Every finding on record at Colonial Poplin Nursing Home

Based on interview and record review, the facility failed to have a water management plan that included all the necessary elements to prevent the growth and spread of Legionella and other opportunistic waterborne pathogens in a facility with a census of 42 residents.Findings include:Review on 4/30/26 of the facility's Water Management Plan, revised on 2/23/26, revealed the plan did not include an accurate description of the facility water system, did not identify specific areas where Legionella could grow and spread, and did not establish ways to intervene when identified control limits were not met. Further review of the control measures identified on the plan revealed that the temperature of the hot water storage tank should be maintained between 130 and 150 degrees Fahrenheit and that the temperature would be checked and recorded. The plan did not specify how frequently the hot water storage tank temperature should be monitored.Interview on 4/30/26 at approximately 10:15 a.m. with Staff B (Infection Preventionist) revealed that the facility had two resident rooms with bathtubs that were not in use (rooms [ROOM NUMBERS]), as well as eyewash stations (low-use areas).Review on 4/30/26 of the maintenance log book from December 2025 through April 2026 revealed no water temperatures had been recorded for the hot water storage tanks.Interview on 4/30/26 at approximately 1:00 p.m. with Staff A (Administrator) confirmed the above findings. Staff A revealed that the plan does not include all risk area such as the two resident bathtubs that are not in use and the eye wash stations.

Based on observation, interview, and record review it was determined that the facility failed to implement their policy and procedures for Transmission Based Precautions (TBP) for 3 of 4 residents reviewed for infection control practices for COVID-19 (Resident Identifiers #4, #36, and #38). Findings include: Review on 5/1/24 of the facility's COVID-19 Positive Tracking report revealed the following; Resident #4 tested positive for COVID-19 on 4/20/24 and had no symptoms. Resident #36 tested positive for COVID-19 on 4/25/24 and had no symptoms. Resident #38 tested positive for COVID-19 on 4/20/24 and was symptomatic. Observation on 4/30/24 at 10:10 a.m. of Staff A (Dietary Manger) was in Resident #4's room talking to Resident #4 within approximately 3 feet of the resident. There was a sign posted outside the door that read Droplet and Contact Precautions Staff Required: gown and gloves; Procedure: mask with eye protection. Staff A was not wearing an N95 mask, gown, or gloves. Staff A was then observed leaving Resident #4's room and entering another resident's room which did not have a Droplet and Contact Precaution sign up, while still wearing the same mask (KN95 mask). Observation on 4/30/24 at approximately 10:15 a.m. of Staff B (Transportation Staff) was in Resident #4's room approximately 3 feet away from the resident. Staff B was not wearing an N95 mask (had on a KN95 mask), gown, or gloves. Interview on 4/30/24 at 10:20 a.m. with Staff B confirmed that he/she had been in Resident #4's room and stated that he/she did not think they needed to wear full personal protective equipment (PPE) [N95 mask, gown, gloves, eye protection] as long as he/she did not touch anything in the room. Interview on 4/30/24 at 10:18 a.m. with Staff C (Assistant Director of Nursing) and Staff D (Director of Nursing) confirmed that all employees should be wearing gowns, gloves, N95 masks, and eye protection. Observation on 4/30/24 at approximately 10:21 a.m. revealed that Staff A was in Resident #36's and Resident #38's room (same room) speaking with both residents. Staff A was not wearing an N95 mask, gown, gloves, or eye protection. Staff A was wearing a KN95 mask and was observed approximately 3 feet away from the residents. There was a sign outside the residents' room that read Droplet and Contact Precautions Staff Required: gown and gloves; Procedure: mask with eye protection. Interview on 4/30/24 at 10:21 a.m. with Staff A confirmed the above. Staff A stated that he/she did not think they needed to wear any additional PPE other than the mask he/she was wearing since he/she did not touch anyone. Interview on 4/30/24 at 10:29 a.m. with Staff D confirmed that all staff should be wearing full PPE when in the above resident's rooms. Interview on 4/30/24 at 10:41 a.m. with Staff E (Infection Preventionist) and Staff F (Administrator) confirmed that staff should be wearing an N95 mask, gown, gloves, and eye protection while in the above residents's rooms, even if just going into speak with the resident. Review on 5/1/24 of the facility's KN95 mask box containing the KN95 masks used by the facility revealed the outside of the box read .Precautions. 1. This mask is NOT for medical use and Non Medical . Interview on 5/1/24 at 2:19 p.m. with Staff E and Staff G (Regional Nurse) revealed that the facility used the Centers for Disease Control and Prevention (CDC) guidance for infection control policies. Review on 5/1/24 of the facility's policy titled Transmission-Based (Isolation) Precautions revised on 2/9/24, revealed: .The facility will use standard approaches, as defined by the CDC, for transmission-based precautions . The category of transmission-based precautions will determine the type of personal protective equipment (PPE) to be used .10. Contact Precautions - a. Intended to prevent transmission of pathogens that are spread by direct or indirect contact with the resident or the resident's environment . c. Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. d. Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination . 11. Droplet Precautions - a. Intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions (i.e. respiratory droplets that are generated by a resident who is coughing, sneezing, or talking . Type and Duration of Transmission-Based Precautions Recommended for Selected Infections and Conditions . Infection/Condition .SARS-CoV-2 (COVID-19) . Precaution . Droplet or Airborne (dependent if symptomatic) . Duration . As per CDC symptom-based strategies based on severity of illness . Review on 5/1/24 of the facility's policy titled Personal Protective Equipment revised 6/14/23, revealed: .1. All staff who have contact with resident and/or their environments must wear personal protective equipment as appropriate during resident care activities and at other times in which exposure to blood, body fluids, or potentially infectious material is likely . Review on 5/1/24 of the CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated March 18, 2024 and retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, revealed: .2. Recommended Infection Prevention and Control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection .Personal Protective Equipment HCP [Health Care Personnel] who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH [National Institute for Occupational Safety and Health] approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face) .

Based on observation, interview, and review of manufacturer's instructions, it was determined that the facility failed to label opened glucometer control solution bottles with expiration dates to ensure glucometers were in safe operating condition for 2 of 2 glucometers reviewed. Findings include: Observation on 5/22/23 at approximately 8:45 a.m. of opened high and low control solution bottles revealed no opened dates or open expiration dates labeled on them, or on the open box they were stored in. Interview on 5/22/23 at approximately 8:45 a.m. with Staff A (Licensed Practical Nurse / Unit Manager) confirmed the above finding. Review of control solution manufacturer's instructions, dated 2/2022, revealed: Storage and Handling .The control solution can be used for three months after opening the vial.

Based on interview, record, policy and manufacturer's instructions review, it was determined that the facility failed to obtain consent and inform a Durable Power of Attorney (DPOA) of the Federal Drug Administration (FDA) black box warning for 1 out of 5 residents reviewed for unnecessary medications in a final sample of 13 residents (Resident Identifier is #39). Findings include: Review on 5/23/23 of Resident #39's electronic medical record revealed that Resident #39 has a diagnosis of Alzheimer's Disease, Dementia with behavioral disturbances, and depression. Review on 5/23/23 of Resident #39's May 2023 Medication Administration Record (MAR) revealed the following order: Seroquel Oral [Quetiapine Fumarate] Tablet 50 mg [milligram] Give 50 mg by mouth one time only for agitation for 1 day dated 5/11/23. Review on 5/23/23 of Resident #39's record revealed that there was no consent signed for the 1 day use of Seroquel on 5/11/23. Interview on 5/23/23 at 1:30 p.m. with Staff A (Licensed Practical Nurse / Unit Manager) confirmed that for Resident #39 there was no consent signed for the 1 day use of Seroquel on 5/11/23. Review of 5/23/23 of the manufacturer's instructions for Seroquel, .WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS; and SUICIDAL THOUGHT AND BEHAVIORS . Review on 5/23/23 of the facility's policy titled, Use of Psychotropic Medication, revised 5/2/22, revealed . 5. Residents and/or representatives shall be educated on the risks and benefits . Review on 5/23/23 of the facility's policy titled, Unnecessary Drugs-Without Adequate Indication for Use, revised 5/2/22, revealed . 3. Documentation will be provided in the resident's medical record to show adequate indication for medication's use and the diagnosed condition for which it was prescribed .

Based on observation, interview, and record review, it was determined that the facility failed to assess a resident's ability to self-administer medications for 1 of 3 residents reviewed for choices in a final sample of 13 residents (Resident Identifier is #23) Findings include: Observation on 5/22/23 at approximately 10:09 a.m. of Resident #23's bedside table revealed the following medications: one bottle of Fexofenadine 24 hour allergy with expiration date of May 2022, one bottle of Flonase nasal spray, and one bottle of Systane eye drops. Resident #23 was not in the room. Interview on 5/22/23 at approximately 10:58 a.m. with Staff B (Registered Nurse) confirmed the above finding. Interview further revealed that Resident #23 is alert and oriented and that Resident #23 did not have an order to self-administor medications. Review on 5/22/23 of Resident #23's medical record revealed that there were no physician's order for Fexofenadine 24 hour allergy, Flonase, or Systane, and that Resident #23 had not been assessed to self-administer medications. Review on 5/23/23 of the facility's policy titled Resident Self-Administration of Medication, with revision date of 5/4/22, revealed the following: .A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered .7. Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into other resident's rooms or to confused roommates of the resident who self-administers medications .8. All nurses and aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage.

Based on observation, interview, and record review it was determined that the facility failed to ensure that physician orders were obtained to address skin conditions that required an intervention for 1 out of 2 residents reviewed for skin conditions in a final sample of 13 residents (Resident Identifier is #196). Findings include: The Potter-Perry, 2009, Fundamentals of Nursing 7th Edition, St. Louis, Missouri: Mosby, Chapter 23 Legal Implications in Nursing Practice, on page 336- Physicians' Orders states, The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Observation on 5/22/23 at approximately 9:13 a.m. revealed a dressing at Resident #196's right upper arm dated 5/16/23. Review on 5/22/23 of Resident #196's medical record confirmed that Resident #196 was admitted to the facility on [DATE] from an inpatient hospitalization and that Resident #196 had a PICC [peripherally inserted central catheter] intravenous access removed and dressed prior to discharge from the hospital. Record review further revealed that Resident #196 did not have a physician's order for assessment or removal of his/her right upper arm dressing. Interview on 5/22/23 at approximately 10:55 a.m. with Staff B (Registered Nurse) confirmed the above observation and record review information. Interview further revealed that there was not a current physician's order for assessment or removal of Resident #196's right upper arm dressing. Review on 5/23/23 of Resident #196's admission nursing assessment dated [DATE] revealed documentation of a dressing at his/her right upper arm. Review on 5/23/23 of Resident #196's weekly skin assessment dated [DATE] revealed the following: .intact dress RUA [right upper arm] where PICC line was removed. Review on 5/23/23 of the facility's policy titled PICC/Midline/CVAD Dressing Change, with revision date 11/28/22, revealed the following: .Physician's orders will specify type of dressing and frequency of changes.

Based on interview and record review, it was determined that the facility failed to monitor and maintain a resident's ordered fluid restriction for 1 of 1 resident reviewed for hydration in a final sample of 13 residents (Resident Identifier is #197). Findings include: Review on 5/22/23 of Resident #197's medical record revealed that Resident #197 was admitted to the facility from an inpatient hospitalization on [DATE] and that Resident #197 had a diet order that stated the following: 1500 fluid restriction/ [every] 24 hours . 360 cc [cubic centimeter] with all meals 420 cc nursing and snacks with a start date of 5/19/23. Review on 5/23/23 of Resident #197's hospitalization discharge summary revealed that Resident #197 was diagnosed while inpatient with hyponatremia [low blood sodium], with a treatment plan of sodium chloride tablets and fluid restriction. Review on 5/23/23 of Resident #197's Licensed Nursing Assistant (LNA) task documentation revealed the following fluid intake amounts in milliliters (mL) documented by LNA's from 5/19/23 through 5/22/23: 5/22/23 1620 mL total Interview on 5/23/23 at approximately 12:00 p.m. with Staff B (Registered Nurse) confirmed the above finding that Resident #197's fluid intake on 5/22/23 from LNA documentation exceeded the ordered fluid restriction. Review on 5/23/23 of Resident #197's medication and treatment administration record and nursing notes revealed no information on Resident #197's fluid intake from nursing. Interview on 5/23/23 at approximately 12:00 p.m. with Staff B confirmed that Resident #197 has an ordered daily fluid restriction, but that Resident #197 did not have documented fluid intake amounts from nursing notes or documented fluid intake totals from LNAs and nursing notes, and the physician was not notified on 5/22/23 of Resident #197's fluid intake exceeding the fluid restriction amount. Review on 5/23/23 of the facility's policy titled Fluid Restriction, with a revision date of 4/7/22, revealed the following: .It is the policy of the facility to ensure that fluid restrictions will be followed in accordance to physician's orders .and will be recorded on the medication record or other format as per facility protocol.

Based on observation, interview, and record review, it was determined that the facility failed to follow or clarify physcian orders for 4 residents in a final sample of in a final sample of 16 residents (Resident identifiers are #17, #100, #12, and #3). Findings include: Standards: Potter, Patricia A., and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336- Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Resident #17 Interview on 7/13/22 at 11:12 a.m. with Resident #17 revealed that he/she had recently readmitted to the facility and did not get all of his/her medications, including pain medications, the first night he/she returned. Review on 7/14/22 of Resident #17's MDS (Minimum Data Set) tab in the electronic record revealed that Resident #17 admitted to the facility on [DATE], discharged to the hospital on 6/28/22, and returned to the facility on [DATE]. Review on 7/15/22 of Resident #17's July 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] tablet 25 milligrams at 9:00 p.m.; -[MEDICATION(S)] tablet extended release 10 milligrams at 8:00 p.m.; -[MEDICATION(S)] 100 milligrams at 8:00 p.m.; -[MEDICATION(S)] ARespimat Aerosol at 9:00 p.m. Interview on 7/15/22 at 3:53 p.m. with Staff H (Medication Nursing Assistant) confirmed that he/she had not given the above medications to Resident #17 on 7/11/22 because they were not available from the pharmacy. Staff H stated he/she did not tell the nurse. Interview on 7/15/22 at 3:53 p.m. with Staff G (Assistant Director of Nursing) confirmed that the medication [MEDICATION(S)] was available in the emergency medication dispenser that was in the medication room and should have been administered to Resident #17. Staff G stated that physician should have been notified. Review on 7/15/22 of Resident #17's progress notes revealed that there was no documentation that the physician had been notified of the above missed doses. Review on 7/15/22 of the facility's policy Unavailable Medications revised on 8/2020 revealed .Medications use by resident in the nursing facility may be unavailable for dispensing from the pharmacy on occasion . The facility must make every effort to ensure that medications are available to meet the needs of each resident . The nursing staff shall: 1. Notify the attending physician (or on-call physician when applicable) of the situation and explain the circumstances, expected availability, and alternative therapy(ies) available. If the facility nurse is unable to obtain a response from the attending physician or on-call physician, the nurse should notify the nursing supervisor and contact the Facility Medical Director for orders and/or direction . Observation on 7/13/22 at 11:12 a.m. of Resident #17 revealed he/she was in bed with a [CONDITION(S)] machine on. Interview on 7/13/22 at 11:12 a.m. with Resident #17 revealed Resident #17 was not sure if the machine had been cleaned since returning from the hospital (on 7/11/22). Review on 7/13/22 of Resident #17's May, June, and July medical record, including the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 7/13/22 of Resident #17's physician's orders revealed on 7/13/22 an order that read May use [CONDITION(S)] at home setting. Clean tubing daily. Interview on 7/15/22 at 3:23 p.m. with Staff A (Administrator) revealed that Resident #17 applied the [CONDITION(S)] machine themselves. Review on 7/15/22 of Resident #17's progress notes revealed the following: -On 5/30/22 at 4:13 a.m. [CONDITION(S)] in place. -On 7/13/22 at 4:56 a.m. [CONDITION(S)] in place. Interview on 7/15/22 at 4:15 p.m. with Staff I (MDS) confirmed that there were no orders for Resident #17's [CONDITION(S)] machine, including for care and for settings. Review on 7/15/22 of the facility's policy Noninvasive Ventilation revised on 12/14/21 revealed Policy: It is the policy of this facility to provide noninvasive ventilation as per physician's orders and current standards of practice . 2. The facility will obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .device and settings from the practitioner. 3. A personal [CONDITION(S)]/[CONDITION(S)] . device may/may not be brought into the facility for the resident's use. If brought in, the nurse/respiratory therapist will verify the settings on the machine prior to use. 4. The facility will follow the manufacturer's instructions for use of the machine. 5. Nursing will assess the skin integrity around the mask site daily to ensure there is no impairments to the skin . 6. Document use of the machine, resident's tolerance, and skin, respiratory or other changes and response(s). 7. Follow manufacturer instructions for the frequency of cleaning/replacing filters and servicing the machine . Resident #100 Review on 7/14/22 of Resident #100 census tab in the electronic record revealed that Resident #100 admitted to the facility on [DATE], discharged to the hospital on 7/6/22, and readmitted to the facility on [DATE]. Review on 7/14/22 of Resident #100 medical record revealed the following; -A piece of paper in the front of the paper chart that read Allergies and listed [MEDICATION(S)] as an allergy. Review on 7/14/22 of Resident #100's July 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] Capsule 100 milligrams give one capsule by mouth at bedtime for pain. This medication was documented as being administered July 1, 2, 3, 4, and 5, 2022 (5 doses). -[MEDICATION(S)] Capsule 100 mg give 1 capsule by mouth at bedtime for sleep. This medication was documented as being administered July 12 and 13, 2022 (2 doses). Further review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 7/14/22 of Resident #100's progress notes revealed the following; -On 7/1/22 an Order Note that read The system has identified a possible drug allergy for the following order: [MEDICATION(S)] Capsule 100 mg. -On 7/12/22 an Order Note that read The system has identified a possible drug allergy for the following order: [MEDICATION(S)] Capsule 100 mg. Interview on 7/14/22 at 2:55 p.m. with Staff J (Licensed Practical Nurse) confirmed that Resident #100 was receiving [MEDICATION(S)] and that the medication was listed as an allergy. Interview on 7/14/22 at 3:15 p.m. with Staff G revealed that Resident #100 received the [MEDICATION(S)]. Staff G stated the allergy should have been discussed with the physician. Review on 7/15/22 of the facility's policy Administering Medications revised December 2002, revealed .5. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or it suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's Attending Physician or the facility's Medical Director to discuss the concerns . 8. The following information must be checked/verified for each resident prior to administering medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #12 Review on 7/15/22 of Resident #12 physician's orders revealed the following orders with allergy alerts: [MEDICATION(S)] Powder breath Activated 100-25 MCG/INH [micrograms/ ]([MEDICATION(S)]-Vilanterol) 1 puff inhale orally one time a day for [CONDITION(S)] ([CONDITION(S)]) Give Five minutes after the incruse inhaler ellipta inhaler -Order date- 05/31/2022 [MEDICATION(S)] Tablet 100 mg [milligram] ([MEDICATION(S)]) Give 1 tablet by mouth one time a day for hypertension -Order Date- 08/25/2021 Incruse Ellipta Aerosal Powder Breath Activated 62.5 MCG/INH ([MEDICATION(S)]) 1 puff inhale orally one time day for [CONDITION(S)] Give five minutes prior to [MEDICATION(S)] -Order Date- 05/31/2022 Review on 7/15/22 of Resident #12 July's MAR's (Medication Administration Record) revealed the above mediations were given every day since the medications were ordered. Review on 7/15/22 of Resident #12's medical record revealed Resident #12's allergy list contains the following: ACE (Angiotensin-converting enzyme) Inhibitors (help lower blood pressure), [MEDICATION(S)] Diskus ( long-acting medication that prevents breathing difficulties, [MEDICATION(S)] (antibiotic), [MEDICATION(S)] (antibiotic) and [MEDICATION(S)] (narcotic). Review on 7/15/22 of Resident #12's Progress Notes revealed on 5/31/22 a note written by Staff C (Unit Manager) The system has identified a possible drug allergy for the following order: Incruse Ellipta Aerosal Powder Breath Activated 62.5 MCG/INH ([MEDICATION(S)]) 1 puff inhale orally one time day for [CONDITION(S)] Give five minutes prior to [MEDICATION(S)] Review on 7/15/22 of Resident #12's Progress Notes revealed on 5/31/22 a note written by Staff C (Unit Manager) The system has identified a possible drug allergy for the following order: [MEDICATION(S)] Powder breath Activated 100-25 MCG/INH [MEDICATION(S)]-Vilanterol) 1 puff inhale orally one time a day for [CONDITION(S)] ([CONDITION(S)]) Give Five minutes after the incruse inhaler ellipta inhaler Review on 7/15/22 of Resident #12's physician order revealed the physician did not address the allergies until 7/15/22 via a telephone order Discontinue Ace Inhibitors Allergy and [MEDICATION(S)] Allergy. MD (physician) states to continue with Cozzar at this time. Review on 7/15/22 of Resident #12's progress note dated 7/15/22 revealed that note written by Staff C revealed per Staff D (Nurse Practitioner) okay to administer Incruse Ellipta Aerosal Powder and [MEDICATION(S)] Aerosal with allergy to Advir Interview on 7/15/22 at 2:55 p.m. with Staff C confirmed that Resident #12 was receiving Incruse Ellipta Aerosal Powder and [MEDICATION(S)] Aerosal with allergy to Advir and Cozzar and that the medication was listed as an allergy. Interview on 7/15/22 at approximately 3:00 p.m with Resident #12 revealed he/she had allergies but he/she couldn't rember them all or what they did. Resident #3 Observation on 7/13/22 at approximately 9:35 a.m. revealed that Resident #3 had a [CONDITION(S)] machine at bedside. Review on 7/14/22 of Resident #3's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's MDS (Minimum Data Set) revealed section O for special treatments, procedures, and programs was coded YES for Non-Invasive Mechanical Ventilator ([CONDITION(S)]/[CONDITION(S)]). Review of Resident #3's current physician's orders revealed that there was not an order written [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 7/15/22 at approximately 2:00 p.m. with Staff C (Unit Manager) revealed that the Staff C took the [CONDITION(S)] off Resident #3 that morning. Staff C did not know the setting for the [CONDITION(S)]. Interview on 7/15/22 at approximately 2:30 p.m. with Staff D (Nurse Practitioner), and Staff A (Administrator) confirmed that there was no documentation of Resident #3's [CONDITION(S)] machine being ordered.

Based on interview and record review, it was determined that the facility failed to ensure that a Registered Nurse was on duty for 8 consecutive hours a day, 7 days a week for 6 out of 14 weekend days reviewed. Findings include: Interview on 7/13/22 at 8:51 a.m. with Staff A (Administrator) revealed that the facility did not have any nurse staffing waivers. Review on of the facility's daily staffing from 6/4/22 to 7/15/22 revealed that a Registered Nurse was not scheduled or documented as worked on Saturday and Sunday for the following days: 6/11/22, 6/12/22, 6/25/22, 6/26/22, 7/9/22, 7/10/22 (total of 6 days). Interview on 7/15/22 at 2:40 p.m. with Staff A (Administrator) confirmed that there was not a Registered Nurse on duty the above dates.

Based on observation, interview, review of policy and manufacturer's instructions, it was determined that the facility failed to ensure nutritional shakes were properly labeled and dated in the main walk in cooler observed and maintain sanitation of kitchen equipment to prevent foodborne illness and 1 of 1 kitchen. Findings include: Observation on 7/13/22 at approximately 8:45 a.m. in the walk in cooler revealed a tray of approximately 18 thawed nutritional shakes on a shelf without any thawed dates on them. Interview on 7/13/22 8:45 a.m. with Staff E (Cook) revealed that the nutritional shakes arrive frozen to the facility and are placed in a walk in cooler to thaw. The individual nutritional shakes were thawed and were not dated. Staff E confirmed that the nutritional shakes were not dated, but should be dated. Review on 7/13/22 of the manufacturer's instructions on the nutritional shakes revealed: Store frozen. Thaw under refrigeration (40 degrees or below). After thawing, keep refrigerated. Use within 14 days after thawing. Observation on 7/13/22 at 8:50 a.m. revealed dry dark brown debris in the meat slicer. Interview on 7/13/22 at approximately 8:51 a.m. with Staff E confirmed that the meat slicer had dry dark brown debris on it and confirmed the meat slicer was not used during breakfast. Review on 7/13/22 of the Cleaning Instructions: Slicers Policy: The slicer will be cleaned and santized after each use.

Based on interview and record review, it was determined the facility failed to notify resident representatives and families of those residing in the facility by 5 p.m. the next calendar day following the subsequent occurrence each time a confirmed infection of COVID-19 is identified for 4 of 5 days reviewed from July 5, 2022 to July 13, 2022 [when there were newly confirmed positive COVID-19 cases]. Findings include: Interview on 7/13/22 at 8:51 a.m. with Staff A (Administrator) revealed that the facility had 13 residents and 6 staff members positive for COVID-19. Review on 7/14/22 of the facility's COVID-19 line listing (for both staff and residents) revealed that the the facility received positive COVID-19 test results on 7/5/22, 7/6/22, 7/7/22 , 7/10/22, and 7/12/22. Interview on 7/14/22 at 12:04 p.m. with a family member (who wished to remain anonymous) revealed that he/she had received two emails from the facility for the current COVID-19 facility outbreak. The family member confirmed the emails were dated 7/6/22 and 7/12/22. The family member stated he/she wished there were more updates and inquired if the virus had spread to more residents. Review on 7/14/22 at 12:46 p.m. of the facility's emails to families/representative confirmed that two emails were sent and revealed the following: -On 7/6/22 the email identified three COVID-19 positive residents. -On 7/12/22 at 7:24 a.m. the email stated that the facility continued to be in a COVID-19 outbreak and that the facility would be doing rapid testing 7/12/22). Interview on 7/14/22 at 4:06 p.m. with Staff A (Administrator) revealed that he/she will email families/representatives with the COVID-19 updates. Staff A confirmed that the above two emails were the only emails he/she could find that were sent. Interview on 7/15/22 at 12:27 p.m. with Staff B (Regional Nurse) confirmed that families/representatives were not notified of COVID-19 conditions on 7/7/22, 7/8/22, 7/11/22 and 7/13/22. Review on 7/15/22 of the facility's policy Coronavirus Surveillance revised on 6/1/22 revealed .9. Surveillance data will be used for reporting to . staff, residents, and resident representatives . c. Residents and representatives will be kept up to date on the conditions inside the facility related to COVID-19. Minimum information to be reported: i. Within 12 hours and subsequently: the occurrence of a single confirmed infection of COVID-19, or 3 or more residents or staff with new-onset of respiratory symptoms that occur within 72 hours. ii. Weekly: Update on conditions, such as current numbers of COVID-19 case or suspected cases .

Based on observation, interview, and record review it was determined that the facility failed to develop a comprehensive care plan in order to provide the appropriate care and services for 2 of 3 residents reviewed for Respiratory Care in a final sample of 16 residents. (Resident identifiers are #17 and #3 ). Findings include: Resident #17 Observation on 7/13/22 at 11:12 a.m. of Resident #17 revealed he/she was in bed with a [CONDITION(S)] machine on. Review on 7/15/22 of Resident #17's progress notes revealed the following: -On 5/30/22 at 4:13 a.m. [CONDITION(S)] in place. -On 7/13/22 at 4:56 a.m. [CONDITION(S)] in place. Interview on 7/15/22 at 4:15 p.m. with Staff I (MDS) revealed that there was not a care plan for Resident #17's [CONDITION(S)] machine, including for care, cleaning, and for settings. Review on 7/15/22 of the facility's policy Care Plan Development and Implementation dated 7/1/21 revealed, .Policy: Each resident will have an individualized interdisciplinary plan of care in place .3. The interdisciplinary team will develop and implement the Comprehensive Care Plan within 21 days of admission . 7. The Care Plan Summary will include: Treatments . Resident #3 Observation on 7/13/22 at approximately 9:35 a.m. revealed a [CONDITION(S)] (Continuous Positive Airway Pressure) machine, hose and mask on Resident #3's bedside stand. Interview on 7/13/22 at approximately 9:35 a.m. with Resident #3 indicated that he/she wears the [CONDITION(S)] every night. Review on 7/14/22 of Resident #3's care plan revealed no documented evidence of interventions including care, cleaning and for setting for a [CONDITION(S)] care plan for Resident #3. Interview on 7/15/22 at approximately 2:30 p.m. with Staff D (Nurse Practitioner), and Staff A (Administrator) and review of the TAR, care plan and nursing progress notes confirmed that Resident #3 that there was not a care plan for Resident #3's [CONDITION(S)] machine, including for care, cleaning, and for settings. Review on 7/15/22 of the facility's policy Care Plan Development and Implementation dated 7/1/21 revealed, .Policy: Each resident will have an individualized interdisciplinary plan of care in place .3. The interdisciplinary team will develop and implement the Comprehensive Care Plan within 21 days of admission . 7. The Care Plan Summary will include: Treatments .

Based on observation, interview, and record review it was determined that the facility failed to ensure that services met professional standards according to accepted standards of clinical practice for 1 of 4 residents reviewed for pain management, following physicians orders for 1 out of 11 residents reviewed, and clarifying physicians orders for 2 out of 11 residents reviewed in a final sample of 11 residents. (Resident identifiers are #24, #38, #41 and #140.) Findings include: Professional reference: Potter, Patricia A., and Anne Griffin Perry. Fundamentals of Nursing. 7th Edition, St Louis, Missouri: Mosby Elsevier, 2009. Chapter 23 Legal Implications Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Chapter 35 Medication Administration Page 699-Prescriber's Role Prescriber must document the diagnosis, condition, or need for use for each medication ordered Page 706-709-Standards The prescriber often gives specific instructions about when to administer a medication Resident #24 Observation on 6/29/21 at 11:00 a.m. of Staff D (Medication Nursing Assistant) administering medications to Resident #24 revealed that after administering the resident's routine medications Resident #24 asked Staff D for two acetaminophen. Staff D administered the PRN (as needed) acetaminophen without asking the resident what the medication was for and without asking a nurse to assess the resident. Interview on 6/29/21 at 11:10 a.m. with Resident #24 revealed he/she requested the acetaminophen for shoulder pain. Interview on 6/29/21 at 1:20 p.m. with Staff D confirmed that he/she did not consult the nurse prior to administering the medication. Staff D stated the resident requested the acetaminophen for leg pain. Review on 6/30/21 of Resident #24's June Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] tablet give 600 milligrams (mg) by mouth every 8 hours as needed for pain [level of] 6 - 7. This was given on 6/2/21, 6/5/21, 6/6/21, 6/11/21, 6/14/21, 6/15/21, 6/19/21, 6/22/21, 6/30/21 (nine days) without documenting the pain level assessed. - Acetaminophen 500 mg give 2 tablets every 4 hours as needed for pain. This was administered on 6/1/21, 6/2/21, 6/9/21, 6/11/21, 6/15/21, 6/16/21, 6/18/21, 6/29/21 with no assessment for pain. Interview on 6/30/21 at 1:59 p.m. with Staff B (Assistant Director of Nurses) confirmed that there were no pain assessments for administration of both acetaminophen and [MEDICATION(S)] on the above dates for Resident #24. Review of the facility's job description titled Medication Nursing Assistant read, in part, . Essential Job Functions: Responsibilities and Standards . 2. Documents resident care services . Appropriately notifying the charge nurse on duty prior to as needed medication usage Resident #41 Review on 6/29/21 of Resident #41's April and May 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] April 2021 [MEDICATION(S)] 25 MG (milligram) Give 1 tablet by mouth two times a day for hypertension, hold if SBP (systolic blood pressure) less than 100/HR (heart rate) less than 55. Order date 4/20/21. Review on 6/29/21 of Resident #41's April MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . May 2021 [MEDICATION(S)] 25 MG Give 1 tablet by mouth two times a day for hypertension hold for SBP less than 100/HR less than 55. Order date 4/20/21. Review on 6/29/21 of Resident #41's May MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 6/29/21 of Resident #41's May MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 6/30/21 at approximately 10:00 a.m. with Staff B (Assistant Director of Nurses) confirmed that the medications were administered outside of the physician's indicated parameters. Resident #140 Review on 6/30/21 of Resident #140's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] HCl solution Reconstituted 1 GM (gram) Use 1 gram intravenously every 12 hours for leg wound until 6/30/21, Order date 6/24/21. [MEDICATION(S)] Flush Solution, Use 10 ml (milliliters) intravenously every 8 hours for IV (intravenous) patency flush with 10 cc (cubic centimeter) of 0.9% [MEDICATION(S)], Order date 6/24/21. Interview on 6/30/21 at approximately 9:00 a.m. with Staff B revealed that the [MEDICATION(S)] flush solution order was transcribed incorrectly, The flush should be before and after the administration of the antibiotic. Review on 6/30/21 of the facility policy titiled, 2-4 Flushing of Venous Access devices, effective date February 20, 2017 revealed: .Vascular Access Device Flushing Protocol .Midline . 10 ml NS (Normal Saline) Pre-med flush (Yes) .10 ml NS Post-med flush (Yes) . Resident #38 Review on 6/30/21 of Resident #38's June 2021 MAR's (Medication Administration Record) revealed the following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] Sodium (Porcine) Solution 5000 UNIT/ML (milliliter) Inject 5000 unit subcutaneously every 12 hours for DVT (Deep Vein Thrombosis) Prophylaxis, May D/C (discontinue) when completed. Order date, 6/3/21. Interview on 6/30/21 at approximately 12:30 p.m. with Staff B stated, The current order does not indicate when it should be discontinued, The order should say, May D/C when the resident is ambulatory.

Based on observation, interview, pharmacy recommendations for injectable medications, and facility policy's review, it was determined that the facility failed to date opened multidose medications in 1 out of 1 medication rooms and failed date opened multidose medications to properly store a medication that required refrigeration in 2 out of 2 medication carts observed. Findings include: Medication Room Observation on 6/29/21 at approximately 9:35 a.m. of the facility medication room revealed the following: 3 vials of [MEDICATION(S)] (Tuberculin) test opened in the refrigerator Interview on 6/29/21 at approximately 9:35 a.m. with Staff A (Director of Nurses) confirmed that the vials in the refrigerator were opened and were not labeled with an opening date. Review on 6/30/21 of the [pronoun omitted] Pharmacy Solutions, Recommended Minimum Medication Storage Parameters* (based on manufacturers guidance) Injectable Medications, revised 1/16 revealed: .[MEDICATION(S)] Injection (tuberculin test), . Date when opened and discard unused portion after 30 days East Medication Cart Observation on 6/29/21 at approximately 9:45 a.m. with Staff D (Medication Nurse Assistant) revealed Resident #36 had a [MEDICATION(S)] Insulin Pen in the East Medication Cart opened and not labeled with an opening date. Interview on 6/29/21 at approximately 9:50 a.m. with Staff C (Licensed Practical Nurse) confirmed that Resident #36's [MEDICATION(S)] Insulin Pen was opened and was not labeled with an opening date. Review on 6/30/21 of the facility policy titled, Labeling of Medication Containers, revised date April 2007 revealed: Policy Statement All medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations 3. Label for individual drug containers shall include all necessary information, such as: .h. The expiration date when applicable; . Resident #36 (North Medication Cart) Observation on 6/30/21 at 7:35 a.m. of Staff E (Licensed Practical Nurse) during medication pass revealed Staff E removed a bottle of Acidophilus with [MEDICATION(S)] (a [MEDICATION(S)] dietary supplement) from the medication cart and administered the supplement to a resident. Review on 6/30/21 at 7:35 a.m. of the bottle revealed the handwritten date of 5/18/21 (on the cap) and that the directions on the bottle read (in bold print), Refrigerate after opening. The bottle contained 5 of the original 100 capsules. The bottle was not cold. Interview on 6/30/21 at approximately 7:40 a.m. with Staff E confirmed the bottle was stored in the cart and that the date on the cap was the date the bottle had been opened. Staff E stated he/she did not know that it needed to be refrigerated after opening.

Based on record review, and interview it was determined that the facility failed to ensure 1 resident out of 5 residents reviewed for unnecessary medications were free from chemical restraints out of a final sample of 11 residents. (Resident identifier is #38.) Findings include: Review on 6/30/21 of Resident #38's June 2021 MAR (Medication Administration Record) revealed the following PRN (as needed) medications administered simultaniously: Trazadone HCL (Hydrochloride) Tablet 50 MG (milligrams) Give 0.5 tablet by mouth every 8 hours as needed for anxiety, Order date 6/8/21. Administered 6/10/21 at 1609. [MEDICATION(S)] Tablet 25 MG (Quetiapine Fumurate) Give 25 MG by mouth every 8 hours as needed, Order date 6/8/21. Administered 6/10/21 at 1609. Oxycodone HCL Tablet 5 mg Give 1 tablet by mouth every 4 hours as needed for Severe Pain 7-10, Order date 6/3/21. Administered on 6/10/21 at 1610. [MEDICATION(S)] Tablet 3 MG Give 2 tablets as needed QHS (every bedtime) for [CONDITION(S)], Order date 6/3/21. Administered on 6/10/21 at 1611. Interview on 6/30/21 at approximately 12:00 p.m. with Staff B (Assistant Director of Nurses) revealed that he/she would expect a PRN medication for [CONDITION(S)] would not be administered at 4:00 p.m.s Staff B said, PRN sleep medications are usually administered between 8:00 p.m. to 9:00 p.m. or later. Interview on 6/30/21 at approximately 3:00 p.m. with Staff I (Licensed Practical Nurse) revealed that on 6/10/21 he/she gave the MNA (Medication Nurse Assistant) orders on 6/10/21 to administer the 4 PRN's within 3 minutes from each other. Staff I revealed that Resident #38 made numerous attempts to stand and was going to fall and hurt themself. Staff I stated the medications that [pronoun omitted] has prescribed don't work and it is not my job to notify the physician that the medications are not working. The resident had not slept in days and needed something to sleep. Staff I revealed that he/she would administer the 4 PRN medications again in the same time period without waiting any time in between administering the doses to determine the effectiveness of each medication. Review on 7/1/21 of Nursing 2021 Drug Handbook, 41st edition, revealed the following: Trazadone: can cause drowsiness, dizziness, nerousness, fatique, and confusion. [MEDICATION(S)]: can cause dizziness, headache, drowsiness, and somolence. Oxycodone HCL: can cause respiratory and circulatory depression.

Based on observation, inteview and record review, it was determined that the facility failed to ensure thr medication error rate was not greater than 5% (percent) during medication administration observations with 28 medication opportunities. (Resident identifier #10) Findings include: Observation on 6/30/21 at 7:20 a.m. of Staff F (Medication Nursing Assistant) administering medications to Resident #10 revealed that Staff F poured one tablet of Vitamin D 1000 units (25 micrograms (mcg)) and one tablet of Vitamin B12 500 mcg and administered them whole to Resident #10. Resident #10 was observed swallowing both medications. Review on 6/30/21 at approximately 7:25 a.m. of Resident #10's Medication Administraton Record revealed: Vitamin D tablet give 2000 units by mouth one time a day; Vitamin B12 tablet 500 mcg give 1 tablet sublingually (placing tablet under the tongue to disolve) one time a day. Interview on 6/30/21 at 7:30 a.m. with Staff F confirmed they gave Resident #10 the incorrect dose of Vitamin D and stated they should have 2 tablets to equal 2000 units. Staff F confirmed that the order did not specify how many tablets of Vitamin D to administer and should have clarified it with a nurse. Staff F confirmed that they did not adminsiter the Vitamin B12 as ordered. Interview on 6/30/21 at 7:31 a.m. with Staff C (Licensed Practical Nurse) confirmed that Resident #10 should have received 2 tablets of the Vitamin D. Review on 6/30/21 of the facility's undated policy titled 6-1 Medication Administration Specific Procedures reveal .4. Open medication book to the appropriate resident and note the first medication to administer. Nurse is respinsuble for any [NAME] on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Prepare medication as follows: a. pour the correct number of tablets or capsules into the medication cup There were 2 medication errors out of a total of 28 medication administration opportunities resulting in a 7.14% error rate.

Based on observation, interview, and policy review, it was determined that the facility failed to adhere to the Centers for Disease Control and Prevention (CDC) guidelines for universal masking in a facility with a census of 35 residents. Findings include: Observation on 6/29/21 at approximately 11:15 a.m. at the nursing station revealed Staff C (Licensed Practical Nurse) with surgical mask below Staff C's chin. Interview on 6/29/21 at approximately 11:15 a.m. with Staff C revealed that he/she was sneezing and removed surgical mask. Observation on 6/29/21 at approximately 1:00 p.m. with Staff G (Licensed Nursing Assistant) in the resident hallway (near the nursing station) revealed Staff G's surgical mask was below his/her nose. Interview on 6/29/21 at approximately 1:00 p.m. with Staff G stated, I know it [the surgical mask] keeps falling. Interview on 6/30/21 at approximately 1:00 p.m. with Staff A (Director of Nursing/Infection Preventionist) confirmed that all staff should have a surgical mask on when in resident areas. Observation on 6/29/21 at 2:15 p.m. of Staff E (Licensed Practical Nurses) sitting at the nurses' station talking on the telephone. Staff E's face mask was below his/her chin. Interview on 6/29/21 at 2:30 p.m. with Staff E confirmed that he/she had the face mask below his/her chin and that the mask should be on when at the nurses station. Interview on 6/29/21 at approximately 2:30 p.m. with Staff A (Director of Nurses) confirmed that masks should be worn to cover the nose and mouth at the nurses' station. Review on 6/30/21 of The CDC's Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-COV-2 Spread in Nursing Homes, updated 3/29/21 revealed: . HCP should wear well- fitting source control at all times while they are in the healthcare facility, including in breakrooms or there spaces where they might encounter co-workers Review on 7/1/21 of the facility's Healthcare Personnel COVID-19 Vaccination Cumulative Summary of Long-Term Care Facilities tracking worksheet revealed that Staff E was not listed as having received a COVID-19 vaccination. Telephone interview on 7/1/21 at approximately 10:00 a.m. with Staff A confirmed that Staff E had not been vaccinated for COVID-19.

Based on observation, interview, and record review, it was determined that the facility failed to follow physician orders [REDACTED]. (Resident identifiers are #27 and #39.) Findings include: Professional reference: Potter, Patricia A., and Perry, Anne Griffin. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Resident #27 Interview on 10/29/18 at approximately 9:50 a.m. with Resident #27 revealed that Resident #27 had difficulty hearing and needed to have questions repeated. Resident #27 stated that they were supposed to get ear drops and then an ear flush, but that it did not happen and that they did not know why. Review on 10/30/18 of Resident #27's (MONTH) (YEAR) and (MONTH) (YEAR) Medication Administration Records revealed that Resident #27 had an order for [REDACTED].#27 received [MEDICATION NAME] ear drops on 9/30/18 at 6:02 p.m., but never received any ear drops or flushing after that initial dose. Interview on 10/30/18 at approximately 2:30 p.m. with Staff A (Director of Nursing) confirmed that the physician orders [REDACTED].#27's ear drops and flushing. Resident #39 Observation on 10/29/18 at approximately 9:00 a.m. revealed that Resident #39 had a PICC (peripherally inserted central catheter) line in the right upper arm. Review on 10/30/18 at approximately 10:30 a.m. of Resident #39's physicians order revealed the following order dated 10/3/18: Change PICC dressing to right upper extremity once a week day shift every Wednesday. Document site condition, measure length of catheter and arm circumference. Interview on 10/30/18 at approximately 10:45 a.m. with Staff A Director of Nurses revealed that there was no documentation of the catheter length and arm circumferences being measured weekly. Review on 10/31/18 at approximately 9:30 a.m. of the facility policy and procedure titled, 4-5 Central and Midline catheter care and maintenance, revision date (MONTH) (YEAR), effective date (MONTH) 20,2017 revealed: .General Information . Assess for any signs and symptoms of complication or malfunction. If exists, LIP (Licensed Independant Practitioner) shall be notified . Procedure . Assess insertion site including resident site and skin condition as well measurement of external catheter . Documentation . catheter length and external measurement .

Based on observation, interview, and policy review, it was determined that the facility failed to ensure proper storage of expired medications for 1 out of 1 observed medication room. Findings include: Policy: Review on 10/30/18 of facility's policy titled, 7-3 Disposal of Medication Syringes and Needles, revealed that .1. All discontinued medication must be removed from active medications in the medication cart/cabinets immediately .Ointments, creams, and similar substances are placed in trash receptacles in the medication room. Tablets, capsules, and liquids are disposed of in acceptable manner .Expired medications should be destroyed as per above procedures . Observation on 10/29/18 at 9:20 a.m. of the medication room revealed that there were expired Over The Counter (OTC) medications which were 1 opened box of Salonpas (pain relief patch) with an expired date of 7/2018, 1 unopened bottle of [MEDICATION NAME] ([MEDICATION NAME]) oral drops with an expired date of 9/18, 1 unopened box of Dairy Aide (enzyme supplement) with an expired date of 9/2018, and 2 unopened boxes of Altalube ointment (eye lubricant) with an expired date of 9/18 that were stored in the cabinets with the unexpired medications. Interview on 10/29/18 at 9:21 a.m. with Staff B (Registered Nurse) confirmed the above findings. Interview on 10/29/18 at 9:22 a.m. with Staff A (Director of Nursing) revealed that the facility would remove expired medications from the unexpired medications in the cabinet and place the expired medications on the left side countertop to be destroyed per facility policy.

Based on observation, interview and review of manufacturers instructions, the facility failed to properly cover and date food items, as well as to separate non-food items, ice packs, from food items in the one facility kitchenette. Findings include: Observation on 10/3/17 at approximately 9:45 a.m. of the kitchenette located on the East Wing revealed the following: 1. Five Mighty shakes in the refrigerator with no date written on them. 2. Two banana yogurts in the refrigerator, both opened with the foil cover not completely down to cover the opening. Neither of the yogurts were dated. 3. A container of Good Belly [MEDICATION NAME] in the refrigerator, opened but not dated. 4. Four ice packs in the freezer next to food items. Interview on 10/3/17 at approximately 9:45 a.m. with Staff C (Licensed Nursing Assistant) revealed that one of the four ice packs was for Staff C's mouth as Staff C had just had teeth extracted. Review on 10/5/17 of the Manufacturer's Instructions for Mighty Shakes, Revision Date: 9/18/14, revealed that the .Shelf Life: Unopened: 15 months (450 days) frozen .Refrigerated: 14 days thawed. Observation on 10/4/17 at approximately 10:00 a.m. of the kitchenette located on East Wing revealed the following: 1. One banana yogurt in the refrigerator, opened with the foil cover not completely down to cover the opening. The yogurt was dated with the date that was put on it on 10/3/17 during the previous observation of the kitchenette. 2. A container of thickened prune juice, open with no date on it. Observation on 10/5/17 at approximately 1:00 p.m. of the kitchenette located on East Wing revealed the following: 1. One banana yogurt in the refrigerator, opened with the foil cover not completely down to cover the opening. The yogurt was dated with the date that was put on it on 10/3/17 during the observation of the kitchenette. 2. A container of thickened prune juice, open with no date on it. 3. An ice pack in the freezer next to food items. Interview on 10/3/17 at approximately 9:45 a.m. with Staff D (Licensed Practical Nurse) revealed that the banana yogurts were for a resident who used them for medication administration. Staff D removed one of the yogurts and dated the other as Staff D stated that Staff D observed that yogurt being opened that morning. Staff D confirmed that the Mighty Shakes and the Good Belly [MEDICATION NAME], which Staff D removed, should have been dated. Staff D also confirmed that the ice packs should not have been in the freezer with food items, and Staff D removed the ice packs. Interview on 10/5/17 at approximately 1:00 p.m. with Staff B (Director of Nursing) confirmed that the yogurts should have been covered, that the prune juice should have been dated when opened and that the ice pack should not have been in that freezer.