Health inspection·August 8, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 nurses' medication carts (medication cart on 200 hall) reviewed for pharmacy services. The facility failed to discard expired glucometer control solution (used to test and calibrate the glucometer machines) from 200 hall medication cart. This failure placed the residents at risk of incorrect labeling of drugs and biologicals. Findings included. During an observation and interview on [DATE] at 10:15 AM, RN B identified the 200 hall nurse's medication cart. The cart contained a box of control solutions used to calibrate two glucometers which were also stored in the cart. No other control solutions were found within the cart. The box of control solutions reflected an expiration date of [DATE]. No open date was noted on the box. RN B stated he was unaware of the expired control solutions and it was the responsibility of the 10 pm to 6 AM nurse to use the solutions to calibrate the glucometers daily. RN B stated the risk for using expired control solutions included decreased efficacy of the solutions could make the calibration inaccurate which could lead to inaccurate results when testing resident's glucose levels. RN B provided the control logs completed by the 10 PM to 6 AM nurse. During an interview on [DATE] at 10:51 AM, the DON stated the 10:00 PM to 6:00 AM nurses were responsible for calibrating the glucometers on their carts. She stated she, the charge nurses, and the ADON were responsible for ensuring the calibrations were completed and items in the medication carts were up to date. She stated she was surprised to hear about the expired control solution and stated the pharmacy consultant also checked the carts. The DON checked the cart with RN B who showed her the expired solution. He had marked the box as DO NOT USE. The DON instructed RN B to retrieve new test strips and control solutions, re-calibrate the glucometers, and re-test the residents. She stated the risk of using expired solutions for calibration was inaccurate glucose readings when testing residents. On [DATE] at 2:51 PM, attempt to conduct a telephone interview with LVN C , who worked the 10:00 PM to 6:00 AM shift and signed the Glucometer Daily Quality Control Record on [DATE] through [DATE] and [DATE] through [DATE] was unsuccessful. Page 1 of 4 676143 676143 08/08/2024 Mansfield Medical Lodge 301 N Miller Rd Mansfield, TX 76063

F 0755 Level of Harm - Minimal harm or potential for actual harm During an interview on [DATE] at 2:52 PM, LVN D stated she began working at the facility in [DATE] and had performed glucometer calibrations while working the 10:00 PM to 6:00 AM shift on the 200 Hall. She stated she had been trained in performing the calibration tests and the solutions were used to test the machines for high and low readings. LVN D stated she recalled using the control solutions but did not recall checking for an expiration date on the box. Residents Affected - Few In a telephone interview on [DATE] at 3:10 PM, ADON A stated it was her responsibility to ensure the glucometer calibrations were completed properly. She stated the nurses had been trained and should have known to check the expiration dates on the strips and control solutions prior to using them. She stated she routinely checked the medication carts for expired items as did the pharmacy consultant. ADON A stated she was not sure what had happened or if one of the nurses possibly grabbed a box of solution from somewhere else. She stated the risk of using expired solution was it could be ineffective for calibration and could cause incorrect glucose readings for the residents. Record review of the facility's policy titled, Obtaining a Fingerstick Glucose Level dated, revised [DATE] reflected: Purpose: The purpose of this procedure is to obtain a blood sample to determine the resident's blood glucose level. Preparation- .3. Assemble equipment and supplies needed. 4. Ensure that the equipment and devices are working properly by performing any calibrations or checks as instructed by the manufacturer or this facility . Record review of the glucometer manufacturer documentation for their control solution dated Revised 3/2011 reflected: [Company name] Glucose Control Solutions .Intended Use- The purpose of the control solution test is to validate the performance of the [Company Name] Blood Glucose Monitoring System using a testing solution with a known range of glucose. A control test that falls within the acceptable range indicates the user's technique is appropriate and the test strip and meter are functioning properly .Summary- The [Company Name] Control are solutions containing a measured amount of glucose. The solutions are used with your [Company Name] Blood Glucose Test Strips to confirm the acceptance performance of the test strips and the meter .Warnings and Precautions .Always check the expiration date. DO NOT use control solutions if they have expired . 676143 Page 2 of 4 676143 08/08/2024 Mansfield Medical Lodge 301 N Miller Rd Mansfield, TX 76063

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure food was properly stored (moldy food in the fridge, food exposed to air, food on the floor) in the facility's kitchen. This failure could place residents at risk for food-borne illness. Findings Included: Observation of the facility's refrigerator on 08/06/24 beginning at 8:55 AM revealed: - 1 tomato with a black spot and 1 withered tomato; - 7 withered strawberries and 1 strawberry with a brownish green spots; - 5 green bell peppers with black spots; - 1 sweet potato with fuzzy green and white spots; and - 1 frozen bag of mixed berries thawing on top of a box on the second shelf from the top. Observation of the facility's dry storage on 08/06/24 beginning at 9:18 AM revealed: -1 container of ground cinnamon open and exposed to air; - 1 container of onion powder with the expiration date of May 9th (year was missing); and - white powder substance on the floor. Observation of the facility's open area in the kitchen on 08/06/24 beginning at 9:27 AM revealed: -1 unclean container under a prep table next to two hot plate covers; - 1 deep fryer with residue on the exterior of the machine; and - the floor under the juice machine had black residue. Observation of the facility's freezer on 08/06/24 beginning at 9:38 AM revealed: -1 box of cookie dough open and exposed to air; - 1 box of homestyle yeast rolls open and exposed to air; - 1 box of sugar cookie dough open and exposed to air; and 676143 Page 3 of 4 676143 08/08/2024 Mansfield Medical Lodge 301 N Miller Rd Mansfield, TX 76063

F 0812 - 4 cups of ice cream on the floor. Level of Harm - Minimal harm or potential for actual harm In an interview with the Dietary Supervisor on 08/08/24 at 1:26 PM, revealed the refrigerator was cleaned weekly and spills were cleaned immediately. She stated when produce came in, she would check them to make sure there was no mold. She stated all kitchen staff were responsible for ensuring produce was fresh. She stated food was supposed to be thawed on the bottom shelf on a pan. She stated dietary staff had been in-serviced monthly and as needed. She stated everyone maintained the dry storage. She stated she ensured items were dated, closed, and the floor was swept on a weekly basis. She stated the deep fryer was cleaned once a week and sometimes more when used back-to-back to fry different foods. She stated the unclean bucket was the grease bucket used for the deep fryer. She stated the grease bucket should have been cleaned before it was placed back underneath the table. She stated the floor in the kitchen was cleaned twice a day, once during each shift. She stated she ensured the floors were being cleaned. She stated she checked the floor after the first shift and the cooks checked the floor after the second shift. She stated items in the freezer were supposed to be sealed so no air could get to it. She stated twice a week she made rounds and checked the freezer during inventory. She stated improper food storage could cause harm to residents such as contamination and food borne illnesses. Residents Affected - Many Record review of the facility policy titled Food Receiving and Storage, dated July 2014, revealed Foods shall be received and stored in a manner that complies with safe food handling practices. Review of the Food and Drug Administration Food Code, dated 2017, reflected, .3-305.11 Food Storage. (A) .food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination . 676143 Page 4 of 4