Sanctuary of Geneva Limited Partnership

Based on observation, staff interviews and facility policy review, the facility failed to maintain the kitchen area in a clean and sanitary manner. This had the potential to affect all residents in the facility. The facility census was 35.

Findings include:

On 02/04/26 at 3:40 P.M. during the tour of the facility kitchen area with Dietary Staff/Cook #531, an observation of the facility's ice maker revealed a black spotted substance resembling mold on the retaining plate on the inside of the ice bin. The presence of the substance was confirmed by Dietary Staff/Cook #531 and Managing General Partner #508 during an interview at the time of the observation.

Review of the facility's undated Kitchen Sanitation policy revealed the facility was expected to maintain regulatory compliance and protect the health and well-being of residents, staff and visitors through proper sanitation and hygiene practices in all kitchen and food areas.

Based on record review, observation and staff interviews, the facility failed to discard medications that were past the used-by date for Resident #200 and failed to properly date Tuberculin Solution when opened. This affected one resident (#200) reviewed for medication storage and had the potential to affect all affect all 36 residents in the facility.

Findings include:

Review of the medical record revealed Resident #200 was admitted to the facility on 04/07/21 with diagnoses including diabetes, Alzheimer's, and increased lipids. Resident #200 had an order dated 10/10/24 for Fiasp FlexTouch Pen insulin 100 units/milliliter (u/mL) inject subcutaneous (sq) per sliding scale three times daily with meals.

Observation of medication storage on 02/13/25 at 8:56 A.M. revealed Resident #200's Flex- Pen in the medication cart was dated as opened on 10/11/24. Licensed Practical Nurse (LPN) #88 verified that the opened date was 10/11/24 at the time of the observation, and it should have been discarded thirty days after opening.

Interview on 02/13/25 at 9:23 A.M. with Assistant Executive Director #32 verified that Resident #200 had a current order for the Fiasp FlexTouch Pen insulin.

Observation on 02/13/25 at 8:10 A.M. of Tuberculin Solution in the medication cart at the main nursing station revealed the solution was opened with no date on the vial or the box to indicate when it was opened. LPN # 88 verified that there was not a date on the vial or box and discarded the vial.

Based on record review, observation and interview, the facility failed to ensure that Resident #91 was given prescribed medications in a manner authorized by a physician. This affected one resident (#91) of two residents reviewed for medication administration. This had the potential to affect all 36 residents residing in the facility.

Findings include:

Review of the medical record revealed Resident #91 was admitted on 09/20/19 with diagnoses of type II diabetes, proximal atrial fibrillation, and congestive heart failure. An annal assessment from the physician documented that Resident #91 was not safe for self-administration of his medication on 09/17/24.

Observation on 02/13/25 at 7:45 A.M. Licensed Practical Nurse (LPN) #88 put a cup of medication in front of Resident #91 in the dining room and then turned and left the dining room. Interview with LPN #88 at the time of the observation verified that she had left the medications in front of Resident #91 to take on his own.

Interview on 02/13/25 at 12:24 P.M. with Assistant Executive Director #32 verified that Resident #91 had a medication assessment completed by the physician that stated Resident #91 was not safe to self-administer medication.

Based on employee personnel file review and interview, the facility failed to ensure tuberculosis (TB) testing for new employees before they started providing hands on care to residents. This has the potential to affect all 36 residents residing in the facility.

Findings include:

Review of the pre-employment TB test for Licensed Practical Nurse (LPN) #39 indicated that the employee had not had previous TB testing completed for hire date of 05/17/24. LPN #39 started working with residents on 05/23/24, and the first step of TB testing was not completed until 07/09/24.

Review of the pre-employment TB test for Caregiver #76 indicated that the employee had not had previous TB testing completed for hire date of 06/04/24. Caregiver #76's first step of TB testing was not completed until 07/06/24.

Interview with Assistant Executive Director #32 on 02/13/25 at 12:36 P.M. verified that LPN #39 and Caregiver #76 started working with residents before their new hire TB tests were completed.

Based on employee file review, interview and policy/plan review the facility failed to follow the tuberculosis control policy/plan related to employee screening. This has the potential to affect all residents residing in the facility. The census was 37.

Findings include:

Review of six employee files revealed three employees (Employee #508, #516 and #517) did not have evidence of the Signs and Symptom Questionnaire or Potential Exposure Report Form completed in 2022 and a form had not yet been completed in 2023.

On 06/14/23 at 11:43 A.M. interview with the Executive Director verified a Signs and Symptom Questionnaire or Potential Exposure Report Form had not been completed annually for Employee #508, #516 and #517.

Review of the un-dated Tuberculosis ( TB) Control Policy under Ongoing Monitoring and Education revealed after baseline testing, unless signs or symptoms are observed or reported, routine, ongoing monitoring will be done through the following means: The completion of a Signs and Symptom Questionnaire or Potential Exposure Report Form annually by each staff member. This completed form will be maintained in the employee file for two years.