Based on observation and interview, it was determined that the facility failed to ensure that equipment used to prepare food was properly cleaned in the main kitchen. Findings include: Observation on 3/5/25 at approximately 8:20 a.m. in the kitchen revealed a mixer that had dried white and grey particle splatters throughout the machine. Interview on 3/5/25 at approximately 8:45 a.m. with Staff D (Kitchen Manager) confirmed that there were dried white and grey food particles throughout the mixer. He/she was unaware when it was last used. Interview on 3/5/25 at approximately 8:45 a.m. with Staff A (Dietary Aide) revealed the mixer was not used that morning. Interview on 3/5/25 at approximately 11:45 a.m. with Staff B (Director of Culinary Operations) revealed that mixer was used the night before to make mashed potatoes. Review on 3/6/25 of the facility policy titled, HACCP-Based Standard Operating Procedures, 5C: Cleaning & Sanitizing Food Contact Surfaces revealed: Cleaning is defined as physically removing visible food or soil from surfaces with the aid of a detergent, water, and some muscle power. If State or local requirements are used, wash, rinse, and sanitize food contact surfaces of sinks, tables, equipment, utensils, thermometers, carts, and equipment: before each use, between uses when preparing different types of raw animal foods, such as eggs, fish, meat, and poultry, and anytime contamination occurs or is suspected .

Based on observation, interview, and policy review, it was determined that the facility failed to store food in accordance with professional standards. Findings include: Observation on 3/27/24 at 9:00 a.m. of the kitchen's walk-in refrigerator with Staff B (Culinary Manager) and Staff C (Assistant Dietary Manager) revealed the following: A facility container labeled marinara sauce with an open date of 3/18/24 without a use-by date Vegetable pot pie with an open date of 3/19/24 without a use-by date A clear plastic facility container with onions that were soft and sitting in water with a date of 3/16/24 without a use-by date One package of sauerkraut with an open date of 2/19/24 without a use-by date One large plastic container of poppyseed dressing with a manufacturer's use by date of 2/1/23 One large plastic facility container, with the lid open, with cooked pasta and the pasta was hard around the edges and dried with no dates Three sheet pans with potato pancakes uncovered and exposed to the air with no dates Five 8 ounce cartons of milk with a manufacturer's expiration date on the cartons dated 3/22/24 One clear facility container with thick yellow liquid with no identifier and no dates 11 quarts of milk with a manufacturer's expiration date of 3/24/24 Three sheet pans with cut up mushrooms uncovered and exposed to the air with no dates One large eggplant with a large area that was soft and leaking fluid. Interview on 3/27/24 at 9:15 a.m. with Staff B confirmed the above findings and stated that all items should be covered, dated when opened, and should be discarded within 5 days of the open date. Interview on 3/27/24 at 9:20 a.m. with Staff C confirmed the above findings in the walk-in refrigerator. Review on 3/27/24 of the facility's policy titled Dining Service Food Storage (policy not dated) revealed: .Proper storage of food assures that there will be minimal contamination of the food from any sources and that the natural growth of microorganisms in food will not result in food-borne illness. Therefore, measures to prevent the contamination of food must consider the environment in which food is stored and the potential for contamination under these conditions .Food Storage #1 B. Sanitation in storage area: .G. Routinely inspect the area for cleanliness. H. Check for bulging or broken containers, spilled, spoiled, or infected food. Remove immediately, and thoroughly clean the area to prevent contamination to other food .#7 All items should be sealed and labeled Review on 4/5/24 of the 2022 Food Code U.S. Food and Drug Administration, retrieved from https://www.fda.gov/food/FDA-food-code/food-code-2022, revealed the following: .Annex 3, Public Health Reasons/Administrative Guidelines . Chapter 3 Food .3-305.11 Food Storage .FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination .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, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, 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 .(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 .

Based on record review and interview, it was determined that the facility failed to develop a comprehensive care plan for 1 of 1 resident reviewed for accidents and 1 of 1 resident reviewed for anticoagulant medication side effects in a final sample of 12 residents (Resident identifiers are #3 and #14). Findings include: Resident #3 Review on 2/24/23 of Resident #3's medical record revealed an initial admission date of 7/27/19 and diagnoses including: unsteadiness on feet, hemiplegia/hemiparesis following cerebral infarction affecting left aide, and history of falling. Resident #3's 10/25/22 Fall Evaluation score was 11 - At Risk for falls. Review on 2/24/23 of Resident #3's medical record further revealed a fall on 1/5/23 after bumping into furniture resulting in a left superior pubic ramus (pelvic) fracture. Review on 2/24/23 of Resident #3's care plan revealed no fall prevention focal area or interventions dated prior to the fall on 1/5/23. Interview on 2/24/23 at approximately 2:40 p.m. with Staff C (Assistant Director of Nursing) confirmed the finding. Review on 2/24/23 of the facility policy titled, Care Plans, Comprehensive Person-Centered, revised December 2016, revealed: 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframe's; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychological well-being; Resident # 14 Review on 2/24/23 of Resident #14's current physician orders revealed an order for Eliquis (anticoagulant) 2.5 milligrams twice a day, with a start date of 7/12/22. Review on 2/24/23 of Resident #14's current care plan revealed that there interventions identifying that they were taking an anticoagulant or at risk for increased bruising and bleeding. Interview on 2/24/23 at approximately 2:40 p.m. with Staff C (Assistant Director of Nursing) confirmed the finding.

Based on interview and record review, it was determined that the facility failed to ensure that as needed (PRN) orders for psychotropic drugs are limited to duration identified by provider for 1 of 5 residents reviewed for unnecessary medication in a final sample of 12 residents (Resident identifier is #4). Findings include: Review on 2/24/23 of Resident #4's February 2023 Medication Administration Record (MAR) revealed the following active PRN lorazepam orders: Lorazepam 0.5 milligrams (mg) every 6 hours as needed for increased anxiety, with a start date of 1/13/23 and no identified duration or end date Lorazepam 0.5 mg every 6 hours as needed for increased anxiety .order expires in 2 months, with a start date of 12/20/22 and no stop date. Interview on 2/24/23 at approximately 12:00 p.m. with Staff C (Assistant Director of Nursing) confirmed the above information. Review on 2/24/23 of facility policy Psychotropic Medication Use, revised July 2022, revealed .PRN orders for psychotropic medications are limited to 14 days .For psychotropic medications that are NOT antipsychotics: if the prescriber or attending physician believes it is appropriate to extent the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration of the PRN order .

Based on observation, interview, and policy review, it was determined that the facility failed to ensure food was properly dated, labeled, and stored for food safety to prevent foodborne illness in the walk in refrigerator in 1 out of 2 kitchens (Main Kitchen and Skilled Kitchen) observed. Findings include: Observation on 2/22/23 at approximately 10:00 a.m. of the walk-in refrigerator with Staff B (Culinary Staff) revealed: - One (1) container of cooked asparagus with no label or use by date; - One (1) container of diced tomatoes with no label or use by date; - One (1) container of shredded cheese with no label or use by date. - Nine (9) wilted lemons with visible dark spots in a box not labeled or a received date - Four (4) wilted limes with visible dark spots in a box not labeled or a received date. Interview on 2/22/23 at approximately 10:00 with Staff B confirmed that the above food items were not labeled and dated. Staff B stated the lemons and limes should have been discarded. Review on 2/24/23 of the facility's policy titled, Food Receiving and Storage, revised July 2014, revealed Policy Interpretation and Implementation: 8. All foods stored in the refrigerator or freezer will be covered, labeled, and dated [use by date]. Review on 2/24/22 of the facility's policy titled, Refrigerators and Freezers, revised December 2014, revealed Policy Interpretation and Implementation: 5. All food should be appropriately dated to ensure proper rotation by expiration dates. Received dates [date of delivery] will be marked on cases . Use by dates will be completed with expiration dates on all prepared food in refrigerators .

Based on interview and record review, it was determined that the facility failed to employ, at least on a part time basis, an Infection Preventionist that completed specialized training in infection prevention and control. Findings include: Interview on 2/22/23 at 9:12 a.m. during entrance conference with Staff A (Interim Director of Nursing (DON)) revealed that the facility did not have an Infection Preventionist (IP) and that he/she had been acting as the IP for the facility while being the full time DON. Staff A confirmed that he/she had successful completion of infection control and prevention in 2019. Staff A stated that they delegate portions of the Infection Preventionist role out to others, specifically antibiotic tracking, COVID vaccination tracking of staff and residents, and update letters for COVID positives in facility. Review on 2/22/23 of the facility's form 672 Resident Census and Conditions of Residents revealed that the facility census was 21. Cross Reference F881: Antibiotic Stewardship Program and F885: Reporting- Residents, representatives & families.

Based on interview and record review, it was determined that the facility failed to ensure that the irregularities identified by the pharmacist during the monthly review were documented in the residents medical record for 3 out of 5 residents reviewed for unnecessary medications (Resident Identifiers are #4, #6, and #9). Findings include: Resident #9: Review on 2/24/23 of Resident #9's medical record revealed a progress note dated 12/27/22 documenting that a medication regimen review was performed with one new irregularity found. Further review revealed no pharmacy consultation report to identify the irregularities from 12/27/22. Interview on 2/23/23 at approximately 2:00 p.m. with Staff A (Interim Director of Nursing) revealed the facility did not have the December 2022 pharmacy consultation report and could not identify what irregularity were being referred to the 12/27/22 visit. Resident #6 Review on 2/24/23 of Resident #6's medical record revealed a monthly drug regimen review from the pharmacy had irregularities noted on 11/26/22. Further review of Resident #6's medical record revealed no pharmacy consultation report to identify the irregularities from November 2022. Interview on 2/24/23 at approximately 1:00 p.m. with Staff A (Interim Director of Nursing) confirmed that the pharmacy consultation was not reviewed and signed by the provider. Resident # 4 Review on 2/23/23 of Resident #4's progress notes revealed the following monthly drug regimen reviews from the pharmacy had irregularities noted: 2/9/23, 1/26/23 and 12/27/22. Further review of Resident #4's medical record revealed no pharmacy consultation report to identify the irregularities from December 2022 or January 2023. Interview on 2/23/23 at approximately 1:30 p.m. with Staff A (Interim Director of Nursing) confirmed the facility had not received December 2022 or January 2023 pharmacy consultation reports as of yet. Review on 2/24/23 of facility assessment titled Medication Regimen Reviews, revised on May 2019, revealed . 8. Within 24 hours of the MRR [Medication Regimen Review], the Consultant Pharmacist provides a written report to the attending physician for each resident identified as having a non-life threatening medication irregularity

Based on interview and record review, it was determined that the facility failed to follow antibiotic use protocols related to tracking of antibiotics prescribed and the appropriate use of antibiotics for 3 out of 3 months reviewed for antibiotic use (Resident identifiers are #5, #11, #12, #21). Findings include: Review on 2/24/23 of the facility infection surveillance line list for December 2022 through February 2023 revealed the following: - December 2022 - no entries for antibiotic use; - January 2023 - Resident #5 was treated for a urinary tract infection with antibiotics from 1/4/23 through 1/11/23, McGeers Criteria was not met as urgency and pain were only symptoms and the urinalysis obtained was negative with no culture and sensitivity completed; - February 2023 - no entries for antibiotic use. Review on 2/24/23 of facility generated report of all antibiotics ordered from December 2022 through February 2023 revealed: December 2022 - Resident #21 prescribed Cephalexin 500 milligrams (mg) for cellulitis start date of 12/22/22 December 2022 - Resident #21 prescribed Cefpodoxine Proxetil tablet 200 mg for cellulitis on 12/28/22; January 2023 - Resident #11 prescribed Amoxicillin-Pot Clavulante oral tablet 875-125 mg for cellulitis on 1/18/23; February 2023 -Resident #12 prescribed Ciprofloxacin HCL [hydrochloride] oral tablet 500 mg for hematuria on 2/8/23. Interview on 2/24/23 at approximately 11:00 a.m. with Staff A (Interim Director of Nursing) confirmed the monthly antibiotic tracking was incomplete and that the facility could not confirm if antibiotics were prescribed appropriately following the criteria approved by the facility antibiotic stewardship program. Review on 2/24/23 of the facility's policy titled Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes, revised on December 2016, revealed: Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship 4. All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information will include: a. Resident name and medical number; b. Unit and room number; c. Date symptoms appeared; d. Name of antibiotic; e. Start date of antibiotic; f. Pathogen identified; g. Site of infection; h. Date of culture; i. Stop date; j. Total days of therapy; k. Outcome; and l. Adverse events. Review on 2/24/23 of the facility policy titled Antibiotic Stewardship- Orders for Antibiotics revised December 2016, revealed .1. Prior to calling a physician/prescriber to communicate a suspected infection, the nurse will obtain and have the following information available: a. Clinical signs and symptoms of suspected infection (based on approved definitions of infection) .3. Appropriate indications for use of antibiotics include: a. Criteria met for clinical definition of active infection or suspected sepsis; and b. Pathogen susceptibility, based on culture and sensitivity, to antimicrobial (or therapy begun while culture is pending) .7. When a culture and sensitivity (C&S) is ordered, it will be completed , and: a. Lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued .