Based on observation, interview, and record review, it was determined that the facility failed to ensure that open injectable medications were labeled in accordance with the manufacturer's instructions in 1 of 1 medication room observed. Findings Include: Observation on 4/21/25 at approximately 8:30 a.m. with Staff G (Licensed Practical Nurse) in the Chase Unit Medication Room revealed an open multi-dose vial of Tuberculin Purified Protein Derivative (Mantoux) without an open date or an open expiration date in the medication refrigerator. Interview on 4/21/25 at approximately 8:30 a.m. of Staff G confirmed the above findings. Review on 4/21/25 of the Tuberculin Purified Protein Derivative (Mantoux) manufacturer instructions revealed A vial .which has been entered and in use for 30 days should be discarded . Review on 4/21/25 of the facility policy titled Medications and Medication Labels dated 1/25 revealed PROCEDURES .2. Multi-dose vials shall be labeled to assure product integrity, considering the manufacturers' specifications .Nursing staff should document the date opened on multi-dose vials on the attached auxiliary label .

Based on observation, interview and policy review, it was determined that the facility failed to ensure that food is stored in accordance with professional standards for food service safety for 1 out of 1 kitchen observed. Finding Include: Observation on 4/21/25 at approximately 8:20 a.m. in the kitchen with Staff A (Dietary Cook) revealed the following: A small dish of salad covered in plastic wrap without a preparation or use by date in the refrigerator; a clear container with tuna fish covered with plastic wrap, labeled tuna fish with a date of 4/14 (preparation date) in the refrigerator; a clear container with chicken salad covered in plastic wrap, labeled chicken salad with date of 4/13 (preparation date) in the refrigerator; a stainless steel bowl containing cubes of cooked potatoes uncovered without a preparation date; a plastic bag containing 7 thawed chicken breasts dated 4/15 (date pulled from the freezer) in the walk-in refrigerator; a case of cucumbers with 6 cucumbers that is leaking fluid, had black spots, and soft to touch in the walk-in refrigerator; a stainless steel pan containing thawed sliced deli ham dated 3/12 (date pulled from the freezer) in the walk-in refrigerator; and a stainless steel pan continuing thawed sliced salami dated 3/5 (date pulled from the freezer) in the walk-in refrigerator. Interview on 4/21/25 at approximately 8:30 a.m. with Staff A (Dietary Cook) confirmed the above findings. Review on 4/21/25 of the facility's policy titled Food Storage: Cold Foods, Revised 9/2017, revealed .Procedures 5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination . Review on 4/21/25 of the facility's policy titled Food Storage and Retention Guide,with no date, revealed .Ready-To-Eat/Prepared Foods .(Examples: leftovers, deli salads, cut produce .Refrigerator .Up to 7 days Day 1 is the day of preparation .Raw Meat/Poultry/Seafood: Fish, seafood, ground meat, and all poultry .Refrigerator .(Once Thawed) .1-2 days . Interview on 4/22/25 at approximately 11:00 a.m. with Staff B (Dietary Manager) confirmed the above policies. Standard: Review on 4/23/25 of the U.S. Food and Drug Administration Food Code, dated 2017, retrieved from https://www.fda.gov/food/FDA-food-code/food-code-2017 revealed the following: .Chapter 3 Food .3-305.11 Food Storage .Food shall be protected from contamination by storing the Food: .On-premises preparation .(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunchmeat or a roast, or for which date marking is impractical . (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded .; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods .Products which are damaged, spoiled, or otherwise unfit for sale or use in a food establishment may become mistaken for safe and wholesome products and/or cause contamination of other foods . (5) Certain foodborne pathogens that are anaerobes or facultative anaerobes are able to multiply under either aerobic or anaerobic conditions. Therefore special controls are necessary to control their growth. Refrigerated storage temperatures of 5°C (41°F) may be adequate to prevent growth and/or toxin production of some pathogenic microorganisms .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to provide sufficient staff to meet residents' needs in April 2024 and May 2024. Findings include: Review on 5/30/24 of the Facility Assessment revealed Consider the overall needs of your resident population based on your Facility Assessment, MDS [Minimum Data Set], Resident Population Profile and any additional source when indicating the number, average, range or ratio needed. Further review of the Facility Assessment revealed the following staffing levels for direct care staff: [NAME] - 1 Nurse [Registered Nurse (RN)/Licensed Practical Nurse (LPN)], 2 LNAs [Licensed Nurse Aide] day and eves, 1 Nurse, 1 LNA nights. [NAME] - 1 Nurse, 2 LNAs days and eves, 1 Nurse, 1 LNA nights. Review on 5/30/24 of the Daily Staffing Sheets from April 23, 2024 to May 30, 2024, revealed the following 6 shifts (over 4 days) in April and 22 shifts (over 16 days) in May with LNA/Certified Nursing Assistant (CNA) staffing that does not meet levels outlined in the Facility Assessment: 4/23/24 - Tuesday - Day shift - [NAME] Hall - 1 RN, 1 CNA - Unit census 18 4/23/24 - Tuesday - Eve shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 23 4/24/24 - Wednesday - Day shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 19 4/24/24 - Wednesday - Eve shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 19 4/25/24 - Thursday - Day shift - [NAME] Hall - 1 RN, 1 CNA - Unit census 19 4/30/24 - Tuesday - Day shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 19 5/1/24 - Wednesday - Day Shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 19 5/1/24 - Wednesday - Eve Shift - [NAME] Hall - 1 LPN, 0 CNA - Unit census 19 5/2/24 - Thursday - Day Shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 19 5/3/24 - Friday - Day Shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 19 5/3/24 - Friday - Night Shift - [NAME] Hall - 1 RN, 0 CNA - Unit census 19 5/4/24 - Saturday - Day Shift - [NAME] Hall - 1 RN, 1 CNA - Unit census 19 5/5/24 - Sunday - Day Shift - [NAME] Hall - 1 RN, 1 CNA - Unit census 23 5/6/24 - Monday - Day Shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 19 5/8/24 - Wednesday - Day Shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 19 5/9/24 - Thursday - Day Shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 19 5/10/24 - Friday - Day Shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 23 5/10/24 - Friday - Day Shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 19 5/10/24 - Friday - Eve Shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 19 5/11/24 - Saturday - Day Shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 19 5/11/24 - Saturday - Eve Shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 19 5/12/24 - Sunday - Day Shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 19 5/15/24 - Wednesday - Day Shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 19 5/16/24 - Thursday - Day Shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 19 5/17/24 - Saturday - Day Shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 19 5/2124 - Tuesday - Day Shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 19 5/21/24 - Tuesday - Day Shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 25 5/30/24 - Thursday - Day Shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 19 Interview on 5/30/24 at approximately 1:00 p.m. with Staff A (Director of Nursing) confirmed the above findings. Interview on 5/30/24 at approximately 9:35 a.m. with Staff C (Anonymous) stated, LNA staffing is a very serious concern here. Residents get up between 7:00 a.m. and 8:00 a.m., and with one LNA on they're running around non-stop, sometimes not able to get a break. Nurses help LNAs when they can but have their own tasks to tend to. Interview on 5/30/24 at approximately 9:45 a.m. with Staff D (Anonymous) stated, The wait times for residents can be really long because there's not enough LNAs on. One LNA is not enough on any given unit. We need two LNAs on per unit. It seems Administration only considers census and not acuity when they schedule staff. Mealtimes can be challenging and there are delays in feeding residents. Some units have Residents that need lifts and that requires two staff that's hard to come by. Interview on 5/30/24 at approximately 10:00 a.m. with Staff E (Anonymous) and Staff F (Anonymous), stated, We all try to help each other out, but one LNA is not enough. We need two LNAs when we have residents with heavier loads. Interview on 5/30/24 at approximately 10:15 a.m. with Resident #4 on [NAME] Hall revealed, Days, evenings, and shift change is usually when we have the longest waits, varying sometimes from 10-15 minutes and up to 20-40 minutes, depending on staff call outs. There have been times when I use my call bell, but staff don't make it here before I soil myself (fecal matter). One LNA is not enough to provide care that everyone needs. Interview on 5/30/24 at approximately 10:30 a.m. with Resident #3 on Chase Unit stated, No, there's not enough staff, not enough aides. Sometimes when only one aide changes me in bed, I feel like I'm going to fall out of bed. The call bell waits vary, from 5 minutes up to 45 minutes. They could use at least two aides on the unit. Interview on 5/30/24 at approximately 10:45 a.m. with Resident #2 on [NAME] Hall stated, Only sometimes do they have enough staff, but not usually. Interview on 5/30/24 at approximately 11:15 a.m. with Staff G (Anonymous) stated, Ideally there should be two LNAs on [NAME] and [NAME] Halls. With only one LNA on a unit, it can be rough. Interview on 5/30/24 at approximately 12:30 p.m. with Resident #5 stated, I regularly attend Resident Council, and staffing here has been a chronic and considerable problem for many months on all shifts. They'll hire two staff, then two staff quit. They can never catch up. One LNA is absolutely not enough on any unit. One LNA is left running around trying to get people up in the mornings for breakfast, but sometimes they're only able to get half the residents ready for the meal, while the other half still in bed have to wait to eat.

Based on observation and interview, it was determined that the facility failed to prepare food in accordance with professional standards for food service safety and failed to ensure that staff were wearing proper hair restraints in the main kitchen. Findings include: Observation on 4/23/24 at 08:20 a.m., during the initial tour of the kitchen, revealed Staff E (Cook) serving scrambled eggs onto plates. Further observation revealed Staff E had facial hair and was not wearing a facial hair restraint. Interview on 04/23/24 at approximately 8:25 a.m. with Staff E confirmed that he/she did not wear a facial hair restraints when serving food. Review on 04/25/24 of the facility policy titled Staff Attire undated, revealed Procedures .1. All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained. Review on 04/25/24 of Chapter 2 of the FDA (Food and Drug Administration) food code 2022 Management and Personnel document section 2-402 Hair Restraints 2-402.11 Effectiveness (A) Except as provided in ¶ (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to follow physicians' orders for 1 out of 28 medication administrations observed (Resident identifier is #102). Findings include: Standard: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th edition St. Louis, Missouri: Mosby Elsevier, 2009. Page 336- Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Observation on 3/22/23 at approximately 8:45 a.m. with Staff B (Registered Nurse) revealed that Staff B dispensed two tablets of over the counter (OTC) Bisacodyl 5 milligram (mg) in a medication cup. Observation also revealed that Staff B administered the two tablets of OTC Bisacodyl 5 mg to Resident #102. Record review on 3/22/23 at approximately 8:45 a.m. during observation with Staff B revealed that Resident #102's Electronic Medication Administration Record (EMAR) had no order for two Bisacodyl 5 mg tablets to be given by mouth. The EMAR revealed an order for Dulcolax (brand name of Bisacodyl) 10 mg suppository to be given rectally as needed for constipation. Interview on 3/22/23 at approximately 8:50 a.m. with Staff B confirmed the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to ensure proper storage of expired medications for 2 of 2 medication carts observed (Resident identifiers are #25 and #38). Findings include: Chase front medication cart Observation on 3/22/23 at approximately 8:30 a.m. with Staff C (Registered Nurse) revealed that Resident #38's used Breo Ellipta 100-25 microgram/inhalation (mcg/inh) inhaler had an open date of 2/2/23 and a do not use after 3/15/23 date on the inhaler. Further observation of the Breo Ellipta 100-25 mcg/inh inhaler revealed a manufacturer's instruction to discard 6 weeks after the inhaler is opened, which would be 3/16/23. Review on 3/22/23 of Resident #38's March 2023 Electronic Medication Administration Record (EMAR) revealed an active order for Breo Ellipta 100-25 mcg/inh with a start date of 9/27/22. Further review of Resident #38's March 2023 EMAR revealed that Resident #38 received Breo Ellipta 100-25 mcg/inh on 3/17/23 to 3/21/22. Interview on 3/22/23 at approximately 8:30 a.m. with Staff C confirmed the above findings. Staff C stated that Resident #38's currently used the above mentioned Breo Ellipta 100-25 mcg/inh inhaler. [NAME] back medication cart Observation on 3/22/23 at approximately 9:00 a.m. with Staff D (Licensed Practical Nurse) revealed that Resident #25's Novolin 70/30 insulin vial had an open date of 2/1/23 and a do not use after 3/15/23 date on the vial. Further observation of Resident #25's Novolin 70/30 insulin vial revealed a pharmacy label to discard after 42 days after opening, which would be 3/15/23. Interview on 3/22/23 at approximately 9:00 a.m. with Staff D confirmed the above findings in the [NAME] back medication cart. Staff D stated that Resident #23's Novolin 70/30 insulin vial should have been removed from the medication cart and placed in the medication room in a return to pharmacy container. Review on 3/22/23 of Resident #25's EMAR revealed a current order for Novolin 70/30 insulin pen with a start date of 3/16/23. There was not a current order for a Novolin 70/30 insulin vial. Review on 3/22/23 the facility's pharmacy insulin storage recommendations, dated 2022, revealed .Novolin 70/30 do not refrigerate after opening and room temperature for 42 days. Review on 3/23/23 of the facility's policy titled, Disposal/Destruction of Expired or Discontinued Medication, revision date of 2/23/22, revealed .Facility should place all discontinued or out-dated medications in a designated, secure location which is solely for discontinued medications or marked to identify the medication are discontinued and subject to destruction .

Based on interview and record review, it was determined that the facility failed to ensure that a resident received an influenza vaccine after obtaining a consent to administer the influenza vaccine for 1 of 5 residents reviewed for immunizations (Resident identifier is #25). Findings include: Review on 3/24/23 of Resident #25's influenza vaccine consent form revealed that Resident #25 gave the facility permission to administer the appropriate influenza vaccination annually with a sign date of 3/8/23. Review on 3/24/23 of Resident #25's medical record revealed that Resident #25 did not receive an influenza vaccination after consenting on 3/8/23. Interview on 3/24/23 at approximately 11:45 a.m. with Staff A (Director of Nursing) confirmed the above findings. Review on 3/24/23 of the facility's policy titled, Influenza Immunization Program, revision date of 11/15/21, revealed Center will provide the opportunity to receive the appropriate influenza vaccine to patients .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to ensure that the call light system was adequately equipped to allow residents to call for staff assistance for 2 residents in a census of 51 residents (Resident Identifiers are #6 and #26). Observation on 3/22/23 at 11:32 a.m. revealed that there were only 2 residents who resided on the [NAME] Unit. It was observed that the nurse's station was under repair and there were no facility staff scheduled to work on that unit. Staff from the [NAME] Unit were responsible for Resident #6 and Resident #26 on the [NAME] Unit. Both resident rooms were over 120 feet away from the nurse's station on the [NAME] Unit and could not be seen from the [NAME] Unit. Observation on 3/22/23 at 11:35 a.m. revealed that Resident #26 resided in room [ROOM NUMBER] which was approximately half way down the nursing unit. Interview with Resident #26 on 3/22/23 at 11:35 a.m. revealed that he/she enjoyed living on the unit because of how quiet it was. He/She stated that the staff check on him/her periodically. Resident #26 stated that he/she is very independent and mostly takes care of him/herself. Resident #26 stated that he/she would yell out for help until someone came if he/she fell. Observation on 3/23/23 at 8:35 a.m. revealed that Resident #6 resided in room [ROOM NUMBER] which was on the opposite side of the unit from Resident #26 and approximately half way down the nursing unit. Interview with Resident #6 revealed that he/she enjoyed living on the unit because of how quiet it was and that he/she had a private suite. Resident #6 stated that the staff will come down to visit during the day to see if everything was ok. Resident #6 stated that he/she takes care of him/herself and would walk to the nurse's station if he/she needed help. Interview on 3/23/23 at 10:34 a.m. with Staff D (Licensed Practical Nurse) on the [NAME] Unit, who stated that they make periodic rounds on the [NAME] Unit to make sure the residents were okay. Staff D stated both residents were independent and did not need much assistance. He/She stated that the call system does not ring to the nurse's station on the [NAME] Unit. When asked how a staff member would know if the residents on that unit needed help, Staff D stated that he/she would not know until a staff member went down to the unit during their periodic rounds. Interview on 3/23/23 at 1:40 p.m. with Staff E (Licensed Nursing Assistant) on the [NAME] Unit stated that staff will go to the [NAME] Unit during every meal. He/She stated that both residents were pretty independent. He/She said that he/she wouldn't know if someone from the [NAME] unit needed help if they fell or needed immediate assistance. Observation on 3/23/23 at 11:51 a.m. revealed that when Resident #26's call light was pressed, the audible sound could not be heard at the [NAME] Unit nurse's station. Review on 3/24/23 of the facility's policy titled Call Lights revised on 6/1/21 revealed, . All Genesis HealthCare patients will have a call light or alternative communication device with their reach at all times when unattended. Staff will respond to call lights and communication devices promptly . Purpose. To ensure safety and communication between staff and patients.