Every finding on record at Presbyterian Communities Of South Carolina-Florenc

Based on observation, interview, and review of facility policy, the facility failed to ensure that food items were properly stored/maintained at or below 41 degrees Fahrenheit (F), to reduce the potential of foodborne illnesses. The facility further failed to monitor equipment (refrigerator) to ensure proper functioning in 1 of 1 satellite kitchen reviewed.Findings include:Review of facility policy titled Policy for recording temperatures in a culinary department, with no revision date, documented, 1. Understand the temperature danger zone. - The temperature danger zone is the range where bacteria multiply rapidly, between 41 degrees Fahrenheit (5 degrees Celsius) and 135 degrees Fahrenheit (57 degrees Celsius). - Food should be kept out of this zone as much as possible. 2. Utilize appropriate equipment. - Accurate thermometers: Use calibrated thermometers for refrigerators, freezers, and for checking the internal temperature of food. - Temperature logs: Have standardized log sheets for different stages of food handling. 3. Establish critical control points (CCPs) for temperature monitoring. - Storage: Maintain refrigerated foods at or below 41 degrees Fahrenheit (5 degrees Celsius). 4. Implement monitoring and recording procedures: - Documentation: Record the date, time, food item, temperature, and initials of the person taking the reading. Include corrective actions taken if the temperature is out of range. - Health and safety risks: Neglecting maintenance can create unpleasant odors, attract pests, and potentially lead to the spread of bacteria and foodborne illnesses.During an observation on 08/05/25 at 10:40 AM of the Healthcare Service Kitchen (satellite kitchen) located on Price Hall Unit, with the Executive Chef, revealed refrigerator temperature logs for the dates of 07/01/25 - 08/05/25 were documented out of safe range. Inside the refrigerator there were 6 cartons of milk, individual packages of butter, and individual packages of grape and strawberry jelly. The refrigerator internal temperature reading was 38 degrees Fahrenheit. The Executive Chef checked the temperature of the milk with a thermometer, and the milk temperature was found to be above the normal range at 52 degrees Fahrenheit. The Executive Chef instructed the kitchen staff to remove and discard everything that was in the refrigerator, not to use the refrigerator and to notify maintenance to have the refrigerator checked. Review of the Refrigeration, Freezer, and Dry Storage Temperatures for the month of July 2025 - August 2025, Location: Healthcare Kitchen, revealed the following documented temperatures:July 1: AM (morning) 51 Degrees Fahrenheit / PM (afternoon/evening) 52 degrees Fahrenheit (external) and AM 51 / PM 52 (Internal), [DATE]: AM DEF / PM DEF (External), AM DEF / PM DEF (Internal), [DATE]: AM 49 / PM 52 (External), AM 52 / PM 52 (Internal), [DATE]: AM 49 / PM 52 (External), AM 50 / PM 52 (Internal), [DATE]: AM DEF / PM 50 (External), AM 51 (Internal), [DATE]: AM DEF / PM DEF (External), AM 52 / PM 51 (Internal), [DATE]: AM DEF / PM DEF (External), AM 51 / PM 52 (Internal), [DATE]: AM 47 / PM DEF (External), AM 52 / PM 51 (Internal), [DATE]: AM 46 / PM 51 (External), AM 50 / PM 55 (Internal), [DATE]: AM 47 / PM 50 (External), AM 50 / PM 53 (Internal). Further review of the temperature log revealed the remaining dates for the month of [DATE] - [DATE]; the documented temperatures were over the regulated range. During an interview on 08/05/25 at 10:45 AM, the Executive Chef revealed the temperatures are checked daily and monitored by the sous chef. The Executive Chef could not explain the out-of-range refrigerator temperatures and the lack of action being taken to correct the problem. Food items and beverages are transferred from the main kitchen and plated and served to the residents from the satellite Healthcare Service Kitchen located on the Price Hall Unit.During an interview on 08/06/25 at 9:38 AM, Culinary Manager revealed if any discrepancy is noted with the temp, the staff should notify someone immediately. The Sous Chef is supposed to check temperature logs daily to ensure temps are being checked and logs are being filled out. He is not sure why the problem wasn't addressed sooner.During an interview on 08/06/25 at 10:00 AM, the Registered Dietitian (RD) revealed the kitchen staff are all trained in diets, temperature and documentation. The temperature checks should be the responsibility of everyone. The Culinary Director should be monitoring the temperature logs. Some of the outside gauges are not working properly; therefore, internal gauges should be checked for accurate temperature reading. During an interview on 08/06/25 at 10:12 AM, the Director of Nursing (DON) revealed she was made aware of the temperature logs discrepancy today.During an interview on 08/06/25 at 10:33 AM, the Sous Chef revealed, she is responsible for checking and verifying temperature logs. She would rather see temperature logs filled in rather than not. She normally asks the kitchen staff whether the temperatures have been done, and she takes their word without checking. She doesn't take the time to check the temperature log to see what the reading is. The Sous Chef stated the kitchen staff have been taught how to check the temperatures and to be aware of normal and abnormal temperature ranges. Her expectation is for the kitchen staff to do what is supposed to be done. The Sous Chef concluded, I am being honest; I haven't been doing what I am supposed to be doing by checking and verifying the temperature logs. I'm just being honest.During an interview on 08/07/25 at 10:15 AM, the Director of Facilities revealed he received a work order on Tuesday, 08/05/25, for the refrigerator not temping like it should. The refrigerator was then pulled and placed out of service. All the food items that were in the refrigerator have been discarded. The kitchen staff has been instructed not to use the refrigerator. The Director of Facilities stated his expectation is the maintenance staff is to notify of any malfunction of equipment. All malfunctioning equipment is to be reported immediately.

Based on review of the facility policy, observation and interview, the facility failed to ensure an excessive amount of lint was removed from 1 of 3 clothes dryers.Findings include:Review of the undated facility policy with no title documented, Policy Statement Lint Trap should be kept clean. Policy Interpretation and Implementation: All dryer lint traps will be cleaned after each load. Procedure: 1. After removing clothes from dryer, clean lint trap after every load. Review of the facility policy titled Laundry with an implementation date of 04/15/25 documented, Policy Explanation and Compliance Guidelines: . 5. Laundry equipment will be used and maintained according to manufacturer's instructions . 12. Laundry staff will be in-serviced on handling linens and laundry on a regular basis. During an observation on 08/07/25 at 9:10 AM revealed the laundry attendant opened an empty dryer and removed the lint trap. The lint trap baskets and the three walls below the dryer were observed with excessive amounts of lint. Laundry Staff and the Director of Facilities were immediately made aware of these findings.During an interview with the Laundry Specialist on 08/07/25 at 9:30 AM, the Laundry Specialist stated, Sometimes I clean the lint after every load if the load has heavy linen. If the load has light linen, I wait until the end of the day to clean the lint basket.During an interview on 08/07/25 at 9:45 AM the Director of Nursing stated, The Administrator is currently on leave, and I do not know about the dryers and all that. The Director of Facilities can help you with that.During an interview on 08/07/25 at 10:00 AM the Director of Facilities revealed lint traps should be cleaned after every load of laundry. He also stated that the Laundry Specialist had been educated as recently as this morning that she should be cleaning the lint basket and walls of the dryers of lint after each load of laundry.

Based on review of facility policy, observation and interview, the facility failed to ensure expired medications and/or biologicals were removed from and not stored with other medications and/or biologicals in use for residents in one of one treatment cart.Findings include: Review of the facility policy titled Medication Storage revealed under 1. General Guidelines: 8. Unused medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our Destruction of Unused Drugs Policy. During an observation on 08/07/25 at 7:30 AM, of the treatment cart revealed the following:- One bottle of Iodoform Packing, sterile, 1 x 1/4 x 15 feet, manufactured by Curity with Cardinal Health Ref 7831, opened and partially used, no longer sterile and stored back on the treatment cart.- One Occlusive Gauze Strip Overwrap, 5 x 9, Manufactured by Covidien, with Lot #2101405, was expired on 09/30/24. - Four Occlusive Gauze Strip Overwraps, 5 x 9, Manufactured by Covidien, with Lot #3081406, were expired on 07/31/25.- One Occlusive Gauze Strip Overwrap, 5 x 9, with Lot #4111404, open and left on the treatment cart, no longer sterile. - Two AMD Antimicrobial, Sterile 2 x 2's, manufactured by Curity, with Lot #19K181062, were expired on 10/01/24.- One Plus Silicone Border Dressing, manufactured by Zetruvit, with Lot #200504131, was expired on 08/01/25. During an interview on 08/07/25 at 8:00 AM, the Director of Nursing confirmed the expired biologicals, and they were removed from the treatment cart.

Based on review of facility policy, observation and interview, the facility failed to ensure proper handling and processing of the resident's laundry; furthermore, the facility failed to follow enhanced barrier precautions for (R)4 during care.Findings include:Review of the facility policy titled, Laundry with an implementation date of 04/15/25, states: Policy: The facility launders linens and clothing in accordance with current CDC guidelines to prevent transmission of pathogens. Policy Explanation and Compliance Guidelines: 1. Aligning with the principles of standard precautions, staff shall consider all previously worn clothing and used linens as potentially contaminated. 3. Soiled laundry will be kept separate from clean laundry at all times.Review of the facility policy titled, Hand Hygiene with an implementation date of 04/15/25, states: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Definitions: Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHIR).Policy Explanation and Compliance Guidelines:1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 6. Additional considerations: a. the use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.Review of the facility policy titled, Enhanced Barrier Precautions with an implementation date of 04/15/25, states: Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Definitions: Enhanced [NAME] precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and cloves use during high contact resident care activities. Policy Explanation and Compliance Guidelines:1. Prompt recognition of need: All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions. b. All staff receive training on high-risk activities and common organisms that require enhanced barrier precautions. c. The facility will have the discretion on how to communicate to staff which residents require the use of EBP, as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities. 2. Initiation of Enhanced Barrier Precautions: b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters. PICC lines, midline catheters) even if the resident is not known to be infected or colonized with a MDRO. (Peripheral IVs, continuous glucose monitors, insulin pumps, or ostomies without an associated indwelling medical device are not an indication for EBP.). 3. Implementation of Enhanced Barrier Precautions: b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. 4. High-contact resident care activities include: a. Dressing b. Bathing c. Transferring d. Providing hygiene e. Changing linens f. Changing briefs or assisting with toileting g. Device care or use: central lines, urinary catheters, hemodialysis catheters, PICC lines, midline catheters h. Wound care: any skin opening requiring a dressing. 10. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk.Review of R4's Face Sheet revealed the facility admitted R4 on 12/15/23 with diagnoses including but not limited to: urinary tract infection, severe protein calorie malnutrition, dysphagia following other cerebrovascular disease and sepsis due to pseudomonas. R4 is on EBP due to the foley catheter.During an observation on 08/06/25 at 8:50 AM, revealed R4 was on EBP as indicated by a sign on the resident's room door. Licensed Practical Nurse (LPN)1 was asked to confirm that there was a privacy bag on R4's foley bag. LPN1 entered the resident's room with no personal protective equipment on. LPN1 touched R4's foley catheter and anchor device with no gloves or other personal protective equipment in place. The anchor device had dislodged and was no longer anchoring the foley catheter. LPN1 exited R4's room to retrieve another anchor device. LPN1 returned to R4's room at 9:00 AM. LPN1 reentered R4's room with a gown and gloves on. LPN1 touched the blinds to close them with her gloves on and then touched the resident's foley catheter.During an observation on 08/07/25 at 9:30 AM, revealed the Laundry Specialist pushed the clean linen cart along with the soiled linen cart in the hall at the same time. She put on gloves to get the soiled linen from the shower room on the Price Hall unit where the soiled bins are stored. She also removed soiled clothing protectors from the soiled linen hampers in the dining room on the Price Hall unit. She took off the gloves to put the clean linen in the clean linen closet and she did not sanitize or wash her hands. She repeated this process in the shower room and the two clean linen closets on the [NAME] Grove unit. The Laundry Specialist put on gloves to get the soiled linen from the shower room on the [NAME] Grove unit. She took off the gloves to put the clean linen in the clean linen closets and she did not sanitize or wash her hands.During an interview with LPN1 at 9:15 AM revealed, I thought you were just going to show me something. That is why I did not put on the personal protective equipment at first. I know I touched the blind with my gloves on. I am sorry.During an interview with the Laundry Specialist on 08/07/25 at 9:35 AM, the Laundry Specialist confirmed that she did not wash her hands after removing her gloves. She stated that no one had ever trained her to wash her hands after removing gloves.During an interview with the Director of Nursing (DON) on 08/06/25 at 9:45 AM, revealed, I expect one hundred percent compliance with the knowledge of enhanced barrier precautions.During an interview with the Director of Facilities on 08/07/25 at 10:00 AM, revealed that he has educated the Laundry Specialist about washing her hands up to the elbows each time she removes gloves.

Based on record review, interviews, and review of facility policy, the facility failed administer medication to Resident (R)26, in a timely manner, for 1 of 6 residents reviewed for unnecessary medications. Specifically, R26 was administered multiple medications late on multiple day. Finding include: Review of a document, provided by the Administrator, undated and titled Medication Pass Statement revealed, PCSC (Presbyterian Communities of South Carolina) Follows a Liberalized Med Pass Structure which states: Daily 7a-11a Evening 3p-8p QHS (bedtime) 8p-12a PPI 5a-6:30a FSBS 6:30a-730a BID 7a-11a and 7p-11p TID 7a-11a and 11a-3p and 7p-11p Review of R26's Face Sheet revealed R26 was admitted to the facility on [DATE], with diagnoses including but not limited to: systolic (congestive) heart failure, atypical flutter and insomnia. During an interview on 08/13/24 at approximately 1:00 PM, R26 stated that for the past several weeks she was being woken up after her normal 9:00 PM bedtime so that medications could be administered. On 08/13/24 at approximately 3:30 PM, a review of R26's Physician Orders and Medication Administration Record (MAR) revealed that medications were being administered at the scheduled time. On 08/13/24 at approximately 4:15 PM, this Surveyor asked the Administrator to provide R26's Medication Administration Audit Report (MAAR) for July 2024, which will show the actual time of administration and not the default time as shown on the MAR for July 2024. On 08/14/24 at approximately 11:55 AM, a copy of R26's July 2024 MAAR was provided by the Director of Nursing (DON) with subsequent review by the Surveyor on 08/14/24 at approximately 12:05 PM, revealing that multiple medications, were being administered late according to the facility's liberalized med pass structure. The medications are listed as follows: 1. Digoxin 12.5 mcg (microgram) Give 1 tablet in the evening related to ATYPICAL ATRIAL FLUTTER Hold for pulse less than 60. 1900 (7:00 PM), administered late approximately eighteen (18) times varying between 43 minutes late on 07/18/24 and 4 hours 15 minutes late on 07/5/24, given at 0015 hours (12:15 am) on 07/06/24. 2. Boudreauxs Butt Paste External Ointment 17% (percent) (Zinc Oxide Topical) Apply to sacrum topically every day and night shift for preventive measures. 1900, administered late approximately nineteen (19) times varying between none (zero) being administered on 07/05/24 and 9 hours 16 minutes late on 07/13/24 given at 0516 (5:16 AM) on 07/14/24. 3. Metoprolol Succinate ER (extended release) Oral Tablet Extended Release 24 hour 25 mg (milligram) give 1.5 tablet two times a day relayed to HYPERTENSIVE HEART DISEASE WITH HEART FAILURE. 1900 administered late approximately two (2) times varying between 1 hour 10 minutes and 1 hour 14 minutes. 4. Apixaban Oral Tablet 5 mg Given 1 tablet by mouth two times daily related to CHRONIC ATRIAL FIBRILLATION, UNSPECIFIED 1900 administered late approximately one (1) times by 1 hour 10 minutes. 5. Mirtazapine Tablet 7.5 mg Give 2 tablet by mouth at bedtime for insomnia and appetite stimulant related to INSOMNIA, UNSPECIFIED. 2000 (8:00 PM), on 07/13/24 administered late on 07/14/24 0007 (12:07 AM). During an interview on 08/14/24 at approximately 1:05 PM, the Director of Nursing reviewed some of the findings and confirmed that multiple medications were being given late.

Based on review of facility policy, record review, observation, and interview, the facility failed to implement care plan interventions for Resident (R)20's refusal of oxygen, for 1 of 2 residents reviewed. Findings include: Review of the undated facility policy titled Developing and Evaluating Goals and Objectives, Care Plans states, 1. Care plan goals and objective are defined as the desired outcome for a specific resident problem. 2. When goals and objectives are not achieved the resident's clinical record will be documented as to why the results were not achieved and what new goals and objectives have been established. Care plans will be modified accordingly. Review of R20's Face Sheet revealed R20 was admitted to the facility on [DATE], with diagnoses including, but not limited to: dependence on supplemental oxygen, chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, hypertensive heart and chronic kidney disease, thalassemia, dementia, cerebral infarction, and posthemorrhagic anemia. Review of R20's unspecified Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/31/24, revealed R20's Brief Interview for Mental Status (BIMS) score was not notated, resident's cognitive skills are impaired. Further review revealed under section E revealed R20 did not exhibit signs of rejection of care behavior. Review of R20's unspecified MDS with an ARD of 07/08/24, revealed R20's BIMS score was 8 out of 15, indicating R20 had moderate cognitive impairment. Further review revealed under section E revealed R20 did not exhibit signs of rejection of care behavior. Review of R20's Physician Orders revealed R20 has an order for, Oxygen at 2 liters continuous: may remove for short period of time or for transport every day and night shift. Review of R20's Care Plan revealed, R20 has COPD and shortness of breath. The Goal outlined in this Care Plan indicated that R20 will display optimal breathing patterns daily through review date. The Interventions directed staff to give aerosol or bronchodilators as ordered. Monitor/document any side effects and effectiveness. The nursing staff are to monitor for signs and symptoms of acute respiratory insufficiency: anxiety, confusion, restlessness, shortness of breath at rest, cyanosis, somnolence. Monitor/document/report as needed any sign and symptom of respiratory infection: Fever, Chills, increase in sputum, chest pain, increased difficulty breathing (Dyspnea), increased coughing and wheezing. Oxygen settings are O2 at 2L/min via NC continuous. Further review of the Care Plan revealed, [R20] has oxygen therapy related to COPD. At times removes continuous oxygen. The Goal outlined in this Care Plan indicated that R20 will not have any sign and symptom of poor oxygen absorption through review date. The Interventions directed staff to give medications as ordered by physician. Monitor/document side effects and effectiveness. Monitor for sign and symptoms of respiratory distress and report to physician. Staff to assess as needed R20's respirations, pulse oximetry, increased heart rate (Tachycardia), restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis, hemoptysis, cough, pleuritic pain, accessory muscle usage, skin color. Oxygen settings: oxygen at 2L/min via nasal cannula continuous. Staff to reapply oxygen nasal cannula when noted to be taken off by R20. During an observation on 08/13/24 at 12:06 PM, R20 was not wearing the nasal cannula. Nasal cannula was observed on the recliner chair in the resident's room, with the oxygen concentrator running at 2 liters per minute. R20 was in his wheelchair, leaning in tripod position (physical stance that people may assume when they are out of breath or experiencing respiratory distress. The position involves sitting or standing while leaning forward and supporting the upper body with the hands on the knees or another surface) unable to answer questions in a full sentence without catching his breath. No staff was observed in the resident's room. Licensed Practical Nurse (LPN)1, who was the nurse on the unit, was assisting with lunch trays. During an observation and interview on 08/13/24 at 12:11 PM, LPN1 was informed of the respiratory concerns for R20. LPN1 entered the resident's room and witnessed R20 in the tripod position. LPN1 stated, R20 is noncompliant with oxygen. R20 stated, he did not need oxygen. LPN1 stated, This morning his SPO2 [oxygen saturation, is a percentage that measures the amount of oxygen-carrying hemoglobin in the blood] was 94% around 9 AM and he refused oxygen since earlier this morning. LPN1 states, she has not been able to chart or notify anyone regarding R20's refusal to receive oxygen. LPN1 further states she has not rechecked R20's SPO2 since 9 AM and denied calling a physician or notifying the Nurse Practitioner. LPN1 stated, This is his usual behavior and I've been assisting with passing trays for lunch. I tried to assist [R20] but he refused and at one point was standing up from wheelchair. During an observation and interview on 08/13/24 at 12:16 PM, R20 stated, he refused oxygen because the nasal cannula hurts his nostrils. R20 was unable to state this in a full sentence without needing to catch his breath. LPN1 was still present to witness the conversation with R20. When the interview was completed with R20, LPN1 exited the room and began assisting with lunch trays. During an interview and observation on 08/13/24 at 12:19 PM, this surveyor immediately revealed R20's respiratory concerns to the Director of Nursing (DON). The DON revealed if a patient has been refusing oxygen, the Nurse Practitioner should be contacted and the nurse should do continuous or very frequent oxygen saturation checks, the responsible party should be notified and documentation of the refusal as soon as possible. On 08/13/24 at 12:29 PM, the DON went to R20's room to observe the location of the nasal cannula and resident concern. The DON assessed R20 immediately. The portable Spirometer (finger) monitor was unable to read R20's SPO2, after multiple attempts. A Hill-Rom [NAME] Allyn Spot Vital Signs 4400 (a machine used to take residents' vital signs) was brought into the room to obtain R20's SPO2. At 12:36 PM, R20's SPO2 reading was 82%-84%. LPN1 was observed still passing lunch trays. The DON requested LPN1 to stop and assist with assessing the resident. During an interview on 08/13/24 at 12:43 PM, the Nurse Practitioner (NP) revealed that she is familiar with the resident and is aware that he has the behavior of not following orders for his diet and oxygen. The NP revealed that she expects the nurse to redirect the patient. If the patient is refusing, the staff should continue to monitor for respiratory distress and notify if there is a condition change. The NP stated, In general, if the SPO2 is 88% or lower and not increasing with or without supplement oxygen, I expect to be notified as soon as possible. I have only been here for a month. I have not been contacted today regarding [R20's] refusal of oxygen or [R20] having a low SPO2. During an interview on 08/13/24 at 2:51 PM, the DON revealed to the Assistant Director of Nursing (ADON) that R20 was in a tripod position and should have been assessed by LPN1. The DON stated she witnessed LPN1 not assisting with the resident. The DON expressed concerns regarding the non-action and presented this surveyor with R20's Care Plan that directed the staff with interventions to be followed when R20 refuses oxygen. The DON stated that the nurse is expected to place priorities on airway, breathing, and circulation of a resident over passing out lunch trays. 31846

Based on review of the facility policy titled, Labeling and Dating Foods (date Marking), observation, and interview, the facility failed to ensure foods that were opened and stored contained an open date in 1 of 1 main kitchen. The facility further failed to ensure expired items were removed from 1 of 2 nutrition refrigerators on 1 of 2 halls. Findings include: Review of the facility policy titled, Labeling and Dating Foods (Date Marking), states, All foods stored will be properly labeled according to the following guidelines. 1. Date marking for dry storage food items, states The exception to dating individual dry storage food items includes individually packaged food items stored in bulk containers such as packets of hot chocolate, tea bags, saltine crackers, packets of sugar and packets of individual cookies, etc. There is no data on the policy for removing packages from boxes and using portions and then dating them after resealing them for future use. 2. Date marking for refrigerated storage food items: Once opened, all ready to eat, potentially hazardous food will be re-dated with a use by date according to current safe food storage guidelines or by the manufacturers expiration date. 3. Date marking for freezer storage food items: Once a package is opened, it will be redated with the date the item was opened and shall be used by the safe food storage guidelines or by the manufacturer's expiration date. On [DATE] at 10:45 AM during initial tour of the main kitchen revealed the following: An observation of the dry storage area in the main kitchen revealed a plastic bag of Oreo cookie crumbs, opened, and partially used and resealed with no open date. A large disposable beverage cup with a dark liquid belonging to an employee was sitting on a shelf with other items to be used in preparing meals. Tour of the walk in freezer revealed frozen cream filling, opened and covered with a plastic wrap with no open date, and a bag of donuts opened and partially used with no open date. A bag of chocolate chip cookies, unsealed without an open date was also observed. Tour of the walk in refrigerator revealed an undated tray of salads in carry out containers. An interview on [DATE] at 10:46 AM with the Dining Services Director confirmed the findings. Review on [DATE] at 12:50 PM of 1 of 2 nourishment refrigerators on the units revealed: 4 cartons of Non Fat Milk expired on [DATE], 3 Peanut Butter and Jelly sandwiches dated [DATE] - [DATE] were in the refrigerator, hard and dried out, and a box of Ready Care was expired on [DATE]; opened and in use for residents. An interview on [DATE] at 12:50 PM with the Registered Nurse, Life Enrichment Worker, confirmed the findings and brought them to the attention of the Assistant Director of Nursing.

Based on review of the facility policy, observation, and interview, the facility failed to ensure trash and debris was removed from the area around the base of 3 of 3 facility dumpsters. Findings include: Review of the facility policy titled,Maintaining a Safe and Sanitary Environment around Trash Receptacles, states under Dumpster Care: Dumpsters and surrounding area should be kept clear of large debris that could impede pickup and delivery of dumpster. No garbage should be placed on top of dumpster. Dumspters should not be overloaded. An observation on 9/27/22 at 8:45 AM of the outside trash receptacles revealed a large amount of paper products, a white plastic apparatus, and a discarded broom. The findings were confirmed on 9/27/22 at 8:45 AM by a Maintenance Worker. On 9/27/22 at 9:10 AM, during an interview with the Administrator, and her viewing of the dumpsters with this surveyor, she also confirmed that there was a large amount of paper products, a white plastic broken apparatus, and a discarded broom was on the ground outside the 3 dumpsters.

Based on review of the facility policy, observation, and interview, the facility failed to ensure an excessive amount of lint was removed from 2 of 3 clothes dryers. Findings include: Review of the untitled and undated facility policy revealed, Lint trap should be kept clean. All dryer lint traps will be cleaned after each load. After removing clothes from dryer, clean lint trap after every load. An observation on 9/27/22 at 11:10 AM of the laundry room revealed 2 clothes dryers with an excessive amount of lint in the bottoms, on all 3 upper walls and hanging off the filled lint baskets. During the observation of the clothes dryers, the Administrator and the Laundry Worker (LW) were in attendance and verified the excessive amount of lint in the 2 clothes dryers. During an interview on 9/27/22 at 11:15 AM with the LW, she stated the lint is removed from the dryers after 3 loads. The LW then stated she sweeps it out as best as she can and the maintenance department will come every once in a while and vacuum out the bottoms of the dryers. The LW provided a copy of the log which should be documented that the lint has been removed from the dryers after 3 loads and the log did not have any documentation to ensure the clothes dryers were cleaned of the lint on 9/26/2022, and until 11:00 AM on 9/27/2022 the log was not not completed. The laundry worker states she starts washing and drying clothes at 5:00 AM in the morning.

Based on review of the facility policy and procedures, observation, and interview, the facility failed to assure expiration dating of an insulin product in 1 of 2 medication carts. Findings include: Review of the facility's policy titled, Storage and Expiration of Medications, Biologicals, effective 12/01/07 and updated 7/21/22 sets forth the procedures relating to the storage and expiration dates of medications biological, syringes and needles. The policy states once any medication or biological package is opened, facility should follow manufacturer/supplier guideline with respect to expiration dates for opened mediations, facility staff should record the date opened on the primary medication container (vial, bottle, inhale) when the medication has a shortened expiration date once opened or opened and if a multi-dose vial of an injectable mediation has been opened or accessed (e.g. (for example) 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. Further review of the manufacturer package insert states in-use (opened) prefilled pens expires 28 days after opening, On 09/26/22 at approximately 10:45 AM inspection of the medication cart for rooms 1 through 19 revealed an opened, undated, and in use Insulin [MEDICATION(S)] Pen belonging to Resident (R)7, which had been labeled by pharmacy Discard unused medications after 28 days. Date _______. There was no date entered on the pharmacy applied label or the plastic bag container the insulin pen. On 9/26/22 at approximately 10:49 AM this finding was verified by Licensed Practical Nurse (LPN)1.

Based on record review and interview the facility failed to ensure the resident's medical record was complete and accurate for 1 of 1 resident (Resident (R) 1). The facility failed to ensure documentation of the treatments administered ensuring the resident's medical record was complete and accurate. This failure could affect the resident's quality of care. Findings include: In a review of R1s undated Face Sheet, R1 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R1s Admission Minimum Data Set assessment with an Assessment Reference Date of 06/16/21 revealed R1 had a Brief Interview of Mental Status score of 09, indicating moderate impairment. In a review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Medication Administration Report (MAR), dated 07/21, revealed there was no documentation of empty or burping of [CONDITION(S)] bag for the 7 AM to 7 PM shift on 07/04/21 and 7 PM to 7 AM shift on 07/09/21. In a review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of MAR, dated 07/21, revealed there was no documentation of monitoring mid-abdomen surgical site for signs and symptoms of infection every shift for the 7 AM to 7 PM shift on 07/04/21. In a review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of MAR, dated 07/21, revealed there was no documentation of skin prep to bilateral heel every day and night shift for the 7 AM to 7 PM shift on 07/04/21 and 7 PM to 7 AM shift on 07/09/21. In a review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of MAR, dated 07/21, dated 07/21, revealed there was no documentation of cleansing peri [CONDITION(S)] stoma area with wound cleanser, skin prep peri stoma area, and place new wafer and bag for 07/09/21. In a review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Cover non-adherent dressing. Monitor skin tear every day and night shift until skin tear is resolved. A review of MAR, dated 07/21, revealed there was no documentation of treatment provided to lower left leg skin tear for 7 AM to 7 PM on 07/04/21. In a review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Cover non-adherent dressing. Monitor skin tear every day and night shift until skin tear is resolved. A review of MAR, dated 07/21, revealed there was no documentation of treatment provided to right leg skin tear for 7 AM to 7 PM on 07/04/21. In a review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of MAR, dated 07/21, revealed there was no documentation of the application of [MEDICATION(S)] Skin Protectant Ointment 50% to right buttock for the 7 PM to 7 AM shift on 07/09/21. In an interview with the Administrator on 11/12/21 at 12:45 PM, she acknowledged the documentation was not complete; adding the documentation should have been entered in the MAR upon completion of the task.

Based on observation, record review, interview, and review of the facility policies titled, Fluid Restriction and Discharge Process Protocol, the facility failed to monitor a fluid restriction for Resident #10 (1 of 5 residents reviewed for Unnecessary Medications); failed to ensure Resident #26 had continuous oxygen in use as ordered by a physician (1 of 1 residents reviewed for Infection Non Urinary Tract Infection/Respiratory); and failed to ensure Resident #130 had the correct code status listed on the order sheet (1 of 1 residents reviewed for Advanced Directives). The findings included: The facility admitted Resident #10 on 12/4/2018 with [DIAGNOSES REDACTED]. Review on 5/30/2019 at approximately 10:44 AM of the Nurses Notes dated 4/1/2019 through 5/29/2019 stated on 4/15/2019 and 5/7/2019 that Resident #10 was non-compliant with the physician ordered Fluid Restriction. Review on 5/30/2019 at approximately 10:52 AM of the physician orders [REDACTED]. The fluid restriction was as follows: 240 mls with breakfast, 240 mls with lunch, and 240 mls with dinner. Also included was 100 mls with 3 hydration passes and 145 mls with 4 med passes every day and night. No documentation was found to ensure the 1600 mls fluid restriction was monitored for Resident #10. No amounts of fluid intake were recorded in the medical record for Resident #10 to ensure s/he received the 1600 mls. Review on 5/30/2019 at approximately 10:59 PM of the facility policy titled, Fluid Restriction, revealed it stated, When a physician orders [REDACTED]. The purpose states, To maintain hydration requirements and monitor and promote compliance with fluid restriction. Number 4 states, Maintain strict fluid intake. During an interview on 5/30/2019 at approximately 3:20 PM with the Director of Nursing (DON) confirmed that no fluid amounts were documented in the medical record for Resident #10 to ensure a strict fluid restriction was monitored. The facility readmitted Resident #26 on 05-24-19 with [DIAGNOSES REDACTED]. During the initial tour of the facility on 05-28-19 at approximately 11:15 AM Resident #26's oxygen concentrator was observed in his room covered with a plastic bag. The portable oxygen tank was observed in a portable rolling holder with no tubing attached. Resident #26 was observed on 05-28-19 at approximately 11:20 AM in the dining room without oxygen applied and without distress. Subsequent observations on 05-28-19 throughout the afternoon revealed Resident #26 remained without his oxygen applied. Observations on 05-29-19 at approximately 9:00 AM, 2:15 PM and 3:29 PM of Resident #26's room revealed the oxygen concentrator continued to be covered and the portable oxygen tank was in the rolling holder. Resident #26 was observed on 05-29-19 at approximately 9:05 AM, 2:15 PM, and 3:30 PM without oxygen applied. Record review of the Treatment Administration record on 05-29-19 at approximately 03:08 PM revealed resident #26 had an order on 05-06-19 for Oxygen at 2 liters per minute via nasal canula continuous monitor saturation every shift for [MEDICAL CONDITION]. Record Review of Vital Signs oxygen saturation from 05-24-19 to 05-29-19 revealed the resident's lowest oxygen level was 94% on room air. During an interview on 05-29-19 at approximately 3:36 PM with Licensed Practical Nurse (LPN) #1, s/he confirmed resident #26 had an order for [REDACTED].#1 also confirmed the concentrator was covered and the portable oxygen was in the holder and not applied to the resident. During an interview on 05-29-19 at approximately 4:18 PM with Registered Nurse (RN) #1, confirmed that s/he covered the concentrator yesterday because it was not in use. RN #1 stated the resident was not on oxygen yesterday and the portable oxygen tank was in the residents room and not in use. RN #1 reviewed the resident Treatment Administration Record and confirmed that the continuous oxygen had been signed on for 05-28-19 as being administered. The facility admitted Resident #130 with [DIAGNOSES REDACTED]. Review of the electronic health record on 05/29/19 at approximately 2:10 PM revealed the Code Status for Resident #130 stated both Do Not Resuscitate and Full Code. In an interview on 05/29/19 at approximately 2:11 PM, the DON stated Resident #130 was currently a Full Code but had a Do Not Resuscitate order from a previous admission that should have been discontinued at the time Resident #130 was discharged . Review of facility policy entitled Discharge Process Protocol revealed, Discontinue all orders in the system as one of the required actions.

Based on observation and interview, the facility failed to ensure proper storage and/or labeling of items in 1 of 1 kitchens. The findings included: During the initial tour of kitchen on 05/28/19 at approximately 11:00 AM with the Certified Dietary Manager (CDM), the following were observed: a 10 pound box of shredded coconut not labeled as to date opened and the bag not tied or secured, 2 plastic containers of sliced mushrooms with no labeling as to date opened, fresh green and red bell peppers and zucchini with areas of decay/spoilage and a package of frozen fish with no markings to show when opened or stored. During the tour at the time of discovery, the CDM confirmed these items should have been labeled by facility staff.

Based on observation, record review, and interview, the facility failed to formulate a plan of care for Resident #10 to include a chronic dark/red area around the right eye with orbital [MEDICAL CONDITION] for 1 of 5 residents reviewed for unnecessary medications. The findings included: The facility admitted Resident #10 on 12/4/2018 with [DIAGNOSES REDACTED]. An observation on 5/28/2019 at approximately 10:45 AM revealed Resident #10 with discoloration of the right eye and peri orbital [MEDICAL CONDITION]. During an interview on 5/28/2019 at approximately 11:15 AM with Resident #10, who had a Brief Interview of Mental Status (BIMS) of 14/15, he/she stated that the condition of his/her right eye comes and goes and s/he was not sure why. The chronic eye discoloration and [MEDICAL CONDITION] was verified by the Nurse, Certified Nursing Assistant, Director of Nursing, and Assistant Director of Nursing. Review on 5/29/2019 at approximately 4:23 PM of the medical record for Resident #10 revealed a Plan of Care dated 12/7/2018. The Plan of Care did not include the purplish discoloration and peri orbital [MEDICAL CONDITION] to the right eye. During an interview on 5/30/2019 at approximately 4:40 PM, the Care Plan Coordinator confirmed that the Plan of Care did not include the discoloration and orbital [MEDICAL CONDITION] of Resident #10's right eye. The Care Plan Coordinator then presented a corrected copy of the Plan of Care for Resident #10.

Based on record review and interview, the facility failed to provide written Notice of Transfer to residents and/or resident representatives for 2 of 3 sampled residents reviewed for hospitalization (Residents #17 and #22). The findings include: The facility admitted Resident #17 with [DIAGNOSES REDACTED]. Record review on 05/31/19 at approximately 8:58 AM revealed a Notice of Resident Transfer or Discharge for Resident #17 dated 05/24/19. It was noted on the form by the facility Social Worker that the Resident Representative was verbally notified. The facility admitted Resident #22 with [DIAGNOSES REDACTED]. Record review on 05/30/19 at approximately 8:25 AM revealed Notices of Resident Transfer or discharge date d 05/03/19 and 05/05/19 related to Resident #22 being sent to the hospital. Both documents had notations at the bottom that the resident representative was called by phone related to the transfers. In an interview on 05/30/19 at approximately 3:12 PM, the Director of Nursing stated that the document is reviewed with residents at the time of transfer and the Social Worker follows up with a phone call. The Social Worker stated the documents were not provided in writing to the residents or resident representatives for Residents #17 and #22.

Based on record review and interview, the facility failed to provide written Notice of Bed Hold Policy to the resident and/or resident representative for 1 of 3 sampled residents reviewed for hospitalization (Resident #22). The findings include: The facility admitted Resident #22 with [DIAGNOSES REDACTED]. Record review on 05/30/19 at approximately 8:25 AM revealed Notices of Bed Hold Policy dated 05/03/19 and 05/05/19 related to Resident #22 being sent to the hospital. Both documents had notations that the Resident Representative was called by phone related to the transfers. In an interview on 05/30/19 at approximately 3:12 PM, the Director of Nursing stated that the document is reviewed with residents at the time of transfer and the Social Worker follows up with a phone call. The Social Worker stated the document was not provided in writing to the resident or resident representative.

Based on observation, interview and review of the facility policy and procedures the facility failed to ensure, that cold food temperatures were appropriate at point of service and during storage, expired food discarded, and staff wearing appropriate hair restraints in 2 of 2 kitchens. The findings included: During final tour of the Main Kitchen on [DATE] at 4:00 PM an observation was made of multiple Time Temperature for Controlled for Safety Foods (TCS) / Potentially Hazardous Foods (PHF) stored at room temperature and stored on the preparation tables throughout the kitchen: Small pan of sliced pork loin in gravy with date of [DATE]/discard date [DATE], a pan of chicken noodle soup with date of [DATE] expiration date ,[DATE], an unlabeled pan of pasta salad, an unlabeled pan of aluminum foil wrapped baked potatoes, an unlabelled pan of a mixture of cooked lima beans and okra, and an unlabeled pan of melted butter with a pastry brush stored in the melted butter mixture. This observation was verified by Cook #1. Cook #1 verified that the items were stored at room temperature and should have been refrigerated and immediately discarded. The facility provided a copy of the form titled: Policy: 5.1 Hazard Analysis Critical Control Points (HACCP) Food Handling Principles, Revised ,[DATE], which states: Procedure: 1. Foods are held at or below 41 degrees Fahrenheit (F) or at or above 135 degrees F to keep them out of the danger zone for bacterial contamination or growth 17. Upon completion of meal service, all suitable prepared foods are covered, labeled and dated with a prepared date, and a use-by date and are chilled rapidly ., Cook #1 was observed on [DATE] at approximately 4:00 PM when he/she entered the kitchen and food preparation areas without hair restraint covering the hair on his/her head. Cook #1 was wearing a beard restraint, but no hair restraint on the head. Cook#1 said that he/she had planned to cover his/her hair on the head with beard restraint as the kitchen was out of hair restraints. He/She walked over to the area where the hair restraints were stored and verified that there were no hair restraints for covering the hair on his/her head. The facility provided a copy of the form titled: Policy 5.22 Use of Hair Restraints, Revised ,[DATE], which states: Dietary staff must wear hair restraints as a preventive measure against the spread of illness and to prevent hair from contacting exposed foods. Procedure: 1. Hair nets, .must be worn when any employee is in the food production and kitchen area. During initial tour of the Serving Kitchen on [DATE] at approximately 4:15 PM an observation was verified by Cook#2 of a small bowl of shredded cheddar cheese date [DATE], discard date [DATE]. Cook #2 verified the cheese was in the refrigerator beyond the expiration date and immediately discarded. During an observation which was verified by the Director of Dining on [DATE] at 5:25 PM of the food temperatures at point of service in the Serving Kitchen. During this observation, the thermometer was calibrated to 32 degrees and then the temperature of the Chicken Salad dinner service was 65.3 degrees. The Director of Dining said that the temperature should be 41 degrees or less and then he/she transported the Chicken Salad to the Main Kitchen. He/She said that the Chicken Salad was to be placed in the Blast Chiller to get the temperature down to 41 degrees or less. He/She returned to the Service Kitchen at 6:00 PM with the Chicken Salad stored in a pan of ice with ice on top of the chicken salad and temperature was 53.8 degrees at 6:00 PM. At 6:25 PM, the Chicken Salad was 40.4 degrees. During an interview with the Director of Dining on [DATE] at approximately 4:00 PM, he/she said that the Chef who had prepared the chicken salad on [DATE] had recipes which showed that the temperature of the chicken salad should be 41 degrees or less at point of service. The Director of Dining provided a copy of the form titled, Quantified Recipe, Recipe #53, which states, .Sandwich Chicken Salad White Trayline, Internal Temperature 38 Degrees, .Critical Control Point (CCP)-cold hold at 41 degrees Fahrenheit (F) or less until time of service. The facility provided a copy of the form titled: Policy: 5.1 Hazard Analysis Critical Control Points (HACCP) Food Handling Principles, Revised ,[DATE], which states: .3 .Cold foods are to be served at 33 to 50 degrees .14. Almost any food can be contaminated. Certain foods are considered more hazardous than others and are called, Potentially Hazardous Foods (PHF) or Time/Temperature Controlled for Safety (TCS) food. Examples of PHF/TCS foods include ground beef, poultry, chicken,

Based on record review and interview, the facility failed to complete a recapitulation or summary of the resident stay prior to transferring the resident to another skilled nursing facility. The findings included: The facility admitted Resident #5 on 04/18/18 with [DIAGNOSES REDACTED]. On 07/03/18 at 08:55 AM, review of the IDT (Interdisciplinary Team) Recapitulation of Stay Assessment revealed Social Services had documented the resident's cognitive status as alert and oriented and a comment that the resident was being transferred to be closer to his/her son/daughter. The dietary section included the resident's weight but no other information. There was no documentation by nursing, rehabilitation staff, or any advance directive information. During an interview on 07/03/18 09:58 AM, the Assistant Director of Nursing (ADON) confirmed the lack of documentation in the the IDT Recapitulation of Stay Assessment. The ADON stated that medication and treatment records, all active orders, recent labs results, advance directive, and Hospital Discharge summary were included in a discharge packet and sent to the receiving facility including any scheduled follow-up appointments. The ADON confirmed the Recapitulation had not been completed and the information that was in the assessment was computer-populated.

Based on observation and interview, the facility failed to identify, remove and dispose of expired medication in 1 of 2 medication carts reviewed. The findings included: On 07/01/18 at 04:40 PM, review of the Willow Trace Medication Cart revealed a unit dose package of [MEDICATION NAME] 10 mg (milligrams) with an expiration date of 05/31/18. During an interview at 04:55 PM, LPN (Licensed Practical Nurse) #1 confirmed the medication expired 05/31/18. The LPN further stated that expired medications were bagged and returned to the pharmacy. In addition, the LPN stated the pharmacy was at the facility last week and that audits were done weekly by the Registered Nurses.

Based on record review and interview the facility failed to utilize accepted standards of infection control practices during wound care for Resident #26, 1 of 1 reviewed for pressure ulcer. The findings included: The facility admitted Resident #26 on 05/17/18 with [DIAGNOSES REDACTED]. During observation of wound care on 07/03/18 at 09:04 AM, RN (Registered Nurse) #2 sanitized her/his hands and donned gloves. After spraying wound cleanser into wound bed, 4 x 4 gauze were used to clean the center of the wound bed, wiping several times through the wound bed and the immediate peri-wound area and back to the wound bed. The RN left the soiled 4 x 4 gauze in the wound bed while removing the gloves, sanitized her/his hands and donned clean gloves. The RN then removed the soiled gauze, discarded the gauze, and applied [MEDICATION NAME] to the wound bed using a contaminated gloved finger then applied a clean border dressing. During an interview on 07/03/18 at 10:25 AM, RN #2 confirmed that s/he wiped the wound bed several time and returned to the wound bed with the gauze after wiping the peri-wound. The RN also confirmed s/he left the soiled gauze in the wound bed stating that the resident would have rolled back over onto the soiled brief while s/he changed gloves. The RN confirmed that s/he applied the [MEDICATION NAME] with her/his gloved finger and that it was contaminated after removing the soiled gauze and that s/he should not have used a finger to apply the medication.