Every finding on record at Carecore at Margaret Hall

Based on record review, staff interview, and policy review, the facility failed to conduct adequate infection control surveillance. This had the potential to affect all of the residents residing in the facility. The facility census was 87 residents. Findings include: Review of the infection control logs with the Director of Nursing (DON) revealed the facility did not conduct infection surveillance for the following months: August 2025, September 2025, October 2025, November 2025, December 2025, January 2026, February 2026, March 2026,April 2026. Interview on 07/23/26 at 1:53 P.M with the DON verified the facility had not conducted infection surveillance for the following months: August 2025, September 2025, October 2025, November 2025, December 2025, and January 2026, February 2026, March 2026, April 2026. Review of facility policy titled Infection Prevention and Control Program dated 01/28/25 revealed the facility would conduct infection surveillance and would report surveillance findings to the facility's Quality Assessment and Assurance Committee.

Based on observation, staff interview, and review of facility documents and policy, the facility failed to ensure food was stored and prepared under sanitary conditions. This had the potential to affect all residents in the facility with the exception of one facility-identified (Resident #61) who did not receive food from the facility kitchen. The facility census was 87 residents.Findings Include:1. Observation on 07/20/26 at 9:08 A.M. of the dry food storage area revealed there was a box of thickened hot chocolate mis with a use by date of 11/02/25 and a box of thickened coffee with a use by date of 02/15/26. Interview on 07/20/26 at 9:17 A.M. with [NAME] #272 verified thickened hot chocolate and thickened coffee were expired and should have been discarded. 2. Observation on 07/20/26 at 9:30 A.M. of the facility kitchen revealed that each refrigerator and freezer in the kitchen area had a temperature log sheet dated July 2026 on which refrigerator and freezer temperatures were documented. Interview on 07/22/26 at 12:30 P.M. with Dietary Manager (DM) #229 verified the facility did not have refrigerator or freezer temperature logs for any dates prior to 07/01/26. Review of the facility policy titled Food Receiving and Storage dated October 2017 revealed functioning of the refrigeration would be monitored at designated intervals throughout the day by the food and nutrition services manager or designee and documented according to state-specific requirements. 3. Observation on 07/20/26 at 9:44 A.M. of the kitchen ice machine revealed there was an orange and black substance on the interior flap located just above the ice machine module assembly. This growth was able to be removed with a dry paper towel. Interview on 07/20/26 at 9:44 A.M. with [NAME] #272 verified the orange and black substance on the ice machine and stated the machine needed to be cleaned. Review of the facility policy titled Ice Machine Cleaning revealed ice machines should bee maintained in a clean and sanitary condition to prevent contamination and reduce the risk of infection transmission. 4. Observation on 07/22/26 at 11:32 A.M. revealed [NAME] #216 did not sanitize the thermometer between tray line temperature checks of meatloaf, scalloped potatoes, and mixed vegetables. [NAME] #216 wiped the thermometer probe off with a paper towel between temperature checks. Interview on 07/22/6 at 11:32 A.M. with [NAME] #216 confirmed she used a paper towel to wipe off the thermometer probe between checking the temperatures of the meatloaf, scalloped potatoes, and mixed vegetables. [NAME] #216 stated she normally used alcohol wipes to sanitize the thermometer between food items. Review of the facility policy titled Food Preparation and Service dated April 2019 revealed food thermometers used to check food temperatures should be clean, sanitized and calibrated for accuracy. 5. Review of the food temperature logbook revealed it did contain any documented food temperatures prior to dinner on 07/16/26. There were no temperatures documented for the following dates/meals: breakfast, lunch, and dinner on 07/17/26, dinner on 07/19/26, breakfast and lunch on 07/20/26. Interview on 07/22/26 at 12:23 P.M. with DM #229 confirmed the facility did not have any food temperature logs prior to dinner on 07/16/26. DM #229 also verified the missing food temperatures on 07/17/26, 07/19/26, and 07 that food temperatures were not documented for breakfast or lunch on 07/16/26; breakfast, lunch, or dinner on 07/17/26; dinner on 07/19/26; breakfast or lunch on 07/20/26. Review of the facility policy titled Food Preparation and Service dated April 2019 revealed food and nutrition services employees should prepare and serve food in a manner that complied with safe food handling practices and the temperature of foods held in steam tables should be monitored throughout the meal by food and nutrition services staff. 6. Observation on 07/23/26 at 9:29 A.M. of the refrigerator and freezer at the third-floor nurses' station revealed the refrigerator contained the following items: three unlabeled and undated Styrofoam containers of food, a jar of jam with a best by date of 07/16/26, two bags of undated frozen mixed vegetables, a clear plastic container undated with a cake inside. The bottom of the freezer was covered with a layer of a light brown frozen substance. There was no thermometer located in the freezer nor was there temperature log sheet on which staff could document refrigerator and freezer temperatures. Interview on 07/23/26 at 9:39 A.M. with Regional Nurse Manager (RNM) #500 verified the unlabeled, undated, and expired food items in the third-floor nurses' station refrigerator/ freezer. RNM #500 stated the freezer needed to be cleaned due to the layer of a brown frozen substance in the bottom and also confirmed there was no thermometer in the freezer. Interview on 07/23/26 at 10:53 A.M. with RNM #500 confirmed there was no temperature log for the third-floor nurses' station refrigerator/freezer. Review of the facility policy titled Food Receiving and Storage dated October 2017 revealed all food items which are stored in refrigerators on the nursing units must be labeled with a use by date and that food items belonging to residents must be labeled with the resident's name. Refrigerators must have working thermometers and be monitored for appropriate temperature. 7. Observation on 07/23/26 at 10:19 A.M. of the refrigerator at the second-floor nurses' station revealed it contained the following: a partially filled container of Jevity tube feeding undated, an undated and unlabeled Styrofoam container of food. There was no thermometer inside of the refrigerator and the temperature log attached to the front of the refrigerator was dated May 2026 and had only one temperature recorded on 05/08/26. Interview on 07/23/26 at 10:29 A.M. with Certified Nursing Assistant (CNA) #247 verified the following: there were undated and unlabeled items in the refrigerator, there was no thermometer in the refrigerator, the temperature was dated May 2026 and contained only one temperature for 05/06/26. Interview on 07/23/26 at 10:53 A.M. with RNM #500 confirmed the facility did not have a current temperature log for the second-floor nurses' station refrigerator.

Based on medical record review, staff interview, and policy review, the facility failed to notify the Ombudsman of resident discharges and hospitalizations and did not provide bed hold notices. This affected four (Residents #3, #10, #92, and #95) of seven residents reviewed for discharge and hospitalizations. The facility census was 87 residents. Findings include: 1.Review of the medical record for Resident #3 revealed an admission date of 06/18/26 with diagnoses including diabetes, hypertensive heart/kidney disease, and morbid obesity and a discharge to home date of 07/13/26.Review of the facility's Ombudsman monthly report of discharges dated July 2026 revealed it did not include Resident #3's discharge on [DATE] 2. Review of the medical record for Resident #10 revealed an admission date of 05/27/26 with diagnoses including chronic kidney disease, dementia, and cerebral infarction and discharge to assisted living date of 07/17/26. Review of the facility's Ombudsman monthly report of discharges dated July 2026 revealed it did not include Resident #10's discharge on [DATE] 3. Review of the medical record for Resident #95 revealed an admission date of 09/11/25 with diagnoses including dementia, cerebral infarction, and fibromyalgia. Review of the nurse progress notes for Resident #95 revealed the resident was discharged to the hospital on [DATE]. Review of the medical record for Resident #95 revealed it did not include a bed hold notice for the resident's hospitalization on 06/28/26. 4. Review of the medical record for Resident #92 revealed an admission date of 04/06/24 with diagnoses including pleural effusion, Alzheimer's disease, and depression. Review of the nurse progress notes for Resident #92 revealed the resident was discharged to the hospital on [DATE]. Review of the medical record for Resident #92 revealed it did not include a bed hold notice for the resident's hospitalization on 07/02/26. Interview on 07/21/26 at 2:50 P.M. with Regional Nurse #500 verified the facility had not included Resident #3 and #10's discharges from the facility in the monthly report to the Ombudsman nor did the facility provide bed hold notices for Resident #92 and #95's hospitalizations. Review of the facility policy titled Discharge Planning dated 07/28/25 revealed the facility must notify the Ombudsman of recent resident discharges.

Based on medical record review, resident interview, staff interview, and policy review, the facility failed to ensure dependent residents received showers. This affected four (Residents #51, #1, #9, #65) of 18 residents reviewed for activities of daily living (ADLs). The facility census was 87 residents. Findings include: 1.Review of the medical record for Resident #51 revealed an admission date of 05/28/26 with diagnoses including acute osteomyelitis right ankle and foot, type two diabetes, and urge incontinence. Review of the Minimum Data Set (MDS) assessment for Resident #51 dated 06/03/26 revealed the resident had intact cognition and was dependent on staff assistance for bathing and hygiene. Review of facility shower logs and shower sheets revealed Resident #51 was scheduled for showers on the following dates but was not showered nor offered a shower: 05/28/26, 06/02/26, 06/05/26, 06/09/26, 06/13/26, 06/16/26, 06/19/26, 06/24/26, 06/26/26, 06/27/26, 07/03/26, 07/07/26, 07/10/26, 07/14/26, 07/17/26. Interview on 07/20/26 at 11:50 A.M with Resident #51 confirmed he did not receive showers regularly. 2.Review of the medical record for Resident #1 revealed an admission date of 05/05/26 with diagnoses including esophageal varices, hepatic encephalopathy, and major depressive disorder. Review of the MDS assessment for Resident #1 dated 05/11/26 revealed the resident had intact cognition and required staff assistance with showering. Review of facility shower logs and shower sheets revealed Resident #1 was scheduled for showers on the following dates but was not showered nor offered a shower: 05/06/26, 05/09,26, 05/13/26, 05/16/26, 05/20/26, 05/23/26, 05/27/26, 06/27/26, 07/01/26, 07/04/26, 07/11/26, 07/15/26. 3. Review of the medical record for Resident #9 revealed an admission date of 01/06/26 with diagnoses including cerebral infarction, muscle weakness, and cognitive communication deficit. Review of the MDS assessment for Resident #9 dated 04/15/26 revealed the resident was moderately cognitively impaired and was dependent on staff assistance for showering. Review of the shower sheets and shower logs revealed Resident #9 was scheduled for showers on the following dates but was not showered nor offered a shower: 04/04/26, 04/15/26, 04/18/26, 04/29/26, 05/02/26, 05/06/26, 05/09/26, 05/13/26, 05/23/26, 05/30/26, 06/06/26, 06/13/26, 06/17/26, 06/20/26, 06/27/26, 07/01/26, 07/04/26, 07/11/26, 07/18/26. 4. Review of the medical record for Resident #65 revealed an admission date of 06/27/26 diagnoses including unspecified severe protein-calorie malnutrition and bipolar disorder. Review of the MDS assessment for Resident #65 dated 07/03/26 revealed the resident had intact cognition and required staff assistance with showering. Review of facility shower logs and shower sheets revealed Resident #65 did not receive nor was offered a shower since she had been at the facility. Interview on 07/22/26 at 4:18 P.M with the Director of Nursing (DON) confirmed Residents #51, #1, #9, and #65 did not receive regular showers as scheduled and there was no documentation of refusal of showers. The DON further verified dates of missed showers for Residents #51, #1, and #9 were accurate and verified Resident #65 had not received a shower since admission to the facility. Review of facility policy titled Bath, Shower/Tub dated February 2018 revealed the facility should document the date and time the shower was performed, document any refusals, and complete showers to ensure cleanliness and provide comfort to the resident. This deficiency represents noncompliance investigated under Complaint Number 3016546 and Complaint Number 3053375.

Based on medical record review, staff interview, and policy review, the facility failed to ensure catheter care orders were in place for residents requiring catheter care. This affected one (Resident #5) of two residents with catheters. The facility census was 87 residents. Findings include:Review of the medical record for Resident #5 revealed an admission date of 6/01/26 with diagnoses including hydronephrosis, dementia, retention of urine, and chronic kidney disease. Review of the progress note for Resident #5 dated 06/01/26 revealed the resident had a urinary catheter in place upon admission. Review of the Minimum Data Set (MDS) assessment for Resident #5 dated 06/07/26 revealed the resident was severely cognitively impaired and was dependent on staff assistance with activities of daily living (ADLs.) Review of the progress notes for Resident #5 dated 06/02/26 to 06/17/26 revealed the notes did not include documentation regarding catheter care for the resident. Review of the physician's orders for Resident #5 revealed orders dated 06/18/26 for the following: change foley catheter as needed, catheter care every shift, may irrigate foley with 30 cubic centimeters (cc) of normal saline (NS) as needed for blockage. Review of the Treatment Administration Record (TAR) for Resident #5 dated June 2026 revealed there was no documentation of completion of catheter care for the resident from 06/01/26 to 06/17/26. Interview on 07/22/26 at 2:49 P.M. with the Director of Nursing (DON) confirmed Resident #5 admitted to the facility on [DATE] with a catheter in place, but catheter care orders were not placed for the resident until 06/18/26. The DON also verified Resident #5's medical record did not include documentation of provision of catheter care from 06/01/26 through 06/17/26. The DON stated catheter care activities should be documented on the TAR and orders for catheter care for Resident #5 should have been put in place upon admission. Review of a facility policy titled Catheter Care, Urinary dated September 2014 revealed staff are expected to document the date and time that catheter care was given, along with the staff member's name and title as well as all assessment date obtained when giving catheter care.

Based on medical record review and staff interview, the facility failed to provide Notice of Medicare Non-Coverage (NOMNC) when therapy services were completed and failed to provide Skilled Nursing Facility/Advance Beneficiary Notice of Non-coverage (SNF/ABN) notifications. This affected two (Residents #5 and #9) of three residents reviewed for NOMNC and SNF/ABN notices. The facility census was 87 residents. Findings include: 1. Review of the medical record for Resident #5 revealed an admission date of 06/01/26 with diagnoses including cataracts, dementia, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment for Resident #5 dated 06/07/26 revealed the resident had severe cognitive deficits and required substantial assistance to total dependence on staff for activities of daily living (ADLs). Review of the medical record for Resident #5 revealed it did not include a NOMNC. Interview on 07/23/26 at 11:03 A.M. with Business Office Manager (BOM) #267 verified that Resident #5 did not receive a NOMNC and the facility should have issued one. 2. Review of the medical record for Resident #9 revealed an admission date of 01/06/26 with diagnoses including dysphagia, ischemic cardiomyopathy, and depression. Review of the MDS assessment for Resident #9 dated 04/15/26 revealed the resident had mild cognitive deficits and was dependent on staff for ADLs. Review of the medical record for Resident #9 revealed it did not include NOMNC or SNF/ABN. Interview on 07/23/26 at 11:10 A.M. with BOM #267 verified the facility had not issued a SNF/ABN or NOMNC to Resident #9 and the facility should have issued these notices.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure resident assessments were accurate. This affected two (Residents #97 and #106) of 18 residents sampled. The facility census was 87 residents. Findings include: 1. Review of the medical record for Resident #106 revealed an admission date of 04/06/26 with diagnoses including colostomy status, kidney disease, and depression.Review of the Minimum Data Set (MDS) assessment for Resident #106 dated 04/17/26 revealed the resident had a colostomy and was coded as incontinent of bowel. 2. Review of the medical record for Resident #97 revealed an admission date of 05/15/26 with diagnoses including colostomy status, diabetes, and small bowel ischemia. Review of the MDS assessment for Resident #97 dated 06/14/26 revealed the resident had a colostomy and was coded as incontinent of bowel. Interview on 07/23/26 at 2:00 P.M. with the Director of Nursing (DON) verified the MDS assessments for Residents #106 and #97 were not accurate as bowel continence should be marked as not rated as opposed to being marked as incontinent due to both residents having colostomies. Review of the facility policy titled Certifying Accuracy of the Resident Assessment November 2019 revealed any person completing a portion of the MDS must sign and certify the accuracy of that portion of the assessment.

Based on medical record review, observation, resident interview, staff interview, and policy review, the facility failed to ensure baseline care plans were accurate. This affected one (Resident #51) of 18 residents sampled. The facility census was 87 residents. Review of the medical record for Resident #51 revealed an admission date of 05/28/26 with diagnoses including acute osteomyelitis right ankle and foot, type two diabetes, and urge incontinence.Review of the Minimum Data Set (MDS) assessment for Resident #51 dated 06/03/26 revealed the resident had intact cognition, was dependent on staff assistance with toileting, and had a urinary catheter. Review of the baseline care plan for Resident #51dated on 05/28/26 revealed the resident was incontinent of bladder but not indicate the presence of a urinary catheter or basic interventions for the resident's catheter. Observation on 07/20/26 at 11:50 A.M. revealed Resident #51 had a urinary catheter in place. Interview on 07/20/26 at 11:51 A.M. with Resident #51 confirmed he was admitted with a urinary catheter in place. Interview on 07/22/26 at 4:35 P.M. with the Director of Nursing (DON) confirmed Resident #51's baseline care plan did not reflect the presence of Resident #51's urinary catheter and/or did not include basic interventions for the resident's catheter. Review of facility policy titled Care Plans-Baseline dated December 2016 revealed the baseline care plan was developed to ensure residents' care needs are met and maintained.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure care conferences were conducted on a quarterly basis. This affected three residents (Residents #2, #6, and #67) of 18 residents sampled. The facility census was 87 residents. Findings include:1.Review of the medical record for Resident #2 revealed an admission date of 07/29/24 with diagnoses including congestive heart failure, chronic obstructive pulmonary disease, and depression.Review of medical record for Resident #2 revealed staff conducted a care conference for the resident on 02/02/26. There were no additional care conferences documented.Review of the Minimum Data Set (MDS) assessment for Resident #2 dated 05/07/26 revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs.)Interview on 07/23/26 at 8:18 A.M. with Social Service Director (SSD) #230 verified resident care conferences should be completed quarterly and the only care conference documented for Resident #2 occurred on 02/02/26.2. Review of the medical record for Resident #6 revealed an admission date of 09/18/25 with diagnoses including anxiety disorder, depression, and bipolar disorder.Review of medical record for Resident #6 revealed staff conducted a care conference for the resident on 09/18/25. There were no additional care conferences documented.Review of the MDS assessment for Resident #6 dated 06/20/26 revealed the resident was cognitively intact and required staff assistance with ADLs.Interview on 07/23/26 at 8:19 A.M. with SSD #230 verified the only care conference conducted for Resident #6 occurred on 09/18/25. 3. Review of the medical record for Resident #67 revealed an admission date of 04/21/25 with diagnoses including dementia with psychotic disturbance, anxiety disorder, and major depressive disorder. Review of medical record for Resident #67 revealed staff conducted care conferences for the resident on 04/24/25, 08/04/25, and 10/16/25. There were no additional care conferences documented.Review of the MDS assessment for Resident #67 dated 06/26/26 revealed the resident was moderately cognitively impaired and required staff assistance with ADLs. Interview on 07/23/26 at 8:20A.M. with SSD #230 verified the facility had not conducted a care conference for Resident #67 since 10/16/25. Review of the facility policy titled Participation in Care Conference dated 02/10/25 revealed the facility would conduct resident care conferences with the interdisciplinary team (IDT) quarterly, annually and with any significant changes.

Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure a medication error rate below five percent (%). The medication error rate was 11.1 % based on 27 medication opportunities and three medication errors. This affected one (Resident #73) of three residents observed for medication administration. The facility census was 87 residents. Findings include: Review of the medical record for Resident #73 revealed an admission date of 08/07/25 with a diagnoses including ocular hypertension and hypertension. Review of the Minimum Data Set (MDS) assessment for Resident #73 dated 05/16/26 revealed the resident had no cognitive deficits and required staff assistance with activities of daily living (ADLs.) Observation of medication administration on 07/21/26 at 8:54 A.M. per Licensed Practical Nurse (LPN) #201 to Resident #73 revealed three ordered medications were omitted: Spironolactone 25 milligrams (mg), carboxymethycellulose sodium eye drops, Entresto 97-103 mg. Interview on 07/21/26 at 2:26 P.M. with LPN #201 verified she omitted three of Resident #73's medications during medication administration on 07/21/26. Review of the facility policy titled Administering Medications Policy dated April 2019 revealed medications should be administered in a safe and timely manner, and as prescribed. This deficiency represents noncompliance investigated under Complaint Number 3008476.

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure residents' insulin was properly labeled. This affected two (Residents #54 and #30) of 21 facility-identified residents with orders for insulin. The facility census was 87 residents. Findings include: 1.Review of the medical record for Resident #54 revealed an admission date of 05/03/26 with a diagnosis of type two diabetes mellitus. Review of the Minimum Data Set (MDS) assessment for Resident #54 dated 05/09/26 revealed the resident had intact cognition and required staff assistance with activities of daily living (ADLs). Review of the physician's orders for Resident #54 revealed an order dated 06/04/26 for insulin glargine 10 units subcutaneously at bedtime. Observation of the 200 Hall medication cart on 07/22/26 at 5:24 P.M with the Director of Nursing (DON) revealed Resident #54's insulin glargine pen was open and undated. Interview on 07/22/26 at 5:25 P.M. with the DON verified Resident #54's insulin pen was opened and undated. The DON stated all insulin pens and vials should be dated upon opening. 2. Review of the medical record review for Resident #30 revealed an admission date of 02/19/26 with a diagnosis of type two diabetes. Review of the MDS assessment for Resident #30 dated 05/30/26 revealed the resident had severe cognitive impairment and required staff assistance with ADLs. Review of the physician's orders for Resident #30 revealed an order dated 03/12/26 for Lantus insulin 30 units subcutaneously at bedtime. Observation on 07/22/26 at 5:24 P.M of the 200-Hall with the DON revealed Resident #30's Lantus insulin pen was open and undated. Interview on 07/22/26 at 5:25 P.M with the DON verified Resident #30's Lantus insulin pen was open and undated. Review of the facility policy titled Storage of Medications dated November 2020 revealed medications should be properly labeled before storing.

Based on interview and record review, the facility failed to thoroughly investigate an injury of unknown origin. This affected one (#24) resident out of three residents reviewed for injury of unknown origins. The facility census was 80. Review of Resident #24's chart revealed Resident #24 admitted to the facility on [DATE] with unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, Type Two Diabetes Mellitus without complications, acute embolism and thrombosis of unspecified vein, cognitive communication deficit, muscle weakness, hyperlipidemia, altered mental status, dysphagia, other toxic encephalopathy, insomnia, essential hypertension, orthostatic hypertension, peripheral vascular disease, depression, unspecified urinary incontinence, full incontinence of feces and gastrostomy status.Review of Resident #24's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 was moderately cognitively impaired and Resident #24 required set up assistance with eating. Resident #24 required supervision with oral hygiene, upper body dressing, sitting to lying, lying to sitting, sitting to standing, chair transfers and walking ten feet and Resident #24 required moderate assistance with toileting, showering, lower body dressing, putting on and taking off footwear, toilet transfers, and tub transfers. Resident #24 was independent with personal hygiene, and rolling left to right. Review of Resident #24's Nurse Practitioner (NP) progress note dated 03/16/25 revealed Resident #24 was seen by NP #500. Resident #24 was noted with a swollen upper lip. Resident #24 stated he tripped and hit his lip, but other staff members noted different stories of the injury. Resident #24 denied any pain or concerns. Staff were to continue monitoring the swollen upper lip and adjust the treatment plan as needed. Review of Resident #24's chart from 03/16/26 to 03/25/26 revealed no documentation that Resident #24's swollen lip was monitored by facility staff as directed by NP #500. Review of Resident #24's skin assessment dated [DATE] at 5:38 P.M. revealed Resident #24 had a feeding tube to his abdomen. No other skin issues were noted. Review of the facility's self reported incidents (SRIs) from 03/15/26 to 04/13/26 revealed the facility did not file an SRI for Resident #24's swollen upper lip or injury of unknown origin. Observation of Resident #24 on 04/13/26 at 10:30 A.M. revealed Resident #24 was sitting in a chair in the hallway. Resident #24 appeared clean and was dressed appropriately.Interview with Resident #24 on 04/13/26 at 10:30 A.M. revealed Resident #24 denied being abused or neglected at the facility. Resident #24 denied being harmed at the facility and Resident #24 denied ever having a swollen lip at the facility. Interview with Licensed Practical Nurse (LPN) #92 on 04/13/26 at 10:32 A.M. revealed LPN #92 was not present at the facility when Resident #24 sustained a swollen lip. LPN #92 stated she came back to work on an unknown date and Resident #24's lip was swollen. LPN #92 stated that she did not ask Resident #24 what happened, but staff told her that Resident #24 hit his lip on the bed rail. Interview with NP #500 on 04/13/26 at 1:15 P.M. revealed staff reported Resident #24 had a swollen upper lip on 03/16/26. NP #500 stated she could not recall which staff told her about Resident #24's lip, but NP #500 assessed the resident that day. NP #500 reported Resident #24 had a swollen upper lip with some dark purple coloration to the upper top inside and outside of the lip. NP #500 stated Resident #24 was eating and drinking without difficulty and Resident #24 reported no pain. NP #500 reported therapy staff told NP #500 that Resident #24 was outside when a tree limb hit him in the face, but Resident #24 stated he tripped and hit his face. NP #500 stated nursing staff told her that they did not know what happened to Resident #24's lip. NP #500 reported she notified the Director of Nursing (DON) about Resident #24's lip being swollen on 03/16/26. NP #500 reported that she ordered ice and the area to the lip was healed the next time she saw Resident #24. NP #500 stated that Resident #24 has a history of dementia and Resident #24 had confusion. Interview with the DON on 04/13/26 at 1:18 P.M. verified the facility did not have any documentation of Resident #24's swollen upper lip with dark purple discoloration in Resident #24's progress notes. The DON verified Resident #24's skin assessment completed 03/16/26 at 5:38 P.M. did not document Resident #24's swollen upper lip with dark purple discoloration and that there was no other documentation of Resident #24's swollen upper lip with dark purple discoloration in Resident #24's chart except for in NP #500's notes completed 03/16/26 and on 03/26/26. The DON confirmed the facility did not know how Resident #24 sustained the swollen upper lip with dark purple discoloration. The DON verified the facility did not complete an investigation and did not have copies of resident or staff statements related to the injury of unknown origin and the facility did not complete a SRI for the injury of unknown origin. Interview with LPN #92 on 04/13/26 at 3:08 P.M. verified LPN #92 did not notify Resident #24's family when LPN #92 discovered Resident #24 had a swollen upper lip. LPN #92 stated she worked on 03/15/26 and Resident #24's lip was not swollen. LPN #92 reported Resident #24's lip was swollen when she returned to work on 03/16/26. LPN #92 verified she did not document any information on Resident #24's swollen lip in the chart. LPN #92 stated she could not recall who told her that Resident #24 hit his lip on the bed rail. Review of the facility's undated abuse policy revealed it was the facility's policy to investigate all alleged violations including abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property including injuries of unknown source. Facility staff should immediately report such allegations to the Administrator and to the state surveying agency. An injury of unknown source was defined as an injury where the source of the injury was not obtained by any person or the source of the injury could not be explained by the resident and the injury was suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular point in time or the incidence of injuries over time. The policy also stated the resident representative should be notified of the incident. This deficiency represents non-compliance investigated under Complaint Number 2807672.

Based on interview and record review, the facility failed to monitor a resident's swollen upper lip with dark purple discoloration as ordered by the Nurse Practitioner (NP). This affected one (#24) resident out of three residents reviewed for monitoring resident conditions. The facility census was 80. Review of Resident #24's chart revealed Resident #24 admitted to the facility on [DATE] with unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, Type two Diabetes Mellitus without complications, acute embolism and thrombosis of unspecified vein, cognitive communication deficit, muscle weakness, hyperlipidemia, altered mental status, dysphagia, other toxic encephalopathy, insomnia, essential hypertension, orthostatic hypertension, peripheral vascular disease, depression, unspecified urinary incontinence, full incontinence of feces and gastrostomy status.Review of Resident #24's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 was moderately cognitively impaired and Resident #24 required set up assistance with eating. Resident #24 required supervision with oral hygiene, upper body dressing, sitting to lying, lying to sitting, sitting to standing, chair transfers and walking ten feet and Resident #24 required moderate assistance with toileting, showering, lower body dressing, putting on and taking off footwear, toilet transfers, and tub transfers. Resident #24 was independent with personal hygiene, and rolling left to right. Review of Resident #24's Nurse Practitioner (NP) progress note dated 03/16/25 revealed Resident #24 was seen by NP #500. Resident #24 was noted with a swollen upper lip. Resident #24 stated he tripped and hit his lip, but other staff members noted different stories of the injury. Resident #24 denied any pain or concerns. Staff were to continue monitoring the swollen upper lip and adjust the treatment plan as needed. Review of Resident #24's chart from 03/16/26 to 03/25/26 revealed no documentation that Resident #24's swollen lip was monitored by facility staff as directed by NP #500. Review of Resident #24's skin assessment dated [DATE] at 5:38 P.M. revealed Resident #24 had a feeding tube to his abdomen. No other skin issues were noted. Review of Resident #24's skin assessment dated [DATE] at 10:45 P.M. revealed no skin issues were noted. Review of Resident #24's NP progress note dated 03/26/26 revealed Resident #24 was noted with a contusion of the upper lip on the prior visit. The area had resolved and the lip was back to normal. Resident #24 reported no current pain. Resident #24 continued to have baseline confusion. Observation of Resident #24 on 04/13/26 at 10:30 A.M. revealed Resident #24 was sitting in a chair in the hallway. Resident #24 appeared clean and was dressed appropriately.Interview with NP #500 on 04/13/26 at 1:15 P.M. revealed staff reported Resident #24 had a swollen upper lip on 03/16/26. NP #500 stated she could not recall which staff told her about Resident #24's lip, but NP #500 assessed the resident that day. NP #500 reported Resident #24 had a swollen upper lip with some dark purple coloration to the upper top inside and outside of the lip. NP #500 stated Resident #24 was eating and drinking without difficulty and Resident #24 reported no pain. NP #500 reported therapy staff told NP #500 that Resident #24 was outside when a tree limb hit him in the face, but Resident #24 stated he tripped and hit his face. NP #500 stated nursing staff told her that they did not know what happened to Resident #24's lip. NP #500 reported she notified the Director of Nursing (DON) about Resident #24's lip being swollen on 03/16/26. NP #500 reported that she ordered ice and the area to the lip was healed the next time she saw Resident #24. NP #500 stated that Resident #24 has a history of dementia and Resident #24 had confusion. Interview with the DON on 04/13/26 at 1:18 P.M. verified the facility did not have any documentation of Resident #24's swollen upper lip with dark purple discoloration in Resident #24's progress notes. The DON verified Resident #24's skin assessment completed 03/16/26 at 5:38 P.M. did not document Resident #24's swollen upper lip with dark purple discoloration and that there was no other documentation of Resident #24's swollen upper lip with dark purple discoloration in Resident #24's chart except for in NP #500's notes completed 03/16/26 and on 03/26/26. The DON confirmed the facility did not know how Resident #24 sustained the swollen upper lip with dark purple discoloration. The DON verified there was no documented monitoring of Resident #24's swollen upper lip with dark purple discoloration from 03/16/26 to 03/25/26 as ordered by NP #500 on 03/16/26. Interview with LPN #92 on 04/13/26 at 3:08 P.M. LPN #92 stated she worked on 03/15/26 and Resident #24's lip was not swollen. LPN #92 reported Resident #24's lip was swollen when she returned to work on 03/16/26. LPN #92 verified she did not document any information on Resident #24's swollen lip in the chart.

Based on interview and record review, the facility failed to notify a resident's resident representative of a change in condition or an injury of unknown origin. This affected one (#24) resident out of three residents reviewed for notification of change in condition. The facility census was 80. Review of Resident #24's chart revealed Resident #24 admitted to the facility on [DATE] with unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, Type Two Diabetes Mellitus without complications, acute embolism and thrombosis of unspecified vein, cognitive communication deficit, muscle weakness, hyperlipidemia, altered mental status, dysphagia, other toxic encephalopathy, insomnia, essential hypertension, orthostatic hypertension, peripheral vascular disease, depression, unspecified urinary incontinence, full incontinence of feces and gastrostomy status.Review of Resident #24's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 was moderately cognitively impaired and Resident #24 required set up assistance with eating. Resident #24 required supervision with oral hygiene, upper body dressing, sitting to lying, lying to sitting, sitting to standing, chair transfers and walking ten feet and Resident #24 required moderate assistance with toileting, showering, lower body dressing, putting on and taking off footwear, toilet transfers, and tub transfers. Resident #24 was independent with personal hygiene, and rolling left to right. Review of Resident #24's Nurse Practitioner (NP) progress note dated 03/16/25 revealed Resident #24 was seen by NP #500. Resident #24 was noted with a swollen upper lip. Resident #24 stated he tripped and hit his lip, but other staff members noted different stories of the injury. Resident #24 denied any pain or concerns. Staff were to continue monitoring the swollen upper lip and adjust the treatment plan as needed. Review of Resident #24's chart from 03/16/26 to 03/25/26 revealed no documentation that Resident #24's swollen lip was monitored by facility staff as directed by NP #500. Review of Resident #24's skin assessment dated [DATE] at 10:45 P.M. revealed no skin issues were noted. Review of Resident #24's NP progress note dated 03/26/26 revealed Resident #24 was noted with a contusion of the upper lip on the prior visit. The area had resolved and the lip was back to normal. Resident #24 reported no current pain. Resident #24 continued to have baseline confusion. Observation of Resident #24 on 04/13/26 at 10:30 A.M. revealed Resident #24 was sitting in a chair in the hallway. Resident #24 appeared clean and was dressed appropriately.Interview with NP #500 on 04/13/26 at 1:15 P.M. revealed staff reported Resident #24 had a swollen upper lip on 03/16/26. NP #500 stated she could not recall which staff told her about Resident #24's lip, but NP #500 assessed the resident that day. NP #500 reported Resident #24 had a swollen upper lip with some dark purple coloration to the upper top inside and outside of the lip. NP #500 stated Resident #24 was eating and drinking without difficulty and Resident #24 reported no pain. NP #500 reported therapy staff told NP #500 that Resident #24 was outside when a tree limb hit him in the face, but Resident #24 stated he tripped and hit his face. NP #500 stated nursing staff told her that they did not know what happened to Resident #24's lip. NP #500 reported she notified the Director of Nursing (DON) about Resident #24's lip being swollen on 03/16/26. NP #500 reported that she ordered ice and the area to the lip was healed the next time she saw Resident #24. NP #500 stated that Resident #24 has a history of dementia and Resident #24 had confusion. Interview with the DON on 04/13/26 at 1:32 P.M. verified the facility did not have any documentation that Resident #24's resident representative was notified of Resident #24's swollen upper lip with dark purple discoloration. Interview with LPN #92 on 04/13/26 at 3:08 P.M. verified LPN #92 did not notify Resident #24's family when LPN #92 discovered Resident #24 had a swollen upper lip. LPN #92 stated she worked on 03/15/26 and Resident #24's lip was not swollen. LPN #92 reported Resident #24's lip was swollen when she returned to work on 03/16/26. LPN #92 verified she did not document any information on Resident #24's swollen lip in the chart. LPN #92 stated she could not recall who told her that Resident #24 hit his lip on the bed rail. Review of the facility's undated abuse policy revealed it was the facility's policy to investigate all alleged violations including abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property including injuries of unknown source. Facility staff should immediately report such allegations to the Administrator and to the state surveying agency. An injury of unknown source was defined as an injury where the source of the injury was not obtained by any person or the source of the injury could not be explained by the resident and the injury was suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular point in time or the incidence of injuries over time. The policy also stated the resident representative should be notified of the incident.

Based on interview and record review, the facility failed to ensure an injury of unknown origin was reported to the state surveying agency. This affected one (#24) resident out of three residents reviewed for injury of unknown origins. The facility census was 80. Review of Resident #24's chart revealed Resident #24 admitted to the facility on [DATE] with unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, Type Two Diabetes Mellitus without complications, acute embolism and thrombosis of unspecified vein, cognitive communication deficit, muscle weakness, hyperlipidemia, altered mental status, dysphagia, other toxic encephalopathy, insomnia, essential hypertension, orthostatic hypertension, peripheral vascular disease, depression, unspecified urinary incontinence, full incontinence of feces and gastrostomy status.Review of Resident #24's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 was moderately cognitively impaired and Resident #24 required set up assistance with eating. Resident #24 required supervision with oral hygiene, upper body dressing, sitting to lying, lying to sitting, sitting to standing, chair transfers and walking ten feet and Resident #24 required moderate assistance with toileting, showering, lower body dressing, putting on and taking off footwear, toilet transfers, and tub transfers. Resident #24 was independent with personal hygiene, and rolling left to right. Review of Resident #24's Nurse Practitioner (NP) progress note dated 03/16/25 revealed Resident #24 was seen by NP #500. Resident #24 was noted with a swollen upper lip. Resident #24 stated he tripped and hit his lip, but other staff members noted different stories of the injury. Resident #24 denied any pain or concerns. Staff were to continue monitoring the swollen upper lip and adjust the treatment plan as needed. Review of Resident #24's chart from 03/16/26 to 03/25/26 revealed no documentation that Resident #24's swollen lip was monitored by facility staff as directed by NP #500. Review of Resident #24's skin assessment dated [DATE] at 10:45 P.M. revealed no skin issues were noted. Review of Resident #24's NP progress note dated 03/26/26 revealed Resident #24 was noted with a contusion of the upper lip on the prior visit. The area had resolved and the lip was back to normal. Resident #24 reported no current pain. Resident #24 continued to have baseline confusion. Review of the facility's self reported incidents (SRIs) from 03/15/26 to 04/13/26 revealed the facility did not file an SRI for Resident #24's swollen upper lip or injury of unknown origin. Observation of Resident #24 on 04/13/26 at 10:30 A.M. revealed Resident #24 was sitting in a chair in the hallway. Resident #24 appeared clean and was dressed appropriately.Interview with Resident #24 on 04/13/26 at 10:30 A.M. revealed Resident #24 denied being abused or neglected at the facility. Resident #24 denied being harmed at the facility and Resident #24 denied ever having a swollen lip at the facility. Interview with Licensed Practical Nurse (LPN) #92 on 04/13/26 at 10:32 A.M. revealed LPN #92 was not present at the facility when Resident #24 sustained a swollen lip. LPN #92 stated she came back to work on an unknown date and Resident #24's lip was swollen. LPN #92 stated that she did not ask Resident #24 what happened, but staff told her that Resident #24 hit his lip on the bed rail. Interview with NP #500 on 04/13/26 at 1:15 P.M. revealed staff reported Resident #24 had a swollen upper lip on 03/16/26. NP #500 stated she could not recall which staff told her about Resident #24's lip, but NP #500 assessed the resident that day. NP #500 reported Resident #24 had a swollen upper lip with some dark purple coloration to the upper top inside and outside of the lip. NP #500 stated Resident #24 was eating and drinking without difficulty and Resident #24 reported no pain. NP #500 reported therapy staff told NP #500 that Resident #24 was outside when a tree limb hit him in the face, but Resident #24 stated he tripped and hit his face. NP #500 stated nursing staff told her that they did not know what happened to Resident #24's lip. NP #500 reported she notified the Director of Nursing (DON) about Resident #24's lip being swollen on 03/16/26. NP #500 reported that she ordered ice and the area to the lip was healed the next time she saw Resident #24. NP #500 stated that Resident #24 has a history of dementia and Resident #24 had confusion. Interview with the DON on 04/13/26 at 1:18 P.M. verified the facility did not have any documentation of Resident #24's swollen upper lip with dark purple discoloration in Resident #24's progress notes. The DON verified Resident #24's skin assessment completed 03/16/26 at 5:38 P.M. did not document Resident #24's swollen upper lip with dark purple discoloration and that there was no other documentation of Resident #24's swollen upper lip with dark purple discoloration in Resident #24's chart except for in NP #500's notes completed 03/16/26 and on 03/26/26. The DON confirmed the facility did not know how Resident #24 sustained the swollen upper lip with dark purple discoloration. The DON verified the facility did not complete an investigation and did not have copies of resident or staff statements related to the injury of unknown origin and the facility did not complete a SRI for the injury of unknown origin. The DON verified there was no documented monitoring of Resident #24's swollen upper lip with dark purple discoloration from 03/16/26 to 03/25/26 as ordered by NP #500 on 03/16/26. Review of the facility's undated abuse policy revealed it was the facility's policy to investigate all alleged violations including abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property including injuries of unknown source. Facility staff should immediately report such allegations to the Administrator and to the state surveying agency. An injury of unknown source was defined as an injury where the source of the injury was not obtained by any person or the source of the injury could not be explained by the resident and the injury was suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular point in time or the incidence of injuries over time. The policy also stated the resident representative should be notified of the incident. This deficiency represents non-compliance investigated under Complaint Number 2807672.

Based on record review, review of hospital paperwork, staff interview, policy review and review of online medical resources, the facility failed to monitor and record resident bowel functioning. This resulted in Actual Harm for Resident #76 whose last documented bowel movement occurred on 11/19/25. Resident #76 was subsequently treated in the hospital for a fecal impaction on 01/25/26. This affected one (Resident #76) of three residents reviewed for hospitalization. The facility census was 78 residents. Findings include:Review of the medical record for Resident #76 revealed an admission date of 02/06/24 with diagnoses including cerebral infarction, dysphagia, depression, and mood disorder. Resident #76 was discharged to the hospital on [DATE] and did not return to the facility.Review of the physician's orders for Resident #76 revealed an order dated 02/06/24 for milk of magnesia 30 milliliters (ml) via feeding tube every 24 hours as needed for constipation, and senna oral tablets 8.6 milligrams (mg) two tablets via feeding tube every 24 hours as needed for constipationReview of the care plan for Resident #76 updated 09/23/25 revealed the resident was at risk for constipation related to decreased mobility, medications, and decreased food intake. Interventions included the following: record bowel movement patterns each day, monitor/document/report to medical director signs/symptoms of complications related to constipation including change in mental status, new onset of confusion and agitation. Review of the Minimum Data Set (MDS) assessment for Resident #76 dated 12/06/25 revealed the resident had moderate cognitive deficits, was dependent on staff for activities of daily living (ADLs), and was always incontinent of bowel and bladder.Review of the bowel records for Resident #76 dated December 2025 and January 2026 revealed there were no bowel movements documented. Review of the change in condition evaluation for Resident #76 dated 01/25/26 revealed the situation section had been completed and signed and the only signs and symptoms noted were a fever of 100.4 degrees Fahrenheit (F) and shortness of breath. Other vital signs listed included a blood pressure of106/59, pulse of 110 beats per minute (bpm), and oxygen saturation of 98 percent on room air. Review of the hospital history and physical for Resident #76 dated 01/25/26 revealed the resident was admitted to the hospital with acute hypoxic respiratory failure with pneumonia, encephalopathy, hypernatremia, and hyperglycemia. Upon examination, the resident was found with a fecal impaction and concern for stercoral colitis. Resident #76 moaned and grimaced and withdrew due to pain as staff manually removed a fecal impaction. Review of the computed tomography (CT) scan of the abdomen and pelvis for Resident #76 dated 01/26/26 revealed there was a large ball of stool in the rectum. In addition to removing the fecal impaction, Resident #76 was treated with Zosyn (an antibiotic), a soap suds enema, and was started on a bowel regimen of Miralax and Senna twice per day. During an interview on 02/11/26 at 2:28 P.M., the Director of Nursing (DON) verified there was no documentation showing Resident #76 had a bowel movement since 11/19/25. The resident's bowel records for December 2025 and January 2026 were blank. During an interview on 02/17/26 at 11:16 A.M., Nurse Practitioner (NP) #325 stated she was unsure if staff had alerted her to the absence of bowel movements for Resident #76. NP #325 stated she was also unaware the staff had not documented bowel movements for Resident #76 for the months of December 2025 and January 2026 and further stated her expectation was for staff to document the presence or absence of resident bowel movements every shift. During an interview on 02/17/26 at 11:54 A.M., Licensed Practical Nurse (LPN) #600 stated she worked from 5:00 P.M. on 01/25/26 to 7:00 A.M. on 01/26/26. LPN #600 stated she relieved Assistant Director of Nursing (ADON) #300 who mentioned Resident #76 had not had a recent bowel movement and was having respiratory issues. LPN #600 stated her focus when sending Resident #76 to the hospital was respiratory concerns and she did not assess the resident's abdomen. Review of the facility policy titled Bowel Management Protocol dated 09/30/25 revealed nursing staff must document bowel movements each shift in the resident's medical record.Review of information from the National Library of Medicine at https://www.ncbi.nlm.nih.gov/books/NBK560608/ revealed stercoral colitis is a rare inflammatory colitis that occurs when impacted fecal material leads to distention of the colon and eventually fecaloma formation. Fecalomas can lead to focal pressure necrosis and perforation, while colonic distention and increased intraluminal pressure can lead to compromise of the vascular supply and ischemic colitis.Review of information from the National Library of Medicine at Constipation - self-care: MedlinePlus Medical Encyclopedia revealed Constipation is when you do not pass stool as often as you normally do. Your stool may become hard and dry, and it can be difficult to pass. And under the section, When to contact a medical professional, Contact your provider if you have not had a bowel movement in 3 days. This deficiency represents noncompliance investigated under Complaint Number 2726965 and Complaint Number 2709700 and Complaint Number 2610295

Based on observation, staff interview, and policy review, the facility failed to ensure kitchen staff had access to adequate handwashing facilities in the kitchen. This had the potential to affect 76 residents. The facility identified two (Residents #49 and #50) who did not receive food from the kitchen. The facility census was 78 residents. Findings include: Observation upon entry into the kitchen on 02/10/26 at 8:00 A.M. revealed Dietary [NAME] (DC) #340 was standing at the stove making scrambled eggs. The Surveyor attempted to wash hands at the hand-washing sink at the front of the kitchen, but the water did not flow. Interview on 02/10/26 at 8:01 A.M. with DC #340 confirmed the water did not work in the hand-washing sink and instructed the Surveyor to use the hand-washing sink in the back of the kitchen and stated that it was where he normally washed his hands. Observation on 02/10/26 at 8:02 A.M. revealed the Surveyor turned on the water at the hand-washing sink in the back of the kitchen, but there was no soap available by the sink. Interview on 02/10/26 at 8:02 A.M. with DC #340 confirmed there was no soap at the hand-washing sink in the back of the kitchen and suggested the Surveyor to get soap from hand-washing sink at the front of the kitchen. Observation on 02/10/26 at 8:03 A.M. revealed DC #340 turned the water from the pot filling spiggot, which had been pulled over the sink, and suggested the Surveyor could complete handwashing by using the pot filling spiggot. There were no paper towels available at the hand-washing sink at the front of the kitchen, and DC #340 took a roll of paper towels from the food preparation area and handed it to the Surveyor. Interview on 02/10/26 at 8:03 A.M. with DC #340 verified there were no paper towels available at the hand-washing sink at the front of the kitchen. Interview on 02/10/26 at 9:21 A.M. with Dietary Manager (DM) #345 stated he was not aware the hand-washing sink at the front of the kitchen was not working and further verified hand soap should be available at all hand-washing sinks in the kitchen. Review of the facility policy titled Handwashing/Hand Hygiene dated 2021 revealed hand hygiene products and supplies (sinks, soap, towels) should be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies.This deficiency represents noncompliance investigated under Complaint Number 1395179.

Based on observation, staff interview, and policy review, the facility failed to ensure staff wore hair restraints in the kitchen, failed to ensure staff washed their hands upon entering the kitchen and before handling food, and failed to ensure food was stored in a manner to protect against the potential spread of foodborne illness. This had the potential to affect 76 of 78 residents residing in the facility. The facility identified two (Residents #49 and #50) who did not receive food from the kitchen. The facility census was 78 residents.Findings include: 1. Observation on 02/10/26 at 8:00 A.M revealed Dietary [NAME] (DC) #340 was standing at the stove preparing eggs and had a full beard that was approximately one-quarter of an inch in length. DC #340 was not wearing a facial beard restraint. Observation on 02/10/26 at 8:13 A.M. revealed Dietary Aid (DA) #350 was covering food prepared on the tray line and had facial hair on his chin that was approximately one inch in length. DA #350 was not wearing a facial beard restraint. Observation on 02/10/26 at 8:24 A.M. revealed Dietary Manager (DM) #345 entered the kitchen and began preparing food and had a full beard that varied in length from one-half inch to one inch. DM #345 was not wearing a facial beard restraint. Observation on 02/10/26 at 8:57 A.M. revealed Floor Tech (FT) #513 was putting lids onto prepared breakfast plates and had a full beard with chin hair, measuring approximately two inches in length. FT #513 was not wearing a facial beard restraint. Interview on 02/10/26 at 9:02 A.M. with DC #340 verified that neither he nor DA #350, DM #345, or FT #513 were wearing facial beard restraints in the kitchen. Interview on 02/10/26 at 9:02 A.M. with FT #513 confirmed facial hair restraints were not available in the kitchen. Interview on 02/10/26 at 9:03 A.M. with DM #345 verified employees with facial hair should wear facial hair restraints in the kitchen. Review of the facility policy titled Food Preparation and Service dated April 2019 revealed food and nutrition services staff should wear hair restraints (hair net, hat, beard restraint) so that hair does not contact food. 2. Observation on 02/10/26 at 8:57 A.M. revealed FT #513 entered the kitchen, immediately applied gloves and went to the tray line area and began putting lids onto prepared breakfast plates. FT #513 did not wash his hands upon entering the kitchen.Interview on 02/10/26 at 8:58 A.M. with FT #513 confirmed he had not washed his hands upon entering the kitchen. Interview on 02/10/26 at 9:21 A.M. with DM #345 confirmed all employees should wash their hands immediately upon entering the kitchen. Interview on 02/10/26 at 2:44 P.M. with Registered Dietitian (RD) #420 verified all staff should wash their hands immediately upon entering the kitchen . Review of the facility policy titled Handwashing/Hand Hygiene dated 2021 revealed an alcohol-based hand rub or soap and water should be used before and after handling food. Review of the facility policy titled Food Preparation and Service dated April 2019 revealed food preparation staff should adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. Food and nutrition services staff should wash their hands before serving food to residents. 3. Observation on 02/10/26 at approximately 8:30 A.M. revealed DC #340 retrieved a thermometer from a pan below the food preparation table which contained two metal spatulas and placed the thermometer into the scrambled eggs on the steam table. DC #340 obtained the temperature of the scrambled eggs, removed the thermometer, and immediately placed it into a sausage patty to check the temperature. Interview on 02/10/26 at 8:34 A.M. with DC #340 verified he did not clean the thermometer before placing it into the eggs and did not clean the thermometer before putting it in the sausage patty. Interview on 02/10/26 at 2:44 P.M. with RD #420 verified alcohol wipes should be utilized to clean thermometers prior to use and in between obtaining the temperatures of each food. Review of the facility policy titled Food Preparation and Service dated April 2019 revealed food-contact equipment should be cleaned and sanitized between uses. Food thermometers used to check food temperatures should be cleaned, sanitized, and calibrated for accuracy. 4. Observation on 02/10/26 at 8:41 A.M. of the cooling on the tray line revealed it contained an open carton of nectar thickened water with a best by date of 01/19/26 and no date upon opening and a large, opened container of cottage with and open date of 01/29/26. Interview on 02/10/26 at 8:42 A.M. with DM #345 verified the carton of nectar thick water had a best by date of 01/19/26 with no open date and the container of cottage cheese was dated 01/29. DM #345 stated both items should have been discarded or used within 10 days of opening. Interview on 02/10/26 at 2:44 P.M. with RD #420 verified all foods should be labeled with an open and a throw out date. Review of the facility policy titled Food Receiving and Storage dated October 2017 revealed all foods stored in the refrigerator or freezer should be covered, labeled, and dated with a use by date. 5. Observation on 02/10/26 at 9:18 A.M. revealed staff were distributing breakfast trays to residents from a cart in the hallway and staff accidentally dropped one of the breakfast trays onto the floor. Staff picked the items up from the floor, placed them back on the tray, and then placed the dirty tray on top of the cart of clean meal trays. The cart also had a rack of clean glasses, another resident's meal tray, condiments for the meal, and a gallon of milk. Interview on 02/10/26 at 9:36 A.M. with DM #345 verified staff had placed the dirty tray from the floor onto the cart of clean meal trays and other clean items.

Based on observation, staff interview, resident interview, and policy review, the facility failed to ensure food was served at the appropriate temperature and was palatable. This had the potential to affect 76 of 78 residents in the facility. The facility identified two (Residents #49 and #50) who did not receive food from the kitchen. The facility census was 78 residents.Findings include: Observation of a test tray on 02/10/26 at 9:33 A.M. after all trays had been passed revealed the eggs and sausage were lukewarm to taste and not palatable. The eggs were 93 degrees Fahrenheit (F) and the sausage was 93.4 degrees F. The milk was poured from a carton which had been placed on top of the cart of trays into a glass was 48.8 degrees F and the orange juice was 51 degrees F. Interview on 02/10/26 at 9:34 A.M. with Dietary Manager (DM) #345 confirmed he did not want to taste the food. DM #345 verified the eggs were 93 degrees F, sausage was 93.4 degrees F, milk was 48.8 degrees F, and the orange juice was 51 degrees F. DM #345 stated his expectation was for hot food to be at least 120 degrees F and milk and juice should be 40 degrees or less when it is served to the residents. Interviews on 02/10/26 between 9:45 A.M. and 10:00 A.M. with Residents #66, #67, and #74 confirmed their eggs and sausage were cold when they received their trays. Review of the facility policy titled Food Preparation and Service dated April 2019 revealed the danger zone for food temperatures was between 41 degrees F and 135 degrees F which promoted the rapid growth of pathogenic microorganisms that caused foodborne illness. Potentially hazardous foods (PHF) included meats, poultry, eggs, and milk. The longer foods remained in the danger zone, the greater the risk for growth of harmful pathogens. Therefore, PHF must be maintained below 41 degrees F or above 135 degrees F. This deficiency represents noncompliance investigated under Complaint Number 1395179 and Complaint Number 1395177 and Complaint Number 1395176.

Based on observation, review of the facility menu and dietary spreadsheets, and staff interview, the facility failed to ensure the menu was followed and portion sizes were served as planned on dietary spreadsheets. This had the potential to affect 76 residents in the facility. The facility identified two (Residents #49 and #50) who did not receive food from the kitchen. The facility census was 78 residents. Findings include: Review of the menu for 02/10/26 revealed residents on regular textured diets were to receive cereal, toast, and sausage egg bake.Review of the dietary spreadsheet for 02/10/26 revealed all diets were to receive six ounces of cereal. The type of cereal varied depending on the diet, with some diets specifying a specific hot cereal.Review of the dietary spreadsheet for 02/13/26, when scrambled eggs were on the menu, revealed all diets were to receive a #16 scoop (two ounces) of eggs.Observation on 02/10/26 at 8:10 A.M. revealed Dietary [NAME] (DC) #340 served food from the steam table for the breakfast meal. The steam table contained pureed eggs, pureed toast, scrambled eggs, sausage patties, and toast. A sausage egg bake was not observed on the steam table. For residents on a regular diet, DC #340 placed a four-ounce scoop of scrambled eggs, one sausage patty, and a slice of toast on each plate. Continued observation revealed residents with pureed diets were served a three-ounce scoop of pureed eggs, a two-ounce scoop of pureed toast and an insulated bowl of hot cereal. Further observation revealed the hot cereal was served directly from a pan on the stove, utilizing a slotted spoon, two scoops into an insulated bowl, filling the bowl approximately halfway to the top. Interview on 02/10/26 at 8:18 A.M. with DC #340 verified he was using a four-ounce scoop for the scrambled eggs and a three-ounce scoop for the pureed eggs. DC #340 verified he was serving scrambled eggs, sausage patties, and toast instead of the sausage egg bake. DC #340 stated he had worked at the facility for three months and always does it that way when casseroles and [NAME] are on the menu because those are the basic ingredients used for the menu items and the facility had several residents who did not eat pork so he had to consider their needs. Interview on 02/10/26 at 8:24 A.M. with Dietary Manager (DM) #345 verified the egg bake was not prepared for the breakfast meal because half of the residents did not eat pork. DM #345 further stated he does the other casseroles and [NAME] the same way.Interview on 02/10/26 at 8:50 A.M. with DM #345 verified DC #340 used a slotted spoon to serve the hot cereal and it was not a measurable amount. DM #345 stated DC #340 scooped the hot cereal into the insulated bowls without being measured.Interview on 02/10/26 at 8:51 A.M. with DC #340 stated the insulated bowls had a capacity of eight ounce and that was approximately about how much hot cereal he had served. Observation on 02/10/26 at 8:59 A.M. revealed DC #340 served one scoop of hot cereal from a slotted spoon onto a divided plate. DC #340 returned to the steam table and placed pureed eggs and pureed toast on the same divided plate. Interview on 02/10/26 at 9:06 A.M. with DC #340 verified the portion sizes served did not match the dietary spreadsheets. DM #345 stated in monthly food committee meetings residents complain about portion sizes being too small, so he has been trying to give them more. Interview on 02/10/26 at 9:28 A.M. with DM #345 verified the foods served at breakfast did not match what was on the menu. DM #345 affirmed they do not make casseroles and [NAME] when on the menu and stated they make scrambled eggs and whatever breakfast meat is supposed to be in the casseroles/[NAME] instead. DM #345 stated he had not talked to Registered Dietitian (RD) #420 about the substitutions made, but verified substitutions should be reviewed by the RD. Interview on 02/10/26 at 2:44 P.M. with Registered Dietitian (RD) #420 verified her expectation was for the menu and spreadsheets to be followed as planned and she should be consulted for menu changes. RD #420 stated the egg bake should have been provided as planned and residents who do not eat pork should have been provided an alternate selection. This deficiency represents noncompliance investigated under Complaint Number 2709700.