Every finding on record at Hackett Hill Healthcare Center

Based on observation, interview, and record review, the facility failed to ensure that the water management plan accurately described the facility's water system, failed to identify all specific areas where Legionella and other opportunistic waterborne pathogens may grow, failed to outline control measures to prevent such growth, and failed to establish monitoring procedures with defined acceptable ranges that had the potential to affect the facility with a census of 62 residents.Findings include: Review on 4/22/26 of the facility's water management plan, review date of 3/25/26, revealed the following: The water management plan description and flow diagram section identified that water flowed through the boilers and heat up to 142 plus degrees (it did not specify Fahrenheit or Celsius). Further review revealed that on the domestic side, water was delivered at 142 plus degrees (it did not specify Fahrenheit or Celsius) to a mixing valve, where hot water is balance with cold water to a temperature of 105 to 120 degrees (it did not specify Fahrenheit or Celsius). All hot water is delivered to faucets and showers throughout the building. It did not describe how many boilers and where the water flows from which boilers. The water management plan revealed the areas subject to Legionella included dead legs and hot water holding tanks. The plan did not describe the locations of dead legs in the facility, and the number of hot water holding tanks and where water flows from which hot water holding tanks. The water management plan revealed the following section of the control measures: Hot water temperatures were monitored weekly at point of delivery, on the commercial side, washing machine, dish machine, and three bay sinks. On the domestic side, random faucets and showers. The control measure for monitoring hot water temperatures did not specify acceptable ranges for temperatures and did not indicate to monitor temperature of the water holding tanks. There were no control measures for dead legs. The control measures for HVAC (Heating, Ventilation, and Air Conditioning)/PTAC (Packaged Terminal Air Conditioner) was to inspect and change filter every three months. The control measure for hot water holding tanks was to flush the tanks monthly, it did not indicate to monitor temperatures, and it did not specify acceptable ranges for temperatures. Interview on 4/23/26 at approximately 9:51 a.m. with Staff D (Infection Preventionist) revealed that that he/she was not involved in reviewing the control measures outlined in the water management plan. Further interview revealed that Staff E (Maintenance Director) was responsible for implementing the control measures outlined in the facility's water management plan. Interview on 4/23/26 at approximately 9:51 a.m. and approximately 11:30 a.m. with Staff E (Maintenance Director) revealed that the boilers were operating at 180 degrees Fahrenheit and the water holding tanks were at 160 degrees Fahrenheit. Interview with Staff E revealed that he/she initially stated there were no dead legs in the facility, then later clarified that the facility has six dead legs. Staff E reported that he/she flushes the water holding tanks weekly but does not document this activity. Staff E also stated that he/she flushes the six dead legs weekly and does not document this activity. Further interview with Staff E revealed that the facility utilizes an HVAC (Heating, Ventilation, and Air Conditioning) system and PTAC (Packaged Terminal Air Conditioner) units. The PTAC units are located in the [NAME] unit, are used during the summer, and Staff E cleans and washes the filters weekly on Fridays and does not document this activity. Observation on 4/23/26 at approximately 11:30 a.m. with Staff E of the facility revealed a boiler located in the mechanical room behind the main kitchen with a temperature gauge that read 180 degrees Fahrenheit. In the chemical storage room near the main kitchen, there was a water holding tank with no temperature gauge. The storage room between the chemical storage room and the laundry room, there was a water holding tank with three temperature gauge and none of them were above 140 degrees Fahrenheit. Further observation revealed a room next to the rehabilitation room revealed two boilers that had temperature gauges that read 180 degrees Fahrenheit when the pump was on and a water holding tank with a temperature gauge that read approximately above 140 degrees Fahrenheit. Interview on 4/23/26 at approximately 11:30 a.m. with Staff E confirmed the above observation and that he/she did not check the temperature of the water holding tanks that was in the chemical storage room and the room between the chemical storage room and laundry room. Review on 4/23/26 of the weekly temperature logs from January 2026 to April 2026 revealed missing temperatures and locations for the boilers and water holding tanks: On 1/2/26, 1/9/26, 1/16/26, 1/23/26, and 1/30/26, no temperatures and locations were documented for the three boilers and three water holding tanks; On 2/26/26, 2/13/26, 2/20/26, and 2/27/26, no temperatures and locations were documented for the three water holding tanks. On 2/13/26, boiler #1 (located in the [NAME] unit next to the rehabilitation room) had a temperature of 100 degrees when the pump was off and no temperature was documented when the pump was on; On 3/6/26,3/12/26, and 3/27/26, one (160 degrees) temperature was documented for a water holding tank and it did not specify which water holding tank. On 3/16/26, no temperatures and locations were documented for the three boilers and three water holding tanks; and On 4/3/26, 4/10/26, and 4/17/26, one (160 degrees) temperature was documented for a water holding tank and it did not specify which water holding tank. Review on 4/23/26 of the weekly flushing logs for the water lines in unoccupied resident room sink, bathroom sink or shower/tub unit, and dead legs from January 16, 2026 to March 2026 revealed the following:Flushing was documented on 1/16/26, 1/23/26, 1/30/26, 2/6/26, 2/13/26, 2/20/26, 2/27/26, 3/5/26, 3/12/26, and 3/27/26 at the following locations: Central Supply, Derryfield Soiled, Laundry sink/hopper, [NAME] Soiled, [NAME] Supply, [NAME] Tub, Rehabilitation dishwasher, and Rehabilitation washing machine. On 3/27/26, flushing was also documented for room [ROOM NUMBER] and room [ROOM NUMBER]. There was no documentation indicating dead legs were flushed weekly. Review on 4/24/26 of maintenance logs revealed that there were five HVAC in the facility and the PTAC cleaning log revealed that PTAC units were last cleaned on 3/23/26. The log did not indicate which PTAC units were cleaned and how many were cleaned. Interview on 4/24/26 at approximately 11:00 a.m. with Staff G (Regional Maintenance Director) revealed that the all the PTAC units were cleaned and that the cleaning log did not specify how many and which PTAC units were cleaned. Staff G also revealed that there were six PTAC units in the facility.Review on 4/24/26 of the CDC website title, Controlling Legionella in Potable Water Systems, dated 1/3/25, retrieved from:https://www.cdc.gov/control-legionella/php/toolkit/potable-water-systems-module.html, revealed, .Operation, maintenance, and control limits Monitor temperature, disinfectant residuals, and pH [potential of hydrogen] frequently based on performance of WMP or Legionella performance indicators for control. Adjust measurement frequency according to the stability of performance indicator values. For example, increase the measurement frequency if there's a high degree of measurement variability. Hot water: Store hot water at temperatures above 140 F (60 C). Ensure hot water in circulation does not fall below 120 F (49 C). Recirculate hot water continuously, if possible .Flushing: Flush low-flow piping runs and dead legs at least weekly. Flush infrequently used fixtures (e.g., eye wash stations, emergency showers) regularly as needed to maintain water quality parameters within control limits . Legionella control measures Review on 4/24/26 of the CDC website title, Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings, dated 9/30/25, retrieved from: https://www.cdc.gov/control-legionella/media/pdfs/toolkit.pdf, revealed .Elements of a Water Management Program .Describe Your Building Water Systems Using Text .This description should include details like where the building connects to the municipal water supply, how water is distributed, and where pools, hot tubs, cooling towers, and water heaters or boilers are located Describe Your Building Water Systems Using a Flow Diagram .Identify Areas Where Legionella Could Grow & Spread .Once you have developed your process flow diagram, identify where potentially hazardous conditions could occur in your building water systems .Control Measures & Corrective Actions: The Basics .Decide Where Control Measures Should Be Applied .Control measures and limits should be established for each control point .Control measures and limits should be established for each control point .Decide How to Monitor Your Control Measures .Decide How to Monitor Your Control Measures Verification: Are we doing what we said we would do? Your program team should establish procedures to confirm, both initially and on an ongoing basis, that the water management program is being implemented as designed. This step is called verification. For example, if you said you would test the hot tub daily for chlorine and record and communicate those results, have you been doing that? If you found a problem, did you take the action included in your program? People should not verify the program activity for which they are responsible. For example, if one person is responsible for maintaining the hot tub and another is responsible for the cooling tower, they could verify each other's work, not their own .Validation: Is our program actually working? Now that you have a water management program, you need to be sure that it is effective. Your program team should establish procedures to confirm, both initially and on an ongoing basis, that the water management program effectively controls the hazardous conditions throughout the building water systems. This step is called validation .Document & Communicate All the Activities of Your Water Management Program .

Based on observation, interview, and record review, the facility failed to follow professional standards for1 of 3 resident observed for medication administration and for 1 of 1 residents reviewed for general concerns in a final sample of 18 residents. (Resident identifiers are #43 and #56.)Findings include: Standard: [NAME], [NAME] A., and [NAME] [NAME]. Fundamentals of Nursing. 10th edition St. Louis, Missouri: Elsevier, 2021. Page 614 .It is essential to verify the accuracy of every medication you give to your patients with the patient's order .Do not give a medication until you are certain that you can follow the seven rights of medication administration . Page 639 .Before administering medication, it is critical that all information is correct. You should check for accuracy three times: 1. First check is when the medications are pulled or retrieved from the automated dispensing machine, the medication drawer, or whatever system is in place at the agency. 2. The second check is when preparation of the medications for administration takes place. 3. The final check occurs at the patient's bedside just before medications are given . Page 672 .seven rights of medication administration include right medication, right dose, right patient, right route, right time, right documentation and right indication . Resident #43 Review on 4/23/26 of Resident #43's April 2026's MAR (Medication Administration Record) revealed the following physician's orders: Metoprolol Succinate Oral Capsule ER (extended release) 24 hour sprinkle 50 mg (milligrams), Give 1 capsule by mouth two times a day for AFIB (afibrillation) HOLD for SBP (systolic blood pressure) < 110 or HR (heartrate) <60, start date 4/7/26. Further review revealed: the following am doses were administered with vital signs not within the parameters of the order: 8:00 a.m. 4/17 bp (blood pressure) 101/65, 4/18 bp 101/52, and 4/22 bp 106/66. The following pm doses were administered with vital signs not within the parameters of the order: 4/15 bp 105/60, 4/21 bp 101/64, and 4/22 104/63. Enestro Oral Tablet 49-51 mg, Give 1 tablet by mouth two times a day for HTN (hypertension), hold for SBP <110 or HR <60. Further review revealed: the following am doses were administered with vital signs not within the parameters of the order: 4/17 bp 101/65, 4/18 bp 101/52, 4/21 bp 99/60, 4/22 bp 105/68. The following pm doses were administered with vital signs not within the parameters of the order: 4/15 bp 105/60, 4/16 bp 97/61, 4/21 bp 101/64, and 4/22 104/63. Interview on 4/23/26 at approximately 10:30 a.m. with Staff A (Director of Nursing) confirmed the above findings. Review on 4/23/26 of the facility policy titled, Medication Administration, General Guidelines, dated 1/26, revealed, 3. Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record. Resident #56 Review on 4/23/26 at approximately 8:56 a.m. with Staff C (Licensed Practical Nurse) of Resident #56's Electronic Medication Administration Record (EMAR) during medication administration observation revealed a scheduled 9:00 a.m dose of Bupropion Hydrochloride (HCl) 75 milligram (mg) was due to be administered. Observation on 4/23/26 at approximately 8:56 a.m. with Staff C revealed that Staff C prepared Resident #56's medications. Staff C retrieved the Bupropion HCl 75 mg bingo card with orange round tablets but did not pop a tablet into the medication cup. Staff C proceeded to click Y [Yes] for the Bupropion HCl 75 mg in the EMAR. After popping the remaining medications, Staff C locked the medication cart, did not verify that all scheduled medications were in the medicine cup, and proceeded to Resident #56's room. Interview on 4/23/26 at approximately 8:56 a.m. with Staff C revealed that he/she marked the scheduled medications as Y in the EMAR after he/she popped it out of the medication bingo card and into the medicine cup. Interview on 4/23/26 at approximately 9:10 a.m. with Staff C revealed that he/she had completed preparing the scheduled medications for administration, indicating that he/she was about to administer the medications without the scheduled Bupropion HCl 75 mg dose for Resident #56. Staff C confirmed that the Bupropion HCl 75 mg (orange round tablet) was not in the medication cup. Observation on 4/23/26 at approximately 9:12 a.m. with Staff C revealed Staff C proceeded to administer Resident #56's medications and did not double-check the contents of the medication cup before handing it to Resident #56. Interview on 4/23/26 at approximately 9:17 a.m. with Staff C revealed that he/she would verify that all the scheduled medications were in the medication cup prior to handing it to residents. Review on 4/23/26 of the facility policy titled, Medication Administration General Guidelines, dated 1/26, revealed, .Verifying medication is correct three (3) times before administering the medication. a. When pulling medication package from med [medication] cart b. When dose is prepared c. Before dose is administered .

Based on observation, interview, and record review, it was determined that the facility failed to ensure proper treatment and care for good foot health for 1 of 2 residents reviewed for ADLs (activities of daily living) in a final sample of 18 residents. (Resident identifier is #18.)Findings include: Observation on 4/22/26 at approximately 9:00 a.m. of Resident #18's left foot revealed his/her toenails were thick and elongated. Interview on 4/22/26 at approximately 9:00 a.m. with Resident #18 revealed he/she was unsure of the last time they were seen by a podiatrist.Observation and Interview on 4/23/26 at approximately 8:15 a.m. with Staff F (Unit Manager) of Resident #18's left foot confirmed his/her toenails were thick and elongated. Interview on 4/23/26 at approximately 8:40 a.m. with Staff F revealed that Resident #18 was last seen by a podiatrist on 9/25/25. Further interview revealed the podiatrist was last at the facility on 12/29/25.Review on 4/24/26 of Resident #18's last podiatrist note, dated 9/25/25, revealed, Progress note . Non-professional treatment is hazardous to the patient, . Recall: As medically necessary but no sooner than 60 days.Review on 4/24/26 of the Podiatry Schedule for 12/29/25 revealed Resident #18 was not on the list to be seen.Interview on 4/24/26 at approximately 11:00 a.m. with Staff A (Director of Nursing) confirmed the above findings.Review on 4/24/26 of the facility policy titled, NSG217 Foot Care, Revision Date 8/7/23, revealed, Patients who have complicating disease processes requiring foot care including, ., must be referred to qualified professionals such as podiatrists or other qualified providers. The center is responsible for assisting patients in making appointments and arranging transportation to obtain needed services. Purpose, To ensure patients receive proper treatment and care to maintain mobility and good foot health.

Based on interview and record review, it was determined that the facility failed to have physician's orders at admission for a wound that resulted in hospitalization for 1 of 4 residents reviewed for wound care (Resident identifier is #3).Findings include:Review on 12/17/25 of Resident #3's medical record revealed he/she was admitted on [DATE].Review on 12/17/25 of Resident #3's Clinical Admission assessment, dated 11/5/25, revealed a puncture wound present on admission to the right groin.Review on 12/17/25 of Resident #3's Vascular Surgery Discharge summary dated [DATE], revealed discharge instructions for daily wound treatment to the right groin wound.Review on 12/17/25 of Resident #3's admission orders revealed no treatment orders for the right groin wound.Review on 12/17/25 of Resident #3's November 2025 Treatment Administration Record (TAR) revealed no wound treatments performed for the right groin wound.Review on 12/17/25 of Resident #3's progress note, dated 11/12/25, revealed that Resident #3 was sent to the hospital during a vascular surgery follow up appointment on 11/12/25.Review on 12/17/25 of Resident #3's vascular surgery visit note, dated 11/12/25, revealed Physical Exam:.RIGHT:.Right groin incision is seroma [the buildup of fluids under the skin] drainage and maceration and slough.Assessment/Plan:.[pronoun omitted] has been at rehab the past week and reports that [pronoun omitted] groin dressing was not changed. [pronoun omitted] now has wound dehiscence [the splitting or bursting open of a wound] macerated sloughed incision and draining seroma fluid. [pronoun omitted] will require admission and surgical debridement.Interview on 12/17/25 of Staff A (Director of Nursing) confirmed above findings and that Resident #3 went 7 days without treatment to their right groin wound.Review on 12/17/25 of the facility's documentation of corrective action for the above admission order omission revealed that all licensed nursing staff and leadership were re-educated on verifying and transcribing all medications and treatments from the hospital discharge summary (admitting orders) immediately upon the resident's arrival that was completed on 11/14/25, a facility-wide audit of all new admission orders for the past 30 days was completed on 12/14/25, monitoring accuracy of admission orders through audits and reviewing the audits at the Quality Assurance and Performance Improvement meetings.

Based on observation, interview and record review, it was determined that the facility failed to ensure staff wear appropriate (Personal Protective Equipment) PPE and perform hand hygiene during a dressing change for 1 of 1 resident observed for wound care (Resident identifier is #4).Findings include:Observation on 12/17/25 at approximately 9:50 a.m. revealed Resident #4 had a sign for Enhanced Barrier Precautions (EBP) next to their door. Staff B (Wound Nurse) performed hand hygiene and donned gloves and a gown while preparing to perform Resident #4's sacral dressing change. Staff B removed the wound dressing from Resident #4's sacral wound. Staff B doffed his/her gloves and donned clean gloves without performing hand hygiene in-between. Staff B cleansed the wound, doffed their gown and gloves, and exited the room. Staff B did not perform hand hygiene and proceeded to retrieve additional supply from the treatment cart. Staff B returned to Resident #4's room and performed hand hygiene and donned gloves. Staff B did not donn a gown. Staff B applied treatment to Resident #4 wound and applied the dressing.Interview on 12/17/25 at approximately 10:00 a.m. with Staff B confirmed above findings.Review of the Centers for Disease Control and Prevention recommendations retrieved 12/17/25 from Clinical Safety: Hand Hygiene for Healthcare Workers | Clean Hands | CDC revealed the following: Know when to clean your hands; Immediately before touching a patient. Before performing an aseptic task such as placing an indwelling device or handling invasive medical devices. Before moving from work on a soiled body site to a clean body site on the same patient. After touching a patient or patient's surroundings. After contact with blood, body fluids, or contaminated surfaces. Immediately after glove removal.Review on 12/17/25 of facility policy titled IC203 Hand Hygiene with a revision date of 5/1/25 revealed POLICY:.If a task requires gloves, perform hand hygiene, before donning gloves and immediately after removing gloves.Review on 12/17/25 of facility policy titled IC308 Enhanced Barrier Precautions with a revision date of 11/14/25 revealed .Definitions: Enhanced Barrier Precautions.it employs targeted personal protective equipment (PPE) use during high contact patient activities [dressing changes/wound care].

Based on interview and record review, it was determined that the facility failed to inform residents or resident's representative of the risk and benefits of psychotropic medication use for 2 out of 5 residents reviewed for unnecessary medications in final sample of 17 residents. (Resident identifiers are #16 and #50.) Findings include: Resident #16 Review on 3/12/25 of Resident #16's medical record revealed a physician's order for Ativan Oral Tablet 0.5 MG[milligram] (Lorazepam) Give 0.5 tablet by mouth two times a day for anxiety monitor for anxiousness, restlessness and other signs of anxiety, start date of 1/21/25. Further record review revealed there was no documentation of consent for the psychotropic medication use for Resident #16. Resident #50 Review on 3/12/25 of Resident #50's medical record revealed a physician's order for Buspirone HCL Oral tablet 15 MG (Buspirone HCL) Give 1 tablet by mouth two times a day for anxiety monitor for increased anxiousness, restlessness and other signs of anxiety, start date of 9/10/24. Further record review revealed there was no documentation of consent for the psychotropic medication use for Resident #50. Interview on 3/12/25 at approximately 2:20 p.m. with Staff D (Clinical Lead) confirmed the above findings. Review on 3/13/25 of the facilities policy Behaviors: Management of Symptoms Revision Date, 7/1/24 revealed .6. When a medication is ordered for behavioral symptoms: 6.1 Obtain Consent .

Based on observation, interview and record review it was determined that the facility failed to follow the professional standards of care for 3 residents in a final sample of 17 residents. (Resident identifiers are #33, #55 and #7.) Findings include: Standard: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 10th edition St. Louis, Missouri: Elsevier, 2021. Page 614 .It is essential to verify the accuracy of every medication you give to your patients with the patient's order. If the medication order is incomplete, incorrect, or inappropriate, or if there is a discrepancy between the original order and the information on the MAR [Medication Administration Record]. consult with the health care provider. Do not give a medication until you are certain that you can follow the seven rights of medication administration . Page 672 .seven rights of medication administration include right medication, right dose, right patient, right route, right time, right documentation and right indication .` Resident #33 Interview on 3/12/25 at approximately 7:35 a.m. with Staff F (Licensed Practical Nurse) revealed that Resident #33's CBG (capillary blood sugar) had obtained by a nurse on the the previous shift and was 151. Staff F had the CBG result written on a piece of paper. Further interview revealed that Staff F would use the CBG to decide if Resident #33 required insulin based on their physician order. Staff F thought the CBG was obtained around 6:45 a.m Observation on 3/12/25 at approximately 7:45 a.m. revealed Staff F administered 2 units of insulin to Resident #33 for the CBG of 151. Review on 3/12/25 of Resident #33's physician orders revealed the following order: Humalog Solution 100 unit/ml (milliliters) . inject as per sliding scale: . 151-200= 2 units, .subcutaneously before meals for sliding scale insulin coverage for diabetes must take finger stick blood glucose prior to administration., Start Date 1/18/25. Interview on 3/12/25 at approximately 1:30 p.m. with Staff E (Nurse Practitioner) revealed that he/she would expect CBG's to be performed closer to administration/meal time when a sliding scale is being used for insulin. Resident #55 Review on 3/11/25 of Resident #55's physician orders revealed the following order: Ertapenem Sodium Injection Solution Reconstituted 1 GM (gram), Use 1 gram intravenously in the morning for infection until 3/27/25, Start Date 2/20/25. Interview on 3/11/25 at approximately 11:00 a.m. with Staff B (Registered Nurse) and Staff D (Clinical Lead) confirmed the the above order did not have an infusion rate. Observation on 3/12/25 at approximately 8:30 a.m. of Resident #55's IV pole in his/her room revealed a bag that was empty with a hand written orange label 3/13/24 0730 without a pharmacy label or infusion rate. 51399 Standard: [NAME], P.A, [NAME], A.G., Stockhart, P.A., & Hall, A. (2021). Fundamentals of Nursing. Elsevier. Page 1262. Changing Dressings A Health care provider's order for wound care indicates the dressing type, the frequency of changing, and any solutions or ointments to be applied to the wound. Resident #7 Observation on 3/11/25 at approximately 9:50 a.m. revealed a dressing on Resident #7's lower left thigh that was undated. Interview on 3/11/25 at approximately 9:50 a.m. with Resident #7 revealed that Staff G (Registered Nurse) confirmed the above observation. Staff G stated that the dressing was applied the previous day. Review on 3/12/25 of Resident #7's Treatment Administration Record revealed that there was no active order on 3/11/25 to apply a dressing to Resident #7's left thigh. Interview on 3/12/25 at approximately 2:40 p.m. with Staff G confirmed that he/she applied the dressing without a physician's order. 49819

Based on observation, interview, and record review, it was determined that the facility failed to follow policies and procedures for 1 of 2 residents reviewed for Enhanced Barrier Precautions (EBP) (Resident identifier is #55) and 1 of 3 residents reviewed for disinfection of glucometer (Resident identifiers are #165 and #166). Findings include: Observation on 3/11/25 at approximately 11:40 a.m. of Staff C (Medication Nursing Assistant) revealed he/she went from Resident #165's room to Resident #166's room with a glucometer and a cup with alcohol wipes, lancets, and test strips in it, and no cleaning/disinfecting wipes. The glucometer was observed to not be visibly soiled. Review on 3/11/25 of Resident #165's and Resident #166's Medication Administration Record revealed provider orders for capillary blood glucose (CBG). Interview on 3/11/25 at approximately 11:40 a.m. with Staff C revealed that he/she tested capillary blood glucose for Resident #165 and then Resident #166. Further interview revealed he/she had not disinfected the glucometer between these residents. Staff C stated that he/she should have disinfected the glucometer between resident use with an Environmental Protective Agency (EPA) disinfectant. Review on 3/13/25 of facility policy titled Fingerstick Glucose Measurement with a review/revision date of 6/15/22 revealed .4. Clean and disinfect meter before use with EPA approved disinfectant, following manufacturer instructions .19. Clean and disinfect the blood glucose meter after use with EPA approved disinfectant, following manufacturer's instructions . Review on 3/13/25 of glucometer manufacturer instructions revealed 4. To disinfect your meter, clean the meter with one of the validated disinfecting wipes listed below. Other EPA registered wipes may be used . 38218 Resident #55 Observation on 3/11/25 at approximately 11:15 a.m. with Staff B (Registered Nurse) revealed Staff B accessing Resident #55's Peripherally Inserted Central Catheter (PICC) line without a face shield or protective gown on. Interview on 3/11/25 at approximately 11:15 a.m. with Staff B confirmed the above findings. Interview on 3/11/25 at approximately 2:15 p.m. with Staff A (Infection Preventionist) confirmed that staff should be wearing PPE when accessing a PICC line. Review on 3/11/25 of the facility policy titled, Infection Control Standards, Dated 10/24 revealed: . Standard Precautions are used during all resident care procedures that potentially expose the clinician to blood and bloody fluids is anticipated or there is the potential for splash or spray of blood or body fluids. Single use disposable gown, . Eye protection/face shield. Review on 3/11/25 of the facility policy titled, IC308 Enhanced Barrier Precautions, Revision Date 12/16/24 revealed: .Patient Status, Has a wound or indwelling medical device without secretions or excretions that are unable to be covered or contained and not known to be infected or colonized with MDRO (Multidrug Resistant Organisms), Use EBP. Review on 3/11/25 of the facility policy titled, Enhanced Barrier Precautions, Revision Date 5/1/24 revealed: .Enhanced Barrier Precautions, . Chronic wounds and/or indwelling medical devices (e.g., central line, .), .Device care or use central line, . Gown, gloves prior to high contact care activity, (Change PPE before caring for another patient) (Face protection may also be needed if performing activity with risk of splash or spray)

Based on observation, interview and record review, it was determined that the facility failed to maintain patient care equipment per manufacturer's instruction for 1 of 2 residents reviewed for respiratory care in a final sample of 17 residents. (Resident identifier is #7). Findings include: Interview on 3/11/25 at approximately 9:50 a.m. with Resident #7 revealed concerns that his/her Continuous Positive Airway Pressure (CPAP) machine parts needed replacement for a long time and no one is assisting with replacing the parts of his/her headpiece. Observation on 3/11/25 at 9:50 a.m. revealed that the head strap had brownish discoloration, areas of the head piece were in disrepair, and the tubing to the mask was yellowish in color. Interview on 3/12/25 at approximately 10:00 a.m. with Staff D (Clinical Lead) confirmed the above findings. Interview on 3/13/25 at approximately 10:40 a.m. with Staff K (Unit Manager) revealed that the face mask, tubing, and headgear have not been changed since Resident #7 was admitted to the facility. Review on 3/13/25 of Resident #7's medical record revealed that Resident #7 had been admitted to the facility in July of 2024. Review on 3/13/25 of Resident #7's March 2025 Treatment Administration Record (TAR) revealed a treatment order dated 2/10/24 for CPAP: Change or clean intake filter and disposable supplies(e.g., tubing) per manufacturer?s [sic] instructions. Every night shift, every Saturday and was completed on 3/1/25 and 3/8/25. Review on 3/13/25 of the manufacturer's instructions revealed . If any visible deterioration of system component is apparent ( .discoloration, .) the component should be discarded and replaced.3. Check the air filter and replace every six months .

Based on interview and record review, it was determined that the facility failed to ensure that the resident and/or resident representative was informed, in writing, the items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services for 2 of 2 residents reviewed for Beneficiary Notices who remained in the facility (Resident identifiers are #17 and #65). Findings include: Resident #17 Review on 3/11/25 of the Advanced Beneficiary Notice (ABN) - Resident discharged within the last 6 months form, completed by the facility, revealed Resident #17 was discharged from Medicare services and remained in the facility. Resident #17's last covered day was 10/31/24. Review on 3/11/25 of Resident #17's Skilled Nursing Facility (SNF) ABN dated 10/29/24 revealed that beginning on 11/1/24, Resident #17 will no longer require Physical Therapy, Occupational Therapy, Skilled Nursing Care, and will no longer be covered by Medicare. Further review revealed the SNF ABN did not contain the services that the facility offers and for which the resident may be charged, and the amount of charges for those services. Instead the SNF ABN stated Medicaid Rate as the per day/item or service. Resident #65 Review on 3/11/24 of ABN - Resident discharged within the last 6 months form, completed by the facility, revealed Resident #65 was discharged from Medicare services and remained in the facility. Resident #65's last covered day was 3/6/25. Review on 3/11/25 of Resident #65's SNF ABN dated 3/4/25 revealed that beginning on 3/7/25, Resident #65 will no longer required Physical Therapy, Occupational Therapy, Skilled Nursing Care, and will no longer be covered by Medicare. Further review revealed the SNF ABN did not contain the services that the facility offers and for which the resident may be charged, and the amount of charges for those services. Instead the SNF ABN stated Medicaid Rate as the per day/item or service. Interview on 3/11/25 at approximately 2:15 p.m. with Staff L (Clinical Care Coordinator) confirmed the above findings and that Staff L stated it was their practice to write Medicaid Rate instead of an estimated cost of items and services.

Based on interviews and record reviews, it was determined that the hospice agency and the facility failed to provide collaborative services for 1 of 1 resident reviewed for hospice services in a final sample of 18 residents (Resident Identifier #44). Findings include: Review on 4/2/24 of Resident #44's care plan for hospice revealed the following: Hospice Nursing 2-3x (times) a week and PRN (as needed) to assess and manage symptoms, comfort/pain, and bowel function, date initiated: 2/26/24 Hospice Nursing Assistant 1-2x a week to complement ADL (activities of daily living) care and provide comfort, date initiated: 2/26/24 Hospice Social Work 1x month and PRN to provide psychosocial support related to end of life care, date initiated: 2/20/24 Hospice Volunteer 1x month and PRN for companionship, date initiated 2/20/24 Review on 4/2/24 of Resident #44's Hospice Certification and Plan of Care (POC) dated 2/19/24 - 5/18/24, revealed: Frequency/Duration of Visits: SN 7x week x1, 3x week x12; Master of Social Work (MSW) 1x month x1; and Chaplain (CH) 1x month x1 Review on 4/2/24 of Resident #44's medical record revealed the following Communication/Continuation Notes from hospice: On 2/19/24 SN visit (medication recommendations), on 3/1/24 SN visit (medication recommendations), on 3/18/24 SN visit (medication recommendations), and on 4/1/24 SN visit (medication recommendations). Interview on 4/2/24 at approximately 12:00 p.m. with Staff C (Unit Manager) revealed there were no other notes from hospice visits than the above Communication/Continuation Notes. Staff C also revealed that he/she was only aware of SN from hospice coming in on Mondays. Staff C also confirmed that Resident #44's care plans and Hospice POC did not match. Interview on 4/2/24 at approximately 1:20 p.m. with Staff D (Administrator), who is the acting Hospice Liason, revealed that there was no communication between the hospice agency and the facility as to when visits would occur. Staff D also revealed that the hospice did not have any nursing assistants or volunteers available to visit with Resident #44. Review on 4/3/24 of the facility's policy titled OPS118 Hospice revision date 3/1/18 revealed: .5. The Center: .5.2 is responsible for ensuring that the hospice services provided meet professional standards and principles for the timeliness of those services. 6. The hospice and center must communicate, establish, and agree upon a coordinated plan of care which reflects the hospice philosophy and is based on an assessment of the patient's needs. The plan of care must include: . 6.2 The most recent hospice plan of care; .7.2.1.5 Obtaining the following information from the hospice; 7.2.1.5.1 Most recent hospice plan of care .

Based on observations, interviews, and record reviews it was determined that the facility failed to ensure the medication error rate was not 5 percent (%) or greater for 2 out of 4 residents observed for medication administration (Resident Identifiers #24 and #41). Findings include: Resident #24 Observation on 4/2/24 at approximately 7:30 a.m. of Staff A (Licensed Practical Nurse (LPN)) preparing medication for Resident #24 revealed Staff A was going to administer Aspirin 81 milligrams (mg). Further observation revealed Staff A removed Resident #24's Novolin N Insulin Pen and placed it on the medication cart. Staff A dialed the pen to 16 units. Staff A proceeded to administer the 16 units of insulin without rolling the pen (to ensure that the insulin in the pen was the correct dosage). Staff A did not prime the insulin pen and did not wait the 5 seconds prior to removing the insulin pen from Resident #24's abdomen. Review on 4/2/24 of Resident #24's April 2024 Medication Administration Record (MAR) revealed the following physician's orders: Novolin N Subcutaneous Suspension 100 UNIT/ML [milliliters], inject 16 units subcutaneously in the evening for DM [Diabetes Mellitus], start date 3/13/24; Aspirin EC [enteric coated] tablet delayed Release 81 mg, give 1 tablet by mouth one time a day for cardiac health, start date 2/2/24. Interview on 4/2/24 at approximately 7:35 a.m. with Staff A confirmed the above findings. Review on 4/2/24 of the manufacturer's instructions for Novoliln N FlexPen, revision date 6/22, revealed: .To resuspend FlexPen, gently move the pen up and down 20 times so the glass ball moves from one end of the cartridge to the other until the suspension appears uniformly white and cloudy. Inject immediately. Mixing by rolling and inverting the Pen is important to make sure you get the right dose .Priming your Pen .Prime before each injection. Priming your Pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin .To prime your Pen, turn the dose knob to select 2 units .Slowly push the plunger of the syringe all the way in, and then leave the needle in the skin for 10 seconds. If you are using a pen, while holding the base against the skin, push down on the injection button. You will hear a loud click. This will insert the needle and start the injection. Keep holding the pen against your skin until you hear a second click in about 5 to 10 seconds . Review on 4/2/24 of the facility's procedure titled Skills Checklist 8: Insulin Medication Administration, undated, revealed: .8 .c. Dial up 2 units of insulin (or per manufacturer's recommendations); hold pen upright and perform an air shot to prime the pen .18. During injection with a pen, push the plunger and slowly inject the insulin; hold the pen in place for 5-10 seconds per manufacturer's instructions . Resident #41 Observation on 4/2/24 at approximately 9:00 a.m. of Staff B's (LPN) medication administration with Resident #41 revealed: Staff B administered Resident #41's Miralax Oral Powder through his/her Jejunostomy tube. Review on 4/2/24 of Resident #41's April 2024 MAR revealed the following physician's order: Miralax Oral Powder 17 gm [grams]/scoop, give 1 scoop by mouth one time a day for bowel management, order date 3/29/24. Interview on 4/2/24 at approximately 9:00 a.m. with Staff B confirmed the above findings. There were 3 medication errors out of a total of 29 medication administration opportunities resulting in a 10.34% error rate.

Based on observations, interviews, and record reviews, it was determined that the facility failed to ensure open injectable medications were labeled in accordance with the manufacturer's instructions in 1 out of 2 medication carts and in 1 of 1 medication rooms observed and refrigeration temperatures were not monitored daily for medications storage in 1 out of 1 medication rooms observed. Findings include: Observation on 4/1/24 at approximately 8:10 a.m. of Webster Street Medication Cart revealed an open Lantus Insulin Pen without an open or open expiration date. Interview on 4/1/24 with Staff F (Registered Nurse) confirmed the above finding. Review on 4/2/24 of the Lantus Insulin Pen manufacturer's instructions revealed After 28 days, throw your opened Lantus pen away - even if it still has insulin in it. Observation on 4/1/24 at approximately 8:20 a.m. of the Derryfield Medication Room revealed an open vial of Tuberculin Purified Derivative without an open or open expiration date. Interview on 4/1/24 at approximately 8:20 a.m. with Staff G (Registered Nurse) confirmed the above finding. Review on 4/2/24 of the Tuberculin Purified Derivative manufacturer's instructions revealed: .Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency . Review on 4/2/24 of the facility's policy titled 5.3 Storage and Expiration Dating of Medications, Biologicals dated January 2022 revealed: .5.3 If a multi-dose vial of injectable medication has been opened or accessed (e.g. needle-punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial . Review on 4/1/24 of the medication refrigerator logs for March 2024 revealed missing temperatures on 3/2, 3/4, 3/8, 3/22, 3/29, and 3/30. Interview on 4/1/24 at approximately 8:20 a.m. with Staff G confirmed the above findings. Review on 4/2/24 of the facility's policy titled 5.3 Storage and Expiration Dating of Medications, Biologicals dated January 2022 revealed: .10.3.1 Facility should monitor the temperature of medication storage areas at least once a day .

Based on interviews and record reviews, it was determined that the facility failed to ensure that residents received treatment for hearing loss for 1 of 1 resident reviewed for hearing and vision in a final sample of 18 residents (Resident Identifier #7). Interview on 4/1/24 at approximately 11:00 a.m. with Resident #7 revealed he/she was very hard of hearing. Resident #7 stated he/she had wax in them [their ears]. Review on 4/1/24 of Resident #7's diagnosis list revealed a medical diagnosis of Bilateral Hearing Loss. Interview on 4/2/24 at approximately 9:30 a.m. with Staff E (Recreation Assistant) regarding Resident #7 revealed, communication is difficult, does not engage in conversations or attend group activities. Review on 4/2/24 of Resident #7's Audiology visit dated 1/29/24 revealed that the degree of hearing loss could not be determined. He/she had too much wax in bilateral ear canals to complete a hearing evaluation. A large amount of wax was removed, but the resident could not tolerate further cleaning. Medical consult is needed for wax removal orders. Re-evaluate resident after wax removal. Interview on 4/2/24 at approximately 12:15 p.m. with Staff C (Unit Manager) confirmed the above findings. Staff C revealed that Resident #7 had not received any treatment after the Audiology consult on 1/29/24.

Based on interview and record review, it was determined that the facility failed to ensure that nursing staff postings reflected the actual hours worked by licensed and unlicensed nursing staff on shifts for 7 out of 30 days of daily nursing staff postings reviewed. Findings include: Review on 1/9/24 of the facility's working nursing schedule revealed the following: On 12/9/23 evening shift, there were 5 Certified Nursing Assistants (CNAs) also known as Licensed Nursing (LNAs) and 1 unlicensed unit aide. Night shift had 2 CNAs on the schedule. On 12/11/23 evening shift, there were 4 CNAs, and 1 unlicensed unit aide; night shift had 3 CNAs, and 1 unlicensed unit aide. On 12/14/23 evening shift, there were 3 CNAs, and 1 unlicensed unit aide; night shift had 3 CNAs and 1 unlicensed unit aide. On 12/15/23 night shift, there were 3 CNAs and 1 unlicensed unit aide. On 12/16/23 night shift, there were 2 CNAs and 1 unlicensed unit aide. On 12/18/23 evening shift, there were 6 CNAs and 1 unlicensed unit aide; night shift had 3 CNAs and 1 unlicensed unit aide. On 1/3/24 night shift, there were 4 CNAs. Review on 1/9/24 of the facility's daily nursing staff postings revealed the following: On 12/9/23 evening shift had 6 CNAs and night shift had 3 CNAs. On 12/11/23 evening shift had 5 CNAs and night shift had 4 CNAs. On 12/14/23 evening shift had 5.75 CNAs and night shift had 4 CNAs. On 12/15/23 night shift had 4 CNAs.On 12/16/23 night shift had 3 CNAs. On 12/18/23 evening shift had 7 CNAs and night shift had 5 CNAs. On 1/3/24 night shift had 3 CNAs. Further review of the postings revealed that the postings were printed the day before the posting date and no update was noted on the postings for any changes in the nursing schedule as mentioned above. Review on 1/9/24 at approximately 12:30 p.m. with Staff A (scheduler) confirmed the above findings. Staff A stated that he/she is responsible for the daily nursing staff postings. Staff A also stated that he/she or anyone else does not update the daily nursing staff postings at the beginning of the evening shift and night shift that would reflect the actual hours worked by licensed and unlicensed nursing staff on that shift.

Based on interview and record review, the facility failed to give written notice to the resident before the resident's room or roommate in the facility was changed (Resident identifiers are #1, #2, #3, #4). Findings include: Resident #1 Interview with Resident #1 on 5/4/23 at 8:53 a.m. revealed that he/she was admitted on [DATE] and liked his/her old room. The resident stated that they asked him/her to move and then was moved immediately. The resident stated that they did not give him/her a reason for the move. Resident #1 thinks his/her room change occurred around 12 p.m. on 5/3/23. Resident #1 stated that he/she was not given any paperwork regarding the room change. Record review on 5/4/23 at 10:15 a.m. revealed a Social Service note dated 5/3/23 stated Left VM [voice mail] for DPOA [Durable Power of Attorney] to alert [pronoun omitted] of room change. Interview with Resident #1's DPOA on 5/4/23 at 10:07 a.m. DPOA stated that he/she received a voice mail around 10 a.m. from the facility on 5/3/23, which stated that they had moved family member to a different room in the facility. The facility never gave him/her a reason why the room change had to happen and he/she had not spoken to anyone at the facility. Resident #3 Record review of Resident #3 on 5/4/23 revealed no documentation that the resident was told that he/she would be getting a new roommate. Resident #2 Interview with Resident #2 on 5/4/23 at 9:04 a.m. Resident #2 stated that they had moved from a different room yesterday. Resident #2 was originally asked to change rooms on 5/1/23 but did not want to. Resident #2 stated that they had to move because of the new Rehabilitation Program. Resident #2 stated that on 5/3/23, facility staff came into their room with boxes and stated that Resident #2 had to move. Resident #2 stated that they do not like the new room because they had a private room and now they have a roommate. Resident #2 stated that he/she would have stayed in his/her previous room if he/she could have, but did not know that they had the right to refuse a room change. Resident #2 stated that he/she did not receive any paperwork regarding the room change. Resident #2 stated that he/she told the staff that he/she did not want to move while they were packing Resident #2's belongings. Resident #2 stated that he/she spoke to the Ombudsman's office about their room change. Record review on 5/4/23 at 10:30 a.m. of a Social Service note dated 5/1/23 revealed TW [This writer] and Admissions Director spoke with patient about changing rooms. Resident expressed that he/she knew this was coming and asked if it had anything to do with insurance. He/She was assured that this had nothing to do with anything financial and that because he/she is LTC [long term care] the thought was to transition him/her into a long term care room with a roommate. Patient was initially upset about this but ultimately agreed and said he/she would change rooms. Resident #4 Record review of Resident #4 on 5/4/23 revealed no notification that the resident was told that he/she would be getting a new roommate. Interview on 5/4/23 at approximately 9:45 a.m. with Staff A (Social Service Director) revealed that they do not provide written notification to residents, or resident representatives, upon room change. Upon the completion of a room change Staff A stated that a note is put in the resident's medical record that the room change occurred. Review on 5/4/23 of the Facility's Policy titled Room Transfers revision date 3/9/20. Policy .The patient has the right to refuse to transfer to another room in the Center, if the purpose of the transfer is: To relocate a resident of a SNF [Skilled Nursing Facility] from the distinct part of the institution that is SNF to a part of the institution that is not a SNF; or to Relocate a resident of a NF [Nursing Facility] from the distinct part of the institution that is a NF to a distinct part of the institution that is a SNF. Solely for the convenience of staff. Process .#3 Social Services or designee will process and coordinate all request for room changes in accordance with state and federal regulations. 5.1 Give the patient/resident representative as much notice as possible including an explanation of the reason for the move #7. For a patient who is receiving a new roommate: 7.1 give the patient as much notice as possible 7.4 If requested by patient/resident representative or per state regulation, give patient/resident representative a copy of the Room Transfer/New Roommate change form #11. Maintain the Room Transfer/New Roommate Change Form (electronic or non-electronic), in the medical record. 37488

Based on interview and record review, the facility failed to recognize a resident's right to refuse transfer for 1 of 2 residents reviewed for a room change (Resident identifier is #2). Findings include: Interview with Resident #2 on 5/4/23 at 9:04 a.m. Resident #2 stated that he/she had moved to a different room yesterday. Resident #2 stated that on 5/3/23, facility staff came into his/her room with boxes and stated that he/she had to move right now. They proceeded to pack his/her belongings and moved him/her into his/her new room. Resident #2 stated that he/she would have stayed in his/her previous room if he/she could have but did not know that he/she could have refused to be moved. Resident #2 stated that he/she told the staff that he/she did not want to be moved while facility staff was packing Resident #2's belongings. Interview on 5/4/23 at approximately 9:45 a.m. with Staff A (Social Service Director) revealed that Staff A does not provide written notification to residents, or resident's representatives, upon room change. Upon the completion of a room change Staff A stated that a note is put in the resident's medical record that the room change occurred. Review on 5/4/23 of the Facility's Policy titled Room Transfers revision date 3/9/20. Policy .The patient has the right to refuse to transfer to another room in the Center, if the purpose of the transfer is: To relocate a resident of a SNF [Skilled Nursing Facility] from the distinct part of the institution that is SNF to a part of the institution that is not a SNF; or to Relocate a resident of a NF [Nursing Facility] from the distinct part of the institution that is a NF to a distinct part of the institution that is a SNF. Solely for the convenience of staff. Process .#3 Social Services or designee will process and coordinate all request for room changes in accordance with state and federal regulations. 5.1 Give the patient/resident representative as much notice as possible including an explanation of the reason for the move #7. For a patient who is receiving a new roommate: 7.1 give the patient as much notice as possible 7.4 If requested by patient/resident representative or per state regulation, give patient/resident representative a copy of the Room Transfer/New Roommate change form #11. Maintain the Room Transfer/New Roommate Change Form (electronic or non-electronic), in the medical record.

Based on observation and interview, it was determined that the facility failed to provide a clean and safe environment in 1 out of 2 kitchenettes used by residents and staff. Observation on 3/8/23 at 9:00 a.m. of the Derryfield kitchenette revealed a countertop ice machine dripping water into a cabinet drawer and a wet area in the right back corner of the cabinet. Inside the cabinet drawer were condiments and snacks. Further observation revealed 2 damp packages of instant oatmeal and 2 damp packages of hot chocolate mix. Observation on 3/8/23 at 9:03 a.m. of the Derryfield kitchenette revealed a large, black, and moist area in the back of a cabinet under the sink. Further observation of the cabinet revealed the wood along the front right and bottom side of the cabinet was damp, cracked, and jagged. Interview on 3/8/23 at 9:04 a.m. with Staff A (Director of Culinary Services) confirmed the above findings. Interview on 3/9/23 at 11:45 a.m. with Staff B (Regional Property Manager) revealed that facility uses an electronic work order system. Interview with Staff B further revealed that staff would notify facilities of any issue through work orders. Interview on 3/9/23 at 11:50 a.m. with Staff C (Maintenance Manager) revealed that there was a leak in the sink that happened a while ago and the wood has been rotted for a long time but he/she was not aware it was damp. Staff C stated that he/she was aware of the leak but there was no work order created. Interview on 3/9/23 at 11:55 a.m. with Staff C revealed that he/she was responsible for performing environmental rounds but did not. Interview on 3/10/23 at 1:30 p.m. with Staff D (Administrator) revealed that environmental rounds should be maintained in the electronic work order system.

Based on observation, interview and record review, it was determined that the facility failed to store prepared foods and maintain sanitation of kitchen equipment to prevent foodborne illness in 2 out of 2 kitchenettes and 1 of 1 kitchen observed. Findings include: Kitchen Observation on [DATE] at 8:40 a.m. revealed staff personal items including coats, shoes and socks stored on shelves and floor under an open storage rack used for clean dining linens in the kitchen. Interview on [DATE] at 8:42 a.m. with Staff I (Food Service Director) confirmed the above finding and confirmed that staff store personal items on the shelves daily Observation on [DATE] at 8:45 a.m. revealed dry tan/brown debris on the top and around the dishwasher and on the floor in the dish room. Observation also revealed visual dust on the air vent located directly over the dishwasher. Interview on [DATE] at 8:47 a.m. with Staff I confirmed the above finding. Interview with Staff I revealed that the dishwasher had not been operated that morning and that the debris observed on top of the dishwasher, was from a couples of days ago. Interview also revealed that the dry tan/brown debris on the floor was from last night and the floor had not been cleaned after the dinner meal ([DATE]). Observation on [DATE] at 8:52 a.m. revealed one bag of opened, cooked, frozen chicken with no open date/expired date and one bag of opened tortillas with no open date/expired date in the kitchen freezer. Interview on [DATE] at 8:54 a.m. with Staff I confirmed the above finding. Observation on [DATE] at 8:57 a.m. revealed one covered container of diced tomatoes with no open date in the kitchen refrigerator. Observation on [DATE] at 9:00 a.m. revealed one uncovered, unlabeled bucket like container of powdered food thickener with no open date. Observation further revealed dry, brown specks of debris in the powder food thickener. Interview on [DATE] at 9:01 a.m. with Staff I confirmed the bucket contained powdered food thickner with unidentified dry brown specks of debris. Observation on [DATE] at 9:02 a.m. revealed brown, sticky film adhered to the inside, bottom surface of the microwave. Interview on [DATE] at 9:03 a.m. with Staff I confirmed the above finding. Interview with Staff I confirmed that the microwave had not been used for the breakfast meal on [DATE]. Observation on [DATE] at 9:05 a.m. revealed one box of opened cream of wheat cereal labeled with best by date: [DATE] located on a shelf located in the prep area of the kitchen. Further observation revealed a staff purse with a surgical mask also stored on the shelf. Interview on [DATE] at 9:07 a.m. with Staff I confirmed the above finding and stated it should not be there. Observation on [DATE] at 8:40 a.m. revealed brown, sticky film adhered to the inside, bottom surface of the microwave in the kitchen as observed on [DATE] at 9:02 a.m Interview on [DATE] at 8:42 a.m. with Staff H (Dietary Cook) confirmed the above finding. Interview further revealed Staff H had not used the microwave on [DATE] and had not had a chance to clean the microwave after observed on [DATE]. Review on [DATE] of facility provided document titled, 6am-2am Position #2 revealed: 6:,d+[DATE]:00 .Open microwave door and clean inside and out of microwave Deerfield Unit Kitchenette Observation on [DATE] at 9:15 a.m. revealed dry tan/brown debris on the bottom surface of the cabinet and drawers. Further observation revealed brown/yellow dry particles adhered to the inside top and sides of the microwave and dry, brown sticky film adhered to the inside bottom of the microwave. Interview on [DATE] at 9:17 a.m. with Staff I confirmed the above finding. Observation on [DATE] at 8:35 a.m. revealed brown frozen particles adhered to the bottom surface of the freezer. Observation revealed staff personal clothing stored in the kitchenette. [NAME] Unit Kitchenette Observation on [DATE] at 9:19 a.m. revealed one box of opened sugar packets containing a brown paper towel with dried brown substance adhered to the paper towel. Observation further revealed the paper towel with brown substance adhered to sugar packets with brown staining. Observation on [DATE] at 9:20 a.m. revealed one container of ice cream with no name or open date and one chicken pot pie with no name or open date in the freezer. Observation on [DATE] at 9:22 a.m. revealed one container of peeled garlic with no name, expiration date of [DATE]; one container of cut fruit purchased from a store with no name, expiration date [DATE]; one block of cheese with no name and no open date; one container of thickened dairy with use by date of [DATE], no name; one tuna salad take out box sell by date of [DATE], no name; one take-out box with meatloaf and green beans, no name and no open date; one container of veggie rice with no name and no open date; one take-out bag containing a fish sandwich, fries and coleslaw with no name and no open date and one cup of tuna salad with no name and no open date. Interview on [DATE] at 9:30 a.m. with Staff I confirmed the above finding. Observation on [DATE] at 9:31 a.m. revealed brown/yellow dry particles adhered to the top, bottom and side surfaces of the microwave . Observation on [DATE] at 8:30 a.m. revealed a sticky, wet, substance adhered to two refrigerator shelves. Observation further revealed brown/yellow dry particles adhered to top, bottom and sided surfaces of microwave. Interview on [DATE] at 8:33 a.m. with Staff G (Licensed Practical Nurse) confirmed the above finding. Review on [DATE] of the facility's policy, titled 4.1 Food and Brought in for Patient/Residents, revised [DATE] read in part, .Food brought to patients/residents by family or visitors will be handled and stored in a safe and sanitary manner 1.2 Food items that require refrigeration must be labeled with patient's/resident's name and date the food was brought in 1.4 Foods considered unsafe for consumption or beyond the expiration date will be discarded by staff upon notification to patient/resident 1.5 Food will be held in refrigerator for three ( 3) days following date on the label and will be discarded by staff upon notification to patient/resident Review on [DATE] of the facility's policy, titled 4.7 Food Handling, revised [DATE] read in part, . 3. Any food equipment used in the processing of allergen-containing foods corresponding to known patient /resident allergies (including utensils, pots, pans, preparation surfaces) is thoroughly cleaned and sanitized after use 22.1 Unused portions that have been properly handled, refrigerated, covered, labeled and dated with use by dates or frozen and reheated and served according to the HACCP Food Flow Charts can be served by the use by date 25. Foods that are marked with the manufacturer's use by date that are properly stored can be used until that date as long as the product has not been combined with any other food or prepared in any way including portioning. Once a product has been prepared or portioned, a new use by date is established. Follow the Use By Dating Guidelines (Appendix) to establish new date 26. Foods in dry storage are in closed, labeled, and dated containers; no open boxes or bags. For products that have been opened but not fully used, a use by date is included on the label. Review on [DATE] of the facility's policy, titled 5.6 Dry Storage, revised date [DATE] read in part, . Purpose: To prevent damage, spoilage, contamination, and infestation of products 1.3 Routine cleaning and pest control procedures are followed 2.3 Food stock is dated on the day of receipt. Items that are removed from the original box are individually dated 2.6 Open packages are stored in closed containers, tightly secured with ties or in food quality storage bags and include the use by date. No single use containers are used for food storage (empty cans, jars, or plastic containers) Review on [DATE] of the Food Code U.S. Public Health Service 2017 U.S. Department of Health and Human Services retrieved from https://www.fda.gov/food/fda-food-code/food-code-2017 revealed the following: .Annex 3, Public Health Reasons/Administrative Guidelines . Chapter 3 Food . Page 458 Manufacturer's use-by dates It is not the intent of this provision to give a product an extended shelf life beyond that intended by the manufacturer. Manufacturers assign a date to products for various reasons, and spoilage may or may not occur before pathogen growth renders the product unsafe. Most, but not all, sell-by or use-by dates are voluntarily placed on food packages the manufacturer's use-by date is its recommendation for using the product while its quality is at its best. Although it is a guide for quality, it could be based on food safety reasons. It is recommended that food establishments consider the manufacturer's information as good guidance to follow to maintain the quality (taste, smell, and appearance) and salability of the product. If the product becomes inferior quality-wise due to time in storage, it is possible that safety concerns are not far behind.

Based on interview and record review, it was determined that the facility failed to follow antibiotic use protocols related to a system to monitor antibiotic use for 4 of 4 months reviewed of line lists reviewed in a final sample of 18 Residents. Findings include: Interview on 3/24/22 at approximately 10:20 a.m. with Staff C (Infection Preventionist) revealed that he/she will review the facility's Infection Control Report Forms to assess if a resident that was receiving antibiotic either met or did not meet criteria to be on the antibiotic. Staff C stated that he/she did not document this assessment in the patient chart or on the antibiotic line listing. Staff C stated that he she had not had anyone not meet criteria for the appropriate use of antibiotics in January or February 2022. Review on 3/25/22 of the the facility's antibiotic line listings from November 2021 to February 2022 revealed the following; -The November and December 2021 line listing did not indicate if the residents met criteria for antibiotic use for both [NAME] and Derryfield Units; -The January and February 2022 for [NAME] Unit line listing did not indicate if the residents met criteria for antibiotic use; -The February 2022 for Derryfield Unit line listing did not indicate if 4 residents met criteria and listed 6 residents that did not meet criteria for antibiotic use. Interview on 3/25/22 at approximately 10:30 a.m. with Staff C and Staff B (Director of Nursing) confirmed that the above. Review on 3/25/22 of the facility's policy titled Antibiotic Stewardship revised on 11/15/20, revealed, .Centers will implement an Antibiotic Stewardship Program (ASP) that includes antibiotic us protocols and systems for monitoring antibiotic use Purpose. To reduce inappropriate antibiotic use. To prevent development of antibiotic-resistant organisms. To prevent adverse outcomes for patients . Review on 3/25/22 of the facility's Antibiotic Stewardship Program, dated 10/19/16 and reviewed on 12/18/19, revealed, .Infection Preventionist. Monitors and supports antibiotic stewardship activities through rounds, review of provider orders, PCC (PointClickCare) documentation and available PCC/pharmacy/lab reports . 5. Tracking . Monitor measures of antibiotic use by auditing available reports and patient medical records for adherence to: clinical evaluation documentation (i.e., sign/symptoms, vital signs, physical exam findings) . Review on 3/25/22 of Center of CDC (Center for Disease Control and Prevention) website titled, The Core Elements of Antibiotic Stewardship in Nursing Homes, review date June 11, 2020, revealed that .Infection and syndrome specific interventions to improve antibiotic use .Identify clinical situations which may be driving inappropriate courses of antibiotics such as asymptomatic bacteriuria or urinary tract infection prophylaxis and implement specific interventions to improve use .Infection prevention program coordinators have key expertise and data to inform strategies to improve antibiotic use. This includes tracking of antibiotic starts, monitoring adherence to evidence-based published criteria during the evaluation and management of treated infections Broad interventions to improve antibiotic use .Standardize the practices which should be applied during the care of any resident suspected of an infection or started on an antibiotic. These practices include improving the evaluation and communication of clinical signs and symptoms when a resident is first suspected of having an infection, optimizing the use of diagnostic testing, and implementing an antibiotic review process, also known as an antibiotic time-out, for all antibiotics prescribed in your facility. Antibiotic reviews provide clinicians with an opportunity to reassess the ongoing need for and choice of an antibiotic when the clinical picture is clearer and more information is available .