Based on interview and record review, it was determined that the facility failed to follow it's grievance policy for tracking, investigating, and prompt resolution of grievances for 1 out of 1 resident reviewed for grievances (Resident identifiers is #4). Findings include: Interview on 6/4/25 at approximately 11:45 a.m. with Resident #4 revealed that Resident #23 wanders into their room frequently throughout the day and evening and has for some time now. Resident #4 stated they have voiced this concern to staff and nothing has been done to help keep Resident #23 out of their room. Interview on 6/6/25 at approximately 12:15 p.m. with Staff J (Infection Preventionist) stated that on 5/12/25 they spoke to Resident #4 and their roommate regarding Resident #23 wandering into their room. Staff J stated that this information was written up on a grievance form and brought to the managers morning meeting on 5/13/25. Interview on 6/6/25 at approximately 12:30 p.m. with Staff D (Administrator) revealed that the grievance from Resident #4 on 5/12/25 was not logged on the Grievance/Complaint log. Interview with Staff D further revealed that there was no investigation into Resident #4's grievance nor corrective actions taken, if needed. Review on 6/6/25 of the facility policy titledOPS204 Grievance/Concern, revised 10/15/24, revealed .Purpose: to Assure prompt receipt and resolution of patient or representative grievance/concern .4. Upon receipt of the Grievance/Concern Form, the Administrator or designee will document the grievance/concern on the Grievance Concern Log. 5. When the grievance/concern is logged, the Administrator and appropriate departments manager will be notified. 5.1 Immediate action will be taken to prevent further potential violations of any patient rights while the alleged violation is being investigated .6. The department manger will: 6.1 Contact the person filing the grievance to acknowledge receipt; 6.2 Investigate the grievance; 6.3 Take corrective actions, if needed; 6.4 Engage the support of the Ombudsman, if warranted; and 6.5 Notify the person filing the grievance of resolution in a timely manner .

Based on interview and record review, it was determined that the facility failed to thoroughly investigate after a resident's fall for 1 of 1 resident reviewed for falls in a final sample of 18 residents. (Resident Identifier is #82). Findings include: Review on 6/6/25 of the facility's policy titled Abuse Prohibition revised on 10/24/22 revealed, .The Center will implement an abuse prohibition program through the following: .Investigation of incidents and allegations; . Reporting of incidents, investigations, and Center response to the results of their investigations .10. At monthly Quality Assurance and Performance Improvement (QAPI) meetings, review all allegations of abuse, neglect, misappropriation of patient property, and exploitation that were reported to the state to: 10.1 Analyze occurrences to determine what changes are needed, if any, to prevent further occurrences; 10.2 Identify situations which a potential for risk; and 10.3 Determine what preventative measures will be implemented by staff. Review on 6/6/25 of Resident #82's Progress Note dated 4/24/25 at 5:22 p.m. and signed by Staff C (Registered Nurse) revealed, Pt's [Patient's] roommate came out in hall looking for a nurse, saying that pt had fallen, Nurse responded immediately, abd [abdomen] pt was found on the ground laying on [pronoun omitted] left side. Pt was unresponsive and not able to follow cues. 911 was immediately notified. Pt was observed to have twitches, and a pillow was applied to under [pronoun was omitted] head. Pt was asked to wait on the floor. 911 was notified. Daughter updated, PA [Physician Assistant] updated, Report called into [Hospital name omitted]. Pt was unable to respond appropriately to questions, Breathing WNL [Within Normal Limits]. Pt. sent with BIPAP [Bilevel Positive Airway Pressure] machine and Daughter called back and was updated on pt's situation. Pt. transferred to [Pronoun omitted] by EMTs [Emergency Medical Technician] at 5:00 p.m. on 4/24/25. Interview on 6/6/25 at 11:00 a.m. with Staff C confirmed the above and revealed that Resident #82 was unresponsive to answering questions. Staff C found Resident #82 by his/her bed so assumed he/she fell out of bed, but is not sure, since the resident was unable to answer any questions. Staff C assessed Resident#82 where he/she had fallen and did not move the Resident #82, but EMS providers arrive within 5 minutes of calling them. Further interview with Staff C on 6/6/25 at approximately 11:00 a.m. revealed that he/she fill in the required incident report and EMS paperwork, but no other paperwork was asked for regarding the fall for an investigation. Interview on 6/6/25 at approximately 10:30 a.m. with Staff B (Director of Nursing) and Staff D (Administrator), revealed that the facility did not attempt to further investigate into the fall to see what the circumstances were. Staff B and Staff D confirmed that neither one had interviewed the roommate or staff after the fall. Staff B and Staff C confirmed the facility had no evidence the facility had interview or investigated the fall. Review on 6/6/25 of the facility's policy titled Falls Management revised on 3/15/24 revealed, . A fall is defined as unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force (e.g., patient pushes another patient 5. Post-Fall Management: . 5.5 Document circumstances of the fall, post -fall assessment , and patient outcome;

Based on interview, and record review, it was determined that the facility failed to revise a care plan for 1 resident in a final sample of 18 residents (Resident identifiers is #23). Findings include: Interview on 6/4/25 at approximately 11:45 a.m. with Resident #4 revealed that Resident #23 wanders into their room frequently in the evening and night for some time now. Interview on 6/6/25 at approximately 11:45 a.m. with Staff E (Licensed Practical Nurse) stated that Resident #23 will wander into Resident #4's room sometimes. Staff E said the staff will redirect Resident #23 when this occurs. Interview on 6/6/25 at approximately 11:55 a.m. with Staff F (Licensed Nursing Assistant) stated that Resident #23 will wander into Resident #4's room. Staff F said that staff will redirect Resident #23 with items to fidget with and will also try to engage her in activities. Review on 6/5/25 of Resident #23's progress notes revealed the following: On 4/11/25, Resident #23 required frequent redirection as he/she enters other resident's rooms and touches other resident's walkers; On 5/1/25, Resident #23 has been having increased behaviors; On 5/28/25, Resident #23 sleeps intermittently, wanders at night; On 5/29/25, Resident #23 goes into the nurse's station and other residents rooms and Resident #23 can be difficult to redirect and often becomes agitated. Review on 6/5/25 of Resident #23's care plan revealed a care plan, initiated on 10/5/22, for elopement risk related to Cognitive loss/Dementia. Further review of Resident #23's care plan revealed no care plan interventions for wandering into others rooms. Interview on 6/6/25 at approximately 8:50 a.m. with Staff G (Director of Social Services) confirmed that Resident #23 does wander into others rooms and that Resident #23's care plan does not have interventions to address Resident #23's wandering. Review on 6/6/25 of the facility policy titled NSG 206 Behaviors: Management of Symptoms, revised 7/1/24, revealed .Purpose: To identify, prevent and manage behavioral symptoms by: Using non-pharmacological approaches as initial interventions and ongoing; Promoting a therapeutic and safe environment for patients and staff: Monitoring outcomes of care plan interventions. To Minimize the use of psychotropic medications, including antipsychotics, for patients with behavioral symptoms and/or dementia .Practice Standards .2. Staff will monitor for and document in the medical records any exhibited behavioral symptoms .3. Identify, to the extent possible, potential underlying causes of behavioral symptoms .4. Implement individualized, person-centered, non pharmacologic interventions as the initial behavior mitigation strategy and update care plan accordingly .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to follow physician orders for 1 of 4 residents reviewed for medication administration in a final sample of 18 residents (Resident Identifiers is #77). Findings include: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 10th edition St. Louis, Missouri: Elsevier, 2021. Page 614 .It is essential to verify the accuracy of every medication you give to your patients with the patient's order. If the medication order is incomplete, incorrect, or inappropriate, or if there is a discrepancy between the original order and the information on the MAR [Medication Administration Record]. consult with the health care provider. Do not give a medication until you are certain that you can follow the seven rights of medication administration . Page 672 .seven rights of medication administration include right medication, right dose, right patient, right route, right time, right documentation and right indication . [NAME], [NAME]; [NAME], [NAME] A.; [NAME], Wendy; and [NAME], [NAME]. Clinical Nursing Skills & Techniques. 10th ed. [NAME], Pennsylvania: Elsevier, 2022. Page 597 - Safe Medication Preparation: Right Time With time-critical medications (e.g., antibiotics, anticoagulants, insulin, immunosuppressives), early or delayed administration of the maintenance doses of more than 30 minutes before or after the scheduled dose will most likely cause harm or result in subtherapeutic responses in a patient. Interview on 6/4/25 at approximately 11:00 a.m. with Resident #77 revealed that his/her short acting insulins are often given late. He/she stated it has happened multiple times since his/her admission within the last month and it didn't matter which meal. He/She indicated one time he/she had chocolate cake by the time the nurse gave him/her their insulin. Review on 6/4/25 of Resident #77's admission's Minimum Data Set (MDS) with an assessment reference date of 5/19/25 revealed Resident #77 had a Basic Interview for Mental Status (BIMS) score of 15 out of 15 indicating cognitively intact. Review on 6/4/25 of the facility's mealtime schedule revealed that breakfast is at 8:00 a.m., lunch is at 12:30 p.m., and dinner is 6:15 p.m. The meals trays are delivered to the individual rooms. Review on 6/5/25 of the manufacturer's instructions for Insulin Lispro revealed Lispro is given within 15 minutes before a meal, or right after eating. Review on 6/5/25 of the manufacturer's instructions for Glargin-ygf revealed .Administer Insulin Glargine-yfgn subcutaneously once daily at any time of day but at the same time every day . Review on 6/4/25 of Resident #77's Location of Administration Report from 5/1/2025 through 5/31/2025 revealed the following days that the short acting insulin was not given per the manufacturer's instructions: On 5/17/25 HumaLog Kwikpen 100 Unit/ML (milliliters) (Insulin Lispro) (short acting insulin) inject as per sliding scale: if 70 - 150 = 0 units; 151-200 = 2 units; 201- 250= 4 units; 251-300= 6 units; 301-351= 8 units; 351-400 = 10 units> 400 12 units and call provider, subcutaneously before meals for DM (Diabetes Mellitus) was administered at 7:17 p.m. and dinner mealtimes are 6:15 p.m. On 5/21/25 Insulin Lispro 100 unit/ML inject as per sliding scale: 151-200 = 2 units; 201- 250= 4 units; 251-300= 8 units; 301-400= 10 units; 401-402=12 call MD (Medical Doctor) over 400, subcutaneously three times a day for DM, was administered at 6:44 a.m. and breakfast mealtimes at 8:00 a.m. On 5/22/25 Insulin Lispro 100 unit/ML inject as per sliding scale: 151-200 = 2 units; 201- 250= 4 units; 251-300= 8 units; 301-400= 10 units; 401-402=12 call MD 400, subcutaneously three times a day for DM, was administered at 6:51 a.m. and the breakfast mealtimes are 8:00 a.m. On 5/24/25 Insulin Lispro 100 unit/ML inject as per sliding scale: 151-200 = 2 units; 201- 250= 4 units; 251-300= 8 units; 301-400= 10 units; 401-402=12 call MD over 400, subcutaneously three times a day for DM, was given at 6:53 a.m. while the breakfast mealtimes are at 8:00 a.m. On 5/25/25 Insulin Lispro 100 unit/ML inject as per sliding scale: 151-200 = 2 units; 201- 250= 4 units; 251-300= 8 units; 301-400= 10 units; 401-402=12 call MD over 400, subcutaneously three times a day for DM, was given at 6:37 a.m., while the breakfast mealtime is at 8:00 a.m. On 5/26/25 Insulin Lispro 100 unit/ML inject as per sliding scale: 151-200 = 2 units; 201- 250= 4 units; 251-300= 8 units; 301-400= 10 units; 401-402=12 call MD over 400, subcutaneously three times a day for DM, was given at 6:58 a.m., while the breakfast mealtime is at 8:00 a.m. On 5/27/25 Insulin Lispro 100 unit/ML inject as per sliding scale: 151-200 = 2 units; 201- 250= 4 units; 251-300= 8 units; 301-400= 10 units; 401-402=12 call MD over 400, subcutaneously three times a day for DM, was given at 5:59 a.m. and the breakfast mealtime is scheduled for 8:00 a.m. Insulin Lispro 100 unit/ML inject as per sliding scale: 151-200 = 2 units; 201- 250= 4 units; 251-300= 8 units; 301-400= 10 units; 401-402=12 call MD over 400, subcutaneously three times a day for DM, was given at 11:05 and the lunch mealtime is scheduled for 12:30 p.m. On 5/28/25 Insulin Lispro 100 unit/ML inject as per sliding scale: 151-200 = 2 units; 201- 250= 4 units; 251-300= 8 units; 301-400= 10 units; 401-402=12 call MD over 400, subcutaneously three times a day for DM, was given at 6:10 a.m. and the breakfast mealtime is scheduled for 8:00 a.m. Insulin Lispro 100 unit/ML inject as per sliding scale: 151-200 = 2 units; 201- 250= 4 units; 251-300= 8 units; 301-400= 10 units; 401-402=12 call MD over 400, subcutaneously three times a day for DM, was given at 11:21 a.m. and the lunch mealtime is scheduled for 12:30 p.m. On 5/29/25 Insulin Lispro 100 unit/ML inject as per sliding scale: 151-200 = 2 units; 201- 250= 4 units; 251-300= 8 units; 301-400= 10 units; 401-402=12 call MD over 400, subcutaneously three times a day for DM, was given at 6:48 a.m. and the breakfast mealtime is scheduled for 8:00 a.m. On 5/30/25 Insulin Lispro 100 unit/ML inject as per sliding scale: 151-200 = 2 units; 201- 250= 4 units; 251-300= 8 units; 301-400= 10 units; 401-402=12 call MD over 400, subcutaneously three times a day for DM, was given at 6:45 a.m. and the breakfast mealtime is scheduled for 8:00 a.m. On 5/31/25 Insulin Lispro 100 unit/ML inject as per sliding scale: 151-200 = 2 units; 201- 250= 4 units; 251-300= 8 units; 301-400= 10 units; 401-402=12 call MD over 400, subcutaneously three times a day for DM, it was given at 6:27 a.m. and the breakfast mealtime is scheduled for 8:00 a.m. Insulin Lispro 100 unit/ML inject as per sliding scale: 151-200 = 2 units; 201- 250= 4 units; 251-300= 8 units; 301-400= 10 units; 401-402=12 call MD over 400, subcutaneously three times a day for DM,. it was given at 4:55 p.m. and the dinner mealtime is scheduled for 6:15 p.m. Further Review of Resident #77's Location of Administration Report For May 2025 revealed the following long acting insulins were given more than an hour after the ordered time: On 5/18/25 Insulin Glargine-yfgn (long-acting insulin) 100 units/ML inject 10 unit subcutaneously two times a day for diabetes, was scheduled for 6:00 p.m. and was given at 7:14 p.m. On 5/20/25 Insulin Glargine-yfgn (long-acting insulin) 100 units/ML inject 10 unit subcutaneously two times a day for diabetes, was scheduled for 6:00 p.m. was given at 8:19 p.m. On 5/22/25 Insulin Glargine-yfgn (long-acting insulin) 100 units/ML inject 10 unit subcutaneously two times a day for diabetes, was scheduled for 6:00 p.m. and was given at 7:44 p.m. On 5/27/25 Insulin Glargine-yfgn (long-acting insulin) 100 units/ML inject 10 unit subcutaneously two times a day for diabetes, was scheduled for 6:00 p.m. and was given at 7:21 p.m. Review on 6/4/25 of Resident #77's Location of Administration Report from 6/1/2025 through 6/4/2025 revealed the following days that the short acting insulin was not given per the manufacturer's instructions: On 6/1/25 Insulin Lispro 100 unit/ML inject as per sliding scale: 151-200 = 2 units; 201- 250= 4 units; 251-300= 8 units; 301-400= 10 units; 401-402=12 call MD over 400, subcutaneously three times a day for DM, it was given at 6:50 a.m. and the breakfast mealtime is scheduled for 8:00 a.m. On 6/2/25 Insulin Lispro 100 unit/ML inject as per sliding scale: 151-200 = 2 units; 201- 250= 4 units; 251-300= 8 units; 301-400= 10 units; 401-402=12 call MD over 400, subcutaneously three times a day for DM, was given at 6:37 a.m. and the breakfast mealtime is scheduled for 8:00 a.m. Insulin Lispro 100 unit/ML inject as per sliding scale: 151-200 = 2 units; 201- 250= 4 units; 251-300= 8 units; 301-400= 10 units; 401-402=12 call MD over 400, subcutaneously three times a day for DM, was given at 5:44 p.m. and the dinner mealtime is scheduled at 6:15 p.m. On 6/3/25 Insulin Lispro 100 unit/ML inject as per sliding scale: 151-200 = 2 units; 201- 250= 4 units; 251-300= 8 units; 301-400= 10 units; 401-402=12 call MD over 400, subcutaneously three times a day for DM, was given at 6:43 a.m. and the breakfast mealtime is scheduled at 8:00 a.m. On 6/4/25 Insulin Lispro 100 unit/ML inject as per sliding scale: 151-200 = 2 units; 201- 250= 4 units; 251-300= 8 units; 301-400= 10 units; 401-402=12 call MD over 400, subcutaneously three times a day for DM, was given at 6:53 a.m. and the breakfast mealtime is scheduled at 8:00 a.m. Interview on 6/5/25 at approximately 7:00 a.m. with Staff B (Director of Nursing) confirmed that the above medications were administered late. Interview further revealed that Staff B was not notified of the late medications and therefore the physician was not aware. Review on 6/5/25 of the facility's policy titled Medication Administration with a date of 1/25 revealed, Medication Administration: 1. Medications are administrated in accordance with written orders of the prescriber .3. Medication administration timing parameters include the following .b. Medications to be given with meals are to be scheduled for administration at the residents' meal times .14. Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes.

Based on interview and record review, it was determined that the facility failed to ensure that trauma survivors have interventions identified to eliminate or mitigate triggers that may cause re-traumatization for 1 of 1 resident reviewed for mood and behaviors in a final sample of 18 residents. (Resident identifier is #4). Findings include: Review on 6/5/25 of Resident #4's Psychiatric note, dated 5/13/25, revealed the following: .[Pronoun omitted] was referred for psychiatric medication management services for depression, anxiety, and PTSD [Post-Traumatic Stress Disorder] .[Name omitted] reports ongoing depressive and anxiety symptoms related to situational stressors .[Pronoun omitted] has also had a difficulty with several residents here and feels uncomfortable around them .[Name omitted] reports chronic nightmares and poor sleep related to childhood molestation .PTSD based symptoms nightmares .Chronic PTSD: chronic nightmares and flashbacks related to childhood sexual abuse perpetrated by her brother, [Name omitted]. Appears to have relational difficulties related to her childhood trauma . Review on 6/5/25 of Resident #4's medical record revealed a care plan, initiated on 3/11/25, that for reported past experience of trauma as evidenced by: Repeated, disturbing memories, thoughts or images of a stressful experience from the related history of abuse. Further review of Resident #4's care plan revealed no identified triggers and interventions. Interview on 6/6/25 at 9:30 a.m. with Staff H (Unit Manager) revealed they were unaware of trauma or PTSD for Resident #4. Interview on 6/6/25 at approximately 11:45 a.m. with Staff E (Licensed Practical Nurse) revealed they were unaware of Resident #4 having trauma. Interview on 6/6/25 at approximately 11:55 a.m. with Staff F (Licensed Nursing Assistant) revealed they were unaware of Resident #4 having trauma. Review on 6/6/25 of Resident #4's admission social services assessment, dated 1/13/25, revealed .C. Mental Health & Wellness .4. Trauma History 1. Does the patient/resident report or does the medical record reflect any history of trauma and /or Post-Traumatic Stress Disorder (PTSD)? YES . 1a 1. if yes select type of trauma and describe using the corresponding comment box .m. Other .m1. Comments car accident and husband passing away . Review on 6/6/25 of Resident #4's quarterly social services assessment, dated 4/9/25, revealed that .C. Mental Health & Wellness .4. Trauma History 2a. Ask: in in the past month , have you had repeated, disturbing memories, thoughts or images of experiences from the past? marked 3. Moderately 2b. Ask: In the past month, have you felt very upset when something reminded you of a stressful experience from the past? Marked 3. Moderately, 5. Comments Mental Health & Wellness Comments a. Use to elaborate on patient's/resident's mental health and wellness: VA [Vehicular Accident] that took place and her husbands passing . Interview on 6/6/25 at approximately 9:a.m. with Staff G (Director of Social Services) revealed that Resident #4 has informed them that they have been sexually abused in their childhood, and does not mind male caregivers. Staff G stated that Resident #4 does not like to feel trapped and that is why she has a door bed and not a window. Staff G stated that Resident #4's the care plan does not address the history of sexual abuse or that she does not like to be trapped. Review on 6/6/25 of the facility policy titled SS100 Social Services Assessment revised 3/15/24, revealed .Purpose: To determine the patient's social, functional, emotional, and cognitive status and history of trauma and/or post-traumatic stress disorder (PTSD). To develop an individualized Social Services plan of care.

Based on observation, interview, and record review, it was determined that the facility failed to implement infection control policies and procedures for 1 of 1 resident observed for wound care in the final survey sample of 18 residents. (Resident identifier is #66). Findings include Observation on 6/4/25 at approximately 10:00 a.m. with Staff A (Licensed Practical Nurse) performing wound care for Resident #66 revealed the following: Staff A entered Resident #66's room and placed wound care supplies on a sterile field on the bedside table. Staff A pulled a pair of scissors out of his/her nursing scrub top pocket and placed it onto the bedside table without disinfecting/cleaning the scissors. Right great toe metatarsal wound care: Staff A donned gloves then proceeded to cut Resident #66's right foot dressing off with the unclean scissors and placed them back onto the bedside table with the wound care supplies. After removing the old dressing, Staff A cleaned the right great toe metatarsal wound with normal saline. Staff A used the unclean scissors to cut the new foam dressing and applied it to the ball of the right great toe and then secured it with a border gauze dressing. Staff A doffed their gloves. Staff A did not change his/her gloves between removing the old dressing and applying the new dressing. Left Plantar Foot wound care: Staff A donned a new pair of gloves. Staff A used the unclean scissors to cut the old dressing off and placed them back onto the bedside table with the wound care care supplies. The left plantar foot wound was cleaned with the wound cleanser. Staff A applied a calcium alginate, covered it with a foam dressing, and secured it with border gauze. Staff A doffed their gloves. Staff A did not change his/her gloves between removing the old dressing and applying the new dressing. Interview on 6/4/25 at approximately 10:30 a.m. with Staff A confirmed the above observations. Review on 6/4/25 of the facility policy titled Wound Dressings: Aseptic, revised 2/24/25, revealed .4. Prepare a clean, uncluttered, disinfected surface. 5. Create an aseptic field at bedside and place clean barrier on over-bed table. Place supplies on barrier .16.1 Apply clean gloves .16.2 Discard soiled dressing and gloves in the appropriate receptacle .18 Apply gloves. Review on 6/4/25 of the CDC's website titled, Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007), retrieved from: https://www.cdc.gov/infection-control/hcp/isolation-precautions/summary-recommendations.html, revealed .Summary of Recommendations .IV. Standard Precautions .IV.A. Hand hygiene .Perform hand hygiene ~ in the following clinical situations: .If hands will be moving from a contaminated-body site to a clean-body site during patient care .After removing gloves .IV.B. Personal protective equipment (PPE) .IV.B.2.Gloves V.B.2.a.Wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, nonintact skin, or potentially contaminated intact skin (e.g., of a patient incontinent of stool or urine) could occur .IV.B.2.d. Change gloves during patient care if the hands will move from a contaminated body-site (e.g., perineal area) to a clean body-site (e.g., face) .

Based on observation, interview, and policy review, it was determined that the facility failed to store food in accordance with professional standards for food safety to prevent foodborne illness for 1 of 1 kitchen observed. Findings include: Review on 4/4/24 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: .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: . 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 . 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 . Observation on 4/2/24 at 8:25 a.m. of the walk-in refrigerator revealed the following: Seventeen (17) soft moist green peppers with white and black spots visible on all of the peppers in the case Fifteen (15) soft moist celery stalks with brown spots visible on all of the celery in a bin with no lid Three (3) bags of hearts of romaine lettuce with brown spots visible on the outer leaves Twenty-eight (28) 4-ounce cartons of Ready Care Chocolate Shakes with no thawed date or use by date One (1) clear plastic container of meat sauce with no prepared date or use by date One (1) large metal tray of mashed sweet potatoes with no prepared date or use by date One (1) gallon size zip lock bag of cooked ham with no prepared date or use by date Three (3) individually wrapped packages of sliced white cheese with no opened date or use by date Interview on 4/2/24 at 8:30 a.m. with Staff B (Culinary Manager) confirmed the above findings. Review on 4/2/24 of the facility's policy titled Receiving revised 2/2023, revealed: .5. All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation . Review on 4/2/24 of the manufacturer's instructions for Ready Care Chocolate Shakes under storage and handling revealed .After thawing keep refrigerated. Use within 14 days after thawing . Review on 4/2/24 of the facility's policy titled Labeling and Dating Chart revealed: .Ready to eat, time/temperature control for safety foods including but not limited to: .cheese . sliced meats . use by date 7 days after opening .

Based on observation, interview, and record review, it was determined that the facility failed to provide privacy of medical records on 1 of 4 units (Resident identifiers are #8 and #17). Findings include: Observations on 3/22/23 at 11:00 a.m., 12:00 p.m., and again at 2:00 p.m., revealed Resident #8's and Resident #17's Radiology Exam Order containing Resident #8's and Resident #17's name, date of birth , and image results stored face-up on the top counter of the nurse station viewable to unauthorized personnel on B-Wing. Observation on 3/22/23 at approximately 2:00 p.m., a document titled Rochester Manor Census List for B Wing Rooms 15-28 revealed full resident names, diet types and dietary notes stored face-up on the top counter of the nurse station viewable to unauthorized personnel. Interview on 3/22/23 at approximately 2:15 p.m. with Staff D (Licensed Practical Nurse) revealed staff utilize the counter for medical record documents due to lack of space. Interview on 3/22/23 at approximately 2:20 p.m. with Staff A (Director of Nursing) confirmed the observations. Review on 3/22/23/23 of the facility's policy titled 4.6 Health Insurance Portability and Accountability Act (HIPPA), last revised 5/1/22, revealed: Service locations will keep confidential all information contained in the patients'/residents' (hereinafter patient) records, regardless of the form or storage method . 4. Secure patient records containing protected health information such that they are not readily accessible by unauthorized parties.

Based on observation, interview, and policy review, it was determined that the facility failed to store food according to acceptable standards for food safety to prevent foodborne illness in the main kitchen and 1 of 2 unit kitchenettes observed. Findings include: Review on 3/24/23 of the Food Code U.S. Public Health Service 2017 U.S. Department of Health and Human Services retrieved from https://www.fda.gov/food/FDA-food-code/food-code-2017 revealed the following: .Annex 3, Public Health Reasons/Administrative Guidelines . Chapter 3 Food . Page 458 Manufacturer's use-by dates It is not the intent of this provision to give a product an extended shelf life beyond that intended by the manufacturer. Manufacturers assign a date to products for various reasons, and spoilage may or may not occur before pathogen growth renders the product unsafe. Most, but not all, sell-by or use-by dates are voluntarily placed on food packages the manufacturer's use-by date is its recommendation for using the product while its quality is at its best. Although it is a guide for quality, it could be based on food safety reasons. It is recommended that food establishments consider the manufacturer's information as good guidance to follow to maintain the quality (taste, smell, and appearance) and salability of the product. If the product becomes inferior quality-wise due to time in storage, it is possible that safety concerns are not far behind . Observation on 3/22/23 at 9:00 a.m. in the main kitchen with Staff E (Culinary Director) revealed: Two (2) packages of hot dog rolls with a use by date of 2/27/23; Six (6) packages of long grinder rolls with a use by date of 3/17/23; Three (3) loaves of white bread with no use by date; Two (2) packages of round sandwich rolls with no use by date. Interview on 3/22/23 at 9:05 a.m. with Staff E confirmed the above were expired or without a use by date. Observation at 3/22/23 at 9:25 a.m. of the walk in refrigerator revealed: Twenty-Six (26) soft moist green peppers with black spots visible on all of the peppers in the case; Twelve (12) soft moist celery stalks with brown spots visible on all of the celery in an open bin; Two (2) six packs of hard boiled eggs with no label or use by date. Interview on 3/22/23 at 9:30 a.m. with Staff E confirmed that the hard boiled eggs should have been labeled with a use by date. Staff E stated the green peppers and the celery should have been discarded. Observation on 3/22/23 at 9:40 a.m. of A kitchenette revealed: Two (2) packages of English muffins with no use by date; Two (2) packages of round sandwich rolls with no use by date; One (1) package of small dinner rolls with no use by date; One (1) package of white bread with no use by date. Interview on 3/22/23 at 9:42 a.m. with Staff E confirmed the above were open with no use by date. Review on 3/24/23 of the facility's policy titled, Food Handling, revised July 15, 2018, revealed Use By dating guidelines: 25. Foods that are marked with the manufacturer's use by date .Once a product has been prepared or portioned, a new use by date is established . 26. Foods in dry storage are in closed, labeled, and dated containers . For products that have been opened by not fully used, a use by date is included on the label. Review on 3/24/23 of the facility's policy titled, Refrigerated/Frozen Storage, revised July 15, 2018, revealed Process: 1. Refrigeration: 1.4 All foods are labeled with name of product and the date received and use by date once opened .

Based on interview, record review, and policy review, it was determined that the facility failed to implement an antibiotic stewardship program which included a system to track and monitor antibiotic use during 2 of 6 months reviewed. Findings include: Review on 3/24/23 of the facility's Infection Control Monthly Line Listing for January and February 2023 revealed tracking for the use of antibiotics for 14 residents. The line listings did not indicated clinical signs and symptoms to determine if the residents met the criteria for the use of antibiotics. For the month of January 2023 there were 5 residents receiving antibiotics (3-urinary tract infections (UTI), 1-osteomyelitis, and 1- hordeolum). For the month of February 2023 there were 9 residents receiving antibiotics (2-c-difficile, 3-pneumonia, 1-UTI, 1-surgical wound, 1- cellulitis, and 1-conjunctivitis). Interview on 3/24/23 at 9:10 a.m. with Staff B (Infection Preventionist) and Staff A (Director of Nursing) confirmed the line lists for January and February 2023 did not contain clinical signs and symptoms. Staff B stated that signs and symptoms were on the Infection Control Reporting Form but was not able to provide completed forms for residents on the above line lists. Review on 3/24/23 of facility policy titled, IC402 Antibiotic Stewardship, last revised 10/24/22, revealed: 5. Tracking - Monitor both antibiotic use practices and outcomes related to antibiotics in order to guide practice changes and track the impact of new interventions: 5.1 Monitor measures of antibiotic use by auditing available reports and patient medical records for adherence. Monitor: 5.1.1 Clinical evaluation documentation (e.g., signs/symptoms, vital signs, physical exam findings); .