Brookdale Trillium Crossing

Based on interview and record review the facility failed to ensure Resident #2's and #32's antibiotics were given as ordered by the physician this affected two (# 2 and #32) of three reviewed for antibiotic administration. The facility also failed to ensure laboratory test were completed as ordered. This affected one (#6) of three reviewed for laboratory test. The facility census was 60.

Findings include:

1. Review of Resident #2's medical record revealed an admission date of 02/18/25 with diagnoses including cardiac murmur, osteoarthritis, sciatica, chronic pain, and major depression.

Review of Resident #2's progress notes dated 06/12/25 revealed the Certified Nurse Practitioner (CNP) visited the resident and recommended Cephalexin (antibiotic) 500 milligrams (mg) three times a day for seven days.

Review of Resident #2's physician order dated 06/13/25 to 06/19/25 revealed an order for Cephalexin 500 mg three times a day for seven days.

Review of Resident #2's Medication Administration Record (MAR) for June 2025 revealed Cephalexin was documented as not administered twice on 06/15/25, but was otherwise administered as ordered.

Review of Resident #2's progress notes dated 06/15/25 revealed one note related to Cephalexin indicated it was ordered. The other note did not indicate why it was not administered.

Review of the incident investigation dated 06/23/25 revealed an allegation was made that an antibiotic was given on 06/21/25 that was not scheduled in the MAR. The summary of the allegation stated Resident #2's daughter emailed indicating her mom was given an antibiotic on the morning of 06/21/25. However, she did not receive any doses on 06/20/25 and was told the course of antibiotics was completed. The nurse told her mother that the antibiotic popped up in her record. Resident #2 was interviewed on 06/23/25 and stated she did receive an antibiotic on the morning of 06/21/25. She was unsure if she missed any doses of her antibiotic because she was not sure how many days she was on them. Interview with Licensed Practical Nurse (LPN) #117 revealed she did give the resident an antibiotic on 06/21/25 because there were antibiotics left in her bubble card (a dose medication packing system) and she wanted to make sure she received all of her doses, however the medication did not it did not come up in the MARs as needing to be administered. LPN #213 indicated she had pulled one dose of the medication from the Emergency kit (E-Kit). Registered Nurse (RN) #110 indicated she pulled two doses from the E-Kit and one dose she borrowed from a different facility resident who lived on the second floor.

Review of the facility investigation revealed it included a picture of three medication cards labeled 'Pills left in the Cart' The image contained three Cephalexin 500 mg for Resident #2 cards each labeled morning, afternoon, and bedtime, the cards indicated there had been a quantity of seven pills per card. The morning card had five pills remaining, the afternoon card had three pills remaining, and the evening had two pills remaining. The investigation included a packing slip indicating the pharmacy delivered 21 capsules of Cephalexin for Resident #2 on 06/13/25, however, the slip was not signed off until 06/16/25. It also included a document indicating the Emergency kit contents at an unknown time there were 16 pills of Cephalexin 500 mg in the box. Written on this document was that an audit of the kit was done on 06/23/25 and it was found that eight were left and eight were removed from the box. Only one slip was found to account for two doses for Resident #2 and there was another slip for a dose on another resident. A E-kit removal receipt indicated two doses of Cephalexin 500 mg were pulled for Resident #2 on 06/16/25. Finally, the investigation included scans of two cards of Cephalexin 500 mg from the E-kit. Both cards indicated they were dispensed on 02/25/25. The first card had three pills missing and five pills remaining and the second card had five pills missing and three pills remaining.

Interview on 07/16/25 from 2:04 P.M. to 3:00 P.M. with the Health and Wellness Coordinator (HWC) #119 revealed after Resident #2's Cephalexin order was completed she had 10 left over pills. She reported two doses of Cephalexin were pulled for the resident from the E-kit, however, there were no additional slips indicating more doses were pulled for her.

Interview on 07/16/25 at 3:33 P.M. and on 07/17/25 at 7:45 A.M. with the Administrator verified a nurse gave Resident #2 antibiotics without an order on 06/21/25. She also verified there were two missing doses on the MARS. One note on 06/15/25 indicated the medication was ordered, however, according to the packing slip the medications were in the facility. The Administrator reported the nurses had to go get medications from the front desk after they're delivered, and she was unsure if that happened.

Interview on 07/16/25 at 3:20 P.M. with the Health and Wellness Director (HWD) #127 verified there was only evidence that two of the pills from the E-kit went to Resident #2 leaving eight doses of antibiotic unaccounted for. The E-kit was last audited on 05/20/25 and would have been full at that time.

Review of the policy 'Emergency Kit Clinical Guideline' dated February 2025, revealed the HWD or designee was responsible providing the pharmacy with a clinically verified physician order with a remaining dispensing quantity prior to or at the time of removing medication from the E-kit and completing the E-kit withdrawal form, faxing it the pharmacy, and retaining it for community records.

Review of the policy 'Medication and Treatment- General guidance for medication administration and Assistance' revised July 2025 revealed medications were to be administered within the parameters of the physician orders.

Review of the policy 'Medication and Treatment Medication Administration Record Audit' dated April 2022, revealed if a medication was unavailable then the person responsible for assisting with the medication should document appropriately on the MAR.

2. Review of Resident #32's medical record revealed an admission date of 10/31/22 with diagnoses including rheumatoid arthritis, anxiety, depression, and celiac disease.

Review of Resident #32's physician order dated 12/23/24 revealed an order for Cephalexin 500 mg one time a day for rheumatoid arthritis.

Review of Resident #32's Medication Administration Record (MAR) for June 2025 revealed Cephalexin was not administered on 06/09/25, 06/11/25, 06/20/25, and 06/25/25.

Review of Resident #32's progress notes from 06/09/25 to 06/25/25 revealed no justification for missing medication.

Interview on 07/16/25 at 4:00 P.M. with Health and Wellness Coordinator (HWC) #119 verified Resident #32 did not receive medications as ordered.

Review of the policy 'Medication and Treatment General guidance for medication administration and Assistance' revised July 2025 revealed medications were to be administered within the parameters of the physician orders.

3. Review of Resident #6's medical record revealed an admission date of 02/19/25 with diagnoses including cardiac murmur, sepsis, myelodysplastic syndrome, refractory anemia with ring sideroblasts, and hypertension.

Review of Resident #6's CNP note dated 06/05/25 revealed orders for repeat complete blood count (CBC) on 06/09/25.

Review of Resident #6's medical record revealed no evidence laboratory tests were completed on 06/09/25.

Interview on 07/17/25 at 8:50 A.M. with HWC #119 verified Resident #6's laboratory tests were not completed on 06/09/25 as ordered by the CNP.

This violation represents noncompliance investigated under complaint OH00167405

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure medications were administered accurately and to the resident they were prescribed for. This affected two (#2 and #45) residents. The facility census was 60.

Findings include:

1. Review of Resident #2's medical record revealed an admission date of 02/18/25 with diagnoses including cardiac murmur, osteoarthritis, sciatica, chronic pain, and major depression.

Review of Resident #2's progress notes dated 06/12/25 revealed the Certified Nurse Practitioner (CNP) visited the resident and recommended Cephalexin (antibiotic) 500 milligram (mg) three times a day for seven days.

Review of the incident investigation dated 06/23/25 revealed the facility was investigating inappropriate antibiotic administration for Resident #2. Registered Nurse (RN) #110 indicated to give Resident #2 her antibiotic she pulled two doses from the emergency kit (E-kit) and one dose she borrowed from a resident on the second floor.

Interview on 07/16/25 at 3:57 P.M. with RN #110 revealed she had been unable to locate Resident #2's antibiotics and she pulled the same antibiotic from Resident #32's prescription supply. Her reasoning for doing this was Resident #32 received the antibiotic daily. She was unsure if the pill was replaced.

Interview on 07/16/25 at 4:02 P.M. with Health and Wellness Director (HWD) #127 verified it was inappropriate to take one pill from another resident, especially when the medication was available in the E-Kit. He indicated Resident #32's pills would have been replaced using the E-kit, however, there were no slips to verify this.

Review of the policy 'Medication and Treatment Administration and Assistance' dated July 2024, revealed medication administration should be in accordance with the prescriber's orders. The individual administering medication should verify the residents identify before giving them their medication and check the label three times.

3. Review of Resident #6's medical record revealed an admission date of 02/19/25 with diagnoses including cardiac murmur, sepsis, myelodysplastic syndrome, refractory anemia with ring sideroblasts, and hypertension.

Review of Resident #6's comprehensive blood count (CBC) dated 05/30/25 revealed he had a critically low hemoglobin.

Review of Resident #6's progress note dated 06/04/25 revealed Certified Nurse Practitioner (CNP) #159 was notified of the critically low hemoglobin and ordered repeat labs.

Review of Resident #6's progress notes from 06/30/25 to 06/06/25 revealed no evidence the resident or family was notified of his laboratory results.

Interview on 07/17/25 at 8:50 A.M. with Health and Wellness Coordinator (HWC) #119 verified the CNP was not notified timely of critical labs on 05/30/25. She additionally reported the resident, and his family were not notified of the critical labs until 06/06/25.

Based on observation, staff interview and facility policy and procedure review, the facility failed to properly clean the glucometer. This had the potential to affected one (Resident #45) of one resident observed for a finger stick blood sugar. The census was 60.

Findings include:

Review of Resident #45's medical record revealed she was admitted to the facility on 04/17/25. Diagnoses included diabetes, ulceration of vulva, acute kidney failure, high blood pressure, atrial fibrillation, heart failure, multiple myeloma, and peripheral vascular disease.

On 07/16/25 at 4:10 P.M. Observation of Licensed Practical Nurse (LPN) #119 revealed she cleaned the resident's glucometer with an alcohol prep pad, obtained the finger stick blood sugar (FSBS) 215, removed gloves and collected supplies to discard. LPN #119 was observed to use hand sanitizer to clean hands. LPN #119 then put on new gloves and wiped the glucometer down with an alcohol prep pad and placed the glucometer in Resident #45's cupboard. Interview with LPN #119 on 07/16/25 at 4:23 P.M. verified she had cleaned the glucometer with an alcohol prep pad.

Review of the facility policy and procedure How to clean and maintain a Blood Glucose Glucometer dated 08/12 and revised 10/23 revealed residents should have their own glucose meter and it is to be intended for individual use only. It should be cleaned using a PDI super sani-cloth germicidal wipe, wait two minutes afterwards until the bactericidal, tuberculocidal, and virucidal properties can be effective.

This violation is a recite to the annual survey completed 01/03/24.

Based on personnel record review and staff interview, the facility failed to ensure evidence of tuberculosis (TB) testing was completed upon hire. This affected three of six employee's reviewed for TB testing. This had the potential to affect the 60 residents residing in the facility.

Findings include:

1. Review of Licensed Practical Nurse (LPN) #210's personnel file revealed a hire date of 06/30/25. There was no documented evidence a TB test was completed upon hire.

2. Review of Personal Care Assistant (PCA) #113's personnel file revealed a hire date of 04/03/25. There was no documented evidence a TB test was completed upon hire.

3. Review of Server #211's personnel file revealed a hire date of 06/06/25. There was no documented evidence a TB test was completed upon hire.

Interview on 07/17/25 at 12:10 P.M. the Administrator verified the facility had no evidence LPN #210, PCA #113 and Server #211 had a TB test completed upon hire.

Based on observation, staff interview, and review of facility policy and procedure, the facility failed to ensure food was stored and prepared in a manner to prevent potential contamination and spoilage. This had the potential to affect all 60 out of 60 residents residing in the facility.

Findings include:

Observation on 07/16/25 at 9:24 A.M. of the reach in freezer revealed chicken tenders, french fries and hamburger patties that were stored uncovered and opened to air.

Observation on 07/16/25 at 9:30 A.M. of the freezer revealed a container of vanilla ice cream stored uncovered and open to air.

Observation on 07/16/25 at 9:42 A.M. of the reach in refrigerator revealed dill sauce with a labeled discard date of 06/31/25 and cooked quinoa with a labeled discard date of 7/14/25. There was also observed uncovered containers of shredded cheese and sliced cheese and an undated container of raw hamburger patties.

Observation on 07/16/25 at 9:52 A.M. of the kitchen revealed the scoop for the flour was stored on the bottom of the container that held the bag of flour, the scoops for the sugar was stored on the bottom of the container that held the bag of sugar, and the scoop for the breadcrumbs was stored on the bottom of the container that held the bag of breadcrumbs. Food residue was seen surrounding the scoops on the bottom of each respective container.

Observation on 07/16/25 at 10:00 A.M. of the walk in freezer revealed an opened undated bag of shredded hashbrown potatoes. There was also observed a tray of cookie dough stored uncovered, open to air on a service rack in the walk in freezer.

Observation on 07/16/25 at 10:02 A.M. of the freezer revealed a bag of chocolate icing with a labeled discard date of 03/31/25.

Observation on 07/16/25 at 10:07 A.M. revealed an opened bag of lentils stored inside a larger plastic food storage container, the bag was sitting on top of lose lentils that were on the bottom of the container.

Observation on 07/16/25 at 10:13 A.M. of the dry storage area revealed a container of walnuts with a labeled discard date of 07/13/25 and five miniature pie crusts wrapped together in plastic which were unlabeled.

Observation on 07/16/25 at 11:00 A.M. of the lunch meal preparation revealed Cook #142 actively preparing food while wearing a hat. However, the Cook ' s hair extended out of the hat down to almost the shoulder level beyond the bottom of the hat, and the hair was not contained in a hair net.

Interview on 07/17/25 at 11:41 A.M. with Director of Dining Services #170 verified vanilla ice cream was being stored uncovered in the freezer.

Interview on 07/17/25 at 11:45 A.M. with Director of Dining Services #170 verified the food items in the walk in freezer were not stored correctly and were not discarded according to their discard date.

Interview on 07/17/25 at 11:48 A.M. with Director of Dining Services #170 verified the bag of lentils was being stored directly on top of loose lentils within a larger container.

Interview on 07/17/25 at 11:53 A.M. with Director of Dining Services #170 confirmed Cook's 142's hair was not contained in a hair net and also confirmed posted facility policy that employees participating in food service should be wearing hair nets to prevent contamination of foods.

Review of facility policy titled Hair Restraints effective 2005, last revised 12/24 revealed all associates working in food preparation must wear hair restraints. Further review of this policy revealed that all hair must be kept covered, and hair that cannot be effectively restrained by a hat must wear a hairnet.

This violation is a recite to the annual survey and post survey revisit conducted on 12/03/20.

Based on observation and staff interview, the facility failed to ensure garbage containers were covered in the kitchen. This had the potential to affect all 60 out of 60 residents residing in the facility.

Findings include:

Observation during breakfast meal service on 07/16/25 at 9:21 A.M. revealed two open uncovered refuse containers with trash in the containers in the food production area of the kitchen. One container was near the cold service line and the other container was at the end of the food prep line. At the same time, two additional large opened uncovered refuse containers with trash in them were observed outside of the dishwashing area. Interview with Director of Dining Services #170 verified the refuse containers were opened and uncovered, at the time of the observation.

Further interview with Director of Dining Services #170 on 07/16/25 at 9:25 A.M. revealed the refuse containers in food preparation areas should be covered, and the lids for refuse containers had been ordered but not yet delivered.

This violation is a recite to the annual survey conducted on 01/03/24.

Based on observation and staff interview, the facility failed to maintain a clean and sanitary kitchen as evidenced by accumulation of food residue and debris on surfaces throughout the kitchen. This had the potential to affect all 60 out of 60 residents.

Findings include:

Observation on 07/16/25 at 9:28 A.M. through 10:58 A.M. of the kitchen revealed the following: an accumulation of dark brown food residue on outside surface of the service cooler, food debris on the inside of the service cooler with salads and fruit observed being stored in the cooler. There was also food debris accumulation observed in internal compartments of the cooler holding used to store cut fruit and salad dressings. There was an accumulation of food debris, along with loose trash including plastic wrappers, plastic bags for utensils, and napkins inside the ice cream cooler next to and around an uncovered container of ice cream. The ice cream cooler also had a built up ice around the internal surfaces of the cooler. There was an observed accumulation of loose food particles and food debris in bottom of reach-in cooler closest to the stove. There was an observed dark residue flaking off the can opener in the kitchen. The food prep line cooler was observed to have a broken rubber gasket on the bottom of the door, and there was food debris in the cooler.

Observation throughout the time of the initial kitchen tour on 07/16/25 between 9:21 A.M. and 11:08 A.M. revealed significant accumulation of dust and debris on ceiling tiles above food preparation areas and dishwashing area.

Interview with Director of Dining Services #170 on 07/17/25 at 11:41 A.M. verified the food residue and debris in kitchen and verified the dark residue flaking off the can opener. The Director of Dining Services stated that staff would be instructed to do a deep cleaning of food service appliances and food holding units.

Interview with Director of Dining Services #170 on 07/17/25 at 11:55 A.M. verified there was dust and debris on ceiling tiles above the food preparation areas and dishwashing area. Further interview revealed the ceilings are usually cleaned quarterly or sooner as needed, but Director of Dining Services #170 added the ceiling needed cleaning at the time of survey.

Based on review of facility fire drill records and staff interview, the facility failed to conduct a fire drill on each shift at least once every three months in the past year and failed to obtain and/or record receipt of successful transmission of activated fire alarms after each fire drill. This had the potential to affect all residents in the facility. The census was 60.

Findings include:

Review of facility fire drill reports for the past 12 months revealed a lack of any record or confirmation of alarm transmission receipt associated with the monthly fire drills performed by the facility.

Review of facility fire drill log over the past 12 months revealed the facility did not conduct a fire drill on first shift between the months of December 2024 and March 2025. Fire drills conducted during this time included 12/30/24 at 12:43 A.M., 01/29/25 at 2:10 P.M., 02/26/25 at 2:05 P.M., and 03/27/25 at 2:32 A.M. Additional review of facility fire drill log revealed the facility did not conduct a fire drill on third shift between the months of April 2025 and June 2025. Fire drills conducted during this time included 04/30/25 at 10:00 A.M., 05/21/25 at 1:30 P.M., and 06/17/25 at 2:30 P.M.

Interview with Director of Maintenance #209 on 07/16/25 at 2:30 P.M. verified the facility had not been recording a confirmation receipt of alarm transmission for fire drills, as the maintenance director stated they were not aware of this requirement for the facility fire drill record. Director of Maintenance #209 also verified the facility did not conduct fire drills on each different shift quarterly for the first and second quarter of 2025. Director of Maintenance #209 stated that there were points in the past year where unexpected alarm signals were activated, which led to deviation from the normal schedule of fire drills.

Based on personnel record review and staff interview, the facility failed to ensure staff received transfer/discharge provisions and state and local phone numbers (Ombudsman and health departments) upon hire. This affected the four of six personnel records reviewed.

Findings include:

1. Review of Licensed Practical Nurse (LPN) #210's personnel file revealed a hire date of 06/30/25. There was no documented evidence of review of the transfer/discharge provisions or a copy of the addresses and telephone numbers of the board of health of the health district of the county in which the home is located, the county department of human services of the county in which the home is located, the state departments of health and human services, the state and local offices of the department of aging, and any Ohio nursing home ombudsman program.

2. Review of Personal Care Assistant (PCA) #113's personnel file revealed a hire date of 04/03/25. There was no documented evidence of review of the transfer/discharge provisions or a copy of the addresses and telephone numbers of the board of health of the health district of the county in which the home is located, the county department of human services of the county in which the home is located, the state departments of health and human services, the state and local offices of the department of aging, and any Ohio nursing home ombudsman program.

3. Review of Server #211's personnel file revealed a hire date of 06/06/25. There was no documented evidence of review of the transfer/discharge provisions or a copy of the addresses and telephone numbers of the board of health of the health district of the county in which the home is located, the county department of human services of the county in which the home is located, the state departments of health and human services, the state and local offices of the department of aging, and any Ohio nursing home ombudsman program.

4. Review of Licensed Practical Nurse (LPN) #119 revealed a hire date of 05/28/26. There was no documented evidence of review of the transfer/discharge provisions or a copy of the addresses and telephone numbers of the board of health of the health district of the county in which the home is located, the county department of human services of the county in which the home is located, the state departments of health and human services, the state and local offices of the department of aging, and any Ohio nursing home ombudsman program.

Interview with the Administrator on 07/17/25 at 12:10 P.M. verified the above staff did had no documented evidence of receiving the required documents.

Based on personnel record review and staff interview, the facility failed to ensure evidence of written acknowledgement staff received copies upon hiring transfer/discharge provisions and state and local phone numbers (Ombudsman and health departments). This affected the four of six personnel records reviewed.

Findings include:

1. Review of Licensed Practical Nurse (LPN) #210's personnel file revealed a hire date of 06/30/25. There was no documented evidence of review of the transfer/discharge provisions or a copy of the addresses and telephone numbers of the board of health of the health district of the county in which the home is located, the county department of human services of the county in which the home is located, the state departments of health and human services, the state and local offices of the department of aging, and any Ohio nursing home ombudsman program.

2. Review of Personal Care Assistant (PCA) #113's personnel file revealed a hire date of 04/03/25. There was no documented evidence of review of the transfer/discharge provisions or a copy of the addresses and telephone numbers of the board of health of the health district of the county in which the home is located, the county department of human services of the county in which the home is located, the state departments of health and human services, the state and local offices of the department of aging, and any Ohio nursing home ombudsman program.

3. Review of Server #211's personnel file revealed a hire date of 06/06/25. There was no documented evidence of review of the transfer/discharge provisions or a copy of the addresses and telephone numbers of the board of health of the health district of the county in which the home is located, the county department of human services of the county in which the home is located, the state departments of health and human services, the state and local offices of the department of aging, and any Ohio nursing home ombudsman program.

4. Review of Licensed Practical Nurse (LPN) #119 revealed a hire date of 05/28/26. There was no documented evidence of review of the transfer/discharge provisions or a copy of the addresses and telephone numbers of the board of health of the health district of the county in which the home is located, the county department of human services of the county in which the home is located, the state departments of health and human services, the state and local offices of the department of aging, and any Ohio nursing home ombudsman program.

Interview with the Administrator on 07/17/25 at 12:10 P.M. it was verified there was no written acknowledgement signed by the staff indicating they received the required documents.

Based on interview and record review the facility failed to timely address Resident #6's request for a referral to hematology. This affected one resident (#6) of three residents reviewed for laboratory tests. The facility census was 60.

Findings include:

Review of Resident #6's medical record revealed an admission date of 02/19/25 with diagnoses including cardiac murmur, sepsis, myelodysplastic syndrome, refractory anemia with ring sideroblasts, and hypertension.

Review of Resident #6's Certified Nurse Practitioner (CNP) note dated 04/10/25 revealed the resident requested a referral to hematology oncology for anemia and the CNP agreed.

Review of Resident #6's progress note dated 04/15/25 revealed a message was left with hematology oncology to schedule an appointment.

Review of Resident #6's medical record from 04/16/25 to 05/29/25 revealed no documentation of attempts to make a referral to hematology oncology.

Review of Resident #6's CNP note dated 05/29/25 revealed a hematology appointment had been arranged for 06/10/25.

Review of Resident #6's physician order entered 05/31/25 revealed the resident had an appointment scheduled for hematology oncology on 06/10/25.

Interview on 07/17/25 at 8:50 A.M. with Health and Wellness Coordinator (HWC) #119 revealed the resident and family had been requesting a hematology appointment since he admitted. She verified there was no evidence attempts had been made to arrange the appointments until the end of May 2025.

Interview on 07/17/25 at 9:50 A.M. with Resident #6 revealed he had been requesting a referral to hematology since he was admitted to the facility. He reported the facility just kept telling him they were working on it.

Interview on 07/17/25 at 10:53 A.M. with CNP #159 revealed Resident #6 had been requesting hematology visits since admission. She thought the facility had gone back and forth about getting it scheduled but was unable to provide more information.

Based on observation, medical record review, staff interview, and review of a facility policy, the facility staff failed to implement a policy and appropriately sanitize glucometers. This affected one (#47) of three residents reviewed for glucometers. The census was 65.

Findings include:

Review of Resident #47's medical record revealed the resident was admitted on 01/24/23 with diagnoses including diabetes. The resident had a physician's order dated 01/28/23 for blood glucose checks completed by the staff daily before breakfast.

Observation on 01/03/24 at 8:17 A.M. during medication administration revealed Licensed Practical Nurse (LPN) #72 cleaned Resident #47 bloody glucometer using an alcohol wipe after obtaining a blood sugar reading. At that time, LPN #72 verified she sanitized the glucometer with an alcohol wipe and had no Super Sani-cloth wipes (disinfecting wipes) on the medication cart.

Interview on 01/03/24 at 8:30 A.M. with the Director of Nursing (DON) verified the nursing staff should use Super Sani-cloth wipes to appropriately sanitize glucometers. The DON identified three (#41, #47 and #49) residents each had their own glucometers in their room.

Review of the policy titled, How to Clean and Maintain a Blood Glucose Glucometer

Based on observation, staff interview, and policy review, the facility failed to serve food at safe temperatures. This had the potential to affect all 65 residents residing in the facility. The census was 65.

Findings include:

Observations of the breakfast meal service on 01/03/24 at 8:40 A.M. revealed the scrambled eggs on the steam table were 124 degrees Fahrenheit (F) using the facility digital thermometer. Interview with Director of Dining #80 verified the scrambled egg temperature at the time of discovery.

Review of the dining policy titled, Hot Holding

Based on observation, staff interview, and review of a food safety checklist, the facility failed to provide covered refuse containers with trash in the food production areas of the kitchen. The finding had the potential to affect all 65 residents residing in the facility. The census was 65.

Findings include:

Observations during breakfast meal service on 01/03/24 at 8:40 A.M. revealed two open refuse containers located near the stove and the cold food service area with trash noted inside and no tight fitting coverings. Interview with Director of Dining #80 verified the observation at the time of discovery.

Review of a document titled, Food Safety and Sanitation Audit

Based on observation, staff interview, medical record review, and review of a facility policy, the facility failed to provide appropriate signs for areas were oxygen was stored or used. This affected one (#45) of one residents reviewed for oxygen use. The census was 65.

Findings include:

Review of Resident #45's medical record revealed an admission date of 11/28/22 with diagnoses including chronic obstructive pulmonary disease. The resident had a physician's order dated 11/28/22 for supplemental oxygen two to three liters as needed for low oxygen saturation levels.

Observations with the Director of Nursing (DON) on 01/03/24 at 10:40 A.M., revealed there was an oxygen concentrator stored in Resident #45's room without a sign near the outside of the door to indicate No Smoking, oxygen in use. Interview with the DON verified the finding at the time of the observation.

Review of the policy titled, Oxygen Management Policy