Every finding on record at Cumming Operating Company LLC

Based on observations, staff interviews, record review, and review of the facility's policy titled, Safe Water Temperatures Policy, the facility failed to ensure hot water temperatures remained within safe limits in 10 of 24 Rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], 200 Hall Shower Room, and the 300 Hall Shower Room) on two of four hallways (200 Hall and 300 Hall). The deficient practice had the potential to place residents at risk of injury. Residents on two of four Halls had the potential to be affected. The facility census was 87 residents.Findings include:A review of the facility's policy titled, Safe Water Temperatures Policy last reviewed/revised 7/25/2025, documented under Policy Explanation and Compliance Guidelines: .4. Staff will report abnormal findings, such as complaints of water too cold, or hot, burns or redness, or any problems with water temperature (ex. Water is painful to touch or causes redness), 5. Water temperatures will be set to a temperature of no more than 109 Fahrenheit (F), or the state's allowable maximum water temperature, 6. Maintenance staff will check water heater temperature controls and the temperatures of tap water in all hot water circuits weekly and as needed. 7. Documentation of testing will be maintained for 3 years and kept in the maintenance office.Observations on 12/2/2025 at 11:01 am in room [ROOM NUMBER] revealed water was hot to touch.Observation and Interview on 12/2/2025 at 11:15 am with the Maintenance Director (MD) revealed he arrived with a facility thermometer and checked hot water temperatures on the 200 and 300 hallways that revealed:room [ROOM NUMBER] with reading of 126.0 degrees Fahrenheit (F).room [ROOM NUMBER] with reading of 127.0 degrees F.room [ROOM NUMBER] with reading of 125.0 degrees F.room [ROOM NUMBER] with reading of 122.7 degrees F.room [ROOM NUMBER] with reading of 127.0 degrees F.room [ROOM NUMBER] with reading of 127.0 degrees F.200 Hall Shower Room with reading of 126.0 degrees F.300 Hall Shower Room with reading of 128.5 degrees F.The MD confirmed that he knew hot water temperatures should be below 110 degrees F. Further, he revealed that he checked water temperatures weekly, and the mixing valve had been changed about three weeks ago. The MD presented an invoice of a mixing valve purchased on 10/22/2025 and installed on 11/13/2025.Observations on 12/2/2025 at 4:04 pm to 4:18 pm of recheck of hot water temperatures revealed 200 and 300 hallways temperatures were:room [ROOM NUMBER] with a reading of 106.4 degrees F.room [ROOM NUMBER] with a reading of 108.6 degrees F.The 200 Hall shower room with a reading of 110.2 degrees F.room [ROOM NUMBER] with a reading of 111 degrees F.room [ROOM NUMBER] with a reading of 111 degrees F.Observations on 12/3/2025 at 11:09 am to 11:18 am rechecks of hot water temperatures revealed:room [ROOM NUMBER] with a reading of 95.0 degrees F.room [ROOM NUMBER] with a reading of 89.9 degrees F.room [ROOM NUMBER] with a reading of 95.1 degrees F.room [ROOM NUMBER] with a reading of 93.7 degrees F.200 Hall shower central bath with a reading of 95.2 degrees F.300 Hall shower central bath with a reading of 93.6 degrees F.Interview on 12/4/2025 at 1:16 pm with the Administrator revealed that expectations were for water checks to be done weekly by the MD. He allowed the MD to do things he was able to do, but if something major came up, they would call the plumber immediately. The Administrator confirmed that he was aware of the hot water temperatures on the 200 and 300 Halls and was told by MD on 12/2/2025.

Based on observation, staff interview, and review of the facility's policy titled, Date Marking for Food Safety, the facility failed to label and date 34 porkchops, eight chicken breast, and six hamburger patties in one of three freezers and the facility failed to discard 22 expired snack cookies on two of two pantries. In addition, the facility failed to maintain proper sanitary conditions for one of three ice machines and the facility failed to discard 140 expired 240 mL (milliliter) water bottles and four cases with six count each of one gallon sized water from the emergency water supply. The total of residents that received an oral diet was 81. Findings Include: Review of facility's undated policy titled, Date Marking for Food Safety under the section titled Policy revealed, The facility adheres to a date marketing system to ensure the safety of ready-to-eat, time/temperature control for safety food. Under the section titled Policy Explanation and Compliance Guidelines for Staffing revealed, 2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded.3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. 4. The marking system shall consist of a color-coded label, the day/date of opening, and the day/date the item must be consumed or discarded. 5. The discard day or date may not exceed the manufacturer's use-by date, or four days, whichever is earliest. The date of opening or preparation counts as day 1. (For example, food prepared on Tuesday shall be discarded on or by Friday). 6. The Head Cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly. 7. The Dietary Manager, or designee, shall spot check refrigerators weekly for compliance, and document accordingly. Corrective action shall be taken as needed. Observation during the tour of the kitchen on [DATE] at 10:33 am with Regional Manager MM revealed no labels or dates on three meat products; 34 porkchops, eight chicken breast, and six hamburger patties. These items were immediately discarded by Regional Manager MM. Observation on [DATE] at 12:30 pm with [NAME] President (VP) of Clinical Services AA of two dry storage areas revealed 14 expired snack cookies: two chocolate chips and 12 lemon cookies in the main pantry. The tour concluded on the short-term rehab unit near the 400 hall whereas the second pantry revealed eight expired snack lemon cookie and a dirty ice machine. VP of Clinical Service AA and Housekeeping Supervisor HH observed and confirmed these findings. Interview on [DATE] at 12:50 pm with Housekeeping Supervisor HH revealed he performed laundry and housekeeping duties. Housekeeping Supervisor HH revealed, he cleaned the ice machine located on 400 hall yesterday however, he confirmed the dirt-like substance and proceeded to shut down the ice machine to reclean. Interview on [DATE] at 2:32 pm with Regional Manager MM revealed she identified why the frozen items found during initial tour were unlabeled because she obliviously orders more than the previous manager, and someone took items out the box to make space and did not label them. Regional Manager MM confirmed it was her responsibility to check dates in kitchen but was not certain who was responsible for checking pantries, but stated she would do an in-service for it. Observation on [DATE] at 4:52 pm of the emergency water supply revealed a limited supply of food and four cases with six count each of one gallon sized water and 140 count of 240 ml water bottles expired. Regional Manager MM made directive to Housekeeping Supervisor HH to discard them.

Based on observations, staff interviews, record review, and review of facility's policies titled Resident Environmental Quality and Safe and Homelike Environment, the facility failed to maintain a clean and sanitary environment. Specifically, the filters for Heating Ventilation, and Air Conditioning (HVAC) unit vents contained visible thick grayish white dust particles that covered the filters for the residents that occupied rooms (103,100,101,104,105 and 106). This deficient practice had the potential to cause poor air quality that could lead to respiratory illness. The sample size was 40 residents. Findings include: Review of the facility's policy titled Resident Environmental Quality dated 6/24/2024, under the section titled Policy revealed, It is the policy of this facility to be designed, constructed, equipped and maintained to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Under the section titled Policy Explanation and Compliance Guidelines revealed, The facility shall: (2.) Maintain all essential mechanical, electrical, and patient care equipment in safe operating condition. Under the section titled General Guidelines: revealed, (1.) Preventative maintenance schedules, for the maintenance of the building and equipment, should be followed to maintain a safe environment. Review of the facility's policy titled Safe and Homelike Environment dated 12/1/2023 under the section titled Policy revealed, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. Under the section titled Policy Explanation and Compliance Guidelines revealed, (3.) Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. Observation on 8/13/2024 at 10:45 am of room [ROOM NUMBER] revealed, both filters of the (HVAC) unit vents were covered with thick grayish white dust particles. Interview on 8/13/2024 at 10:50 with the Maintenance Director (MD) in room [ROOM NUMBER] revealed the process was for housekeeping to monitor and clean them monthly. The MD confirmed the (HVAC) units had a buildup of thick grayish white dust particles that that covered it. Observation on 8/13/2024 at 10:55 am of room [ROOM NUMBER] room revealed, both filters of the HVAC unit vents were covered with thick grayish white dust particles. Observation on 8/13/2024 at 11:05 am room of 101 room revealed, both filters of the HVAC unit vents were covered with thick grayish white dust particles. Observation on 8/13/2024 at 11:10 am room of 104 room revealed, both filters of the HVAC unit vents were covered with thick grayish white dust particles. Observation on 8/13/2024 at 11:15 am room of 105 room revealed, both filters of the HVAC unit vents were covered with thick grayish white dust particles. Observation on 8/13/2024 at 11:30 am room of 106 room revealed, both filters of the HVAC unit vents were covered with thick grayish white dust particles. Interview on 8/15/2024 on 8:32 am with Housekeeper (HK) GG revealed she check the air conditioner heater vents every couple of weeks and clean them monthly either by dusting off or rinsing if heavy dust was observed. HK GG also revealed there was no log or tracker for rooms that had been done. Interview with the Housekeeping Supervisor revealed his expectation of staff was that they clean them at least monthly. He stated that he also had a daily checklist but does not always use it.

Based on observations, staff interviews, and review of the facility's policy titled Medication Storage, the facility failed to ensure that a Schedule IV medication was secured under double lock and key for one of two medication storage rooms. This deficient practice had the potential to cause loss of controlled and other medications. The facility census was 81 residents. Findings include: Review of the facility's undated policy titled Medication Storage, under the section titled Policy Explanation and Compliance Guidelines revealed, 2. Narcotic and Controlled Substances: (a.) Schedule II drugs and back up stock of schedule III, IV and V medications are stored under double-lock and key. Observation and interview on 8/14/2024 at 1:18 pm of the medication storage room on the 400 hall with Licensed Practical Nurse (LPN) II revealed, the medication room was locked and that the nurse held the key however the refrigerator had no lock. During the observation, the refrigerated drugs were noted to have an emergency box closed with plastic tear away locks. The medications in the emergency box which was clear plastic container held Ativan 2mg (milligram) injectable. LPN II confirmed Ativan present in box however she was unsure whether it was properly secured. Interview on 8/14/2024 at 1:25 pm with facility pharmacist revealed the plastic tear away lock meets the requirement for double lock security for controlled drug storage. Interview on 8/15/2024 at 10:25 am with Director of Nursing confirms controlled substances should be kept under double lock but did not confirm what constitutes a double lock. The DON revealed the pharmacy has ordered a new container that will be bolted into the refrigerator and with a key lock that the nurses will carry a key for it.

Based on observations and staff interviews, the facility failed to promote care in a manner that maintained or enhanced each resident's dignity and respect. Specifically, the facility failed to provide privacy during incontinent care for one of 40 sampled resident (R) (R132) reviewed for dignity. Findings include: Observation on 8/13/2024 at 10:00 am revealed Certified Nursing Assistant (CNA) NN providing incontinent care to R132 in his room with the privacy curtain not completely closed. The privacy curtain was observed pulled towards the end of the bed but did not circle the bottom of the bed leaving an open view of the resident to anyone entering the room. Further observation, revealed, the room door was also left open during care and the resident was observed to be naked from the waist down. Interview on 8/13/2024 at 2:41 pm with CNA NN revealed that today was her first day working at the facility. She stated that she was an Agency staff member. She stated she was unaware the door was left open and confirmed that she did not close the curtain all the way. Interview on 8/15/2024 at 12:10 pm with the Nurse Manger revealed all CNAs are required to know about residents rights. She stated during orientation the nursing staff received an in-service education on how to treat residents with dignity. She stated whenever she witness noncompliance among her staff, she schedule an education module.

Based on staff interviews, record review, and review of facility's policy title Comprehensive Care Plans, the facility failed to develop a comprehensive person-centered care plan for two residents (R) R8 and R59 that addressed the residents' peripherally inserted central catheter (PICC) line. The sample size was 40 residents. Findings include: Review of the facility's policy titled Comprehensive Care Plan dated March 2023 under the section titled, Policy revealed, It is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a residents medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 1. Review of R8's electronic medical record (EMR) revealed, the resident had diagnoses that included but was not limited to type 2 diabetes mellitus with foot ulcer, vascular dementia, non-pressure chronic ulcer of right heel and midfoot, other acute osteomyelitis, depression and delirium due to known physiological mood. Review of R8's physician orders revealed, an order with order date of 8/6/2024 for Daptomycin solution reconstituted 500 mg (milligram); Use 250 mg intravenously every 24 hours for Infection until 8/27/2024. Review R8's care plan with revision date of 8/13/2024 revealed, that she was ordered antibiotic therapy Daptomycin through 8/27/2024 related to right foot osteomyelitis. Further review of the care plan revealed, there was no care plan in place that addressed the resident's PICC line. Interview on 8/15/2024 at 12:15 pm with the Minimum Data Set (MDS) Coordinator confirmed the PICC line was not on the care plan and revealed it had been added on 8/14/2024. 2. Review of R59's EMR revealed, the resident had diagnoses that included but was not limited to anemia, colostomy, chronic pain and muscle wasting. Review of R59's physician orders revealed with order date of 8/13/2024 for Invanz injection solution reconstituted 1 (one) GM (gram) (Ertapenem Sodium) Use 1 (one) gram intravenously one time a day for abscess Review of R59's care plan dated 7/30/2024 revealed that the resident had an infection (abscess) and was at risk for infection. Further review of the care plan revealed, there was no care plan in place that addressed the resident's PICC line. Interview on 8/15/2024 at 12:15pm with the MDS Coordinator confirmed that the PICC line was not on the care plan and asked if she could go ahead and add it. 50526

Based on observations, record review, and interview, the facility failed to maintain sanitary conditions of the kitchen ice machine. The census was 62 residents. Findings include: Review of document provided by facility labeled Ice Machine dated June 2021, revealed supplies and procedure for cleaning the ice machine. Procedure indicated that the ice bin should be cleaned daily by wiping the interior of the ice bin or ice chute above the ice layer, including the drip edge of the ice deflector shield and around the ice bin door using a clean towel and sanitizer solution, being careful not to drop sanitizer on the ice. Observation on 10/26/22 at 10:05 a.m. and 10/27/22 at 8:00 a.m. using a white paper towel wiping the inside of the ice bin, revealed build-up of black substance in the bin of the ice machine. Review of a document provide by the Dietary Manager, titled ML-Safety and Sanitation with completion date of 10/4/2022, revealed under Score Summary for sanitation, a score of 64.71%, which indicated a corrective action plan is needed. Under sanitation, it was documented that the ice machine is to be well maintained and free from mold and foreign contaminants, maintenance records (cleaning) are to be posted on or near unit, and a master daily, weekly, and monthly cleaning schedule must be in place, posted and used routinely. Interview on 10/26/22 at 10:05 a.m. with Dietary Manager (DM), stated that he is the person that is responsible for cleaning the ice machine. He stated that it is supposed to be cleaned every week, but it has not been cleaned due to staffing issues. When asked to produce the cleaning logs, he stated that they were in storage.

Based on observations, interviews, and review of the policy titled Medication Storage, the facility failed to ensure that one of three medication carts was locked and secured when the cart was out of view of the nurse. The census was 62. Findings include: Review of the facility policy titled Medication Storage dated 5/4/22 revealed policy explanation and compliance guidelines: 1. a. All drugs and biologicals will be stored in a locked compartment (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. 1.c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. Observation on 10/25/22 at 9:25 a.m., medication cart on 300 Hall, located between rooms [ROOM NUMBERS], was unlocked and unattended without a nurse or staff member within eyesight. Licensed Practical Nurse (LPN) AA approached the cart and verified she left the cart unlocked and unattended. She stated she had walked away to give a resident water and forgot to lock the cart. She confirmed the cart should be locked and secured when unattended. Interview on 10/27/22 at 11:15 a.m. with the Director of Nursing (DON), stated her expectations are for all medication carts to be locked and secured when left unattended. She stated the pharmacy consultants provide monthly in-services related to medication administration, medication storage and other relevant pharmacy topics.

Based on interview, observation, and review of policy titled Food Storage and Use and Storage of Food Brought in by Family or Visitors the facility failed to discard expired items, and failed to label and date items upon delivery. This included dry storage area in the kitchen and two of two food pantries. The census was 74 residents. Findings include: Observation on [DATE] at 11:39 a.m. during a brief kitchen tour with the Dietary Manager revealed the following: 1. In the reach in freezer there 19 loaves raisin bread that did not have a received date or an expiration date. 2. In the reach in freezer there were two containers of minin count cheese danish (30 in each) with an ,[DATE] receive date but there was no expiration date. There was no use by date on the packages. 3. On the bread rack there were 40 full loaves of bread and one partial loaf of bread that did not have a thawed on date or a use by date. There were also two loaves of raisin bread that did not have dating. During second tour of kitchen on [DATE] at 12:46 p.m. the following was observed: 1. None of the food items on shelves in the dry food storage area had a received by date. Observation on [DATE] at 2:11 p.m. of resident pantry on 400 hall revealed: 1. There was 1 pint container of raw honey without an in date or use by date. 2. There was 1 container of Ready Care Vanilla Shake that did not have a thaw date. 3. There were 7 Sidekick frozen treats in freezer with no in date or expiration dates. Central pantry observation on [DATE] at 2:40 p.m. with the Dietary Manager revealed the following: 1. There were 33 Sidekick frozen treats in the freezer that did not have expiration dates. 2. There was a 4 pack of Ensure clear with a use by date (MONTH) 1, (YEAR). 3. There was a box of Boost with six 8 fluid ounce containers with an expiration date of (MONTH) 14, (YEAR). 4. There were 2 boxes of instant grits with a best if used by date of (MONTH) 8, (YEAR). Interview on [DATE] at 12:11 p.m. with the Dietary Manager who reported that all bread arrives frozen and bread is placed on shelves as needed to thaw. Once thawed the bread should be used within 7 days. The Dietary Manager acknowledged that she was unable to tell when bread was put out to thaw. Interview on [DATE] at 12:46 p.m. with Dietary Manager to review food storage policy. Upon review of the policy the Dietary Manager confirmed that none of the food items in dry food storage are dated per the policy, except for the emergency food. Interview on [DATE] at 2:21 p.m. with Licensed Practical Nurse (LPN) AA reported food from family is normally dated prior to placing in the refrigerator. LPN AA clarified that the container that read raw honey was not honey but soup and it was brought in by a resident's family on Sunday. LPN AA reported that dietary is responsible for assuring the correct dates on the shakes and other juices in the refrigerator and freezer. Interview on [DATE] at 2:33 p.m. with the Dietary Manager who reported that the 7 Sidekick frozen treats were just an extra treat gotten for residents. Dietary Manager was unable to tell exact date received but reported receiving about a month ago and was unable to provide expiration date for the frozen items. Dietary Manager reported that Dietary staff cleans the refrigerator nightly and should have removed undated items. Interview on [DATE] at 2:40 p.m. with the Dietary Manager who reported that dietary staff clean the cabinets and should have seen that the grits were expired. Dietary Manager reported that the refrigerator is cleaned every night and expired items should have been removed by the dietary staff. The Dietary Manager further reported that if food items are not labeled and dated the items should be removed from the refrigerator even if it belonged to the resident. Policy: Food Storage 8. All stock must be rotated with each new order received. Rotating stock is essential to ensure the freshness and highest quality of all foods. c. Food should be dated as it is placed on the shelves. 15. Refrigeration: e. All foods should be covered, labeled, and dated. 16. Frozen c. Foods should be covered, labeled, and dated. d. All food items should be stored upon delivery and careful rotation procedures should be followed. Flowers Bakeries printed information dated [DATE] Easy handling and long shelf life for first day fresh bread, thaw at room temperature for 12 to 24 hours. Once thawed, store at ambient temperature and the bread will stay fresh for 5 to 7 days. Use and Storage of Food Brought in by Family or Visitors Policy Explanation and Compliance Guidelines: 2. All food items that are already prepared by the family or visitor brought in must be labeled with content and dated. a. The facility may refrigerate label and dated prepared items in the nourishment refrigerator. b. The prepared food must be consumed by the resident within 3 days. c. If not consumed within 3 days, food will be thrown away by facility staff.

Based on observation, staff interview, and documentation review the facility failed to ensure food items in the walk-in refrigerator were discarded by the used by date for two (2) of four (4) days of the survey; failed to date opened food items before storage; and failed to maintain food temperatures above one hundred thirty five degrees Fahrenheit (135°F) on the steam table for one food which was the main entrée. This deficient practice had the potential to effect eight three (83) residents receiving an oral diet. Finding include: Observation on 04/11/16 on 10:40 a. m. of walk in refrigerator revealed that a five (5) container of pimento cheese spread was opened and partial used. The pimento cheese spread did not have a date of when it was opened. Continued observation revealed eight (8), 8 ounce cartons of buttermilk with a use by date of 04/10/16. Interview on 04/11/16 at 10:40 a. m. with the Dietary Manager (DM) revealed that she confirmed that the pimento cheese spread was opened and did not have a date of when it was opened. The DM revealed that she expects and requires staff to date food items after opening. Continued interview with the DM revealed that she confirmed that the buttermilk had a use by date of 04/10/16. The DM revealed that the evening cook has a cleaning check list that they are to complete and a task on the cleaning list is to check food items in the walk-in refrigerator for dates. The DM expected that the evening cook would have noticed that the buttermilk was going to go beyond the use by date. She expects all staff to discard food items past expiration and use by dates. The DM revealed that she does a walk-through of the kitchen, walk-in refrigerator, walk-in freezer, and dry storage making sure that the staff have cleaned the area, and have labeled and dated food items. She revealed that she did not have the time to look through the walk-in refrigerator today. Observation on 04/13/16 at 10:40 a. m. of the walk-in refrigerator revealed that there were six (6), 4 ounce cups of Dannon Strawberry Banana yogurt with a use by date of 04/12/16. Interview on 04/13/16 at 10:40 a. m. with the DM revealed that she confirmed that the use by date on the Dannon yogurt was 04/12/16. The DM revealed that she expected the evening cook to check dates on food items as part of their nightly cleaning routine. Tray line temperatures were completed on 04/13/16 at 12:35 p. m. using the facilities calibrated thermometer and JJ , dietary cook, obtaining the food temperatures. Continued observation revealed that the main entrée of Pork Rib Patty had a temperature of one hundred thirteen degree Fahrenheit (113°F). Interview on 04/13/16 at 12:35 p. m. with JJ revealed that the she confirmed that the temperature of the Pork Rib Patty was 113°F. Continued interview with the dietary cook revealed that food items should be on the steam table above 135°F. JJ confirmed that the three hundred (300) hall and the main dining room residents remain to be feed. Interview on 04/13/16 at 12:35 p. m. with the DM revealed that she expects staff to maintain food temperatures of hot foods in the steam table above 135°F. The DM revealed that there were forty one (41) residents from the 300 hall and main dining room that were to receive the regular consistency main entrée. Review of facilities policy for Food Storage revealed that each item is clearly labeled and dated before being refrigerated. Review of the facilities policy for Food Temperatures revealed that all hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135F. Hot food items may not fall below 135F after cooking. Review of the cleaning log sheets revealed that a task for the walk-in refrigerator was anything near out date (if so need to use) and nothing out of date (must take out). Continued review of the cleaning sheet for the evening of 04/10/16 and 04/12/16 revealed that the evening cook had marked the sheet that all tasks had been completed. Review of the in-service dated 04/17/15 revealed dietary staff were educated on dates and labels. The in-serviced dated 06/04/15 revealed staff were educated on anything going in the cooler has to be labeled and dated . The in-service dated 06/12/15 revealed dietary staff were educated on sanitation and time/temperature control. The in-serviced dated 06/17/15 revealed that dietary staff were educated on puree diet and if temp is not right . In-service dated 10/02/15 revealed that dietary staff were educated on label and dating.

Based on observation and staff interview the facility failed to have a recipe system in place for pureed food items to establish proper consistency and appropriate nutrient content. This deficient practice had the potential to effect eighteen (18) resident receiving a puree consistency diet. Findings include: Observation on 04/13/16 at 10:15 a. m. of JJ , dietary cook, puree Pork Rib Patty for the resident lunch meal revealed that she placed twenty one (21) pork rib patties in the food processor bowl with 21 slices of bread. She turned on the food processor and then started to add warm water through the open hole of the top lid. Interview on 04/13/16 at 10: 18 a. m. with JJ when asked if there was a recipe for pureed pork rib patties she revealed that she was not aware of a printed recipe for any pureed items. JJ revealed that she was instructed that for every piece of meat to add one (1) slice of bread then add enough water or broth to have a pureed consistency. When asked how much liquid she adds to make the food product the correct consistency she replied that she adds until it looks correct. Continued interview with JJ revealed that if she uses the commercial thickener to thicken pureed food items such as vegetables she just adds a little thicker at a time. She revealed that she does not reference to the recommendations of the thickening agent. Interview on 04/13/16 at 10:20 a. m. with the Dietary Manager (DM) revealed that the facility does not have recipes for pureed meat/protein items that use bread as the thickening agent. The DM revealed that staff were told to use 1 slice of bread and 1 ounce of fluid for each piece/portion of meat. When asked if she had a policy stating the pureed meat proportions the DM referred to the production sheet which indicated pureed meat, 1 meat & 1 bread . When asked if staff knew how much liquid and what type of liquid to add to the food product she revealed that staff estimate liquid based on the food item pureeing. She revealed that some food items they use apple juice as a liquid, broth, or water. When asked what would happen if a relief cook needed to assist with food production would they know how much liquid and the type of liquid to add, the DM confirmed that without a recipe someone stepping in to puree food items would not know the portions of bread or liquid. Review of the Diet Census Summary revealed that 18 residents would receive puree consistent diet.

Based on record review and staff interview, the facility failed to ensure that the Minimum Data Set (MDS) accurately reflected the assessment of one (1) resident (#24) regarding anti-depressant medication from a total sample of twenty-four (24). Findings include: Resident #24 was admitted to the facility in May 2014 with Alzheimer's, Anxiety, and [MEDICAL CONDITION]. Review of the March 2015 physician's orders [REDACTED]. Review of the November and December 2014 Medication Administration Records revealed [MEDICATION NAME] fifty (50) mg at HS starting 11/28/14 had been administered according to the physician's orders [REDACTED]. Review of the Quarterly MDS dated [DATE] revealed no evidence of antidepressant medication being completed under section N0410. Interview with the MDS Coordinator "BB" on 3/3/15 at 2:20 p.m., revealed that the [MEDICATION NAME] was overlooked during the seven (7) day look back period (11/27/14-12/3/14) and the resident was taking the [MEDICATION NAME] during that time.

Based on record review, and staff interview, the facility failed to develop a care plan for one (1) resident (#76) regarding vision from a total of twenty-four (24) sampled residents. Findings include: Resident #76 was admitted to the facility in March 2014 with Dementia, left side weakness, and [MEDICATION NAME] Degeneration. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that resident #76 has impaired vision yet sees large print without any corrective lenses. Further review of the Care Area Assessment (CAA) dated 10/20/14 revealed that vision triggered and would be addressed in a care plan. Review of the resident's current care plan with a continuation date of 1/22/15 revealed no evidence of vision being care planned. Interview with the MDS Coordinator "AA" on 3/4/15 at 9:15 a.m., revealed there was no care plan related to vision. .

Based on review of funds, and staff interviews, the facility failed to ensure that resident funds were available on the weekends for sixty-three (63) resident with fund accounts. Finding include: Review of resident funds revealed that the facility manages sixty-three (63) resident accounts. Interview with the Business Office Manager (BOM) on 3/4/15 at 10:45 a.m., revealed that residents has access to their account Monday through Friday from 9:00 a.m. to 5:00 p.m., but not on the weekends. She revealed that until two (2) years ago, the money was available on the weekends with the supervisor; however, no resident ever requested any money, so the Administrator decided to just make the money available Monday through Friday. Interview with the Administrator on 3/4/15 at 12:30 p.m., revealed that after the facility was cited seven to eight (7-8) years ago for not having funds available for the residents on the weekends, the facility left $50.00 with the weekend nursing supervisor. He further indicated that about three to four (3-4) years ago, this procedure was stopped because the residents were not using the money over the weekends. He indicated that no resident had complained of monies not being available on the weekends.

Based on observation, staff interviews and review of cleaning logs, the facility failed to ensure that one (1) ice machine and food storage areas in the kitchen were maintained in a sanitary manner. Eighty-two (82) of eighty-five (85) residents received oral alimentation. Findings include: 1. Observation of the kitchen ice machine with the Dietary Manager (DM) on 8/5/13 at 11:30 a.m., revealed a black material on the inside top of the machine where the ice drops; the black material came off on a paper towel when wiped. Continued observation revealed dust on top of the ice machine. Observation and interview with the DM on 8/5/13 at 11:30 a.m., revealed the maintenance supervisor does a major cleaning of the ice machines every three (3) months. Continued observation revealed when the DM wiped the inside top of the ice machine with a paper towel, she obtained black material. Review of the cleaning log, by the Maintenance Supervisor, for the dietary ice machine revealed it had received a major cleaning on 7/7/13. Interview with the DM on 8/8/13 at 9:45 a.m., revealed there was a staff member who deep cleaned the dietary ice machine weekly on Tuesday. Review of the deep cleaning chart , revealed that the staff member did not document that the deep cleaning was done. 2. Observation with the DM of the kitchen on 8/5/13 at 11:35 a.m. revealed the wire shelves in the walk-in cooler had scattered areas of thick orange to brown material, which came off on a paper towel when wiped. Interview with the DM on 8/5/13 at 11:35 a.m., revealed the shelves were cleaned once (1) a week and she acknowledged that the shelves were dirty. Continued interview on 8/6/13 at 3:55 p.m., revealed there is no cleaning schedule/log for the shelves in the walk-in cooler, so she could not confirm when they had been cleaned. 3. Observation of a large plastic storage bin with sugar in it on 8/5/13 at 11:35 a.m., revealed the handle was sticky. Observation and interview with the DM on 8/5/13 at 11:35 a.m., revealed that the handle of the sugar bin was sticky.

Based on observation, review of the ice machine cleaning log and staff interview, the facility failed to maintain two (2) of two (2) ice machines in a sanitary manner. Findings include: 1. Observation with Registered Nurse (RN) "AA" on 8/8/13 at 11:32 a.m., revealed the ice machine in the 400 hall pantry had flecks of black material on the white hard plastic interior. Review of the cleaning log for the 400 hall pantry ice machine revealed that the maintenance supervisor had done a major cleaning of the ice machine on 7/8/13. Continued review revealed no further evidence of cleaning the ice machine. 2. Observation with Licensed Practical Nurse (LPN) "BB" on 8/8/13 at 11:40 a.m., revealed the ice machine in the pantry for the 100/200/300 halls had a thick black substance around the chute where the ice falls into the bin. Continued observation revealed when staff "BB" wiped the material, a pea-sized piece fell into the ice. Review of the cleaning log for the 100/200/300 hall pantry ice machine revealed that the maintenance supervisor had done a major cleaning of the ice machine on 7/10/13; however, there was no further evidence of cleaning the ice machine. Telephone interview on 8/19/13 at 11:15 a.m. with the Dietary Manager, during the Quality Assurance process, revealed that the ice machines in the pantries for the 400 hall and the 100/200/300 hall were wiped down weekly, both inside and out by dietary staff.

Based on observation, record review and staff and resident interview the facility failed to inform four (4) residents ("F", "E", "A" and "B") of thirty-four (34) sampled residents of services provided by the state Ombudsman Program including contact information. Findings include: 1. During an interview conducted 2/02/12 at 11:00 a.m. resident "F" stated she was not aware of services provided by the Ombudsman Program and did not know how to contact the facility Ombudsman. 2. Resident " E " was interviewed on 2/02/12 at 11:15 a.m. and also stated she did not remember being informed by the facility of services provided by the Ombudsman. 3 & 4. On 02/02/12 at 12:30 and 1:10 p.m., residents "A" and "B" stated they did not know who the Ombudsman was. Resident "A" stated they had seen the Ombudsman poster on the wall, but did not pay it any attention as they didn't know what the Ombudsman did. The residents did not recall anybody at the facility talking to them about the Ombudsman. The facility assessed both of the residents' Cognitive Status Summary Scores on their most recent Minimum Data Set (MDS) as 14 (a score of 13-15 is cognitively intact). The Administrator was interviewed on 2/02/12 at 2:00 p.m. and stated resident rights information is provided to family members during the admission process. Information regarding the Ombudsman is not covered at council meetings but posters displayed near the lobby on a bulletin board do include the information.

Based on observation, record review and staff and resident interview the facility failed to inform two (2) of thirty-four (34) sampled residents of their right to contact the state agency with concerns and grievances. Findings include: Resident " F " was interviewed on 2/02/12 at 11:00 a.m. as representative for the Resident Council. She stated she had attended every meeting since her admission. A review of the Resident Council Minutes for calendar year 2011 and January 2012 revealed she was a regular participant. She further stated various facility departments are invited to the meetings to discuss relevant issues and address any concerns. She also stated resident rights were not discussed with the except a voting and the ability of the council to meet without staff if the residents so desire. Resident "F" was not aware of contact information for the State Agency. The Administrator was interviewed on 2/02/12 at 2:00 p.m. and stated resident rights information was provided to family members during the admission process. He further stated this was a very long process and usually does not involve the resident. The facility staff did not cover resident rights at council meetings and did not currently have another means of covering this information after admission except for posters displayed near the lobby on a bulletin board. On 02/2/12 at 1:10 p.m., resident "B" stated that they did not know that they could contact the State agency for care complaints, and that nobody in the facility had talked to him/her about this. The facility assessed resident "B"'s Cognitive Status Summary Score on their most recent Minimum Data Set (MDS) as 14 (a score of 13-15 is cognitively intact).

Based on record review, staff and resident interview, the facility failed to report an allegation of verbal abuse to the state agency for one (1) resident ("D") from a sample of thirty four ( 34) residents. Findings include: Interview with resident "D" on 1/30/12 at 2:22 p.m. revealed that he/she had reported a staff member for screaming at her/him on or about 10/20/11. Allegations of abuse made by residents "C" and "D" during interviews conducted during Stage 1 of the survey revealed both residents reported this Certified Nursing Assistant (CNA) as rude and speaking harshly to them. Interview with the Director of Nursing (DON) on 2/02/12 at 11:23 a.m. revealed that she was aware of the allegation of verbal abuse toward resident "D". However, she did not investigate and/or report the incident with resident "D" because the CNA was terminated as a result of the incident. She provided written documentation of the termination notice which revealed the staff member was observed screaming at the resident and was subsequently terminated because "this type of abuse to a resident was not tolerated". When asked for written documentation of the investigation of the incident, which occurred 10/21/11, and led to the CNA's termination, she stated she did investigate it, but made no written record of her investigation. She confirmed she did not consider it abuse and did not report it to the State Agency. The DON revealed an internal investigation was conducted but the allegation was not reported to the state agency. The DON further stated she did talk with resident "C" on 2/01/12, but did not receive any information relevant to the resident's allegation and therefore did not continue her investigation. Review of the facility Abuse Prohibition, Identification and Response and Procedures policy revealed that the facility was to notify the State Agency of any allegations of abuse. Interview with the Administrator on 2/02/12 at 1:30 p.m. confirmed that the State agency should have been notified of the allegation of verbal abuse.