Based on observation, resident and staff interview, and policy and procedure review, the facility failed to ensure infection prevention practices were implemented during meal delivery during 2 of 3 meal observations in the main dining room. The census was 32. The findings were: 1. Observation on 4/22/25 from 4:48 PM showed dietary aide #1 was taking orders for the evening meal using a pen and pad of paper. After obtaining the orders the dietary aide returned to the kitchen and obtained milk, coffee, and hot water, and served the beverages to residents with her fingers touching the rims of the cups. Further observation showed the dietary aide continued to serve beverages to residents in the same manner without performing hand hygiene. 2. Interview on 4/22/25 at 10:55 AM during resident council with resident # 20 revealed staff handled the cups at the top when they served beverages at meals. 3. Observation on 4/23/25 at 12:33 PM showed CNA #1 carried a beverage cup to a resident with her palm covering the top of the cup and fingers wrapped around the sides of the cup. Further observation at 12:37 PM showed CNA #2 carried another resident's beverage cup in the same manner. 4. Observation on 4/23/25 at 12:36 PM showed dietary aide #2 carried hot plates to residents with her shirt sleeves wrapped over her hands. The sleeves made full contact with the eating surface of the plate. 5. Interview on 4/24/25 at 8:50 AM with the dietary manager revealed her expectation was for staff to hold cups at the bottom when beverages were served to residents. 6. Review of the facility policy titled Hand Hygiene, last revised 11/2022 showed Hand hygiene (using either alcohol-based hand rubs or soap and water) should be performed before and after each resident contact and after contact with a resident's belongings, environmental surfaces, and resident care equipment . 2. Hands must be thoroughly washed with soap and water: (20 sec. minimum scrub time) .b. Prior to handling food (preparation or assistance with meals) .

Based on medical record review and staff interview, the facility failed to ensure an advanced directive was formulated for 1 of 16 residents (#25) reviewed. The findings were: 1. Review of the electronic medical record (EMR) showed resident #25 was listed as do not resuscitate (DNR). Further review of the medical record showed no evidence of an advanced directive signed by the resident or the resident's representative. 2. Interview on 2/27/24 at 2:21 PM with the NHA and the RAC confirmed the facility did not have a record of the DNR status of the resident.

Based on observation, review of temperature log sheets, staff interview, and manufacturer's instructions, the facility failed to ensure the temperature of 1 of 1 medication storage refrigerator was monitored. The findings were: 1. Observation on 2/28/24 at 10:25 AM of the medication storage room showed a GE refrigerator contained medications for resident use which included Ozempic (a diabetic medication) and eye drops. The follow concerns were identified: a. Review of the temperature monitoring logs from 2/24/24 to 2/28/24 showed the facility failed to record the temperature of the medication storage refrigerator. b. Observation on 2/28/24 at 10:25 AM showed the thermometer inside the refrigerator read 32 degrees Fahrenheit. 2. Interview on 2/28/24 at 4:11 PM with the RAC revealed it was the facility's expectation the temperature of the medication storage refrigerator be monitored every shift and be recorded. 3. Review of the Temperature Ranges For GE Refrigerators with no date, provided by the facility on 2/29/24 at 12:38 PM showed The temperature ranges available .can vary depending on which model you have. However, in general, here's what you can expect:. the coldest setting 34 degrees Fahrenheit and 42 degrees Fahrenheit for the warmest setting with a default of 37 degrees. 4. According to https://www.ozempic.com/how-to-take/ozempic-pen.html?showisi=true&&utm_source=google&utm_medium=cpc&utm_term=storage%20ozempic&utm_campaign=1_All_Shared_BR_Branded_Specifics_2023&mkwid=s-dc_pcrid_676991889727_pkw_storage%20ozempic_pmt_p_slid__product_&pgrid=158457156870&ptaid=kwd-450547815488&gad_source=1&gclid=CjwKCAiAxaCvBhBaEiwAvsLmWA2ppY3FA1OKj4n6UpEAzmPLZfnDsX_O4tvOjCzi7Aw8RF6KM1YmuhoC38EQAvD_BwE&gclsrc=aw.ds retrieved on 3/6/24 at 11:23 AM showed: How to store your Ozempic® pen . Store your new, unused Ozempic® pens in the refrigerator between 36°F to 46°F (2°C to 8°C) and Do not freeze Ozempic®. Do not use Ozempic® if it has been frozen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policies and CDC immunization recommendations, the facility failed to ensure residents were offered pneumococcal immunizations based on CDC recommendations for 2 of 5 sample residents (#7, #20) reviewed for immunizations. The findings were: 1. Review of the medical record showed resident #7 was [AGE] years old. Further review showed the resident received the pneumococcal 13 valent conjugate (PCV13) on 2/1/18. There was no evidence the resident was offered a pneumococcal immunization since the last administration in 2018. 2. Review of the medical record showed resident #20 was [AGE] years old. Further review showed the resident received the PCV13 on 10/28/14. There was no evidence the resident was offered a pneumococcal immunization since the last administration in 2014. 3. Interview with the NHA on 2/28/24 at 5:53 PM revealed the facility followed CDC recommendations for immunizations and confirmed there was no evidence resident #7 or resident #20 were offered pneumococcal immunizations in accordance with CDC guidelines. 4. Review of the facility's policy Pneumococcal Immunization, effective 10/9/07, showed 1. Upon admission and annually, resident's immunization history will be obtained, including compliance with current CDC recommendations for pneumococcal vaccination . 5. According to the Adult Immunization Schedule by Age by CDC located at https://www.cdc gov/vaccines/schedules/hcp/adult.html (accessed on 3/12/24) showed individuals 65 years or older who previously received only the PCV13 vaccine should receive 1 dose of either the PCV20 or PCVS23 vaccine at least 1 year after the last PCV13 dose.

Based on observation, staff interview, and policy and procedure review, the facility failed to ensure residents' private health information was protected for 3 out of 16 (#11, #19, #26) resident rooms observed and during multiple random observations of the medication cart. The census was 28. The findings were: 1. Random observation on 2/26/24 from 4 PM to 6 PM showed LPN #1 left the medication cart unattended (not in the vicinity) several times with private medical information observable on the computer screen (EMR) which included the resident's name, medication, medication dose, and administration time, and was visible for unauthorized people to read. Staff from different departments, visitors, and other residents were noted to pass by the medication cart during this timeframe. 2. Observation on 2/27/24 at 8:03 AM showed LPN #2 left the medication cart with the EMR visible and unsecured in the dining room. 3. Observation on 2/28/24 at 9:21 AM showed LPN #1 had left the medication cart unsecured with visible EMR in the intersection of the 100 and 200 hallways. 4. Observation on 2/28/24 showed residents (#11, #19, #26) had their care plans pinned to the cork board immediately upon entrance into each of the resident's rooms and visible from the hallway. The information included the resident's birth date, medications, their incontinence status, transfer requirements and wound information. 5. Interview on 2/28/24 at 4:52 PM with the RAC confirmed the resident care plans should have been located inside the resident's closet and not pinned to the cork board. 6. Interview on 2/29/24 at 11:12 AM with the RAC, while observing EMR unsecured information on the medication cart, revealed it was the facility's expectation to follow HIPAA (Health Insurance Portability and Accountability Act) policies. 7. Review of the facility policy titled HIPAA 0042, dated April 14, 2003 showed: 1. The purpose of this policy is to maintain an adequate level of security to protect patient, resident, client and facility information from unauthorized access .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of the dishwasher and refrigerator/freezer temperature log sheets, manufacturer's instructions, hot and cold food temperature logs, policy and procedures, and the 2022 FDA Food Code, the facility failed to ensure a sanitary environment in 1 of 1 kitchen and failed to ensure temperatures were monitored for 5 of 5 refrigerator/freezers which stored food for resident use outside of the kitchen (downstairs pantry, upstairs pantry, 100 hallway, 200 hallway, and 400 hallway). The census was 28. The findings were: Related to temperature monitoring of food storage units: 1. Review of the December 2023, the January 2024, and February 2024 temperature monitoring log sheets for food storage areas outside of the kitchen showed the following concerns: a. Review of the downstairs pantry refrigerator/freezer log sheets showed the temperature of the refrigerator/freezer was to be checked by the evening shift CNA daily. The facility was unable to locate the December log sheet. The January log sheet showed 6 out of 31 days and the February log sheet showed 7 out of 27 days that failed to include documentation of the temperature of the refrigerator/freezer. In addition, the January log sheet showed 22 days and the February log sheet showed 7 days where the temperature of the freezer was not documented. b. Review of the upstairs pantry refrigerator/freezer log sheets showed the temperature of the refrigerator/freezer was to be checked by the evening shift CNA daily. The facility was unable to locate the December log sheet. The January log sheet showed 6 out of 31 days and the February log sheet showed 4 out of 27 days that failed to include documentation of the temperature of the refrigerator/freezer. In addition, the January log sheet showed 5 days and the February log sheet showed 1 day where the temperature of the freezer was not documented. c. Observation on 2/28/24 at 4:19 PM showed a small Midea refrigerator was located in the 200 hallway which contained drinks and snacks for resident consumption. There was no evidence the facility monitored the temperature of the refrigerator. d. Observation on 2/28/24 at 4:21 PM showed a small GE refrigerator was located in the 100 hallway which contained drinks and snacks for resident consumption. There was no evidence the facility monitored the temperature of the refrigerator. e. Observation on 2/28/24 at 4:25 PM showed a small Hanai refrigerator was located in the 400 hallway which contained drinks and snacks for resident consumption. There was no evidence the facility monitored the temperature of the refrigerator. f. Interview on 2/28/24 at 12:10 PM with team leader #2 revealed she was unable to locate the December 2023 log sheets for the downstairs and upstairs pantry refrigerator/freezers. g. Interview on 2/28/24 at 4:17 PM with the RAC revealed a system had not been developed to monitor the small refrigerators in the resident common rooms. In addition, the RAC confirmed the temperature log sheets were incomplete. 2. Review of the December 2023, the January 2024, and February 2024 CC Cooling Unit Temp Log sheets showed columns to record the temperature of the Cook's Fridge, the A la Carte Top & Bottom, the Office Fridge & Freezer, the Double Fridge, the Single Fridge, the Single Freezer, the Double Freezer, and the White Freezer used for food storage equipment inside the kitchen. The following concerns were identified: a. Review of the December 2023 temperature log sheet showed 10 days when the temperature of the food storage equipment was not recorded. b. Review of the January 2024 temperature log sheet showed 5 days when the temperature of the food storage equipment was not recorded. c. Review of the February 2024 temperature log sheet showed 4 out of 27 days where the temperature of the food storage equipment was not recorded. d. Interview with the dietitian on 2/28/24 at 4:30 PM revealed it was her expectation the temperature of the food storage equipment be monitored daily. 3. Review of the policy and procedure titled PREPARING AND HOLDING FOOD last reviewed in 2019, showed POLICY: The use of proper techniques for preparation and holding of foods. Adherence to established sanitation practices in food service and holding, to protect foods from contamination and reduce the potential for food borne illness outbreak. PROCEDURE: .9. Cold food items are refrigerated at 41 degrees or below . 4. According to the 2022 FDA Food Code 2-103.11 Person in Charge. The PERSON IN CHARGE shall ensure that .(J) FOOD EMPLOYEES are properly maintaining the temperature of TIME/TEMPERATURE CONTROL FOR SAFETY FOODS during thawing through daily oversight of the FOOD EMPLOYEE'S routine monitoring of FOOD temperatures . Related to the sanitary environment of the kitchen: 1. Observation on 2/27/24 at 8 AM showed cook #1 was preparing made to order breakfast for residents in the facility kitchen. The cook was not wearing a beard restraint over his facial hair. Interview with the cook on 2/27/24 at 8:18 AM revealed he had not received any education related to wearing a beard restraint while preparing or serving food. Interview on 2/28/24 at 4:30 PM with the dietitian revealed it was her expectation kitchen staff with facial hair wear a beard restraint while preparing and serving food. 2. Observation on 2/27/24 at 8:07 AM showed cook #1 removed a glove from his left hand and used hand sanitizer before donning a new glove. Interview with the cook at 8:18 AM revealed he used hand sanitizer after removing his gloves unless his hands were visibly soiled and then he would wash them with soap and water. The hand sanitizer used was 3M Avagard and was labeled as healthcare personnel hand sanitizer. Interview with the dietitian on 2/28/24 at 4:30 PM confirmed hand sanitizer should not be used in the kitchen and removed the bottle at that time. 3. Observation on 2/26/24 at 4:04 PM showed the Traulsen freezer had opened original bags, of what appeared to be breaded meat, which was not labeled with an open or expiration date. The Continental freezer showed multiple plastic bags, with what appeared to be breaded meats, which were not labeled with an open date or an expiration date. The [NAME] upright freezer showed multiple plastic bags, both original and resealable, which were unlabeled and undated and had what appeared to be a build-up of frost. Interview with the dietitian on 2/28/24 at 4:30 PM revealed opened frozen food should be transferred to a storage bag and labeled with the open date and an expiration date of 6 months. The dietitian was unable to locate a food storage guide for staff to reference. 4. Observation on 2/26/24 at 4:04 PM showed the kitchen contained a [NAME] high-temperature dishwashing machine. Review of the December 2023, January 2024, and February 2024 CC Dishmachine Temps log sheets showed the temperature of the wash and rinse water was to be measured 3 times per day. Review of the [NAME] dishmachine manufacturer's instructions showed the minimum wash temperature was 150 degrees Fahrenheit and the minimum rinse temperature was 180 degrees Fahrenheit. The following concerns were identified: a. Review of the temperature log sheets showed the required temperature of the wash and rinse water was not documented on the form. b. Review of the December 2023 log sheet showed the temperature of the wash and rinse water was not checked 28 out of 93 opportunities. Of the 65 recorded temperatures the wash water was below 150 degrees Fahrenheit 41 times and the temperature of the rinse water was below 180 degrees Fahrenheit 21 times. c. Review of the January 2024 log sheet showed the temperature of the wash and rinse water was not checked 9 out of 93 opportunities. Of the 84 recorded temperatures the wash water was below 150 degrees Fahrenheit 38 times and the temperature of the rinse water was below 180 degrees Fahrenheit 14 times. d. Review of the February 2024 log sheet showed the temperature of the wash and rinse water was not checked 23 out of 77 opportunities. Of the 54 recorded temperatures of the wash water it was below 150 degrees Fahrenheit 26 times and the temperature of the rinse water was below 180 degrees 2 times. e. Interview with dietary aide #1 on 2/27/24 at 8:15 AM revealed she was not aware of what the temperature ranges for the dishwasher were supposed to be and only recorded the results. The dietary aide stated she had been an employee for approximately 1 month. f. Interview with the dietitian on 2/28/24 at 4:30 PM revealed it was her expectation the temperature of the wash and rinse water be monitored as directed on the log sheet. In addition, the dietitian confirmed the temperature ranges of the wash and rinse water were not readily available for staff to reference. 5. Interview on 2/27/24 at 8:18 AM with cook #1 revealed breakfast was served from 6 AM to 9 AM and was the only meal which was prepared in the facility. The hospital kitchen prepared the noon and evening meals for the residents. The hospital was located across the parking lot and the food was brought to the facility via an enclosed foodservice cart and placed on the steam table. The following concerns were identified: a. Review of the January 2024 food temperature log showed 82 out of 93 opportunities failed to show documentation of the food's temperature before it was served to residents. b. Review of the February 2024 food temperature log showed 64 out of 72 opportunities failed to show documentation of the food's temperature before it was served to residents. c. Review of the December 2023, January 2024, and February 2024 Cool Check Temp Log which was used to monitor the temperature of the juice and milk which was kept outside of the storage units during each meal. The December log sheet showed 58 out of 93 opportunities had not been recorded. The January log sheet showed 37 of 93 opportunities had not been recorded. The February log sheet showed 57 out of 78 opportunities had not been recorded. d. Observation and interview with dietary aide #1 on 2/27/24 at 8:15 AM showed the dietary aide was checking the temperature of the juice and the milk. The dietary aide stated she was unaware of when the temperature of the cold liquids should be taken and did not know where the temperatures were recorded. e. Interview with the dietitian on 2/28/24 at 4:30 PM revealed it was her expectation the temperature of the cold liquids should be obtained prior to being placed back into storage after the meal service, and the temperature of food items should be taken prior to meal service. 6. Review of the policy and procedure titled Food Service Uniforms/Grooming, last revised in 2019, showed Policy: To establish and maintain a high standard of cleanliness .Procedure: 1. Hair must be clean and neatly groomed while on duty .Hair needs to be secured in a surgical cap or hair net. 2. Mustaches should be kept to moderate length and well trimmed. Extremely long or full mustaches will not be permitted. 7. Review of the 2022 FDA Food Code showed 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. 8. According to the 2022 FDA Food Code showed 2-301.16 Hand Antiseptics. In the 2005 Food Code, the use of the term hand sanitizer was replaced by the term hand antiseptic to eliminate confusion with the term sanitizer, a defined term in the Food Code, and to more closely reflect the terminology used in the FDA Tentative Final Monograph for Health-Care Antiseptic Drug Products for OTC Human Use, Federal Register: June 17, 1994. In addition, 2-301.16 Hand Antiseptics (A) A hand antiseptic used as a topical application, a hand antiseptic solution used as a hand dip, or a hand antiseptic soap shall: (1) Comply with one of the following: (a) Be an APPROVED drug that is listed in the FDA publication Approved Drug Products with Therapeutic Equivalence Evaluations as an APPROVED drug based on safety and effectiveness; (b) Have active antimicrobial ingredients that are listed in the FDA monograph for OTC Health-Care Antiseptic Drug Products as an antiseptic handwash, . 9. According to the 2022 FDA Food Code showed 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B) After using the toilet room; (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in 2-403.11(B); (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using TOBACCO PRODUCTS, eating, or drinking; (E) After handling soiled EQUIPMENT or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; (H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands. 10. Review of the 2022 FDA Food Code showed 4-703.11 Hot Water and Chemical. Efficacious sanitization depends on warewashing being conducted within certain parameters. Time is a parameter applicable to both chemical and hot water sanitization. The time hot water or chemicals contact utensils or food-contact surfaces must be sufficient to destroy pathogens that may remain on surfaces after cleaning. Other parameters, such as rinse pressure, temperature, and chemical concentration are used in combination with time to achieve sanitization. When surface temperatures of utensils passing through warewashing machines using hot water for sanitizing do not reach the required 71ºC (160ºF), it is important to understand the factors affecting the decreased surface temperature. A comparison should be made between the machine manufacturer's operating instructions and the machine's actual wash and rinse temperatures and final rinse pressure. The actual temperatures and rinse pressure should be consistent with the machine manufacturer's operating instructions and within limits specified in §§ 4-501.112 and 4-501.113. If either the temperature or pressure of the final rinse spray is higher than the specified upper limit, spray droplets may disperse and begin to vaporize resulting in less heat delivery to utensil surfaces. Temperatures below the specified limit will not convey the needed heat to surfaces. Pressures below the specified limit will result in incomplete coverage of the heat-conveying sanitizing rinse across utensil surfaces. 11. Review of the policy and procedure titled PREPARING AND HOLDING FOODS, last reviewed in 2019, showed PROCEDURE .11. Food Items (sic) will be prepared in batches and placed on the tray line no more than 1/2 hour prior to meal service. Temperatures of foods in heated holding units are recorded previous to service of each meal, and recorded on each hour the food is held in heated holding units to insure (sic) the safety of food is maintained.