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32 | (Continued from LIC 809) At the reception desk, LPA obtained a copy of the weekly meal menu, which included Breakfast, Lunch, and Dinner from Sunday through Saturday. The kitchen was observed for its ability to safely prepare and serve meals. Food service was reviewed for appropriate quantity and proper storage practices. At approximately 9:43 a.m., while touring the walk-in refrigerator and freezer, LPA observed prepared food items and ingredients that were not properly stored or labeled. Inside the refrigerator, LPA observed two containers and a tray containing various repackaged meats in plastic baggies. According to a cook present, the containers held hamburger patties and pickles. LPA did not observe labels indicating the contents or the date they were stored. In the walk-in freezer, LPA observed single servings of pie placed on plates and covered with plastic wrap, as well as uncovered single-serving ice cream. No labels were observed on any of these items. LPA observed a sufficient amount of two-day perishable and seven-day perishable food. The Culinary Service Director utilizes Sysco for meal planing and food ordering.
Laundry rooms and other storage rooms were observed for linen, tools, toxic cleansers, and general storage. Laundry rooms accessible to residents were clean and no hazards observed. Storage room and laundry room containing chemicals. detergents and cleaning solutions were observed locked.
At approximately 10:33 a.m., the medication room and cart were reviewed for proper storage. The medication room and cart were observed locked. Complete first aid kits are maintained in the medication rooms. LPA observed a box overflowing with medication on the counter. LPA was informed by staff the medication is ready for destruction. Review of medication revealed a liquid medication bottle that according to staff belonged to a resident that passed away December 2024. According to the ED the facility relies on their pharmacy representative to destroy all medications however the representative had not been following through with this arrangement. LPA's review of the Plan of Operation outlines that permanently discontinued medications will not be retained at the facility. Instead, a designated staff member confirms the discontinuation with the physician, discusses it with the resident or responsible party, and ensures proper disposal and documenting the process on the Centrally Stored Medication Record.
LPA toured six (6) randomly selected resident bedrooms, two (2) of which were vacant. Personal accommodations were observed to meet standards for safety, privacy, and comfort. Hot water temperatures in the facility’s bathrooms are logged and maintained by the BSD. During the visit, hot water temperatures were measured and ranged between 105 and 120 degrees Fahrenheit.
(LIC809-C continued) Page 2 of 3
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