Bethesda Home Of Aberdeen

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the provider failed to ensure the staff educated the resident or resident's representative of the risk versus benefits of medications or of alternative treatments to make an informed decision for the consent for the use of psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) before they were given for two of two sampled residents (7 and 10). Findings include:1. Review of resident 2's electronic medical record (EMR) revealed that she was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease (a progressive and irreversible brain disorder that affects memory, thinking, social abilities, and body functions), unspecified psychosis not due to a substance or known physiological condition, unspecified hallucinations, delusional disorder (false beliefs and distorted views of reality), dementia (a group of symptoms affecting memory, thinking, and social abilities), depression, and anxiety disorder (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability). She was unable to make decisions regarding her medical care, and her son was her power of attorney (POA, a designated person on a legal document to act on behalf of a resident).
On 1/12/26, her mental health provider ordered aripiprazole 5 milligrams (mg) (an atypical antipsychotic medication that alters neurotransmitter activity in the brain to reduce symptoms of mental health conditions) at bedtime for hallucinations (to see, hear, smell, taste, or touch something that is not there). The first dose was given on 1/12/26 at bedtime. There was no documentation that resident 2's POA was notified about the new medication, if risks versus benefits were discussed, or if consent was obtained regarding the use of that psychotropic medication. The aripiprazole was discontinued on 2/11/26 as her hallucinations and other mental health symptoms were continuing without improvement.
2. Review of resident 7's electronic medical record (EMR) revealed that he admitted to the facility on [DATE]. His 2/20/26 Brief Interview for Mental Status (BIMS) assessment score was 3, which indicated his cognition was severely impaired. His diagnoses included anxiety disorder, symptoms and signs involving cognitive functions and awareness, delusional disorder, and dementia with behavioral disturbance.
His 3/12/26 care plan (personalized plan that addresses a resident's care needs, goals, and interventions) had a focus area that read, The resident has potential to be verbally aggressive towards residents and staff r/t [related to] Poor impulse control, with an intervention that read, Keep family and physician updated. Another focus area read, The resident uses antipsychotic medications [a drug that alters neurotransmitter activity in the brain to reduce symptoms of mental health conditions] r/t behavior management with an intervention that read, Discuss with MD [medical doctor], family re [regarding] ongoing need for use of medication. Review behaviors/interventions and alternate therapies attempted and their effectiveness per policy.
A 11/27/24 physician's order for mirtazapine (an antidepressant) 15 mg at bedtime for anxiety was received. There was no documentation that the resident's representative was notified of the new medication order, the indication for the medication, the risk versus benefits of that medication, or alternative treatments to that medication.
On 1/8/25, the mirtazapine dose was ordered to be increased to 30 mg at bedtime. There was a progress note that stated the nurse had attempted to call the resident's representative but there was no answer. There was no further documentation that the nurse reattempted to call the resident's representative or that the resident's representative returned the call.
A 2/5/25 physician's order for sertraline (an antidepressant) 25 mg every day for anxiety was received. A progress note indicated resident 7's representative was notified of the new medication but there was no documentation that the risk versus benefits or alternative treatments were addressed.
On 3/7/25, there was a physician's order to reduce resident 7's mirtazapine to 15 mg for 28 days, then 7.5 mg for 28 days, then 3.75 mg for 14 days, and then to stop the medication due to ineffective behavioral results. Resident 7's representative was documented as having been notified of this change.
On 3/17/25, there was a physician's order to increase resident 7's sertraline to 50 mg daily and started aripiprazole (Abilify, an antipsychotic medication) 5 mg at bedtime for mood and delusions. There was no documentation that the resident's representative was notified of the new medication order, the indication for the medication, the risk versus benefits of that medication, or alternative treatments to that medication.
On 4/3/25, resident 7's mirtazapine was ordered to be continued at 15 mg every day at bedtime, the scheduled reduction of that medication was to be stopped, and his Abilify was increased to 10 mg at bedtime. There was no documentation that the resident's representative was notified of the changed medication orders, the indication for the changes, the risks versus benefits of those medications, or alternative treatments to those medications.
On 4/16/25, resident 7's physician ordered to increase the Abilify to 15 mg at bedtime, decrease his mirtazapine to 7.5 mg for two weeks and then stop, and to increase his sertraline to 75 mg daily for two weeks, then increase it to 100 mg daily. Resident 7's representative was notified of the changed medication orders, but there was no documentation that resident 7's representative was informed of the indication for the changes, the risks versus benefits of those medications, or alternative treatments to those medications.
On 6/24/25, resident 7's sertraline increased to 125 mg daily. Resident 7's representative was notified of the changed medication order, but there was no documentation that resident 7's representative was informed of the indication for the change, the risks versus benefits of the medication, or alternative treatments to the medications.
On 7/17/25, resident 7's physician ordered lorazepam (an antianxiety medication) 0.5 mg every four hours as needed for anxiety and restlessness. There was no documentation that the resident's representative was notified of the new medication order, the indication for the medication, the risks versus benefits of that medication, or alternative treatments to that medication.
On 12/2/25, resident 7's Abilify was decreased to 12.5 mg at bedtime. There was no documentation that resident 7's representative was informed of the changed medication order, the indication for the change, the risks versus benefits of the medication, or alternative treatments to the medications.
On 3/5/26, resident 7's Abilify was decreased to 10 mg at bedtime. There was no documentation that resident 7's representative was informed of the changed medication order, the indication for the change, the risks versus benefits of the medication, or alternative treatments to the medications.
3. Interview on 3/11/26 at 4:36 p.m. with director of nursing (DON) B revealed that written informed consents were not obtained from a resident or resident representative before beginning a psychotropic medication. The residents' medications were reviewed with the resident or their representative upon admitting to the facility and the resident or resident's representative signed that medication list. Neither the medication list nor the residents' baseline care plan addressed the risks versus benefits of psychotropic medications.
4. Interview on 3/12/26 at 1:42 p.m. with licensed practical nurse (LPN) R revealed that when a resident had a new medication order or a change in the dose of a medication, the nurse was to call that resident's representative and notify them of the change. If the resident's representative could not be reached, that nurse would pass that on in her report to the next shift and place the order in a file folder labeled waiting for family. The next shift would then attempt to call the residents' representative to notify them of the medication order.
When LPN R called to notify a resident's representative of a new medication, she reviewed the reason the medication was being ordered, the risks of the medication, and answered any questions the resident's representative had. Once the resident's representative was notified of the new medication or change in the dosage of the medication, the notification was to be documented in the resident's progress notes under the communication with family category.
5. Interview on 3/12/26 at 1:50 p.m. with Minimum Data Set (MDS) registered nurse (RN) E revealed that the nurses were to notify the resident's representative before a psychotropic medication was started. They did not have a consent form for psychotropic medications that contained the medications' risks versus benefits review with the resident's representative. She was not aware that the regulation required the risks versus benefits and alternative treatments to the medication was to be reviewed with the resident or the resident's representative before a psychotropic medication was started.
She expected the staff to document in the resident's progress notes that they had notified the resident's representative when a new medication was started or if there was a change in that medication's dose.
She explained that resident 7's representative was difficult to reach, and he did not call the provider back after he was called. She expected the staff to document any attempts made to contact a resident's representative in that resident's progress notes.
6. Interview on 3/12/26 at 1:57 p.m. with DON B revealed that a resident or the resident's representative was to be notified if there was a new medication ordered, a dose of a current medication was changed, or if a medication was discontinued and that notification was to be documented in a progress note in that resident's EMR. She expected the nurses to discuss the risk versus benefits as well as the reason the psychotropic medication was started, or why the dose of the medication was changed with the resident or the resident's representative.
She stated they did not have a professional reference for the nurses to use when they reviewed the risks versus benefits of the psychotropic medications and alternative treatments.
She mentioned that resident 7's family was difficult to reach at times, but she expected the nurses to document their attempts to reach resident 7's representative in a progress note.
She was not aware that the regulation required the risks versus benefits and alternative treatments to be reviewed with the resident or the resident's representative before a psychotropic medication was started.
7. Further interview on 3/12/26 at 2:35 p.m. and 2:50 p.m. with DON B revealed that resident 2's POA was not too involved with her care. They left voicemails on his contact phone number because he rarely answered their calls. She confirmed that she could not find documentation showing that informed consent was obtained from resident 2's POA regarding the aripiprazole. There currently was no system in place to ensure staff were educating and obtaining informed consents from the residents and their representatives about changes in the residents' care.
8. Review of the provider's 10/5/22 Use of Psychotropic Medication policy revealed that the resident's attending physician was responsible for managing the resident's medications. The policy included that the residents and/or representatives shall be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments/non-pharmacological interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 October 2025 review revealed the provider failed to ensure staff electronically submitted Minimum Data Set Minimum Data Set (MDS) (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) assessments to the Center for Medicare and Medicaid Services (CMS) within the required 14 day time frame from the residents' discharge for three of three sampled discharged residents (33, 43, and 92).Findings include: 1. Review of resident 33's electronic medical record (EMR) revealed he was admitted to the facility on [DATE]. He was discharged to the hospital on [DATE]. His 11/4/25 discharge tracking MDS assessment was not transmitted to CMS. 2. Review of resident 43's EMR revealed she was admitted to the facility on [DATE]. She was discharged on 11/25/25 to her daughters' home. Resident 43's 11/25/25 discharge tracking MDS assessment was not transmitted to CMS.3. Review of resident 92's EMR revealed she was admitted to the facility on [DATE]. She passed away on 12/5/26 while at the hospital. Resident 92's 12/5/25 discharge tracking MDS assessment was not transmitted to CMS.4. An interview and record review on 3/11/26 at 2:52 p.m., with Minimum Data Set (MDS) registered nurse (RN) F, regarding the tracking and transmission of discharge MDS assessments revealed she was responsible for ensuring the MDS assessments were transmitted to CMS within the required time frames. She reported she used the RAI Manual Version 1.20.1 October 2025 for reference, and acknowledged she was aware of the required MDS transmission timelines, including completion of a resident's discharge MDS within fourteen days of the date of discharge and transmission to CMS within fourteen days of the MDS completion date.After reviewing the discharge MDS assessments for residents 33, 43, and 92, she confirmed that those discharge tracking MDS assessments were not transmitted to CMS. She reported she was using an electronic MDS system along with a paper cheat sheet tracking form to monitor MDS transmissions. Resident 43's 1/4/26 discharge was not added to her paper tracking form.Upon further review of the discharge MDS assessments, MDS RN F identified that resident 33's discharge MDS assessment was not completed and therefore not transmitted to CMS. She acknowledged the assessment should have been completed within seven days of resident 33's discharge from the facility.Additionally, MDS RN F reported that Resident 92 had passed away at the hospital; however, the discharge MDS assessment incorrectly indicated the resident had passed away in the facility.Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 October 2025 revealed Assessment Transmission . Tracking Information Transmission: For Entry and Death in Facility tracking records, information must be transmitted within 14 days of the Event Date (A1600 + 14 days for Entry records and A2000 + 14 days for Death in Facility records).

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (2) with dementia and episodes of hallucinations, behaviors, and agitation, had person-centered interventions included in the resident's plan of care for the staff to implement to assist the resident during those episodes to meet her dementia care needs. Findings include:1. Observation and interview on 3/11/26 at 9:44 a.m. in the Morning Dove Lounge revealed that resident 2 was sitting in a recliner. She had her left leg pulled up towards her torso, and she appeared to be trying to adjust her gripper sock or the cuff of her pants. Her walker was in front of her. She was not wearing shoes. When asked how she was doing that day, she mumbled about there being a bum on or near her left foot. She was not easily understood. She put her left foot back down on the floor, reached forward, and continued to point and readjust her pant leg while talking about the bum. 2. Interview on 3/12/26 at 12:29 p.m. with certified nurse aide (CNA) K revealed that resident 2 often wandered throughout the facility without shoes on. They helped resident 2 put gripper socks on in the mornings in case the resident decided to take her shoes off. She confirmed that resident 2 often experienced hallucinations about a lost dog or children. They would not try to bring her out of the hallucinations, instead they would validate her experience by acknowledging the dog or children that were not actually there. This helped the resident remain calm instead of worrying about the lost dog or children. 3. Review of resident 2's electronic medical record (EMR) revealed that her diagnoses included Alzheimer's disease (a progressive and irreversible brain disorder that affects memory, thinking, social abilities, and body functions), unspecified psychosis not due to a substance or known physiological condition, unspecified hallucinations, delusional disorder (false beliefs and distorted views of reality), dementia (a group of symptoms affecting memory, thinking, and social abilities), depression, and anxiety disorder (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability). Her care plan included a Background focus area that was last updated on 10/3/24 that read, [Resident 2] has been living at [a local assisted living center] since 11/10/23. In recent weeks became very paranoid / untrusting / seeing / talking to someone not there. The associated care plan goals, last revised on 9/5/25, included, Will adjust to LTC [long term care] stay and relying on others for cares as needed through next review. Will show interest in planning / organizing her daily routine through [next] review. Enjoy time with family as they visit through next review. The associated care plan interventions, all initiated on 7/18/24 and not revised since, included, Give cues, reminders, supervision and hands on direction. Keep lines of communication open with Resident / Family / Staff. Provide opportunity to plan / organize her day of offering activities which will provide opportunity to enhance her optimum level of functioning / well being in LTC. Her care plan did not include any focus areas, goals, or interventions related to her usual hallucinations or the staff's approaches to address her hallucinations. There were several progress notes that documented her hallucinations, including a 2/26/26 behavior note that read, Resident actively hallucinating this shift. Seeing children and becoming agitated when staff doesn't acknowledge them. Loudly saying, 'open your eyes boys and girls, your parents are here.'. Her 2/23/26 quarterly Minimum Data Set (MDS) assessment included that she experienced hallucinations and delusions. Her Brief Interview for Mental Status (BIMS) assessment score was 3, which indicated that she had severe cognitive impairment. Her 6/16/25 annual MDS assessment Care Area Assessment worksheet included that she had Long-standing mental health problem associated with the behavioral disturbances, such as schizophrenia, bipolar disorder, depression, anxiety disorder, post-traumatic stress disorder, Delusions, and Hallucinations. The care plan considerations associated with those conditions read, Delusions and hallucinations have been observed. [Diagnoses] of anxiety and depression and on [medications] for [the] same. Does follow with [local psychiatric provider.] 4. Interview on 3/12/26 at 3:11 p.m. with social services director W revealed that she and the other social worker were responsible for the behavior portion of a resident's care plan. However, they reviewed and revised each resident's care plan as an interdisciplinary team. If a resident had hallucinations, she said, We might put a history of hallucinations. She confirmed that resident 2's care plan did not include interventions for the staff to consider when the resident was experiencing her hallucinations. Resident 2's care plan did include, however, that she had a history of paranoia and seeing things that are not there. She expected staff to utilize the resident's care plan, the electronic medical record, and for other experienced staff to know how to take care of each resident. 5. Review of the provider's 4/2019 Comprehensive Care Plans policy revealed that the policy statement read, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident.that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The policy included utilizing the comprehensive MDS assessment and all triggered Care Area Assessments when developing the comprehensive care plan. One of the topics described to be included in each comprehensive care plan included, The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, record review, interview, and policy review, the provider failed to ensure the staff followed nursing professional standards related to following physician orders regarding blood glucose monitoring and physician notification for one of one sampled resident (3) who had low blood sugar levels, and oxygen saturation (percentage of oxygen in the blood) monitoring for one of one sampled resident (32) with physician's orders to keep her oxygen saturation levels above 90 percent. Findings include: 1. Interview on 3/10/26 at 3:00 p.m. with resident 3 revealed he received insulin. He had a history of low blood sugar levels in the mornings. He mentioned that he did not feel any different when his blood sugar level was low. The staff usually gave him a glass of juice if his blood sugar was low. Sometimes, his blood sugar level got as low as 50 to 57 (milligrams per deciliter, mg/dL) in the mornings. 2. Review of resident 3's electronic medical record (EMR) revealed he had a diagnosis of Type 2 Diabetes Mellitus (a condition involving disruptions in how the body regulates blood sugar) with diabetic chronic kidney disease. He had a current 3/2/26 physician's order for Accuchecks [a brand of blood glucose monitoring systems] BID [twice per day] [notify] Dr. [doctor] if BS [blood sugars] [are] less than 70, or greater than 400 two times a day. His previous order for blood sugar level checks read, Accuchecks BID Dr. if BS less than 70, or greater than 400 every morning and at bedtime. That order was active from 9/2/25 through 3/2/26. On 2/8/26 his blood sugar was 55 mg/dL, on 2/7/26 his blood sugar was 59 mg/dL, and on 10/16/25 his blood sugar was 65 mg/dL. There was no documentation that his physician was notified of those low blood sugar levels. 3. Interview on 3/12/26 at 4:08 p.m. with LPN T revealed that if a resident's blood sugar fell below or above specified parameters, the resident's physician was to be notified. 4. Interview and record review on 3/12/26 at 4:10 p.m. with staff education director/infection preventionist U revealed that she confirmed there were no physician notifications for the above-listed dates. She said that she talked to the nurse that was on shift those days, and that nurse informed her that resident 3 also experienced low blood sugars on 2/2/26, 2/3/26, and 2/4/26. She notified the physician of those low blood sugars, and the physician did not change any interventions. The nurse told staff education director/infection preventionist U that she did not notify resident 3's physician on 2/7/26 and 2/8/26 because she did not think he would change any of the resident's interventions or provide further direction to address resident 3's low blood sugar levels. 5. Interview on 3/12/26 at 4:11 p.m. with DON B revealed that she expected the staff to notify the residents' physician each time the blood sugars were out of the specified ranges according to the physician's orders. 6. Review of the provider's 7/28/23 Glucometer Standards (Assure Pro) policy revealed that critical high and low tests of residents will be managed according to their physician's orders. The instructions read, Check each resident's [parameter] and report per physician's order. 7. Review of the provider's 5/24/23 Physician Notification Policy revealed that it is the policy of this facility to timely notify the physician.of changes in resident condition. The policy defined promptly as results shall be relayed with little or no delay to the ordering physician. The policy explanation included, The facility must promptly notify the attending physician. of changes in resident condition that falls outside the 'normal' range for that specific resident, in accordance with facility policies and procedures. Delayed notification may contribute to delays in changing the course of treatment or care plan. 8. Observation on 3/11/26 at 9:03 a.m. in resident 32's room revealed that there was an oxygen concentrator machine (a device that filters room air into purified oxygen) at the foot of her bed. The machine was turned on, but no one was in the room using it. 9. Review of resident 32's EMR revealed that she had a 6/3/25 physician's order for O2 [oxygen] at 2L [liters] via nasal cannula [flexible tubing with prongs that delivers oxygen through the nose] to keep sats [saturation; percentage of oxygen in the blood] above 90% [percent] every morning and at bedtime related to ACUTE RESPIRATORY FAILURE WITH HYPOXIA [low oxygen levels in the body]. Resident 32's medication administration record, treatment administration record and record of vital signs (measurements of the body's basic functions, such as temperature, blood pressure, pulse, and respiration rate) documentation indicated that her blood oxygen saturation was last documented as measured on 3/1/26. From 1/1/26 to 3/11/26, her blood oxygen saturation levels were documented as measured a total of six times. Her care plan included a 4/29/25 intervention that read, OXYGEN SETTINGS: O2 via nasal [cannula] @ [at] 2L at night and when sleeping. 10. Interview on 3/11/26 at 3:39 p.m. with registered nurse (RN) Q revealed that a resident's blood oxygen saturation was to be monitored more frequently if the oxygen flow rate was adjusted. If the resident asked for oxygen, she expected the resident's blood oxygen saturation level to be measured before administering oxygen and rechecked an hour later. 11. Interview on 3/11/26 at 3:42 p.m. with LPN S revealed that resident 32 usually received oxygen with the use of the oxygen concentrator at night. 12. Interview on 3/11/26 at 3:51 p.m. with RN Q revealed that she reviewed resident 32's EMR and confirmed that the resident's oxygen order in the EMR system did not include blood oxygen saturation checks. 13. Interview on 3/11/26 at 4:01 p.m. with DON B revealed that she expected the staff to monitor and measure a resident's blood oxygen saturation levels according to the physician's orders. She expected the staff to measure resident 32's levels before she went to bed each night. She confirmed staff was not doing that. 14. Review of the provider's 12/10/24 Oxygen Administration policy revealed that the resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as. Monitoring of SpO2 (oxygen saturation) levels and/or vital signs, as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the provider failed to ensure pressure injury prevention interventions were identified and implemented for one of one sampled resident (70) who developed a deep tissue injury (DTI) (a pressure ulcer/injury with purple or maroon discolored skin and underlying soft tissue damage, caused by intense, prolonged pressure) on her right heel. Findings include: 1. Observation and interview on 3/10/26 at 2:35 p.m. with resident 70 while she was in her room watching television, revealed that her bed was located next to the window. She had hard surface protective boots on both her lower legs and feet. There were Velcro straps that were wrapped around her lower legs, holding those boots in place. She stated that she had multiple sclerosis (a condition where the immune system attacks the nervous system, causing damage and scar tissue) and that she had a left heel pressure injury that developed before she was admitted to this facility from another long-term care facility. After she was admitted to this facility, she received a protective boot for her left foot and heel. Resident 70 stated she then developed a pressure injury to my right heel. She reported that 24/7 (twenty-four hours a day, seven days a week) continuous boot use on her left foot and the involuntary movement of her left leg while in bed caused friction between her right and left heels, which she believed contributed to the development of the pressure injury on her right heel. The resident stated that the left heel injury had healed. 2. Observation and interview on 3/12/26 at 1:31 p.m. with resident 70 revealed resident 70 was in her room, sitting in her wheelchair, sorting through clothes, with tennis shoes on both of her feet. Resident 70 stated that she had attended a wound care appointment earlier that day, and that the wound care staff informed her that her left heel was healed. Her right heel would only need iodine on the scab until it falls off, and no dressing was required for her right heel at this time. Resident 70 stated she was instructed to continue to wear both protective boots when in bed and occasionally during the day. Resident 70 stated that when she was in bed, she was able to adjust her upper body using the grab bar (bar attached to the bed) located on the left side of her bed and by holding onto the windowsill on the right side. She said that she could not independently reposition her lower body and that her legs occasionally had muscle spasms. She was able to feel the pressure injury on her right heel and stated that it hurt. 3. Review of resident 70's electronic medical record (EMR) revealed she was admitted to the facility on [DATE]. Her Brief Interview of Mental Status (BIMS) assessment score was a 15, which indicated her cognition was intact. Her diagnoses included: Multiple Sclerosis (MS), paraplegia (the loss of motor and sensory function in the lower body), muscle wasting and atrophy (wasting of muscle tissue, leading to reduced size, weakness, and limited mobility) of the right and left thighs and lower legs, and muscle weakness. Her 1/21/26, 2/4/26, and 2/11/26 Braden Scale (a tool used to assess the risk of developing pressure ulcers) assessment scores were all 19, which indicated she was not at risk for the development of a pressure injury. There were no further documented Braden Scale assessments after 2/11/26. Resident 70's Wound-Weekly Observation Tool assessments revealed that on 2/5/26, she had developed a facility acquired, Type [of wound]: pressure to her right heel. The assessment identified the Pressure Ulcer Stage as a suspected DTI (SDTI). The wound measurements were 22 millimeters (mm) by 32 mm, with no depth recorded. The peri-wound tissue (the skin surrounding a wound edge) was described as Pink, dry, intact. The treatment was Foam dressing weekly et [and] Multipodus boot [a specialized, rigid orthopedic device designed to prevent and correct pressure ulcers [injury] in bedridden or immobile patients]. On 2/9/26 the measurements of her SDTI were 20 mm x 30, with no depth recorded. The treatment was Foam dressing weekly et Multi-podus boots. Resident 70's 3/9/26 right heel SDTI measurements were 15 mm x 25 mm, with no depth recorded. The SDTI was described as Pink, dry, intact. Treatment was Foam dressing et Multi-podus boots to BLE [bilateral lower extremities]. The wound was described as Wound is [the] same in size as [the] previous week's measurement. Scab is starting to lift up around the edges. Will continue ordered tx [treatment] and to monitor. Resident 70's 1/19/26 Dietitian Nutritional Assessment, completed by Registered Dietitian Nutritionist (RDN) X, indicated she had a pressure injury to her left heel and resident reports her legs are 'too weak' to return [to her home]. Resident does have history of MS, and Resident does have [a] history of MS and endorses lower extremity weakness. Will communicate [the] addition of 1 oz [ounce] of Prosource daily to CDM [certified dietary manager]. Her 2/10/26 Dietitian Nutritional Assessment indicated writer [RDN] was also notified of SDTI to [the] right heel that was identified by resident [70's] nurse. 4. An interview on 3/12/26 at 1:45 p.m. with certified nursing assistant (CNA) K regarding resident 70's right heel SDTI injuries revealed that when she arrived at work in the morning, resident 70 typically had her protective boots on her feet. CNA K stated that she would then remove the boots and place shoes on resident 70 so the resident was able to use a sit-to-stand lift (a mechanical lift used to assist from a seated to a standing position) to go into the bathroom. Afterward, resident 70 was assisted into a wheelchair using the sit-to-stand lift, and the protective boots were then placed back on her feet. CNA K reported that resident 70 was able to use her call light. She stated that the staff repositioned residents and attempted to offload resident 70's heels; however, resident 70 would sometimes allow the staff to offload her heels, and at other times she refused. Resident 70's left leg would sometimes twitch when a staff member was applying her protective boots. 5. An interview on 3/12/26 at 2:00 p.m. with registered nurse (RN)/resident care coordinator (RCC) H regarding resident 70's heel pressure injuries revealed that resident 70 was admitted to the facility with a pressure injury to the left heel and was referred to wound care, who ordered a boot for the resident's left heel. Resident 70 wore a foam boot on the left heel until the Podus boot (an orthopedic device with a rigid outer frame and a soft, often removable, liner that keeps the ankle in a neutral position while elevating the heel to eliminate pressure) arrived. RN/RCC H was unable to recall when the Podus boot arrived. RN/RCC H reported that the pressure injury on resident 70's right heel was identified as a facility-acquired SDTI, which she attributed to the resident sitting in her wheelchair, wearing shoes, and having a diagnosis of MS. At that time, resident 70 was wearing a shoe on the right foot. RN/RCC H stated that a Podus boot for the right foot was subsequently ordered. Before that, interventions included the use of skin preparation and a foam dressing. RN/RCC H reported that resident 70 could reposition and move her legs while she was in her bed and that her legs were floated (the process of elevating the legs off the bed to remove contact, ensuring they do not bear weight) when she was in her bed to reduce pressure to her heels. 6. Review of the provider's revised 6/1/22 Pressure Injury Prevention and Management policy revealed Licensed nurses will conduct a pressure injury risk assessment, using the Braden Scale, on all residents upon admission/re-admission within 24 hrs [hours], weekly x [times] four weeks, after a change of condition, after any newly identified pressure injury, and quarterly. Review and revise Care Plan with needed interventions . Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). Interventions will be documented in the care plan and communicated to all relevant staff. In the absence of prevention orders, the licensed nurse will utilize nursing judgement in accordance with pressure injury prevention guidelines to provide care, and will notify [the residents'] physician to obtain orders as needed. 7. Review of the provider's 2025 Pressure Injury Prevention Guidelines revealed Use positioning devices or folded linens to keep body surfaces from rubbing against one another. Consider use of prophylactic dressings for prevention of sacral and heel pressure injuries. Ensure that heels are floated off the surface of the bed, using pillows or devices that elevate and offload the heel in such a way as to distribute the weight of the leg along the calf without placing pressure on the Achilles tendon [a tendon connecting calf muscles to the heel bone]. 8. Interview, record review, and policy review, on 3/12/26 at 2:09 p.m. with director of nursing (DON) B revealed resident 70 was admitted to the facility with a SDTI on her left heel. Resident 70 had developed a facility-acquired SDTI on her right heel shortly after she was admitted . She stated the Braden Scale assessments were completed when a resident was admitted to the facility and then weekly for the next three weeks, if they had a pressure injury or a significant change in condition, each quarter, when they returned from hospitalization, and when a resident developed a new pressure injury. After DON B reviewed the providers Pressure Injury Prevention and Management policy and the Pressure Injury Prevention Guidelines policy she stated she expected a resident's Braden Scale assessment to be completed with every new pressure injury, and weekly until the pressure injury was healed. After reviewing resident 70's 2/11/26 Braden Scale assessment, she agreed that question 1's answer to Ability to respond meaningfully to pressure-related discomfort was incorrect and should have been coded at least slightly limited impairment. She stated, Even her diagnoses would have indicated that. She indicated question 8 Friction & [and] . was coded incorrectly and should have been coded as Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation leads to almost constant friction. She stated that resident 70 was unable to move independently in bed, and in hindsight, maybe [we] should have ordered two [Podus boots] to begin with. She confirmed resident 70's left side Podus boot could have rubbed her right heel if resident 70's leg spasmed when she was in bed. After reviewing resident 70's care plan, DON B confirmed that resident 70's care plan should have included the necessary care she required, and her care plan had not included her not being able to reposition her legs, the use of Podus boots, or that her heels were floated. She stated that pressure injuries are typically included in the residents' care plans. She indicated RN/RCC H was responsible for updating resident 70's care plan, or that RN/RCC H should have asked MDS RN F for help in updating it. DON B stated, We should have been repositioning [resident 70], and we do have pressure-reducing mattresses, or pillows.

Based on observation, interview, and record review, the provider failed to ensure the menu serving sizes and therapeutic diet menus were created and followed regarding:*One of one chef (P) failed to follow the menu serving sizes for each resident who was offered food at the facility for one of two observed meal services.*Nine of nine sampled residents (1, 7, 15, 17, 42, 48, 53, 75, and 90) who were prescribed a NAS (no added salt) diet, and eighteen of eighteen residents (9, 20, 21, 23, 27, 32, 33, 40, 41, 46, 50, 57, 63, 68, 71, 78, 79, and 87) who were prescribed a Heart healthy diet, and did not have their therapeutic diet created or followed. Findings include:1. Observation on 3/12/26 at 8:41 a.m. in the kitchen of chef P revealed he was serving breakfast from a steam table. He served ham and cheese egg scramble with a green-handled #12 scoop, and breakfast potatoes with a pair of tongs. There was a meal ticket printer that printed the residents' meal choices. Those meal tickets included the menu item, but not the serving sizes. 2. Review of the provider's menu and recipe binder at that time revealed that the serving size for the ham and cheese egg scramble was four ounces. The binder did not include a recipe or serving size for the breakfast potatoes. 3. Interview on 3/12/26 at 8:51 a.m. with chef P revealed that the facility did not have a chart noting scoop sizes. He said that they just have to know the amounts. He said he believed the green #12 scoop that he was using for the ham and cheese egg scramble was about four ounces. 4. Interview on 3/12/26 at 8:54 a.m. with culinary managers C and D revealed that they confirmed there was no conversion chart referencing scoop sizes. The green #12 scoop was three ounces, not four ounces. At that time, the survey team requested a copy of the menu with serving sizes for each meal during the survey week. Culinary manager D said they did not have menus with serving sizes listed because the serving size information was listed in each recipe within the menu and recipe binder. Record review and interview at that time with culinary managers C and D revealed that there were no recipes included in that binder for the breakfast potatoes, baked beans (on the menu for lunch on 3/12/26), and minestrone soup (on the menu for lunch on 3/12/26). Culinary managers C and D were not aware that those recipes were not included in the menu and recipe binder. Culinary manager D said the staff use iPads to order the residents' meals within a software program that, instead of listing serving sizes, tells the staff if the residents exceeded their allotted nutritional count for that meal. They confirmed that residents on therapeutic diets, such as a diabetic diet, heart healthy diet, or low sodium diet, all received the same menu as the regular diet. 5. Continued interview on 3/12/26 at 9:16 a.m. with culinary managers C and D revealed that it was standard for the staff to use the green scoop when serving the ham and cheese egg scramble. Culinary manager D confirmed the staff should have used a four-ounce scoop instead. They confirmed that using tongs to serve the breakfast potatoes was not the best choice as they could not verify the quantity served. 6. Review of the provider's menu for breakfast on 3/12/26 revealed the serving sizes were hand-written on the menu. The menu included four ounces of ham and cheese scramble, three ounces of breakfast potatoes, seven ounces of apple juice, one muffin, three-fourths cup of oatmeal, and seven ounces of milk. 7. Review of the provider's 11/11/25 dietitian-signed menu revealed that the following therapeutic diets were available: pureed, mechanically altered, gluten free, renal, and carbohydrate controlled. There was no menu for a heart healthy or no added sodium diets. 8. Review of the diet type report revealed that residents 1, 7, 15, 17, 42, 48, 53, 75, and 90 were prescribed a NAS (No Added Salt) diet, and residents 9, 20, 21, 23, 27, 32, 33, 40, 41, 46, 50, 57, 63, 68, 71, 78, 79, and 87 were prescribed a Heart healthy diet.

Based on observation, interview, record review, and policy review, the provider failed to ensure the staff followed food safety standards to:*Maintain a clean and sanitary food service environment in one of one main kitchen and one of one activity room kitchenette.*Store raw meat to prevent potential cross-contamination in one of one walk-in cooler.*Label and date bulk food ingredients in one of one activity room kitchenette according to the provider's policy.*Ensure one of one activity room dishwasher used for special events reached the temperature required for sanitizing residents' drinkware and dishes.*Ensure hand hygiene (washing hands or using hand sanitizer) was performed after direct contact with soiled surfaces and resident equipment by certified nurse aide (CNA) (M) before the CNA poured water into glasses for three of three sampled residents (1, 19, and 67) during one of two observed meal services. Findings include: 1. Observation on 3/10/26 at 8:35 a.m. in the dining room revealed the popcorn machine was sitting in the bar area. The machine had leftover popcorn kernels in the bottom of the basin and the kettle had a black burnt-on oily residue.
Observation during the initial kitchen tour on 3/10/26 from 8:41 a.m. to 9:16 a.m. revealed there was limescale buildup in the dishwasher. There was a crusty white residue that had built up on the wash arms, inside the doors, and within the door seams of the dishwasher.
The handwashing sink in the dishroom appeared stained and had food debris in the basin and in the drain.
The walk-in freezer floor was made of stainless steel. Some areas of the floor had turned black with a buildup of an unknown residue. There was a collection of empty food packaging, food crumbs, and dirt on the floor.
There was an opened bag of diced onions in the walk-in cooler that did not have an open date on it to indicate when the bag was opened.
There was a metal rack of raw meat in the walk-in cooler. There were two 10-pound tubes of ground beef on the top shelf, four packages of beef stew meat on the middle shelf, and at least three cases of raw pork loin chops on the bottom shelf.
There was a missing ventilation hood panel above the cooking equipment in the kitchen.
There was a beverage station in the dining room. The coffee dispenser had limescale buildup on the spouts. The juice dispenser had an unidentified black substance buildup near the spouts, and the refrigeration vents had a buildup of dust.
2. Observation on 3/10/26 at 12:04 p.m. during lunch service in the main dining room revealed that certified nurse aide (CNA) M was assisting residents into the dining room for the noon meal. She assisted resident 1 to her table in the dining room by pushing her wheelchair. CNA M then knelt down on the dining room floor, unlocked resident 1's wheelchair foot pedals, moved them back, and adjusted resident 1's feet under the table. CNA M then stood and, without performing hand hygiene, picked up resident 1's water glass from the table and poured a glass of water for resident 1. CNA M then picked up resident 67's water glass from the same table and poured him a glass of water. She did not perform hand hygiene after pouring water and exited the dining room.
At 12:15 p.m., CNA M returned to the main dining room, pushing resident 19's wheelchair. She assisted resident 19 to her table, touched her right foot pedal lock to adjust it, but resident 19 refused to have her foot pedals adjusted. Then, without performing hand hygiene, she picked up resident 19's water glass from the table and poured a glass of water for her. She did not perform hand hygiene after pouring the water and then exited the dining room.
3. Observation on 3/11/26 at 9:35 a.m. in the activity room kitchenette revealed the microwave had splatters of crusted food on the inside.
There were two containers labeled Sugar and Flour in the cupboards. Neither container was labeled with the date it was filled. There was a spoon sitting within the sugar inside the sugar container.
There was a standard household model dishwasher. It was an ASKO brand, and the model number was D5424. There were several different program options, including Daily wash, Heavy wash, Normal wash, Eco wash, Quick wash, and Rinse & [and] Hold. There were two additional options to choose from, including High temperature and Long dry. There were dishes inside the dishwasher, including coffee cups, a metal mixing bowl, a glass measuring cup, a crockpot ceramic bowl, a glass crockpot lid, and metal eating utensils like forks and spoons.
4. Interview on 3/12/26 at 8:32 a.m. with culinary associate V revealed that she had worked at the facility for about three months. At the end of each shift, they wiped down the outside of the beverage dispensers in the dining room, but she was never instructed to take the machines apart to clean the inside or the dispenser spouts.
5. Observation on 3/12/26 at 8:56 a.m. in the walk-in cooler revealed that the meat shelf had more meat on it than the observation on 3/11/26 during the initial kitchen tour. The top shelf had one 10-pound tube of raw ground beef. The tube of beef was sitting in a reddish puddle of liquid. Directly below that shelf, there was a container of raw turkey roast that was thawing in a pan. Directly below that shelf, there were two additional packages of raw turkey roast. Directly below that shelf, there were packages of raw beef stew meat. The sheet pan that the packages of raw beef stew meat were sitting on had a large puddle of red liquid. Directly below that shelf, there was a case of raw pork loin chops.
6. Interview on 3/12/26 at 8:57 a.m. with chef P revealed that raw poultry was supposed to be on the bottom shelf. Meats like fish were supposed to be at the top. He believed that raw ground meats, like the tube of ground beef in the cooler, could be stored above whole cuts of meat like the pork loin chops. He was not aware that whole cuts of meat were supposed to be stored above ground meats.
When asked about cleaning tasks in the kitchen, chef P mentioned that each chef position was assigned cleaning duties daily. There was an additional cleaning checklist that any staff member could choose from to clean. He did not know how often the dishwasher was delimed. He confirmed that the freezer floor was usually swept, but he was not aware if there were any specific chemicals used to scrub or mop the freezer floor.
When looking at the cleaning checklists, he confirmed that sweeping or cleaning the freezer was not included on the list.
7. Review of the above-described cleaning checklists revealed that there was one chef cleaning checklist, and one additional cleaning checklist that did not include the frequency expectations of the cleaning tasks.
The March 2026 chef cleaning checklist included different tasks to complete Monday through Friday. The freezer, beverage dispensers, and dishwasher were not included on that list.
The undated Cleaning Task checklist included various cleaning tasks in the kitchen and dining room. The handwashing sink in the dish room was marked as last cleaned on 12/24/25. The dishwasher was marked as last delimed on 1/5/26. The juice and coffee dispensers were marked as last cleaned on 1/6/26. There was a task item listed to Sweep/Mop walk in fridge but no tasks listed for cleaning the walk-in freezer.
8. Interview on 3/12/26 at 9:16 a.m. with culinary managers C and D revealed that staff should be sweeping the floors daily, and mopping the freezer floors monthly. They had a special chemical to mop the freezer floor.
They expected the staff to delime the dishwasher every other week. Culinary manager D printed out a new dishwasher deliming schedule and posted it in the dish room for their main commercial dishwasher in the kitchen. Staff delimed the dishwasher the day before, and she commented that she did not know when the dishwasher was last delimed. They were not aware that the cleaning checklist indicated the main commercial dishwasher in the kitchen was last delimed in January 2026.
Culinary manager C confirmed that raw poultry should be on the bottom shelf, then ground meats above that, then other meats like the beef stew meat above the ground meats, and fish at the top. Neither culinary manager C nor D were aware that the raw meat in the walk-in cooler was not stored that way.
Culinary manager C said that the dishwasher in the activity room kitchenette was the responsibility of the activity department. They did not know if that style of dishwasher was capable of sanitizing dishes.
9. Interview on 3/12/26 at 10:25 a.m. with activities director I revealed that they used the household model dishwasher in the kitchenette to clean residents' coffee cups, happy-hour dishes like glasses, forks, and spoons, and other dishes used when baking treats for residents. The dishes cleaned in that dishwasher did not come into contact with TCS foods (time/temperature control for safety). She was not aware if that dishwasher was capable of sanitizing dishes or not. She used the generic brand of dish detergent pods and ran the dishwasher like normal. She did not know if the detergent pods contained chemicals for chemical sanitization.
She said the popcorn machine was cleaned each time it was used. They usually just wipe it all out.
The activities staff were responsible for monitoring and maintaining the food ingredients in the activity room kitchenette. She said that they did not usually store the scoop in the bulk ingredient containers. She was not aware that there was a spoon stored in the bulk sugar container. She was not aware of when those bulk ingredients were last filled, or when the containers were last cleaned. She indicated that activities staff and sometimes residents' family members would use the ingredients in the kitchenette to make treats for residents.
10. Review of the provider's dish detergent pods used for the activity room dishwasher revealed it did not contain any chemicals used for chemical sanitization of dishes.
11. Interview on 3/12/26 at 11:08 a.m. with culinary manager D revealed that a high-temperature commercial dishwasher needed to reach at least 180 degrees Fahrenheit to sanitize the dishes. She was not aware if the dishwasher in the activity room kitchenette had the capability to sanitize dishes.
12. Review of the owner's manual for the ASKO D5424ADA W/B/S dishwasher revealed that the maximum temperature reached during any of the wash and rinse cycles was 150 degrees Fahrenheit. When using the High temperature option, the maximum rinse temperature reached was 160 degrees Fahrenheit, but only for the Heavy wash cycle. The owner's manual did not include information on whether it had the capability to sanitize dishes.
13. Interview on 3/12/26 at 11:18 a.m. with administrator A revealed that the dishwasher in the activity room kitchenette did not reach 180 degrees according to the owner's manual. They did not have a way to monitor the maximum water temperature for that dishwasher. He confirmed items like resident coffee cups and happy hour dishes were cleaned in that dishwasher. The dishes cleaned in that dishwasher did not come into contact with TCS foods (time/temperature control for safety). There were no current respiratory or gastrointestinal infectious disease outbreaks in the facility. If the staff could not use that dishwasher for whatever reason, they had two backup dishwashers: one in the main kitchen, and one in the attached child daycare facility.
14. Interview on 3/12/26 at 4:15 p.m. with director of nursing (DON) B revealed that she expected the staff to perform hand hygiene before and after direct resident contact, after direct contact with resident equipment, and before assisting residents with a meal service. DON B acknowledged that hand hygiene should have been performed by CNA M before and after resident contact to help prevent the transmission of infection.
15. Review of the provider's revised 4/3/20 Hand Cleansing policy revealed that the staff should wash hands before and after resident contact. The policy described hand hygiene to be the primary means of preventing the transmission of infection. Staff should cleanse their hands before and after direct resident contact, before and after eating or handling food, before and after assisting a resident with meals, and after handling soiled equipment or utensils.
16. Review of the 2022 Food and Drug Administration (FDA) Food Code found at https://www.fda.gov/food/fda-food-code/food-code-2022 revealed that, Equipment food-contact surfaces and utensils shall be sanitized. Methods for sanitization include using hot water or chemicals. After being cleaned, equipment food-contact surfaces and utensils shall be sanitized in: .(B) Hot water mechanical operations by being cycled through EQUIPMENT that is set up as specified under [Sections] 4-501.15, 4-501.112, and 4-501.113 and achieving a UTENSIL surface temperature of 71 [degrees Celsius] [160 degrees Fahrenheit] as measured by an irreversible registering temperature indicator.
Section 4-501.112 includes requirements for Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. The temperature of hot water delivered from a warewasher sanitizing rinse manifold [a central component or pipe fitting that consolidates, distributes, or controls the flow of fluids between multiple sources and destinations] must be maintained according to the equipment manufacturer's specifications and temperature limits specified in this section to ensure surfaces of multiuse utensils such as kitchenware and tableware accumulate enough heat to destroy pathogens that may remain on such surfaces after cleaning.
The surface temperature must reach at least 71 [degrees Celsius] (160 [degrees Fahrenheit]) as measured by an irreversible registering temperature measuring device to affect sanitization. When the sanitizing rinse temperature exceeds 90 [degrees Celsius] (194 [degrees Fahrenheit]) at the manifold, the water becomes volatile [unstable] and begins to vaporize reducing its ability to convey sufficient heat to utensil surfaces. The lower temperature limits of 74 [degrees Celsius] (165 [degrees Fahrenheit]) for a stationary rack, single temperature machine, and 82 [degrees Celsius] (180 [degrees Fahrenheit]) for other machines are based on the sanitizing rinse contact time required to achieve the 71 [degrees Celsius] (160 [degrees Fahrenheit]) utensil surface temperature.
17. Review of the provider's 11/11/25 Cleaning Dishes in Dish Machine policy revealed that All flatware, serving dishes, and cookware will be cleaned, rinsed, and sanitized after each use.
18. Review of the provider's 2021 Deliming Dish Machines policy revealed that the dishwasher was supposed to be delimed twice a month.
19. Review of the owner's manual for the main dishwasher in the kitchen revealed that the manufacturer recommended your dishwasher should be de-limed regularly; how often will depend on the mineral content of your water. The weekly maintenance checklist included clean accumulated lime deposits from the wash tank heating element.
20. Review of the provider's 2021 Cleaning Instructions: Coffee, Beverage, Juice, Frozen Yogurt, or Ice Cream Machines policy revealed the coffee machine was to be cleaned weekly by following the manufacturer's instructions, and the juice dispenser should be cleaned by disassembling the parts, running them through the dishwasher, and allowing them to air dry before reassembling. The outside of the machines should be cleaned with cool water and a cleaning solution. The policy indicated to follow the juice dispenser manufacturer's instructions.
21. Review of the provider's 2021 Food Storage policy revealed that food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination.
The policy indicated that plastic containers with tight-fitting covers or sealable plastic bags must be used for storing.sugar.and broken lots of bulk foods or opened packages. All containers or storage bags must be legible and accurately labeled and dated.
In reference to storing meats, the policy included raw animal foods should be separated from each other and stored on lower shelves (below cooked foods or raw fruits and vegetables) and in drip proof containers. The policy did not indicate in what order the raw animal meats should be stored.
22. Review of the provider's 2021 Cleaning Instructions: Freezers policy revealed that freezers will be cleaned on a regular basis. Debris should be removed by sweeping. The floors were to be mopped using floor cleaner for below 0 [degrees Fahrenheit].
23. Review of the provider's 6/1/24 Popcorn Machine Cleaning Policy revealed that the purpose of the policy was to ensure that all popcorn machines are cleaned regularly and properly to maintain food safety, equipment performance, and a sanitary environment for customers and staff. The policy indicated that the activities staff were responsible for cleaning and maintaining the popcorn machine.
The policy indicated that the popcorn machine must be cleaned after each use by removing unpopped kernels and popcorn debris, wiping the interior surfaces and glass panels, cleaning the kettle exterior, emptying and cleaning the crumb tray, and wiping all interior and exterior surfaces. On a weekly basis, the staff were to perform a deep cleaning of the kettle and interior surfaces, and inspect for grease buildup and remove as needed.
24. Review of the provider's infection control program binder revealed no current resident cases of any respiratory or gastrointestinal infections or symptoms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to develop in collaboration with hospice a comprehensive care plan for one of one resident (288) who received oxygen and hospice services. Findings include:
1. Observation and interview on 11/19/24 at 9:42 a.m. with resident 288 in her room revealed:
*She was short of breath, spoke softly, and was wearing oxygen nasal cannula tubing (tubing with nasal prongs) on her face.
*There was an oxygen concentrator (a device that delivers concentrated oxygen) with a humidifier attached to it. The oxygen flow rate was set at 5 Liters (L) per minute.
*A portable oxygen tank was on the back of her wheelchair.
2. Review of resident 288's electronic medical record (EMR) revealed:
*Resident 288 had been admitted on [DATE] from home with continued hospice services.
*Her diagnoses included malignant neoplasm of unspecified bronchus or lung, chronic obstructive pulmonary disease, chronic kidney disease, and other forms of dyspnea.
*There was a physician's order dated 11/7/24 for O2 [oxygen] [with a flow rate of] 1 5L/N/C [liters via nasal cannula] every morning and at bedtime for comfort.
3. Interview on 11/21/24 at 8:40 a.m. with certified nursing assistant I revealed:
*She confirmed that resident 288 was receiving hospice services.
-She knew how to care for residents receiving hospice services because the nurse reviewed that information with her before each shift.
*Her worksheet and the care plan in the provider's EMR also provided information about how much assistance a resident needed for transfers and personal care.
*Hospice provided a bath to residents once a week.
*She was unable to locate a hospice care plan for resident 288.
4. Review of resident 288's current care plan revealed:
*Focus area: SOB [short of breath] with resting, exertion and laying flat [Resident 288] was admitted on hospice from home.
-Intervention: O2 [oxygen] continuously.
*Focus area: Resident and family have opted for hospice benefits and comfort care only.
-Intervention/Task: Keep family and hospice involved in care planning and decision making as well as updated on any changes in conditions or orders.
*The care plan did not include:
-The type of oxygen delivery systems used by the resident included continuous oxygen via nasal cannula from an oxygen concentrator with a humidifier, nebulizer treatments, and a portable oxygen concentrator.
-The frequency of cleaning and that equipment and changing the oxygen tubing and humidifier.
-That resident 288 required assistance administering her nebulizer treatments.
-Equipment settings for the prescribed flow rate.
-Monitoring of SpO2 (oxygen saturation) levels and/or vital signs, as ordered.
-Monitoring for complications associated with the use of oxygen.
-Goals integrated from an updated hospice plan of care when the resident moved from her private residence to the facility.
-The services and equipment that hospice was providing to the resident.
5. Review of the hospice binder at the north nurse's station regarding resident 288 revealed:
*It contained information about which nurse was assigned to resident 288 and instructions for when and how facility staff were to contact hospice.
*The hospice plan of care was not located in that binder.
*There was no documentation of the resident's oxygen needs or interventions in that binder.
6. Review of resident 288's paper Hospice Plan of Care provided upon request revealed:
*It had not been uploaded into resident 288's electronic medical record.
*Location Type: Private Residence.
*Service Location Home.
*Start of care date 09/22/2024.
-Resident 288 was admitted to the facility on [DATE].
*Oxygen; 1 ea [each] as directed; Instructions Use 2L/min [liters per minute] via nasal canula [cannula].
*Oxygen; inhalation; gas; 1-5L as needed; Purpose: SOB.
*Goal #10: Patient/Caregiver will demonstrate progressive independence in the management of oxygen therapy as evidenced by appropriate adherence to ordered therapy and demonstration of appropriate safety measures by time of discharge.
7. Interview on 11/21/24 at 8:45 a.m. with director of nursing (DON) B revealed:
*The services hospice provided to the residents varied from resident to resident based on their hospice diagnosis.
-This information would have been found on the resident's care plan.
*Minimum Data Set (MDS)/registered nurse (RN) K and infection control RN J were responsible for updating resident facility developed care plans but any nurse can.
-The care plan should have been updated when there is any change in the care that a resident received.
*Hospice had a separate care plan that was part of the resident's overall care plan.
-The hospice care plan was to be uploaded in their EMR system point click care (PCC) when it was completed.
-She expected that the hospice care plan would have reflected the care resident 288 was receiving in the facility.
-Resident 288's hospice care plan should have been updated when she moved from her private home to the facility.
*She confirmed that resident 288's care plan should have included:
-Her oxygen needs which included:
-The need for assistance completing her nebulizer and the use of the humidifier.
--Resident 288 had been able to self-administer her nebulizer treatments when she came into the facility, but it had been determined that she was no longer able to.
-The amount of oxygen she received and the equipment she used.
--Hospice provided resident 288 with an oxygen concentrator and she had her own portable oxygen tank.
--Hospice provided the oxygen humidifier and nasal cannula tubing for the concentrator and for the portable, however, it was the responsibility of the facility nursing staff to change that oxygen tubing and humidifier.
-The frequency of cleaning of the oxygen equipment and changing the oxygen tubing -Resident 288 had been able to self-administer her nebulizer treatments when she came into the facility, but it had been determined that she was no longer able to.
Review of the provider's 5/30/23 Oxygen Administration policy revealed:
*The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to:
-The type of oxygen delivery system.
-When to administer, such as continuous or intermittent and/or when to discontinue.
-Equipment setting for the prescribed flow rate.
-Monitoring of SpO2 (oxygen saturation) levels and/or vital signs, as ordered.
-Monitoring for complications associated with the use of oxygen.
8. Review of the provider's April 2019 Comprehensive Care Plan policy revealed:
*It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.
*The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS [Minimum Data Set] assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review the provider failed to maintain the cleanliness of the oxygen concentrator, tubing, and humidifier and to administer the nebulizer treatment appropriately after determining the resident could not self-administer that treatment for one of one observed sampled resident (288) who received oxygen. Findings include:
1. Observation on 11/19/24 between 8:25 am and 9:02 a.m. with resident 288 in her room revealed:
*At 8:25 a.m. registered nurse (RN) F started her nebulizer (neb) machine for the administration of her neb medication treatment and then left the room.
-Resident 288 asked the surveyor to return when she completed that nebulizer treatment.
*At 8:40 a.m. the nebulizer treatment was running and resident 288 was wearing a neb mask.
*At 8:55 a.m. the nebulizer was still running and resident 288 was holding the mask in her hand.
*At 9:02 a.m. RN F walked by resident 288's room and into room [ROOM NUMBER]. Resident 288's nebulizer was still running at that time, and her neb mask was on the floor.
Observation and interview on 11/19/24 at 9:42 a.m. with resident 288 in her room revealed:
*Her breakfast tray was on the table. The individual containers were wrapped in plastic wrap and the fruit cup was unopened. She stated she could not open the fruit cup. I'll just leave it.
*She ate in her room by choice.
*She was short of breath, spoke softly, and wore oxygen via a nasal cannula.
*The oxygen concentrator was stored in the bathroom.
-The oxygen concentrator was covered in white dust, and the filter on the back contained visible lint and debris.
-The oxygen flow meter was set at five liters.
-The oxygen tubing and the humidifier were not labeled or dated.
-An oxygen humidifier container with a green top was attached between the concentrator and the tubing.
-The humidifier container was dry and contained an unidentified white flaky substance at the bottom.
*There was a portable oxygen tank on the back of her wheelchair.
-The nasal cannula connected to the portable oxygen was not labeled or dated.
2. Observation and interview with RN F in resident 288's room on 11/19/24 between 9:47 a.m. and 9:56 a.m. revealed:
*The concentrator was stored in the bathroom because of the noise it produced and to provide more space in the room.
*She stated the oxygen tubing and humidifiers were changed once a week on Wednesday as ordered on the treatment administration record (TAR).
*When asked what was in the humidifier, she tapped the humidifier, and stated, A smidge of water.
*When asked to confirm that there was no water in the humidifier, she stated there was dry water in the bottom of the container, and stated It's dirty, and that she would go get some sterile water.
*She stated that there should have been a sticker on the oxygen tube with the date it had been changed, but it must have fallen off.
*At 9:56 a.m. RN F returned to resident 288's room with an oxygen humidifier with a black top that contained water, a nasal cannula, and green oxygen tubing.
-She replaced the existing humidifier and tubing and dated it on a piece of tape.
*She did not change the oxygen tube on the portable oxygen unit which hung on the back of the wheelchair.
*There was no visible jug of distilled water in resident 288's room or bathroom.
3. Interview on 11/19/24 at 10:15 a.m. RN F regarding resident 288's oxygen humidifier revealed:
*When asked what had been in the humidifier which she had removed from resident 288's room she stated, Dry water that has been dry for a day.
*When asked where the oxygen humidifier brought to resident 288's room had been filled she took the surveyor to the unit kitchenette.
*When asked again where the water had come from, she stated The water jug was actually kept in the medication room.
*When asked to see the jug, she stated it had been empty and thrown away and the trash had already been taken out.
*The water jugs to fill the oxygen humidifiers came from the main kitchen.
-She stated there were no more jugs of water on the unit and she would have to get more from the kitchen.
*RN F stated she needed to pass medications and ended the interview.
4. Interview on 11/19/24 at 10:21 a.m. with RN C regarding oxygen equipment revealed:
*Oxygen humidifiers were to be filled with distilled water.
*She showed the surveyor a one-gallon jug stored in the unit's utility room.
*Each resident with an oxygen humidifier was expected to have a jug of distilled water in their room.
-That jug would be dated on the day it was opened.
*Open bottles of distilled water were not stored in the medication room or the kitchenette.
*She had not seen resident 288's humidifier and was unaware of where RN F would have filled her humidifier.
*Hospice provided resident 288's concentrator, humidifier, and oxygen tubing.
*The facility provided the distilled water, and the facility nurse changed the tubing every week on Wednesday, but not the humidifier.
-She expected the nurse would have checked the humidifier and refilled it with distilled water as needed.
5. Interview on 11/19/24 at 10:29 a.m. with RN L in resident 288's room revealed:
*Hospice had provided resident 288 with the oxygen concentrator.
*RN L confirmed that there was no jug of distilled water in resident 288's room.
-She stated the distilled water would have been provided by the facility.
*At 10:32 a.m. RN F entered the room, placed an unopened jug of distilled water, dated 11/19/24, on resident 288's bedside table, and then left the room.
6. Observation on 11/20/24 at 9:55 a.m. in resident 288's room revealed the nasal cannula attached to the portable oxygen on her wheelchair was resting on the floor.
7. Interview on 11/21/24 at 8:45 a.m. with director of nursing (DON) B revealed:
*Hospice provided resident 288 with an oxygen concentrator and she had her own portable oxygen tank.
*Hospice provided the oxygen humidifier and nasal cannula tubing for the concentrator and for the portable, however, it was the responsibility of the facility staff to change that oxygen tubing and humidifier.
*There was an order in the resident's treatment administration record (TAR) to change oxygen tubing once a week on Wednesdays.
-She expected that oxygen tubing would have been marked with the date they were changed on a small piece of tape.
*She expected the oxygen humidifier to have been filled by the nurse with distilled water provided by the facility whenever it was low and needed more water.
-Distilled water was kept in a one-gallon jug, with the date it was opened, in each resident's room who required it.
*She expected the nurse to clean the oxygen concentrator filter weekly when the tubing and humidifier were changed.
-The concentrator was to have been cleaned monthly.
*Resident 288 had been able to self-administer her nebulizer treatments when she came into the facility, but it had been determined that she was no longer able to.
-She expected that the nurse would have stayed with resident 288 while she completed her nebulizer treatment.
8. Interview on 11/21/24 at 9:35 am with infection control RN J revealed:
*There were hooks for oxygen tubing to hang on in each resident's room.
-She expected oxygen tubing, when not being used, to have been hung on those hooks.
*Oxygen humidifiers were filled with distilled water as needed.
-Each resident who required humidified oxygen would have had a dated one-gallon jug kept in their room.
9. Review of resident 288's electronic medical record (EMR) revealed:
*Resident 288 had been admitted on [DATE] from home with continued hospice services.
*Her diagnoses included malignant neoplasm of unspecified bronchus or lung, chronic obstructive pulmonary disease, chronic kidney disease, and other forms of dyspnea.
*Her Brief Interview for Mental Status (BIMS) assessment score was 14, which indicated she was cognitively intact.
*An 11/7/24 physician's order for O2 [oxygen] 1-5L/N/C [liters via nasal cannula] every morning and at bedtime for comfort.
*An 11/7/24 physician's order for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG [milligram]/3ML [milliliters]. 1 vial inhale orally four times a day.
*An 11/7/24 physician's order for Albuterol Sulfate Inhalation Nebulization Solution (2.5MG/3ML) 0.083%. 1 vial inhale orally via nebulizer every 4 hours as needed for SOB [shortness of breath].
*Her Medication Self-Administration Safety Screen completed on 11/13/24 revealed:
-Medications being considered for resident self-administration included:
--Albuterol 0.083% q4hour [every four hours].
--Ipratropium-Albuterol Inhalation .05-2.5mg/3ml.
-The resident can correctly administer inhalant medications according to proper procedure, was marked Unable.
-It is reported that this resident is not capable of taking her neb [nebulizer] treatments unsupervised as before, weakness. Resident reports she falls asleep when she takes it and cant [can't] hold it. will switch to a mask.
-IDTC [interdisciplinary team] feels resident is safe to administer listed medications? was marked No.
*A physician's order to Clean O2 concentrator with Clorox wipes, clean filters, change tubing. Every day shift every Wed [Wednesday] Clean O2 concentrator with Clorox wipes, clean filters with water and air dry, put new tubing on machine and date with tape. If they have a tank put new tubing on [the] tank.
-This was marked as completed on 11/13/24.
Review of the provider's 5/30/23 Oxygen Administration policy revealed:
*Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences.
*Cleaning of concentrators and filters will be completed weekly.
*Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated.
*Change humidifier bottle weakly Use only distilled water for humidification.
*Cleaning and care of equipment shall be in accordance with facility policies for such equipment.
*Staff shall monitor for complications associated with the use of oxygen intake precautions to prevent them Respiratory infections related to contaminated humidification systems.

Based on observation, interview, record review, and policy review, the provider failed to ensure safe food was at safe temperatures prior to serving residents food by one chef (H) during an observed breakfast meal service.
Findings include:
1. Observation and interview on 11/19/24 at 7:45 a.m. with chef M, chef H, and culinary services manager (CSM) D revealed:
*Chef M was at the steam table serving breakfast to residents and stated chef H would have done the food temperatures this morning.
*Chef H was by the ovens and the food prep area, and stated she forgot to take the food temperatures that morning.
-The food temperature logs indicated food temperatures had not been documented that morning and chef H stated she would sometimes take the food temperatures but not log them and sometimes she would just forget to take the food temperatures.
-She stated she should check the temperatures of the food coming out of oven and at the steam table.
*CSM D told chef H to temp the next batch of food and log those temperatures. Chef H completed that task.
2. Record review and interview on 11/19/24 at 8:00 a.m. regarding food temperatures and documentation with CSM E revealed:
*She stated she did not know the food temperatures (temps) had not been done that morning and that temps were not being documented on the logs.
-She agreed the temperature logs indicated food temps had not been done as they should have been.
-She stated she would check the logs periodically and had not been monitoring them for a while because the temps were being done, and said I see now they aren't logging them again.
*When asked how she would know food temperatures were at the appropriate temperature to safely serve food to residents without temping food before serving it to the residents, she stated, I don't.
*Food temperature logs were reviewed with CSM E and indicated multiple dates for breakfast, lunch, and supper did not have food temperatures documented.
-There was no log sheet started for that week which indicated it should have been started on Sunday 11/17/24.
-She expected that food would have been temped three times per day at each meal and documented on the logs.
-She stated, We will have to start monitoring the logs again.
*She stated she wasn't sure what the policy said and would have to look that up.
3. Observation on 11/19/24 at 11:11 a.m. revealed food temperatures were done for the lunch meal with no concerns and now placing temp log on wall beside steam table with logs from lunch and supper noted on the log.
4. Interview on 11/19/21 at 11:15 a.m. with chef G revealed, Food temps should have been checked with each meal and logged.
5. Interview on 11/20/24 at 9:56 a.m. with chef M revealed he would have temped and logged two meals, twice for each meal, once for food removed from oven then again for food in the steam table during his shift.
6. Interview on 11/20/24 at 12:10 p.m. with administrator A revealed he was not aware that food temperatures were not taken or logged at meal times and expected that the residents' food would be temped with each meal. We have come a long way in kitchen and dining, but temps should have been done.
7. Record review of food temperature logs from 10/19/24 to 11/19/24 revealed the residents' food for thirty 38 of 67 meals had not been temped or logged for breakfast, lunch, and supper.
8. Record review of the Provider's 2021 policy and procedure for food temperatures revealed, the temperatures of all food items will be taken and properly recorded prior to service of each meal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the Hospice and Nursing Facility Services Agreement, the provider failed to ensure an integrated plan of care had been developed and made accessible between the provider's nursing staff and hospice agency for one of one sampled resident (288) who received hospice services.
Findings include:
1. Review of resident 288's facility care plan revealed:
*She had been admitted on [DATE].
*Her diagnoses included malignant neoplasm of unspecified bronchus or lung, chronic obstructive pulmonary disease, chronic kidney disease, and other forms of dyspnea.
*[Resident 288] was admitted on hospice from home.
*A focus area: Resident and family have opted for hospice benefits and comfort care only.
*A goal: Will receive additional support from hospice. Have comfort and dignity maintained on [a] daily basis.
*Interventions/Tasks:
-Keep family and hospice involved in care planning and decision making as well as updated on any changes in conditions or orders.
-Keep hospice staff involved with changes and notify them in [the] event of death.
-Maintain [an] open line of communication and involvement with hospice staff.
-Offer emotional/spiritual support to [the] resident and family.
Review of resident 288's paper Hospice Plan of Care provided upon request revealed:
*It had not been uploaded into resident 288's electronic medical record.
*Location Type: Private Residence.
*Service Location: Home.
*Principal Program: Home Hospice.
*Start of care date 09/22/2024.
-Resident 288 was admitted to the facility on [DATE].
Review of the hospice binder at the north nurse's station regarding resident 288 revealed:
*It contained information about which nurse was assigned to resident 288 and instructions for when and how facility staff were to contact hospice.
*The hospice plan of care was not located in that binder.
*There was no documentation of the resident's oxygen needs or interventions in that binder.
2. Interview on 11/21/24 at 8:40 a.m. with certified nursing assistant I revealed:
*She confirmed that resident 288 was receiving hospice services.
-She knew how to care for residents receiving hospice services because the nurse reviewed that information with her before each shift.
*Her worksheet and the care plan in point click care also provided information about how much assistance a resident needed for transfers and personal care.
*Hospice provided a bath to residents once a week.
*She was unable to locate a hospice care plan for resident 288.
Interview on 11/21/24 at 8:45 a.m. with director of nursing (DON) B revealed:
*The services hospice provided to the residents varied from resident to resident based on their hospice diagnosis.
-This information would have been found on the resident's care plan.
*Minimum Data Set (MDS)/registered nurse (RN) K and infection control RN J were responsible for updating resident facility developed care plans but any nurse can.
-The care plan should have been updated when there is any change in the care that a resident received.
*Hospice had a separate care plan that was part of the resident's overall care plan.
-The hospice care plan was to be uploaded in their EMR system point click care (PCC) when it was completed.
-She expected that the hospice care plan would have reflected the care resident 288 was receiving in the facility.
-Resident 288's hospice care plan should have been updated when she moved from her private home to the facility.
*She confirmed that resident 288's care plan should have included:
-Her oxygen needs which included:
-The need for assistance completing her nebulizer and the use of the humidifier.
--Resident 288 had been able to self-administer her nebulizer treatments when she came into the facility, but it had been determined that she was no longer able to.
-The amount of oxygen she received and the equipment she used.
--Hospice provided resident 288 with an oxygen concentrator and she had her own portable oxygen tank.
--Hospice provided the oxygen humidifier and nasal cannula tubing for the concentrator and for the portable, however, it was the responsibility of the facility nursing staff to change that oxygen tubing and humidifier.
-The frequency of cleaning of the oxygen equipment and changing the oxygen tubing -Resident 288 had been able to self-administer her nebulizer treatments when she came into the facility, but it had been determined that she was no longer able to.
3. Review of the provider's 1/17/19 Hospice and Nursing Facility Services Agreement revealed:
*Facility's representative will perform the following duties: (a) Collaborate with Hospice staff and coordinate Facility staff's participation in the care planning process .
*Joint Responsibilities/Mutual and Hospice Promises. Development and Implementation of Plan of Care Hospice and Facility shall jointly develop and agree upon the Patient's plan of care Hospice and Facility each shall maintain a copy of each Patient's plan of care in the respective clinical records maintained by each Party.
*Hospice Plan of Care. All services provided to Hospice Patients under the Agreement must be in accordance with the plan of care.
-The plan of care shall identify the care and services needed and specifically identify whether Hospice or Facility is responsible for performing the respective functions that have been agreed upon and included in the plan of care.
-The plan of care shall reflect the participation of Hospice, Facility and the Hospice Patient and such Patient's family, to the extent possible including a description of the Hospice Services, Inpatient Services and Room and Board Services furnished by Facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review the provider failed to ensure:
*One of seven refrigerators was set at an appropriate temperature for safe food storage.
*Two of seven refrigerators were monitored for safe temperature control.
1. Observations on 7/24/23 at 3:27 p.m. in the kitchen revealed:
*The south refrigerator had four glass doors.
*The gasket around the bottom right door was torn in several places.
*The thermometer on the front of the refrigerator read 51 degrees.
*The thermometer on the inside of the refrigerator read 58 degrees.
*Refrigerator temperatures should be maintained between 35 and 41 degrees.
*The refrigerator contained the following:
-Fifty-nine bowls of cherry crisp dessert.
-thirty-three bowls of lettuce salad.
-thirty-six cups of French salad dressing.
-Six ham salad sandwiches.
-Two cakes labeled Hawaiian.
Interview on 7/24/23 at 3:29 p.m. with culinary dining assistant I about the above observations revealed:
*The south refrigerator was mainly used for salads, desserts and sandwiches for the residents.
*He thought the refrigerator should have been at 40 degrees or below.
*The kitchen staff recorded the refrigerator temperatures daily.
Observations on 7/24/23 between 4:31 p.m. and 5:39 p.m. in the kitchen revealed:
*The south refrigerator had temperature ranges from 49 to 51 degree readings from the thermometer on the front of the refrigerator.
*The thermometer on the inside of the refrigerator had readings between 52 to 54 degrees.
*Kitchen staff had taken the 33 bowls of lettuce salad and served them to the residents for supper.
Observation and interview on 7/25/23 at 7:54 a.m. with culinary manager G revealed:
*The south refrigerator had a temperature of 47 degrees on the thermometer on the outside of the refrigerator.
* The thermometer on the inside of the refrigerator had a reading of 43 degrees.
*She had issues with that refrigerator in the past and had a repair man work on it.
*She would have staff empty the refrigerator and discard the remaining contents as it was not holding a temperature of 41 degrees or below.
*She needed to call the repair man and have him look at it.
Review of the provider's Freezer and Refrigerator Temperature Sample Form for July revealed:
*All refrigerators and freezers were to have both internal and external temperatures checked and recorded at least twice a day.
*The south refrigerator was missing documentation for the mornings of July 9, 10, 13, 14, 15, 16, 18, 19, 21, 22, 23, and 24.
*The south refrigerator was missing documentation for the afternoons of July 2, 3, 6, 7, 11, 13, 15, 16, and 21.
Interview on 7/26/23 at 9:02 a.m. with culinary manager F revealed:
*The refrigerator was not holding proper temperature.
*The repair man would have to come back and work on it again.
*She knew the refrigerator temperatures were to have been recorded twice a day.
*It was her expectation that staff would monitor the refrigerator temperatures according to the provider's policy.
2. Observation and record review on 7/25/23 at 8:25 a.m. in the activity room revealed:
*The activity refrigerator contained an egg carton flat with five eggs with no expiration date.
*An egg carton with six eggs.
*The expiration date on that egg carton was 12/12/22.
*The refrigerator monthly temperature log had only been completed on April 12, 2023 and May 3, 2023.
*There was no documentation for the months of June or July 2023.
Interview on7/26/23 at 1:40 p.m. with activities director E regarding the activity refrigerator revealed she:
*Had gotten the eggs from the main kitchen, but was unsure when she had gotten them.
*Had known that the food items needed to have an expiration date on them.
*Refilled the small egg carton from the main kitchen as it was easy to store in the refrigerator.
*Agreed the documentation for monitoring refrigerator temperatures in the activity room was missing.
Review of the provider's 2021 Food Storage policy from [NAME] & Associates, Inc. manual revealed:
13. Refrigerated food storage:
a. All refrigerator units should be kept clean and in good working condition at all times.
b. TCS foods must be maintained at or below 41 degrees F unless otherwise specified by law. Periodically take temperatures of refrigerated food to assure temperatures are maintained at or below 41 degrees F. Temperatures for refrigerators should be between 35 to 39 F. Thermometers should be checked at least two times each day. (See Sample Freezer and Refrigerator Temperature Forms on the following pages.) Check for proper functioning of the unit at the same time.
c. Every refrigerator must be equipped with an internal thermometer .