Based on observation, interview and document review, food was not served in a sanitary manner for 15 residents who dined in the north dining area, observed during dining services. In addition, the facility failed to maintain the ice machine in a sanitary manner to prevent potential illness for 15 residents who currently received ice from the ice machine in the north dining area. Further, the facility failed to maintain proper holding food temperatures for 13 of 17 residents observed to receive egg salad sandwiches. These deficient practices had the potential to cause foodborne illness. Findings include: FOOD SERVICE During an observation on 12/10/24 at 12:06 p.m., dietary aide (DA)-A washed her hands in the north kitchen, applied gloves to both hands, picked up an i-pad with resident dietary information on it and placed it on the counter next to the steam trays. DA-A opened a drawer with her left hand, removed utensils from the drawer with both hands and placed utensils into each food item on the steam tray area. DA-A proceeded to open a bag of buns, touched the i-pad with her left hand, picked up a baked potato with her right hand and placed the potato onto a plate. DA-A opened the potato with both hands and a knife and placed other food items on the plate with utensils and handed the plate to the server. DA-A touched the i-pad with her left hand, picked up a bun with her left hand and placed onto the plate. DA-A picked up a baked potato with her right hand, placed onto the plate, opened the potato with both hands and a knife, then placed other food items on the plate with utensils and handed the plate to the server. DA-A continued to touch the i-pad in between each resident served, picked up a bun and or a baked potato with her gloved hands for all residents who received a bun and or baked potato. DA-A then opened a kitchen cupboard with the same gloved hand, removed a salt shaker and handed it to the server. DA-A continued to touch the i-pad in between each resident's meal setup, placed a bun and or baked potato onto residents plates for the remaining of the lunch meal wearing the same pair of gloves. At no time during the observation did DA-A wash hands and re-apply new gloves. During an interview on 12/10/24 at 1:40 p.m., DA-A confirmed she touched the i-pad frequently throughout the meal service, touched the cupboard/drawer and then touched the buns and baked potatoes while wearing the same pair of gloves and without washing her hands. DA-A stated the i-pad was to be cleaned after each shift with an alcohol wipe and the i-pad had not been cleaned prior to meal service. DA-A stated other staff used the i-pad during the day to assist residents with deciding their meals for each day. DA-A stated the cupboards and drawers were not on a schedule to be cleaned. DA-A stated staff should not touch food with gloved hands if the gloves have touched other objects as germs could get onto the residents food. During an interview on 12/10/24 at 1:55 p.m., dietary manager (DM) verified the expectation of staff would be to wash hands and change gloves when the staff touched non-food items. DM confirmed it was important to prevent the spread of germs to the residents and could cause food-borne illness. ICE MACHINE During an observation of the north kitchen area on 12/10/24 at 11:27 a.m., the ice and water machine spouts on the ice machine had a white powder substance approximately one fourth to one half an inch in height around the entire inside and outside of both spouts. In addition, there was a white powder substance present expanding across the entire drain plate below the ice and water spouts. During an interview on 12/10/24 at 1:55 p.m., DM confirmed a white powder substance was present on the ice and water spouts of the ice machine. DM stated the facility had issues with the ice machine leaking. DM stated there was no cleaning process in place for the ice machine. DM stated the white powder substance had the potential to spread germs to the residents. During an interview on 12/11/24 at 8:56 a.m., maintenance staff stated the ice machine dripped when the ice melted and the machine was cleaned every three months. Maintenance staff stated the facility did not keep a log to verify cleaning of the ice machine. Maintenance staff stated the white powder substance could have bacteria present and residents could develop illness as a result. FOOD TEMPERATURE During an observation on 12/9/24 at 4:45 p.m., DA-B entered the north kitchen with a cart of food from the main kitchen. DA-B placed hot food items on the steam trays and proceeded to obtain beverages and fruit cups from the fridge and delivered to each resident table. DA-B placed a plastic tray with six egg salad sandwiches from the cart on the counter next to the steam tray and placed a small bowl of egg salad on the counter next to the sandwiches. During continued observation at 5:12 p.m., DA-B temped the egg salad in the bowl at 50 degrees. DA-B temped an egg salad sandwich at 55.7 degrees. DA-B started to place an egg salad sandwich onto a resident place when surveyor intervened and asked DA-B what the recommended temperature for cold food would be. DA-B looked at the facility food temp log to see what the recommended cold food holding temperature should be. DA-B then placed the egg salad bowl and sandwiches in the freezer. During an observation on 12/9/24 at 5:19 p.m., three and a half egg salad sandwiches were on the center counter on a plastic tray in the main kitchen. The cook temped the egg salad sandwich at 51.6 degrees. During an interview on 12/9/24 at 5:44 p.m., the cook stated the egg salad sandwiches were removed from the walk in fridge prior to food service and placed onto the center counter. The cook stated cold sandwiches were usually placed on a plastic tray and served from the center counter. The cook verified cold sandwiches were not put on ice. The cook stated cold food items holding temperature should be under 41 degrees to prevent residents from becoming ill. During an interview on 12/10/24 at 9:22 a.m., DM confirmed the expectation staff were to temp foods prior to serving and if a cold food was not in the recommended holding temperature, staff would place the food back in the fridge and re-temp prior to serving. DM stated the process was important to prevent foodborne illness. During an interview on 12/11/24 at 10:26 a.m., dietician confirmed the expectation staff would be to have cold foods on an ice-bath during food service. Dietician verified it was important to maintain holding temperatures, to prevent foodborne illness and bacteria growth, and to ensure quality of food for the residents. The Food and Drug Administration food code identified the danger zone refers to the range of temperatures at which bacteria can grow between 40 degrees Fahrenheit (F) and 140 degrees F. For food safety, keep food below or above the danger zone. A facility policy titled Food Safety Requirements dated 1/25/23, food service safety referred to handling, preparing, and storing food in ways that prevented foodborne illness. Staff would monitor food temperatures while holding for delivery to ensure proper hot and cold holding temperatures were maintained. Staff would refer to the current Food and Drug Administration (FDA) food code and facility policy for food temperatures. Foods and beverages would be distributed and served to residents in a manner to prevent contamination and maintain food at the proper temperature and out of the Danger Zone. Staff would not touch food with bare hands, exhibiting appropriate use of gloves. Gloves would be worn when directly touching ready-to-eat foods. A facility policy titled Sanitization of I-Pad Screen dated 10/3/23, identified staff were to clean the screen, sides, and back of the I-pad with an alcohol wipe before and after each meal and let air dry. A facility policy titled Ice Chests and Machines undated, identified the facility was to keep the ice machine clean and sanitary to prevent contamination. The ice machine would be drained, cleaned and sanitized according to manufacturer's specification. The tray would be run through a dishwasher or sterilized daily. A manufacturer form provided by the facility titled Scotsman Ice Systems dated September 2020, identified over time the drip tray and cup rest/spouts may become coated with scale or dirt. They could be removed and scrubbed in a sink. The spouts/chutes and drip tray were to be washed and to use ice machine scale remover if needed to dissolve scale. Recommended cleaning the ice machine every six months and more frequent cleanings may be required based on the mineral content of the water, run time and potential airborne contamination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to establish an on-going infection control program which included comprehensive surveillance of resident infections including, signs and symptoms of infections, an antibiotic timeout (timeframe used after an antibiotic was initiated to ensure appropriate use and effectiveness) was performed and start/stop dates of antibiotics to prevent the spread of communicable disease and infections. This deficient practice had the potential to affect all 46 residents who resided in the facility. Findings include: A review of the facility's infection control surveillance log monthly report dated September - December 2024, revealed the following: -Columns on the log included resident name, the station resident resided on, if symptoms were present on admission, if the patient was hospitalized , date of onset symptoms, diagnosis, site of infection, the results if a culture was obtained, if an antibiotic was ordered, if a culture was re-obtained, precaution to prevent spread of infection, and date the symptoms were resolved. - The facility's current surveillance log lacked tracking necessary data which included: signs and symptoms for each infection, dates cultures were obtained, when the antibiotic was completed, when the antibiotic was discontinued, and when symptoms resolved. -During the month of September 2024, the infection control surveillance log identified nine entries for infections. Five urinary tract infections (UTIs), three probable tooth infections, and one chronic obstructive pulmonary disease (lung condition) (COPD). No signs and symptoms were documented, no antibiotic time out was documented, no dates of when an antibiotic was started, no dates when the antibiotic was discontinued, and no room numbers were used. -During the month of October 2024, the infection control surveillance log identified that five antibiotics had been ordered. One for possible aspiration, one for diverticulitis (inflammation of the colon/anaplasmosis (illness caused by ticks), one for urinary tract infection, one for prophylaxis for nasal packing (prevent complications), and one for possible aspiration. There were no room numbers documented, no signs and symptoms documented, no dates when an antibiotic was started, no date when the antibiotic was discontinued, no antibiotic timeout documented, dates resolved were marked as not applicable (n/a) for a prophylaxis nasal packing and possible aspiration. During the month of November 2024, the infection control surveillance log identified that 12 antibiotics had been ordered. One for a toe infection, two for chronic obstructive pulmonary disease (COPD), two for respiratory infection, one for cystitis (inflammation of the bladder), two for cellulitis (bacterial skin infection), two for yeast infections, and two for urinary tract infection. No room numbers were used, no signs and symptoms were documented, no start dates for antibiotics, no stop dates for antibiotics and no antibiotic timeouts. The date resolved was left blank for the yeast infection. -During the month of December 2024 the infection control surveillance log identified one antibiotic was ordered, the date of onset was 12/2/24, the diagnosis was for respiratory symptoms, the site of infection was respiratory, no culture was documented, no start date for an antibiotic, no antibiotic stop date, no antibiotic timeout was documented and no room number was documented. The date resolved is blank. During an interview on 12/11/24 at 11:24 a.m., infection preventionist (IP) stated she was responsible for overseeing the facility's infection control program and maintaining the facility's infection control surveillance log. IP confirmed the facility's current surveillance log lacked necessary data which included; signs and symptoms for each infection, dates of cultures obtained, when an antibiotic was started, when an antibiotic was discontinued, if an antibiotic timeout was done, and when symptoms resolved. IP confirmed the date resolved was typically the time frame when the antibiotic regimen was completed not the time the symptoms or infections were resolved. During an interview on 12/11/24 at 1:10 p.m., director of nursing (DON) stated the IP was responsible for overseeing the facility infection control program and maintaining the facility's infection control surveillance log. DON confirmed the facility's current surveillance log lacked necessary data which included signs and symptoms for each infection, dates of cultures obtained, when the antibiotic was started, when the antibiotic was discontinued, if an antibiotic timeout was completed, and when symptoms resolved. The DON stated the expectation would be to have the surveillance log completed according to national standards to help prevent the spread of infectious diseases and infections A policy titled Infection Prevention and control manual dated 8/23/24, revealed essential elements of a surveillance system included: Standardized definitions and listing of the symptoms of infections based upon national standards of practice. Sources of relevant data that can be used for outcome surveillance for infections, antibiotic use and susceptibility may include: -monitoring a resident with a fever or other signs that may indicate an infection, -laboratory cultures or other diagnostic test results consistent with potential infections to detect clusters, -trends, or susceptibility patterns, -antibiotic orders, -laboratory antibiograms (antibiotic susceptibility profiles), -medication regimen review reports. -The infection preventionist collects and reviews data on an ongoing basis including: -elevations in temperatures/ presence of fever, -purulent drainage, -culture results or other diagnosis test results consistent with potential infections, -change in x-ray results consistent with possible infection, -increased falls, -change in mental status, -change in vital signs, -signs and symptoms of infection based upon nationally accepted surveillance definitions (i.e. CDC/[NAME] position statement: surveillance definitions of infections in long-term care facilities: revisiting the McGeer Criteria or NHSN). The infection preventionist would ensure data collection to complete a comprehensive monthly infection control log for surveillance activities on: -The infection site, -pathogen (if known), -signs and symptoms (which the surveillance log did not include) -resident location (room numbers not used, only what station they were on) -summary and analysis of number of residents and/or staff with infections, -observations of staff adherence to policies and procedures, -identification of outcomes that were unusual or unexpected that could potential lead to patterns, treads or outbreaks. The infection preventionist or designee would be able to identify any necessary interventions in order to identify trends or clusters for actions, the infection preventionist would keep an updated map of infections to identify any clusters or trends.

Based on observation, interview, and document review, the facility failed to ensure grievances forms and procedures were posted in prominent locations throughout the facility for residents and resident representatives to file grievances anonymously if desired, for 5 of 5 residents (R17, R40, R37, R31, R5) reviewed for grievances. Findings include: On 1/9/24 at 2:00 p.m., a resident council meeting was held with five residents who attended. All five residents, R17, R40, R37, R31, and R5, confirmed they were not aware of how to file a grievance at the facility or how to file one anonymously. During an observation on 1/9/24 at 2:30 p.m., a walk-through of the facility was conducted. The walk-through revealed there were no grievances forms or procedures posted for residents or resident representatives to refer to. During an interview on 1/9/24 at 2:34 p.m., nursing assistant (NA)-C, indicated a resident would go to social services staff to have a grievance filed. During an interview on 1/9/24 at 3:43 p.m., licensed practical nurse (LPN)-A stated grievance forms were kept in both nurses' stations in the filing drawer and indicated residents could receive a grievance form to complete upon request. During an interview on 1/9/24 at 3:47 p.m., registered nurse (RN)-B stated grievance forms were kept in both nurses' stations in the filing cabinet. RN-B indicated residents could receive a grievance form upon request and indicated residents were not able to complete a grievance form anonymously. During an interview on 1/9/24 at 3:56 p.m., social worker (SW)-A indicated residents would have to verbally ask for a grievance form when they wanted to file a grievance. SW-A stated she was not aware of how a resident could file a grievance anonymously. During an interview on 1/10/24 at 11:15 p.m. activity director (AD)-A stated SW-A would assist residents in completing a grievance form when they wanted to file a grievance. AD-A stated residents would have to request a grievance form. AD-A stated she was not aware of how a resident could file a grievance anonymously. During an interview on 1/10/24 at 11:28 a.m., director of nursing (DON) stated that SW-A, or a nurse would provide a grievance form to a resident upon request. DON stated SW-A would follow up with the resident regarding a grievance. DON was not aware of how a resident could file a grievance anonymously. Facility policy titled grievance policy and procedure dated 3/7/23, identified forms were located in the social service office, nursing policy and procedure manual, and in the business office. The policy lacked identification of posting in prominent locations thought the facility, and instructions how to file a grievance anonymously.

On 1/8/24 at 6:32 p.m., during the initial tour of the kitchen, the coffee machine was observed to have a white/green powdery substance build up on the right spout outlet. On 1/9/24 at 9:04 a.m., during a kitchen tour with the dietary manager (DM), the coffee machine in the kitchen was observed and the right spout outlet was covered with a white and green powder substance. The DM stated there were two spouts on the machine, the left spout was for coffee and the right spout was for hot water. On 1/10/24 at 7:42 a.m., cook-A stated the right spout of the coffee machine was for hot water only and it was drained every morning by the nursing assistant. The coffee machine was observed to have a white/green powdery substance build up on the right spout. During an interview on 1/10/24 at 7:46 a.m., the DM stated the coffee machine was wiped down weekly with a cloth and the water drained daily in the morning by the nursing assistant. When asked if the outlet spouts were cleaned, the DM stated the facility did not clean the spouts on the outside of the machine. The DM was unaware of a policy or procedure for cleaning the coffee machine. The DM was observed to touch the right spout on the coffee machine and scraped it with her fingernail. A white and green powdery looking substance flaked off some pieces onto the counter area and the rest of the white and green powder looking substance was adhered to the spout. During an interview on 1/10/24 at 3:05 p.m., the director of nursing (DON) verified her expectation was that staff would follow the manufacturer's recommendations for cleaning the coffee machine. The DON was unaware of a facility policy for cleaning the coffee machine. The DON indicated the unclean spout could result in an infection control issue and residents could develop a food borne illness as a result. Per the Cafitesse Quantum 11 Operator manual provided by the facility indicated the external parts of the coffee machine were to be cleaned daily with a damp, clean cloth and rinsed off with clear water. in addition, the manual recommended to clean and flush the drink outlets once a week. A facility policy was requested and one was not provided. Based on observation, interview and document review, the facility failed to ensure infection control practices such as hand hygiene, avoiding contamination of utensils during a water pass, and ensuring the personal laundry was transported in a manner that prevented risk of contamination for 2 of 5 hallways observed for linen transportation. In addition, the facility failed to ensure the spout of the coffee machine in that facility's kitchen was free of build up. Findings include: Review of Centers for Disease Control (CDC ) guidance, Appendix D - Linen and Laundry Management updated 5/4/23, identified linens must be sorted, packaged, transported, and stored in a manner that prevented risk of contamination by dust, debris, soiled linens or soiled items. In addition, CDC Handwashing in Communities: Clean Hands Save Lives updated 7/18/22, identified handwashing is the most important thing to prevent food poisoning. During an observation on 1/9/24 at 9:24 a.m., in the 400 hallway nursing assistant (NA)-A pushed a cart that contained glasses, water pitchers and an uncovered cooler with ice down the hallway. NA-A proceeded to use a scoop to place ice in five glasses. NA-A removed a water pitcher and glass of ice from the cart and placed the water pitcher and glass in R10's room. NA-A returned to the hallway,sanitized hands and removed another glass with ice and a water pitcher off the cart and placed the water pitcher and glass in R28's room. NA-A returned to the hallway, sanitized hands and removed a water pitcher and glass with ice from the cart and placed the water pitcher and glass in R 23's room. NA-A returned to the hallway, sanitized hands and removed a glass with ice and water pitcher off the cart and placed the water pitcher and glass in R8's room. During a continuous observation on 1/10/24 at 10:13 a.m., resident support staff (RS) pushed a cart down the 300 hallway that contained glasses, water pitchers, plastic spoons which were in one of the glasses and an uncovered cooler with ice. RS placed the cart with the uncovered cooler in the 400 hallway. RS did not perform hand hygiene and grabbed an uncovered plastic spoon from the glass. While holding the spoon by the bowl and the heel ( the concave part of the spoon that is used to eat from), RS proceeded to walk down the hallway to the dining room approximately 150 feet to obtain a packet of thickener. RS walked approximately 150 ft. back to the cart, emptied the thickener into a glass which contained water from the cart and used the spoon she had been holding in her hand to mix the thickener into the glass of water. RS delivered the glass of thickened water to R22. RS returned to the cart, used the scoop from the cart to place ice from the uncovered cooler into a glass, grabbed a water pitcher from the cart and placed the water pitcher and glass in R10's room. RS returned to the cart, used the scoop to place ice from the uncovered cooler into a glass, grabbed a water pitcher from the cart and placed the water pitcher and glass in R23's room. RS returned to the cart, used the scoop to place ice from the uncovered cooler into a glass, grabbed a water pitcher from the cart and placed the water pitcher and glass in R8's room. RS returned to the cart, used the scoop to place ice from the uncovered cooler into a glass, grabbed a water pitcher from the cart and placed the water pitcher and glass in R41's room. At 10:26 a.m., RS proceeded to move the cart with the uncovered cooler down the hallway as two visitors walked past the cart. RS placed the cart with the uncovered cooler in the 500 hallway. RS removed a glass from the cart, used the scoop to place ice from the uncovered cooler into the glass, grabbed a water pitcher from the cart and placed the water pitcher and glass in R6's room. RS returned to the cart, used the scoop to place ice from the uncovered cooler into a glass, grabbed a water pitcher from the cart and placed the water pitcher and glass in R26's room. RS pushed the cart with the uncovered cooler down the hall as a visitor walked past the cart. RS used the scoop to place ice from the uncovered cooler into a glass, grabbed a water pitcher from the cart and placed the water pitcher and glass in R42's room. RS returned to the cart, used the scoop to place ice from the uncovered cooler into a glass, grabbed a water pitcher from the cart and placed the water pitcher and glass in R16's room. RS returned to the cart, used the scoop to place ice from the uncovered cooler into a glass, grabbed a water pitcher from the cart and placed the water pitcher and glass in R39's room. At no time, did RS perform hand hygiene during the above observation. During an observation on 1/10/24 at 11:59 a.m., an uncovered cart which contained residents' personal laundry was present in the 300 hallway. Laundry aide (LA) exited R14's room, did not perform hand hygiene and proceeded to push the uncovered laundry cart down the hall as staff and residents walked past the cart. LA-A removed laundry from the uncovered cart and placed the laundry in R37's closet. LA-A pushed the uncovered laundry cart down the hallway past staff and residents. LA-A removed laundry from the uncovered cart and placed the laundry in R35's closet. LA-A did not perform hand hygiene and removed laundry from the uncovered cart and placed the laundry in R45's closet. At no time, during the observation did LA-A perform hand hygiene. During an interview on 1/10/24 at 10:41 a.m., nursing assistant (NA)-A stated while he was passing water to the residents on 1/9/24, the cooler which contained ice had not been closed. NA-A stated his usual practice was to place the cover on the cooler after obtaining ice however he had forgotten to place the cover on the cooler. During an interview on 1/10/24 at 10:32 a.m., RS verified she had touched the bowl and the heel of the spoon that was used to stir thickener in a glass of water for R22. RS confirmed she had not performed hand hygiene or placed the cover on the ice cooler while passing water on 1/10/24. RS stated her usual practice was to sanitize hands when she exited a resident room and to leave the ice uncovered so she was able to complete the water pass faster. RS indicated she should have only touched the handle of the spoon that she used to stir the thickener for R22. During an interview on 1/10/24 at 12:00 p.m., LA-A verified the laundry cart had been uncovered while she passed laundry. LA stated she had been told the laundry cart could remain open while she passed the laundry. LA indicated the expectation was that hand hygiene would have been performed after exiting each room. During an interview on 1/10/24 at 12:47 p.m., laundry supervisor (LS) indicated she was not aware laundry was being delivered in an uncovered cart. LS stated her expectation was laundry would have been covered while being delivered and staff would have performed hand hygiene before and after passing linen to resident rooms. During an interview on 1/10/24 at 12:51 p.m., infection preventionist (IP) stated infection control practices such as hand hygiene, holding utensils by the handles, covering the ice cooler and covering the laundry were important strategies to prevent the spread of infection and food borne- illness. IP indicated her expectation was that hand hygiene would have been performed, staff would hold utensils by the handles only and that the ice and laundry would have been covered. During an interview director of nursing (DON) stated staff were expected to perform hand hygiene when passing water or linen. DON stated staff should only be touching utensils by the handle. DON indicated staff were expected to cover the ice cooler and the linen cart when passing water and linen. A facility policy titled Food Safety Requirements dated 1/25/23, indicated food would be stored, prepared, distributed and served in accordance with professional standards for food safety. Identified staff would wash hands prior to handling clean dishes, and handle them by outside surfaces or touch only the handles of utensils and all food should be covered when traveling a distance such as down a hallway or to a different unit. A facility policy titled Clean Linen Handling undated, indicated all clean linen handling would be performed in a manner to minimize the potential for infection in residents, staff and visitors. Identified clean linen would be transported to the areas of use in a covered container. . .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to provide assistance to ensure hearing aids were available to maintain hearing/communication needs for 1 of 1 resident (R32) reviewed for hearing. Findings include: R32's quarterly Minimum Data Set (MDS) dated [DATE], indicated R32 was cognitively intact and had diagnoses which included heart failure, diabetes mellitus and depression. The MDS indicated R32 had no rejection to cares, and utilized hearing aids or other hearing appliances with no difficulty hearing when the hearing aid/appliance was used. Review of R32's Inventory of Personal Possession sheet dated 8/20/20, indicated R32 had hearing aids for his left and right ear. R32's care plan revised on 9/14/22, indicated R23 had hearing problems related to the aging process and directed staff to use bilateral hearing aids and to monitor for changes in hearing. R32's nursing assistant [NAME] dated 10/12/22, indicated under special needs: R32 had bilateral hearing aids and staff were to assist with them. During an observation and interview on 10/10/22, at 2:47 p.m. R32 was observed seated in his recliner with no hearing aids noted while visiting with his wife. R32's wife was observed to be repeating herself several times during the conversation she had with R32. R32's wife stated R32 had a difficult time hearing her. R32 stated he had been without hearing aids for over a year as he had lost one of his hearing aids and the other one was not functioning. R32 indicated he had made a request to several different staff members since last June to make an appointment for him with Veterans Affairs (VA) to be fitted for new hearing aids. R32 stated staff responded back to him an appointment had not been made due to the staff had been unable to reach anyone at the VA office to make an appointment for him. During an interview on 10/12/22, at 11:25 a.m. registered nurse (RN)-A stated R32 required staff assistance with his activities of daily living (ADL's) and was hard of hearing. RN-A confirmed R32's care plan identified he required the use of hearing aids. RN-A stated she was not aware R32 ever had hearing aids and indicated the inventory sheet which addressed his belongings identified he did have hearing aids before. RN-A stated she and R32 had discussed making an audiology appointment at the VA for new hearing aids and verified the appointment had not yet been made. During an interview on 10/12/22, at 11:48 a.m. NA-B stated R32 required staff assistance with ADL's. NA-B indicated R32 would often have his TV volume on a loud setting. NA-B stated she was not aware R32 ever had hearing aids. During an interview on 10/12/22, at 1:15 p.m the director of nursing (DON) confirmed R32's careplan and indicated R32 required the use of hearing aids. The DON verified staff had not followed up on R32's request for an appointment to obtain new hearing aids and confirmed he did not currently have hearing aids. The DON stated she expected staff to respond to the needs of the residents and ensure appointments were made in a timely manner according to facility policy. Review of facility policy titled, Hearing Aids revised on 4/18/21, indicated staff were to assist with cleaning and maintaining hearing aids.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to help reduce unnecessary antibiotic use and reduce potential drug resistance for 1 of 2 residents (R16) reviewed for unnecessary medication. Findings include: The Center's for Disease Control and Prevention (CDC)'s Core Elements Of Antibiotic Stewardship For Nursing Homes, dated 2015, included recommendations to identify clinical situations which may be driving inappropriate use of antibiotics and implement specific interventions to improve use, as well as pharmacists could provide assistance in ensuring antibiotics were ordered appropriately. R16's quarterly Minimum Data Set (MDS) dated [DATE], identified R16 had moderate cognitive impairment and had diagnoses which included: chronic kidney disease, Parkinson's disease (progressive disorder that affects nervous system and the parts of the body controlled by the nerves) and anxiety. R16's MDS indicated R16 required extensive assistance with bed mobility, transfers, toilet use, dressing and personal hygiene. R16's MDS identified R16 had received antibiotics seven of the last seven days. R16's care plan last revised 8/8/22, identified R16 required limited to extensive assistance of one staff for hygiene, dressing and bathing. R16's care plan lacked information related to the use of prophylactic antibiotics. Review of R16's Order Summary Report signed 10/5/22, identified R16's orders included: -doxycycline monohydrate (antibiotic) tablet, give 100 milligram (mg) by mouth two times a day for prophylaxis (taken to prevent infection) per orthopedic physician (OP)-A (physician who specializes in musculoskeletal issues involving bones, muscles, joints, tendons and ligaments) with start date of 11/23/21, and no end date. Review of R16's Consultant Pharmacist Medication Review from 12/22/2021, to 9/26/22, identified the following: -12/22/21, no comments or recommendations related to R16's antimicrobial prophylaxis use of doxycycline monohydrate -1/28/22, no comments or recommendations related to R16's antimicrobial prophylaxis use of doxycycline monohydrate -2/25/22, no comments or recommendations related to R16's antimicrobial prophylaxis use of doxycycline monohydrate -3/26/22, no comments or recommendations related to R16's antimicrobial prophylaxis use of doxycycline monohydrate -4/27/22, no comments or recommendations related to R16's antimicrobial prophylaxis use of doxycycline monohydrate -5/26/22, no comments or recommendations related to R16's antimicrobial prophylaxis use of doxycycline monohydrate -6/13/22, no comments or recommendations related to R16's antimicrobial prophylaxis use of doxycycline monohydrate -6/24/22, no comments or recommendations related to R16's antimicrobial prophylaxis use of doxycycline monohydrate -7/29/22, no comments or recommendations related to R16's antimicrobial prophylaxis use of doxycycline monohydrate -8/25/22, no comments or recommendations related to R16's antimicrobial prophylaxis use of doxycycline monohydrate -9/26/22, no comments or recommendations related to R16's antimicrobial prophylaxis use of doxycycline monohydrate R16's Consultant Pharmacist Medication Reviews lacked documentation of review of continued prophylactic antibiotic use. Review of R16's medication administration records (MARs) reviewed from 9/1/22, to 10/11/22, identified the following: -9/1/22, to 10/11/22, R16 received doxycycline monohydrate two times a day. Review of R16's physician visit note dated 10/5/22, revealed R16's orders and diagnoses were reviewed and R16's medications were reviewed per nursing home (NH) MAR in detail. The note identified no new orders or medication changes were made. The notes lacked documentation the risks and benefits of continued long term antibiotic use had been reviewed and discussed. During a telephone interview on 10/12/22, at 10:10 a.m. R16's primary care physician (PCP)-A confirmed he served as the facility's medical director and was involved in the facility's antibiotic stewardship program. PCP-A stated the facility's goal was to decrease prophylactic antibiotic use. PCP-A indicated R16 had been receiving doxycycline monohydrate when admitted to the facility and he was unsure why R16 continued to receive doxycycline prophylactically. PCP-A stated the antibiotic should have been discontinued as it was important to prevent R16 from developing resistance to antibiotics. During a telephone interview on 10/12/22, at 11:20 a.m. pharmacy consultant (PC)-A indicated R16 previously had an infection related to an orthopedic ( a branch of medicine, involving musculoskeletal issues which involve bones, muscles, joints, tendons and ligaments) procedure and R16 was placed on prophylactic doxycycline monohydrate by OP-A at that time. PC-A confirmed pharmacy recommendations had not been made regarding R16's continued prophylactic antibiotic use of doxycycline monohydrate. PC-A stated long term prophylactic use of antibiotics was not recommended as it has been known to cause antibiotic resistance. During an interview on 10/12/22, at 11:57 a.m. infection preventionist (IP)-A confirmed R16 had been admitted to the facility on doxycycline monohydrate for prophylaxis. IP-A stated she tracked all antibiotics used in the facility and confirmed the facility had not reviewed the rationale for R16 to continue on the prophylactic antibiotic. During an interview on 10/12/22, at 1:00 p.m. director of nursing (DON) confirmed R16 was on a prophylactic antibiotic. DON stated her expectations were the facility would have reviewed the rationale for R16's continued prophylactic antibiotic use. The facility policy titled St. [NAME] Living Center Antibiotic Stewardship Policy, revised 9/15/22, identified the facility mission was to promote the appropriate use of antibiotics to treat infections and reduce possible adverse events associated with antibiotic use. The policy identified the physician, nursing and pharmacy leads were responsible for promoting and overseeing antibiotic stewardship activities. The policy identified the facility would monitor antibiotic use, stewardship actions and outcomes related to antibiotic use in order to guide practice change and track antibiotic stewardship program impact. The policy indicated antibiotic data would be tracked by infection preventionist (IP) and reviewed by the consulting pharmacist, then IP would interpret the monthly data, define any necessary action steps and compile the information for the monthly antibiotic stewardship program report. The policy identified the antibiotic stewardship team (AST) would identify actions to directly impact inappropriate antibiotic use including the use of antibiotics for prophylactic indications.