nursing (DON) indicated that the refrigerator was to remain locked at all times. During an observation on 01/03/24 at 12:58 PM, the medication cart, identified as team 2 med cart, was unlocked and unattended by nursing staff. During an observation on 01/04/24 at 11:00 AM, the medication cart next to the bird aviary was unlocked and unattended by nursing staff. Review of the facility policy Medication Management, effective 04/21/23, revealed (a) the purpose was to outline safe storage of medications, (b) storage- all medications are securely stored in a locked cabinet/cart or locked medication room that is inaccessible to residents and visitors, and (c) after receiving controlled substances and adding them to inventory, they are immediately placed into a double locked secure storage area.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by: 1. Failing to maintain proper temperature of sliced roast beef on the food preparation line. 2. Failing to discard expired food in the walk in cooler. These deficient practices have the potential to result in food borne illness among any and all 29 residents of the facility. Findings include: 1. On 1/3/2 at approximately 11:45 AM, during the noon meal observations in the kitchen, a stainless steel container was observed sitting on a bed of ice cubes. Sliced sandwich roast beef was observed in the pan, elevated above the bottom of the pan on a plastic grid. The internal temperature of the roast beef was measured using a metal stem probe digital thermometer, and found to be 50°F. An interview was conducted with [NAME] B at this time and learned the product had been in the pan for about 20 minutes. [NAME] B was requested to use a facility thermometer to measure the temperature of the roast beef, who then agreed and reported a temperature of 52°F. [NAME] B was then asked if the temperature of the product had been recorded 20 minutes prior, to which was the response Yes. It was 37°F When asked how the temperature had risen so much so fast, no explanation was given. The FDA Food Code 2017 states: 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57°C (135°F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54°C (130°F) or above;P or (2) At 5ºC (41ºF) or less. 2. On 1/3/24 at approximately 9:30 AM, the walk in cooler was observed during the initial tour of the kitchen. A 32 oz container of garlic in water was observed on a shelf with a stamp: Best if used by 7/15/23. A 30 oz container of Basis Pesto was observed on the same shelf labeled: Opened 11/7. Further review of the Pesto container revealed the following information about the product: Keep Frozen. Once thawed is considered perishable. An interview with Certified Dietary Manager (CDM) A was conducted on 1/3/24 at approximately 9:55 AM. CDM A confirmed the two mentioned products were expired and disposed of them. Additionally, CDM A stated the Pesto product was no longer used for menu items for the residents, as the residents didn't like it. On 1/4/24 the three week menu cycle provided to the survey team, was reviewed. Week 2, Thursday Dinner listed Basil Pesto Pizza for the entree. On 1/4/24 at approximately 10:40 AM, an interview with CDM A was conducted related to the disparity between the menu and the statement of the Pesto product not being used. CDM A stated, Oh. I gave you the wrong menus.