Every finding on record at Barron Center

Based on interviews and record review, the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included but is not limited to, the attending physician, a registered nurse, a Certified Nurses Aid (CNA) with responsibility for the resident, a member of nutrition services and to the extent possible participation of the resident and/or his/her representative after each assessment for 6 of 21 reviewed for care planning. (Resident #6, #3, #5, #91, #99 and #8).1. On 8/18/25 at 10:59 a.m., during an interview, with Resident #6 and his/her representative, Resident #6 stated he/she is not aware of the meetings and I've never been invited. The resident representative stated the IDT's have We do it on the phone and it's been without [Resident #6].Review of Resident #6's medical record, the surveyor noted IDT meetings held on 2/21/25 and 12/19/24. The medical record lacked evidence that the resident was invited and/or participated in his/her IDT meetings, and the meetings lacked the participation of the attending physician, a Certified Nurses Aid (CNA) with responsibility for the resident, and a member of nutrition services.On 8/20/25 at 10:17 a.m., during an interview with both the Director of Social Services and the Licensed Social Worker #1, the Director of Social Services stated, all residents and family receive a letter inviting them to the IDT meetings. At this time the surveyor requested copies of the letters inviting Resident #6 to his/her IDT's on 2/21/25 and 12/19/24.On 8/20/25 at 1:39 p.m., the LSW #1 provided the surveyor with resident #6's invitation letters for the above IDT dates. Review of the IDT invitation letter for the scheduled 12/19/24 meeting was handwritten with the date of the meeting being on Wednesday 12/18/25.On 8/20/25 at 1:49 p.m., during an interview with the Administrator, the Surveyor questioned the vitality/integrity of the letter as it was signed with the IDT date of 12/18/25 (future date) and was supposed to be for the 12/19/24 IDT meeting. The surveyor questioned if the letter was created today.On 8/20/25 at 2:14 p.m., during an interview with 3 surveyors present, LSW #1 confirmed the IDT invitation letter with the date of 12/18/25 for the IDT which occurred on 12/19/24, was created today, stating, That was on me, I didn't invite her to this meeting. I did sign this today.On 8/20/25 at 2:37 p.m., during an interview with the Administrator, the Surveyor discussed the LSW#1 falsification of Resident #6's medical record relating to the IDT invitation letter for the meeting which was held on 12/19/24. 2. Review of Resident #3's medical record, the surveyor noted an IDT meeting held on 3/19/25, with only the participation of the social worker and a member of nutrition services. Further review showed no evidence that an IDT meeting occurred after the Quarterly Minimum Data Sets (MDS) 3.0 dated 12/4/24 and the significant Change MDS dated [DATE]. 3. Review of Resident #5's medical record, the surveyor noted an IDT meeting held on 7/9/25, with only the participation of the social worker and a member of nutrition services. 4. Review of Resident #91's medical record, the surveyor noted an IDT meeting held on 7/9/25 and 10/23/24, with only the participation of the social worker and a member of nutrition services 5. Review of Resident #99's medical record, the surveyor noted an IDT meeting held on 11/13/24, with only the participation of the social worker and a member of nutrition services. On 8/20/25 at 10:17 a.m., during an interview the above was confirmed with both the Director of Social Services and the Licensed Social Worker #1.

Based on observations, interviews, record reviews and facility policy review, the facility failed to maintain a sanitary environment for 2 of 3 residents reviewed for respiratory care. (Resident #6 & #64) The facility's policy Oxygen Use and Storage, dated 10/20/21, indicates that: A sanitary environment must be maintained to prevent the transmission of disease and infection. Oxygen tubing must be discarded and changed every two weeks, labeled with the date and staff initials. Nasal cannulas must be discarded and changed weekly, labeled with the date and staff initials. Staff changing the tubing or cannula must document the change on the Treatment Administration Record (TAR). On 8/18/25 at 11:52 a.m. Resident #64 was observed receiving oxygen via nasal cannula through an oxygen concentrator. The oxygen tubing was dated 7/17/25, and per facility policy, should have been changed on 8/31/25. (18 days past due for replacement) The nasal cannula had no label, no date of change, and no staff initials as required by facility policy. At this time, the surveyor confirmed the finding with Registered Nurse (RN) #6, who verified that the tubing was past due for replacement and the nasal cannula had not been labeled. Review of Resident #64's Treatment Administration Record (TAR) revealed no documentation of tubing or cannula changes per policy. On 8/18/25 at 3:00 p.m., the surveyor discussed this finding with the Administrator. 1. On 8/19/25 at 2:09 p.m., the surveyor observed Certified Nurses Aid (CNA) #3 and CNA #4 perform personal hygiene on Resident #6. During this process, the resident's oxygen nasal cannula tubing with the nasal prongs lying on the floor under the bed. After the personal hygiene was completed and the resident was made comfortable in the bed, CNA #4 picked up the nasal cannula off the floor and placed it on the resident's face. The surveyor immediately intervened and discussed the nasal cannula being on the floor and lack of maintaining a sanitary environment to prevent transmission of disease or infection. CNA#4 stated, it was still attached to the Oxygen concentrator. At this time, the Surveyor requested the resident receive a new nasal cannula tubing. On 8/19/25 at 2:20 p.m., the above observation was discussed with the Administrator.

Based on observations and interviews, the facility failed to adequately date and properly dispose of open medications according to manufacturer specifications and failed to ensure expired medications were removed from the supply available for use on 3 of 4 units observed (2 South, 2 North and 3 South).1. On 8/18/25 at 12:09 p.m., during review of 2 South Medication room with the Registered Nurse (RN) #1, the following was observed: one unopened, available for use, bottle of Naproxen Sodium with exp date of 5/2025. The refrigerator contained 2 opened and undated vials of Lantus insulin with manufactures directions of, Throw away any medicine that remains 28 days after first use and one opened and undated Basaglar insulin KwikPen with manufactures directions of, throw away the Pen you are using after 28 days, even if it still has insulin in it. At this time, the expired and unlabeled medications were confirmed with RN#1. 2. On 8/19/25 at 8:06 a.m., during review of 3 South Certified Nurses Aid - Medication Technician (CNA-M) #1 cart the surveyor observed one bingo card of Zofran 4mg with 27 tabs remaining with the expiration date of 5/13/25 and another bingo card of Zofran 4mg with 22 tabs remaining with the expiration date of 5/29/25. At this time, CNA-M#1 confirmed the meds were expired and removed them form the cart. 3. On 8/19/25 at 8:42 a.m., during review of the 2 North Medication room and the 2 North Nurse Medication cart with RN#4, the following was observed:The medication room contained one unopened, available for use, bottle of Calcium 600 with Vitamin D with expiration date of 7/2025 and the refrigerator contained an opened vial of Tuberculin Purified Protein Derivative labeled with the open date of 7/17/25 with manufactures directions of Once entered, vial should be discarded after 30 days.The Nurse Medication cart contained an opened and undated Basaglar insulin KwikPen with manufactures directions of, throw away the Pen you are using after 28 days, even if it still has insulin in it. At this time, RN#4 confirmed the expired and unlabeled medications.

Based on observations, interviews, and record review, the facility failed to maintain a safe and sanitary environment for food preparation and storage. Specifically, the facility did not consistently maintain temperature logs for kitchen equipment and food storage areas, failed to monitor tray line temperatures, neglected to check for outdated supplies in unit kitchenettes, and did not ensure cleanliness of food preparation equipment. Main Kitchen Refrigerator/Freezer Logs:On 8/18/2025 at 9:15 a.m., during the initial visit to the Kitchen, with the Director of Dietary Services, a surveyor observed no ongoing documentation of refrigerator/freezer temperatures in the main kitchen. The only record provided was a single sheet with the last entry dated 5/5/2025. The Director of Food Services confirmed the absence of current documentation.Dish Machine Temperature Logs:On 8/18/2025 at 11:00 a.m., document review revealed that dish machine temperatures were not consistently recorded. Of 129 days reviewed, 37 days lacked documentation, including dates spanning April through August 2025.Tray Line Temperature Checks:On 8/18/2025 at 11:30 a.m., review of 14 weeks of tray line temperature audits showed 4 sheets without dates and 110 meals out of 294 lacked temperature documentation.Unclean Food Preparation Equipment:On 8/19/2025 at 10:15 a.m., during the return visit to the Kitchen, with Director of Dietary Services and Food Production Manager, the meat slicer was observed with dried debris. The large floor mixer and countertop mixer were covered in dust and debris. Staff confirmed the equipment had been used recently, indicating inadequate cleaning practices.Unit Refrigerator/Freezer Temperature Logs:On 8/21/2025 between 7:00 a.m. and 8:15 a.m., surveyors reviewed temperature logs across multiple units:Third Floor Day Room: 180 of 336 opportunities not documented for both refrigerator and freezer.Second Floor Day Room: No documentation for May-August; 336 missed opportunities.2 North & 2 South Kitchenettes: 235 and 233 missed opportunities respectively.Zolov Unit: 76 missed fridge checks and 74 missed freezer checks out of 242 opportunities.Outdated Supply Checks in Unit Kitchenettes:On 8/21/2025 at 9:00 a.m., documentation showed:3rd Floor: 11 of 20 days not checked.2nd Floor: 9 of 20 days not checked.Zolov Unit: 1 of 20 days not checked.Administrator Confirmation:On 8/21/2025 at 9:25 a.m., the facility Administrator confirmed all findings during an interview

Based on facility policy, observations, interviews and record reviews, the facility failed to maintain an Infection Control Program designed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to the use of Personal Protective Equipment (PPE) for residents on Enhanced Barrier Precautions (EBP) (Resident #118 and #6) for 1 of the 4 days of survey. (8/19/25)The facilities Infection Control: Standard and Transmission-Based Precautions & Enhanced Barrier Precautions policy and procedure last updated on 10/2023 states under Enhanced Barrier Precautions that targeted gown and gloves use during high contact resident care activities: dressing, bathing, showering providing hygiene, changing linens, toileting or care r/t wound care. For both active and colonized MDRO. When a resident has an indwelling medical device, i.e. Foley catheters, feeding tubes. - EBP when caring for the device (high contact activity). 1. On 8/19/25 at 8:30 a.m., Resident #118's bedroom was posted with Enhanced Barrier Precautions sign and a yellow bag hanging on the door containing gloves and a tub of purple top Sani cleaner wipes. The door was open and the surveyor observed 2 Registered Nurse (RN) managers, RN#5 and RN#6 at the residents bedside wearing only gloves. RN#6 had the residents the gastrostomy tube (G-tube) connected to a syringe and appeared to be cleansing around the tube site and holding the syringe. RN #5 stepped away from the beside to the dresser where she obtained a gauze pad and brought it over to the resident. At that time RN#6 observed the surveyor watching and closed the door. The surveyor immediately knocked on the door, entered the room, introducing herself. Both of the RN's were wearing only gloves. At this time, the surveyor intervened questioning the lack of proper PPE which included a gown while providing care to the residents G-tube, with no response from either RN, the surveyor exited the room.At 8:36 a.m., during an interview with RN#4, who was at the nurse's medication cart adjacent to resident #118's room. The surveyor asked RN#4 what she would wear for PPE while caring for Resident #118 and the G-tube site. RN#4 stated gloves. She then stated the nurse managers are in with the resident because he/she dislodged his/her tube. The surveyor asked again what PPE would be used while caring for his/her G-tube, while showing the RN#4 the EBP posted on door. RN#4 stated, I never understood that and [He/she] is not on precautions, [he's/she's] not on any precautions. The surveyor explained R#118 had an indwelling device (G-Tube) that is why the EBP is posted. At that time RN#4 paused then stated she would also use a gown in addition to gloves for care. At 8:39 a.m., RN#5 exited R#118's room and approached the surveyor stating, both her and RN#6 were not providing care on the tube. At this time, the surveyor discussed what was observed, including G-tube care and asked what PPE should be worn during G-tube care. RN#5 stated, should've worn gowns.At 8:42 a.m., the surveyor observed RN #4, bring a gown into to RN#6 who was still in Resident#118's room. 2. On 8/19/25 at 2:09 p.m., Resident #6's room was posted with Enhanced Barrier Precautions sign and a yellow bag hanging on the door containing gloves and gowns. At this time, the surveyor observed Certified Nurses Aid (CNA) #3 and CNA #4 wearing only gloves, perform personal hygiene including peri care on Resident #6 who has a diagnosis of neurogenic bladder requiring a suprapubic catheter and a history of Extended-Spectrum Beta-Lactamase (ESBL), a Multidrug-Resistant Organism (MDRO), in the urine. On 8/19/25 at 2:15 p.m., during an interview, CNA #4 confirmed she provided catheter care. The surveyor asked why neither of them were a gown, CNA#4 stated, I was under the impression we only wear it when we are emptying the foley bag, The posted EBP on both Resident #118 and #6's room stated the following instructions: Enhanced Barrier Precautions. Providers and staff must also: wear gloves and a gown for the following High-Contact Resident Care Activities. Providing hygiene, changing briefs or assisting with toileting, Device care or use: .urinary catheter, feeding tube . On 8/19/25 at 2:20 p.m., the above observation was discussed with the Administrator.

Based on the facility's policy, record review, and interviews, the facility failed to investigate an allegation of potential misappropriation of a resident's loss of personal property, and failed to ensure that the facility's investigation was sent to the State Agency within 5 business days of the incident for 1 of 6 intake investigations reviewed during an annual survey.A review of the facility's policy, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, Section G. Reporting and Response, stated All allegations of abuse or neglect will be reported to the Administrator or designee at the time the allegation is made. The facility will: Immediately report all alleged violations to the administrator.Take all necessary actions as a result of the investigation, which may include, but are not limited to the following: Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent future occurrences. Procedure. Internal Reporting: a. Employees must always report any abuse or suspicion of abuse immediately to the Administrator or designee. b. The Administrator or designee will involve key leadership personnel as necessary to assist with reporting, investigation and follow-up. External Reporting: Report the results of all investigations to the Administrator or designee and to other officials in accordance with State law, and follow-up report to the State Survey Agency within 5 working days of the incident. The Administrator or designee will inform the resident or resident's representative of the report of an incident and that the investigation is being conducted. On 4/8/25, the Division of Licensing and Certification received the facility's report that Resident #30 (R30) was missing 2 cell phones, a [NAME] case containing the resident's identification, Medicare card and a small amount of cash. A copy of an email, dated 4/8/25, sent to the social worker from R30's son stated he/she has never lost these items before and is usually mindful of where they are, because he/she uses them regularly every day for entertainment and contacting family. I believe on possible theory that was mentioned to us was that maybe these items fell into the trash can, which he/she keeps beneath the bedside tray. Although, this is possible, it feels unlikely, especially that all three items would fall into the trash and go unnoticed. A follow-up email, dated 4/8/25 from the social worker to R30's son stated when the items were discovered missing, staff searched trash, the resident's room, and notified the kitchen and laundry departments. The social worker notified the local police department via an online crime report. On 4/10/258, the police department replied and stated the report had been rejected because We do not complete police reports for missing or lost property. A review of R30's medical record noted a personal effects inventory, dated 2/5/25, which included an android phone with green wallet case, and an IPhone with charger and cord. On 8/19/25 at 2:20 p.m., in an interview with a surveyor, the facility's Social Services Director stated she was not able to locate evidence that an investigation had been completed, or that a 5-day report was sent to the State Agency on this incident. On 8/20/25 at 2:00 p.m., in an interview with a surveyor, the facility's Administrator stated the incident had never been reported to her. At this time, the facility's Director of Nursing stated she had no knowledge of the incident either and that it had not been discussed at morning staff meetings.

Based on interview and record review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to properly care for 1 of 4 sampled residents reviewed for new admissions (Resident #5).Resident #5 was admitted on [DATE] with a diagnosis of cerebrovascular accident with right arm flaccid paralysis, type 2 diabetes mellitus, lung mass, fracture of right humerus with delayed healing, dysphagia and recurrent fall. Review of the clinical record lacked evidence of a baseline care plan was completed within 48 hours to include the instructions necessary to properly care for Resident #5's immediate health and safety needs for the above concerns. The care plan was initiated on 7/3/25, 3 days after admission. On 8/20/25 at 12:31 p.m., during an interview, the above was discussed with the Director of Nursing.

Based on observations, record reviews and interviews, the facility failed to ensure that a comprehensive plan of care was developed in the area of Multidrug-Resistant Organism (MDRO) and Preadmission Screening and Resident Review (PASRR) for 2 of 23 residents reviewed for comprehensive care plans. (Resident #6 and #9)1. On 8/18/25 and 8/19/25 observations of Resident 6's bedroom door with an Enhanced Barrier Precautions (EBP) sign posted on the door. The clinical record indicated he/she was re-admitted to the facility in April 2025 with a diagnosis of neurogenic bladder requiring a suprapubic catheter and a history of Extended-Spectrum Beta-Lactamase (ESBL), an MDRO, in the urine. The current care plan, last updated on 6/3/25, lacked evidence of goals and interventions relating to the use of EBP precautions and history of ESBL in the urine. 2. Resident #9's clinical record was reviewed and included a Level II PASRR, dated 1/22/19 which indicated the resident was eligible for services due to diagnosis of Alzheimer's disease, major mental psychotic disorder and deaf and mute since childhood. As of 8/20/25, Resident #9's care plan lacked evidence of goals and interventions in the area of PASRR. On 8/20/25 at 12:31 p.m., during an interview, the Director of Nursing confirmed both Resident #6 and 9's care plans lacked the above required information.

Based on record review, Centers for Disease Control and Prevention (CDC) recommendations, and interview, the facility failed to develop a Coronavirus (COVID-19) policy and procedure for COVID-19 vaccination, and failed to offer an updated 2024-2025 COVID-19 vaccination for 1 of 5 residents reviewed for immunizations (Resident #80).1. A review of the facility's policies and procedures for infection control lacked evidence of a COVID-19 policy and procedure regarding immunizations.On 8/20/25 at 11:00 a.m., in an interview with a surveyor, the Director of Nursing, confirmed she was unable to find a current policy and procedure regarding COVID-19 vaccinations.2. Clinical record review indicated R80, was admitted in March, 2025, and is currently [AGE] years old. R80's last documented COVID-19 vaccination was on 11/3/22. There was no evidence R80 had received, been offered, or refused the COVID-19 vaccination.A review of the CDC website, COVID-19, last revised 6/6/25, Stay Up to Date with COVID-19 Vaccines | CDC, indicated that CDC recommends the 2024-2025 updated COVID-19 vaccines are especially important if one has never received a COVID-19 vaccine, are aged 65 years and older, at high risk for severe COVID-19, living in a long-term care facility. The adult immunization recommendations state, Previously vaccinated before 2024-25 vaccine with: 1 or more doses Moderna or Pfizer-BioNTech: 1 dose 2024-25 Moderna or Novavax or Pfizer-BioNTech at least 8 weeks after the most recent dose. 1 dose Novavax: 1 dose 2024-25 Novavax 3-8 weeks after most recent dose. If more than 8 weeks after most recent dose, administer 1 dose 2024-25 Moderna or Novavax or Pfizer-BioNTech. 2 or more doses Novavax: 1 dose 2024-25 Moderna or Novavax or Pfizer-BioNTech at least 8 weeks after the most recent dose. 1 or more doses [NAME]: 1 dose 2024-25 Moderna or Novavax or Pfizer-BioNTech. For adults [AGE] years of age and older, Previously vaccinated before 2024-25 vaccine: follow recommendations above for previously vaccinated persons ages 19-64 years and administer dose 2 of 2024-25 Moderna or Novavax or Pfizer-BioNTech 6 months later (minimum interval 2 months).On 8/20/25 at 11:00 am, the Director of Nursing confirmed the clinical record did not indicate staff had offered R80 a COVID-19 vaccination upon admission.

Based on observations, record reviews and interviews, the facility failed to ensure that the Minimum Data Sets (MDS) 3.0 were coded accurately in the area of Active Diagnosis and Preadmission Screening and Resident Review (PASRR) for 2 of 21 sampled (Resident #6 and #9).1. On 8/18/25 and 8/19/25, Resident 6's bedroom door was observed to have an Enhanced Barrier Precautions sign posted on the door. Review of the clinical record indicated the resident was re-admitted to the facility in April 2025 with a diagnosis of neurogenic bladder requiring a suprapubic catheter and a history of Extended-Spectrum Beta-Lactamase (ESBL), a Multidrug-Resistant Organism (MDRO), in the urine. Review of the Quarterly MDS dated [DATE], the Significant Change MDS dated [DATE] and the most recent Quarterly MDS dated [DATE] indicates, under Active Diagnosis section I1700 stated that the resident #6 did not have a Multidrug-Resistant Organism. 2. On 8/20/25, Resident #9's clinical record was reviewed and included a Level II PASRR, dated 1/22/19 which indicated the resident was eligible for services due to diagnosis of Alzheimer's disease, major mental psychotic disorder and deaf and mute since childhood. Review of the Quarterly MDS's dated 7/31/24, 10/25/24, 1/24/25, 7/17/25 and the Annual MDS dated [DATE] under section S0510 PASRR lacked evidence of a PASRR level II being completed. On 8/20/25 at 12:31 p.m., during an interview, the Director of Nursing confirmed both Resident #6 and 9's MDS's were coded incorrectly.

Based on Interviews and Record Review the facility failed to provide care, based on the comprehensive assessment and the resident's comprehensive person-centered care plan as outlined in the facility policy Comprehensive Person-Centered Care Planning for resident (Resident #1) resulting in an avoidable accident (fall) as reported in the facility reported incident of 1/17/25. Finding: Review of the clinical record documents that on 1/17/25, during the night shift, Certified Nursing Assistant (CNA) #1 failed to follow the resident care plan for Resident #1 and attempted to toilet with a bed pan, alone when the care plan stated that the resident was a Max two assist. CNA#1 rolled the resident away from her and the resident fell past the bed rail and onto the floor. The bed was at waist level for care. Resident sustained visible injury to her left foot, right toes, and left big toe. Resident complained of pain to touch, and pain of neck and back, and she complained that she was dizzy, and had blurred vision and lethargy. Resident sent to hospital for evaluation. Additionally, the following documents were reviewed: Incident report form completed on 1/17/25 and documentation from the Nursing Supervisor states, Injury due to care plan not followed. Resident care planned for Max 2 assist. Statement from CNA#1 made on 1/17/25 that states, Having cared for the resident many times before independently, I also approached this task the same. On 1/30/25 the Administrator and the Director of Nursing (DON) stated and provided documentation of the correction actions that were taken as a result of the incident: -The resident was transported to the hospital for evaluation and treatment. Imaging done to all areas of concern and no injuries were found. Resident returned to the facility -CNA#1 was placed on paid administrative leave pending the outcome of the investigation. -Education provided to staff that day (1/17/25) by the DON -Education provided to staff on 1/22/25 by Nurse Educator -Follow-up education provided to staff on 1/27/25 by Nurse Educator -The facility has informed the union representing CNA#1 of the facility's intent to terminate the employee, with final meeting with employee and termination is scheduled for this week

Based on observations, interviews, and record reviews, the facility failed to ensure expired medications, vaccinations, and point of care testing supplies were removed from the supply available for use in 1 of 8 medication carts, and 1 of 5 medication refrigerators. In addition, the facility failed to ensure vaccines were stored in a refrigerator without a freezer compartment for 1 of 5 medication refrigerators, and failed to provide evidence of temperature monitoring for medication refrigerators in accordance with United States Center for Disease Control and Prevention recommendations, for 4 of 5 medication refrigerators. Findings: 1. On 7/21/22 at 10:00 a.m., observation of 1 of 3 medication carts on the 2-South unit, found 1 expired medication of Liquid Tylenol, a 16 fluid ounce bottle, with an expiration date of 11/21, and two Seracult (testing solution for Occult blood) 15 ml (milliliter) bottles, with expiration dates of 6/22. The finding was confirmed with the Charge nurse and the Director of Nursing on 7/21/22 at 10:25 a.m. Additionally, on 7/21/22 at approximately 10:45 a.m., the medication refrigerator in the first floor supervisor's office was noted to contain the following: > 7 unopened boxes, and 1 opened box, of [MEDICATION(S)] Influenza Vaccine Quadrivalent, Lot number P 28, expiration 6/30/22, and; > 1 bottle of [MEDICATION(S)] (TB) Purified Protein Derivative (Mantoux), [MEDICATION(S)], manufacturer Sanofi Pasteur, Lot # C5841AB, expiration 6/17/23. The bottle was marked that it was opened on 5/2/22. The RN Admissions Coordinator confirmed at that time, that all of the items should have been removed from the refrigerator and that the bottle of TB solution should have been destroyed 30 days after opening, as per manufacturer's instructions. On 7/21/22 at 11:00 a.m., the finding of the expired influenza vaccine and TB solution was discussed with the Director of Nursing. 2. The United States Centers for Disease Control and Prevention's website, The Pink Book, Vaccine Storage and Handling, dated 8/21, states Never store any vaccine in a dormitory-style or bar-style combined unit. These units often have a single exterior door and an evaporator plate/cooling coil, usually located in an icemaker/freezer compartment. These units pose a significant risk of freezing vaccines, even when used for temporary storage. Additionally, refrigerators should maintain temperatures between 2°C (Celsius) and 8°C (36°F (Fahrenheit) and 46°F). The current temperature should be checked and recorded a minimum of two times (at the start and end of the workday). On 7/21/22, from approximately 9:50 a.m. to 11:00 a.m., observations of the medication storage refrigerators were completed. > On all nursing units: Zolov, 2 South, 3 South and 3 North units, dormitory style refrigerators with internal freezer compartments were observed. In the Zolov unit's medication storage refrigerator, 1 unit dose vial of Prevnar-13 (pneumococcal 13-valent conjugate), with an expiration date of 1/25/23, was observed. The finding was confirmed by the unit Nurse Manager. A review of medication refrigerator temperature logs, dated 7/1/22 through 7/21/22, revealed: > On the Zolov unit, 6 temperatures of 63 degrees F were recorded. > On the 2 South unit, there were 11 days with no temperatures recorded. > On the 3 South unit, there was no evidence of temperatures recorded for July. > On the 3 North unit, there were 5 days with no temperatures recorded. On 7/21/22 at 1:00 p.m., the Director of Nursing confirmed the findings concerning use of dormitory style refrigerators and lack of consistent monitoring and documentation of temperatures for medication refrigerators.

Based on interviews and record review and facility policy, the facility failed to ensure an injury of unknown origin was thoroughly investigated for 1 of 5 facility reported incidents reviewed. (#6). Findings: Review of facility policy titled Falls Management dated 10/21 states.A fall incident report will be completed after a resident has had a fall, whether it is witnessed for not. an unwitnessed fall will cause the licensed nurse to initiate neurological checks. Complete a Post Fall Observation Tool following a fall to help identify if the cause of the fall is related to mental status changes, physical limitations or environmental factors . On 4/14/22 the Division of Licensing and Certification received from the facility a Reportable Incident Form which indicated Resident #6 obtained an injury of unknown origin. (large bruise lateral and superior to his/her right eye). Resident #6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility provided Falls List for May, June, and July 2022 reveled Resident #6 fell on 9 occasions during this time period. Review of Resident #6's MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . (1 tablet/0.5 mg) daily in 2000 for anxiety. The clinical record revealed follow-up note dated 4/15/22 injury of unknown origin Date of incident 4/14/22 around 08:45 .head injury observed. Bruise, left head, superior and lateral to eye .? resident's room . possible cause: suspect unwitnessed fall; high risk, ability to right self, inability to remember. Or unwitnessed altercation with other resident-hx of this as well. Further review, the clinical record lacked evidence that an investigation was completed regarding this incident. Review of Resident #6's clinical record lacked evidence that a Post Fall Observation Tool was completed following the above falls. Further review of Resident #6's clinical record lacked evidence that Resident #6's injury of unknown origin dated 4/14/22 was completely investigated to find the cause of the injury. During an interview on 7/19/22 at 12:05 p.m., Unit Manger (UM) indicated that a formal investigation was not completed or documented for Resident #6's injury on 4/14/22 because he/she has a predictable pattern and his/her anxiety level has increased since his/her admission in January (2022) as it is a new environment for him/her. UM further indicated that Resident #6 did have a change in his/her [MEDICATION(S)] but it has not increased or decreased his/her number of falls. In an interview with a surveyor on 7/20/22 at approximately 1:18 p.m., the surveyor confirmed with the Administrator that the injury of unknown origin was not thoroughly investigated.

Based on record reviews and interviews, and Facility Reported Incident review, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 5 sampled residents reviewed for falls (#6), and for 1 of 3 sampled residents reviewed for respiratory care (#47). Findings: 1. On 4/14/22 the Division of Licensing and Certification received from the facility a Reportable Incident Form which indicated Resident #6 obtained an injury of unknown origin. (large bruise lateral and superior to his/her right eye). Resident #6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the signed doctors' orders for April 2022 reveled, order with start date of 3/3/22 for [MEDICATION(S)] 0.5 milligram (mg) tablet by mouth (0 .5 tablet/0.25 mg) daily 0800 for anxiety and order with start date of 4/13/22 for [MEDICATION(S)] 0.5 mg tablet by mouth . (2 tablet/1 mg) b.i.d. (twice daily) 1400 for anxiety. Order with start date of 1/8/20 for Omeprazole 20 mg capsule delayed release by mouth. (1 capsule/20 mg) by mouth daily 0800 for .reflux, and Order with start date of 1/8/22 for [MEDICATION(S)] 25 mcg (1000 UT) tablet by mouth . 1 capsule daily at 0800 for [CONDITION(S)]/vit d def. The Medication Administration Report (MAR) dated April 2022 lacked evidence that Resident #6 received [MEDICATION(S)] 0.5 mg at 1400 on 4/11/22 and 0800 on 4/13/22, 1 mg [MEDICATION(S)] at 1400, 20 mg of Omeprazole at 0800 or 25 mcg of [MEDICATION(S)] at 0800 on 4/21/22. During an interview on 7/19/22 at 12:05 p.m., the Unit Manger indicated that all medications given should be signed off on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 7/21/22 at approximately 12:46 p.m. the Director of Nursing confirmed the above findings. 2. On 7/19/22 at 11:55 a.m. and 7/20/22 at 12:50 a.m., the surveyor and a Registered Nurse (RN) observed the Resident #47's nasal cannula and oxygen tubing that was attached to an oxygen concentrator laying on the floor next to the bed. Two labels on the oxygen concentrator indicated the oxygen tubing was changed on 6/10/22 and 6/30/22. The surveyor and RN reviewed the July Treatment Administration Records (TAR) which indicated that the oxygen tubing had been changed on 7/7/22 and 7/14/22. Review of facility policy titled Respiratory Care revised 1/22 states, Nasal Cannula's should be discarded and changed weekly. A label indicating the date and the initials of the staff changing the cannula/tubing should be applied to the nasal cannula. Oxygen Tubing should be discarded and changed every 2 weeks. A label indicating the date and the initials of staff changing the tubing should be applied to the tubing. Resident #47 TARs, order dated 4/16/21 instructs staff to Change all oxygen tubing and nebulizer sets every week on Thursdays the day shift. Sign and date new tubing, cannulas and nebulizer set up every week on Thursdays. On 7/20/22 12:57 pm, a surveyor confirmed the finding above of inaccurate documentation with the Director of Nursing (DON) who stated that she would inform the RN to change the tubing again.

Based on observations, interviews, and facility policy, the facility failed to maintain an Infection Control Program designed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to wound care for and proper placement of Foley bag (urine drainage bag) for 1 of 1 resident (#25). Findings: Review of facility provided wound care guidelines, undated states . wash your hands thoroughly and don gloves. Ensure strict aseptic technique during dressing changes 1. Resident #25 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A providers order dated 6/23/22 instructs nursing to, Skin/wound treatment daily dressing change for scrotal wound daily . AM QID PRN . 1) wound cleanser: Vashe soaks-Dampen gauze and leave in place on wound for 3 to 5 minutes with each dressing change .2) Wipe away after removing the soaked gauze .3) Apply Cavillon border spray to peri wound area. 4) Dressing: Mesalt gauze gently tucked into the wound depth . 5) ABD pad and rolled gauze over Mesalt gauze packing . During observation of Residents #25's dressing change on 7/19/22 at 12:55 p.m., Registered Nurse (RN) was observed washing her hands at the sink and walked to the residents bed where she placed a glove on her right hand and then put her ungloved left hand in her left pocket and pulled out a paper tape measure and placed it directly on the residents side table. RN was then observed to take her left ungloved hand and removed the residents catheter bag from the bedframe and placed it on top of the bed and then proceeded to put a glove on her left hand without performing hand hygiene. At this time Surveyor asked if she is supposed to perform hand hygiene after removing gloves and before donning clean ones. RN stated, I don't have to sanitize my hands in between glove changes because this is a dirty wound, and you don't perform hand hygiene in between glove changes for dirty wounds. RN then used her left gloved hand to remove ABD dressing from the wound, picked up a spray bottle of wound cleanser with same left gloved hand and placed the wound cleanser bottle directly on the residents bed. RN then removed glove from left hand and donned a new left glove without performing hand hygiene. RN then used her left gloved hand and pulled packing out of the residents wound and placed it in the trash, removed bilateral gloves and immediately donned new gloves without performing hand hygiene. RN then used her left gloved hand to pick up package containing sterile Q tips, opened them, used left gloved hand to remove Q tip from the usable end and pulled it out of the package. She then put the Q tip inside the residents wound and then picked up the paper measuring tape to measure the depth of the wound and placed it on top of the side table. RN then removed both gloves and placed them in the trash and immediately donned new gloves. At this time RN removed clean chux from package with gloved left hand and used her right gloved hand to support it against her body to roll the chux into a log. She then dropped the chucx on the floor, picked it up with her left gloved hand and continued to roll it with the intent to place it on the residents bed. At this time surveyor intervened stating, you just dropped that chux on the floor didn't you. RN replied yes, I'll just get a new one then. RN then placed the chux in the trash can and took a new one out of the packaging with the same left gloved hand and again used her body to roll the chux. She then placed it under the resident. During an interview on 7/19/22 at 3:25 p.m., a surveyor discussed above with the Director of Nursing, she indicated the facility does not have a wound care policy, but that it was her expectation that nurses sanitize their hands in between glove changes and practice standard of care during dressing changes. 2. During an observation of Resident #25 on 7/19/22 at 8:45 a.m. and 11:15 a.m., his/her catheter bag was noted directly on the floor and visible from door. Review of Resident #25's care plan initiated on 6/10/22 most recently updated 7/16/22 states, I have a suprapubic catheter because I have a [CONDITION(S)] bladder. in the past I have had a hx Urinary Tract infections, antibiotic resistant bacteria in my urine. I need my nurses to .care for my catheter .I have a history of developing infection leading to [CONDITION(S)] quickly . During an interview on 7/20/22 at approximately 1:09 p.m. a surveyor discussed above findings with the Director of Nursing.

Based on record review and interviews, the facility failed to issue a written transfer/discharge notice, which included information regarding appeal rights, and the name and address of the Office of the State Long-Term Care Ombudsman, to the resident or resident's representative for 1 of 3 sampled residents transferred/discharged by the facility to an acute care hospital (#3). Finding: Resident #3's clinical record noted he/she was transferred to an acute care facility on 4/11/22 and again on 5/15/22. The clinical record lacked evidence that the facility issued a written transfer/discharge notice to the resident, family member or legal representative for the transfer. On 7/19/22 at 11:45 a.m., in a discussion with the surveyor, the social worker stated the facility provides transfer/discharge notices only to residents who are on Medicaid. The social worker stated Resident #3 was private pay so did not receive the notices at the time of transfers to the hospital.

Based on clinical record review and interview, the facility failed to ensure that the Minimum Data Sets, version 3.0 (MDS) were accurately coded for 2 of 2 resident reviewed for smoking (#97 and #99) Findings: 1. Resident #97 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Annual MDS assessment dated [DATE] and the Quarterly MDS assessments dated 1/20/22, 4/14/22 and 7/5/22, under section J1300- (current tobacco use) were coded to indicate that Resident #97 does not use tobacco. On 7/19/22 at 8:34 a.m., during an interview, Resident #97, confirmed he/she smokes cigarettes daily. 2. Resident #99's History and Physical dated 11/16/20 noted history of tobacco use. The medical record noted that Safe Smoking Assessments were completed on 8/7/20, 10/27/20 and 7/9/22. A review of the Annual MDS assessment dated [DATE] and the Quarterly MDS assessments dated 1/22/22, 4/14/22 and 7/8/22, under section J1300- (current tobacco use) were coded to indicate that Resident #99 does not use tobacco. On 7/21/22 at 10:06 a.m., during an interview, Resident #99, confirmed he/she smokes 3 cigarettes daily. On 7/21/22 at 10:27 a.m., during an interview with the MDS coordinator, the above coding inaccuracy was confirmed.

Based on observation and interview, the facility failed to post the current daily nurse staffing information that includes the facility name, day of the month, a breakdown of the number of registered and licensed nursing staff responsible for direct resident care and indicate which shifts the numbers corresponded to for facility census for 4 of 4 survey days. Findings: During observations of facility on 7/18/22, 7/19/22, 7/20/22 and 7/21/22 there was no evidence of posted daily staffing ratios for the facility. During an interview on 7/21/22 at 11:45 a.m. Nursing Scheduler (NS) indicated that she posts the schedule in the glass case daily. At this time a surveyor asked to see where the posted staffing was. NS escorted surveyor to the elevator area and pointed to an empty glass case indicating that she posts staffing in the glass case. At this time NS confirmed that posted staffing was not in place during 4 of 4 survey days. During an interview on 7/21/22 at 11:50 a.m. a surveyor discussed with Director of Nursing that staffing has not been posted during 4 of 4 survey days.

Based on interviews and record review the facility failed to ensure that a resident requiring [MEDICAL TREATMENT] received services consistent with the professional standards of practice and the comprehensive person-centered care plan for 1 of 2 residents sample who receive [MEDICAL TREATMENT] services (Resident #95). Finding: On review of Resident #95's clinical record, a surveyor noted the resident was receiving [MEDICAL TREATMENT] services for [MEDICAL CONDITION], stage 5. Resident #95's physician's diet order, originally dated 7/23/19 with a re-order dated 12/17/19, indicated FLUID RESTRICTION - 1600 ml (milliliters)/day. The surveyor noted on review of Resident #95's comprehensive person centered care plan, dated 10/16/19, that [MEDICAL TREATMENT] was addressed on the care plan and indicated, I need my nurses to observe me for changes in my mental status or behavior, collaborate with Southern Maine [MEDICAL TREATMENT] regarding my fluid balances, and [MEDICAL TREATMENT] treatments on M-W-F, . monitor my fluid intake as I am on a 1600 ml (milliliters)/day fluid restriction. On review of Resident #95's electronic Medication and Treatment Administration Record (MAR/TAR), the surveyor noted documentation from 12/1/19 through 1/7/20 did not reflect consistent monitoring of fluid intake. The MAR/TAR for this time period reflected 73 out of 111 shifts where fluid intake was not monitored and 37 out of 37 days where documentation did not reflect monitoring for the entire 24 hour period. In an interview with the surveyor on 1/07/20 at 12:56 PM, the charge nurse stated she looked at Resident #95's MAR/TAR and noted that the fluid intake was not being monitored according to the physician's orders [REDACTED]. In an interview with the Director and Assistant Director of Nursing on 1/7/20 at 3:15 PM, they stated Resident #95 is active throughout the facility and is noncompliant with fluid restrictions, making it very difficult for staff to monitor the resident's intake. During the interview, the surveyor confirmed the finding.

Based on interviews and record review, the facility failed to report immediately an alleged violation of sexual abuse to the Division of Licensing and Certification (State Survey Agency) and law enforcement officials for 1 of 1 investigated allegations of sexual abuse (Resident #1). Finding: On review of the facility's Abuse Investigation and Reporting policy and procedure, dated 11/2017 and updated 5/25/18, the surveyor noted: All alleged violations involving abuse, neglect, exploitation, or mistreatment will be reported by the facility Administrator, or his/her designee, to: . d. Law enforcement officials; and An alleged violation of abuse, neglect, exploitation or mistreatment will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse . The Division of Licensing and Certification (DLC) received a facility reported incident dated stamped by fax on 7/8/19 at 12:31 p.m., in which Resident #1 alleged an employee sexually abused him/her on the evening of 7/7/19. Further review of the clinical record indicated the incident occurred prior to 1800 (6:00 p.m.) as the nurses notes indicated, Female staff assigned to perform (Resident #1's) care immediately at 1800. The surveyor could not locate evidence that the allegation was reported immediately to law enforcement and the DLC. In an interview with the Director of Nursing on 7/15/19 at 9:15 a.m., the surveyor confirmed the allegation was not reported to local law enforcement. In an interview with the Registered Nurse (RN)/Unit Manager, on 7/15/19 at 10:02 a.m., the surveyor confirmed the allegation was submitted to the DLC the next day, approximately 18 hours later. On 7/15/19 at 11:22 a.m., in an interview with the Charge Nurse/RN who was on duty the evening the allegation occurred, the surveyor confirmed he/she did not immediately report the allegation to the DLC and local law enforcement.

Based on observations, interviews and review of the "Daily Maintenance Log," the facility failed to ensure that hot water temperatures accessible to residents did not exceed 120 degrees Fahrenheit in 17 of 124 resident rooms, and in one shower room. The failure of the facility to lower hot water temperatures when logs for March 2014, April 2014 and May 2014, indicated temperatures exceeding 120 degrees Fahrenheit, created the potential for resident's to be burned by the domestic hot water. Findings: 1. On 6/2/14 at 11:50 a.m., the surveyor measured and observed hot water temperature of 124 degrees Fahrenheit on the Barron Center II (BCII) Unit Resident Room #1 in the Libbytown neighborhood. 2. On 6/2/14 at 11:58 a.m., the surveyor measured and observed hot water temperature of 123 degrees Fahrenheit in the BCII Unit shower room in Deering neighborhood. 3. On 6/2/14 between 11:00 a.m. and 4:00 p.m., hot water temperatures were tested and exceed 120 degrees Fahrenheit in the following Resident Rooms: N214; N220; S306; S301; N320; L1; D2; N113; S209; N215; N203; N217; N221; S312; S320; S201 and S203. 4. On 6/2/14 at 11:16 a.m., in an interview with a surveyor, a Licensed Practical Nurse stated that no residents or staff had complained of hot water temperatures or had experienced burns relating to the hot water temperatures. On 6/2/14 at 12:19 p.m., in an interview with a surveyor, a Certified Nursing Assistant stated that the hot water was tolerable when wearing gloves. The CNA stated he/she had reported the hot water temperatures but does not remember who he/she reported it to. On 6/2/14 at 3:07 p.m., in an interview with a surveyor, Resident #12 stated that he/she has not found the water to hot and has not had any burns from the water. On 6/2/14 at 1:44 p.m., in an interview with a surveyor, Resident #71 stated that he/she did find the water too hot recently and had reported it to a CNA. The resident stated he/she was not injured from the hot water being to hot. 5. On 6/2/14 at 12:24 p.m., in interview with a surveyor, the Environmental Services Director provided a surveyor with a form tiled "Daily Maintenance Log, which he stated was the facility's logs for monitoring the hot water temperatures. The facility's "Daily Maintenance Log" for March 2014, indicated domestic water temperatures exceeded 120 degrees Fahrenheit on: 3/2/014; 3/9/14; 3/15/14; 3/16/14; 3/17/14; 3/20/14; 3/21/14; 3/22/14; 3/23/14; 3/28/14 and 3/30/14. The facility's "Daily Maintenance Log" for April 2014, indicated domestic water temperatures exceeded 120 degrees Fahrenheit on: 4/3/14; 4/4/14; 4/7/14; 4/11/14; 4/13/14; 4/14/14; 4/18/14; 4/19/14; 4/20/14 and 4/21/14. The facility's "Daily Maintenance Log" for May 2014, indicated domestic water temperatures exceeded 120 degrees Fahrenheit on: 5/1/14; 5/3/14; 5/4/14; 5/11/14; 5/15/14; 5/22/14, 5/25/14; 5/27/14; 5/29/14; 5/31/14 and for 6/1/14. These logs did not indicate any action was taken to ensure the domestic water temperatures did not exceed 120 degree Fahrenheit. 6. On 6/2/14 at 1:35 p.m., in an interview with a surveyor, a Maintenance staff member stated that he recorded temperatures on the "Daily Maintenance Log" and that they only test the kitchenette water temperatures on the units, unless informed of an issue by the nursing staff, then they'd test the specific problem area. The staff member stated he just records/"posts" the temps on the daily maintenance log. 8. On 6/2/14 at 1:45 p.m. in an interview with a surveyor, the Administrator stated that the issue will be resolved immediately, by turning down the boilers, testing them and testing temperatures in resident rooms. On 6/2/14 at 3:45 p.m., spot checks of water temperatures were completed by the surveys and water temperatures tested between 110 to 116 degrees Fahrenheit. The immediacy of the water temperatures was corrected; however quality assurance activities and systemic changes to ensure continued compliance will need to be addressed.

Based on observations, interviews and review of the "Daily Maintenance Log," the facility failed to ensure that hot water temperatures accessible to residents did not exceed 120 degrees Fahrenheit in 17 of 124 resident rooms, and in one shower room. The failure of the facility to lower hot water temperatures when logs for March 2014, April 2014 and May 2014, indicated temperatures exceeding 120 degrees Fahrenheit, created the potential for resident's to be burned by the domestic hot water. Findings: 1. On 6/2/14 at 11:50 a.m., the surveyor measured and observed hot water temperature of 124 degrees Fahrenheit on the Barron Center II (BCII) Unit Resident Room #1 in the Libbytown neighborhood. 2. On 6/2/14 at 11:58 a.m., the surveyor measured and observed hot water temperature of 123 degrees Fahrenheit in the BCII Unit shower room in Deering neighborhood. 3. On 6/2/14 between 11:00 a.m. and 4:00 p.m., hot water temperatures were tested and exceed 120 degrees Fahrenheit in the following Resident Rooms: N214; N220; S306; S301; N320; L1; D2; N113; S209; N215; N203; N217; N221; S312; S320; S201 and S203. 4. On 6/2/14 at 11:16 a.m., in an interview with a surveyor, a Licensed Practical Nurse stated that no residents or staff had complained of hot water temperatures or had [MEDICAL CONDITION] to the hot water temperatures. On 6/2/14 at 12:19 p.m., in an interview with a surveyor, a Certified Nursing Assistant stated that the hot water was tolerable when wearing gloves. The CNA stated he/she had reported the hot water temperatures but does not remember who he/she reported it to. On 6/2/14 at 3:07 p.m., in an interview with a surveyor, Resident #12 stated that he/she has not found the water to hot and has not had [MEDICAL CONDITION] the water. On 6/2/14 at 1:44 p.m., in an interview with a surveyor, Resident #71 stated that he/she did find the water too hot recently and had reported it to a CNA. The resident stated he/she was not injured from the hot water being to hot. 5. On 6/2/14 at 12:24 p.m., in interview with a surveyor, the Environmental Services Director provided a surveyor with a form tiled "Daily Maintenance Log, which he stated was the facility's logs for monitoring the hot water temperatures. The facility's "Daily Maintenance Log" for March 2014, indicated domestic water temperatures exceeded 120 degrees Fahrenheit on: 3/2/014; 3/9/14; 3/15/14; 3/16/14; 3/17/14; 3/20/14; 3/21/14; 3/22/14; 3/23/14; 3/28/14 and 3/30/14. The facility's "Daily Maintenance Log" for April 2014, indicated domestic water temperatures exceeded 120 degrees Fahrenheit on: 4/3/14; 4/4/14; 4/7/14; 4/11/14; 4/13/14; 4/14/14; 4/18/14; 4/19/14; 4/20/14 and 4/21/14. The facility's "Daily Maintenance Log" for May 2014, indicated domestic water temperatures exceeded 120 degrees Fahrenheit on: 5/1/14; 5/3/14; 5/4/14; 5/11/14; 5/15/14; 5/22/14, 5/25/14; 5/27/14; 5/29/14; 5/31/14 and for 6/1/14. These logs did not indicate any action was taken to ensure the domestic water temperatures did not exceed 120 degree Fahrenheit. 6. On 6/2/14 at 1:35 p.m., in an interview with a surveyor, a Maintenance staff member stated that he recorded temperatures on the "Daily Maintenance Log" and that they only test the kitchenette water temperatures on the units, unless informed of an issue by the nursing staff, then they'd test the specific problem area. The staff member stated he just records/"posts" the temps on the daily maintenance log. 8. On 6/2/14 at 1:45 p.m. in an interview with a surveyor, the Administrator stated that the issue will be resolved immediately, by turning down the boilers, testing them and testing temperatures in resident rooms. On 6/2/14 at 3:45 p.m., spot checks of water temperatures were completed by the surveys and water temperatures tested between 110 to 116 degrees Fahrenheit. The immediacy of the water temperatures was corrected; however quality assurance activities and systemic changes to ensure continued compliance will need to be addressed.